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Attention Deficit Hyperactivity Disorder


3% to 10% of children are diagnosed w/ ADHD ... Also: ADD, ADHD, hyperkinetic child syndrome, hyperkinetic reaction of childhood, ... – PowerPoint PPT presentation

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Title: Attention Deficit Hyperactivity Disorder

  • Attention Deficit Hyperactivity Disorder

  • Anne Marie McCarthy, MD
  • February 19, 2009

Outline of Lecture
  • Definition of ADHD
  • Prevalence
  • Pathogenesis
  • Clinical Features
  • Evaluation and Diagnosis
  • Common Co-morbid disorders
  • Treatment Options
  • Prognosis

My View of Developmental Concerns
  • Children want to succeed and please adults
  • No child chooses to be in trouble all the time
  • If they could do it they would
  • Were asking them to do something they cant
  • He did it last week
  • If they arent succeeding, Its the adults
    responsibility to put them in an environment
    where they can succeed

Definition of ADHD
  • Attention-deficit/Hyperactivity disorder
  • Manifests early in childhood
  • Symptoms of hyperactivity, impulsivity and/or
  • 3 to 10 of children are diagnosed w/ ADHD
  • One third to two thirds of those children have
    symptoms that persist into adulthood.
  • 1 to 6 of general Population

Why Do We Care
  • The symptoms affect
  • Cognitive, academic, behavioral, emotional and
    social functioning
  • Have lower academic and occupational performance
  • Increased risk for Social and Financial
  • Increased risk for injury and MVA

  • Overall Prevalence in children, 2 to 16
  • Differences in estimates accredited mostly to
    population studied (Primary care vs Referral)
  • One of most common childhood disorders
  • Prevalence estimate of school aged children
  • 8 to 10
  • Approximately 4.4 million US children

  • Gender Differences
  • Prevalence boys, 11
  • Prevalence girls, 4.4
  • Prevalence increases w/ increasing age
  • 4.1 for children lt 9 yrs old
  • 9.7 for children gt 9 yrs old

  • Major Theory - Genetic Imbalance in Catecholamine
    Metabolism in Cerebral Cortex
  • Global structural brain imaging differences
  • caudate nucleus, cerebral and cerebellar volume,
    smaller posterior corpus callosum regions.
  • Functional brain imaging differences
  • ADHD brains have reduced global activation
  • Reduced local activation of frontal lobe

  • Genetic Imbalance in Catecholamine Metabolism
  • Genetic Basis for the theory is supported by twin
  • As high as 92 concordance for monozygotic twins.
  • 33 concordance for dizygotic twins
  • Studies have identified a number of genes that
    appear to play a role in the development of ADHD

  • Genetic Imbalance in Catecholamine Metabolism
  • Catecholamines - Dopamine, Nor-epinephrine, and
  • Dopamine and Nor-epinephrine are major
    Neuro-modulators in the CNS, (neurotransmitters)
  • Research suggests a Genetic imbalance b/w
    Nor-epinephrine and dopamine systems
  • Dopaminergic activity decreased and Nor-epi

  • ADHD theory is a deficit in Dopamine
  • Dopamine tied to
  • attention,
  • alertness,
  • vigilance,
  • executive function (abstract reasoning, mental
    flexibility, planning and working memory)
  • increased goal directed behavior,
  • control of flow of information from different
    areas of the brain.

  • Dopamine disorders cause decline in
    Neuro-cognitive functions
  • especially memory,
  • attention
  • problem solving.

Clinical Features
Clinical Features
  • Three Categories of Symptoms
  • Hyperactive
  • Impulsivity
  • Inattention
  • Depending on predominant symptoms, three subtypes
    of ADHD have been identified
  • Combined Type (ADHD-C)
  • Hyperactive-Impulsive type (ADHD-HI)
  • Inattentive type (ADHD-I)

Clinical Features
  • ADHD C (Combined type)
  • Classic type that is seen most commonly
  • Diagnosed 6 yrs to 7 yrs old
  • ADHD HI (Hyperactive-Impulsive)
  • Diagnosed 6yrs to 7yrs old,
  • Cant inhibit behavior, cognitive performance
    less likely to be affected
  • ADHD I (Inattentive)
  • Diagnosed 9 yrs to 10 yrs olds (more academically
    challenging age range)
  • FemalegtMale

Clinical Features
  • Hyperactive
  • Excessive fidgetiness or talking
  • Cant remain seated
  • Cant play quietly,
  • runs or climbs excessively or talks excessively
  • Always On the Go restlessness
  • Usually present by 4 yrs old
  • Peak 7 to 8 yrs old
  • Usually barely discernible by adolescent yrs

Clinical Features
  • Impulsive -almost always occurs w/ hyperactive
  • Difficult waiting turns
  • Blurting out
  • Disruptive
  • Intruding, interrupting others
  • Peer rejection
  • Unintentional Injury to self or others
  • Present by 4yrs old , Peak 7 yrs to 8 yrs old
  • Usually persist into adulthood

Clinical Features
  • Inattention
  • Forgetfulness
  • Easily distracted, Does not seem to listen
  • Losing or misplacing things
  • Disorganization
  • Academic underachievement
  • Difficulty sustaining or poor follow-through w/
  • Poor concentration
  • Poor attention to detail
  • Present 8 yrs to 9yrs old
  • Persists into adulthood

Evaluation and Diagnosis
  • Attention-Deficit/Hyperactivity Disorder (ADHD)
  • When problems with attention, hyperactivity, and
    impulsiveness develop in childhood and persist,
    in some cases into adulthood, this mental
    disorder may be diagnosed.
  • Diagnostic criteria for Attention-Deficit/Hyperact
    ivity Disorder(cautionary statement)  
  • A. Either (1) or (2) (1) inattention six (or
    more) of the following symptoms of inattention
    have persisted for at least 6 months to a degree
    that is maladaptive and inconsistent with
    developmental level (a) often fails to give
    close attention to details or makes careless
    mistakes in schoolwork, work, or other
    activities (b) often has difficulty sustaining
    attention in tasks or play activities (c) often
    does not seem to listen when spoken to
    directly (d) often does not follow through on
    instructions and fails to finish school work,
    chores, or duties in the workplace (not due to
    oppositional behavior or failure to understand
    instructions) (e) often has difficulty
    organizing tasks and activities (f) often
    avoids, dislikes, or is reluctant to engage in
    tasks that require sustained mental effort (such
    as schoolwork or homework) (g) often loses
    things necessary for tasks or activities (e.g.,
    toys, school assignments, pencils, books, or
    tools) (h) is often easily distracted by
    extraneous stimuli (i) is often forgetful in
    daily activities 
  • (2) hyperactivity-impulsivity six (or more) of
    the following symptoms of hyperactivity-impulsivit
    y have persisted for at least 6 months to a
    degree that is maladaptive and inconsistent with
    developmental level
  • Hyperactivity (a) often fidgets with hands or
    feet or squirms in seat (b) often leaves seat in
    classroom or in other situations in which
    remaining seated is expected (c) often runs
    about or climbs excessively in situations in
    which it is inappropriate (in adolescents or
    adults, may be limited to subjective feelings of
    restlessness) (d) often has difficulty playing
    or engaging in leisure activities quietly (e) is
    often "on the go" or often acts as if "driven by
    a motor" (f) often talks excessively
  • Impulsivity(g) often blurts out answers before
    questions have been completed (h) often has
    difficulty awaiting turn (i) often interrupts or
    intrudes on others (e.g., butts into
    conversations or games) 
  • B. Some hyperactive-impulsive or inattentive
    symptoms that caused impairment were present
    before age 7 years. 
  • C. Some impairment from the symptoms is present
    in two or more settings (e.g., at school or
    work and at home). 
  • D. There must be clear evidence of clinically
    significant impairment in social, academic, or
    occupational functioning. 
  • E. The symptoms do not occur exclusively during
    the course of a Pervasive Developmental Disorder,
    Schizophrenia, or other Psychotic Disorder and
    are not better accounted for by another mental
    disorder (e.g., Mood Disorder, Anxiety Disorder,
    Dissociative Disorders, or a Personality
  • Code based on type 
  • 314.01 Attention-Deficit/Hyperactivity Disorder,
    Combined Type if both Criteria A1 and A2 are met
    for the past 6 months 314.00 Attention-Deficit/Hy
    peractivity Disorder, Predominantly Inattentive
    Type if Criterion A1 is met but Criterion A2 is
    not met for the past 6 months314.01
    Attention-Deficit/Hyperactivity Disorder,
    Predominantly Hyperactive-Impulsive Type if
    Criterion A2 is met but Criterion A1 is not met
    for the past 6 months Coding note For
    individuals (especially adolescents and adults)
    who currently have symptoms that no longer meet
    full criteria, "In Partial Remission" should be
  • Also ADD, ADHD, hyperkinetic child syndrome,
    hyperkinetic reaction of childhood, minimal brain
    damage, minimal cerebral dysfunction, minor
    cerebral dysfunction
  • Moss, Deborah Shelly the Hyperactive Turtle
  • Quinn, Patricia Putting on the Brakes Young
    People's Guide to Understanding Attention Deficit
    Hyperactivity Disorder 1992
  • nostic Criteria - DSM-IV table

Evaluation and Diagnosis
  • Things to Emphasize w/ DSM-IV Criteria
  • Symptoms must be present in more than one setting
  • Must persist gt6mo
  • Must be present before 7 yrs old
  • Must impair function in academic, social or
    occupational activities
  • Must be excessive for developmental level of
  • Another diagnosis cant account for symptoms

Evaluation and Diagnosis
  • Evaluation should include Medical, Developmental,
    Educational and Psychological Evaluation
  • Information gathered from the patient, parents,
    teachers, any other available care givers.
  • Teachers are a major source of referrals for

Evaluation and Diagnosis
  • Tools exist for rating core behaviors and
    determining degree of functional impairment.
  • Two types of behavior rating scales have been
  • Narrowband scales, aka ADHD specific scales
  • Focus directly on ADHD
  • Sensitivity and Specificity gt90
  • Broadband scales
  • Assess ADHD and other behaviors
  • Less sensitive and specific

Evaluation and Diagnosis
  • Age of diagnosis
  • Diagnosing younger than 6 yrs old is difficult,
  • 79 of those that met criteria at age 4 to 6
    continued to meet criteria three years later.
  • Subtypes can change over the course of time in an

Differential Diagnosis
Differential Diagnosis
  • Learning Disabilities
  • Behavior and Emotional Problems
  • Depression, Bi-polar, Anxiety, PTSD,
  • Mental Retardation
  • Fragile X
  • Environmental Factors
  • Stressful home, Inappropriate school setting
  • Hearing or Visual Impairment
  • Asthma
  • Fetal Alcohol Syndrome
  • Thyroid Abnormalities
  • Sleep Disorders
  • Seizure Disorders

Differential Diagnosis
  • Hint to diagnosis
  • Symptoms persistent and pervasive
  • Should be re-evaluated for wrong diagnosis if
  • Symptoms worsen
  • New symptoms occur
  • Not responding to treatment

Co-morbid Disorders
Co-morbid Disorders
  • As many as ½ of the children diagnosed w/ ADHD
    have one or more co-morbid conditions
  • Oppositional Defiant Disorder
  • Conduct Disorder
  • Depression
  • Anxiety, Tics, OCD
  • Learning Disabilities

Co-morbid Disorders
  • Oppositional Defiant Disorder (ODD)
  • Negativistic, defiant, disobedient and hostile
    toward authority plus four of the following
  • Often loses temper
  • Often argues w/ adults
  • Often actively defies or refused to comply w/
  • Often deliberately annoys people
  • Often blames others for his/her mistakes
  • Often touchy or easily annoyed by others
  • Often angry or resentful
  • Often spiteful or vindictive

Co-morbid Disorders
  • Oppositional Defiant Disorder (ODD)
  • Coexists w/ ADHD up to 35 of cases
  • More common in ADHD-HI type
  • If have ADHD-C or ADHD-HI, are at risk of
    developing ODD
  • ADHD frequently puts them in conflict w/ adults
  • Conflict leads to more discipline and less
    positive reinforcement

Co-morbid Disorders
  • Conduct Disorder
  • Repetitive and persistent pattern of behavior in
    which the basic rights of others or major
    societal norms are violated.
  • Additional symptoms
  • Aggression to people and animals
  • Destruction of property
  • Deceitfulness or theft
  • Serious rule violations

Co-morbid Disorders
  • Conduct Disorder
  • Co-exists w/ ADHD up to 26 of cases
  • Appears more commonly in ADHD-C and ADHD-HI
  • Depression
  • Co-exists w/ ADHD up to 18 of cases
  • Occurs more commonly in ADHD-C and ADHD-I
  • Likely to have family hx of depression
  • During adolescence, increase risk for suicide

Co-morbid Disorders
  • Anxiety Disorder
  • Co-exists w/ ADHD up to 26 of cases
  • More common in ADHD-I
  • Criteria include excessive anxiety and worry,
    about several different events or activities
    which is difficult for child to control plus at
    least one of
  • Restlessness
  • Easy fatigability
  • Difficulty concentrating
  • Irritability
  • Muscle Tension
  • Sleep Disturbance

Co-morbid Disorders
  • Learning Disabilities
  • Data regarding rates of co-existence of specific
    types of learning disabilities and ADHD are
  • Estimates of coexistence ranges from 20 to 60
  • Hard to tell, does the ADHD lead to the
    scholastic delay defined as learning disabilities
  • Or does learning disabilities lead to behavior
    that meets criteria for ADHD
  • Learning Disabilities occur more commonly among
    ADHD-C and ADHD-I

Co-morbid Disorders
  • Learning Disabilities
  • Neuropsychologic testing
  • May help clarify diagnosis and identifying
    strengths and weaknesses
  • Children w/ Learning, Language, visual-motor and
    auditory processing problems usually perform
    poorly only in their particular problem area
  • Children w/ ADHD usually perform poorly in
    several areas of evaluation

Treatment Options
  • Treatment may involve the following alone or in
  • Medication
  • Behavioral/Psychologic Interventions
  • Educational Interventions
  • Decisions should involve patient and parent
  • Weigh risks and benefits of all options

Treatment - General Principles
  • Managed as the chronic condition that it is
  • Specific treatment goals should be set
  • Regularly monitor effectiveness of interventions
  • PCP should be information sources
  • Referral to Specialist if
  • Younger than six
  • Co-morbid psychiatric conditons (ODD, CD,
    substance abuse, emotional problems)
  • Co-morbid medical conditions (sz, PDD)
  • Lack of response to treatment

Treatment - General Principles
  • Management should include setting achievable
  • Sample Target Outcomes
  • Improved peer relations
  • Improved academic performance
  • Improved rule following
  • If goals cant be achieved, should evaluate
    original diagnosis, undiagnosed co-morbid
    conditions and/or treatment compliance

Treatment - MedicATION
  • Approximately 56 of those diagnosed are treated
    w/ medications
  • At least 80 of properly diagnosed children will
    respond to one of the available stimulants if
    they are tried in a systematic way
  • Have significant clinical effect on hyperactivity
  • If fail to respond or experience intolerable side
    effects on one stimulant, other available options
    should be tried

  • Stimulants are first-line treatment
  • Why would I stimulate a child that cant sit
  • Stimulants increase the amount of dopamine
  • Dopamine is an inhibitory force
  • Youre stimulating an inhibitor
  • Youre making the brakes work better.

  • ADHD brains have increased number of dopamine
    transporters which clear dopamine from the
    synapse (extracellular area) too quickly.
  • Medication increases extracellular dopamine in
    the brain
  • Dopamine re-uptake inhibitor
  • Dopamine has inhibitory activity
  • Medication (a stimulant) is stimulating an

Neurotransmitter cell signaling
  • Reuptake Inhibitors

  • Two main classes of drugs Methylphenidate and
  • Affect dopaminergic and noradrenergic systems
  • No demonstrated difference if efficacy b/w
  • Have different formulations w/ different release
    preparations (short acting vs long acting)
  • Differences are individually based
  • Tolerance (If side effects w/ one, should try
    the other)
  • Effectiveness (meeting behavioral needs?,
    addressing symptoms?)

  • Side Effects Safety established over 50yrs of
  • Effects are reversible, (long term side effects
    and drug dependence do no occur)
  • Similar b/w the two main classes
  • Occur more commonly if used in preschool years
  • Anorexia or appetite disturbance (80)
  • Sleep disturbance (3 to 85)
  • Weight Loss (10 to 15)
  • Deceleration of linear growth (Adult height not
  • Less Common Side Effects
  • Increased hrt rate or BP, HA, stomach ache
  • Social withdrawal, nervousness, irritability,

Behavioral Interventions
  • Modifications in Physical and Social Environment
    (environmental modification)
  • Has not been shown to significantly reduce core
  • Can improve behavioral problems
  • Center around consistent rewards and consequences
    depending upon whether specific goals were met

Behavioral Interventions
  • Helpful Strategies
  • Maintaining a daily schedule
  • Minimizing Distractions
  • Helping w/ organization of possessions
  • Setting small, reachable goals
  • Rewarding positive behavior
  • Using visual cues (charts, checklist) to stay on
  • Limiting Choices
  • Finding activities that the child will be
  • Using calm discipline techniques (time-out,
    removal, distraction)

Psychosocial therapies
  • Behavioral Modification Techniques
  • Cognitive Therapy
  • Play therapy
  • Designed to change childs emotional status
  • Work best if other co-existing psychologic
  • Little documented efficacy in tx of core symptoms
  • But, significant improvement of overall quality
    of life for child and family if stressors or
    co-existing conditions exist

Educational Interventions
  • May require changes in educational programming
  • Tutoring
  • Resource Room support
  • Classroom modifications
  • Assignments written on the board
  • Sitting next to teacher
  • Extended time to complete tasks
  • Private signal from teacher if off task
  • Completion of daily report card (monitor

Educational Interventions
  • ADHD qualifies as a disability under IDEA
  • Individuals w/ Disabilities Education Act
  • ADHD may qualify for special education services
  • Or may qualify for accommodations under Section
    504 of the Rehabilitation Act
  • Americans w/ Disabilities Act
  • Provide reasonable accommodations in private
    schools (secular) and post- secondary education

Alternative Therapies
  • Some common Alternative therapies
  • Vision training
  • Special diets (avoidance of sugar, allergens or
    food additives)
  • Megavitamins
  • Herbal and mineral supplements
  • EEG biofeedback
  • Applied Kinesiology

Alternative Therapies
  • Being used in as high as 68 of ADHD pts
  • Benefits have not been demonstrated in double
    blind , randomized controlled trials
  • Risks include potential failure and setback for
    child when symptoms persist and unnecessary

Comparing Treatment Options
  • Stimulant Therapy versus Multimodal Therapy
  • Assigned 600 children b/w 7 and 9.9 yrs old to
    four different groups
  • Medication management (Stimulant tx)
  • Behavioral Treatment (Parenting training,
    child-focused tx and school-based intervention)
  • Combined Treatment (combination of the two above)
  • Community care (Initial assessment explained,
    list of community mental health resources and tx
    as prescribed by their own provider)

Comparing Treatment Options
  • ADHD symptoms improved in all groups over time
  • Combined was not more effective than in reducing
    core symptoms than meds alone
  • If received meds, w/ or w/out behavioral tx,
    showed gt improvement than those w/ behavioral tx
    or community care w/out meds.
  • Behavioral tx w/out meds was similar to community
    care w/out meds.
  • Combined tx improved symptoms like
    oppositional/aggressive, social skills,
    parent-child relations and reading achievement
    the most

  • The symptoms affect
  • Cognitive, academic, behavioral, emotional and
    social functioning
  • Impaired Academic Functioning
  • Completion of less schooling
  • Lower achievement scores
  • Failure of more courses
  • Finding persist even if dont still meet ADHD
  • Employment
  • Lower status jobs
  • Poor performance compared to controls

  • Antisocial Behavior
  • Increased risk for Antisocial Personality
  • 12 to 23 chance if ADHD-HI vs 2 to 3 chance
    in controls
  • Risk appears independent of co-morbid CD
  • 54 arrested by 21yrs old vs 37 of controls

  • Substance Abuse during Adolescense
  • Data unclear, some say increased risk, some dont
  • Increased prevalence if co-morbid condition
  • Those who receive pharmacotherapy tx, have almost
    2 fold reduction in substance abuse.
  • Injuries
  • Increased incidence of intentional and
    unintentional injuries

  • Driving
  • ADHD individuals are 2 to 4 times more likely to
    have MVA than those w/out ADHD
  • Also more likely to have license suspended
  • Driving performance improves w/ stimulant tx

  • ADHD is a prevalent, pervasive disorder that
    affects cognitive, academic, behavioral,
    emotional and social functioning.
  • Diagnosis and treatment can improve functioning
    in most of the affected areas.
  • No child wants to be in trouble all the time.
    Theyre doing the best that they can. Its up to
    us to help them succeed.

(No Transcript)
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