Attention-Deficit/Hyperactivity Disorder Dispelling Myths is Good Medicine

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Attention-Deficit/Hyperactivity
DisorderDispelling Myths is Good Medicine

• Karen J. Kraus, M.D.
• UCSF Fresno Psychiatry Residency Program

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Introduction

• ADHD is a complex disorder of higher brain
  functioning, characterized by inattention, motor
  over-activity and difficulty inhibiting impulsive
  behaviors
• ADHD is one of the most prevalent disorders in
  childhood and adolescence, affecting an estimated
  3-9 of school-age children

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Introduction

• Symptoms occur at an early age, occur in most
  areas of a childs life, and persist over time,
  frequently into adulthood
• The precise constellation of symptoms changes as
  children grow and develop

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Introduction

• ADHD is often inherited
• Imaging, electrophysiological and
  neuropsychological tests, and now, genetic
  analysis, all point to disturbances in specific
  neurotransmitter systems, affecting specific
  areas of the brain

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Introduction

• ADHD is frequently associated with other
  psychiatric and learning problems, which
  complicate diagnosis, treatment and prognosis
• ADHD is a heterogeneous disorder with many known
  causes, all of which mediate similar or identical
  effects on brain functioning

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There is no such thing as ADHD
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Myth 1

• Psychiatric disorders do not occur in children.

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Myth 2

• ADHD is nothing more than applying a diagnostic
  label to normal childhood behavior.

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Myth 3

• If ADHD really existed, wouldnt it be obvious?

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The medicines used to treat ADHD are dangerous
and addictive
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Efficacy and dosing guidelines have not been
established for children Use of these medications
may actually exacerbate the underlying
disorder Associated with high rates of
significant side effects such as irritability,
restlessness,lethargy, hallucinations,
hypertension severe muscle stiffness, even
death In one study, more than 50 of mothers
interviewed had administered this medication
within the past month During an investigative
hearing, one congressman made the comment, The
sad fact is, much of the billion dollar
medication industry is based more on hype then
health care.
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According to the American Association of Poison
Control Centers These medications are the
frequent targets of unintentional ingestions in
young children They rank 2 for intentional
ingestions In 1988, they accounted for 58,000
exposures 77 of all ingestions In 1990, they
accounted for 73,680 exposures (calls to poison
control centers In the case of one medicine,
tracking mechanisms reported a 60 annual
increase in use, abuse and medical contacts for
toxicity
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Stimulant medications, doses and pharmacological
activity
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Non-stimulant Medications in ADHD
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Efficacy

• More than 200 randomized and/or placebo
  controlled studies demonstrate that stimulants
  are effective in reducing the core symptoms of
  ADHD
• Approximately 70 of children with ADHD
  demonstrate a robust response to stimulants

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Medication Effects

• ? fidgetiness
• ?interrupting
• ?physical aggressiveness
• ?antisocial behavior
• ?compliance
• ?peer acceptance
• ?efficiency

• ?on-task behavior
• ?accuracy
• ?short term memory
• ?problem-solving
• ?parent-child interactions
• ?performance of motor tasks

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Efficacy

• The MTA study demonstrated the superior efficacy
  of medications over other kinds of treatment in
  school age children.
• There is less evidence to support the long term
  use of stimulants (gt14 months), or their use with
  preschool children, adolescents, and adults.

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Myth 4

• The medications used to treat ADHD are very
  dangerous

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Myth 5

• The medications used to treat ADHD are addictive

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Rates of psychotropic medication use by children
in the United States
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Substance Abuse ADHD

• A individual with ADHD persisting into adulthood
  is at increased risk to develop a substance abuse
  disorder that risk increases substantially in
  the presence of concurrent Conduct Disorder
• ADHD is associated with earlier onset of
  substance abuse disorders, and a shortened time
  from use to frank abuse

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Substance Abuse ADHD

• Substance abuse disorders in individuals with
  ADHD persisting into adulthood appear to be more
  chronic with lower rates of remission
• Overall, there is a 2-fold increased risk of
  developing a substance abuse disorder

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Substance Abuse ADHD

• The core rate of substance abuse in adolescents
  with ADHD is 10-15
• Teens who were medicated with stimulants showed
  no increased risk as compared to normal teens
• Teens with ADHD who were not medicated have a 3-4
  fold increased risk, as compared with affected
  teens who were treated

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Abuse of Stimulants

• There are only 5 case reports of stimulant abuse
  in the literature
• Epidemiological studies involving adolescents
  have found rates of non-prescription use of
  Methylphenidate ranging from a low of .1 in
  1992, to a peak of 2.8 in 1997 1998, to a rate
  of 2.2 in 2000.

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Abuse of Stimulants

• A survey of 6000 students in Mass. reported that
  13 of high school students and 4 of junior high
  school students had used Methylphenidate without
  a prescription
• A 1999 report on drug-abuse related visits to EDs
  revealed 1,478 notations of Methylphenidate
  abuse, down from 1,728 in 1998

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Abuse of Stimulants

• A 7 year study of incidents involving
  Methylphenidate called into poison control
  centers revealed
• Out of 11,149 cases involving MPH, 1,244 (11.2)
  were related to intentional abuse.
• The data indicated an increasing rate of abuse,
  with 17 cases in 1993 and 158 cases in 1998
• Most were boys between the ages of 14-15

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Abuse of Stimulants

• Continued
• 70 involved MPH only the remainder involved the
  co-consumption of 1-2 additional drugs.
• Use was coded acute in over 87 of cases,
  meaning there was no ongoing use of the stimulant
  either illicitly or therapeutically,
• Use in a chronic context was more likely to
  occur in older adolescents
• The most common route was ingestion.

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Advice to Parents, Kids and other Interested
Observers
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Inattention

• Difficulty initiating and sustaining attention,
  characterized by
• difficulty persisting in tasks, especially if
  they are uninteresting, tedious, sedentary or
  demanding
• switching from one unfinished task to another
• failure to complete tasks, chores, schoolwork,
  etc.

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Inattention

• Difficulty initiating and sustaining attention,
  characterized by
• difficulty following through with directions
• daydreaming, or appearing as if one isnt
  listening or is unable to hear

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Inattention

• Avoidance of, or aversion to, tasks that require
  sustained attention, such as
• tasks that require perseverance or sustained,
  intense mental effort
• tasks that tax limited organizational skills

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Inattention

• Distractibility, characterized by
• sensory distractibility, described as the
  inability to filter out unimportant, extraneous
  stimuli from important, relevant stimuli
• motor distractibility, described as the inability
  to inhibit responses to stimulus or, the
  inability to control the allocation of attention.

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Inattention

• Distractibility, characterized by
• difficulty shifting attention from one task or
  activity to another
• difficulty attending to more than one task at a
  time
• sometimes manifest as an extraordinary awareness
  of detail, however irrelevant

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Inattention

• Difficulty with organization and prioritization
  (impaired executive functions), characterized by
• loses or misplaces belongings or necessary things
  such as homework, school materials, toys, etc.
• difficulty prioritizing tasks in terms of
  importance or planning objectives
• procrastination
• forgetfulness, e.g., misses appointments, fails
  to remember gym clothes, etc.
• poor awareness of time, with similarly poor time
  management skills

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Inattention

• Difficulty with organization and prioritization
  (impaired executive functions), characterized by
• deficits in working memory - the ability to keep
  certain information in mind over short periods
  of time in the absence of environmental stimuli
  manifested by
• difficulty recalling complex instructions, such
  as game rules
• forgetting information that has just been read
• difficulty transferring information
• difficulty with math functions such as
  transposing numbers or computational errors.

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Hyperactivity

• Excessive motor activity, described as
• constantly moving or on the go
• fidgety or restless
• difficulty remaining seated when required to do
  so

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Hyperactivity

• Subjective sense of motor restlessness
• A subtle finding more common in girls, and
  frequently found in adolescents and adults

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Hyperactivity

• Over-talkativeness, described as
• excessive, continuous talking (blabbermouth)
• poor modulation of speech, with loud speech
• verbosity
• blurts out answers, interrupts conversation

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Hyperactivity

• Poor motor control, characterized by
• difficulty engaging in leisure activities
  quietly
• work, particularly handwriting, is often messy
• poor physical boundaries, with socially
  inappropriate, intrusive behavior
• aggressiveness or clumsiness, related to poor
  modulation of motor activities (e.g., breaks
  toys, hurts others unintentionally)

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Impulsivity

• Difficulty inhibiting responses (Ready, fire,
  aim!), manifested by
• intrusiveness
• impatience, manifested by
• difficulty with turn taking in games
• similarly manifest in conversation, with
  interruption and comments out of turn
• inappropriate behavior

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Impulsivity

• Risk taking/Novelty-seeking behavior
• engagement in physically dangerous activities
  without consideration of potential consequences
• often described as accident prone, with a
  history of injuries
• tendency to become easily bored and seek external
  stimulation

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Impulsivity

• Altered responsiveness to behavioral rewards,
  consequences and contingencies
• resistance to conditioning effects of reward or
  punishment
• failure to apply past experiences to current
  situations, resulting in repetitive mistakes
• neurophysiological basis

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Associated Features

• Altered response to social reinforcement
• Because of inattentiveness, negativism, or
  resistance to the conditioning effects of reward
  or punishment, many ADHD children are difficult
  to socialize. They are described as obstinate,
  impervious, stubborn or negativistic, although
  they are not necessarily conduct disordered

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Associated Features

• Altered emotional responsiveness
• Children with ADHD are easily excited and easily
  upset, and tend to react to situations in an
  exaggerated, disproportionate way, with dramatic
  (albeit usually short-lived) shifts in emotions
• They also tend to exhibit poor frustration
  tolerance (a short fuse), particularly with
  delay/denial of gratification, developmental
  challenges or interpersonal conflicts

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Associated Features

• Differences in interpersonal relationships
• Children with ADHD tend to be intense,
  controlling, socially imperceptive and
  intolerant.
• They are often described as immature and in fact,
  often exhibit delayed social development.
• Chronically antagonistic interpersonal
  interactions can lead to social isolation, and
  later on, to depression and angry defiance.

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Associated Features

• Behavioral dyscontrol
• Problematic behavior may signal the presence of a
  co-morbid psychiatric disorder, but may also stem
  from the core neuropsychiatric deficits seen in
  ADHD.
• The gap between the normal developmental
  aspirations of children with ADHD and their
  maturity and judgement further complicates the
  picture .

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Associated Features

• Behavioral dyscontrol
• Examples include
• lying and stealing may be indicative underlying
  impulsivity
• aggressive behavior may be an expression of
  poorly regulated physical force
• temper tantrums are often seen in the context of
  sensory or affective over-stimulation

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Associated Features

• Demoralization
• The curious dissociation between knowing and
  doing often frustrates children with ADHD.
  Despite talent and skills, and often despite
  prodigious effort, children with ADHD chronically
  fall short of expectations
• As a result their inefficient cognitive styles,
  children with ADHD must often work harder and
  longer than their peers to obtain the same
  outcome.
• Over time children with ADHD fatigue, and in the
  context of repeated failures, become demoralized,
  lose motivation and develop a posture of
  defensive defiance