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Adolescent ADHD


ADHD is a heterogeneous behavioral disorder with multiple possible etiologies ... increased the risk for ODD, Major Depression, Bipolar Disorder and Agoraphobia. ... – PowerPoint PPT presentation

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Title: Adolescent ADHD

Adolescent ADHD
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  • ADHD is a heterogeneous behavioral disorder with
    multiple possible etiologies
  • Neuroanatomic/ Neurochemical
  • CNS Insults
  • Genetic Origins
  • Environmental factors

Core Symptoms Areas
DSM-IV CriteriaInattentionSix or more of the
followingmanifested often
  • Inattention to details/
  • makes careless mistakes
  • Difficulty sustaining attention
  • Seems not to listen
  • Fails to finish tasks
  • Difficulty organization
  • Avoids tasks requiring sustained attention
  • Loses things
  • Easily distracted
  • Forgetful

ADHD DSM-IV CriteriaImpulsivity/HyperactivitySi
x or more of the following-manifested often
  • Impulsivity
  • Blurts out answer before questions is finished
  • Difficulty awaiting turn
  • Interrupts or intrudes on others
  • Hyperactivity
  • Fidgets
  • Unable to stay seated
  • Inappropriate running/climbing (restlessness)
  • Difficulty in engaging in leisure activities
  • On the go
  • Talks excessively

Variation in symptoms
  • Symptoms vary in
  • Pervasiveness
  • Frequency of occurrence
  • Degree of impairment

DSM-IV Diagnosis Criteria
  • Symptom criteria must be met for past 6 months
  • Some symptoms must be present before 7 years of
  • Some impairment from symptoms must be present in
    2 or more settings
  • The symptoms lead to significant impairment
  • Symptoms are not exclusively due to other mental

DSM-IV Subtypes
  • ADHD Predominantly Inattentive Type
  • Criteria met for Inattentive but note for
  • ADHD Predominantly Hyperactivity/Impulsivity Type
  • Criteria met for impulsivity/hyperactivity but
    not for Inattention
  • ADHD Combined Type
  • Criteria are met for both inattention and

Impact and cost of ADHD
  • ADHD in adult prison inmates25
  • More drivers with ADHD
  • Drove without a license
  • Had license revoked or suspended
  • Had multiple crashes(2)
  • Had multiple traffic citations(3)
  • Subgroups of ADHD with comorbid ODD/CD were at
    highest risk

Impact and cost of ADHD
  • Despite similar educational levels and IQ scores,
    individuals with ADHD not taking medication
    display significantly more academic problems in
    school (25 repeat a grade) and lower occupation

Impact and cost of ADHD
  • Parents of children with ADHD experience higher
    level of stress, self blame, social isolation,
    depression and marital discord
  • 63 of 144 caregivers after diagnosis of child s
    ADHD changed work status

  • Laufer (1962) The behavior picture described
    tends to disappear with maturation, anywhere
    between twelve and eighteen years of age.
  • Mendelson et al (1971) Our findings suggest
    that hyperactive children are generally behaving
    in a more normal way by the time they enter their
  • Wender (1995)the past decade researchers have
    become convinced thatADHD is a common
    psychiatric disorder in adults
  • Gadow and Weiss (2001) the validity of this
    disorder is now beyond controversy.

Diagnosis of Adolescent ADHD
  • Still an observational diagnosis
  • DSM-IV criteria thought threshold could be too
  • Likely 4/9 (Barkley et al., 2001)
  • Shouldnt apply age 7 criteria (Applegate et al.,
  • Semi-structured interview should be done
  • Measurement of impairment

Pitfall in the diagnosis of adolescent ADHD --I
  • Individuals (esp. girls) who tend to exhibit
    fewer hyperactive symptoms
  • Individuals who exhibit mental rather than
    physical restlessness
  • The ubiquity of inattentive and impulsive
    behavior in normal adolescent life
  • Developmental relativity, age appropriateness

Pitfall in the diagnosis of adolescent ADHD --II
  • Self report Vs parental report
  • Difficulty to obtain data from secondary school
  • Uncooperative adolescents
  • Multiple comorbid disorder
  • Shared features of other adolescent onset
    psychiatric disorders
  • Life span with multiple stresses

Pitfall in the diagnosis of adolescent ADHD --III
  • The uncertain validity of applying DSM-IV
    diagnostic criteria for ADHD in adolescent
  • The difficulty of establishing impairment in
    functioning due to ADHD for adolescent
  • Different definition of remission
  • Syndromatic remission
  • Symptomatic remission
  • Functional remission

Definition of ADHD Remission
Adolescent and adult with ADHDBackground
  • A source of controversy and uncertainty in ADHD
    is the marked differences that have been observed
    in male to female ration between pediatric and
    adolescent samples
  • Gender ration in pediatric sample heavily favors
    male 41 91
  • Adolescent and adult samples have a more even
    gender distribution
  • Differences in gender representation have
    threaten the validity of the diagnosis of
    Adolescent and adult ADHD

Adolescent and adult with ADHDBackground
  • Similar pattern of comorbidity had been
    documented in boys and girls with ADHD
  • However, boys havegt2 fold increased rates of
    disruptive behavior disorder
  • Disruptive behavior disorders drive clinical
    referrals of children but not adults

Follow up studies in ADHD
  • Montreal study by Weiss and Hechtman (1993)
  • New York Study by Mannuzza,Klein et al (1998)
  • Swedish Study by Rasmussen and Gillberg (2001)
  • Milwaukee Study by Barkley (2002)

What predicts persistence of ADHD into
adolescence?(Biederman, Farone et al1996)
  • Familiarity of the ADHD(OR 2)
  • Presence of psychiatry comorbidity (conduct
    disorder, mood or anxiety disorder) (OR 3)
  • Family adversity (paternal mental illness,
    conflict in family) (OR 7)(plt0.001)

Adolescent outcome
  • decline in hyperactivity, improvement in
    attention span and impulse control (Hart, Lahey,
    Loeber, Applegate Frick, 1995)
  • 30-80 of ADHD children continue to display
    symptoms in adolescence (Gittelman, Mannuzza,
    1985 Barkley, Fischer et al, 1990)
  • 25-45 display oppositional or antisocial
    behavior or CD (Biederman, Faraone et al 1996,
    Biederman et al 1997)

How are ADHD adolescents doing in school?
  • 29.3 retained in a grade, 46.3 had been
    suspended, 10 dropped out.(Barkley,
  • ADHD adolescents had more academic
    impairments(compared to baseline), lower IQ and
    mathematics achievement scores and more learning
  • Fail to work independently well
  • Poor organization and planning
  • Poor time management
  • Poor follow through

Differential diagnosis of ADHD--comorbidity
alter the clinical presentation and may require
multiple treatment
  • Coexisting conditions
  • Conduct disorder
  • Learning disorder
  • Oppositional defiant disorder
  • Bipolar affective disorder
  • Epilepsy
  • Tourette syndrome

Comorbid disorders in ADHD adolescents
  • High percentage of antisocial behavior, but low
    rates of mood and anxiety disorders.(Weiss 1993
    Mannuzza 1991)
  • 59 of ADHD adolescents had ODD, 43 had
  • Baseline comorbid CD significantly increase the
    risk for CD and ODD, Bipolar Disorder and alcohol
    and drug dependence on follow up.
  • Baseline comorbid major depression increased the
    risk for ODD, Major Depression, Bipolar Disorder
    and Agoraphobia.
  • Multiple anxiety disorder at baseline increased
    the risk for Anxiety Disorder.
  • Youngster with non-comorbid ADHD had an increased
    risk for ODD, Tic Disorder, and Language
    disorder. (Biederman, Faraone et al, 1996)

Comorbidity of adolescent ADHD
Overlapping Diagnostic Criteria
Psychiatry and Medical Disorders can mimic ADHD
  • Mood Disorder
  • Psychotic Disorder
  • Adjustment Disorder
  • Anxiety Disorder
  • Learning/language Disorder
  • Stress-related Disorder
  • Developmental Disorder
  • Sleep Apnea
  • Substance Use Disorder
  • Use of Other medications
  • Seizure Disorder
  • Vision problem
  • Hearing Impairment

How does having ADHD affect self esteem?
  • ADHD individuals displayed lower self-esteem and
    psychosocial adjustment by adolescents and lower
    educational achievement and occupational status.
    (Mannuzza, Klein,1995)
  • Lowered self esteem is part of the longitudinal
    outcome of ADHD

How are ADHD adolescents getting along with their
  • Parent-adolescent relationship between ADHD
    teenagers and their parents are generally
    characterized by increased conflict, negative
    communication, distorted beliefs, and more
    disengagement, especially when the adolescents
    are diagnosed with ADHDODD.

Adolescent ADHD and substance use
  • Persistence of ADHD symptoms, family history and
    comorbid CD high prediction of drunkenness and
    daily smoking
  • Among different symptom cluster in ADHD,
    inattentiveness is most predictive of substance

ADHD studies
Developmental outcome and developmental course
  • Developmental outcome studyidentifying a cohort
    of children that meet diagnostic criteria for
    ADHD and follow them prospectively to determine
    whether they are at increased risk for any number
    of negative developmental outcome
  • Developmental course study whether the symptoms
    of ADHD persist into adolescent

Developmental outcome studies
  • Thorley (1984)Childhood hyperactivity was
    associated with an increased risk for PD,
    antisocial behavior, peer relationship,
    educational difficulties,as well as continued HIA
  • Clampit and Pirkle (1983) psychostimulants maybe
    effective in ADHD adolescents
  • Barkley et al (1993) children with ADHD are at
    increased risk for a variety of negative
    developmental outcome in adolescence and
  • Barkley et al (2002) the educational,
    occupational, and psychosocial risks are
    associated with a childhood diagnosis of ADHD
    relative to both normal and clinical control

Limitations of developmental outcome studies
  • It remains unclear whether
  • ADHD symptomatology may interfere with normal
    development process, including parent-child
    relationships, peer relationship and/or academic
    performance that in turns increase the risk of
    negative outcome, or
  • ADHD may facilitate the onset and persistence of
    other behaviors/psychiatric disorder that
    increase the risk for negative outcome.

The importance of developmental course study
  • Clarify the mechanism linking childhood ADHD to
    later negative developmental outcome
  • An improved understanding of the developmental
    course of ADHD symptomatology would provide
    information for the construction of
    developmentally sensitive diagnostic criteria

Developmental course studies
  • Diagnostic retention studies
  • Symptom trajectory studies
  • MacCallum et al (2002) repeated measures data
    of a continuous variable provide more information
    than a dichotomous diagnosis

Diagnostic retention studies
  • Hill and Schoener (1996)meta-analysis of 9
    diagnostic retention studies. Rate of ADHD
    desisted by 50 every 5 years(beginning at 9)
  • Barkley(1998)s criticize 1. Many of the studies
    included were initiated prior to the
    establishment of formal diagnostic criteria for
    ADHD. 2. Not enough studies were included.

Symptom trajectory studies
  • Hart et al(1995) 1. Hyperactive-impulsive
    symptoms significantly declined with increasing
    age, whereas inattention symptoms did not. 2.
    Conduct problems predicted persistence of ADHD
    symptom. 3.Developmental changes in ADHD symptom
    did not vary as a function of informants 4.
    Psychosocial and pharmacological interventions
    did not reduce ADHD greatly.
  • Biederman (1998)1.Children and adolescent ADHD
    did not differ in the mean number of ADHD
    symptoms. 2.Clinical phenotype is the same in
    adolescent and children.
  • Biederman (on the same sample,2000) HIA
    decreased significantly as age increased.

Developmental Trajectories of Brian volume
abnormalities in youth with ADHD
  • Design MRI case control study
  • M152 youth with ADHD and 139 controls of both
  • Objectives assess volumetric changes overtime in
    medicated vs unmedicated youth with ADHD and
  • Catellanous JAMA 2002 288-1740

Developmental Trajectories of Brian volume
abnormalities in youth with ADHD
  • Main Findings
  • Smaller brain volumes in all regions
    independently of medication status
  • Smaller total cerebral (-3.2)and cerebellar
    (-3.5) volumes
  • Volumetric abnormalies(except caudate) persistent
    with age
  • No gender differences
  • Volumetric findings correlated with severity of

Developmental Trajectories of Brian volume
abnormalities in youth with ADHD
  • Conclusions
  • Genetic and or early environmental influences on
    brain development in ADHD are fixed,
    nonprogressive and unrelated to stimulant

Maturation lag hypothesis
  • Satterfield JH(1973,1984)ADHD children have more
    slow activity and less activity in the high
    frequency band---signs of immaturity reflecting a
    delayed brain maturation that could be normalized
    with age,or a deviation of brain maturation.
  • Giedd JN(2001)ADHD cerebellum is significantly
    smaller than control.
  • Lou (1984)SPECT findingmaturational lags of CNS
    resulting from delayed myelination.
  • Castellanos (2002)gray matter shows complex
    developmental curves with a preadolescent
    increase but a post adolescent decrease.

Limitations of developmental course studies
  • Sample characteristics predominantly males in
    clinic referred sample
  • Course of ADHD symptomatology differs as a
    function of comorbidity?
  • The need to better understand whether reductions
    in ADHD(due either to sex and/or advancing age)
    are associated with specific changes in
    functional impairment that result from ADHD.
  • Design issues
  • Wide age range
  • Time adjacent study that did not consider the
    functional form that characterizes this change
    over time

More limitations
  • Heterogeneity ADHD is not a homogenous disease
  • Mendelson et al (1971)1/2 improved over time, ¼
    partial improved, ¼unchanged
  • Loney (1981)developmental delay, developmental
    decay, continual display
  • Lambert (1987,community cases)20 remitters,
    residuals 37, persisters (43)
  • Hechtman of Montreal sample(1993)1/3 normal
    outcome, 1/2continual symptoms with function
    impairment, a minority experienced serious

  • Clinicians working with substance abuse
    populations, conduct disordered populations and
    head injury populations should be alert for ADHD.
  • ADHD is a lifelong disorder

Treatment options in comorbid ADHD
  • Assess and treat all disorders
  • Prioritized treatment
  • Treatment of ADHD almost always involves the
    treatment of comorbidity
  • Order of treatment
  • Most debilitating symptoms first
  • Consider interactions of symptoms and side
    effects of stimulants
  • Simple case monotherapy
  • Complex case- combined treatment

Use of Ritain
  • Absolute range per dose5-30 mg
  • Weight-based dose range per day 0.3-2.0mg/kg
  • There is no research to indicate more medicine
    with higher body weight
  • Dose of medicine varied with individuals
    metabolism, severity of ADHD symptoms, presence
    of comorbid conditions, behavior characteristics
    and natural environment

Side effect of Ritalin and its management
  • Anorexia(generally lunch)-give with meals, snacks
  • Insomnia- move dosing earlier, use of clonidine,
  • Mood disturbance- evaluate for mood disorder,
    assess timing of mood to r/o wear off effect
  • Tic disorder- assess for underlying tics, stop
    and rechallenge
  • Headache- lower dose, change prep, consider beta
  • Psychosis- rare, reassess dose and comorbid
  • Delay growth spurt- drug holiday if inattentive

Non-stimulant pharmacotherapy
  • TCA
  • 60-70 effective, but generally less effective
    than stimulants
  • Bupropion
  • First line for ADHD substance abuse/cigarette
  • Maybe helpful in ADHD mood lability
  • Clonidine
  • Useful in ADHD tics
  • Use at night for ADHD related sleep problem
  • Concerns of sudden death case report of 4
    children(clonidine MPH)

Treatment of ADHD with MDD
  • Depression disorder
  • If MDD is severe, then it is the focus of
  • If MDD is less severe or not primary, use
    stimulant trial first
  • After stimulant trial, evaluate the depressive
  • If depressive symptoms continue, use
    antidepressant or psychotherapeutic treatment
  • SSRI effective for depression but not ADHD
  • If depressive symptoms subsided, continue
  • Bupropion and TCA have antidepressant activity in
    adult, but utility in pediatric use had nor been
    established(5 cases of sudden death in younger

Treatment of ADHD with anxiety disorder
  • Differentiate the relationship between ADHD and
    anxiety disorders
  • Start with a stimulant trial
  • If ADHD symptoms improve, but anxiety symptoms
    persisted, apply psychosocial intervention
  • If the anxiety symptoms does not improve with the
    psychosocial intervention, consider adding SSRI
    to the stimulants.

Treatment of ADHD with tics disorder
  • High comorbidity of ADHD (50-70 TS patients)
  • Onset of ADHD before tics
  • Stimulants are highly effective in the treatment
    of ADHD in these patients and in the majority of
    patients tics do not increase
  • Start the stimulant treatment after proper
    informed consent
  • If tics worsen markedly, move on to an
    alternative stimulants
  • If tics do not worsen, and ADHD symptoms respond,
    remain on the stimulants
  • To treat the tics, consider combine medication,
    clonidine and guanfacine may be tried first

Treatment of ADHD with conduct disorder and
  • It stimulant did not reduce antisocial behavior
    despite the attenuation of the ADHD symptoms, use
    mood stabilizer(Li or divalproex sodium), or
    Clonidine in addition to stimulants(Frazier,
    1999)(4 deaths with the combination of Stimulants
    and Clonidine)
  • Use of Clonidinestart with 0.05mg at bedtime,
    never more than 0.3 mg per day. Never use in
    patients with family history of sudden death,
    repeated fainting or arrhythmias.
  • If aggression is severe, and is in immediate
    danger, use atypical neuroleptics, such as 0.5mg
    QD Risperidone, to the stimulants

Prevention of Abuse potential of stimulants in
  • Locked the medicine, keep a record
  • Do not use one students medicine on another
  • Avoid sending medicine to school
  • Use Concerta paste, taken once daily

Oslon, 1959
  • Those who surprised us seems to take a longer
    time to travel a given road, but that road has
    been kept open by parents and teachers who felt
    it worthwhile.
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