ADHD Overview

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ADHD Overview

• Jeanette E. Cueva, M.D.

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Overview

• ADHD history
• Perception and reality
• Diagnosis in the US and UK
• Etiology

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ADHD in 1854 Fidgety Phil

• Let me see if he is able to sit still for once
  at the table.
• Thus Popa bade Phil behave and Mama looked very
  grave
• But fidgety Phil, He wont sit still

http//www.fln.vcu.edu/struwwel/philipp_e.html
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History of ADHD
Date Milestone
1902 Still Description of ADHD symptoms
1937 Bradley Benzadrine. Conceptualization of ADHD involved testing response to stimulants
1955 MPH
1960 Minimal Brain Dysfunction
1980 ADD DSM-III adults acknowledged
1987 ADHD DSM-III R
1994 DSM-IV
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Erroneous Beliefs/Assumptions About ADHD

• Minor disorder if it even exists
• Affects almost solely males
• Has little impact beyond the classroom
• Disappears spontaneously after grade school

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Erroneous Beliefs/Assumptions About ADHD

• Overdiagnosed
• Diagnosis made about any energetic or different
  child
• Medication is only a form of chemical control
• Misdiagnosed in cases of
• Poor parenting
• Rigid, misguided teachers
• Overtreated by physicians who used powerful and
  potentially addicting drugs for a minor,
  temporary ailment

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Erroneous Beliefs/Assumptions About ADHD

• Produced a pattern of treatment in which
  clinicians did not use medications
• OR
• Used low doses of medications
• (Only Monday through Friday)
• (Only during school hours)
• (Gave drug holidays)
• Stopped medications in adolescence

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Erroneous Beliefs vs Evidence
Erroneous Beliefs/Assumptions Are False
ADHD
Evidence Exists to Invalidate Them
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Evidence

• In the beginning, the diagnosis of ADHD was
  unclear due to
• Different names
• Inconsistent nature of impairments
• Feedback from 3rd parties (ie, children are poor
  historians)
• Media controversy
• Lack of validated diagnostic instruments
• But by 1998, the AMA called ADHD
• one of the best-researched disorders in
  medicine, and the overall data on its validity
  are far more compelling than for many medical
  conditions.

Goldman et al. JAMA 19982791100.
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Controlled Studies of Medication in ADHD
Stimulants
21
Antidepressants
12
155
3
Neuroleptics
Antihypertensives
Spencer et al. JAACAP 199635409.
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ADHD Diagnosis

• Based on coding systems
• DSM-IV and DSM-IV TR (www.behavenet.com/capsules/d
  isorders/adhd.htm)
• US
• 314.01 ADHD, Combined Type
• 314.00 ADHD, Predominantly Inattentive Type
• 314.01 ADHD, Predominantly Hyperactive-Impulsive
  Type
• ICD 10 (www.mentalhealth.com/icd/p22-ch01.html)
• EU/US
• F90 Hyperkinetic disorders
• F90.0 Disturbance of activity and attention
• F91.1 Hyperkinetic CD

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ADHD Core Symptom Areas
Inattention
Impulsivity/Hyperactivity
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ADHD DSM-IV Criteria
Inattention
Six or more of the following manifested often

• Inattention to detail/makes careless mistakes
• Difficulty sustaining attention
• Seems not to listen
• Fails to finish tasks

• Difficulty organizing
• Avoids tasks requiring sustained attention
• Loses things
• Easily distracted
• Forgetful

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ADHD DSM-IV Criteria
Impulsivity/Hyperactivity
Six or more of the following manifested often

• Impulsivity
• Blurts out answers before question is finished
• Difficulty in awaiting turn
• Interrupts or intrudes on others

• Difficulty organizing
• Fidgets
• Unable to stay seated
• Inappropriate running/climbing
• Difficulty in engaging in leisure activities
  quitely
• On the go
• Talks excessively

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ADHD DSM-IV Diagnostic Criteria

• Symptom criteria must be met for past 6 months
• Some symptoms must be present before 7 years of
  age
• Some impairment from symptoms must be present in
  2 or more settings
• Symptoms lead to significant impairment
• Social, academic, or occupational
• Symptoms are not exclusionary due to other mental
  disorders

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ADHD DSM-IV Subtypes

• ADHD predominately inattentive type
• Criteria met for inattention but not for
  impulsivity/hyperactivity
• ADHD predominately hyperactivity/impulsivity type
• Criteria met for impulsivity/hyperactivity
• but not for inattention
• ADHD combined type
• Criteria met for inattention and
  impulsivity/hyperactivity

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DSM IV Diagnosis Clinical Subtypes

• Predominately inattentive
• Easily distracted not excessively hyperactive or
  impulsive
• Combined type
• Predominent presentation exhibits all three
  classical signs
• Predominately hyperactive-impulsive
• Extremely hyperactive and impulsive not highly
  inattentive

Predominately inattentive
Combined type
Predominately hyperactive-impulsive
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ADHD ICD 10

• Stresses HK disorders over ADD
• Implies knowledge of psychological process and
  suggests anxious, preoccupied, or dreamy
  apathetic children
• Inattention central feature
• Cardinal features of DSM-IV
• Vague
• Diagnostic guidelines descriptive

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Impairment

• DSM-IV-TR ADHD symptoms must be consistently
  and persistently impairing in at least 2 areas of
  life functioning
• Much more than personality traits and quirks
• Must significantly impair major aspects of
  day-to-day life

Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Text Revision. 2000.
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Impairment in ADHD
Psychiatric comorbidity
School failure
Poor peer relationships
Legal difficulties
Smoking and substance abuse
Accidents and injuries
Family conflict
Parent stress
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ADHD Variations in symptoms
Pervasiveness
Frequency of Occurrence
Degree of impairment
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DSM-IV-Defined ADHD Population (Paediatric 3-19
yrs)
2000 2005 2010 2000-5 Growth (/Yr) 2005-10 Growth (/Yr)
United States 10,362,900 10,391,600 10,225,200 0.1 (0.3)
Europe 9,795,600 9,396,600 8,900,300 (0.8) (1.1)
France 2,185,100 2,133,200 2,082,000 (0.5) (0.5)
Germany 2,581,500 2,471,300 2,270,800 (0.9) (1.7)
Italy 1,637,200 1,565,200 1,480,300 (0.9) (1.1)
Spain 1,222,700 1,108,200 1,052,800 (1.9) (1.0)
United Kingdom 2,169,100 2,118,700 2,014,400 (0.5) (1.0)
Japan 3,432,000 3,265,600 3,233,300 (1.0) (0.2)
Major Market Total 23,590,500 23,053,800 22,358,800 (0.5) (0.6)
Source Decision Resources, Attention Deficit
Hyperactivity Disorder, December 2001
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ADHD World Wide Prevalence in School Aged
Children
Prevalence (per 1000)
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Diagnosis Treatment Rates of ADHD
Source Decision Resources, Attention Deficit
Hyperactivity Disorder, December 2001 Europe
D,F,I,UK,E
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ADHD Etiology

• ADHD is a heterogeneous behavioral disorder with
  multiple possible etiologies

Genetic origins
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Adult ADHDGenetic Basis
Twin Studies
Family Studies
Genetic Basis of ADHD
Molecular Genetics
Adoption Studies
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Heritability of ADHD
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ADHD Etiology

• ADHD is a heterogeneous behavioral disorder with
  multiple possible etiologies

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Pre- and Perinatal Risk Factors for ADHD
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Indicator of Adversity

• Low social class
• Maternal psychopathology
• Paternal criminality
• Family conflict
• Placement outside the home

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Risk for Childhood Mental Disturbance
10
9
8
7
6
Odds Ratio
5
4
3
2
1
0
2
4
1
Number of Indicators of Adversity
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Rutters Indicators of Adversity and Risk for ADHD
5
Gender, parental ADHD
Maternal smoking during pregnancy
4
3
Adjusted Odds Ratio
2
1
0
0
2
1
3
4
Number of Rutters Indicators
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ADHD Diagnostic Considerations
Inattention
Comorbidity
Impulsivity/Hyperactivity
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Risk Factors for ADHD
Boys
Girls
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ADHD Adult Common Comorbid Diagnosis
Male
Female
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Its a guy thing.
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Psychiatric Comorbidity
Anxiety (34)
MD (20 to 30)
7
7
23
4
CD (8 20)
Non-comorbid (55)
2
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ADHD Etiology

• ADHD is a heterogeneous behavioral disorder with
  multiple possible etiologies

Genetic origins
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Affected area of brain
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MRI in Adults with ADHD
MGH-NMR Center Harvard- MIT CITP
Bush G, et al. Biol Psychiatry.
199945(12)1542-1552.
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ADHD Neurochemistry

• ADHD best understood by the interaction of
  multiple neurotransmitters
• Neurotransmitters most critical in ADHD
• Norepinephrine (NE)
• Dopamine (DA)

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Neurotransmitters
Dopamine
Norepinephrine
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(No Transcript)
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Probable Mechanism of Action of
MethylphenidateWilens and Spencer. Handbook of
Substance Abuse Neurobehavioral Pharmacology.
1998501-513.
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The Mechanisms of Action of AmphetamineWilens
and Spencer. Handbook of Substance Abuse
Neurobehavioral Pharmacology. 1998501-513.
AMPH diffuses into vesicle causing DA release
into cytoplasm
AMPH blocks uptake into vesicle
AMPH is taken up into cell causing DA release
into synapse
AMPH Inhibits
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Dopamine Neurotransmission Relative to ADHD
Dopamine
Nigrostriatal Pathway

• Enhances signal
• Improves attention
• Focus
• On-task behavior
• On-task cognition

Mesolimbic Pathway
Substantia nigra
Mesocortical Pathway
Ventral tegmental area
Solanto. Stimulant Drugs and ADHD. Oxford 2001.
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Norepinephrine Neurotransmission Relative to ADHD
Norepinephrine

• Dampens noise
• Executive operations
• Increases inhibition

Solanto. Stimulant Drugs and ADHD. Oxford 2001.
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Catecholaminergic Neurotransmission Relative to
ADHD
Norepinephrine
Dopamine

• Prefrontal
• Dampens Noise
• Distractibility
• Shifting
• Executive operations
• Increases Inhibition
• Behavioral
• Cognitive
• Motoric

• Striatal - Prefrontal
• Enhances Signal
• Improves Attention
• Focus
• Vigilance
• Acquisition
• On-task behavior
• On-task cognitive
• Perception(?)

Solanto. Stimulant Drugs and ADHD. Oxford 2001.
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Questions