Research Report

Defects in moral control, independent of intellectual development Inadequacy of self-control despite seemingly adequate child-rearing or environmental stimulation Deficiencies in attention, moral consciousness, responsiveness to discipline, emotional maturity, and social conduct (e.g., lying and stealing) Increased minor physical anomalies Greater proportion of males Hereditary predisposition Still, 1902

ADHD: Prevalence and Demographics

Affects school-aged children

Overall prevalence 3% to 5% Diagnosed in boys 3 to 4 times more than in girls Unclear if prevalence is similar in other cultures

Accounts for 30% to 50% of mental health referrals for children Prevalence increases as SES level declines Resulted in ~8.6 million physician-office visits in 1999 Persists in some patients into adolescence and adulthood (symptom profile may change)

ADHD: Diagnosis

Diagnostic assessment typically prompted by academic and/or behavioral problems Diagnosis requires meeting DSM-IV criteria Clinical diagnosis requires input from parents, teachers, practitioners Specific physical tests not available Medical and neurological status evaluated

ADHD: DSM-IV Symptoms

Six of more of the following
Inattention

Careless Difficulty sustaining attention in activity Doesnt listen No follow through Cant organize

Avoids/dislikes tasks requiring sustained mental effort Loses important items Easily distracted

Forgetful in daily activities

ADHD: DSM-IV Symptoms

Six or more of the following
Hyperactivity

Impulsivity

Squirms and fidgets Cant stay seated

Blurts out answers Cant wait turn

Runs/climbs excessively
Cant play/work quietly On the go/ Driven by a motor Talks excessively

Intrudes/interrupts others

ADHD: Symptoms and Diagnosis

Symptomsinattention and/or hyperactivityimpulsivity

Present before age 7 years Maladaptive and inconsistent with developmental level Persistent (>6 months) Impairment is present in two or more settings Symptoms not due to other psychiatric/developmental disorders

DiagnosisDSM-IV types
Predominantly inattentive Predominantly hyperactive-impulsive Combined Type

ADHD: Social and Academic Impact

Symptoms of ADHD interfere with childs functioning at home, at school, with peers, which may include
Stress on family
Poor school performance Classroom disruptions

Poor peer interactions

Embarrassment of taking medication at school

ADHD: Potential Consequences

As reported in 1998 NIH Consensus Statement, ADHD has been associated with
Injuries, drug abuse, antisocial behavior when in

combination with conduct disorders Increased parental frustration, marital discord, as reported with other chronic disorders Serious burden of medical costs for families not covered by health insurance Disproportional share of resources and attention from health care system, schools, and other social service agencies

ADULT ADHD
Utah Criteria
A.

Childhood history of ADHD*

1. 2. 3. 4. 5. 6.

Fidgety, restless, always on the go, talked excessively Attention deficit Behavioral problem in school Impulsivity Overexcitability Temper outbursts

*Must have first two characteristics and at least two of the remaining characteristics

ADULT ADHD
Utah Criteria Contd
B.

Presence of ADHD in Adulthood*

1. 2. 3. 4. 5. 6. 7.

Persistent motor hyperactivity Attention deficits Affective lability Inability to complete tasks Poorly controlled temper, explosive, short-lived outbursts Impulsive behavior (distinct from manic episode) Stress intolerance

*Must have first two characteristics and at least two of the remaining characteristics

MANIFESTATIONS OF ADULT ADHD

Impaired social skills Low self-esteem Frequent loss of temper More driving accidents Difficulty organizing/finishing tasks Anxious restlessness Frequent job failures Increased risk for antisocial behavior, mood disorders, substance abuse

ADHD: Differential Diagnosis

A.

Psychiatric
1. Learning disabilities 2. Conduct disorder 3. Affective disorder, depression, bipolar
4. 5. 6. 7.

disorder, mania Pervasive development disorder (e.g., autism) Childhood schizophrenia Anxiety disorders (separation anxiety, school phobia) Mental retardation

ADHD: Differential Diagnosis

B.

Medical 1. Use of phenobarbital as an anticonvulsant 2. Theophylline (used in asthmatics) 3. Substance abuse (amphetamines) 4. Hyperthyroidism 5. Tourettes syndrome

ADHD: Genetic Factors

A.

Family aggregation studies

1. First-degree relatives 2. Second-degree relatives

B.

C.
D.

Adoption Studies Twin Studies Other Genetic Hypotheses

1. Tourettes syndrome (50% of affected

individuals have elements of ADHD) 2. Mutation giving rise to generalized resistance to thyroid hormone

ADHD: Neuroanatomical Substrates

A.

Frontal Lobe Hypothesis

B.

Non-Dominant Frontal-Striatal Dysfunction

Corpus Callosum - ? Decreased Splenial Area

C.

ADHD: Suggested Pathophysiology

Neurochemical pathways
Dopaminergic and noradrenergic implicated

Structural and functional differences from nonADHD controls

PET and MRI

Scans of ADHD patients show reduced glucose metabolism in premotor cortex and superior prefrontal cortex compared to controls Genetic forms of ADHD are associated with abnormalities at the dopamine reuptake transporter gene and the D4 receptor gene

Dopamine transmission

ADHD: Total Treatment Program

Total Treatment Program:

Recommended for maximum benefit

Pharmacological Treatment:
Targets underlying neurochemical causes Enhances behavior management efforts

Behavior Management:
Includes strategies and methods for home and classroom environments

ADHD: Treatment Approaches

Pharmacological Intervention Parent Training Modification of Classroom Environment

Formal classification (IDEA) 504 Accommodations

Self-Control Training with Child Individual or Group Counseling Residential Treatment

ADHD: Unproven Therapies

Removal of food additives, dyes, and flavors Removal of sugar or caffeine from diet Vitamin therapy Sensory-Integration training Avoidance of fluorescent lighting Relaxation training/biofeedback Play therapy

ADHD: Stimulant Treatment

CNS stimulants highly effective

Reduce core symptoms of inattention, hyperactivity,

and impulsivity in 75% to 90% of children with ADHD

Pharmacological treatment usually involves

Methylphenidate products Dextro-amphetamine/amphetamine products

Common side effects

Insomnia, decreased appetites, dysphoric mood Irritability, reduced motor activity Headaches, G-I complaints Tics Decreased frequency of social interactions

ADHD: Methylphenidate Treatment

Methylphenidate
Commonly prescribed medication Formulations currently available Immediate-release Sustained-release Extended-release preparations
Taken only in the morning Typically last between 6-12 hours depending upon dose

ADHD: Non-Stimulant Treatment

Antidepressant Medications Tricyclic Antidepressants Used primarily for ADHD-Inattentive Type Studies have shown superior to placebo but less

effective than stimulant medications Side effects: sedation, constipation, anoxeria, dry mouth, dizziness, increased pulse and BP (case reports of sudden cardiac death)

SSRIs
Controlled studies to date not impressive (unless comorbid depression is present) Some agents (e.g., fluoxetine) can increase hyperactive and or impulsive behavior

ADHD: Non-Stimulant Treatment

Antidepressant Medications Others Buproprion has amphetamine-like effect,
useful in adult ADHD, pervasive developmental disorder

ADHD: Non-Stimulant Treatment

Alpha-2 Agonists Clonidine

Unclear if more effective in patients with greater impulsivity and behavioral dyscontrol (controlled trials equivocal) Commonly used to treat TS + ADHD Less effective than MPH in controlling inattention, distractibility Effect on cognitive and academic performance not established Side effects: sedation, motor retardation, dry mouth, dizziness Often used in combination with MPH

Guanfacine
Similar in action to clonidine but less sedating Controlled trials in ADHD equivocal; proven to useful in treating TS + ADHD

ADHD: Non-Stimulant Treatment

Norepinephrine Reuptake Inhibitors Atomoxetine hydrochoride (approved 12/02)
Selective NE reuptake inhibitor
thought to be related to selective inhibition of the presynaptic norepinephrine transporter

Can be dosed once or twice per day Generally well-tolerated

upset stomach, decreased appetite, nausea and
vomiting, dizziness, tiredness, and mood swings

Cannot be taken with MAOIs, certain SSRIs