Attention Deficit Hyperactive Attention Deficit Hyperactive DisorderDisorder

Monica Arora M.D.Monica Arora M.D.

Attention Deficit Hyperactive Attention Deficit Hyperactive DisorderDisorder

ADHD is a neurobehavioral syndrome that is ADHD is a neurobehavioral syndrome that is characterized by developmentally inappropriate characterized by developmentally inappropriate degrees of inattentiveness, impulsivity and degrees of inattentiveness, impulsivity and hyperactivity. hyperactivity. 

History:History:

End of 19End of 19thth century and early 20 century and early 20thth century- century-morbid defect of moral control (Still 1902)morbid defect of moral control (Still 1902)

Post WW-I – organic nature of the ADHD was Post WW-I – organic nature of the ADHD was postulatedpostulated

Influenza epidemic Influenza epidemic encephalitis lethargica encephalitis lethargica survivor children survivor children exhibited similar symptoms as described by Still.exhibited similar symptoms as described by Still.

““Minimal Brain Syndrome” – 1950’s (Clements and Minimal Brain Syndrome” – 1950’s (Clements and Peter) Peter)

Damage to the central nervous system was considered to be minimal that Damage to the central nervous system was considered to be minimal that only manifestations were behavioral in nature.only manifestations were behavioral in nature.

History:History: Hyper kinetic syndrome of childhood”- DSM- II (APA Hyper kinetic syndrome of childhood”- DSM- II (APA 1968) 1968) “ “ Attention deficit disorder with or without Attention deficit disorder with or without hyperactivity”- hyperactivity”- DSM- III (APA 1980).DSM- III (APA 1980). “ “ Attention Deficit Hyperactive Disorder”- DSM-III-R Attention Deficit Hyperactive Disorder”- DSM-III-R

(1987).(1987).

8/14 symptoms required for diagnosis8/14 symptoms required for diagnosis. . “ “Attention Deficit Hyperactive Disorder”- DSM-IV Attention Deficit Hyperactive Disorder”- DSM-IV (1994)- inattentive, hyperactive- impulsive, (1994)- inattentive, hyperactive- impulsive, combined.combined.

EpidemiologyEpidemiology:: Prevalence - 5-7% (1.7-17.8%)Prevalence - 5-7% (1.7-17.8%) Gender difference- 2-3: 1 (community based samples)Gender difference- 2-3: 1 (community based samples) Most common in first-born males.Most common in first-born males. Manifest in children, usually by the age 3.Manifest in children, usually by the age 3. Most common diagnosis in children 4-11yrs of age.Most common diagnosis in children 4-11yrs of age. ADHD – related outpatient visits to primary care ADHD – related outpatient visits to primary care increased from 1.6 to 4.2 million per year during increased from 1.6 to 4.2 million per year during the years the years 1990-1993.1990-1993. There has been a five-fold increase in the number of There has been a five-fold increase in the number of adults diagnosed with ADHD in the past 5 years.adults diagnosed with ADHD in the past 5 years.

Etiology:Etiology:

1) Genetics:1) Genetics:

Twin studies:Twin studies:

Hereditability of 0.75 ,Concordance rate MZ >DZ.Hereditability of 0.75 ,Concordance rate MZ >DZ.

Family studiesFamily studies: 2-3 fold increase in 1: 2-3 fold increase in 1stst degree relatives. degree relatives.

ASPD, drug and alcohol abusing parents are significantly ASPD, drug and alcohol abusing parents are significantly higher in children with ADHD with or without higher in children with ADHD with or without conduct d/o.conduct d/o.

Molecular genetic studiesMolecular genetic studies: Implicate dopamine : Implicate dopamine transporters (DAT1) gene and the D4 receptor gene transporters (DAT1) gene and the D4 receptor gene (DRD4) in association with ADHD(DRD4) in association with ADHD

EtiologyEtiology::2) Neurochemical: Dysfunction of the adrenergic and 2) Neurochemical: Dysfunction of the adrenergic and

dopaminergic systems. dopaminergic systems.

3) Imaging: PET scan show3) Imaging: PET scan show

Decreased cerebral blood flow Decreased cerebral blood flow

Moderate reduction (~10%) in the size of Moderate reduction (~10%) in the size of the BG, corpus callosum and frontal the BG, corpus callosum and frontal

lobes.lobes.

4) Psychosocial:4) Psychosocial:

Stressful psychic events and emotional Stressful psychic events and emotional deprivation. deprivation.

DiagnosisDiagnosis::

Diagnosis is clinical, based upon detailed Diagnosis is clinical, based upon detailed developmental and symptomatic history.developmental and symptomatic history.Several informants are required.Several informants are required.

DSM IV CriteriaDSM IV Criteria 6 (or more)/9 of the symptoms of 6 (or more)/9 of the symptoms of inattentioninattention or or

hyperactivity-impulsivityhyperactivity-impulsivity have persisted for at least have persisted for at least 6 months to a degree that is maladaptive and 6 months to a degree that is maladaptive and inconsistent with developmental level.inconsistent with developmental level.

Present before age 7 years.Present before age 7 years. Impairment in two or more settingsImpairment in two or more settings SSignificant impairment in social, academic, or ignificant impairment in social, academic, or

occupational functioning.occupational functioning. Not better accounted for by another mental disorder. Not better accounted for by another mental disorder. 

  

DSM IV CriteriaDSM IV CriteriaInattentionInattention

(a) Often fail to give close attention to details or makes (a) Often fail to give close attention to details or makes careless mistakes in school work, work, or other careless mistakes in school work, work, or other activities.activities.

(b) Often has difficulty in sustaining attention in task or (b) Often has difficulty in sustaining attention in task or play activities.play activities.

(c) Often does not seem to listen when spoken to (c) Often does not seem to listen when spoken to directly.directly.

(d) Often does not follow through with instructions and (d) Often does not follow through with instructions and fails to finish schoolwork, chores or duties in the fails to finish schoolwork, chores or duties in the workplace.workplace.

DSM IV CriteriaDSM IV Criteria(e)  Often has difficulty organizing tasks and activities(e)  Often has difficulty organizing tasks and activities

(f)  Often avoids, dislikes or is reluctant to engage in (f)  Often avoids, dislikes or is reluctant to engage in tasks tasks that require sustained mental efforts that require sustained mental efforts

(schoolwork or homework)(schoolwork or homework)

(g) Often looses things necessary for task or activities (g) Often looses things necessary for task or activities (toys, (toys, books, pencils, school assignments or books, pencils, school assignments or tools)tools)

(h) Is often easily distracted by extraneous stimuli(h) Is often easily distracted by extraneous stimuli

(i)  Is often forgetful in daily activities(i)  Is often forgetful in daily activities

DSM IV CriteriaDSM IV CriteriaHyperactivity:Hyperactivity:

(a)  Often fidgets with hands or feet or squirms in seat(a)  Often fidgets with hands or feet or squirms in seat

(b)  Often leave seat in classroom (b)  Often leave seat in classroom

(c)   Often runs about or climbs excessively in situations (c)   Often runs about or climbs excessively in situations in which in which it is inappropriateit is inappropriate

(d)   Often has difficulty playing or engaging in leisure (d)   Often has difficulty playing or engaging in leisure activities quietlyactivities quietly

(e)   Is often “on the go” or often acts as if “driven by a (e)   Is often “on the go” or often acts as if “driven by a motor”.motor”.

(f)    Often talks excessively(f)    Often talks excessively

DSM IV CriteriaDSM IV CriteriaImpulsivity:Impulsivity:

(a)    Often blurts out answers before questions (a)    Often blurts out answers before questions have have been completedbeen completed

(b)   Often has difficulty awaiting turns(b)   Often has difficulty awaiting turns

(c)    Often interrupts or intrudes on others (e.g., (c)    Often interrupts or intrudes on others (e.g., butts butts into conversations or games)into conversations or games)

DSM IV CriteriaDSM IV CriteriaTYPES:TYPES: ADHD-combined type: if criteria A1 and A2 are ADHD-combined type: if criteria A1 and A2 are met met

for the past 6 monthsfor the past 6 months ADHD, predominantly inattentive type: if criteria A1 ADHD, predominantly inattentive type: if criteria A1

is met for the past 6 monthsis met for the past 6 months ADHD, predominantly hyperactive-impulsive type: ADHD, predominantly hyperactive-impulsive type:

if criteria A2 are met for the past 6 months.if criteria A2 are met for the past 6 months.

  

CharacteristicsCharacteristics

Context specific variability in symptom expression is Context specific variability in symptom expression is typical of the disorder.typical of the disorder. Symptoms are more likely to appear when Symptoms are more likely to appear when stimulus salience is low, as doing math stimulus salience is low, as doing math homework, than when stimulus salience is homework, than when stimulus salience is high, as high, as playing Nintendo.playing Nintendo. Children with symptoms most often show up in Children with symptoms most often show up in the situations that demand sustained attention, the situations that demand sustained attention, are repetitive, boring, and are hard.are repetitive, boring, and are hard.

CharacteristicsCharacteristicsChildren with ADHD symptoms do better in Children with ADHD symptoms do better in high high structured settings or with one to structured settings or with one to one one attention by an adult.attention by an adult.ll symptoms are normal to the certain extent at ll symptoms are normal to the certain extent at certain ages. - Avoid misdiagnosiscertain ages. - Avoid misdiagnosis High co morbidityHigh co morbidity

66% of elementary school aged children 66% of elementary school aged children have at least one co morbid psychiatric have at least one co morbid psychiatric diagnosis.diagnosis.

PreschoolPreschool Middle Middle ChildhoodChildhood

AdolescenceAdolescence AdultAdult

InattentiveInattentive

ExcitableExcitable

Unduly sensitive to Unduly sensitive to stimulistimuli

HyperactiveHyperactive

(Running all the time, (Running all the time, climbing on things)climbing on things)

FidgetyFidgety

Spills thingsSpills things

Insatiable curiosityInsatiable curiosity

Destructive playDestructive play

NoisyNoisy

InterruptsInterrupts

AggressiveAggressive

StubbornStubborn

Temper tantrumsTemper tantrums

AccidentsAccidents

DistractibleDistractible

Difficulty sitting still Difficulty sitting still in the chairin the chair

Poorly OrganizedPoorly Organized

Fails to completeFails to complete

Careless errorsCareless errors

Disruptive in classDisruptive in class

Bored all the timeBored all the time

Difficulty getting Difficulty getting alongalong

Interrupts or intrudesInterrupts or intrudes

Cannot wait turnsCannot wait turns

Engage in physicallyEngage in physically

dangerous activitiesdangerous activities

School School underachievementunderachievement

Unwilling or inability Unwilling or inability to complete house to complete house hold choreshold chores

Day dreamDay dream

Poorly OrganizedPoorly Organized

Sense of RestlessSense of Restless

Poor follow Poor follow throughthrough

Require directionsRequire directions

ForgetfulForgetful

Risky behaviorRisky behavior

Low self esteemLow self esteem

School School underachievementunderachievement

Poor peer Poor peer relationships.relationships.

  

Disorganization – Disorganization – failure to plan failure to plan aheadahead

Poor concentrationPoor concentration

Incomplete workIncomplete work

ForgetfulForgetful

ProcrastinatesProcrastinates

ImpulsiveImpulsive

Affective Affective dysregulationdysregulation

AnxiousAnxious

Substance abuseSubstance abuse

Antisocial Antisocial behaviorbehavior

Job instability and Job instability and marital conflictsmarital conflicts

Poor anger controlPoor anger control

PRESENTATION

Co-morbidityCo-morbidity::66% of elementary school aged children have at least 66% of elementary school aged children have at least one co morbid psychiatric diagnosis.one co morbid psychiatric diagnosis.ODD/ conduct d/o ~ 50%ODD/ conduct d/o ~ 50%Major depression ~ 9-38%Major depression ~ 9-38%Anxiety disorders ~ 25%Anxiety disorders ~ 25%Learning disorders ~ 20-30%Learning disorders ~ 20-30%Bipolar Disorder ~ 6%Bipolar Disorder ~ 6%Tourette Syndrome ~ 2%Tourette Syndrome ~ 2%

Course and PrognosisCourse and Prognosis::A. Persistence into Adolescence/ adulthood:A. Persistence into Adolescence/ adulthood:

80% will continue to exhibit symptoms in 80% will continue to exhibit symptoms in adolescence and young adulthood.adolescence and young adulthood.

50-60% display behavior problems and 50-60% display behavior problems and symptoms of the disorder well in to the adult symptoms of the disorder well in to the adult life.life.

B. Functional impairment across multiple settingsB. Functional impairment across multiple settings

Pattern of academic, familial and social Pattern of academic, familial and social dysfunction dysfunction

Course and Prognosis:Course and Prognosis:C. Adolescents – When untreated are more prone to be C. Adolescents – When untreated are more prone to be

Involved in auto accidents Involved in auto accidents

Be cited for traffic violationBe cited for traffic violation

Use illicit drugs (32% vs. 14%)Use illicit drugs (32% vs. 14%)

D. Adults with persistent symptoms often complete D. Adults with persistent symptoms often complete less formal education, lower status jobs, high less formal education, lower status jobs, high rates of ASPDrates of ASPD

Course and Prognosis:Course and Prognosis:With growing age, hyperactivity is replaced by With growing age, hyperactivity is replaced by restlessness, physical impulsivity often replaced by restlessness, physical impulsivity often replaced by verbal impulsivity. In contrast to hyperactivity, verbal impulsivity. In contrast to hyperactivity, symptoms of inattention often don’t diminish over time. symptoms of inattention often don’t diminish over time. Predictors for persistence into adolescence and Predictors for persistence into adolescence and adulthood includeadulthood include

1. Family history of ADHD1. Family history of ADHD

2. Psychosocial adversity2. Psychosocial adversity

3. Co morbid disorders like CD, ODD, 3. Co morbid disorders like CD, ODD, mood disorders and anxiety disorders.mood disorders and anxiety disorders.

Components of Components of diagnostic evaluationdiagnostic evaluation

Prior to office visitPrior to office visit, review information gathered from , review information gathered from the following:the following:

Parent rating scales sent to parent/guardiansParent rating scales sent to parent/guardians Teacher rating scales sent to school via Teacher rating scales sent to school via

parent/guardians (including instructions). Try to parent/guardians (including instructions). Try to obtain from at least two teachers.obtain from at least two teachers.

Report cards and report of standardized intelligence Report cards and report of standardized intelligence tests if availabletests if available

Previous medical and psychiatric history, reports of Previous medical and psychiatric history, reports of hearing and vision tests.hearing and vision tests.

Components of Components of diagnostic evaluationdiagnostic evaluation

During the office visit:During the office visit: Clinical interview Clinical interview Use of behavior rating scalesUse of behavior rating scales Physical examination- Height, weight, blood Physical examination- Height, weight, blood

pressure, Neurological examination, Vision and pressure, Neurological examination, Vision and hearing screenhearing screen

Additional assessment toolsAdditional assessment tools Psychological testsPsychological tests Neuropsychological testingNeuropsychological testing

Psychosocial treatmentPsychosocial treatment

Parent education and trainingParent education and training Social Skill therapySocial Skill therapy School InterventionsSchool Interventions

Classroom InterventionsClassroom Interventions

Daily Report CardsDaily Report Cards

Academic SkillsAcademic Skills

Pharmacological Pharmacological treatmenttreatment

StimulantsStimulantsMixed salt Amphetamine (Adderall, Adderall SR)Mixed salt Amphetamine (Adderall, Adderall SR)Dextroamphetamine (Dexedrine, Dexedrine Dextroamphetamine (Dexedrine, Dexedrine spansule)spansule)Methylphenidate (Ritalin, Ritalin SR, Concerta, Methylphenidate (Ritalin, Ritalin SR, Concerta, Metadate)Metadate)Methamphetamine (Desoxyn)Methamphetamine (Desoxyn)Pemoline (Cylert)Pemoline (Cylert)

Stimulants-Stimulants-Time Action Time Action ProfileProfile

Short acting stimulants (3-4 hrs)Short acting stimulants (3-4 hrs)

Methylphenidate- RitalinMethylphenidate- Ritalin

Dextroamphetamine- DexedrineDextroamphetamine- Dexedrine Mid range stimulants (5-7 hrs)Mid range stimulants (5-7 hrs)

Mixed salt amphetamine- AdderallMixed salt amphetamine- Adderall Longer acting stimulant (6-8 hrs)Longer acting stimulant (6-8 hrs)

Methylphenidate- Ritalin SR, MetadateMethylphenidate- Ritalin SR, Metadate

Dextroamphetamine- Dexedrine SRDextroamphetamine- Dexedrine SR Long acting stimulant (12 hrs)Long acting stimulant (12 hrs)

Methylphenidate- ConcertaMethylphenidate- Concerta

Non stimulantsNon stimulants

Antidepressants-Antidepressants-

Tricyclic antidepressantsTricyclic antidepressants

BupropionBupropion

VenlafaxineVenlafaxine Alpha 2 agonists-Alpha 2 agonists-

ClonidineClonidine

GuanfacineGuanfacine

AtomoxetineAtomoxetine

  

Resources:Resources:CHADDCHADD

Children and Adults with Attention Deficit Children and Adults with Attention Deficit DisorderDisorder

-http://www.chadd.org--http://www.chadd.org-

National ADDANational ADDA

National Attention Deficit Disorder OrganizationNational Attention Deficit Disorder Organization

-http://add.com--http://add.com-

Learning Disability Disorder of AmericaLearning Disability Disorder of America

-http://idanatl.org--http://idanatl.org-