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Attention Deficit Hyperactivity Disorder James H. Johnson, Ph.D., ABPP University of Florida ADHD: Nature of the Problem ADHD is a neurodevelopmental disorder of childhood Characterized by developmentally inappropriate levels of: – Hyperactivity, – Impulsivity, – Inattention. ADHD: How Common is it? Prevalence is estimated at 3 to 9 per cent of the elementary school population. ADHD occurs more often in males than females, with the sex ratio being about 4 to 1. One of the most common disorders of childhood Accounts for a large number of referrals to pediatricians, family physicians and child mental health professionals. ADHD: Not a New Problem Characteristics of this disorder have been recognized for at least a century Still (1902): ADHD Case study Fidgety Phil (http://www.fln.vcu.edu/struwwel/philipp_e.html Has been referred to by a variety of labels; – – – – Minimal Brain Dysfunction (MBD) Hyperkinetic Reaction of Childhood Attention Deficit Disorder (ADD) Attention Deficit Hyperactivity Disorder (ADHD) Some Highlights in the Evolution of the Disorder Encephalitis epidemic of 1917 - 1918 Frontal lobe ablation studies with primates (1930’s) Strauss’ work on Minimal Brain Dysfunction (1940's -1950's) Beginnings of child psychopharmacology; Using Amphetamines for treatment – 1930-1940. MBD becomes Hyperkinetic Disorder (the 1960’s) Evolution of the Disorder (cont.) The focus on attention – The 1970’s Focus on the Feingold diet Studies of psychophysiological responsivity Development of objective diagnostic criteria: DSM III- and ADD (the early 1980’s) The 1990’s - Present: – – – – Imaging, Genetics, DSM IV Focus on Evidence Based Methods. ADHD: Core Features As noted earlier, ADHD is a disorder characterized by developmentally inappropriate levels of : Symptoms of Hyperactivity DSM IV Symptoms of Hyperactivity/Impulsivity Fidgets with hands or feet, squirms in seat. Leaves seat in classroom or in other situations in which remaining seated is expected Runs about or climbs excessively in situations where not appropriate. More Symptoms of Hyperactive Has difficulty playing or engaging in leisure activities quietly. Often "on the go" or often acts as if "driven by a motor“. Talks excessively when inappropriate to the situation Symptoms of Impulsivity Symptoms of Impulsivity Blurts out answers before questions have been completed. Has difficulty awaiting turn. Interrupts or intrudes on others. Six symptoms of hyperactivity and impulsivity (combined) are required for diagnosis. What do we Know about Hyperactivity? Children with ADHD are more active, restless, and fidgety than normal children during the day and during sleep. Different types of hyperactivity. – Gross Motor Activity – Restless/Squirmy – Occasionally see verbal hyperactivity Hyperactivity often varies according to situation Level of stimulation Symptoms of Inattention Symptoms of Inattention Fails to give close attention to details or makes careless mistakes. Has difficulties sustaining attention in tasks or play activities. Does not seem to listen when spoken to directly. Does not follow through on instructions and fails to finish homework, chores, or duties in the workplace More Symptoms of Inattention Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort. Loses things necessary for tasks or activities Easily distracted by extraneous stimuli. Forgetful in daily activities (Six or more symptoms of inattention necessary for diagnosis) What Do We Know About ADHD Attention Problems? ADHD "attention" problems may be most obvious on specific types of tasks. Children with ADHD have their greatest difficulties with sustaining their attention in responding to tasks - in being vigilant. Problems are usually seen in situations requiring the child to attend over time to rather dull, boring, and repetitive tasks. Situational Variations in Symptoms Symptoms can show significant variation across situations. Children do not display symptoms in all situations The absence of symptoms in some situations (e.g. video games) does not mean that the child does not have ADHD. Situations That Increase ADHD Symptoms The greater the demands of the situation, the more problematic the behavior will likely become. An exception might be in situations where the child is being continuously rewarded for complying with demands. In familiar situations where novelty and task stimulation are low. When Fatigued – Studies, monitoring 24 hour activity levels have suggested that the hours of 1 – 5 seem to be peak times for increased activity in children with ADHD. Overview of Diagnostic Criteria Symptom Criteria - Core Symptoms of Hyperactivity & Impulsivity and/or Inattention (Six or More Symptoms of either category). Duration Criterion - Symptoms have Persisted for at Least 6 Months. Developmental Criterion - Symptoms are Inconsistent with Developmental Level (MR). Impairment Criterion - Clear Evidence of Clinically Significant Impairment in Social, Academic, or Occupational Functioning Overview of Criteria (cont.) Age Criterion - Some Symptoms that Cause Impairment Were Present Before Age 7. Situation Criterion - Some Impairment from Symptoms is Present in Two or More Settings. NOTE. The failure to attend to full range of symptoms is not uncommon Presence of hyperactivity, impulsivity, and inattentive symptoms is not necessarily to be equated with ADHD. Types of ADHD Combined Type – Symptoms of hyperactivity, impulsivity and inattention. Hyperactive/Impulsive (Does it really exist?) – Symptoms of hyperactivity and impulsivity. Predominately Inattentive – Symptoms of inattention. ADHD Mimicry Sensory Impairments Medication side effects – Phenobarbital – Dilantin – Some Asthma Medications Seizure Disorder RTH (Resistance to Thyroid Hormone) PTSD Bipolar Disorder Anxiety Disorders Depressive Disorders Auditory Processing Disorder Why is Mimicry of Clinical Significance??? Comorbid Conditions What are comorbid conditions? Controversy over use of the term. Why is it essential to consider the possibility of comorbid conditions in assessing children with ADHD? Importance of distinguishing between comorbid conditions and mimicry. What is the frequency of comorbidities in children with ADHD? Comorbid Conditions Learning Disabilities ~ 19 to 26% Oppositional Defiant Disorder ~ 40% Conduct Disorder ~ 25% children; ~ 45-50% Adolescents. Anxiety Disorders ~ 30% Depressive Disorder ~ 10 - 30% Bipolar Disorder – up to 20%. Tics and Tourette’s Disorder ~ 7% of children with ADHD have a tic disorder. ~ 40 to 50% of those with Tourette’s disorder have ADHD Developmental Issues There are factors in infancy (e.g., difficult temperament) that seem to be precursors of ADHD. Initial development of ADHD is most often during the preschool years. While there is often a decline in the level of hyperactivity and perhaps some improvement in attention and impulse control in adolescence, as many as 70 % continue to be impaired by their symptoms and meet criteria for some type of ADHD. A significant number of children with ADHD (probably over 50%) continue to display problems into the adult years. Prognosis of ADHD Outcome of ADHD in adolescents is highlighted by the results of a study by Barkley, Fischer, et al, (1990). Study followed a large sample of children with ADHD (158) and normal children (81) prospectively for 8 years after diagnosis. 123 hyperactive children and 66 normals were located, interviewed and complete questionnaires. In the hyperactive group 12 (9.7%) were female and 111 were male. In the normal group 4 of the subjects were female and 62 were male. Prognosis In Adolescence The majority of the hyperactive subjects (71.5%) met DSM III-R criteria for ADHD at follow up [Biederman (2000) found ~ 70%]. – Note DSM III – R criteria change More than 59% met criteria for Oppositional Defiant Disorder as compared to 11% of the controls. Approximately 43 % of the hyperactive group could be diagnosed as CD as compared to 1.6% of the control group. What About Driving ? Hyperactive subjects were more likely to have had an auto accident, to have had more automobile accidents, to have had more bodily injuries in accidents, and to be at fault for accidents more often than did controls. Adolescents in the hyperactive group were also more likely to have received traffic citations, especially for speeding How About Substance Use ? Cigarette and alcohol use were the only categories of substance use that differentiated those with hyperactivity from normals. When the the hyperactive sample was separated into groups (purely ADHD and ADHD + CD) purely ADHD subjects showed no greater use of cigarettes, alcohol, or marijuana than did normal controls. Mixed hyperactive/Conduct disordered children displayed two to five times the rate of substance use as did pure hyperactives or normals. What About School Performance? Three times as many hyperactives had failed a grade (29.3% versus 10%), had been suspended (46.3% versus 15.2%) or had been expelled (10.6% versus 1.5%). Results indicated that hyperactivity alone increases the risk of suspension (30.6% vs 15.2%), and dropping out (4.8% vs 0% ) as compared to controls However, the added diagnosis of CD greatly increases the risk (67% suspended, 13% dropped out). The presence of CD accounted almost entirely for the > risk of expulsion within the hyperactive group Prognosis In Adulthood Studies have suggested that anywhere between 4 and 60 % of children diagnosed with ADHD will display symptoms in adulthood serious enough to interfere with academic, vocational or social functioning. Variability in results likely relates to different criteria used for diagnosis of ADHD in adults. There are indications that the type of ADHD that persists into adulthood is more highly genetic than the type that remits in childhood. ADHD in adults is sometimes considered a “hidden disorder” as symptoms are often obscured by other problems. Prevalence is thought to be 2 – 4% with sex ratio of 2 – 1 or lower). Etiology Etiology:ADHD Risk Factors Maternal cigarette use Maternal alcohol use Maternal drug use A variety of factors that can be related to fetal distress – – – – – Unusually long or short labor Forceps delivery Toxemia Meconium staining Nuchal cord Birth during the month of September. Minor physical anomalies Etiology - Genetics Between 10 and 35 per-cent of the immediate family members of children with ADHD also display this disorder. Risk for siblings of children with ADHD is approximately 32% If a parent has ADHD the risk to offspring is on the order of 50+% Twin studies suggest concordance rates for monozygotic twins is around 80% with concordance rates of 30% for dz twins. Etiology - Genetics Overall, twin studies suggest an average heritability of .80 Work in the area of molecular genetics has also identified specific genes related to ADHD. Molecular genetics has begun to identify specific genes related to ADHD These genes have to do with the transport of and post-synaptic sensitivity to the neurotransmitter dopamine in the frontal lobes. Hereditary is one of the most well supported etiological factors in the development of ADHD Etiology – Neurological Insult Multiple factors that can result in brain damage are associated with ADHD. For example, anoxia, is associated with increased frequencies of hyperactivity and attention problems. ADHD occurs more often in children with seizure disorders, who are presumed to have neurological involvement As noted earlier, diseases like encephalitis can also result in symptoms of ADHD, as can various types of infections and injuries. Etiology: Brain Damage These findings suggest that neurological insult can result in an increased probability of developing ADHD. However, most children with ADHD do not have a significant history of brain injury. Such injuries are unlikely to account for ADHD in the vast majority of children. In fact probably 95% of hyperactive children show no evidence of documentable neurological impairment. This does not mean, however, that neurodevelopmental factors are not involved. Neuropsychological Test Findings: Executive functioning deficits Results from research involving neuropsychological testing has often suggested that children with ADHD have problems; – – – – – – – – in inhibiting behavioral responses, in initiating behavior in shifting from one activity to another with working memory, with planning and organization, with perseveration, in motor sequencing, with other frontal lobe functions. Executive Functioning Deficits Not only do children with ADHD show executive functioning deficits but siblings of ADHD children who do not have ADHD, have been shown to display milder yet significant impairments of the same type. This suggests a possible genetic risk for executive function deficits in families. Studies of Brain Function Studies of cerebral blood flow in ADHD and normal children have consistently shown decreased blood flow to the prefrontal regions and pathways connecting these regions to the limbic system via the striatum Studies using PET scans to assess cerebral glucose metabolism in the frontal regions have found diminished metabolism in, adults and adolescent females with ADHD (e.g. decreased activity). Cerebral Blood Flow (cont) A significant correlation between diminished metabolic activity in the left anterior frontal region and severity of symptoms in adolescents with ADHD has also been demonstrated. This demonstration of a relationship between decreased metabolic activity and the symptom severity is crucial to specifically documenting the importance of the link between lower levels of brain activation and ADHD-related behavior. Frontal Lobes Basal Ganglia MRI Studies Some, but not all studies have found the Corpus Callosum, to be smaller in children with ADHD. Other MRI studies have found children with ADHD to have a smaller left caudate nucleus. These findings are interesting in light of the results of prior blood flow studies suggesting lower levels of activation in this area in children with ADHD. MRI Continued Several more recent MRI studies, with larger samples, have suggested that children with ADHD have significantly smaller anterior right frontal regions, a smaller caudate nucleus, and smaller globus pallidus regions than normals. Research has also found decreased cerebellar volume in children with ADHD. Work in this area suggests that abnormalities in the development of the frontal-striatal regions may well underlie the development of ADHD. Neurotransmitter Deficiencies The possibility of a neurotransmitter dysfunction in children with ADHD has been suggested for many years. This notion seemed to originate from the fact that children with ADHD respond to different types of stimulant drugs. The fact that stimulant drugs have an impact on ADHD and that they increase dopamine has contributed to the neurotransmitter dysfunction hypothesis. Other neurotransmitters are also likely to be involved Neurotransmitter Deficiencies There is more direct evidence of neurotransmitter deficiencies from some studies of cerebral spinal fluid in children with and without ADHD, which suggests decreased dopamine levels in children with ADHD There is also some evidence of a deficiency in the availability of norepinephrine in children with ADHD. This is of interest given that a relatively new non-stimulant ADHD medication, Straterra, is thought to act on norepinephrine levels. Etiology: Psychosocial Factors There is little evidence for the role of psychosocial factors in the development of ADHD, although factors such as parent-child conflict may exacerbate problems in a child with ADHD. Psychosocial factors may also contribute significantly to the development of certain comorbid disorders that may complicate the clinical picture. Etiology: Overview In reviewing the literature on the etiology of ADHD, Barkley suggests … – “It should be evident from the research…that neurological and genetic factors make a substantial contribution to symptoms of ADHD and the occurrence of this disorder. – A variety of genetic and neurological etiologies (e.g., pregnancy and birth complications, acquired brain damage, toxins, infections, and genetic effects) can give rise to the disorder through some disturbance in a final common pathway in the nervous system. Overview Continued That final common pathway appears to be the integrity of the prefrontal cortical-striatal network. It now appears that hereditary factors play the largest role in the occurrence of ADHD symptoms in children. It may be that what is transmitted genetically is a tendency toward a smaller and less active prefrontal-striatal network. Overview Continued The condition can also be caused or exacerbated by pregnancy complications, exposure to toxins, or neurological disease Cases of ADHD can arise without genetic predisposition if the child is exposed to a significant disruption or neurological injury to this final common neurological pathway. This would seem to account for only a small minority of ADHD children. “ Why Should We Treat ADHD ? Treatment of ADHD Stimulant Medications Other Medications Psychosocial Treatments Educational Accommodations Commonly Used Stimulant Medications Ritalin Dexadrine Adderall Concerta Between 70 and 80 % of children with ADHD respond positively to stimulant drugs. Stimulant drugs represent an empirically supported treatment for core symptoms of ADHD. Approved Medication For ADHD Side Effects of Stimulants Common side effects can include: loss of appetite, weight loss, sleeping problems, irritability, restlessness, stomachache, headache, rapid heart rate, elevated blood pressure, sudden deterioration of behavior symptoms of depression with sadness, crying, and withdrawn behavior. intensification of tics (muscle twitches of the face and other parts of the body), possible Tourette’s and growth suppression. Side Effects (Cont.) While side effects are always a possibility they are often – Transient in nature – The result of inappropriate medication levels If one medication results in side effects, another might be used without side effects. Sometimes other medications are used to minimize side effects. Good clinical judgment by the clinician may help to minimize side effects. Some Examples of NonStimulant Drugs in ADHD Treatment Non Stimulant ADHD Medication – Straterra - a norepinephrine reuptake inhibitor- selectively blocks the reuptake of norepinephrine, which increases its availability Other Non Stimulant Drugs – Anti-depressants (e.g., Tofranil, Wellbutrin) – Anti-hypertensives (Clonidine) Psychosocial Treatments Parent Training Social Skills Training Cognitive Behavioral Treatments. Psychotherapy for comorbid conditions Educational Interventions Special Education Services for existing learning problems. Classroom accommodations. Classroom behavior modification programs. Treatment: Concluding Comments In treating ADHD it is essential to treat the full range of difficulties that impact on child and family functioning. Treatment of ADDH will often need to be “multimodal” in nature. Findings from the Multimodal Treatment Study suggest that; – Stimulant medication is effective in reducing core symptoms – Psychosocial treatments are of value in addressing associated comorbidities. That’s All Folks!