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Attention Deficit/Hyperactivity Disorder Christopher Lever, MD, FRCP(C) Objectives. Define attention disorders. Appreciate how to “diagnose” an attention disorder. Be aware of the medical problems that may mimic primary attention disorders. List some of the other “co-existing” diagnoses with attention disorders. Have some awareness of the treatment options for children with attention disorders. Discuss when referral for an attention difficulty is appropriate. Case 1 A 7-year-old boy in grade II presents with academic and behavior problems. He was asked to leave two day homes because he harmed other children. His parents struggle with getting him ready in the morning and for bedtime. He behaves better when he’s outside playing, but is known to get overexcited. Parenting classes have been helpful, but both parents feel somewhat stressed looking after him when his two siblings are around. He is thoughtful, curious, and enjoyable when he is alone with one of his parents. Teachers are concerned because his literacy skills are delayed more than one year, and he is frequently removed from the classroom for disrupting the work of others. Case 2 A 14-year-old girl with a known learning disability [literacy skills delayed] presents because she is irritable with her parents and they feel she is depressed. Her learning disability was diagnosed in grade 3. She received special assistance for literacy skills. She did improve, but several teachers suggested she could do better. She remains in a modified educational program that is now failing all of her academic subjects. She is frequently known to be doodling during class time and does not hand in most of her assignments. Her parents find her irritable and reclusive. She is not managing regular chores at home. She has spent more time involved in electronic chat and listening to music. She is smoking marijuana three to five times per week. Case 3 A 9-year-old boy diagnosed with AD\HD; combined type at BC Children’s Hospital at five years old presents for renewal of stimulant medication. Medications include Ritalin SR 20 mg once in the morning, and melatonin 3-6 mg in the evening. Improved attention and decreased hyperactivity is noted two hours after administration and lasts for a total of 5 hours. Hyperactivity is increased around transition in spite of regular medication administration. Growth is good, sleep is better with melatonin. His blood pressure is normal. He is zinc deficient and has asthma. He also wears glasses. It’s about perspective. Who in this room thinks they have attention problems? Who feels restless? Who has had a speeding ticket? Who has ever missed a spelling error in the final draft of a document? Who has ever bought something on sale that they’ve only used once? (not a condom or a coffin) Who has ever asked for instructions to be repeated because they “missed a step”? SPECTRUMS . Attention disorders represent a grouping of children with similar traits. Most do not have a hard pathologic diagnosis. It is simply a pattern of similar clinical characteristics that are maladaptive for the child’s current setting and expectations. A brief controversy. Attention difficulties are described between 4-8% of North American children, but much less in most other parts of the world. It depends who you ask. There is inherent bias in any behavioral symptom. It depends on context for that child. If the world were about better soccer players, the story writers would be doing remedial throw-ins at recess. The pharmaceutical industry and medical education has directly created more public awareness. Attention and impulse/movement regulation are only part of the whole person. A disorder exclusive to inattention, hyperactivity, or impulsivity is naïve. What is ADHD? Cultural. “What’s my age again?” Pathological. Well, it is getting less clear. It is mostly about frontal cortex dopamine. Functional MRI data are accumulating, but the results are not easy to summarize. There are likely multiple reasons for ADHD phenotype. Academic. But 65 % in math is a definite pass. Dotted line – dopamine, dashed line - norepinephrine Stimulants’ Proposed Mechanism of Action = NT = neurotransmitter; dopamine or norepinephrine AMPH = amphetamine MPH = methylphenidate Presynaptic Neuron AMPH Storage Vesicle Neurotransmitter Output Neurotransmitter Transporter NT Transporter (reuptake pump) MPH & AMPH Postsynaptic Neuron Adapted from Wilens & Spencer. Child Adolesc Psych Clin N Am 2000;9:573. DSM-IV-TR A Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: Inattention Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. Often has trouble keeping attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). Often has trouble organizing activities. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). Is often easily distracted. Is often forgetful in daily activities. DSM-IV-TR B Six or more of the following symptoms of hyperactivityimpulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level: Hyperactivity Often fidgets with hands or feet or squirms in seat. Often gets up from seat when remaining in seat is expected. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). Often has trouble playing or enjoying leisure activities quietly. Is often "on the go" or often acts as if "driven by a motor". Often talks excessively. Impulsivity Often blurts out answers before questions have been finished. Often has trouble waiting one's turn. Often interrupts or intrudes on others (e.g., butts into conversations or games). DSM-IV-TR Some symptoms that cause impairment were present before age 7 years. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). There must be clear evidence of significant impairment in social, school, or work functioning. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Based on these criteria, three types of ADHD are identified: ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months. DSM-V revisions. No exclusion for ASD. Other mental health disorders can exist, but ADHD symptoms must not be primarily seen during mental health exacerbations or intoxication or withdrawal. First symptoms before age 12 (not 7) years. Five of nine criteria can diagnose anyone over 17 years of age. http://www.dsm5.org/Documents/ADHD% 20Fact%20Sheet.pdf Information gathering. From parent, both if possible. From teachers. From anybody else who spends time directly observing this child and has expectations of the child. From a trained school observation. The most widely used ADHD screening and treatment monitoring tools are now available online! SELECT A RATING SCALE TO COMPLETE PARENT REPORT TEACHER REPORT YOUTH SELF-REPORT ADULT SELF-REPORT FRANÇAIS ABOUT CLINICIANS PRIVACY SECURITY CONTACT US Online adaptation of the SNAP-IV Online Rating Scale developed by Dr. Don Duncan, MD FRCP(C). SNAP-IV Teacher and Parent Rating Scale originally developed by James M. Swanson, PhD., University of California Irvine. ASRS-v1.1 developed by Leonard Adler, MD, Ronald C. Kessler, PhD, and Thomas Spencer, MD in conjunction with the World Health Organization. Is it a disorder? Academic failure. Social failure. Family disharmony. Emerging negative self-concept. A Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: B Six or more of the following symptoms of hyperactivityimpulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level: Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). There must be clear evidence of significant impairment in social, school, or work functioning. Why bother with this diagnosis? Understand origin of current difficulty. Educate parents and teachers about the nature of attention difficulties. Offer medically proven therapies to improve attention disorder symptoms. Discuss the natural history of attention disorders. Medical differential diagnosis. Serious chronic symptomatic medical health issue. Obstructive sleep apnea. Absence epilepsy. Thyroid disease. Rarely iron and zinc deficiency. Serious head injury. Sensory impairment. Association with preterm delivery. Psychologic concomitant diagnoses. Cognitive impairment. Unique learning profile, “learning disability”. Autistic spectrum disorder. Opposition defiant disorder. Conduct disorder. Obsessive-compulsive disorder. Primary anxiety. Substance abuse. Major depression. Comorbidity of Adult ADHD with Other DSM-IV Disorders in the National Comorbidity Survey Replication (n=154) Comorbid Disorder During Previous 12 Months Major Depressive Disorder Dysthymia Bipolar Disorder Generalized Anxiety Disorder PTSD Agoraphobia Social phobia Alcohol abuse Alcohol dependence Drug dependence Any substance use disorder Intermittent explosive disorder Among Respondents With ADHD 18.6% 12.8% 19.4% 8% 11.9% 8.9% 29.3% 5.9% 5.8% 4.4% 15.2% 19.6% Kessler, Adler, Barkley, Biederman, Conners, Demler, Faraone, Greenhill, Howes, Secnik, Spencer, Ustun, Walters, Zaslavsky – The American Journal of Psychiatry, April 2006, pgs. 716-723 National Comorbidity Survey Replication: Mood Disorders in Adult ADHD N=3199 Adult ADHD Major Depression 18.6% Kessler RC et al. Am J Psychiatry. 2006;163:716-723. Dysthymi a 12.8% Bipolar Disorder 19.4% Any Mood Disorder 38.3% 29 National Comorbidity Survey Replication: Anxiety Disorders in Adult ADHD N=3199 Adult ADHD Generalize d Anxiety Disorder 8% Panic Disorder 8.9% Obsessivecompulsive Disorder 2.7% PTSD 11.9% Any Anxiety Disorder 47% Kessler RC et al. Am J Psychiatry. 2006;163:716-723. Social Phobia 29.3% Agoraphobi a 4% Stress and attention skill. Child abuse. Witnessing violent acts. Medically ill or dying caregiver. [Poor role modeling]- the genetics of ADHD. Chaos – variable and multiple caregivers, foster care, and transiency. Treatment. Education. Balanced diet. Good sleep hygiene. Regular physical activity. [decreased video game playing] Specific behavioral strategies. Medication. Psychostimulant medication. Methylphenidate. Ritalin, Ritalin SR, Concerta, Biphentin. Dextro-amphetamine. Dexedrine (tablet and Spansule). Mixed amphetamine salts. Adderall XR. Lisdexamfetamine- L-lysinedextroamphetamine dimesylate. Vyvanse. Non-stimulant medication. Atomoxetine. (Strattera) Tricyclic antidepressants. Alpha adrenergic agonists. (Clonidine and Guanfacine – Intuniv XR) Buproprion. (Zyban, Wellbutrin XR) When to refer? Complex cases have a role for input from psychology, occupational therapy, and occasionally psychiatry. Lack of comfort with diagnostic process. Inadequate time for evaluation process. Discussion of medication options. Take Home Message Attention difficulties are a subjective group of disorders defined by semi-objective questionnaires rating a particular person in a specific setting with certain expectations. Significantly different attention skills in at least two settings combined with academic and/or social failure and the impression of negative self concept lead to the diagnosis of ADHD. Medical health reasons need to be excluded. Psychological problems need to be recognized and accounted for. Each child requires a thoughtful and comprehensive evaluation prior to labeling or discussion of treatment. Referral may be required for this purpose. Treatment includes: education, healthy lifestyle, behavioral strategies, and medication. In adolescence, encourage condom use and driving a 5 speed.