Download ADHD General Talk Diagnosis & Treatment

ADHD
Diagnosis, Prognosis, Impact
and Treatment
Dr. Jana Davidson
Child & Adolescent Psychiatrist
BC Children’s Hospital
“Hundred Acre Wood”
Owl – Dyslexia
Eeyore – Chronic Depression
Rabbit – Obsessive Compulsive Disorder
Piglet – Anxiety Disorder
Christopher Robin – School Avoidance
Pooh – Developmental Delay, Binge Eating
Tigger – Hyperkinetic Reaction
Program
ADHD
 Etiology,
Definition & Epidemiology
 Diagnosis
 Treatment
ADHD – DSM-IV Definition
Attention-Deficit/Hyperactivity Disorder (ADHD) is
a neurobiological condition that is characterized by
developmentally inappropriate level of inattention,
[concentration, distractibility,] hyperactivity, and
impulsiveness that can occur in various combinations
across school, home, and social settings.
ADHD is Most Likely Caused by a Complex
Interplay of Factors:
Neuroanatomic
Neurochemical
Genetic
origins
ADHD
Environmental
factors
CNS
insults
Heritability of ADHD
Schizophrenia
Height
Hudziak 20001
Nadder 19982
Levy 19972
Sherman 19972
Silberg 19962
Gjone 19962
Thapar 19952
Schmitz 19952
Edelbrock 19922
Gillis 19922
Goodman 19892
Willerman 19732
0
0.2
0.4
Heritability
0.6
0.8
1
Definition of ADHD
Developmental Disorder
recognized by significant symptoms of:
Inattention
Hyperactivity/
Impulsivity
DSM-IV Symptoms of Inattention
Inattention
• Careless
• Difficult sustaining
attention in activity
• Doesn’t listen
• No follow-through
• Avoids/dislikes task requiring
sustained mental effort
• Can’t organize
• Loses important items
• Easily distractible
• Forgetful in daily
activities
DSM IV Symptoms of HyperactivityImpulsivity
Hyperactivity
• Squirms and fidgets
• Can’t stay seated
• Runs/climbs excessively
• Can’t play/work quietly
• “On the go”/”driven by a motor”
• Talks excessively
Impulsivity
•Blurts out
•Can’t wait turn
•Intrudes or
interrupts others
DSM-IV ADHD Diagnostic Criteria
Essentials
• Persistent pattern of symptoms
• Symptoms present for 6 months & before age 7
• 6 or more symptoms in one or both domains
• Impairment in 2 or more settings
• Significant impairment: social, academic, or
occupational
ADHD Clinical Subtypes
Predominantly inattentive:
• Easily distracted
• Not excessively hyperactive or impulsive in
behavior
Predominantly hyperactive-impulsive:
• Extremely hyperactive and impulsive
• Not highly inattentive (may have no inattentive
signs)
• Often younger children
Combined type:
• Most patients
• All three classical signs of the disorder
Combined
Type
Predominantly
Inattentive
20-30%
50-75%
< 15%
Predominantly
Hyperactiveimpulsive
ADHD:
Prevalence and Demographics
•
Overall prevalence ~4–12% in school-aged children
•
Male to female ratio ~4:1 in children and adolescents
•
Females believed to be under-diagnosed since often
inattentive subtype
•
Prevalence declines with age, although up to 65% of
children are still symptomatic as adults
•
Prevalence is similar across cultures; however, wide
variations exist in recognition and treatment
Prevalence of ADHD Symptoms in School
Children
Teacher Reports
Boys (n=140)
% of population
Girls (n=140)
0
Combined
Inattentive
Hyperactive/
Impulsive
Attention Deficit Disorder (ADHD)
• ADHD is a chronic disorder with different
manifestations in:
• Preschoolers
• School children
• Adolescents
• College students
• Adults
ADHD Clinical Presentation: Preschool Years
•
•
•
•
•
Motor restlessness (always on the go)
Aggressive (hits others)
Spills things
Insatiable curiosity
“Fearless–may endanger self or
others
• Low levels of compliance
•
•
•
•
Vigorous and often destructive play
Demanding, argumentative, noisy
Interrupts others
Excessive temper tantrums
ADHD Clinical Presentation: School
Children
• Easily distracted
• Homework poorly organized, careless
errors, often incomplete or lost
• Low academic scores
• Frequent trips to the principal’s office
• Blurts out answers before question
completed (often disruptive in class)
• Often interrupts and intrudes on
others
• Low self-esteem
.
•
•
•
•
•
•
•
Displays aggression
Difficult peer relationships
Does not wait turns in games
Often out seat
Perception of “immaturity”
Unwilling or unable to do chores at home
Accident prone
ADHD Clinical Presentation: Adolescents
• May have sense of inner
restlessness rather than hyperactivity
• Procrastinates and displays
disorganized school work with poor
follow-through
•
•
•
•
•
•
Fails to work independently
Poor self-esteem
Poor peer relationships
Inability to delay gratification
Specific learning disabilities
Behavior not usually modified by
reward or punishment
• Engages in “risky” behavior
(speeding, unprotected sex,
substance abuse)
• Apparent disregard for own safety
(injuries and accidents)
• Difficulties or clashes with authority
Comorbidity Often Complicates the
Diagnosis and Treatment of Childhood ADHD
n = 579
Comorbidities and ADHD
• Comorbidity in ADHD is the rule rather than
the exception
• 87% of ADHD children have at least one
co-morbid condition
• 67% of ADHD children have at least 2
co-morbidities
Patients with Untreated Childhood ADHD
May Be at Risk for Further Complications
In Childhood
In Adolescence
• Disruptive behavior
• School suspension and/or expulsion
• Oppositional defiant disorder
• Further academic difficulties
• Poor academic performance and
learning delay
• Substance dependence or abuse
• Low self-esteem
• Mood disorders
• Poor social skills
• Conduct disorder
• Parent-child relationship difficulties
• Poor motivation
• Physical injury
• Teen pregnancy
• Social exclusion
• Driving accidents
Functional Impairment
Repeat a Grade
ADHD
Normal
Teen Pregnancy
Sexually Transmitted Diseases
Substance Abuse
Intentional Injury
Incarcerated
Fired from Job
Attempt Suicide
0
10%
20%
30%
% of Occurrence
40%
50%
60%
Untreated & Under-Treated ADHD
Health Care
System
50%  in bike accidents1
33%  in ER visits2
Family
Patient
3-5x  Parental Divorce
or Separation11,12
2-4 x  Sibling Fights13
2-4 x more motor
vehicle crashes3-5
Society
School & Occupation
Expelled6
46%
35% Drop Out6
Lower Occupational Status7
Substance Use Disorders:
2 X Risk8
Earlier Onset9
Less Likely to Quit
in Adulthood10
Employer
 Parental
Absenteeism14
and
 Productivity14
% of Study Population with
Substance Abuse at Endpoint
(4 Year Follow-up)
Treatment of ADHD Reduces Risk for
Substance Abuse in Adolescents
P<.001
32%
12%
Unmedicated ADHD
(n=19)
Medicated ADHD
(n=56)
10%
Non-ADHD Controls
(n=137)
Treatment Options in
ADHD
Pharmacological Agents Used
in the Treatment of ADHD
Stimulants
Methylphenidate
(Ritalin & CONCERTA*)
Amphetamine compounds
(Dextroamphetamine & Adderall XR)
Non-Stimulants
Atomoxetine (Strattera)
Antidepressants
Tricyclic antidepressants
Bupropion (Wellbutrin SR)
Antihypertensives
Clonidine
Canadian ADHD Resource Alliance
Practice Guidelines – Key Management Principles
1.
Psychoeducation is a core foundation to effective long-term
compliance and treatment and should include:
1.
2.
3.
4.
2.
3.
Regular support for families
Patient, parent and teacher training
Special educational behavioural interventions
Medication information
ADHD is a chronic medical condition and intervention must be
planned over the long term.
It is critical that symptoms of ADHD be recorded using valid,
reliable and sensitive rating scales to evaluate symptom
frequency and severity.
Canadian ADHD Resource Alliance
Practice Guidelines – Medication Management
First Line Agents – long acting preparations
Adderall XR, Concerta, Strattera
Second Line Agents – short acting and moderate acting preparations
Dexedrine, Dexedrine Spansule, Ritalin, Ritalin SR, PMS or Ratio MPH
Third Line Agents – off label treatments of ADHD/used in treatment failure
Wellbutrin SR (Bupropion SR)
In Summary
1.
Core symptoms of ADHD are inattention,
hyperactivity, and impulsivity
2.
Symptoms of ADHD are present 24/7
3.
These symptoms appear in early childhood and
often persist into adulthood
4.
ADHD symptoms affect many facets of patient’s
life
In Summary
5.
ADHD carries significant morbidity
ADHD carries with it a high burden of
comorbidity
7. Comorbidity complicates the picture
8. ADHD is a treatable disorder
9. Newer treatments provide flexibility for patients
and their physicians
6.
Conclusion
ADHD affects the entire community
especially when it is undiagnosed and
untreated.
The tools available to diagnose and treat
ADHD are improving as is our
understanding of this disorder throughout
the lifespan.
BC Provincial ADHD Program
A provincial resource available to children, adolescents and
adults for the assessment of ADHD.
Clinic Location: Children’s & Women’s Health Centre of BC
Room B425A – Shaughnessy Building
4500 Oak St., Vancouver BC
Mailing Address:
Phone: 604-875-3551
Fax:
604-875-2870
Email: [email protected]
Provincial ADHD Program
Box #178 – 4500 Oak St.
Vancouver BC V6H 3N1
Resources
Children & Adults with ADD: www.chaddcanada.org
Attention Deficit Resource Network: www.adrn.org
National Institute of Mental Health ADHD Booklet:
www.nimh.nih.gov/publicat/adhd.cfm
Centre For ADHD/ADD Advocacy Canada: www.caddac.ca
American Academcy of Child & Adolescent Psychiatry:
www.aacap.org
Mental Health and Highschool: www.cmha.ca/highschool
Thank you!