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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!