Download SHIP conference July 31 2012 Linda Grossman M.D. Anna Maria Wilms Floet M.D.

SHIP conference
July 31 2012
Linda Grossman M.D.
Anna Maria Wilms Floet M.D.
Disclosures
Presenters have:
 No conflict of interest
 No commercial affiliations
 Off label use of medication(s) may be discussed
Goals and objectives (1)
 Offer an overview of what is new in the guidelines
regarding assessment and treatment of ADHD
 Discuss the rationale for these changes based on new
insights in etiology, and research
Goals and objectives (2)
 Discuss the impact of these guidelines on treatments
(non-medical and medical)
 Description of new medications used in treatment of
ADHD
 Describe information about co-occurring problems
and long term outcomes and their implications for
individuals with ADHD
Historical Perspective
 Descriptions go back to Greek and Victorian times

 Medical concerns began in 1910’s following severe influenza
epidemic – post encephalitic survivors often had
overactivity, inattentiveness and learning problems
 Minimal brain damage
 Minimal brain dysfunction (1960s)
 Hyperactivity and attention separated from learning
problems in late 60’s-early 70’s
Current thoughts on the Disorder
Syndrome based: relies on observable signs and symptoms
Symptoms in 2 separate domains: impulsivity/hyperactivity
and inattention
Does not involve deficits in sensory, perceptual, short- or
long term memory although function in these areas worsens
2nd to attention problems
Current thoughts on the Disorder
 Brain based disorder
 Disorder of response inhibition
 Response selection and response inhibition thought as 2
sides of the same coin
 Disorder of attention allocation
ADHD etiologies
ADHD is a heterogeneous behavioral disorder with
multiple possible etiologies: no single causative
cause
o
o
o
o
o
Inherited
Genetic
Neuro-anatomical/neurochemical
CNS insults
Environmental factors
Behavioral Genetics
 Genetic influences account for about 75 % of the
variance on average (range 60-90 %): polygenic
 The remaining variance appears to be due to non-
shared environmental influences (with little evidence
for shared environmental influences)
 Certain genetic conditions (Tourette’s disorder,
neurofibromatosis-I) show higher prevalence of
ADHD
Neuroanatomical:
MRI and Functional MRI Results
 Research findings
Decrease in size and/or activity of key parts of brain
 Right frontal region (alerting and executive fx)
 Anterior cingulate gyrus (executive function)
 Left dorsolateral area (verbal working memory)
 Basal ganglia (caudate and globus pallidus) and cerebellum
(inferior posterior lobe and lobes VIII-X of vermis) – all with regard
to movement and activity
 Problems with research
 Lack of controls
 Some kids medicated and some not
 Differences by age, gender
 Lack of replication by others - ? validity
ADHD: neuro-imaging
Delayed cortical maturation:
Neurochemistry
 Dysregulation of neurotransmitters
 Stimulants act on neurotransmission pathway of
catecholamines ( block re-uptake of dopamine and
norepinephrine)
 Candidate gene studies are
Dopamine genes
 DAT1: dopamine transporter
 DRD4: dopamine receptor D4
Noradrenergic /adrenergic
Drug metabolizing genes ??
CNS insults
 Infection
 Trauma
 Prenatal toxins:
 Tobacco
 Alcohol
 Postnatal toxins:
 Lead
Environmental factors
 No consistent research findings regarding food
allergies, too much screen time, poor parenting, poor
home life, poor school as causing ADHD, though may
exacerbate symptoms and impairment
Correlations/Potential Causes
Pediatrics 2011; 128:4 772-774
Conclusion
 Currently imaging and genetic analysis are not helpful
on a clinical basis because of the wide variety of size
and function of the brain in children with/without
ADHD and the small numbers that have identified
gene abnormalities
ADHD – Diagnosis under DSM-IV
 6 of 9 inattentive items
and/or
 6 of 9 hyperactive/impulsive items
 Note: items were selected by committee decision – not via
scientific process
DSM-IV Hyperactivity-Impulsivity
At least 6 of:
 Hyperactivity

Impulsivity
 Squirms and fidgets

 Can’t stay seated

 Runs/climbs excessively

Blurts out answers
Can’t wait turn
Intrudes/interrupts
others
 Can’t play/work quietly
 “On the go”/”Driven by a motor”
 Talks excessively
DSM IV Inattention
At least 6 of:
 Inattention
 Careless, fails to attend to details
 Difficulty sustaining attention in activity
 Doesn’t seem to listen
 No follow through on instruction, fails to finish
 Avoids/dislikes tasks requiring sustained mental
effort
 Loses things
 Easily distracted by extraneous stimuli
 Forgetful in daily activities
ADHD - Other Requirements
 Symptoms for at least 6 months
 Some symptoms before age 7 yrs.
 Impairment in 2 or more settings
 Significant impairment in social, academic, or
occupational functioning
 R/o PDD, schizophrenia, mood disorder, anxiety
disorder, or personality disorder
3 Types Under DSM-IV
 Attention Deficit Hyperactivity Disorder,
Predominantly Inattentive Type
 Attention Deficit Hyperactivity Disorder,
Predominantly Hyperactive-Impulsive Type
 Attention Deficit Hyperactivity Disorder, Combined
Diagnostic Process
 History - of vital importance, need information from
more than one source
 Physical exam
 to rule out a variety of medical and non-medical
possibilities with similar symptoms
 to look for contraindications to certain medical
interventions
 Laboratory tests - rarely useful except when need to
rule out another condition
NICHQ Vanderbilt Assessment Scales
(Vanderbilt ADHD Rating Scales)
 Based on DSM-IV scales
 Includes items for ODD, CD, anxiety and depression
 Subscales:
 Inattention, Hyperactivity/impulsivity, Oppositional
Defiant/Conduct Disorder, Anxiety/Depression
• Impairments in
 School function: Academic Performance, Behavioral Performance,
 Home: Relationship with parents, siblings, performance in
organized activities
ADHD 2011 guidelines
Replace 2 previously published guidelines
(2000: diagnosis, 2001: management)
 Expanded age range (now includes preschoolers)
 Expanded scope: behavioral interventions if not full
criteria met, though problems identified (DSM-PC)
Pediatrics 2011;128;1007
ADHD 2011 guidelines
Treatment recommendations vary by age:
o Preschool-aged children (4–5 years of age)
o Elementary school–aged children (6–11 years of age)
o Adolescents (12–18 years of age)
DSM-5
1980
1987
1994
2000
New insights : DSM-5
 Age of onset of impairing symptoms
increased from by age 7 to by age 12
 Change subtypes to current presentations
 Add 4th presentation: restrictive inattentive*
* criterion A1 is met(inattention) but no more than 2
symptoms from criterion A2 (hyperactive-impulsive)
over the last 6 months)
New insights : DSM-5
 Change examples in the items to accommodate a lifespan
relevance of each symptom and to improve clarity
 Remove PDD from exclusion criteria
 Information from 2 different informants (parents and
teachers for children, 3rd party/significant other for adults)
www.dsm5.org
ADHD as a chronic condition

60-85% continue to meet criteria as teen

Adult prevalence varies
 Core symptoms differ from childhood
o Impaired peer relations
o Injuries/health problems
o Poor job performance
o Legal encounters
Van Cleave and Leslie. 2008
Pliszka et al. 2007
Impairment or success:
to be determined!