ADHD Guidelines

1. ADHD Guidelines Rachel Reetzke

2. Overview • Introduction • Causes • Diagnosis • Treatment

3. Introduction: ADHD • ADD (attention deficit disorder) is no different from ADHD -it refers to adults in the Diagnostic & Statistical Manual for Mental Disorders (DSM-IV-TR) • Attention-deficit/hyperactivity disorder (ADHD) is the most common child neurobehavioral disorder and can affect: academic achievement, well-being, and social interactions • A neurological condition observed through problems with inattention (criteria A) and hyperactivity-impulsivity (criteria B)

4. Myth and Fact • Myth: ADHD is caused by bad parenting. • Myth: Children who have ADHD will eventually grow out of it. • Myth: ADHD is not a medical condition • Fact: ADHD is a neurobehavioral disorder • Fact: 80% will continue to display symptoms as adolescents. 60% will continue to display symptoms as adults. • Fact: ADHD is a biological brain based condition-recognized by leading medical experts and institutions

5. Causes • Scientists are not sure of definite cause(s) • Genetic- Twins studies showed that 75% of ADHD are genetically inherited. Researchers are currently looking at several genes that may predispose individuals to develop the disorder.2,3 Some versions of genes result in thinner brain tissue in areas of the brain associated with attention, however, symptoms are not permanent as children with this gene grew up, the brain developed normal level of thickness.4 • Dopamine-neurotransmitter that helps control behavior • Norepinephrine-neurotransmitter that works to block distractions and focus attention • Glutamine-precurser of glutamate, which is important to the function of the Pre-frontal cortex

6. Causes (cont) • Environmental factors-Studies suggest a potential link to maternal smoking, alcohol drinking, and premature birth.5,6 Studies show that nicotine can compromise neural pathway development in the brain. Additionally, exposure to organosphosphates (pesticides) and lead might have an effect on multiple neural systems that may underlie ADHD behaviors.7 • Food additives- Recent British research indicates a possible link between consumption of certain food additives like artificial colors or preservatives, and an increase in activity8. Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity. • Other factors- Brain injuries, sugar intake (disproved)

7. How is ADHD Diagnosed? • No single test used to diagnose ADHD (page 5). • New technology such as: MRI, PET and SPECT scans provide ability to view working parts of the brain, but cannot determine if the individual has ADHD. • Diagnosis is usually done through the collaboration of doctors, teachers, counselors and parents by way of screening tools and observations of a child’s behaviors. • Important: documentation must be made in more than 1 major setting.

8. How is ADHD Diagnosed? • Primary care clinician should initiate evaluation for ADHD for any child 4-18 years of age (expanded) who presents problems with: • Behavior • Academic performance • Symptoms of: • Inattention • Hyperactivity • Impulsivity • Assess for other conditions that might coexist in order to offer the most appropriate treatment plan ( • Emotional/Behavioral (e.g. anxiety, depression, oppositional defiant, and conduct disorders) • Developmental (e.g. learning, language, or other neurodevelopment disorders) • Physical (e.g. tics, sleep apnea,

9. Diagnosis: DSM-IV Criteria for ADHD1 • Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is 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 through on 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.

10. Diagnosis: DSM-IV Criteria for ADHD1 • Six or more of the following symptoms of hyperactivity-impulsivity 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 when sitting still is expected. • Often gets up from seat when remaining in seat is expected. • Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). • Often has trouble playing or doing 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).

11. 3 Types of ADHD are identified • Combined Type: if both criteria A and B are met for the past 6 months • Common characteristics: hyperactive, restlessness, disorganized, inattentive, impulsivity • Predominantly Inattentive Type: if criterion A is met but criterion B is not met for the past 6 months • Common characteristics: inattentive, sluggish, slow-moving, unmotivated, daydreamer • Predominately Hyperactive-Impulsive Type: if criterion B is met but criterion A is not met for the past 6 months • Common characteristics: over-focused, obsessive, argumentative

12. ADHD Can Be Mistaken for Other Problems • Parents and teachers can miss the fact that children with symptoms of inattention have the disorder because they are often quiet and less likely to act out. • They may sit quietly, seeming to work, but they are often not paying attention to what they are doing. • They may get along well with other children, compared with those with the other subtypes, who tend to have social problems. • But children with the inattentive kind of ADHD are not the only ones whose disorders can be missed. For example, adults may think that children with the hyperactive and impulsive subtypes just have emotional or disciplinary problems.

13. Classification of ADHD • Developmental disorder • Behavior disorder • Disruptive behavior disorder • Oppositional defiant disorder • Conduct disorder • Antisocial disorder

14. Treatment Options • Medication • Ritalin (methylphenidate hydrochloride), a stimulant, has been used since 1960’s. Ritalin makes dopamine more available to the brain cells, which helps with attention and concentration. • Dexedrine, Adderall, Adderall-XR (amphetamine) • Non-stimulant drugs such as Strattera (atomoxetine) which boosts the production of norepinephrine and Intuniv (guanfacine) which is primarily a blood pressure medication, also used to treat ADHD • Antidepressants such as Tricyclis (imipramine, desipramine) and Buproprion (Wellbutrin)

15. Treatment Options (cont) Behavioral therapy (page 12) • Positive reinforcement (providing rewards or privileges contingent on the child's performance) • Time-out (removing access to positive reinforcement contingent on performance of unwanted or problem behavior) • Response cost (withdrawing rewards or privileges contingent on the performance of unwanted or problem behavior) • Token economy (combining positive reinforcement and response cost) Education and counseling of children and parents regarding attention-deficit/hyperactivity disorder (ADHD), affects of condition, treatment planning, resources Coordination/collaboration of care among clinicians, parents, teachers, child, other school personnel, such as nurses, psychologists, and counselors, as appropriate, to develop and monitor target outcomes Evaluation and reassessment of children who do not meet target outcomes: evaluation of the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditionsCounseling, brain gym exercises, ear training, diet and exercise

16. Preschool age children (4-5 years) • Evidence-based parent and/or teacher-administered behavior therapy • Prescribe Methylphenidate if behavior interventions do not provide improvement and there is moderate-to-severe continuing disturbance in the child’s function. • Weigh risks of starting medication at early age against harm of delaying diagnosis and treatment • Studies have found improvement in symptoms to behavior therapy alone

17. Elementary school-aged children (6-11 years) • Prescribe approved medications for ADHD • Stimulant Medications • Evidence not as strong for: atomoxetine, extended-release guanfacine, and extended-release clonidine • Behavioral Therapy • School environment should be apart of

18. Adolescents (12-18 years) • Prescribe approved medication • Behavior therapy

19. Questions?

20. Citations 1. DSM-IV-TR workgroup. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association. 2. Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P. Molecular genetics of attention-deficit/hyperactivity disorder. Biological Psychiatry, 2005; 57:1313-1323. 3. Khan SA, Faraone SV. The genetics of attention-deficit/hyperactivity disorder: A literature review of 2005. Current Psychiatry Reports, 2006 Oct; 8:393-397. 4. Shaw P, Gornick M, Lerch J, Addington A, Seal J, Greenstein D, Sharp W, Evans A, Giedd JN, Castellanos FX, Rapoport JL. Polymorphisms of the dopamine D4 receptor, clinical outcome and cortical structure in attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 2007 Aug; 64(8):921-931. 5. Linnet KM, Dalsgaard S, Obel C, Wisborg K, Henriksen TB, Rodriguez A, Kotimaa A, Moilanen I, Thomsen PH, Olsen J, Jarvelin MR. Maternal lifestyle factors in pregnancy risk of attention-deficit/hyperactivity disorder and associated behaviors: review of the current evidence. American Journal of Psychiatry, 2003 Jun; 160(6):1028-1040. 6. Mick E, Biederman J, Faraone SV, Sayer J, Kleinman S. Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. Journal of the American Academy of Child and Adolescent Psychiatry, 2002 Apr; 41(4):378-385. 7. Pauly, James R., and Theodore A. Stokin. (2008) “Maternal tobacco smoking, nicotine replacement and neurobehavioral development.” ActaPaediatrica 8. McCann D, Barrett A, Cooper A, Crumpler D, Dalen L, Grimshaw K, Kitchin E, Lok E, Porteous L, Prince E, Sonuga-Barke E, Warner JO. Stevenson J. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet, 2007 Nov 3; 370(9598):1560-1567.