Phenomenology & Diagnostic Classification of ADHD Across Life Span

1. Phenomenology & Diagnostic Classification of ADHD Across Life Span Prof. Fatima AlHaidar Professor & Consultant Child & Adolescent Psychiatrist College of Medicine\ KSU

2. “ADHD is a lifespan condition that affects children, adolescents, and adults of all ages.”

3. Definition: The official definition of ADHD describes the essential features of the disorder as persistent pattern of inattention, & /or hyperactivity – impulsivity that is more frequent & severe than typically observed in individuals at a comparable level of development. These problems have to be chronic, they must have existed before age of 7 years & they must be pervasive; occurring in two or more settings.

4. The Evolving Concepts of ADHD • ≥ 100 years ago, the concept started as a description of behavior. • Before 1940s, children who had difficulty in learning were described as: Mentally retarded, emotionally disturbed, and socially & culturally disadvantaged. • In early 1940s →→ minimal brain damage. • In 1950s →→ MBD had evolved: 1- learning difficulty due to dysfunction in CNS. 2- Problems with hyperactivity & distractibility 3- Emotional & family problems due to 1 or 2. • In 1968; hyperkinetic reaction of childhood : overactivity, restlessness, distractibility & short attention span ( DSM II )

5. The Evolving Concepts of ADHD cont. • In 1980s; attention deficit disorder ADD ; ADD- H & ADD- WH ( DSM-III ). Aresidual category for adult has been described; ADD-residual type. • In 1987; ADHD ( DSM-III-R ). • In 1994, ADHD continues as a term but distractibility had changed to inattention ( DSM-IV ). • 3 subtypes were described: 1- Mixed type. 2- Inattentive type. 3- Hyperactive- impulsive type . • In 2000, ADHD continues as a term with the 3 subtypes. Coding note: ADHD in partial remission; for adolescent & adults who currently have symptoms that no longer meet full criteria ( DSM-IV-TR ).

6. Clinical Findings Suggestive of ADHD in Children Hyperactivity: • Clear Hyperactivity • fidgety or squirmy behavior or something always in motion. • Hyperactivity appears to diminish in overt severity as individual mature to adolescence and later adulthood.

7. Impulsivity: • Being unable / difficulty stopping before speaking or acting. • They know what to do, but they do not stop long enough for that knowledge to influence their behavior. • People evaluate their action as purposeful, non-caring or oppositional when in reality it reflects their immediate need for gratification & inability to stop and think. • Adolescents & adults realize the problem but children do not.

8. Inattention: • This term is used interchangeably with distractibility. • External distractibility: - Auditory - Visual • Internal distractibility

9. Difficulty with gratification: • Not working well for long- term rewards. • Reinforcersdo not change behavior in the long term. • Children with ADHD receive high rates of repeated negative reinforcement. • Behavioral intervention may manage immediate behavior but do not produce long-term modification, sense of responsibility or build independence.

10. Other Aspects: • Children with hyperactive-impulsive type demonstrate more behavioral problems, conduct difficulty and mild depression. • Most children with hyperactive-impulsive type are younger than those with inattentive type. • Those with inattentive type are described to be shy, withdrawn, with more academic and learning problems, low academic motivation, weak self concept, greater problem with depression. • They used to be referred later because of school performance, shyness and social difficulty. • ⅔of urban children with ADHD are reported to display symptoms of inattention. • ⅔of rural children with ADHD are reported to display symptoms of behavioral and oppositional disturbance. • Some of children with initial diagnosis of hyperactive-impulsive type ended later to have combined type.

11. What is so difficult in making the diagnosis of ADHD?

12. Inattention. Children, adolescents or adults might have difficulty maintaining attention for many reasons. ADHD is but one cause. 3 broad tasks are involved with attention: 1- The ability to seek out what one wants to attend and focus on it. 2- The ability to maintain one’s focus. 3- Once the task is done, the ability to stop attending and to move on to something else.

13. The difficulty with (1) is avoidance • The difficulty with (2) is related to several themes. • The difficulty with (3) is related to many factors .·. Not all individuals who are inattentive have ADHD.

14. Hyperactivity-Impulsivity. • Anxiety ( can’t sit still, pay attention, irritability … ) • Depression ( restlessness, unable to stay focus … ) • Learning Disability ( can’t finish class work, difficulty doing homework, appear not listening … ) • ADHD • .·. Not all individuals who are hyperactive or impulsive have ADHD.

15. The Official Diagnostic Criteria of ADHD • The clinical history is the only current means to finalize the proper diagnosis. • Information obtained from the individual, parents, teachers, others, & previous medical and school records leads to the diagnosis. • The official guidelines used by health and mental professionals to diagnose ADHD are found in DSM-IV-TR. • These guidelines reflect ICD-10-CM. • No formal tests are available to establish the diagnosis of ADHD, no physical, laboratory, or neurological findings are associated with the disorder. • However, doing these examination and tests are important to exclude other disorders.

16. Formal instruments used in the diagnostic process 1- Rating scales. • These scales operationalize the DSM criteria. • The Conner’s series for parents and teachers rating scales are the most popular ones. • New rating sheets are being created all the time • Some professionals have their own sheets. 2- Computer-Based Tests CBT. • Several tests have been developed that use computer to assess the individual’s ability to pay sustained attention and whether there is evidence of impulsivity 3- Internet Self-rating Scales • There are many Internet sites about AD/HD that offer various types of questionnaires and lists of symptoms. • These questionnaires are not standardized or scientifically validated

17. Developmental Course

18. Developmental course • 10% of infants & toddlers have history of difficult childhood temperament. • Preschoolers with ADHD might present initially with speech & linguistic problems.75% of them meet full criteria for ADHD on follow up. • Majority of children with ADHD achieve as well as the normal population in elementary school. • However, by later school years, the commutative effect of ADHD on student’s ability to complete tasks hurts academic achievement. • During primary and secondary schools, children with ADHD are described as daydreaming and disinterested in tasks leading to more nonproductive activities which continue as adult poor performance at workplace.

19. Developmental Course cont. • As children with ADHD become adolescents they fall behind one or more years academically. they have impairment in social competence and have more behavioral and emotional adjustment difficulty. • It has been suggested that many of primary symptoms of ADHD diminished by adolescence. • Now, it is clear that the majority of children with ADHD continue to adulthood experience some if not all symptoms consistent with ADHD. • Children with high impulsive behavior progress to more serious adulthood behavior.

20. Developmental Course cont. • Concurrence of ADHD & other family adversity ( depressed mother, alcoholic father ) increase the risk of conduct disorder during childhood and adolescence and later on antisocial behavior during adulthood. • Deficient social skills appear to be the most lasting & disabling co-morbid aspects of adult ADHD. • Presence of combined type of ADHD & aggression in preadolescents, predict later risk for substance abuse.

21. Clinical Findings Suggestive of ADHD in Adolescents

22. 80% of children with ADHD continue to report symptoms of ADHD during adolescence. • They might present with self reporting attention difficulty without overt behavioral problem. • They were described as day dreaming or not there. • They might present with poor self esteem or academic difficulty. • internal distractibility rather than external distractibility. • impulsivity ( speech or acts )

23. Irresponsible behavior, annoying acts or overt aggression. • They receive more traffic citations. • Delinquent behavior. • 20%of adolescents with ADHD has antisocial behavior. Those usually continue to have ADHD as adults. • substance abuse. • 50%of adolescents with ADHD continue to have ADHD as adults.

24. Clinical Findings Suggestive of ADHD in Adults • Mental health professionals who work only with adults might not know to consider this possibility. Therefore adults with ADHD might have difficulty to find a professional to evaluate them. • Some adults realize the possibility of having ADHD when their child is diagnosed with ADHD; That’s me ! • For others, a newspaper or magazine article, a book, or TV program might make them aware that there is a reason for the problems they have had most of their lives.

25. Prevalence. • It is estimated that about 50% of adolescents with ADHD will continue to have this possibility as adults. • Current estimate that 3%-6% of youth have ADHD. Therefore, 1.5%-3% of adults might have ADHD.

26. Diagnosis. • Diagnosis of ADHD in adulthood should include: • 1. A childhood history with evidence that the child met criteria for DSM-IV-TR or ICD-10. • 2. Current ADHD symptoms with cutoff scores of 4\ 9 of inattention & 5\9 of hyperactivity- impulsivity or ( at least total of 6 DSM-IV-TR symptoms ) for adults below 50 years of age. For those older than 50 years old the sample is too small to conclude. • 3. Symptoms producing impairment in many area; job, school, social acceptance, daily responsibilities, relationships, marriage and emotional adjustment. • 4. Other co-morbid problems are understood and delineated. • 5. Assessment conducted by a well-trained person in the field

27. Diagnosiscont. • Many scales & questionnaires have been developed to aid the diagnosis: • BAAD= Brown Attention Activation Disorder scale • Wender Adult Questionnaire • Conner’s Adult Questionnaire.

28. Relationship Between Childhood ADHD and Adulthood ADHD • About 1/2 of adults with ADHD had ADHD as children. • Those who have ADHD as children have worse adult picture of ADHD. • Adults with ADHD who are not identified in childhood as ADHD have milder problems and less areas of dysfunction. • Some people usually come asking for help for mood, anxiety or problems at work, marital or interpersonal problems and sometimes, they come at the request of spouse. At that time the diagnosis of ADHD is established. • The first degree relatives of children with ADHD have high rates of ADHD and antisocial problems.

29. Major Complaints of Adults Seeking Assessment for ADHD 1. Difficulty sustaining attention. 2. Difficulty concentrating. 3.Forgetfulness. 4. Feelings of poor memory. 5. Reporting of difficulty thinking clearly. 6. Low frustration threshold 7. Impulsiveness. 8. Restlessness. 9. Intolerance of boredom. 10. Worry excessively. 11. Feeling of depression.

30. Major Complaints of Adults Seeking Assessment for ADHD 12. poor self esteem. 13. Poor self disciplines. 14. Lack of organization. 15. Difficulty establishing & maintaining rules. 16. Strong feeling of underachievement. 17. Crave stimulation. 18. Impairment of social & occupational functioning. 19.Difficulty locating & maintaining vocation. 20. Performing below level of competence vocationally. 21. Significantly more accidents. 22. Significantly more geographical move. 23. More court referrals.

31. ADHD Behaviors in Adults. • Hyperactivity: • Seeking certain types of job. • Difficulty to sit for long time to finish tasks. • Start with marriage/ having children. • Noticed with work promotion.

32. Inattention: • The main problem is with internal distractibility. • Career demands, marriage and children demands increase this problem.

33. Impulsivity: • Like children & adolescents, Adults might speak or act before thinking. The difference is that adults are aware of the problem & concentrate on controlling. • Stealing, gambling, laying and poor driving are reported more with them. • They have more traffic accidents and more traffic tickets.

34. Organizational Problems: • Organization means the ability to organize pieces of information together into concept, or the ability to break concept into its parts. • The ability to organize one’s thoughts, materials & time is included as well. • Therefore, these problems might relate to organization of time, schedules, material at home or work. Their life is one big organizational problem. • Possible reasons for that might include: 1. Result of inattention & distractibility. 2. Result of learning disability & executive function. .·.intervention should be related to reason.

35. Problems Related to ADHD in Adults • 1. Less formal schooling. • 2. 90% employed but their jobs were of lower occupational ranking. • 3. 20%- 30% of adults with ADHD have of co-morbid substance abuse; particularly alcohol and cocaine. • 4. High rates of personality disorders & mood disorders. • 5. Higher rates of stuttering, enuresis, speech & language disorder. • 6. Only 28% have no other psychiatric disorders. • 7. More traffic accidents. • 8. More marital, family and interpersonal problems.

36. “ADHD is a lifespan condition that affects children, adolescents, and adults of all ages.” ?