Attention-Deficit Hyperactivity Disorder

1. Attention-Deficit Hyperactivity Disorder W. Alexander Ellis, MS III Psychiatry Rotation, April 22, 2011

2. Diagnosing Attention Deficit Hyperactivity Disorder • Attention Deficit Hyperactivity Disorder (ADHD) is a diagnosis based on a set of symptoms of behavior patterns. "There are no laboratory tests, neurological assessments, or attentional assessments that have been established as diagnostic in the clinical assessment of Attention-Deficit/Hyperactivity Disorder.“ -Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision

4. DSM-IV Criteria for ADHD ADHD is defined by five categories labeled A, B, C, D, E. Category A is further subdivided into two sections with multiple criteria

5. DSM-IV Criteria for ADHD- Category A • A. “Persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and is more severe than is typically observed in individuals at comparable level of development.” Individual must meet criteria for either (1) or (2):

6. DSM-IV Criteria for ADHD- Category A (cont.) • Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level: Inattention (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities(b) often has difficulty sustaining attention in tasks or play activity(c) often does not seem to listen when spoken to directly(d) 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)(e) often has difficulty organizing tasks and activities(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)(g) often looses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)(h) is often easily distracted by extraneous stimuli(i) is often forgetful in daily activities

7. DSM-IV Criteria for ADHD- Category A (cont.) (2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity(a) often fidgets with hands or feet or squirms in seat(b) often leaves seat in classroom or in other situations in which remaining seated is expected(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)(d) often has difficulty playing or engaging in leisure activities quietly(e) is often “on the go” or often acts as if “driven by a motor”(f) often talks excessively Impulsivity(g) often blurts out answers before questions have been completed(h) often has difficulty awaiting turn(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

8. DSM-IV Criteria for ADHD- Categories B, C, D, E B. Some hyperactive-impulsive or inattentive symptoms must have been present before age 7 years. C. Some impairment from the symptoms is present in at least two settings (e.g., at school [or work] and at home). D. There must be clear evidence of interference with developmentally appropriate social, academic or occupational functioning. E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorders and is not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

9. DSM-IV Criteria for ADHD3 Types • Attention deficit hyperactivity disorder, combined type: • If both Criteria A1 and A2 are met for the past 6 months • Attention deficit hyperactivity disorder, predominantly inattentive type: • If Criterion A1 is met but Criterion A2 is not met for the past 6 months • Attention deficit hyperactivity disorder, hyperactive-impulsive type: • If Criterion A2 is met but Criterion A1 is not met for the past 6 months • DSM IV-TR as quoted in Kaplan & Sadock (2007)

11. Epidemiology • Reported incidence in school-age children varies from 2 to 20 percent • First-degree relatives are at increased risk of developing it as well as other disorders, e.g., disruptive behavior disorders and learning disorders • “Parents of children with ADHD show an increased incidence of hyperkinesis, sociopathy, alcohol use disorders and conversion disorder.” • Kaplan & Sadock (2007)

12. Epidemiology- Gender • Prevalence: boys more than girls; ratios range from 2 to 1 to 9 to 1 (Kaplan & Sadock, 2007) • However a published summary of a 1996 National Institute of Mental Health (NIMH) conference that considered gender differences in children with ADHD examined the literature and raised questions about the validity of the accepted differences in the ratios

13. Epidemiology- Gender (cont.) • “The consensus was that part of the higher male-to-female ratio in clinical samples results from boys being more likely to be referred for their comorbid conduct or oppositional disorder and aggression (Biederman, 1994; Gaub & Carlson, in press; Lahey, 1994). Even after correction for comorbidity, however, there remained some referral bias favoring referral of boys (Lahey, 1994)” • Arnold, LE (1996). Sex Differences in ADHD, Journal of Abnormal Psychiatry, 24(5)

14. Etiology Possibly multifactorial causes that increase a child’s susceptibilty to developing ADHD • Genetic Factors • Developmental Factors • Brain Damage • Neurochemical Factors • Neurophysiological Factors • Pyschosocial Factors

15. Genetic Factors • Greater concordance between monozygotic twins than dizygotic twins • Siblings of affected child have twice the risk of acquiring the disorder compared to the general population • Greater incidence of ADHD in biological parents than adoptive parents of affected child • Children with ADHD more commonly have parents with alcohol use disorders and antisocial personality disorder than children in the general population • Kaplan & Sadock (2007)

16. Developmental Factors • September is the peak month for births of children with ADHD • Possible contributing factor is 1st trimester exposure to winter infections • Question: May there be an as yet undiscovered TORCH-like virus or fungus that increases the risk for any fetus regardless of family history?

17. Brain Damage • Hypothesis is of “subtle damage” to the CNS during fetal and perinatal development: “associated with circulatory, toxic, metabolic, mechanical, or physical insult to the brain during early infancy caused by infection, inflammation, and trauma.” • Kaplan & Sadock (2007)

18. Neurochemical Factors • The fact that the most effective drugs used to treat ADHD are stimulants that affect dopamine and norepinephrine has contributed to neurotransmitters hypotheses of dysfunction in the dopaminergic and adrenergic systems. • Studies have determined that the locus ceruleus is integral to attention • Possibly a dysregulation of the peripheral noradrenergic system causes an accumulation of epinephrine and a subsequent homoeostatic reset of the centrally-located locus ceruleus

19. Neurophysiological Factors • Some children with delays in the normal post natal growth spurts that the brain undergoes display symptoms of ADHD. • This is often accompanied by abnormal nonspecific EEG patterns • Positron emission tomography (PET) scans have revealed comparatively “lower cerebral blood flow and metabolic rates in the frontal lobes of children with ADHD than in controls.” (Kaplan & Sadock, 2007) • Because cerebral structures maintain an inhibitory control on lower structures, one theory holds that the frontal lobes of affected children is not performing adequately leading to disinhibition.

20. Psychosocial Factors • Children subjected to emotional deprivation display signs of overactivity and poor attention similar to ADHD that disappear when the deprivation is corrected • Genetically or temperamentally predisposed children may develop ADHD due to stressful psychic events, abuse, disrupted family dynamics, or other anxiety-inducing factors

22. Comorbidities • Possible developmental disorders • language • arithmetic • reading • coordination • High incidence of • mood disorders • anxiety disorders • personality disorders • Oppositional Defiant Disorder (30-40%) • conduct disorders (30-50%)

23. Clinical Features • Onset may occur in infancy but is seldom recognized before toddler age • Infants may either be hypersensitive and easily agitated by changes in external stimuli such as light, temperature or may by unusually unresponsive, sleep a lot and be slow to develop • Usually infants belong to the former group and sleep little

24. Clinical Features (cont.) • School age children have learning and behavioral problems characterized by hyperactivity, emotional lability, lack of focus, poor concentration, easy distractibility, impulsivity, memory deficits, and learning disabilities. • Comorbid learning disorders may be the primary cause of learning difficulties, not ADHD • A large majority of children with ADHD additionally have increased irritability and may display aggression and defiance. • The resulting negative response to their behavior affects their self-esteem and may trigger them to act out, thereby creating a self-defeating cycle.

25. Clinical Features (cont.) • “A meta-analysis (Gaub & Carlson, in press) suggested that clinic-referred girls with ADHD had more severe attentional and intellectual impairment across all IQ scales than clinically referred boys with ADHD, but less hyperactivity and conduct disorder, and a similar degree of impairment in most other domains of function.” • Arnold, LE (1996). Sex Differences in ADHD, Journal of Abnormal Psychiatry, 24(5)

26. Clinical Features (cont.) “Females with ADHD symptoms may go unidentified during childhood and adolescence (Quinn & Nadeau, 2000). One possible explanation is that most referrals for ADHD during childhood are triggered by the display of hyperactivity, impulsivity, and aggression. Females are less likely to be hyperactive and aggressive and more likely to manifest inattentive symptoms.” • Lee, D.H., Oakland T., Jackson, G. & Glutting, J. (2008). Estimated prevalence of Attention-Deficit/ Hyperactivity disorder symptoms among college freshmen: Gender, race and rater effects. Journal of Learning Disabilities, 41(371)

28. Differential Diagnosis • Normal active child with a child’s short attention span • Anxiety- in a child can manifest as “overactivity and easy distractibility” (Kaplan & Sadock, 2007) • Mania- shares features with ADHD • “children with bipolar I exhibit more waxing and waning of symptoms than those with ADHD”(Kaplan & Sadock, 2007) • However, having ADHD does not preclude having or developing bipolar disorder • Conduct disorder and ADHD may coexist

29. Course and Prognosis • Course is variable • ADHD symptoms may persist into adulthood in up to 60% of childhood cases • Decreased attention span and impulse control may be the dominant symptoms with a loss of hyperactivity with age • Impulsivity > hyperactive • Remission, when it does occur, usually happens after age 11 years, between the the ages of 12 and 20

30. Course and Prognosis (cont.) • Adolescents with ADHD risk developing conduct disorder • In cases that do remit, most remission is partial. • Sequelae: • Antisocial behavior • Substance use disorders • Mood disorders • Learning problems persist • (Kaplan & Sadock, 2007)

31. Course and Prognosis (cont.) “Because of the prominence of hyperactivity and impulsivity at the younger ages, symptoms more common in children may be overrepresented in the DSM–IV criteria (Barkley, 2006), thus requiring collegestudents to present with more severe symptoms in order to be diagnosed. In addition, ADHD symptoms may manifest differently in adulthood than in childhood, whereas the core ADHD symptoms of inattention, hyperactivity, and impulsivity are overt in children. For example, college students and other adults with ADHD may be more likely to display difficulties with internal distractions (e.g., daydreaming or a constant flow of task-relevant and irrelevant ideas; Conners et al., 1999; Downey, Stelson, Pomerleau, & Giordani, 1997; Weyandt, Iwaszuk, & Fulton, 2003).” • Lee, D.H., Oakland T., Jackson, G. & Glutting, J. (2008). Estimated prevalence of Attention-Deficit/ Hyperactivity disorder symptoms among college freshmen: Gender, race and rater effects. Journal of Learning Disabilities, 41(371)

32. Course and Prognosis (cont.) “A growing number of studies indicate that biased samples might underlie extreme gender effects on the prevalence of ADHD in clinically referred paediatric study samples… Compared with paediatric and adolescent studies, adult ADHD studies have generally shown a more balanced distribution of prevalence in men and women.” • Simon, V., Czobar P., Balint S., Meszaros A. & Bitter, I., (2009). Prevalence and correlates of adult attention-deficit hyperactivity disorder: a meta-analysis. The British Journal of Psychiatry 194, 208.

33. Treatment • Medication is the most effective treatment for ADHD but should be part of an overall treatment plan that may include nonpharmacologic treatment • Psychopharmacological therapy for adults with ADHD may continue indefinitely

35. Pharmacologic Treatments • Central nervous system stimulants are first line • Methylphenidate compounds • Ritalin, Ritalin-SR, Concerta, Metadate CD, Metadate ER, Focalin • Dextroamphetamine • Dexidrine,Dexidrine Spansules, DextroStat • Dextroamphetamine and amphetamine salts • Adderall, Aderall XR

36. Pharmacologic Treatments (cont.) • Non CNS stimulants • Norepinephrine uptake inhibitor • Atomoxetine (Stratera) • Antidepressants • Buproprion (Welbutrin, Welbutrin SR) • Venlafaxine (Effexor, Efexor XR) • α-adrenergic receptor agonists • Clonidine (Catapres), Guanfacine (Tenex)

37. Non-Pharmacologic Treatments • Family, individual and group psychotherapy • Behavior modification techniques and social skill training • Parent psychoeducation • Educational Interventions • Teacher and classroom modifications • Stead, L. G., Kaufman, M. S. & Yanofski, J. (2011). First aid for the psychiatry clerkship (3rd ed.). New York, NY: McGraw-Hill.

38. Attention Deficit Hyperactivity Disorder Not Otherwise Specified • This category is for symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for attention-deficit/ hyperactivity disorder. Examples include: • Individuals whose symptoms and impairment meet the criteria for attention-deficit/ hyperactivity disorder, predominantly inattentive type but whose age of onset is 7 years or after • Individuals with clinically significant impairment who present with inattention and whose symptom pattern does not meet the full criteria for the disorder but have a behavioral pattern marked by sluggishness, daydreaming, and hypoactivity • DSM IV-TR, 2000 as quoted in Kaplan & Sadock, 2007

39. Utah Criteria for Adult Attention Deficit Hyperactivity Disorder • Retrospective childhood ADHD diagnosis • Narrow criterion: met DSM-IV criteria in childhood by parent interview • Broad criterion: both (1) and (2) are met as reported by patient • Childhood hyperactivity • Childhood attention deficits • Adult characteristics: five additional symptoms, including ongoing difficulties with inattentiveness and hyperactivity and at least three other symptoms: • Inattentiveness • Hyperactivity • Mood lability • Irritability and hot temper • Impaired stress tolerance • Disorganization • impulsivity • Exclusions: not diagnosed in presence of severe depression, psychosis, or severe personality disorder

41. References • Sadock, B. J., Sadock, V. A. (2007) Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/ clinical sciences (10th ed.). Philadelphia, PA: Lippincot Williams & Wilkins. • Arnold, LE (1996). Sex Differences in ADHD, Journal of Abnormal Psychiatry, 24(5) • Lee, D.H., Oakland T., Jackson, G. & Glutting, J. (2008). Estimated prevalence of Attention-Deficit/ Hyperactivity disorder symptoms among college freshmen: Gender, race and rater effects. Journal of Learning Disabilities, 41(371)

42. References (cont.) • Simon, V., Czobar P., Balint S., Meszaros A. & Bitter, I., (2009). Prevalence and correlates of adult attention-deficit hyperactivity disorder: a meta-analysis. The British Journal of Psychiatry 194 • Stead, L. G., Kaufman, M. S. & Yanofski, J. (2011). First aid for the psychiatry clerkship (3rd ed.). New York, NY: McGraw-Hill.

43. THANK YOU Questions?