Attention-Deficit Hyperactivity Disorder

Attention-Deficit Hyperactivity Disorder Melissa Stern, M.S. mkstern@phhp.ufl.edu

A Day in the life of….

Attention-Deficit/Hyperactivity Disorder • ADHD is a neurodevelopmental disorder of childhood that is characterized by developmentally inappropriate levels of: • Hyperactivity • Impulsivity • Inattention

ADHD: Prevalence • 3-9% of the elementary school population • more often in males than females, with the sex ratio being about 3:1 to 9:1 • most common disorders of childhood accounting for a large number of referrals to pediatricians, family physicians and child mental health professionals

ADHD Risk Factors • Maternal cigarette use • Maternal alcohol use • Unusually long or short labor • Forceps delivery • Toxemia • Meconium staining • Birth during the month of September • Minor physical anomalies

History of ADHD • Characteristics of this disorder have been recognized for at least a century • The disorder has been referred to by a variety of labels: • Minimal Brain Dysfunction (MBD) • Hyperkinetic Reaction of Childhood • Attention Deficit Disorder (ADD) • Attention Deficit Hyperactivity Disorder (ADHD)

History of ADHD • 1980’s: • DSM III & DSM III-R stimulates ADHD research • development of new assessment methods • new treatment methods • increased focus on biological factors. • 1990’s: • Neuroimaging • genetics • reevaluation of DSM

DSM-IV:Hyperactivity • Often fidgets with hands or feet, squirms in seat • Often leaves seat in classroom or in other situations in which remaining seated is expected • Often runs about or climbs excessively in situations in which it is inappropriate • Often has difficulty playing or engaging in leisure activities quietly

DSM-IVHyperactivity • Is often "on the go" or often acts as if "driven by a motor” • Often talks excessively when inappropriate to the situation • 6 or more of hyperactive and/or impulsive symptoms required for diagnosis

More on Hyperactivity • Children with ADHD are more active, restless, and fidgety than normal children during the day and during sleep • There are different types of hyperactivity: • Gross Motor Activity • Restless/Squirmy • Verbal hyperactivity • Hyperactivity often varies according to situation • Degree of hyperactivity may vary with age

DSM-IV:Impulsivity • Often blurts out answers before questions have been completed • Often has difficulty awaiting turn • Often interrupts or intrudes on others Six symptoms of hyperactivity and impulsivity are required for diagnosis

DSM-IV:Inattention • Often fails to give close attention to details or makes careless mistakes • Often has difficulties sustaining attention in 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 homework, chores, or duties in the workplace

DSM-IV:Inattention • Often has difficulty organizing tasks and activities • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort • Often loses things necessary for tasks or activities • Is often easily distracted by extraneous stimuli. • Is often forgetful in daily activities • 6 or more symptoms needed for diagnosis

More on Inattention • “Attentional" problems may be most obvious on specific types of attentional tasks: • sustained attention: responding to tasks, being vigilant • situations requiring the child to attend over time to dull, boring, and repetitive tasks

Diagnostic Criteria Overview • Symptom Criteria - Core Symptoms of Hyperactivity & Impulsivity and/or Inattention (Six or More Symptoms of either category) • Duration Criterion - Symptoms have Persisted for at Least 6 Months • Developmental Criterion - Symptoms are Inconsistent with Developmental Level • Impairment Criterion - Clear Evidence of Clinically Significant Impairment in Social, Academic, or Occupational Functioning

Diagnostic Criteria • Age Criterion - Some Symptoms that Cause Impairment Were Present Before Age 7 • Situation Criterion - Some Impairment from Symptoms is Present in Two or More Settings

Types of ADHD • Combined Type • Symptoms of hyperactivity, impulsivity and inattention • Hyperactive/Impulsive Type • Symptoms of hyperactivity and impulsivity • Predominately Inattentive Type • Symptoms of inattention

Impairment in ADHD • Social Impairment – What does it look like? • Academic Impairment – Long term outcomes for children with ADHD not so good • Family Impairment • Occupational Impairment • Driving Impairment

ADHD Across the Lifespan • ADHD is a chronic disorder • 60%-80% of children continue to meet diagnostic criteria in Adolescence • 50%-70% of children will continue to meet diagnostic criteria in Adulthood • ADHD in childhood is different from adolescence and different from adulthood

Presentation of ADHD in Adolescence • Gross motor activity tends to disappear • Predominance of Inattention, Restlessness (rather than hyperactivity) and impulsivity • What is a developmentally appropriate level of impulsivity in adolescence?

ADHD in Adults • More similar to adolescent presentation • Mainly problems with inattention and impulsivity • How much inattention and impulsivity affect an adult male? A father? A store clerk? • Impairment is key

Occupational Impairment • Similar problems to those seen in the academic environment • Often unprepared, untimely, easily distracted • “Under Achievers”

Social Impairment • Still there in adolescence and adulthood! • If you don’t attend when people talk, they often think you aren’t interested

Sensation Seeking/Substance Use • Adolescents and adults with ADHD are more likely than those with out to engage in risky behavior including: • Marijuana use • Alcohol Use • Drunk Driving • This is true even when accounting for the presence of oppositional defiant disorder and/or conduct disorder

Driving impairment • Leading cause of death in 15-24 year olds are motor vehicle accidents • Adolescents and adults with ADHD are more likely to have an accident, to have more accidents, to speed, to receive traffic citations, to receive more traffic citations, to have their licenses suspended/revoked, to drive without a license, to drive under the influence

Driving Impairment • One of the most common causes of MVAs is plain old inattention • Adolescents in particularl are more likely to speed, to not use a seatbelt, and to drink and drive • Hmm….what does this mean for people with ADHD

Virtual Reality Researchers are using virtual reality to simulate driving situations and assess performance Here at UF we have a high tech simulator http://driving.phhp.ufl.edu/

Shameless Plug • Driving Impairment in ADHD is my area of research • I am going to need an RA or two to help with my dissertation starting in the Spring or next fall • If you are a sophomore or junior and are interested in getting into research, EMAIL ME!  mkstern@phhp.ufl.edu

But What About Cognitive Impairment • It’s a NEUROdevelopmental disorder, right? • So why hasn’t this lady mentioned cognitive problems?

ADHD & Neuropsychological Deficits • Results from research involving neuropsychological testing has often suggested that children with ADHD have problems: • inhibiting behavioral responses • with working memory • with planning and organization • with verbal fluency • with perserveration • in motor sequencing • with other frontal lobe functions

Neurological Findings • Siblings of children with ADHD who do not have ADHD, have milder yet significant impairments in executive functions • This suggests a possible genetic risk for executive function deficits in families

Other Neurological Findings • Differences in cerebral blood flow • Differences in cerebral metabolism • Differences in the corpus collosum

Neurotransmitter Deficits • Neurotransmitter dysfunction in children with ADHD has been suggested for many years • Originated from observations of the response of children with ADHD to different type of stimulant drugs • The fact that stimulant drugs have an impact on ADHD and that they increase dopamine has contributed to the neurotransmitter dysfunction hypothesis

Comorbidity & ADHD • Why is it essential to consider the possibility of comorbid conditions in assessing children with ADHD? • Importance of distinguishing between comorbid conditions and mimicry • What is the frequency of comorbidities in children with ADHD?

Comorbidities • Learning Disabilities - 19 to 26% • Oppositional Defiant Disorder - 40% • Conduct Disorder - 25% children; 45-50% adolescents • Anxiety Disorders - 30% • Depressive Disorder - 10 - 30% • Bipolar Disorder – up to 20% • Tics and Tourette’s Disorder – 7% of children with ADHD have a tic disorder • 40 to 50% of those with Tourette’s disorder have ADHD

Onto Assessment and Diagnosis!

American Academy of Pediatrics Guidelines • Only governing organization with guidelines for ADHD assessment • Designed for pediatricians • Move toward guidelines in APA

The Interview • Structured or semi-structured • Gold Standard is “The Barkley” • Parent and Self-Report versions • Mostly used in research • Goal is to assess for the three main symptom areas and evidence of impairment which meets DSM criteria

Behavioral Observations • This isn’t technically recommended by AAP • However, if a child is literally climbing the walls, it might be good to note that • Always remember that children may be inclined to be on their “best behavior” in new situations • Coding systems available for looking at hyperactive and inattentive behaviors

Parent-Report Rating Scales • Shorter measures which ask parents about frequency, severity, etc. of various behaviors • Recommended by AAP but not required • Conners’ Parent Rating scale the “Gold Standard” form • Assesses various aspects of inattention, hyperactivity, impulsivity

CPRS • Items are rated on a four-point scale from “Not at all true” to “Very much true” • 87 questions • Each question is part of one or more subscales • The parents’ rating on a given question corresponds to a number 0-3 • You sum the numbers for that scale • You plot subscale sums on the profile chart • Scores in the red area are indicative of greater problems

Parent-Report “Broadband” Measure • Broadband measures assess a wide array of social, emotional, and behavioral problems • They are not recommended for AAP for ADHD diagnosis • However, they are USEFUL for identifying comorbid areas of concern (aggression/conduct problems, depression)

Teacher Reports • These are essential in assessing for ADHD • Need to identify impairment in MULTIPLE SETTINGS • Most children with ADHD will have academic impairment • Teachers may have the best knowledge of “developmentally appropriate” levels because they work with so many children

Teacher Reports • There is a teacher version of the CPRS, called the Conners’ Teacher Rating Scale (CTRS) • Modified for the classroom setting but scored the same way • There are also teacher equivalents of broadband measures

Problems with Parent and Teacher Report • Always the issue of informant bias (wanting to look like a good parent, like a teacher who can “handle” kids) • Sometimes difficult to get in contact with teachers and they often don’t return forms • CPRS and BASC may be biased towards non-European-American Children

Detour: Multicultural Issues in ADHD • ADHD is not limited to the U.S. • It is seen cross-culturally • However, there is concern it is over-diagnosed in Low SES and minority children • Compared to parents of Caucasian children, parents of African-American and Hispanic children have reported significantly more often feeling as though their children are over-diagnosed and over-medicated

Detour: Multicultural Issues In ADHD • Parents of African-American children less likely to associate school problems with ADHD and are less likely to request behavioral interventions compared to parents of Caucasian children • Parents of African-American children more likely to report not knowing the etiology of ADHD and where to go to receive treatment for the disorder compared to parents of Caucasian children

Attention-Deficit Hyperactivity Disorder