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Research Report

Research Report. “Defects in moral control”, independent of intellectual development Inadequacy of self-control despite seemingly adequate child-rearing or environmental stimulation

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Research Report

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  1. Research Report • “Defects in moral control”, independent of intellectual development • Inadequacy of self-control despite seemingly adequate child-rearing or environmental stimulation • Deficiencies in attention, moral consciousness, responsiveness to discipline, emotional maturity, and social conduct (e.g., lying and stealing) • Increased minor physical anomalies • Greater proportion of males • Hereditary predisposition Still, 1902

  2. ADHD: Prevalence and Demographics • Affects school-aged children • Overall prevalence 3% to 5% • Diagnosed in boys 3 to 4 times more than in girls • Unclear if prevalence is similar in other cultures • Accounts for 30% to 50% of mental health referrals for children • Prevalence increases as SES level declines • Resulted in ~8.6 million physician-office visits in 1999 • Persists in some patients into adolescence and adulthood (symptom profile may change)

  3. ADHD: Diagnosis • Diagnostic assessment typically prompted by academic and/or behavioral problems • Diagnosis requires meeting DSM-IV criteria • Clinical diagnosis requires input from parents, teachers, practitioners • Specific physical tests not available • Medical and neurological status evaluated

  4. ADHD: DSM-IV Symptoms Six of more of the following • Inattention • Careless • Difficulty sustaining attention in activity • Doesn’t listen • No follow through • Can’t organize • Avoids/dislikes tasks requiring sustainedmental effort • Loses important items • Easily distracted • Forgetful in daily activities

  5. Hyperactivity Squirms and fidgets Can’t stay seated Runs/climbs excessively Can’t play/work quietly “On the go”/ “Driven by a motor” Talks excessively Impulsivity Blurts out answers Can’t wait turn Intrudes/interrupts others ADHD: DSM-IV SymptomsSix or more of the following

  6. ADHD: Symptoms and Diagnosis • Symptoms—inattention and/or hyperactivity-impulsivity • Present before age 7 years • Maladaptive and inconsistent with developmental level • Persistent (>6 months) • Impairment is present in two or more settings • Symptoms not due to other psychiatric/developmental disorders • Diagnosis—DSM-IV types • Predominantly inattentive • Predominantly hyperactive-impulsive • Combined Type

  7. ADHD: Social and Academic Impact • Symptoms of ADHD interfere with child’s functioning at home, at school, with peers, which may include • Stress on family • Poor school performance • Classroom disruptions • Poor peer interactions • Embarrassment of taking medication at school

  8. ADHD: Potential Consequences • As reported in 1998 NIH Consensus Statement, ADHD has been associated with • Injuries, drug abuse, antisocial behavior when in combination with conduct disorders • Increased parental frustration, marital discord, as reported with other chronic disorders • Serious burden of medical costs for families not covered by health insurance • Disproportional share of resources and attention from health care system, schools, and other social service agencies

  9. ADULT ADHDUtah Criteria • Childhood history of ADHD* • Fidgety, restless, always on the go, talked excessively • Attention deficit • Behavioral problem in school • Impulsivity • Overexcitability • Temper outbursts *Must have first two characteristics and at least two of the remaining characteristics

  10. ADULT ADHDUtah Criteria – Cont’d • Presence of ADHD in Adulthood* • Persistent motor hyperactivity • Attention deficits • Affective lability • Inability to complete tasks • Poorly controlled temper, explosive, short-lived outbursts • Impulsive behavior (distinct from manic episode) • Stress intolerance *Must have first two characteristics and at least two of the remaining characteristics

  11. MANIFESTATIONS OF ADULT ADHD • Impaired social skills • Low self-esteem • Frequent loss of temper • More driving accidents • Difficulty organizing/finishing tasks • Anxious restlessness • Frequent job failures • Increased risk for antisocial behavior, mood disorders, substance abuse

  12. ADHD: Differential Diagnosis • Psychiatric • Learning disabilities • Conduct disorder • Affective disorder, depression, bipolar disorder, mania • Pervasive development disorder (e.g., autism) • Childhood schizophrenia • Anxiety disorders (separation anxiety, school phobia) • Mental retardation

  13. ADHD: Differential Diagnosis • Medical • Use of phenobarbital as an anticonvulsant • Theophylline (used in asthmatics) • Substance abuse (amphetamines) • Hyperthyroidism • Tourette’s syndrome

  14. ADHD: Genetic Factors • Family aggregation studies • First-degree relatives • Second-degree relatives • Adoption Studies • Twin Studies • Other Genetic Hypotheses • Tourette’s syndrome (50% of affected individuals have elements of ADHD) • Mutation giving rise to generalized resistance to thyroid hormone

  15. ADHD: Neuroanatomical Substrates • Frontal Lobe Hypothesis • Non-Dominant Frontal-Striatal Dysfunction • Corpus Callosum - ? Decreased Splenial Area

  16. ADHD: Suggested Pathophysiology • Neurochemical pathways • Dopaminergic and noradrenergic implicated • Structural and functional differences from non-ADHD controls • PET and MRI • Scans of ADHD patients show reduced glucose metabolism in premotor cortex and superior prefrontal cortex compared to controls • Dopamine transmission • Genetic forms of ADHD are associated with abnormalities at the dopamine reuptake transporter gene and the D4 receptor gene

  17. ADHD: Total Treatment Program • Total Treatment Program: • Recommended for maximum benefit • Behavior Management: • Includes strategies and methods for home and classroom environments • Pharmacological Treatment: • Targets underlying neurochemical causes • Enhances behavior management efforts

  18. ADHD: Treatment Approaches • Pharmacological Intervention • Parent Training • Modification of Classroom Environment • Formal classification (IDEA) • “504” Accommodations • Self-Control Training with Child • Individual or Group Counseling • Residential Treatment

  19. ADHD: Unproven Therapies • Removal of food additives, dyes, and flavors • Removal of sugar or caffeine from diet • Vitamin therapy • Sensory-Integration training • Avoidance of fluorescent lighting • Relaxation training/biofeedback • Play therapy

  20. ADHD: Stimulant Treatment • CNS stimulants highly effective • Reduce core symptoms of inattention, hyperactivity, and impulsivity in 75% to 90% ofchildren with ADHD • Pharmacological treatment usually involves • Methylphenidate products • Dextro-amphetamine/amphetamine products • Common side effects • Insomnia, decreased appetites, dysphoric mood • Irritability, reduced motor activity • Headaches, G-I complaints • Tics • Decreased frequency of social interactions

  21. ADHD: Methylphenidate Treatment • Methylphenidate • Commonly prescribed medication • Formulations currently available • Immediate-release • Sustained-release • Extended-release preparations • Taken only in the morning • Typically last between 6-12 hours depending upon dose

  22. ADHD: Non-Stimulant Treatment Antidepressant Medications • Tricyclic Antidepressants • Used primarily for ADHD-Inattentive Type • Studies have shown superior to placebo but less effective than stimulant medications • Side effects: sedation, constipation, anoxeria, dry mouth, dizziness, increased pulse and BP (case reports of sudden cardiac death) • SSRI’s • Controlled studies to date not impressive (unless co-morbid depression is present) • Some agents (e.g., fluoxetine) can increase hyperactive and or impulsive behavior

  23. ADHD: Non-Stimulant Treatment Antidepressant Medications • Others • Buproprion – has amphetamine-like effect, useful in adult ADHD, pervasive developmental disorder

  24. ADHD: Non-Stimulant Treatment Alpha-2 Agonists • Clonidine • Unclear if more effective in patients with greater impulsivity and behavioral dyscontrol (controlled trials equivocal) • Commonly used to treat TS + ADHD • Less effective than MPH in controlling inattention, distractibility • Effect on cognitive and academic performance not established • Side effects: sedation, motor retardation, dry mouth, dizziness • Often used in combination with MPH • Guanfacine • Similar in action to clonidine but less sedating • Controlled trials in ADHD equivocal; proven to useful in treating TS + ADHD

  25. ADHD: Non-Stimulant Treatment Norepinephrine Reuptake Inhibitors • Atomoxetine hydrochoride (approved 12/02) • Selective NE reuptake inhibitor • thought to be related to selective inhibition of the pre-synaptic norepinephrine transporter • Can be dosed once or twice per day • Generally well-tolerated • upset stomach, decreased appetite, nausea and vomiting, dizziness, tiredness, and mood swings • Cannot be taken with MAOI’s, certain SSRI’s

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