Claude Jolicoeur. m.d.

1. Attention-Deficit / Hyperactivity Disorder (ADHD) Trouble du déficit de l’attention/hyperactivité(TDAH) Claude Jolicoeur. m.d.

2. DSM-IV Criteria for ADHD • Symptoms of ADHD ; Topic Contents • The year 2000 Diagnostic & Statistical Manual for Mental Disorders (DSM-IV-TR) provides criteria for diagnosing ADHD. The criteria are presented here in modified form to make them more accessible to the general public. They are listed here for information purposes and should be used only by trained health care providers

3. Inattention • I. Either A or B: • A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: • 1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. • 2. Often has trouble keeping attention on tasks or play activities • 3. Often does not seem to listen when spoken to directly. • 4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

4. next • 5. Often has trouble organizing activities. • 6. 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). • 7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). • 8. Is often easily distracted. • 9. Is often forgetful in daily activities.

5. Hyperactivity/impulsivity B- 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:

6. next • 1. Often fidgets with hands or feet or squirms in seat.2. Often gets up from seat when remaining in seat is expected.3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

7. next • 4. Often has difficulty playing or enjoying leisure activities quietly. 5. Is often "on the go" or often acts as if "driven by a motor". 6. Often talks excessively

8. next • 7. Often blurts out answers before questions have been completed • 8. Often has difficulty waiting one's turn. • 9. Often interrupts or intrudes on others (e.g., butts into conversations or games).

9. next • B. Some hyperactive, impulsive or inattentive symptoms that cause impairment were present before 7 years of age. • C. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). • D. There must be clear evidence of clinically significant impairment in social, school, or occupational functioning. • E The symptoms do not happen exclusively during the course of a pervasiven developmental disorder, schizophrenia, or other psychotic disorder, and are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

10. next • Based on these criteria, three types of ADHD are identified: • 1. ADHD, Combined Type: if both criteria 1A and 1 B are met for the past 6 months • 2. ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1 B is not met for the past six months • 3. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1 B is met but Criterion 1A is not met for the past six months. • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. • [ADHD.._Referençes]

11. The most common disorder - emotional- cognitive- behavioral

12. With a high rate comorbidity - oppositional defiance: 40-70% - anxiety: 10-40% - conduct disorder: 20-56%- bipolar disorders:0-27% - conduct disrder: 20-56%- delinquent/Antisocial Activities: 18-30%- academic Problems: 90%Barkley

13. Social cost • Academic underacheivement • Conduct problems • Underemployment • Vehicle accidents • Bad personnal relations

14. Prevalence • More than- schizophrenia- obsessive-compulsive D- panic disorder • At 4% to 12% Shool-age (USA)

15. Sex ratio • More boys than girl - ratio 3:1 • Adults- ratio 1:1

16. Clinical Presentation (6-12 years) • Easily distracted • Homework poorly organized • Blurts out answers before question • Often interrupts • Fails to wait • Often out of seat • Perceived « immature » Based Greenhill

17. Clinical Presentation (13-18 years) • Inner reslessness more than agitation • Shoolwork disorganized • Engages in risky behaviors • Poor self-esteem • Poor peers relations • Confront with authority Based Greenhill, Conners and Jett

18. Neurobiology Maybe, the dysfunction - is intrinsic to the frontal lobe - is influenced by brains areas with subcortical projections. fMRI, PET studies: - circuits controling attention: less active and smaller

19. Main Neurotransmittors in ADHD • Dopamine • Epinephrine To regulate the inhibitory influences in the frontal-cortical processing of information

20. Dopamine • May - enhances signals - improves: . attention, . focus vigilance, . acquisition, . on-task behavior and cognition

21. Norepinephrine May- dampen « noise »- decrease distractibility and shifting - improve executive operations- increase behevioral, cognitive, motoricinhibition

22. Cognitive functions • Planning • Anticipating • Organizing • Working memory:- maintaining attention - focusing on task

23. Psychostimulants Acting primarily by blocking the reuptake of dopamine • Méthylphénidate: . old - ritalin 5, 10, 20 mg (3-4 hours), ritalin 20 mg Sr, 6-7 hours . new - concerta (long acting 10-12 hours)18, 27, 36, 54 mg. • Amphetamine: . old - dexedrine, short & long acting . new - adderall xr (long acting 10 hours), 5, 10, 15, 20, 25, 30 mg.

24. Nonstimulant • Atomoxetine (strattera), primarily blocking epinephrine reuptake • Buproprion (wellbutrin) • Tricycliques (norpramine-desipramine) • SSRIs (fluoxetine, paroxetine, sertraline) • Venlafaxine (Effexor) • Antipsychotics (risperdone-Risperdal) • Antihypertensives (guanafacine, clonidine)