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ADHD

Dr P.Kasi Krishna raja

DPM DNBAsst proff Of Psychiatry

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Attention-deficit/hyperactivity disorder (ADHD) is

the most common psychiatric disorder among

school-age children

Children with ADHD display the early onset of

symptoms consisting of developmentally

inappropriate overactivity, inattention, academic

underachievement, and impulsive behavior. increased risk of ADHD children for delinquency,

accidents, and substance abuse.

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ADHD is a familial disorder associated with

differences in central nervous system

structure, metabolism, and processing.

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History of ADHD Early 1900s-

inhibitory volition and defective moral control

1917-1918

encephalitis epidemic

brain-injured child syndrome

1940s and 1950s minimal brain damage and minimal brain dysfunction

hyperkinetic impulse disorder

1970 on

attention and impulse control, in addition to hyperactivity

problems in self-regulation and behavioral inhibition

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Different Names for ADHD Through

the years:

1902 Defects in moral character

1934 Organically driven

1940 Minimal Brain Syndrome

1957 Hyperkinetic Impulse Disorder

1960 Minimal Brain Dysfunction (MBD)

1968 Hyperkinetic Reaction of Childhood (DSM II) 1980 Attention Deficit Disorder - ADD (DSM III) with-

hyperactivity without-hyperactivity residual type

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ADHD Exposed

ADHD is identifiable via behavioral, not physicalcharacteristics, making it more likely to bemisunderstood.

Misperceptions: Behaviors that directly result from ADHD are not primarily

attributable to poor parenting, lack of discipline, lowmotivation, or intentional trouble making.

Not everything that fidgets and/or behaves defiantly is

ADHD.

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What Is ADHD?

Neurobehavioral disorder marked by:

Inattention

Difficulties controlling impulses

Excessive motor activity (hyperactivity)

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Indicators of ADHD as a Developmental Disorder

(Barkley, 1995)

Seen in early child

development

Behaviors clearly distinguish

child from non-ADHD

children

Occurs across several

situations (though not

necessarily in all of them)

Behaviors persistent over

time

Child not able to perform at

age-appropriate levels

Not accounted for by

environment of social

causes

Related to brain function

Associated with other

biological factors that can

affect brain function (i.e.

head injuries, genetics)

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ADHD Characteristics

Inattention

Impulsivity

Overactivity

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Inattention-Distractibility

Doesnt seem to listen Fails to finish assigned tasks

Often loses things

Cant concentrate

Easily distracted

Daydreams

Requires frequent redirection

Can be very quiet & missed

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Impulsivity-Behavioral Disinhibition

Rushing into things Careless errors

Risk taking Taking dares

Accidents/injuries prone

Impatience Interruptions

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Hyperactivity - Overarousal Restlessness

Cant sit still

Talks excessively Fidgeting

Always on the go

Easy arousal Lots of body movement

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Things We Can See (aka, Common

Complaints)

Difficulties sustaining attention

Daydreaming

Child doesnt listen

Always losing things Forgetful

Easily distracted

Needs constant supervision Child doesnt finish anything he/she starts

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Common Complaints (contd)

Problems with impulse control

Impatient/Difficulties waiting for things

Always interrupting others

Blurts out answers

Doesnt take turns

Tries to take shortcuts on many tasks (including

chores, homework, etc.)

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Common Complaints (contd)

Hyperactivity

Always on the go

Squirmycant sit still

Talks too much

Frequently hums or makes odd noises

Unable to put the brakes on motor activity

Child has two speeds; asleep and awake

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Mood Component

There is often a mood component with ADHD:

Moodiness (difficulty regulating mood)

Bursts of Hot temper (difficulty controlling temper)

It is possible to have ADHD and Depression, ADHDand Anxiety, ADHD and Bipolar, ADHD and Anger, orany combination of these.

Irritability, anger, rebelliousness, temper tantrums,

grumpiness, defiance or aggressive behavior can allbe symptoms of a treatable Mood Disorder.

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What Do These Behaviors Have in

Common?

Problem isnt as much sustaining attention asit is sustaining inhibitionthis is the hallmarkof ADHD

Inhibition: a mental process that restrains anaction (behavior) or emotion

Problems of inhibition are not a matter of

choice, but are instead a result of what is (or isnot) going on in the childs brain

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DSM-IV Criteria

Developmentally Inappropriate Levels of EitherInattention and/or Hyperactive/Impulsive Behavior

Duration of 6 Months

Cross-setting Occurrence of Symptoms

Impairment in Major Life Activities

Onset of Symptoms/Impairment by 7

Symptoms Not Better Explained by Other Disorders: e.g.,Severe MR, PDD, Psychosis, Bipolar, etc.

Three Subtypes Inattentive, Hyperactive, or CombinedTypes

Affects 5-8% of children, 4-5% of adults

Disorder is found universally

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Comorbid DSM-IV Disorders

Oppositional Defiant Disorder (40-70%) ADHD contributes to and likely causes ODD

Conduct Disorder (20-56%)

Delinquent/Antisocial Activities (18-30%) Psychopathy rates unknown but 20% of CD

Anxiety Disorders (10-40%; referral bias!) Related to poor emotion regulation than to fear

Major Depression (0-45%; 27% by age 20) Likely genetic linkage to ADHD

Bipolar Disorder (0-27%; likely 6-10% max.) Not documented in any follow-up studies to date

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Childhood Developmental Risks

Language Disorders (10-60%)

Developmental Coordination Disorder (50+%)

Accident Proneness 1.5 to 4x risk

Poor School Performance (90%+)

Low Academic Achievement (10-15 pt. deficit)

Low Average Intelligence (7-10 point deficit) Learning Disabilities (24-70%)

Increased Parent-Child Conflict & Stress

Peer Relationship Problems (50-70%+)

Poor Emotional Self-control

Greater Antisocial Activities in Adolescence Related primarily to development of early CD

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ADHD and the Human Brain

Portions of brains frontal lobe are responsible

for Executive functions:

Consolidating information from other areas of the

brain

Considers potential consequences and

implications of behaviors

Puts brakes on (inhibits) impulsive reactions

Initiates appropriate response to environment

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ADHD and the Brain (contd)

Research suggests that in in children with

ADHD, these executive areas of the brain are

under-active

Increasing the activity level in these areas of

the ADHD brain have been shown to decrease

behavioral symptoms. This is the logic behind

using Stimulant medications as a first linetreatment for the disorder.

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Other Neurobiological Conditions

Related to ADHD:

Central Auditory Processing Disorder (CAPD)

Sensory Integration Disorder

Motor Planning Disorder

Self-Regulatory Disorder

Autistic Spectrum Disorder - PDD, MSD, Globally

Delayed, Autistic

Neurological Conditions: Epilepsy, Tourette

Syndrome

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What Research is Telling Us about

ADHD Genetically transmitted in 70-95% of cases

Results from chemical imbalance or deficiency in certain

neurotransmitters-chemicals which help brain regulatebehavior

Rate at which brain uses glucose, its main energy

source, is lower in subjects with ADHD than those

without (Zametkin et al, 1990)

Depressed release of Dopamine might have role in

ADHD (Volkow et al, 2003)

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Research also tells us about ADHD

that:

Central pathological deficits of ADHD are linked to severalspecific brain regions

Frontal Lobe Its connections to Basal Ganglia

Their relationships to central aspect of Cerebellum

Less electrical activity in brain & show less reactivity to

stimulation in one or more of above brain regions Brains are 3-4% smaller-in more severe-frontal lobes,

temporal gray matter, caudate nucleus & cerebellum weresmaller

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PET Scan of Metabolism of Glucose

Adult Brain with ADHDPositron Emission Tomography (PET) Pictures of

Adult with ADHD Normal Adult

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ADHD & LD lead to Diminished

Executive Functions

Deficient self-regulation of behavior, mood,

response

Impaired ability to organize/plan behavior overtime

Inability to direct behavior toward future

Diminished social effectiveness & adaptability

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What is the Impact of these

Disorders?

Neurologically based behavioral issues can

keep child from developing normally

Lack of full coordination of gross & fine

motor skills

Lack of complete age appropriate speech,language & communications

Impaired self-esteem

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What is the Impact of ADHD on

people?(Barkley, 2002)

32-40% of students with ADHD drop out of school

Only 5-10% will complete college

50-70% have few or no friends 70-80% will under-perform at work

40-50% will engage in antisocial activities

More likely to experience teen pregnancy & sexually

transmitted diseases Have more accidents & speed excessively

Experience depression & personality disorders

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Assessment Tools

Conners Rating Scales, by parents andteachers, most common (subjective)

WISC III (Wechsler Intelligence Scale forChildren,Also shows Depression)

TOVA (Test of Variables of Attention)

Wisconsin Card sorting (tests FrontalLobe)~

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TOVA

The T.O.V.A. was developed by Dr Greeenberg, an

authority on hyperactivity and ADHD, and a leader in

the field for the past 25 years.

The T.O.V.A is a 22.5 minute computerizedassessment (visual or auditory) which in conjunction

with teacher and parent behavior rating scales, is a

highly effective screening tool for ADHD.~

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Overview: Medication Treatments for ADHD

FDA-Approved Treatments Stimulants

Schedule II Drugs

Potentiate dopamine/norepinephrine neurotransmission

Atomoxetine (Strattera; Eli Lilly)

Non-stimulant Norepinephrine reuptake inhibitor

Off-Label Treatments

Modafanil (Provigil; Cephalon) arousal-promoting

Guanfacine - alpha-2 agonist

Clonidine - alpha-2 agonist

Bupropion (Wellbutrin family) norepinephrine/dopaminereuptake inhibitor

Tricyclic Antidepressants

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The Stimulant Landscape: Drugs & CompaniesAmphetamine Line

Extended Release Formulations (up to 12hours)once daily

Vyvanse capsules (Shire)lisdexamfetamine,d-amphetamine/L-lysine prodrug; approved2/07, launched 2nd quarter 2007

Adderall XR capsules (Shire)mixedamphetamine salts of dextroamphetamine &racemic d/l-amphetamine

Dexedrine SR spansules (GlaxoSmithKline) &generic versions of Dexedrine SR -dextroamphetamine

Immediate Release Formulations (3-6hours)2-3 times daily

Adderall tablets (Barr/Duramed-Shire Deal)

Generic versions of Adderall (ie, mixedamphetamine salts)

Dexedrine tablets (GlaxoSmithKline) -dextroamphetamine

Generic versions of Dexedrine

Methylphenidate Line

Extended Release Formulations (up to 12hours)once daily

Concerta tablets (McNeil Pediatrics) -methylphenidate

Focalin XR capsules (Novartis) -dexmethylphenidate

Daytrana Transdermal Patch (Shire) -methylphenidate

Intermediate-Release Formulations,Second-Generation (6-8 hours)

1-2x daily

Ritalin LA capsules (Novartis; Celgene);ANDA filed for generics 11/2007 withParagraph IV certification

Metadate CD Capsules (UCB) -methylphenidate +metadate ER

Intermediate-Release Formulations, First-Generation (3-6 hours)1-2x daily

Ritalin SR tablets (Novartis) & genericversions - methylphenidate

Metadate ER tablets & generic versionsmethylphenidate

Immediate Release Formulations (2-4hours), 2-4x daily

Ritalin tablets (Novartis) & generic versionsmethylphenidate

Focalin tablets (Novartis) & generic versions(approved 2/07) - dexmethylphenidate

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The Prodrug Concept Lisdexamfetamine dimesylate is a therapeutically

inactive prodrug

The active ingredient d-amphetamine is covalentlylinked to the amino acid l-lyine

The active ingredient d-amphetamine is released during

the enzymatic breakdown of the prodrug in the gut andliver

Saturation kinetics govern the breakdown into theactive d-amphetamine form (unlike other stimulants)

Pharmacokinetic properties associated with the prodrugmechanism of action confer unique clinical and safetyproperties

First-in-class prodrug stimulant