Putting Solutions into ActionADHD and Learning Disorders

in High School

Robert Milin, MDDirector, Adolescent Day Treatment UnitYouth Psychiatry ProgramRoyal Ottawa Mental Health CentreClinical ScientistInstitute of Mental Health ResearchAssociate ProfessorDepartment of PsychiatryUniversity of Ottawa Date: February 15, 2013

Disclosures of Potential ConflictsSource Research

FundingAdvisor/

ConsultantEmployee Speakers’

BureauBooks,

Intellectual Property

In-kind Services

(example: travel)

Stock or Equity

Honorarium or expenses

for this presentation or meeting

Bristol- Meyers Squibb Canada

Canadian Institute of Health Research

Royal Ottawa Foundation for Mental Health

Learning Disorders (LD)

DSM-IV definition: Individual’s achievement as measured by standardized

tests (academic achievement) in reading, math, or written expression is substantially lower than expected for age, schooling and intellectual level

Significant impairment in academic achievement or activities of daily living that requires the specific learning skill/ability

Learning Disorders

Prevalence rates range from 2-10%5% of US public school students identified with a learning

disorderReading Disorder is believed to be the most prevalent LD at

~4%

It is important to differentiate and take into consideration such factors as lack of opportunity, poor teaching or culture

Learning Disorders

About 1.5 times greater school drop out rate

Common co-occurrence (10-25%) with Disruptive Behavioural DisordersConduct DisorderOppositional Defiant DisorderADHD

Communication Disorders

Types include: Expressive Language DisorderMixed Receptive-Expressive Language DisorderPhonological Disorder (formerly Developmental

Articulation Disorder)

Intellectual Functioning

General intellectual functioning is defined by the intelligence quotient (IQ or IQ-equivalent) on individual assessment with a standardized intelligence test

Important that IQ testing procedures adequately reflect the individual’s ethnic, cultural or linguistic background

IQ

Range Score Percentile Rank

Average 80-120 9-91%

True Average 90-110 25-75%

Low Average 80-90 9-25%

High Average 110-120 75-91%

IQ Indices

Verbal Comprehension Perceptual Reasoning Working Memory (WM) Processing Speed (PS) WM & PS are referred to as the cognitive proficiency

indices

Borderline Intellectual Functioning

DSM-IV definition:When overall cognitive abilities fall within the IQ range of

71-84An IQ score of 85 is equivalent to the 16% rank

ADHD DSM-IV CRITERIAA. Either (1) or (2):

1. Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that’s maladaptive and inconsistent with developmental level

INATTENTIONa) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or

other activitiesb) Often has difficulty sustaining attention in tasks or play activitiesc) Does not seem to listen when spoken to directlyd) Often does not follow through on instructions, fails to finish schoolwork, chores or duties in the

workplacee) Often has difficulty organizing tasks and activitiesf) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effortg) Often loses things necessary for tasks or activitiesh) Is often easily distracted by extraneous stimulii) Is often forgetful in daily activities

ADHD DSM-IV CRITERIAA. Either (1) or (2):

2. Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that’s maladaptive and inconsistent with developmental level

HYPERACTIVITYa) Often fidgets with hands or feet or squirms in seatb) Often leaves seat in the classroom or in other situations in which remaining seated is

expectedc) Often runs about or climbs excessively in situations in which it is inappropriate d) Often has difficulty playing or engaging in leisure activities quietlye) Is often “on the go” or often acts as if “driven by a motor”f) Often talks excessively

IMPULSIVITYg) Often blurts out answers before questions have been completedh) Often interrupts or intrudes on others

ADHD DSM-IV CRITERIAB. Some hyperactive-impulsive or inattentive symptoms that

caused impairment were present before age 7 years

C. Some impairment from the symptoms is present in two or more settings

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning

E. The symptoms do not occur exclusively during the course of PDD, schizophrenia or other psychotic disorder and are not better accounted for by another mental disorder

Characterization of DSM-IV ADHD subtypes:

ADHD/AD - academic problems, fewer behavioural problems and higher proportion of girls (20-30%), prevalence increases with age

ADHD/HI - behavioural problems, few academic problems and low rate of anxiety or depressive symptoms (<10-15%)

ADHD/CT - both behavioural and academic problems, most prevalent subtype and likely most impaired subtype with the worst prognosis (50-75%)

DSM-V Changes in ADHD Maximum age of onset of 12 years; up from 7

years

Elimination of DSM-IV subtypes; include specifiers of current manifestation at the time of assessment

Broaden age-related symptoms to include examples relevant to adults

DSM-V Changes in ADHD

Broaden comorbidities to include Autism Spectrum Disorders (previously excluded)

ADHD clustered under Neurodevelopmental Disorders rather than Disruptive Behavioural Disorders

Epidemiology

Estimate of 3-7% of school-aged children in the U.S.

Ontario Child Health Study-6.3%. Most common diagnosis, ADHD ages 4-11 and Conduct Disorder, ages 12-16.

Adults ~ 4% in the US.

Gender ratio 3 Boys: l Girl, approaches 1:1 in adulthood.

30% - 50% of all child psychiatric outpatients demonstrate symptoms of ADHD.

Cross culture differences in prevalence rates related to differences in nomenclature, diagnostic decision processes and cultural variations in perceptions of disruptive childhood behaviours.

Faraone SV et al. World Psychiatry 2003;2:104-113.

0 5 10 15 20

Puerto Rico

New York City

Pittsburgh

Iowa

Tennessee

Minnesota

Oregon

Missouri

Virginia

N. Carolina

NY, MI, WI

IndiaChina

NetherlandsNew Zealand

JapanBrazil

UkraineGermany

Netherlands/BelgiumSwitzerland

IsraelUnited Kingdom

IrelandCanada

New ZealandSpain

0 5 10 15 20

ADHD: Worldwide Prevalence (%)

Spencer,Spencer, 2005, Harvard Update; 2005, Harvard Update; McGough, Smalley, McCracken McGough, Smalley, McCracken et al. et al. American Journal of PsychiatryAmerican Journal of Psychiatry, , September 2005, Vol. 162, Page September 2005, Vol. 162, Page 16211621

22%

44%

56%

78%

In ChildhoodIn Childhood In AdulthoodIn Adulthood

Inattentive Inattentive TypeType

Combined Combined TypeType

Inattentive Inattentive TypeType

Combined Combined TypeType

3:13:1Male to FemaleMale to Female

1:11:1Male to FemaleMale to Female

ADHD Types: Childhood vs. Adulthood

Assessment of ADHD in Youth Modified from Weiss & Murray,

CMAJ, March 2003

Assess current ADHD symptoms using interview and rating scales with youth normsEstablish childhood history of ADHD– retrospective parent

or self-report - collateral history including elementary school report cards and previous psychological assessment

Assess functional impairment in multiple domains

Assessment of ADHD in Youth

Developmental history—especially behavioural and school history including indication of a learning disorder/disability

Psychiatric history—rule out or establish comorbid disorder—particular attention to substance use history

Family psychiatric history

Rule out medical causes

ADHD remains a clinical diagnosis with clinician-administered interview as the cornerstone of diagnostic evaluation