ADHDADHD
Hill, P. Child & Adolescent Mental Health in Primary Care 2003; 1(1):2-4
““Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder (ADHD) is a pattern of behaviour which is (ADHD) is a pattern of behaviour which is the most recent in a series of American the most recent in a series of American attempts to characterise inattentive attempts to characterise inattentive restlessness as a condition. It is effectively a restlessness as a condition. It is effectively a syndrome encompassing hyperactivity, poor syndrome encompassing hyperactivity, poor concentration and marked impulsive, concentration and marked impulsive, impatient, excitable behaviour. Most, but not impatient, excitable behaviour. Most, but not all, instances are predominantly genetic in all, instances are predominantly genetic in origin, with various inherited deficiencies of origin, with various inherited deficiencies of the dopamine neurotransmitter system.”the dopamine neurotransmitter system.”
InattentionInattention HyperactivityHyperactivity
ImpulsivityImpulsivity
Symptoms of ADHDSymptoms of ADHD
ADHD: Prevalence and ADHD: Prevalence and DemographicsDemographics
Overall prevalence 3% to 10% in school-Overall prevalence 3% to 10% in school-
aged childrenaged children
Diagnosed in boys 3 to 4 times more often Diagnosed in boys 3 to 4 times more often
thanthan
in girlsin girls
Persists in 30% to 50% of patients into Persists in 30% to 50% of patients into
adolescence and adulthood (symptom adolescence and adulthood (symptom
profile may change)profile may change)
Neurochemical Neurochemical Pathophysiology of ADHDPathophysiology of ADHD
Receptors
Synapse
NerveImpulse
Transporter
Noradrenaline Dopamine
Impact of ADHD on PatientsImpact of ADHD on Patientsand Familyand Family
PatientsPatients Poor academic Poor academic
achievementachievement Social impairmentSocial impairment Low occupational Low occupational
statusstatus Increased risk of Increased risk of
substance abuse substance abuse Increased risk of Increased risk of
injuryinjury
FamilyFamily Increased stress Increased stress
levelslevels Increased Increased
depressiondepression Increased marital Increased marital
discorddiscord Changed work Changed work
statusstatus
Impact of ADHD onImpact of ADHD onSchool PerformanceSchool Performance
Poor classroom behaviourPoor classroom behaviour Poor academic achievementPoor academic achievement Special education requirements (tutoring Special education requirements (tutoring
and special educational programmes)and special educational programmes) School exclusion (either suspension or School exclusion (either suspension or
expulsion)expulsion) Repetition of gradesRepetition of grades Failure to gain external qualificationsFailure to gain external qualifications
Effects of ADHD on Effects of ADHD on Behavioural DevelopmentBehavioural Development
Problems with productivity and motivationProblems with productivity and motivation
Reduced ability to express ideas and Reduced ability to express ideas and
emotionsemotions
Decreased working memoryDecreased working memory
Problems with social interactionProblems with social interaction
Impairments in speechImpairments in speech
Problems with verbal reasoningProblems with verbal reasoning
Developmental Impact of Developmental Impact of ADHDADHD
Pre-school Adolescent AdultSchool-age College-age
Behaviouraldisturbance
Behavioural disturbanceAcademic problemsDifficulty with social interactionsSelf-esteem issues
Academic problemsDifficulty with social interactionsSelf-esteem issuesLegal issues, smoking and injury
Academic failureOccupational difficultiesSelf-esteem issuesSubstance abuseInjury/accidents
Occupational failureSelf-esteem issuesRelationship problemsInjury/accidentsSubstance abuse
Defining ComorbidityDefining Comorbidity
ADHD is highly comorbidADHD is highly comorbid
Comorbidity is defined as two different Comorbidity is defined as two different
diagnoses present in an individual patientdiagnoses present in an individual patient
It is important to recognise comorbid It is important to recognise comorbid
disordersdisorders
Comorbidities may require treatment Comorbidities may require treatment
independent from and different to therapy independent from and different to therapy
for ADHDfor ADHD
Co-occurring Disorders in Co-occurring Disorders in Children (Children (n n = 579)= 579)
ADHDalone31%
AnxietyDisorder
34%
Mood Disorders 4%MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096
OppositionalDefiant
Disorder40%
Tics11%
Conduct Disorder14%
Common Associated Common Associated ComorbiditiesComorbidities
(%)
Milberger et al. Am J Psychiatry 1995; 152: 1793–1799Biederman et al. J Am Acad Child Adolesc Psychiatry 1997; 36: 21–29Castellanos. Arch Gen Psychiatry 1999; 56: 337–338Goldman et al. JAMA 1998; 279: 1100–1107Szatmari et al. J Child Psychol Psychiatry 1989; 30: 219–230
60
40
20
0
Oppositionaldefiant
disorder
Anxiety disorder
Learning disorder
Mood disorder
Conductdisorder
Smoking Substance use
disorder
Tics
Input Needed to Make Input Needed to Make a Diagnosisa Diagnosis
DiagnosisDiagnosisTeacherTeacher
ChildChild
ParentParent
ImpulsivityImpulsivityTalks excessively Talks excessively ††
Blurts out answersBlurts out answers
Cannot await turnCannot await turn
Interrupts othersInterrupts others
Intrudes on othersIntrudes on others
DSM-IV – Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association, 1994)ICD-10 – International Classification of Diseases, 10 th Edition (World Health Organisation, 1993)
HyperactivityHyperactivityFidgetsFidgets
Leaves seat in classLeaves seat in class
Runs/climbs Runs/climbs excessivelyexcessively
Cannot play/work Cannot play/work quietlyquietly
Always ‘on the go’Always ‘on the go’
Talks excessively *Talks excessively *
InattentionInattentionDoes not attendDoes not attend
Fails to finish Fails to finish taskstasks
Can’t organiseCan’t organise
Avoids sustained Avoids sustained efforteffort
Loses things, Loses things, ‘forgetful’‘forgetful’
Easily distractedEasily distracted
* ‘Talks excessively’ is one of the DSM-IV criteria for hyperactivity but not one of the ICD-10 criteria† ‘Talks excessively’ is one of the ICD-10 criteria for impulsiveness but not one of the DSM-IV criteria
Symptom GroupsSymptom Groups
DSM-IV ADHD Diagnostic DSM-IV ADHD Diagnostic CriteriaCriteria
List of symptoms must be present for past 6 List of symptoms must be present for past 6
monthsmonths Must have six (or more) symptoms of Must have six (or more) symptoms of
inattention inattention and/orand/or hyperactivity–impulsivity hyperactivity–impulsivity Some symptoms present before 7 years of ageSome symptoms present before 7 years of age Some impairment from symptoms must be Some impairment from symptoms must be
present in two or more settings (e.g. school present in two or more settings (e.g. school and home)and home)
Significant impairment: social, academic or Significant impairment: social, academic or occupationaloccupational
Exclude other mental disordersExclude other mental disorders
DSM-IV Subtypes of ADHDDSM-IV Subtypes of ADHD
Predominantly inattentivePredominantly inattentive
Predominantly hyperactive–impulsivePredominantly hyperactive–impulsive
Mixed/combined Mixed/combined
In partial remissionIn partial remission
Not otherwise specified (NOS)Not otherwise specified (NOS)
ICD-10 HKD Diagnostic ICD-10 HKD Diagnostic CriteriaCriteria
Used to diagnose hyperkinetic disorder (HKD), Used to diagnose hyperkinetic disorder (HKD), a more severe form of ADHDa more severe form of ADHD
List of symptoms must be present for at least List of symptoms must be present for at least six monthssix months
Must have:Must have: at least six symptoms of inattention at least six symptoms of inattention ANDAND
at least three symptoms of hyperactivity at least three symptoms of hyperactivity ANDAND at least one symptom of impulsivityat least one symptom of impulsivity
Onset of symptoms no later than 7 years of ageOnset of symptoms no later than 7 years of age Impairment of symptoms must be present in Impairment of symptoms must be present in
two or more settings (e.g. school and home)two or more settings (e.g. school and home) Significant impairment: social, academic or Significant impairment: social, academic or
occupationaloccupational
Important Rating Tools for Important Rating Tools for ADHDADHD
Conners Parent Rating Scale – assesses and Conners Parent Rating Scale – assesses and monitors response to treatmentmonitors response to treatment
IOWA Conners – measures dimensions of IOWA Conners – measures dimensions of behaviour associated with ADHDbehaviour associated with ADHD
SKAMP Measures – measures the classroom SKAMP Measures – measures the classroom manifestation of ADHDmanifestation of ADHD
SNAP-IV Scale – derived from descriptions in SNAP-IV Scale – derived from descriptions in DSM-IVDSM-IV
Continuous Performance Test (CPT) – measures Continuous Performance Test (CPT) – measures the attention span in children with ADHD the attention span in children with ADHD
C-DISC – computer-assisted diagnostic interview C-DISC – computer-assisted diagnostic interview schedule for childrenschedule for children
Therapy Options as Part of a Therapy Options as Part of a Total Treatment Programme Total Treatment Programme
Behavioural treatmentBehavioural treatment
Medication managementMedication management
Combining medication/behavioural Combining medication/behavioural
treatmenttreatment
Educating parents/patient about ADHD Educating parents/patient about ADHD
Educational support servicesEducational support services
Cunningham, Barkley. Child Dev 1979; 50: 217–224
Tools Used in Behavioural Tools Used in Behavioural TreatmentTreatment
Specific strategiesSpecific strategies Reward systemReward system Time outTime out Social reinforcementSocial reinforcement Behaviour modellingBehaviour modelling
Support for parentsSupport for parents Family and patient educationFamily and patient education
Group problem-Group problem-solvingsolving
Sports skillsSports skills Social skills trainingSocial skills training
Behavioural Treatment in the Behavioural Treatment in the HomeHome
Identify problem situations and the Identify problem situations and the
precipitating factorsprecipitating factors
Enhance positive parent–child interactionsEnhance positive parent–child interactions
Limit negative parent–child interactionsLimit negative parent–child interactions
Use cost systems to reduce problem Use cost systems to reduce problem
behavioursbehaviours
Use time outs as punishment for serious Use time outs as punishment for serious
problem behavioursproblem behaviours
Atkins, Pelham. 1992:69–88; Barkley, Cunningham. Arch Gen Psychiatry 1979; 36: 201–208
Behavioural Treatment in the Behavioural Treatment in the ClassroomClassroom
Behavioural treatment in school setting Behavioural treatment in school setting similar to the approach used in home with similar to the approach used in home with parentsparents
Goal: Reduce inattention and disruptive Goal: Reduce inattention and disruptive behaviourbehaviour
Specific school accommodations:Specific school accommodations: Ensure structure and predictable routinesEnsure structure and predictable routines Employ cost–response token economy systemsEmploy cost–response token economy systems Use daily report cardsUse daily report cards Teach organisational and work/study skillsTeach organisational and work/study skills
Effectiveness of Behavioural Effectiveness of Behavioural TherapyTherapy
Parent training is generally regarded as Parent training is generally regarded as the most effective behavioural therapythe most effective behavioural therapy
Parent training combined with medication Parent training combined with medication management increases parent management increases parent acceptability of medicationacceptability of medication
School-based treatment is more effective School-based treatment is more effective than individual strategies, however than individual strategies, however benefits are only seen during treatment benefits are only seen during treatment programmesprogrammes
Individual treatment approaches have not Individual treatment approaches have not been shown to be effective been shown to be effective
StimulantsStimulants MethylphenidateMethylphenidate(Recommended(Recommended Amphetamine compounds Amphetamine compounds first-line therapy)first-line therapy) DextroamphetamineDextroamphetamine
PemolinePemoline
AntidepressantsAntidepressants TricyclicTricyclic antidepressantsantidepressantsBupropionBupropion
AntihypertensivesAntihypertensives ClonidineClonidine Guanfacine Guanfacine
Wilens T, et al. ADHD, In Annual Review of Medicine, 2002: 53Greenhill L. Childhood attention deficit hyperactivity disorder: pharmacological treatments. In: Nathan PE, Gorman J, eds. Treatments that Work. Philadelphia, PA: Saunders; 1998:42-64
Pharmacological Agents UsedPharmacological Agents Usedin Treatment of ADHD*in Treatment of ADHD*
* Not all agents are available in some countries
ADHD Pharmacotherapy – ADHD Pharmacotherapy – ResponsivenessResponsiveness
0 10080604020
% Responders
Methylphenidate
Amphetamine
Pemoline
Tricyclic antidepressants
Bupropion
MAOI
Clonidine/Guanfacine
Wilens TE, Spencer TJ. Presented at Massachusetts General Hospital’s Child and Adolescent Psychopharmacology Meeting, March 10-12, 2000, Boston, MA