adhd

Phil stop acting like a worm the table is no place to squirm Thus speaks the father to his son severely say it, not in fun. Mother frowns and looks around although she doesn’t make a sound. But Philip will not take advice he’ll have his way at any price. He turns and churns he wriggles and jiggles Here and there on the chair. Phil these twists I cannot bear. - by Heinrich Hoffman, 1863 Historical Perspectives of ADHD • • • • “Mad idiots”, Impulsive insanity, defective inhibition (Late 19th century) Defect in moral control -( George F. Still 1902) Brain damaged child (1920-30) - successful use of stimulants Other terms – – – Organic drivenness (Kahn and Cohen 1934) Minimal brain dysfunction (Clements and Peters 1962) Hyperactive child syndrome (Stella chess 1960) • • • • Attention Deficit Disorder (Douglasand Barkley 1970) Lack of inhibitory control (Barkley 1994) Between 1957 and 1960: 31 articles Between 1977 and 1980 :7000 articles Famous People With ADHD • Mozart - Music composer • Thomas Alva Edison - Inventor • Albert Einstein - Physicist • Abraham Lincoln - President of USA • Edgar Allen Poe - Author • George Bernard Shaw - Author • Salvador Dali - Painter Features of ADHD 11’I’s • • • • • • • • • • • Impulsivity Increased MHPG Inattention Incomplete task Incoordination Inability to wait turn Instability Instructions unable to follow Interrupt others Incomplete listening Involvement in dangerous activity Prevalence of ADHD • Peak prevalence • Boys : Girls 1.2 - 8% 9% : 3.3% • Common age group • Common age of referral • Common in Urban setting 4-11 years 6-9 years Prevalence Rates of ADHD Prevalence (% of population affected) Age range Age group School-aged Adolescent (years) 4-11 12-16 Males 10.1 7.3 9.0 Females 3.3 3.4 3.3 Total population 4-16 Mechanism of Symptoms In ADHD • Disregulation of cortical activities (frontal lobe) • Disruption of – Attention – Cognition – Impulse control – Memory – Psycho-motor activity – Sensory motor coordination Dopaminergic Underactivity Restlessness Chronic autonomic Instability Sympathetic excitation Characteristics of ADHD • Inattention • Impulsivity • Overactivity DSM-IV Criteria For ADHD • Symptoms of inattention • Symptoms of hyperactivity-impulsivity DSM-IV - Subcategories • ADHD- (primarily) inattentive type • ADHD- (primarily) hyperactive-impulsive type • ADHD-combined type • ADHD-in partial remission Symptoms of Inattention (DSM IV) ( 6 Symptoms For > 6 Months) • Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities • Has difficulty sustaining attention in tasks or play activities • Does not seem to listen when spoken to directly • Does not follow through on instructions Symptoms of Inattention (DSM IV) ( 6 Symptoms For > 6 Months) • Has difficulty organizing tasks and activities • Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) • Loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools) • Is easily distracted by extraneous stimuli • Is forgetful in daily activities Symptoms of Hyperactivity (DSM IV) ( 6 Symptoms For > 6 Months) • Fidgets with hands or feet or squirms in seat • Leaves seat in classroom • Runs about or climbs excessively in inappropriate situations • Has difficulty playing or engaging in leisure activities quietly • Often on the go or acts as if driven by a motor • Often talks excessively Symptoms of Impulsivity (DSM IV) ( 6 Symptoms For > 6 Months) • Blurts out answers before the question has been completed • Has difficulty awaiting turn • Interrupts or intrudes on others • Symptoms of impulsivity ADHD (DSM-IV) • Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years Some impairment from the symptoms is present in two or more settings (e.g., at school (or work) and at home) There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning The symptoms do not occur exclusively during the course of a Pervasive Development Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., MD, AD, DD, or PD) • • • Difference Between DSM-IV And ICD-10 DSM-IV Criteria Lenient ICD-10 Rigid Symptoms Comorbidity Less Multiple diagnosis More Discourages multiple diag. ADHD Without HA (Inattentive Type) • Less impulsive, HA, • aggressive • Less peer rejection • Less ODD and CD • Later age of onset • Later age of referral • IN : CB = 2 : 1 (but less • referral) •  comorbid LD •  internalizing symptoms •  depressive symptoms  shyness Socially withdrawn Day dreamers Lethargic Sluggish  attention span Distractibility Failure to finish task Forgetting 60-75% academically impaired • • • • • • • • Core Difficulties of The Syndrome • Inappropriate or excessive activity unrelated to the task at hand, which generally has an intrusive or annoying quality Poor sustained attention Difficulties in inhibiting impulses in social behavior and on cognitive tasks Difficulties getting along with others School underachievement Poor self-esteem secondary to the above Other, coexisting externalizing behavior disorder, concomitant specific learning disabilities, anxiety disorders and depression • • • • • • Inappropriate or Excess Activity • Not only overactivity but an activity off-task • Children act differently in different situation • Measuring of hyperactivity – Child x Perceiver x Sitting (Wahlen & Henker) • Restlessness changes and diminishes – Running all the time-pre school – Not able to sit still - early schools – Fidgetiness - adolescent to adult Poor Sustained Attention • • • In class - poor school work In playground - unpopularity with peers Puzzling aspect is “variability” of attention – “Selective inattention” - related to motivation and interest – Poor in the task they find boring, repetitive or difficulty Performance on Continuous performance test (CPT) – Hyperactive children < normal children – More errors of omission and commission – Reaction time - variable and longer – Poor co-relation between CPT and classroom attention • Difficulty In Inhibiting Impulse • • • • Impulsivity in everyday life and in the performance of cognitive tasks Impulsive in work, interrupting, impatience, physically dangerous activities (Fractures and accidents) Lab Tests - CPT, matching familiar figure test (MFFT) and proteus maze test Impulsivity is pervasive and enduring • Russel Barkley: the capacity of delay responding to a signal, event or stimulus Difficulties In Getting Along With Others • ADHD children are unpopular with their peers • Difficulties with parents, siblings and teachers • Enduring friendships are rare • Social isolation in adulthood • ADHD children cause trouble, get others into trouble School Underachievement • ADHD children are behind normal children in spelling, reading and arithmetic • ADHD may be associated with various learning disabilities – Poor organizational skills, planning – Poor sequential memory, judging time – Deficit in fine and gross motor skills • Poor performance leads to poor motivation Low Self-Esteem • Various factors lead to poor selfesteem • May be associated with depressive childhood disorder Differential Diagnosis • Age appropriate normal hyperactivity(58%) • Specific LD without ADHD • Conduct disorder without ADHD • Adjustment disorders Conditions That Are Associated With ADHD or Mimic It Medical disorders Developmental disorders chronic disease communication disorders hearing impairment learning disability sleep disorders mental retardation Neurologic disorders Psychiatric disorders brain injury mood disorders tic disorder obsessive/compulsive seizure disorder Genetic/Endocrine/Metabolic disorder conduct disorders Fetal alcohol syndrome family dysfunction thyroid disease Adult ADHD • Symptoms of 2/3 of children with ADHD persist in adulthood • 85% of adult ADHD have comorbid psychiatric conditions – Affective, anxiety, personality, alcohol or substance abuse disorders • Adult ADHD - under recognized, under-treated and so refractory to treatment Motor Hyperactivity • Inability to relax • Dysphoric when inactive Attention Deficit • Inability to focus • Forgetfulness Affective Liability • • • • Shifts of Mood Spontaneous Last short period Reactive Adult ADHD Impulsivity • In decision Hot Temperament • Explosive, short lived • In personal life • In relationship • In ability to delay Emotional Reactivity • Stress intolerance • Inappropriate problem solving Disorganization • Inability to complete tasks Chronic Psychosocial Difficulties Related To ADHD Include: • • • • • • • • • Underachievement in academic and occupational settings Difficulties in initiating tasks and behaviors procrastination Problems with intimacy Trouble with authority Patterns of self-defeating behaviors Impatience Impulse outbursts and tantrums Risk-taking activities and Low self-esteem and self-worth Psychosocial Aspects of ADHD Attention Deficits Distractibility Difficulty staying on task Tends to disregard details  Poor interpersonal relationships  Inability: To decipher the social roles To attend to cues of the mind role of other  Social awkwardness Psychosocial Aspects of ADHD Attentional deficits  Trouble paying attention to internal experience  Inability for progressive discrimination between internal feelings (“noise”)  Can’t find quiet place within self  Feeling of instatement from oneself  Ineptitude to predict the feelings of self Psychosocial Aspects of ADHD Impulsivity  Interrupting others, cuts off conversation in middle, throws tantrums  Hampering interpersonal exchanges  Immaturity Psychosocial Aspects of ADHD Disorganization Planning, prioritizing, difficulty in executing activities, short-term memory problems   Inability to sustain tasks committing interpersonal and professional slights  Being perceived as unreliable, inconsiderate, selfish Psychosocial Aspects of ADHD Cycle of self-recrimination Failure in work life and relationships Inability to learn from past experiences Inability to achieve goals Divorce, separation, conflict with others, lower occupational status, lower socioeconomic status Discouragement, guilt, negative self perception     Need for conflict and trauma Problem initiating action and dangers of success Problems with intimacy Neurobiology of ADHD • Neurochemistry • Structural neuroimaging • Functional neuroimaging Neurochemistry • Dopamine • Noradrenaline • Serotonin Structural Neuroimaging (MRI) • Small frontal lobe • Small right prefrontal cortex • Smaller corpus callossum • Loss of normal caudate nucleus asymmetry Functional Neuroimaging (PET)  metabolic activity in frontostriatal circuitry Genetics of ADHD • Familial studies show a familial aggregation of ADHD with five to six fold  in the incidence of ADHD in first-degree relatives Twin studies high concordance rate MZ > DZ Molecular genetic studies – – – Focus on genes of dopaminergic system DAT1 involved in the mechanism of action MPD DRD4 - D4 receptor gene novelty seeking behavior including excitability and impulsivity • • • 61% of generalized resistance to thyroid hormone (GRTH) have ADHD but not vice versa Environmental Contributors • Nonshared environmental factors: biologic or social factors • Toxins, lead, alcohol and cigarette smoke • Food additives and allergenic whole foods • Iron, zinc and other mineral deficiency, deficiencies in essential fatty acids Biological Vulnerability Psychosocial Factors Economic Factors New Theories About The Neuropsychology of ADHD • Denkla: “intention” deficit disorder • Barkley: a deficit in the development of the inhibition of behavior Models of Attention • Ability to focus - sup. Temporal and inf. parietal cortices; striatum • Encoding - hippocampus, amygdala • Sustaining attention - rostral midbrain structures including pontine RAS • Shifting attentions - prefrontal anterior cingular cortex (Different children may have variable deficits) Psychosocial Influences For ADHD • Family stress • Low socioeconomic status • Negative mother-child relationship • Vulnerability of ADHD child • Over arousing or intrusive mothering • Changing society and family structure • Lack of special educational needs Comorbidity of Other Disorders With ADHD • • • • • Comorbidity may be expression of the same disorder Comorbidity may represent distinct disorder Comorbidity may share common vulnerability ADHD may be early manifestation of comorbidity ADHD may put the child at risk of development of comorbidity • • Carryout complete assessment for comorbidity Presence of comorbidity indicates poor prognosis Prevalence of LD And ADHD • ADHD • LD • ADHD in LD : : : 3 - 7% upto 15% 9 - 92% • LD in ADHD : 20 - 80% ADHD • Impulsive • ADHD With RD  attention • • •  executive functions  conduct problems • •  language function  memory function  MHPG level  2 adrenoreceptor response Intact phenomenological • skills • Treatment • Careful assessment of academic skills • Placement in an academic remedial program • Treating ADHD • Stimulants do not directly improve reading skills but concentration increases Association Between Developmental Coordination Disorder (DCD) And ADHD • • Since 1970 - MBD MBD - combination of inattention, hyperactivity, poor visual-motor abilities and clumsiness Developmental Dyspraxia • Inability to develop appropriate motor planning • ADHD - child outgrows clumsiness after primary school • ADHD + DCD - continues to be clumsy Comorbidity of Other Disorders With ADHD Comorbid Disorder Range of Overlap ADHD + antisocial disorders ADHD + mood disorders ADHD + anxiety disorders ADHD + learning disorders 23%-64% 15%-75% 8%-30% 6%-92% ODD And CD With ADHD - I • Co-occur in 30% to 50% • ODD: negativistic, hostile and defiant behavior • CD: habitual rule breaking defined by a pattern of aggression, destruction, lying, stealing, or truancy • ADHD and CD represent related but independent dimensions ODD And CD With ADHD - II • Children with ADHD and CD: earlier age at onset • ADHD + CD: more aggressive, more persistent conduct-related behaviors than children with CD alone • ADHD with ODD higher rate of school dysfunction Pharmacotherapy of ADHD, CD, Aggression • • • • • Behavioral management techniques Psychosocial treatment Impaired social skills Dysphoric conduct-mood stabilizers Stimulant medications (may reduce aggression) ADHD And Mood Disorders • 15 - 75% cases • ADHD and first children + 1st degree relatives:  mood disorders • Parents with mood disorders  children have  chances of ADHD Similarities And Differences Between ADHD And Mania Similarities • Distractibility • Impulsivity Differences • Severe irritability • Explosive reactions • Hyperactivity ADHD And Anxiety Disorders • 25% comorbidity •  ADHD in children of parents with anxiety disorders • Presence of anxiety disorder predicts poor response to MPD Pharmacotherapy of ADHD And Anxiety And Depression Antidepressants – TCAs – Bupropion – Venlafaxine – Adjuvant SSRIs Treatment of ADHD And Mania • Mood stabilizers – – – – – Carbamazepine Valproic acid Lamotrigine Topiramate Tiagabine • Antipsychotics (atypical) – Risperidone – Olanzapine – Clozapine Treatment of Developmental Disorders And ADHD • Agitation: CPZ, thioridazine • Withdrawal: Trifluperazine, haloperidol • Aggression, self abusive behavior: -blockers, clonidine • Hyperactivity: stimulants ADHD Plus Tics • Stimulants may cause / exacerbate tics - not certain •  tic disorders in boys with ADHD • Treatment - stimulants, clonidine, guanfacine Prognosis • 30% - function well • 50 - 60% - adult ADHD • 10% - antisocial / psychiatric problems Prognosis of ADHD • IQ - ADHD + low IQ - poor prognosis • Symptoms - mild S/S of ADHD • Comorbidity – – – – – LD Aggression ODD + CD Mood disorders Substance abuse Predictors of Outcome • Individual characteristics of the child • Family parameters • Treatment Family Parameters • Parental pathology • Child rearing practices • Socioeconomic status Diagnostic Scorecard Medical/Family history Behavior Cognition Coordination (motor skills) At least 2 checks for diagnosis of ADHD Diagnostic Framework - I Step 1: Assess medical and family history • Explore history of potential brain injury • Identify syndromes: Fragile X, Williams, fetal alcohol • Explore family history of ADHD, learning disabilities • Ask about parent’s reading ability Diagnostic Framework - II Step 2: Qualify and quantify behavior • Behavior related more to inattention and impulsiveness than noncompliance • Driven quality to behavior • Behaviors have persisted over time • Behaviors occur in multiple settings Diagnostic Framework - III Step 3: Assess cognitive skills • History of language delay • Documented learning disability • Assess grades and academic performance • Identify split or scatter on psychological testing • Assess reading and phonetic analysis Diagnostic Framework - IV Step 4: Assess motor skills • History of hypotonia in infancy • Survey general motor coordination • Assess athletic ability • Assess handwriting Medical Evaluation • Baseline height and weight with growth curve • Baseline pulse and BP • R/o cardiac abnormalities • CBC and LFT - pemolen Principles of Medication • ADHD is a chronic neuro-psychiatric condition • Medication response unpredictable • Dosing requires a “start low go slow” approach • Medication when effective improves – Attention span – Behavior – Mood stability – Cognitive aptitude – Memory processing – Sensory-motor coordination Prescribing and Titrating Stimulant Dosage • • • • Methylphenidate (MPD) - drug of choice Amphetamine - before 6 years Negative response to one stimulant does not preclude negative response to another Dose of MPD – – – – 2.5-5 mg in morning and noon Weekly  2.5-5 mg/dose 30 mins after meals or with meals if anorexia Dose of pemolene 37.5 mg  by 18.15 mg every 3-5 days Predicting Response To Methylphenidale • • • • • • Good: Severe problems with attention, concentration, coordination and overactivity Poor: Depression, anxiety, cognitive problems, poor parental management Dose not > 20 mg/dose (45-60 mg/day) Third dose may be needed in late afternoon Maybe discontinued on weekends, holidays, vacations Sustained release form useful for OD dosing Monitoring Response - Mandatory • There are few indicators that accurately predict children’s responses to specific doses of stimulants • Because social behavior and psychological and cognitive functioning are constantly changing as children develop, monitoring drug effects is particularly complex • Children are less able to report the presence of adverse effects Assessing Initial Response • Behavior rating scales by caregivers and teachers • Direct observations of behavior • Laboratory tests of cognitive functioning • Measures of activity and academic performance Assessment of Long-Term Progress • Behavioral ratings completed by both parents and teachers • Assessment of side effects • Careful evaluating regarding recent stressors and possible familial discord Terminating Treatment • Decision made by the doctor, the child and the family, independent of the child’s age • • Treatment discontinued on an annual basis Assessment be conducted to evaluate for behavior at school and at home NIMH MTA Study For ADHD (1999) • Number of children - 579 • Diagnosis: combined type ADHD • Four management strategy: (14 months) – Medication only – intensive BT – Medication + intensive BT – Standard community care NIMH MTA Study For ADHD (1999) Outcome (6 domains) • (ADHD symptoms, aggression - ODD, internalizing symptoms, social skills, parentchild relations, academic achievement) • All groups showed significant reduction • For ADHD - medications and medications + BT > other 2 groups • For other measures, medications + BT > BT and community care > medication only • Conclusion BT may be sufficient in some cases.If BT response suboptimal, recourse to adding medications Stimulants And Behavioral Therapies • Stimulants + behavioral therapy - treatment of choice • Lower dose of methylphenidate needed with BT Short-Term Adverse Effects of Stimulants • • • • • Decreased appetite Insomnia Irritability Emotional lability Abdominal pains • • • • • Headaches Mood disturbance Tics Anxiety Nightmares • Social withdrawal Long-Term Adverse Effects of Stimulants • ? Potential weight and height suppression • Cardiovascular side effects • Abuse potential Contraindications • Tics and ADHD • IDDM, cystic fibrosis • H/o liver disorders - pemoline Response Rate For Stimulants • 75% for each medication • Two medications together 90% • Lower in preschool-age children and adolescents Strategies For Reducing Side Effects of Stimulants - I • Verify that the side effect is indeed medication related • Consider brief trial off medication • Try a lower dose of the same medication • Administer the medication with a meal Strategies For Reducing Side Effects of Stimulants - II • Try changing from a long-acting to a short-acting preparation (e.g., if problems with appetite at lunch) • • Change to a different stimulant medication Split morning dose so that half is given 30 minutes before the other half • Encourage trials off medication (over the weekend or summer) Strategies For Reducing Side Effects of Stimulants - III • • • Treat side effects (e.g., an evening dose of clonidine to reduce the insomnia) Placebo trial (if nonorganic etiology is suspected) Change from 5 day/week to 7 day/week dosing (if side-effects are only seen on Monday after resuming medication following a weekend off medication) Stimulants In Adults ADHD • Dose: .6-.9 mg/kg per day (higher the dose more robust is the response) • Start low dose and increase at weekly intervals • Short half-life produce rebound symptoms before next dose • Adults with brain trauma are sensitive to small dose • 50% - 80% of adults improve on MPD methamphetamine > dexamphetamine Differential Response To MPD • Change in overt behavior – Occurs at lower dose – Sustained over longer period • Change in cognition – Occurs at higher dose – Sustained for shorter period Unusual Adverse Effects • “Cognitive constriction” • Stereotypical behaviors • Adventitious movements • Paranoia • Disruptive outburst • Treatment: stop medication Alternative Medications • TCAs • Bupropion •  Adrenergic agonists - clonidine, guanfacine • Antipsychotics • Mood stabilizers - CBZ, Li TCAs • Imipramine • Nortriptyline • Desipramine • Amitriptyline Clinical Indications For TCAs • Unsuccessful clinical response to the stimulant medications • Significant side effects to the stimulant • High risk for tic disorder • Tolerance to stimulants Imipramine In ADHD • Most frequently used TCA • Given in divided doses • Younger children - 20 mg for each dose; adolescents 25 mg for each dose • Dose increased every 7 to 10 days by 10, 20, or 25 mg • Take 1 to 2 weeks to begin working Contraindications of Imipramine • Known hypersensitivity • History of cardiac conduction disorders • With a monoamine oxidase (MAO) inhibitor • Seizure disorder Side Effects of Imipramine • Fatigue • Sedation • Cholinergic effect - constipation, dry mouth, blurred vision • Morning insomnia Bupropion • Aminoketone • Not as effective as TCAs • 75 mg twice a day; increased every 7 to 10 days by 75 mg or 100 mg • Side effects fatigue, agitation, dry mouth, insomnia, headaches, nausea, vomiting • Higher doses (450 mg/d), caused seizures Clonidine • 0.025 mg  to 0.05 - 0.1 mg / dose • Side effect - fatigue, somnolence • Monitor pulse and BP • Clonidine at bedtime to  insomnia of stimulants Combined Pharmacotherapy • If stimulant medication dose cannot be raised - other drug added to lower the dose of the stimulant • Stimulant dose only lasts 3 hours or less TCA added to cover the times when the stimulant is no longer effective • Child needs medication early in the morning and/or in the evening - long-acting medication added to stimulant Additional And Alternative Medications For Comorbid Conditions Comorbid Condition Anxiety disorder OCD Depression Anger-control disorder Tic disorder Aggressiveness Sleep disturbance Additional and Alternative Medication TCA, SSRI SSRI TCA, SSRI SSRI Clonidine, guanfacine Clonidine, CBZ Clonidine, guanfacine Alternative Treatments • Diet • Megavitamin therapy • Nootropics (Donepezil) • Antioxidants • Vision therapy and oculovestibular treatment • Homeopathy • Auditory stimulation: Tomatis method • Biofeedback hypnotherapy Dietary Management • • • • Feingold diet Allergenic foods Sugar and aspartame Dietary supplements – – – – – – Essential fatty acids Zinc Megavitamin therapy Magnesium Iron Pyridoxine Antioxidants And Herbs • Pycnogenol • Melatonin • Gingko biloba • Herbs - camomile, kava, lemon balm Thank You !! For being attentive For being less impulsive For for being less restless