Approaching Children Adolescents with ADHD

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Approaching Children Adolescents with ADHD Powered By Docstoc
					Approaching Children /
Adolescents with ADHD

 Nihal M.Erfan            M.D., FRCPC
Consultant Child & Adolesc. Psychiatrist
   Head, Department of Psychiatry
         Neurosciences Center
       King Fahad Medical City
•   Definition & shifts in conceptualization
•   Diagnosis
•   ADHD – core dimensions
•   Prevalence & etiology
•   The assessment process
•   Treatment
                   Defining ADHD
•   Complex neurodevelopmental disorder
•   Most commonly Dx. Childhood psych. Dis
•   30 – 80% persists into adolescence
•   65 % have symptoms into adulthood
•   Major public health concern
    Shifts in Conceptualizing ADHD
• 1968 – Hyperkinetic disorder of Childhood
• 1980 – Attention Deficit Disorder
           - With or Without Hyperactivity
           - Residual Type recognized
• 1987 – ADHD ( only combined type )
• 1994 – AD/HD – 3 types
• 2000 – AD/HD ( impaired Exec Function )
                      DSM - IV ADHD
•    Predominantly Inattentive type
           at least 6 of 9 inattentive sx
• Predominantly Hyper – Impulsive type
           at least 6 of 9 hyper/impulsive sx
• Combined type
           at least 6 of each symptom set
 significant impairment 2 or more settings
 Age of onset
 ADHD Nos , or in partial remission
         STEREOTYPES of persons with ADHD
                                   Brown 2000



•   Young boys , not girls
•   physically hyperactive
•   never able to concentrate
•   not smart , low achieving
•   severe behavioral problems
•   sx remit in adolescence
             ADHD – Core dimensions
• Impulsivity or hyperactivity & inattention
   ( remain throughout sch. Yrs – Bauermeister ’92)
• Inattention sx persist more than hyper/impulsive
  sx
• Hyperactivity declines over time
• During transition to adulthood – attention
  problems stable & predictive of wider problems
 Current trend in understanding core deficits

• Barkley’s model of ADHD
          EXECUTIVE FUNCTIONS
   - Lack of Behavioral Inhibition =
        core deficit
   - problems with BI linked to abn in
        frontal lobes & others ( caudate, GP)
• “ Executive function “ ( EF )
  wide range of central control processes
  connect , prioritize & integrate functions
• “ Working memory “ ( WM )
  subset of short term memory functions
  manipulate info currently processed ,
  activates recall of long term memories
  = RAM on computer
           Characteristics of ADD Sx
                                       Brown 2000




• Dimensional not categorical
   ( like depression not pregnancy )
• Situational variability
• Looks like a willpower problem
                ADHD PREVALENCE
•   Varies across studies 1.9 % - 14.4 %
•   6 – 8 % children , 3 – 4 % adults
•   Male – female : 6:1 , 4:1 , 1:1( adults)
•   All levels of IQ & SES
                             ADHD ETIOLOGY
•   Family & Genetic factors
•   Prenatal , perinatal factors
•   Chemical toxins
•   Acquired , traumatic
•   Psychosocial stressors
      THE ASSESSMENT PROCESS
• “ No test can make a Dx “ - AACAP 97
• Clinician has a multifaceted task
• Need to consider DDx:
      - organic disorders
      - functional dis
      - developmental dis
• Need to consider COMORBIDITIES
                         FACTS !!!!!!
• Comorbidities are the rule
• 50 % have ODD , CD
• 25 % have LD
• 1/3 – 2/3 of pts had ,have or will have a
  mood disorder ( inc accidents, suicide )
• 40 % have 2 or > anxiety disorders
  ( genetically independent , ADHD
  anxiogenic )
         AACAP practice parameters
1.   Clinical assessment
2.   Collateral information
3.   Medical evaluation
4.   Structured interviews , checklists
5.   Psychometric testing
                      Clinical Assessment
•   HPI
•   Hx and domains of impairment
•   Current functioning – social & areas of strength
•   Past psych. Hx
•   Developmental hx
•   Medical hx
•   Family hx
    Structured interviews & checklists

•   Barkley interview for ADHD
•   Brown ADD diagnostic form
•   SCID – IV
•   K – SADS
•   Conners rating scales
•   CBCL
•   Stoney Brook
                      TREATMENT
• MTA study of ADHD Tx
   - 579 children ( 7-9 yrs )
   - ADHD Combined type
   - 14 months duration
   - 6 sites
                       MTA Results
1. Combined Tx = Med Mgmt for ADHD sx
2. Combined Tx slightly better for related
   probs
3. Med Mgmt better than ComCare meds
                       1. STIMULANTS
•   Individuals vary in sensitivity
•   Side effects decrease with time
•   76 % response rate
•   Increase medication only as fast as s/e allow
•   Assess s/e at peak dose & in rebound
•   Optimal dose NOT related to body mass
                 Available stimulants
•   Ritalin 10 mg
•   Ritalin SR 20 mg
•   Dexedrine 5mg
•   Dexedrine Spansule 10mg , 15mg
•   Adderall ( D, L amphetamine )
•   MPH ( Concerta ) 18mg , 54mg
•   Cylert ( Pemoline ) 37.5mg
                  What do they do ?
• Cognitive effects
     -cognition , vigilance , reaction time
     -short term memory , learning verbal &
      non- verbal material
• Behavioral effects
     -decrease in impulsivity , noisiness .
      mother – child interactions
                     How do they work ?
• Block reuptake of DA & NE into presynaptic
  neuron
• Increase release of monoamines into extraneuronal
  space
• MPH binds to DA transport prtn in similar way to
  sympathomimetics BUT SLOWER
  CLEARANCE RELATED TO LOWER
  POTENTIAL FOR ABUSE
                 NEURON
                 (Presynaptic)

    AMPH blocks                  AMPH
    Uptake into vesicle
                                           AMPH diffuses into
                                           Vesicle causing DA
Storage                                    Release into synapse
vesicle

                           Cytoplasmic DA


 MPH & AMPH                                          AMPH is taken up
                          DA Transporter
 Inhibit                                             Into cell causing
                          protein
                                                     DA release into
                                                     synapse

                      SYNAPSE
       Management of Side effects
• Somatic side effects
    - dec appetite , insomnia , stomachache,
      growth , rash & picking
• Psychiatric side effects
    - rebound , “zombie “ like state,
      depression , tics
                           FACTS !!!!
• Untreated ADHD poses greater risk for
  PSUD
• Comorbidities with ADHD increase risk for
  PSUD ( CD , Anxiety disorders )
• Treatment with stimulants DECREASES
  the risk of PSUD ( Biederman, 99)
          Consequences of untreated ADHD

•   Underachievement
•   Impaired peer relationships
•   Strained family relationships
•   Demoralization
•   Debased self esteem
•   Chronic stress, frustration
                2. Other medications
1. Tricyclic antidepressants –esp for
   hyperactivity
2. Novel Antidepressants – Bupropion
3. Alpha 2 agonists – clonidine
4. Others
                  OTHER INTERVENTIONS
•   Monitoring & adjusting treatments
•   Home based interventions
•   School based interventions
•   Interventions to provide therapy & support
                                    ADHD CHECKLIST

Please complete this checklist both before starting medication, and following the
completion of titration.

Symptoms of Inattention
                  1. Fails to give close     0     1       2        3
                  attention to details or
                  makes careless
                  mistakes in my work.

                  2. Difficulty sustaining   0     1       2        3
                  my attention in tasks
                  or fun activities.

                  3. Don’t listen when       0     1       2        3
                  spoken to directly.
4. Don’t follow through on instructions and fail to finish work. 0 1 2 3
5. Having difficulty organizing tasks and activities.              0 1 2 3
6. Avoid, dislike, or reluctant to engage in work that requires sustained mental
    effort.                                                         0 1 2 3
7. Lose things necessary for tasks or activities.                   0 1 2 3
8. Easily distracted.                                               0 1 2 3
9. Forgetful in daily activities. Leave my seat in classroom or in other situations in
    which seating is expected.                                      0 1 2 3
                                   HYPERACTIVITY
                                    IMPULSIVITY

10. Fidget with hands or feet or squirm in my seat               0 1      2 3
11. Leave my seat in classroom or in other situations in which seating is expected
                                                                 0 1       2 3
12. Feel restless.                                               0 1 2 3
13. Have difficulty engaging in leisure activities or doing fun things quietly.
                                                                0 1 2 3
14. Feel “on the go” or “driven by a motor.”                     0 1       2 3
15. Talk excessively.                                            0 1       2 3

16. blurt out answers before questions have been completed. 0 1          2   3
17. Having difficulty awaiting turn.                        0 1         2    3
18. forgetful in daily activities.                          0 1         2    3
                           Conclusion
• ADHD not a unitary disorder
• Developmental, heritable
• Dimensional not categorical
• Comorbidities are common , affect
  treatment outcome
• Treatment is multimodal

				
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