hanipsych, adhd

Attention-Deficit Hyperactivity Disorder, Early Detection

Prof. Hani Hamed Dessoki, M.D.PsychiatryProf. Hani Hamed Dessoki, M.D.PsychiatryProf. PsychiatryProf. Psychiatry

Chairman of Psychiatry DepartmentChairman of Psychiatry Department

Beni Suef UniversityBeni Suef University

APA memberAPA member

DisclosureDisclosure

• NO relevant financial relationships with a NO relevant financial relationships with a commercial interest.commercial interest.

Outline of Presentation

I. History of ADHD II. Diagnosis and Associative Features

III. Statistics

IV. Etiology A. Environmental Theories B. Biogenic Theories

V. Prognosis and Impact

VI. Treatment

Attention Deficit Hyperactivity Disorder (ADHD(

ADHD is a pervasive, heterogeneous behavioural syndrome characterised by

the core symptoms of inattention, hyperactivity and impulsivity.

ADHD: Historical Development of the Concept

1902: George Still identified impulse control difficulties in some children

1950s: Medical model explanations predominated: “minimal brain damage”,and “educationally subnormal” labels were used

1970s: Psychological/Familial/Environmental models gained ground:individual and family coping strategies were emphasised

1980s: In the USA, “Attention Deficit Disorder” had been added to DSMIII

1990s: Concept of “Attention Deficit” and ADHD gained ground in the U.K.In the U.S., DSMIV added “hyperactivity” to the main diagnosis andADD became one of the sub-categories.

Disruptive Behavior Disorders

• ADHD: Attention Deficit Hyperactive Disorder

• ODD: Oppositional Defiant Disorder

• CD: Conduct Disorder

Diagnosing ADHD• Clinical examinations and questionnaires are important because of the

many controversial diagnosis of ADHD (Jackson & Farrugia, 1997(

• Medical and family history– physical examination– interviews with parents, the child, and child’s teacher– behavior rating scales by parents and teacher– observation of the child– psychological tests (IQ, social and emotional adjustment, and

indication of learning disabilities(

• DSM-IV (1994( allows for adult diagnosis as long as the associative characteristics are met...

Attention-Deficit Hyperactivity Disorder

(ADHD( – DSM IV definition

Attention-Deficit Hyperactivity Disorder (ADHD)

is a neurobiological condition that characterized by developmentally inappropriate level of inattention (concentration, distractibility)

hyperactivity and impulsiveness that can occur in various combinations across school, home,

and social settings.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Myth #1

• Psychiatric disorders do not occur in children.

Myth #2

• ADHD is nothing more than applying a diagnostic label to normal childhood behavior.

Myth #3

• If ADHD really existed, wouldn’t it be obvious?

“The medicines used to treat ADHD are dangerous and

addictive”

Myth #4

Attention-Deficit/Hyperactivity Disorder

Statistics

• Effects 3-5% of all school-aged children

• Most commonly diagnosed behavioral disorder in children

• 9-18% of school-aged children with mental retardation meet criteria for ADHD (comorbidity is high in ADHD( (Epstein et al, 1986(

• Males to female ratio ranges from 4:1 to 9:1 depending on the setting (clinic or general population( (DSM-IV, 1994(

Statistics

• Occurs in all cultures, with prevalent findings in Western cultures (due to diagnostic methods( (DSM-IV(

• Mood and Anxiety, Learning, Substance-related, and Antisocial Personality Disorders are more prevalent in family members of those with ADHD (high rate of comorbidity( (DSM-IV(

• 9.5 million adults are suffering from ADHD (Quinn, 1997(

Why the Explosion in ADHD?

- Possible Explanations1. We are better at finding and helping

children and adults who really do have ADHD.

2.There are more children now who actually have ADHD

Why the Explosion in ADHD?

- Possible Explanations3.We have loosened the definition so more

kids are being diagnosed and treated.

4.We are actually diagnosing and treating many children who don’t have ADHD, even by a loosened definition.

AetiologyAetiology

Aetiology• Heritability is the strongest factor in

development of ADHD• Risk factors account for only a small portion of

variance

• Pregnancy variables: young maternal age, maternal use of tobacco and alcohol, toxaemia, post-maturity and extended labour

• Medical factors: fragile X syndrome, G6PD deficiency, phenylketonuria, brain trauma, lead poisoning, malnutrition

Main Neurotransmitters in ADHD

• Dopamine• Noradrenaline

To regulate the inhibitory influences in the frontal-cortical processing of information

Dopamine

- enhances signals - improves:

. attention, . focus vigilance, . acquisition, . on-task behaviour and cognition

Noradrenaline• dampen « noise »

• decrease distractibility and shifting

• improve executive operations

• increase behavioural, cognitive, motoric inhibition

Associate symptoms with brain regions and circuits that regulate them

Hyperactive Hyperactive symptomssymptoms

Impulsive Impulsive symptomssymptoms

Prefrontal Prefrontal motor motor cortexcortex

Orbital Orbital frontal frontal cortexcortex

Selective Selective attentionattention

Sustained Sustained attention attention problem problem solvingsolving

Dorsal Dorsal ACCACC

DLPFCDLPFC

Stahl , 2008

Match neurotransmitters with circuits

Dorsal Dorsal ACCACC DLPFCDLPFC

HAHANENE DADA AChACh

Selective attentionSelective attention Sustained attention Sustained attention problem solvingproblem solving

•Little attention to detailLittle attention to detail

•Careless mistakesCareless mistakes

•Does not listenDoes not listen

•Loses thingsLoses things

•DistractedDistracted

•forgetfulforgetful

•Sustaining attentionSustaining attention

•follow through/finishfollow through/finish

•OrganizingOrganizing

•Avoids sustained Avoids sustained mental effortmental effortStahl , 2008

Aetiology

• ADHD symptoms and a diagnosis of ADHD may themselves create interpersonal problems and produce additional symptoms in the child

• Some children sensitive to colourings/preservatives – not sugar per se

- Neurophysiological Factors:

Studies using PET have found lower cerebral blood flow and metabolic rates in the frontal lobe areas of children with ADHD than controls, pointing towards frontal-striatal dysfunction.

- Psychosocial Factors:

Stressful psychic events, disruption of family equilibrium and other anxiety provoking factors contribute to the initiation or perpetuation of ADHD.

Etiology of ADHD

Symptoms and Early Detection

Inattention symptoms• Fails to give close attention; careless mistakes• Difficulty sustaining attention in tasks or play activities = requires

frequent redirection• Does not seem to listen when spoken to directly• Does not follow through on instructions; fails to finish task (not

oppositional or failure to understand• Difficulty organizing tasks = homework poorly organized• Dislikes sustained mental effort = schoolwork; homework• Loses possessions• Easily distracted• Forgetful

Hyperactivity

• Fidgets

• Leaves seat when expected to sit• Runs or climbs excessively• Difficulty in playing quietly• Often "on the go" or acts as if "driven by a motor"

• Often talks excessively

Perceived « immature »

Accidents/injuries prone

Impulsivity

• blurts out answers before questions completed

• difficulty waiting turn• interrupts or intrudes on others

Impatient Rushing into things Risk taking; Taking dares

DSM IV CriteriaA:• 6 / 9 inattention

&/or • 6 / 9 hyperactivity & impulsivity= 6 months; maladaptive & inconsistent with development level

B: symptoms before age of 7C: impairment in 2 settingsD: clinically significant – social/academicE: not better explained by something else

A) Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: Inattention (CALL FOR FRED)

1) Often does not give close attention to details or makes Careless mistakes in schoolwork, work, or other activities.

2) Often has trouble keeping Attention on tasks or play Activities. 3) Often does not seem to Listen when spoken to directly. 4) Often does not Follow instructions and Fails to finish schoolwork,

chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5) Often has trouble Organizing activities. 6) Often avoids, dislikes, or doesn’t want to do things that take a lot of

mental effort for a long period of time (such as schoolwork or homework). Reluctant

7) Often Loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). 8) Is often easily Distracted. 9) Is often Forgetful in daily activities.


Attention-Deficit/Hyperactivity Disorder --Diagnostic Criteria

B) Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity (RUNS FASTT)

1) Often fidgets with hands or feet or squirms in seat.

2) Often gets up from seat when remaining in seat is expected.

3) Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4) Often has trouble playing or enjoying leisure activities quietly. 5) Is often "on the go" or often acts as if "driven by a motor".

6) Often talks excessively. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.


Impulsivity

7) Often blurts out answers before questions have been finished.

8) Often has trouble waiting one’s turn.

9) Often interrupts or intrudes on others (e.g., butts into conversations or games).



Based on these criteria, three types of ADHD are identified:

1) ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months.

2) ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months.

3) ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.



Depending upon which symptoms predominate DSM-IV-TR

recognized three subtypes of ADHD.

Combined subtype - 50% to 75% Inattentive subtype - 20% to 30% Hyperactive impulsive subtype - <15% cases

Subtypes of ADHD

1.Infancy:

- More active, sleep less and cry much.

- Difficult to recognize until child achieves toddler age.

2.Preschool

- Motor restlessness, insatiable curiosity, vigorous and destructive play ,demanding of parental attention

- Excessive temper tantrums.

- Decrease and/or restless sleep.

- Delays in motor and language development.

Clinical Features

3.School age Children:

- Easily distracted.

- Difficulty in waiting for a turn.

- At home cannot be put off for even a minute.

- Often irritable.

- Emotionally labile – easily set off to laughter and tears.

- Mood and performance is variable and unpredictable.

- Impulsive- unable to delay gratification.

- Accident prone.

- Negative self concept and reactive hostility.

- 75% children show behavioral symptoms of aggression and defiance.

- School difficulties both learning and behavioral coexist.

Clinical Features (cont…)

Scope of problem: school and adolescence

• At least 10% of children under 18 years of age are or have been affected by psychiatric disorders (12% of boys, 8% of girls) - including ADHD, ASD, TS, CD, (and psychosis, eating disorder, depression, and anxiety disorders)

• Another 10% or more are affected by various kinds of psychosocial problems (including drug abuse), some of which may be triggered by or interacting with ESSENCE

• About 5% are affected by “dyslexia” • 1-2% are affected by LD

• Overlap/”Comorbidity”/Co-existence substantial• When looking back: vast majority had symptoms <5 years

4.Adolescents:

- Excessive motor activity.

- Discipline problems, family conflicts.

- Anger and emotional liability.

- Difficulty with authority.

- Significant lags in academic performance.

- Poor peer relationship.

- Poor self esteem.

- Speedy accidents.

- Delinquent children.


5.Adults:

- Difficulty with concentration and performing sedentary tasks.

- Disorganization.

- Forgetfulness.

- Failure to plan.

- Depending on others to maintain order.

- Trouble both getting started and ending tasks.

- Changing plans and jobs in midstream.

- Restlessness , impulsivity.

- Absent mindedness.

- Anti social acts.


Significance of InattentionSignificance of Inattentionfor cognitive processesfor cognitive processes

Chhabildas, Pennington, Willcutt, J Abnorm Child Psychol, 2001Chhabildas, Pennington, Willcutt, J Abnorm Child Psychol, 2001

• Inattention symptom cluster is the Inattention symptom cluster is the strongest predictor of neuropsychological strongest predictor of neuropsychological impairmentsimpairments – vigilance, processing speed, inhibitionvigilance, processing speed, inhibition

• Hyperactivity/impulsivity Hyperactivity/impulsivity notnot associated associated with neuropsychological impairmentswith neuropsychological impairments

Expert Rev Neurother , 2011

• Early detection and intervention may prevent or ameliorate the development of the disorder and reduce its long-term impact.

http://www.ncbi.nlm.nih.gov/pubmed/21469928

http://www.ncbi.nlm.nih.gov/pubmed/21469928

DD• Age appropriate behaviors in active

children, • Intelligent children in under stimulating

environments eg classrooms,• MR• Psychiatric: ODD,CD, Anxiety disorders,

substance use disorders, PTSD, Mood dis, PDD, LD

• Psychosocial: abuse/ neglect; poor nutrition, chaotic family, bullied at school, violent neighborhood

• Medical: Thyroid, heavy metal poisoning, medications: sedating or activating

As many as one-third of children diagnosed with ADHD also have a co-

existing condition

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.

ComorbidityO.C.D.

O.D.D.

C.D.

‘Dyslexia’

Tics/ Tourettes

Anxiety/Depression

Speech & Language

‘Dyspraxia’

Substance Abuse

A.D.H.D. Bipolar Disorder

Asperger’s Syndrome

Sleep Disorders

Oppositional Defiant Disorder (ODD)

A pattern of negativistic, hostile and defiant behavior lasting at least six months, during which four or more of the following are present:

• Often loses temper.• Often argues with adults.• Often actively defies or refuses to follow adults rules.• Often deliberately annoys people.• Often blames others for his/her mistakes.• Often is touchy / easily annoyed by others.• Often is resentful.• Often is spiteful / vindictive.

The disturbance in behavior causes significant impairment in social, academic or occupational functioning.

Conduct Disorder

Repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate norms or rules of society are violated.

• Aggression to people or animals.

• Destruction of property.• Deceitfulness or theft.• Serious violation of rules.

“Hyperactivity and impulsivity are among the most

important personality or individual

difference factors that predict later

delinquency.”

Farrington 1996

Prognosis

• 50% continue to suffer from clinically significant symptoms

• Increased risk for substance use disorders particularly if CD

• Low self esteem and poor social skills

Essential Concepts

• ADHD is a clinical diagnosis based on:– Careful history taking– Clinical examination– Information from several sources & multiple settings (school, home& community)

• Hyperactivity does not need to be present during the mental state exam to diagnose ADHD

• Concomitant learning disabilities & comorbid psychiatric disorders should be evaluated

• Morbidity & disability often persist into adult life

• Children with ADHD have a higher injury rates, increased rate for CD (1/3), criminal behavior, substance abuse, coordination deficits & other psychiatric disorder (over 50%)

• There is increased risk for physical punishment, stress within the family and economic cost to schools and criminal justice

ADHD Guideline Recommendations

1. The primary care clinician should initiate an evaluation for ADHD for any child who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. B/strong recommendation

American Academy of Pediatrics

ADHD Guideline Recommendations2. To make a diagnosis of ADHD, the primary

care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria have been met (including documentation of impairment in more than 1 major setting) with information obtained primarily from parents/guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause. B/strong recommendation

American Academy of Pediatrics


3. Evaluation of a child for ADHD should include assessment for coexisting conditions, including emotional, developmental, and physical. B/strong recommendation


4. The primary care clinician should establish a treatment program that recognizes ADHD as a chronic condition and a child with ADHD as a child/adolescent with special health care needs who needs a medical home. B/strong recommendation

Evaluation

Identify core symptoms. Assess impairment. Identify possible underlying or alternative

causes. Identify co-occurring (co-morbid) conditions.

Assessment• History – parents or caregivers,

− as well as a classroom teacher or other school professional

• Interview of child

• Parent and teacher ratings of ADHD-related behaviours

• Investigations - No clinical examination or lab tests are accepted as either “rule in” or “rule out.” Recommend vision & hearing tested

Overlap and issues

• Is ODD not a comorbidity but an index of severity in ADHD?

• Are learning problems a result of non-assortative mating in parents?

• Are DCD problems an index of a link with ASD?• Is ASD a very common comorbidity signalling

some shared genes?• Are ASD and ADHD in some cases on the same

spectrum?

ImpactEmotional• Low self esteem• Impaired self-regulation• Relationship difficulties

Cognitive• Organizing; planning and time management• Learning delay• Short term memory problems; lack of focus • Language/speech

Physical• Fine & gross motor skill delay

Behaviour• Impaired self-regulation

ManagementManagement

Psychological Psychiatric Educational

Other individually determined strategies

MedicalDietary

Coaching

Behavioural & parent training programmes

Multidisciplinary Management of

ADHD

Substance abuse

Non-Pharmacological Management

Diet• Elimination diets – difficult• Omega 3 – at least 1000mg/day for a month

Academic skills training: focus on following directions, becoming organized, using time effectively, checking work, taking notes

Non-Pharmacological Management

Behavioural therapy- Does not reduce symptoms– May improve social skills and compliance– Does not lead to maintenance of gains or

improvement over time after the therapy is completed

Social skills group - Uses modelling, practice, feedback and

contingent reinforcement to address the social deficits common in children with ADHD

- Useful for the secondary effects of ADHD, such as low self-esteem, but not helpful for core symptoms of ADHD

MEDICATIONS FOR ADHD� Stimulant Medications

–Methylphenidate (Ritalin, Ritalin LA, Concerta)

–Dexamphetamine� Non-stimulant

Atomoxetine (Strattera)� Other

Clonidine (Catapres)Risperidone (Risperdal)

•

MEDICATIONS FOR ADHD

Tricyclic Antidepressants –Desipramine ;Imipramine (Tofranil)Other Antidepressants–Bupropion (Zyban); Fluoxetine

(Prozac)

Stimulants Specific Effects

• Improved sustained attention• Reduced distractibility• Improved short-term memory• Reduced impulsivity• Reduced motor activity• Decreased excessive talking• Reduced bossiness and aggression

with peers

Non-Stimulants Atomoxetine is a highly specific norepinephrine

reuptake inhibitor.

Extended release guanfacine and clonidine are alpha 2 adrenergic agents.


5. Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age:

Preschool-aged Children(4–5 Years of Age(

A. Prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment. A/strong recommendationand

May prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function. B/recommendation

Elementary School-aged Children(6–11 Years of Age(

B. Prescribe FDA-approved medications for ADHD. A/strong recommendation

and/or

Evidence-based parent- and/or teacher-administered behavior therapy as treatment for ADHD.

Preferably both. B/recommendation

Adolescents (12–18 Years of Age(

C. Prescribe FDA-approved medications for ADHD with the assent of the adolescent. A/strong recommendation

and

May prescribe behavior therapy as treatment for ADHD. C/recommendation

Preferably both.


6. The primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects. B/strong recommendation

How ADHD affects children or adolescents and their families.

Potential benefits associated with nonpharmacologic interventions such as parental behavior therapy programs.

Potential benefits and adverse effects associated with psychostimulants and nonstimulants.

Patient preferences regarding diagnosis and treatment options, including pharmacologic and nonpharmacologic interventions.

How they can access information on ADHD about diagnosis and treatment, educational programs, public benefits, and other issues.

What To Discuss With Your Patients and Their Caregivers

Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.

Summary Children from preschool age through

adolescent age can be diagnosed and treated for ADHD.

Both medications (stimulants, selective norepinephrine reuptake inhibitors and alpha adreneric agents) and behavior therapy are effective and safe treatments for ADHD.

Effective treatments require appropriate titration and ongoing monitoring to remain effective.

Effective Treatment of ADHDMultidiscipline:

– Medical

– Psychological

– Educational

– Rehabilitation

The Team : 1.Consultant Child and Adolescent Psychiatrist

2.Clinical Psychologists

3.Occupational Therapists

4.Speech Therapists

5. Parents & Family

6. School officials

hanipsych, adhd

Documents

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