Transcript Slide 1

Attention deficit hyperactivity disorder (ADHD)
Dr Bozhena Zoritch
What this presentation covers
 Background –
recognition,
assessment, treatment
 NICE guideline
 Discussion
Background
Definition of ADHD
 a heterogeneous behavioural syndrome with core
symptoms of inattention, hyperactivity and
impulsivity causing impairment
.
Is ADHD a valid concept?
Controversy regarding the validity of ADHD
diagnosis
Consensus conference discussed
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continuity of symptoms
impact
stability of incidence in time/culture
developmental changes
response to intervention
heritability
neurobiology
environmental influences
ADHD is a valid concept
MRI brain - children with ADHD have a delay in achieving appropriate maturation
Delayed Brain Growth in ADHD
Ns: ADHD = 223; Controls = 223
Greater than 2 years’ delay
0 to 2 years delay
Shaw P et al. Proc Natl Acad Sci USA. 2007;104:19649-19654. Reprinted with permission from the National
Academy of Sciences USA. © 2007.
Slower rate of thinning of the cortex
ADD Before and After Treatment
Before treatment
After treatment
Heritability of Psychiatric Illnesses
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ADHD*
Bipolar^
Schizophrenia**
*Faraone SV, Doyle A. In: Todd R, ed. Genetic Contributions to Early Onset Psychopathology. Philadelphia,
PA: WB Saunders; 2001. ^Edvardsen J et al. J Affect Disord. 2008;106:229-240; **Sullivan PF et al. Arch Gen
Psychiatry. 2003;60:1187-1192.
The PFC Requires Proper “Tuning”
of Catecholamine Levels for Optimal Function1–4
OPTIMAL
INSUFFICIENT
EXCESSIVE
ADHD
Stress
Levels of Catecholamine
(Dopamine and Norepinephrine)
1. Arnsten AFT, et al. J Child Adolesc Psychopharmacol. 2007;17:393406.
2. Granon S, et al. J Neurosci. 2000;20:1208-1215.
3. Vijayraghavan S, et al. Nat Neurosci. 2007;10:376-384.
4. Zahrt J, et al. J Neurosci. 1997;17:8528-8535.
Etiology
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Genes DAT1, DAT4, serotonin, histamine
Environment (methylation of genes in utero)
Genes and environment
Genes interaction
Concentration
 ‘but he can concentrate for
some things…
Can you concentrate? ADHD
No
ADHD
Enjoyable task
yes
yes
Mediated by
Need to do it, homework no
usually
dopamine
Panic stations,
yes
adrenaline
coursework due tomorrow
usually
Comparison with other conditions in childhood
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ADHD incidence 3-9% children, 2 % adults
Asthma 11.4% (vast number seen in primary care only)
Food allergy 5-8%
Attachment disorders 1% (children under 5 years)
Epilepsy 0.06%
Diabetes 0.02%
Anorexia 0.017%
Leukaemia 0.004%
Comorbidity Is Common
Recognition
Is it real? Cause and effect?
If cause suspected, ADHD diagnosis stays irrespective of causes
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Symptoms of ADHD
has to be moderate and impairing in multiple domains (school,
physical risks, relationships, self image, avoiding criminality)
multiple settings
co-morbidity is a rule
Assessing severity – moderate vs. severe
 Clinical judgement
 Using DSM IV and ICD 10 diagnostic criteria, Conners scales or CGAS
scale)
Assess family (mental health, parental ADHD) and educational problems
After diagnosis
 Provide written and on line information for parents and school
– www.addmire.org.uk
 Promote
- positive parent – child contact
- clear boundaries
- structured day
 training programmes
 Stress the need for above average parenting needs – do not
imply bad parenting
 Reframe and include the positive aspects of the condition
Great Things About Having ADD!
E n t e r t a i n y o u r f r i e n d s w i t h w i t t y o n e - l i n e r s a n d s h a r p c o me b a c k s  In so m n ia
mak es f o r mo r e t i me t o s t ay u p an d s u r f t h e n et !  Th e d r i v e o f
Hy p er - f o cu s  Two wo r d s : C h a t A d d i c t i o n  Hy p er act i v i t y +
C r e a t i v i t y + Co m p u l s i v e Li b i d o = On e P o p u l ar Gu y o n Dat es
 R e s i l i e n c e  Can meet , f al l d eep l y i n l o v e, mar r y , f i g h t , h at e
sparkling
an d d i v o r ce al l i n ab o u t 3 5 mi n u t es o r l es s 
personality  can f i x at e o n o n e s u b j ect wh i l e t h e r es t o f t h e
your
of
all
see
Can
wo r l d g o es d o wn t h e t o i l et 
they
…because
time
one
at
possessions
worldly
are all over the floor  Ten d s t o b e v er y g en er o u s wi t h
mo n ey , t i me an d r es o u r ces .  N e v e r h a s e n o u g h m o n e y o r t i m e
 f l ex i b l e  E N T H U S I A S T I C  i nnovat i ve  A s t r o n g s en s e o f
Al er t  Eager 
wh at i s F AI R  Wi l l i n g t o t ak e a RI S K 
Cr eat i v e  P r o v i d es o r i g i n al i d eas o r i s n ’ t af r ai d t o s t eal t h em 
an al o g i es t h at n o o n e el s e u n d er s t an d s .
Mak es f ar r each i n g
Ab s t r act Thi nk e r s 
Wr i t es t h em o f f as “Deep Th o u g h t s ” 
Spontaneous  Al way s Ho p ef u l  Keep s b u s i n es s meet i n g s
l i v el y  T h e M i n d o f a P e n t i u m - w i t h o n l y 2 M e g s o f R A M  Ab l e
t o t i e u n r el at ed i d eas t o g et h er  Pl e asan tl y an d con stan tl y
su r p r i se d b y f i n d i n g cl oth i n g y ou h ad f or g otte n ab ou t 
ABLE TO SEE THE BIG PICTURE wh i l e o t h er s s t u mb l e ar o u n d i n
Parent training
Use evidence-based programmes
They need to:
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Be based on social learning theory
Be structured
Offer relationship enhancing strategies
Offer sufficient sessions – 8-12
Enable parents to identify their own objectives
Include role play and homework for parents
Use supervised and trained facilitators
Follow developer’s manual
Drug treatments
For severe ADHD and adults first line
For moderate ADHD if no improvement with EI,PT,CBT,SST
Pre-drug treatment assessment
Include history of exercise syncope, cardio- vascular symptoms , FH of cardiac disease
and risk for substance abuse/drug diversion
Physical exam to include neurocutaneus stigmata, dysmorphic features and CVS exam
Plot Ht/Wt and BP on centile charts
Do ECG if positive FH or CVS findings
No need for blood tests
 Choice of drug treatment
 Response to treatment
 Licensing
Drug monitoring
 Standard symptom and side effects rating scales at
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least 6 monthly
WT, HT, BP, HR
Sleep problems
Liver damage and suicidal ideas (Atomoxetine)
Seizures
Tics
Psychotic symptoms
Anxiety
Agitation
Drug misuse
ADHD Pharmacotherapy Responsiveness
Wilens, T., Spencer, T., Postered at MGH Child and Adolescent Psychopharmacology meeting, Boston 2009
Wilens T., CNS News 2003
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Drug treatments
School-age children or young
people
Drug
Adults
Moderate/severe
impairment Severe ADHD - offer drug treatment
offer drug
as first line for:
treatment as first
line
 ADHD without significant
methylphenidate
comorbidity
 ADHD with comorbid conduct
disorder
Normally first
choice
 Treatment with methylphenidate
atomoxetine
ineffective
 Intolerance to low or moderate dose
methylphenidate
 Tics, Tourette’s syndrome, anxiety
disorder, stimulant misuse
As for children
Benefits
 Personal health (drug and alcohol abuse, smoking, accidents,
mental and sexual health)
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Society – prevent offending
Education
Productivity
Clinical negligence
? ADHD
Primary care
Severe
Watchful
waiting
School
Mild / moderate
Secondary care:
Diagnosis
Assessment of severity
Pre school
School age
Moderate
Parent training /
education
Review
ADHD NICE
guidance
care pathway
Parent training / education
Review then Drug treatment if
persists or education refused
/
Severe
Drug treatment
Plus parent training /
education
Which route do you want to take?