Transcript ADHD (TDAH)

Attention-Deficit / Hyperactivity Disorder (ADHD)
Trouble du déficit de l’attention/hyperactivité
(TDAH)
Claude Jolicoeur. m.d.
DSM-IV Criteria for ADHD
 Symptoms of ADHD ; Topic Contents
 The year 2000 Diagnostic & Statistical Manual for Mental
Disorders (DSM-IV-TR) provides criteria for diagnosing
ADHD.
The criteria are presented here in modified form to make
them more accessible to the general public. They are listed
here for information purposes and should be used only by
trained health care providers
Inattention
 I. Either A or B:
 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:
 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.
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 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).
 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.
Hyperactivity/impulsivity
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:
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 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).
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 4. Often has difficulty 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
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 7. Often blurts out answers before questions
have been completed
 8. Often has difficulty waiting one's turn.
 9. Often interrupts or intrudes on others (e.g.,
butts into conversations or games).
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 B. Some hyperactive, impulsive or inattentive symptoms
that cause impairment were present before 7 years of age.
 C. Some impairment from the symptoms is present in two
or more settings (e.g. at school/work and at home).
 D. There must be clear evidence of clinically significant
impairment in social, school, or occupational functioning.
 E The symptoms do not happen exclusively during the
course of a pervasiven developmental disorder,
schizophrenia, or other psychotic disorder, and are not
better accounted for by another mental disorder (e.g. mood
disorder, anxiety disorder, dissociative disorder, or a
personality disorder).
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 Based on these criteria, three types of ADHD are
identified:
 1. ADHD, Combined Type: if both criteria 1A and
1 B are met for the past 6 months
 2. ADHD, Predominantly Inattentive Type: if
criterion 1A is met but criterion 1 B is not met for
the past six months
 3. ADHD, Predominantly Hyperactive-Impulsive
Type: if Criterion 1 B is met but Criterion 1A is not
met for the past six months.
 American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC, American
Psychiatric Association, 2000.
The most common disorder
- emotional
- cognitive
- behavioral
With a high rate comorbidity
- oppositional defiance: 40-70%
- anxiety: 10-40% - conduct disorder: 20-56%
- bipolar disorders:0-27%
- conduct disrder: 20-56%
- delinquent/Antisocial Activities: 18-30%
- academic Problems: 90%
Barkley
Social cost
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Academic underacheivement
Conduct problems
Underemployment
Vehicle accidents
Bad personnal relations
Prevalence
 More than
- schizophrenia
- obsessive-compulsive D
- panic disorder
 At 4% to 12% Shool-age (USA)
Sex ratio
 More boys than girl - ratio 3:1
 Adults- ratio 1:1
Clinical Presentation (6-12 years)
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Easily distracted
Homework poorly organized
Blurts out answers before question
Often interrupts
Fails to wait
Often out of seat
Perceived « immature »
Based Greenhill
Clinical Presentation (13-18 years)
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Inner reslessness more than agitation
Shoolwork disorganized
Engages in risky behaviors
Poor self-esteem
Poor peers relations
Confront with authority
Based Greenhill, Conners and Jett
Neurobiology
Maybe, the dysfunction
- is intrinsic to the
frontal lobe
- is influenced by brains areas with subcortical
projections.
fMRI, PET studies:
- circuits controling attention: less active and smaller
Main Neurotransmittors in ADHD
 Dopamine
 Epinephrine
To regulate the inhibitory influences in the
frontal-cortical processing of information
Dopamine
 May
- enhances signals
- improves:
. attention,
. focus vigilance,
. acquisition,
. on-task behavior and cognition
Norepinephrine
May
- dampen « noise »
- decrease distractibility and shifting
- improve executive operations
- increase behevioral, cognitive, motoric
inhibition
Cognitive functions
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Planning
Anticipating
Organizing
Working memory:
- maintaining attention
- focusing on task
Psychostimulants
Acting primarily by blocking the reuptake of dopamine
 Méthylphénidate:
. old - ritalin 5, 10, 20 mg (3-4 hours), ritalin 20 mg Sr, 6-7
hours
. new - concerta (long acting 10-12 hours)18, 27, 36, 54 mg.
 Amphetamine:
. old - dexedrine, short & long acting
. new - adderall xr (long acting 10 hours), 5, 10, 15, 20, 25,
30 mg.
Nonstimulant
 Atomoxetine (strattera), primarily blocking
epinephrine reuptake
 Buproprion (wellbutrin)
 Tricycliques (norpramine-desipramine)
 SSRIs (fluoxetine, paroxetine, sertraline)
 Venlafaxine (Effexor)
 Antipsychotics (risperdone-Risperdal)
 Antihypertensives (guanafacine, clonidine)