Transcript Attention Deficit/Hyperactivity Disorder

Attention Deficit/Hyperactivity Disorder
Christopher Lever, MD, FRCP(C)
Objectives.
 Define attention disorders.
 Appreciate how to “diagnose” an attention
disorder.
 Be aware of the medical problems that may mimic
primary attention disorders.
 List some of the other “co-existing” diagnoses
with attention disorders.
 Have some awareness of the treatment options for
children with attention disorders.
 Discuss when referral for an attention difficulty is
appropriate.
Case 1
 A 7-year-old boy in grade II presents with academic and
behavior problems.
 He was asked to leave two day homes because he harmed
other children.
 His parents struggle with getting him ready in the morning
and for bedtime. He behaves better when he’s outside
playing, but is known to get overexcited. Parenting classes
have been helpful, but both parents feel somewhat
stressed looking after him when his two siblings are around.
He is thoughtful, curious, and enjoyable when he is alone
with one of his parents.
 Teachers are concerned because his literacy skills are
delayed more than one year, and he is frequently removed
from the classroom for disrupting the work of others.
Case 2
 A 14-year-old girl with a known learning disability [literacy
skills delayed] presents because she is irritable with her
parents and they feel she is depressed.
 Her learning disability was diagnosed in grade 3. She
received special assistance for literacy skills. She did
improve, but several teachers suggested she could do
better. She remains in a modified educational program
that is now failing all of her academic subjects. She is
frequently known to be doodling during class time and
does not hand in most of her assignments.
 Her parents find her irritable and reclusive. She is not
managing regular chores at home. She has spent more
time involved in electronic chat and listening to music.
 She is smoking marijuana three to five times per week.
Case 3
 A 9-year-old boy diagnosed with AD\HD; combined type at
BC Children’s Hospital at five years old presents for
renewal of stimulant medication.
 Medications include Ritalin SR 20 mg once in the morning,
and melatonin 3-6 mg in the evening.
 Improved attention and decreased hyperactivity is noted
two hours after administration and lasts for a total of 5
hours. Hyperactivity is increased around transition in spite
of regular medication administration.
 Growth is good, sleep is better with melatonin. His blood
pressure is normal.
 He is zinc deficient and has asthma. He also wears
glasses.
It’s about perspective.
 Who in this room thinks they have attention
problems?
 Who feels restless?
 Who has had a speeding ticket?
 Who has ever missed a spelling error in the final
draft of a document?
 Who has ever bought something on sale that
they’ve only used once? (not a condom or a
coffin)
 Who has ever asked for instructions to be
repeated because they “missed a step”?
SPECTRUMS
.
Attention disorders represent a
grouping of children with similar
traits. Most do not have a hard
pathologic diagnosis. It is simply
a pattern of similar clinical
characteristics that are
maladaptive for the child’s
current setting and expectations.
A brief controversy.
 Attention difficulties are described between 4-8% of North
American children, but much less in most other parts of the
world.
 It depends who you ask. There is inherent bias in any
behavioral symptom.
 It depends on context for that child. If the world were about
better soccer players, the story writers would be doing
remedial throw-ins at recess.
 The pharmaceutical industry and medical education has
directly created more public awareness.
 Attention and impulse/movement regulation are only part of
the whole person. A disorder exclusive to inattention,
hyperactivity, or impulsivity is naïve.
What is ADHD?
 Cultural. “What’s my age again?”
 Pathological. Well, it is getting less clear. It
is mostly about frontal cortex dopamine.
Functional MRI data are accumulating, but
the results are not easy to summarize.
There are likely multiple reasons for ADHD
phenotype.
 Academic. But 65 % in math is a definite
pass.
Dotted line – dopamine, dashed line - norepinephrine
Stimulants’ Proposed Mechanism of
Action
= NT = neurotransmitter;
dopamine or norepinephrine
AMPH = amphetamine
MPH = methylphenidate
Presynaptic Neuron
AMPH
Storage
Vesicle
Neurotransmitter
Output
Neurotransmitter
Transporter
NT Transporter
(reuptake pump)
MPH & AMPH
Postsynaptic Neuron
Adapted from Wilens & Spencer. Child Adolesc Psych Clin N Am 2000;9:573.
DSM-IV-TR
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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
Often does not give close attention to details or makes careless
mistakes in schoolwork, work, or other activities.
Often has trouble keeping attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
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).
Often has trouble organizing activities.
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).
Often loses things needed for tasks and activities (e.g. toys, school
assignments, pencils, books, or tools).
Is often easily distracted.
Is often forgetful in daily activities.
DSM-IV-TR
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B Six or more of the following symptoms of hyperactivityimpulsivity have been present for at least 6 months to an
extent that is disruptive and inappropriate for developmental
level:
Hyperactivity
Often fidgets with hands or feet or squirms in seat.
Often gets up from seat when remaining in seat is expected.
Often runs about or climbs when and where it is not appropriate
(adolescents or adults may feel very restless).
Often has trouble playing or enjoying leisure activities quietly.
Is often "on the go" or often acts as if "driven by a motor".
Often talks excessively.
Impulsivity
Often blurts out answers before questions have been finished.
Often has trouble waiting one's turn.
Often interrupts or intrudes on others (e.g., butts into conversations
or games).
DSM-IV-TR
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Some symptoms that cause impairment were present before age 7
years.
Some impairment from the symptoms is present in two or more
settings (e.g. at school/work and at home).
There must be clear evidence of significant impairment in social,
school, or work functioning.
The symptoms do not happen only during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic
Disorder. The symptoms are not better accounted for by another
mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative
Disorder, or a Personality Disorder).
Based on these criteria, three types of ADHD are identified:
ADHD, Combined Type: if both criteria 1A and 1B are met for the
past 6 months
ADHD, Predominantly Inattentive Type: if criterion 1A is met but
criterion 1B is not met for the past six months
ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is
met but Criterion 1A is not met for the past six months.
DSM-V revisions.
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No exclusion for ASD.
Other mental health disorders can exist, but
ADHD symptoms must not be primarily seen
during mental health exacerbations or
intoxication or withdrawal.
First symptoms before age 12 (not 7) years.
Five of nine criteria can diagnose anyone over
17 years of age.
http://www.dsm5.org/Documents/ADHD%
20Fact%20Sheet.pdf
Information gathering.
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From parent, both if possible.
From teachers.
From anybody else who spends time
directly observing this child and has
expectations of the child.
From a trained school observation.
The most widely used
ADHD screening and treatment monitoring tools
are now available online!
SELECT A RATING SCALE TO COMPLETE
PARENT
REPORT
TEACHER
REPORT
YOUTH
SELF-REPORT
ADULT
SELF-REPORT
FRANÇAIS
ABOUT
CLINICIANS
PRIVACY
SECURITY
CONTACT US
Online adaptation of the SNAP-IV Online Rating Scale developed by Dr. Don Duncan, MD FRCP(C).
SNAP-IV Teacher and Parent Rating Scale originally developed by James M. Swanson, PhD., University of California Irvine.
ASRS-v1.1 developed by Leonard Adler, MD, Ronald C. Kessler, PhD, and Thomas Spencer, MD in conjunction with the World Health Organization.
Is it a disorder?
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Academic failure.
Social failure.
Family disharmony.
Emerging negative self-concept.
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:
B Six or more of the following symptoms of hyperactivityimpulsivity have been present for at least 6 months to an extent
that is disruptive and inappropriate for developmental level:
Some impairment from the symptoms is present in two or more
settings (e.g. at school/work and at home).
There must be clear evidence of significant impairment in social,
school, or work functioning.
Why bother with this diagnosis?
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Understand origin of current difficulty.
Educate parents and teachers about the
nature of attention difficulties.
Offer medically proven therapies to
improve attention disorder symptoms.
Discuss the natural history of attention
disorders.
Medical differential diagnosis.
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Serious chronic symptomatic medical
health issue.
Obstructive sleep apnea.
Absence epilepsy.
Thyroid disease. Rarely iron and zinc
deficiency.
Serious head injury.
Sensory impairment.
Association with preterm delivery.
Psychologic concomitant diagnoses.
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Cognitive impairment.
Unique learning profile, “learning disability”.
Autistic spectrum disorder.
Opposition defiant disorder.
Conduct disorder.
Obsessive-compulsive disorder.
Primary anxiety.
Substance abuse.
Major depression.
Comorbidity of Adult ADHD with Other
DSM-IV Disorders in the National
Comorbidity Survey Replication (n=154)
Comorbid Disorder During Previous 12
Months
Major Depressive Disorder
Dysthymia
Bipolar Disorder
Generalized Anxiety Disorder
PTSD
Agoraphobia
Social phobia
Alcohol abuse
Alcohol dependence
Drug dependence
Any substance use disorder
Intermittent explosive disorder
Among Respondents With
ADHD
18.6%
12.8%
19.4%
8%
11.9%
8.9%
29.3%
5.9%
5.8%
4.4%
15.2%
19.6%
Kessler, Adler, Barkley, Biederman, Conners, Demler, Faraone, Greenhill, Howes, Secnik, Spencer, Ustun, Walters,
Zaslavsky – The American Journal of Psychiatry, April 2006, pgs. 716-723
National Comorbidity Survey Replication:
Mood Disorders in Adult ADHD
N=3199
Adult
ADHD
Major
Depression
18.6%
Kessler RC et al. Am J Psychiatry. 2006;163:716-723.
Dysthymi
a 12.8%
Bipolar
Disorder
19.4%
Any Mood
Disorder
38.3%
29
National Comorbidity Survey Replication:
Anxiety Disorders in Adult ADHD
N=3199
Adult
ADHD
Generalize
d Anxiety
Disorder
8%
Panic
Disorder
8.9%
Obsessivecompulsive
Disorder
2.7%
PTSD
11.9%
Any Anxiety
Disorder
47%
Kessler RC et al. Am J Psychiatry. 2006;163:716-723.
Social
Phobia
29.3%
Agoraphobi
a
4%
Stress and attention skill.
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Child abuse.
Witnessing violent acts.
Medically ill or dying caregiver.
[Poor role modeling]- the genetics of
ADHD.
Chaos – variable and multiple caregivers,
foster care, and transiency.
Treatment.
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Education.
Balanced diet.
Good sleep hygiene.
Regular physical activity.
[decreased video game playing]
Specific behavioral strategies.
Medication.
Psychostimulant medication.
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Methylphenidate. Ritalin, Ritalin SR,
Concerta, Biphentin.
Dextro-amphetamine. Dexedrine (tablet
and Spansule).
Mixed amphetamine salts. Adderall XR.
Lisdexamfetamine- L-lysinedextroamphetamine dimesylate. Vyvanse.
Non-stimulant medication.
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Atomoxetine. (Strattera)
Tricyclic antidepressants.
Alpha adrenergic agonists. (Clonidine and
Guanfacine – Intuniv XR)
Buproprion. (Zyban, Wellbutrin XR)
When to refer?
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Complex cases have a role for input from
psychology, occupational therapy, and
occasionally psychiatry.
Lack of comfort with diagnostic process.
Inadequate time for evaluation process.
Discussion of medication options.
Take Home Message
 Attention difficulties are a subjective group of disorders defined by
semi-objective questionnaires rating a particular person in a specific
setting with certain expectations.
 Significantly different attention skills in at least two settings combined
with academic and/or social failure and the impression of negative self
concept lead to the diagnosis of ADHD.
 Medical health reasons need to be excluded.
 Psychological problems need to be recognized and accounted for.
 Each child requires a thoughtful and comprehensive evaluation prior to
labeling or discussion of treatment. Referral may be required for this
purpose.
 Treatment includes: education, healthy lifestyle, behavioral strategies,
and medication.
 In adolescence, encourage condom use and driving a 5 speed.