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Adolescent ADHD. 長庚兒童醫院 兒童心智科 張學岑醫師. Etiology. ADHD is a heterogeneous behavioral disorder with multiple possible etiologies Neuroanatomic/ Neurochemical CNS Insults Genetic Origins Environmental factors. Core Symptoms Areas. Inattention to details/ makes careless mistakes

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Adolescent adhd

Adolescent ADHD

長庚兒童醫院 兒童心智科

張學岑醫師


Etiology
Etiology

ADHD is a heterogeneous behavioral disorder with multiple possible etiologies

  • Neuroanatomic/ Neurochemical

  • CNS Insults

  • Genetic Origins

  • Environmental factors



Dsm iv criteria inattention six or more of the following manifested often

Inattention to details/

makes careless mistakes

Difficulty sustaining attention

Seems not to listen

Fails to finish tasks

Difficulty organization

Avoids tasks requiring sustained attention

Loses things

Easily distracted

Forgetful

DSM-IV CriteriaInattentionSix or more of the following—manifested often:


Adhd dsm iv criteria impulsivity hyperactivity six or more of the following manifested often

Impulsivity

Blurts out answer before questions is finished

Difficulty awaiting turn

Interrupts or intrudes on others

Hyperactivity

Fidgets

Unable to stay seated

Inappropriate running/climbing (restlessness)

Difficulty in engaging in leisure activities quietly

“On the go”

Talks excessively

ADHD: DSM-IV CriteriaImpulsivity/HyperactivitySix or more of the following-manifested often:


Variation in symptoms
Variation in symptoms

Symptoms vary in

  • Pervasiveness

  • Frequency of occurrence

  • Degree of impairment


Dsm iv diagnosis criteria
DSM-IV Diagnosis Criteria

  • Symptom criteria must be met for past 6 months

  • Some symptoms must be present before 7 years of age

  • Some impairment from symptoms must be present in 2 or more settings

  • The symptoms lead to significant impairment

  • Symptoms are not exclusively due to other mental disorders


Dsm iv subtypes
DSM-IV Subtypes

  • ADHD Predominantly Inattentive Type

    • Criteria met for Inattentive but note for impulsivity/hyperactivity

  • ADHD Predominantly Hyperactivity/Impulsivity Type

    • Criteria met for impulsivity/hyperactivity but not for Inattention

  • ADHD Combined Type

    • Criteria are met for both inattention and impulsivity/hyperactivity


Impact and cost of adhd
Impact and cost of ADHD

  • ADHD in adult prison inmates:25%

  • More drivers with ADHD:

    • Drove without a license

    • Had license revoked or suspended

    • Had multiple crashes(2+)

    • Had multiple traffic citations(3+)

    • Subgroups of ADHD with comorbid ODD/CD were at highest risk


Impact and cost of adhd1
Impact and cost of ADHD

  • Despite similar educational levels and IQ scores, individuals with ADHD not taking medication display significantly more academic problems in school (25% repeat a grade) and lower occupation attainment


Impact and cost of adhd2
Impact and cost of ADHD

  • Parents of children with ADHD experience higher level of stress, self blame, social isolation, depression and marital discord

  • 63% of 144 caregivers after diagnosis of child’ s ADHD changed work status


過去40年的變化

  • Laufer (1962): “The behavior picture described tends to disappear with maturation, anywhere between twelve and eighteen years of age….”

  • Mendelson et al (1971): “Our findings suggest that hyperactive children are generally behaving in a more normal way by the time they enter their teens…”

  • Wender (1995):”…the past decade researchers have become convinced that…ADHD… is a common psychiatric disorder in adults…”

  • Gadow and Weiss (2001): ”…the validity of this disorder is now beyond controversy.”


Diagnosis of adolescent adhd
Diagnosis of Adolescent ADHD

  • Still an observational diagnosis

  • DSM-IV criteria thought threshold could be too high

    • Likely 4/9 (Barkley et al., 2001)

    • Shouldn’t apply age 7 criteria (Applegate et al., 1996)

    • Semi-structured interview should be done

    • Measurement of impairment


Pitfall in the diagnosis of adolescent adhd i
Pitfall in the diagnosis of adolescent ADHD --I

  • Individuals (esp. girls) who tend to exhibit fewer hyperactive symptoms

  • Individuals who exhibit mental rather than physical restlessness

  • The ubiquity of inattentive and impulsive behavior in normal adolescent life

  • Developmental relativity, age appropriateness


Pitfall in the diagnosis of adolescent adhd ii
Pitfall in the diagnosis of adolescent ADHD --II

  • Self report Vs parental report

  • Difficulty to obtain data from secondary school teacher

  • Uncooperative adolescents

  • Multiple comorbid disorder

  • Shared features of other adolescent –onset psychiatric disorders

  • Life span with multiple stresses


Pitfall in the diagnosis of adolescent adhd iii
Pitfall in the diagnosis of adolescent ADHD --III

  • The uncertain validity of applying DSM-IV diagnostic criteria for ADHD in adolescent

  • The difficulty of establishing impairment in functioning due to ADHD for adolescent

  • Different definition of remission

    • Syndromatic remission

    • Symptomatic remission

    • Functional remission



Adolescent and adult with adhd background
Adolescent and adult with ADHDBackground

  • A source of controversy and uncertainty in ADHD is the marked differences that have been observed in male to female ration between pediatric and adolescent samples

    • Gender ration in pediatric sample heavily favors male 4:1– 9:1

    • Adolescent and adult samples have a more even gender distribution

    • Differences in gender representation have threaten the validity of the diagnosis of Adolescent and adult ADHD


Adolescent and adult with adhd background1
Adolescent and adult with ADHDBackground

  • Similar pattern of comorbidity had been documented in boys and girls with ADHD

    • However, boys have>2 fold increased rates of disruptive behavior disorder

    • Disruptive behavior disorders drive clinical referrals of children but not adults


Follow up studies in adhd
Follow up studies in ADHD

  • Montreal study by Weiss and Hechtman (1993)

  • New York Study by Mannuzza,Klein et al (1998)

  • Swedish Study by Rasmussen and Gillberg (2001)

  • Milwaukee Study by Barkley (2002)


What predicts persistence of adhd into adolescence biederman farone et al 1996
What predicts persistence of ADHD into adolescence?(Biederman, Farone et al;1996)

  • Familiarity of the ADHD(OR 2)

  • Presence of psychiatry comorbidity (conduct disorder, mood or anxiety disorder) (OR 3)

  • Family adversity (paternal mental illness, conflict in family) (OR 7)(p<0.001)


Adolescent outcome
Adolescent outcome

  • decline in hyperactivity, improvement in attention span and impulse control(Hart, Lahey, Loeber, Applegate& Frick, 1995)

  • 30-80% of ADHD children continue to display symptoms in adolescence(Gittelman, Mannuzza, 1985; Barkley, Fischer et al, 1990)

  • 25-45% display oppositional or antisocial behavior or CD(Biederman, Faraone et al 1996, Biederman et al 1997)


How are adhd adolescents doing in school
How are ADHD adolescents doing in school?

  • 29.3% retained in a grade, 46.3% had been suspended, 10% dropped out.(Barkley, Fischer,1990)

  • ADHD adolescents had more academic impairments(compared to baseline), lower IQ and mathematics achievement scores and more learning disabilities.

  • Fail to work independently well

  • Poor organization and planning

  • Poor time management

  • Poor follow through


Differential diagnosis of ADHD--comorbidity alter the clinical presentation and may require multiple treatment

  • Coexisting conditions

    • Conduct disorder

    • Learning disorder

    • Oppositional defiant disorder

    • Bipolar affective disorder

    • Epilepsy

    • Tourette syndrome


Comorbid disorders in adhd adolescents
Comorbid disorders in ADHD adolescents

  • High percentage of antisocial behavior, but low rates of mood and anxiety disorders.(Weiss 1993; Mannuzza 1991)

  • 59% of ADHD adolescents had ODD, 43% had CD(Barkley,1990)

  • Baseline comorbid CD significantly increase the risk for CD and ODD, Bipolar Disorder and alcohol and drug dependence on follow up.

  • Baseline comorbid major depression increased the risk for ODD, Major Depression, Bipolar Disorder and Agoraphobia.

  • Multiple anxiety disorder at baseline increased the risk for Anxiety Disorder.

  • Youngster with non-comorbid ADHD had an increased risk for ODD, Tic Disorder, and Language disorder. (Biederman, Faraone et al, 1996)




Psychiatry and medical disorders can mimic adhd

Mood Disorder

Psychotic Disorder

Adjustment Disorder

Anxiety Disorder

Learning/language Disorder

Stress-related Disorder

Developmental Disorder

Sleep Apnea

Substance Use Disorder

Use of Other medications

Seizure Disorder

Vision problem

Hearing Impairment

Psychiatry and Medical Disorders can mimic ADHD


How does having adhd affect self esteem
How does having ADHD affect self esteem?

  • ADHD individuals displayed lower self-esteem and psychosocial adjustment by adolescents and lower educational achievement and occupational status. (Mannuzza, Klein,1995)

  • Lowered self esteem is part of the longitudinal outcome of ADHD


How are adhd adolescents getting along with their families
How are ADHD adolescents getting along with their families?

  • Parent-adolescent relationship between ADHD teenagers and their parents are generally characterized by increased conflict, negative communication, distorted beliefs, and more disengagement, especially when the adolescents are diagnosed with ADHD+ODD.


Adolescent adhd and substance use
Adolescent ADHD and substance use

  • Persistence of ADHD symptoms, family history and comorbid CD– high prediction of drunkenness and daily smoking

  • Among different symptom cluster in ADHD, inattentiveness is most predictive of substance use



Developmental outcome and developmental course research
Developmental outcome and developmental course research

  • Developmental outcome study:identifying a cohort of children that meet diagnostic criteria for ADHD and follow them prospectively to determine whether they are at increased risk for any number of negative developmental outcome

  • Developmental course study: whether the symptoms of ADHD persist into adolescent


Developmental outcome studies
Developmental outcome studies

  • Thorley(1984):Childhood hyperactivity was associated with an increased risk for PD, antisocial behavior, peer relationship, educational difficulties,as well as continued HIA symptoms

  • Clampit and Pirkle(1983): psychostimulants maybe effective in ADHD adolescents

  • Barkley et al(1993): children with ADHD are at increased risk for a variety of negative developmental outcome in adolescence and adulthood.

  • Barkley et al(2002): “…the educational, occupational, and psychosocial risks are associated with a childhood diagnosis of ADHD relative to both normal and clinical control populations.”


Limitations of developmental outcome studies
Limitations of developmental outcome studies

  • It remains unclear whether:

    • ADHD symptomatology may interfere with normal development process, including parent-child relationships, peer relationship and/or academic performance that in turns increase the risk of negative outcome, or

    • ADHD may facilitate the onset and persistence of other behaviors/psychiatric disorder that increase the risk for negative outcome.


The importance of developmental course study
The importance of developmental course study

  • Clarify the mechanism linking childhood ADHD to later negative developmental outcome

  • An improved understanding of the developmental course of ADHD symptomatology would provide information for the construction of developmentally sensitive diagnostic criteria


Developmental course studies
Developmental course studies

  • Diagnostic retention studies

  • Symptom trajectory studies

    • MacCallum et al (2002): “…repeated measures data of a continuous variable provide more information than a dichotomous diagnosis…”


Diagnostic retention studies
Diagnostic retention studies

  • Hill and Schoener (1996):meta-analysis of 9 diagnostic retention studies. Rate of ADHD desisted by 50% every 5 years(beginning at 9)

    • Barkley(1998)’s criticize: 1. Many of the studies included were initiated prior to the establishment of formal diagnostic criteria for ADHD. 2. Not enough studies were included.


Symptom trajectory studies
Symptom trajectory studies

  • Hart et al(1995): 1. Hyperactive-impulsive symptoms significantly declined with increasing age, whereas inattention symptoms did not. 2. Conduct problems predicted persistence of ADHD symptom. 3.Developmental changes in ADHD symptom did not vary as a function of informants 4. Psychosocial and pharmacological interventions did not reduce ADHD greatly.

  • Biederman(1998):1.Children and adolescent ADHD did not differ in the mean number of ADHD symptoms. 2.Clinical phenotype is the same in adolescent and children.

  • Biederman(on the same sample,2000): HIA decreased significantly as age increased.


Developmental trajectories of brian volume abnormalities in youth with adhd
Developmental Trajectories of Brian volume abnormalities in youth with ADHD

  • Design: MRI case control study

  • M=152 youth with ADHD and 139 controls of both genders

  • Objectives; assess volumetric changes overtime in medicated vs unmedicated youth with ADHD and controls

    Catellanous :JAMA 2002; 288-1740


Developmental trajectories of brian volume abnormalities in youth with adhd1
Developmental Trajectories of Brian volume abnormalities in youth with ADHD

  • Main Findings:

  • Smaller brain volumes in all regions independently of medication status

  • Smaller total cerebral (-3.2%)and cerebellar (-3.5%) volumes

  • Volumetric abnormalies(except caudate) persistent with age

  • No gender differences

  • Volumetric findings correlated with severity of AHDH


Developmental trajectories of brian volume abnormalities in youth with adhd2
Developmental Trajectories of Brian volume abnormalities in youth with ADHD

  • Conclusions

    Genetic and or early environmental influences on brain development in ADHD are fixed, nonprogressive and unrelated to stimulant treatment


Maturation lag hypothesis
Maturation lag hypothesis youth with ADHD

  • Satterfield JH(1973,1984):ADHD children have more slow activity and less activity in the high frequency band---signs of immaturity reflecting a delayed brain maturation that could be normalized with age,or a deviation of brain maturation.

  • Giedd JN(2001):ADHD cerebellum is significantly smaller than control.

  • Lou(1984):SPECT finding—maturational lags of CNS resulting from delayed myelination.

  • Castellanos(2002):gray matter shows complex developmental curves with a preadolescent increase but a post adolescent decrease.


Limitations of developmental course studies
Limitations of developmental course studies youth with ADHD

  • Sample characteristics: predominantly males in clinic referred sample

  • Course of ADHD symptomatology differs as a function of comorbidity?

  • The need to better understand whether reductions in ADHD(due either to sex and/or advancing age) are associated with specific changes in functional impairment that result from ADHD.

  • Design issues:

    • Wide age range

    • Time adjacent study that did not consider the functional form that characterizes this change over time


More limitations
More limitations… youth with ADHD

  • Heterogeneity: ADHD is not a homogenous disease

    • Mendelson et al (1971):1/2 improved over time, ¼ partial improved, ¼unchanged

    • Loney (1981):developmental delay, developmental decay, continual display

    • Lambert (1987,community cases):20% remitters, residuals 37%, persisters (43%)

    • Hechtman of Montreal sample(1993):1/3 normal outcome, 1/2continual symptoms with function impairment, a minority experienced serious outcome.


Implications
Implications youth with ADHD

  • Clinicians working with substance abuse populations, conduct disordered populations and head injury populations should be alert for ADHD.

  • ADHD is a lifelong disorder


Treatment options in comorbid adhd
Treatment options in comorbid ADHD youth with ADHD

  • Assess and treat all disorders

  • Prioritized treatment

  • Treatment of ADHD almost always involves the treatment of comorbidity

  • Order of treatment

    • Most debilitating symptoms first

    • Consider interactions of symptoms and side effects of stimulants

  • Simple case– monotherapy

  • Complex case- combined treatment


Use of ritain

Absolute range per dose:5-30 mg youth with ADHD

Weight-based dose range per day: 0.3-2.0mg/kg

There is no research to indicate more medicine with higher body weight

Dose of medicine varied with individual’s metabolism, severity of ADHD symptoms, presence of comorbid conditions, behavior characteristics and natural environment

Use of Ritain


Side effect of ritalin and its management
Side effect of Ritalin and its management youth with ADHD

  • Anorexia(generally lunch)-give with meals, snacks

  • Insomnia- move dosing earlier, use of clonidine, TCA

  • Mood disturbance- evaluate for mood disorder, assess timing of mood to r/o wear off effect

  • Tic disorder- assess for underlying tics, stop and rechallenge

  • Headache- lower dose, change prep, consider beta blocker

  • Psychosis- rare, reassess dose and comorbid

  • Delay growth spurt- drug holiday if inattentive form


Non stimulant pharmacotherapy
Non-stimulant pharmacotherapy youth with ADHD

  • TCA

    • 60-70% effective, but generally less effective than stimulants

  • Bupropion

    • First line for ADHD+ substance abuse/cigarette use

    • Maybe helpful in ADHD+ mood lability

  • Clonidine

    • Useful in ADHD +tics

    • Use at night for ADHD related sleep problem

    • Concerns of sudden death: case report of 4 children(clonidine+ MPH)


Treatment of adhd with mdd
Treatment of ADHD with MDD youth with ADHD

  • Depression disorder

    • If MDD is severe, then it is the focus of treatment

    • If MDD is less severe or not primary, use stimulant trial first

    • After stimulant trial, evaluate the depressive symptoms

    • If depressive symptoms continue, use antidepressant or psychotherapeutic treatment

    • SSRI effective for depression but not ADHD

    • If depressive symptoms subsided, continue stimulants

    • Bupropion and TCA have antidepressant activity in adult, but utility in pediatric use had nor been established(5 cases of sudden death in younger children)


Treatment of adhd with anxiety disorder
Treatment of ADHD with anxiety disorder youth with ADHD

  • Differentiate the relationship between ADHD and anxiety disorders

  • Start with a stimulant trial

  • If ADHD symptoms improve, but anxiety symptoms persisted, apply psychosocial intervention

  • If the anxiety symptoms does not improve with the psychosocial intervention, consider adding SSRI to the stimulants.


Treatment of adhd with tics disorder
Treatment of ADHD with tics disorder youth with ADHD

  • High comorbidity of ADHD (50-70% TS patients)

  • Onset of ADHD before tics

  • Stimulants are highly effective in the treatment of ADHD in these patients and in the majority of patients tics do not increase

  • Start the stimulant treatment after proper informed consent

  • If tics worsen markedly, move on to an alternative stimulants

  • If tics do not worsen, and ADHD symptoms respond, remain on the stimulants

  • To treat the tics, consider combine medication, clonidine and guanfacine may be tried first


Treatment of adhd with conduct disorder and aggression
Treatment of ADHD with conduct disorder and aggression youth with ADHD

  • It stimulant did not reduce antisocial behavior despite the attenuation of the ADHD symptoms, use mood stabilizer(Li or divalproex sodium), or Clonidine in addition to stimulants(Frazier, 1999)(4 deaths with the combination of Stimulants and Clonidine)

  • Use of Clonidine:start with 0.05mg at bedtime, never more than 0.3 mg per day. Never use in patients with family history of sudden death, repeated fainting or arrhythmias.

  • If aggression is severe, and is in immediate danger, use atypical neuroleptics, such as 0.5mg QD Risperidone, to the stimulants


Prevention of abuse potential of stimulants in adolescents
Prevention of Abuse potential of stimulants in adolescents youth with ADHD

  • Locked the medicine, keep a record

  • Do not use one student’s medicine on another

  • Avoid sending medicine to school

  • Use Concerta: paste, taken once daily


Oslon 1959
Oslon, 1959 youth with ADHD

  • Those who surprised us seems to take a longer time to travel a given road, but that road has been kept open by parents and teachers who felt it worthwhile.”


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