Atención-Deficit Disorder and Hyperactivity : Diagnostic keys (SY131 Regular Symposium)

1. Atención-Deficit Disorder and Hyperactivity : Diagnostic keys(SY131 Regular Symposium) J.L. Pedreira-Massa Child and Adolescent Psychiatrist and Psychotherapist Niño Jesús University Children’s Hospital Autonomous University of Madrid

2. Agustín García Calvo Y mientras sigáis aprendiendo, jamás temáis la vejez ni la tumba. Ese es el secreto de la juventud

3. Contents • Clinical diagnostic steps • Diagnostic scales utilization • Recent neurorradiological diagnostic tools

4. Clinical diagnostic steps

5. Clinical facts-dilemmas • In clinical practice ADDH is notoriously frequent: Does it mean high prevalence or overdiagnosis? • Metilphenidate prescription rate is subsequently high Is Metilphenidate prescribed on curative purpose or just to “calm down”?

6. Nosological illusion (?): On line Web pages • ADDH • AD disorder and hypoactivity • Hyperattentional Disorder and hyperactivity • Hyperattentional Disorder and hypoactivity • What ... the future will be?

7. Essential diagnostic criteria • Attention Deficit • Impulsiveness • Hyperactivity Diagnostic criteria? vs. Psychopathological content?

8. Psychopathological content /1 • Quantitative • vs. • Qualitative? • Understanding deficit • vs. • Attention deficit? • Cognitive deficit • vs. • Attention deficit? Attention Deficit

9. Psychopathological content/2 • Quantitative • vs. • Qualitative? • Primary conduct • vs. • reactive behaviour? • Impulsiveness • vs. • aggressiveness? Impulsiveness

10. Psychopathological content/3 • Quantitative • vs. • Qualitative? • Restlessness/nervousness • vs. • Hyperactivity? • Agitation • vs. • Hyperactivity? Hyperactivity

11. Developmental Reactivity in Childhood • Language development and socio-cultural context dependent • Nonverbal stage: Psychomotor and corporal reactivity • Initial language stage: Body language remains and behavioural outburst appears • Stablished language stage: Emotions can be expressed through language

12. Diagnostic scales utilization

13. Exclusion Criteria • Mental disorder related to a medical condition predisposing to one or more symptoms • Generalized Mental Disorder presents essential or associated symptoms which are essential symptoms of less generalized disorders • Clinical practice is hierarchically above complexity, difficulty or subtleness of categorial diagnostic criteria DSM-IV, 1994, pag. 6 DSM-IV-TR, 2002, pag. 7

14. Clinical evaluation according to categories: A call for attention • Criteria are guidelines: An specific training on its utilization is required • Criteria are a consensus: Not all possible clinical conditions are included • Diagnostic Criteria should be used as guidelines according to clinical thinking: “not to be followed as a recipes in cook book” DSM-IV, 1994, pag. XXII; DSM-IV-TR, 2002, pag. XXXI

15. Assessing scales: Diagnostic utilization • Aimed at assessing signs and symptoms • Based on pre-established category criteria • Not replacing clinical observation • They are ancillary tests but not driving directly to a diagnosis • They are more valuables when clinical features are collected within the clinical interview process and translated to scales by clinical staff soon after of the clinical interview • Conner’s and Taylor’s are mostly used

16. Selected clinical cases

17. Clinical cases profile • Boy • Average age:10 years • Main diagnosis: ADDH • Diagnosis based mostly on clinical description/categories • Current treatment: Methylphenidate (prescribed doses slightly lower than recommended)

18. Recent neurorradiological diagnostic tools

19. Attention Deficit Disorder without Hyperactivity • Boy, 8 years • Right handed • Normal pregnancy and delivery, normal psychomotor and language development • Aggressive behaviour toward parents • EEG: Normal • Brain CT: Normal • Blood and biochemistry tests: Normal • Visual SPAN, DD= 6; DI= 2 • DD=4; DI=4 • STROP, Interf.= -3.9 • Poor parental discipline and monitoring • Inability to perform basic routine home and school activities (school failure) • Treatment: Not treatment at the moment but p1reviously MPh and Nemactyl

20. LEFT HEMISPHERE RIGHT HEMISPHFERE Bipolar receptor difference: 500-700 milliseconds Test: CPT Increased cingular activity By courtesy of Prof. T. Ortiz (UCM)

21. Test: Response inhibition (500-700 msec.HD) Increased cingular activity By courtesy of Prof. T. Ortiz (UCM)

22. ADDH • Boy, 7 years of age • Background:Intense hyperactivity evidenced at 3 years of age • Right handed • WISC-R: • IQ= 95 • MR= 100 • VR= 92 • SPAN VISUAL DD=7; DI=5 • DD=3; DI= 2 • Stroop, Interf.= -9,78 • The basic routines pattern seems to be very variable: Ranging from total supervision to almost independent life • The child shows relevant difficulties to: • Inhibitdisruptive behaviour • Accept behaviour supervision • Treatment: Methylphenidate 10 mg/day

23. ADDH (Response inhibition test)(500-700 mseg HD) Decreased cingular activity By courtesy of Prof. T. Ortiz (UCM)

24. ADDH PET-FDG: Bilateral talamic hypometabolism Preserved cortex MR: Normal By courtesy of Dr. A. Maldonado (Complutense PET Center)

25. Discussion/1 • Categories or dimmensions? • As a borderline developmental stage (ex.: Family relationships with poor limits and “bad upbringing”, poor family management) • As a symptom of other conditions (ex.: Cognitive delay, Personality disorder) • ADDH as an specific condition (careful and detailed neuropsychological testing) • Clinical Diagnosis or test score scales? • Psychopathological and contextual assessment • Scales score is not a diagnosis (ex.: Conner’s scales assess pharmacological treatments in childhood)

26. Discussion/2 • Data “struggle”: USA (10-14%) vs. Europe (5-7%) • Treatment: • Give the priority to symptoms/processs evaluation and its sequence in the boy/girl background • Methylphenidate doses and timing: • Initial treatment: Four weeks • Dose prescription according to recommendations (0.5-1 mgr/Kg weight/day) • A breakfast and lunch dose • From Monday to fryday (schedule days) • Treatment term: 2-5 school years • Individual Psychopedagogical support • Family Councelling • Longitudinal follow-up: Continuity vs. discontinuity? ... What about?

27. Philippe Jacottet(La voix, 2002) Qui chante là quand toute voix se tait? Qui chante avec cette voix sourde et pure un si beau chant? Nul ne le sait. Mais seul peut entendre le coeur qui ne cherche la possession ni la victoire