ADHD

1. ADHD Stephanie Stockburger, MD FAAP Assistant Professor Adolescent Medicine Clinic University of Kentucky

2. Objectives • 1. Review Diagnostic Criteria of ADHD • 2. Summarize ADHD Evaluation • 3. Describe Current ADHD Treatment

3. ADHD: Prevalence • Affects 2-18% of children • Depends on diagnostic criteria and population studied • CDC: 9.5% of children ages 4-17 years affected • Affects 8-10% of school aged children • One of the most common disorders of childhood • More common in males than females • Predominantly hyperactive 4:1 (males:females) • Predominantly inattentive 2:1 (males:females) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w ADHD in children and adolescents. Epidemiology and pathogenesis. www.uptodate.com

4. State-based Prevalence Data of ADHD Diagnosis • Percent of Youth 4-17 ever Diagnosed with Attention-Deficit/Hyperactivity Disorder by state: National Survey of Children's Health, 2007 • http://www.cdc.gov/ncbddd/adhd/prevalence.html

5. Comorbid Disorders • Children and Adolescents with ADHD frequently have comorbid psychiatric disorders • Oppositional Defiant Disorder (ODD) • Conduct Disorder • Depression • Anxiety Disorder • Learning disabilities • May be primary or secondary (exacerbated by ADHD) • http://www.cdc.gov/ncbddd/adhd/workshops/outcomes.html

6. Diagnosed Attention Deficit Hyperactivity Disorder and Learning Disability: United States, 2004-2006 • http://www.cdc.gov/ncbddd/adhd/data.html

7. Pathogenesis: What causes ADHD? • Not definitely known. • Genetic imbalance of catecholamine metabolism in the cerebral cortex (illustrated by structural and functional brain imaging, animal studies, and the response to drugs with noradrenergic activity like methylphenidate) • Twin studies: concordance as high as 92 percent in monozygotic twins and 32 percent in dizygotic twins • Number of genes appear to play a role. • Biederman, Faraone. Attention-deficit hyperactivity disorder. The Lancet. Volume 366, Issue 9481, 16–22 July 2005, Pages 237–248. • Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013.

8. Brain Changes • Children with ADHD have differences in brain structures • Changes especially noted in anterior brain areas • Smaller prefrontal cortical volumes • Reduced thickness of the anterior cingulate cortex • Cortical thinning in bilateral superior frontal brain regions • Frontal cortex monitors impulse control! • Attention-deficit hyperactivity disorder. J Biederman, S.V. Faraone. The Lancet. Volume 366, Issue 9481, 16–22 July 2005, Pages 237–248. • Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013. • Cortical abnormalities in children and adolescents with attention-deficit hyperactivity disorder. E.R. Sowell, P.M. Thompson, S.E. Welcome, A.L. Henkenius, A.W. Toga, B.S. Peterson. The Lancet. Vol 362. 2013.

9. What do the brain changes mean? • Neuropsychologic testing suggests that patients with ADHD have: • Impaired executive functions (processes involved in forward planning, including abstract reasoning, mental flexibility, working memory) • And/or difficulties with response inhibition • This goes along with the parts of the brain that are affected! • Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013. • Impact of Executive Function Deficits and Attention-Deficit/Hyperactivity Disorder (ADHD) on Academic Outcomes in Children. Biederman J, Monuteaux MC, Doyle AE, Seidman LJ, Wilens TE, Ferrero F, et al. Journal of Consulting and Clinical Psychology. Vol 72, No. 5;2004, 757-66.

10. Neurotransmitter Changes • Children and Adolescents with ADHD have an increase in dopamine transporter density • This may clear dopamine from the synapse too quickly • Methylphenidate increases extracellular dopamine in the brain (why the medication helps!) • Progress and Promise of Attention-Deficit Hyperactivity Disorder Pharmacogenetics. Froehlich TE, McGough JJ, Stein MA. CNS Drugs. 2010 February;24(2):99-117.

11. Environmental Factors • Dietary influences (controversial) • Food additives (artificial colors, artificial flavors, preservatives) • Refined sugar intake • Food sensitivity (allergy or intolerance) • Essential fatty acid deficiency • Iron and zinc deficiency • Prenatal exposure to tobacco • Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013. • The Diet Factor in Attention-Deficit/Hyperactivity Disorder. Millichap and Yee. Pediatrics 2012;129:330-7.

12. ADHD: Diagnosis • ADHD is characterized by a pattern of behavior, (several symptoms)* present in multiple settings (e.g., school and home), that can result in performance issues in social, education, or work settings. • Two subtypes: • Hyperactivity and Impulsivity • Inattention • DSM 5 Diagnostic Criteria • *change from DSM IV. “Several symptoms” instead of “impairment.” • www.cdc.gov/ncbddd/adhd/diagnosis.html

13. ADHD: Diagnosis • Children must have at least six symptoms from the subtype • Older adolescents and adults (over 17) must have five. • Symptoms must be present before age 12 years* • *change from DSM IV. Previously before age 6. • www.cdc.gov/ncbddd/adhd/diagnosis.html

14. ADHD: Diagnosis • Symptoms interfere with, or reduce the quality of, social, school, or work functioning • Symptoms do not happen only during the course of schizophrenia or another psychotic disorder. • Symptoms are not better explained by another mental disorder (mood d/o, anxiety d/o, dissociative d/o, or personality d/o) • www.cdc.gov/ncbddd/adhd/diagnosis.html

15. Diagnostic Criteria: Hyperactivity • Hyperactivity-Impulsivity subtype (children must have 6, over age 17 must have 5) • Hyperactivity • Often fidgets with hands or feet or squirms in seat • Often leaves seat in classroom or in other situations in which remaining seated is expected • Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to feelings of restlessness) • Often has difficulty playing or engaging in leisure activities quietly • Is often “on the go” or often acts as if “driven by a motor” • Often talks excessively • www.cdc.gov/ncbddd/adhd/diagnosis.html

16. Diagnostic Criteria: Impulsivity • Impulsivity • Often blurts out answers before questions have been completed • Often has difficulty awaiting turn • Often interrupts or intrudes on others (eg, butts into conversations or games) • www.cdc.gov/ncbddd/adhd/diagnosis.html

17. Diagnostic Criteria: Inattention • (children must have 6; over age 17 must have 5) • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities • Often has difficulty sustaining attention in tasks or play activities • Often does no seem to listen when spoken to directly • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) • Often has difficulty organizing tasks and activities • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) • Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, keys, paperwork, cell phones, eyeglasses or tools) • Is often easily distracted by extraneous stimuli • Is often forgetful in daily activities • www.cdc.gov/ncbddd/adhd/diagnosis.html

18. Differential Diagnosis • Developmental variations • Gifted, intellectual disability • Neurologic or developmental conditions • Learning disability, language or communication disorder, autism • Emotional and behavior disorders • Anxiety, ODD, OCD, PTSD • Psychosocial and environmental factors • Maternal depression, stressful home environment • Medical conditions • Lead poisoning, thyroid abnormality, hearing or vision impairment, sleep disorders

19. Treatment • Preschool children (ages 4-5) • Initially: behavioral therapy • If behaviors do not improve consider medication. • Methylphenidate is treatment • ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. Volume 128, Number 5, November 2011.

20. Treatment • School-aged children (age 6 and older) and adolescents • Initial treatment with behavioral therapy combined with stimulant medication. • Non-stimulants may be appropriate for certain children • Co-morbid conditions must be considered • ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. Volume 128, Number 5, November 2011.

21. Medication • Long and short-acting stimulants • Short acting: Focalin, Methylphenidate, Ritalin, Adderall • Long acting: Focalin XR, Concerta, Adderall XR, Vyvanse, Daytrana patch • Non-stimulant: Atomoxetine (Strattera), Clonidine, Guanfacine (Intuniv, Tenex), Wellbutrin (unlabeled use)

22. Medications • Short acting medications must be taken 2-3 times per day • Long-acting medications taken in the morning • Peak at 30-40 minutes • Delayed peak if taken with high fat meal

23. Medication Side Effects • Decreased appetite • Poor growth • Cardiovascular • Dizziness • Insomnia/nightmares • Mood lability • Rebound • Tics • Psychosis • Diversion and misuse

24. Medication Myths • At therapeutic doses, medications do not sedate or tranquilize children • Medications do not increase the risk of addiction if taken as directed • Stimulants are not ‘gateway’ drugs leading to illegal drug or alcohol abuse

25. Medication Dangers • Medication does have abuse potential • Stimulant medications are controlled substances • When doctors prescribe stimulants, a Kasper report must be run every 90 days

26. Prognosis for children and adolescents with ADHD • greater risk for incurring intentional and unintentional injury • 2-4x more likely to have a motor vehicle accident • Impaired academic functioning (completion of less schooling, lower achievement scores, failure of more courses) • Increased risk of substance use if also with conduct or antisocial disorders

27. ADHD in Adolescence: Impulsive behavior • May have more difficulty than other teens in regulating their impulses • May act first and think later-but stakes are higher than when younger child • Substance abuse, aggressive behavior, unprotected sex, reckless driving or other high-risk situations • healthychildren.org

28. ADHD in Adolescence • Minor impulsive behavior like interrupting others and fidgeting at desk may cause academic or social problems. • More ‘mature’ behavior may be expected • Work with adolescent on ways to minimize potentially damaging effects of this behavior • healthychildren.org

29. ADHD in Adolescence: Overall Problems • Difficulty focusing and organizing • Problems with long-term planning • Low self-esteem • Independence issues • healthychildren.org

30. Persistance into Adulthood? • 1/3 to 2/3 continue to manifest ADHD symptoms into adult life • One study found lower status jobs • Increased risk to develop antisocial personality disorder in adulthood • By developing strengths and structuring environment, adults with ADHD can lead very productive lives! • In some careers having high-energy behavior is an asset! • healthychildren.org

31. Daily Life • Communication Style with a child with ADHD: • Pause to get attention • Maintain eye contact • Have child repeat back or explain what you have said to make sure they understand • Avoid interrupting frequently as child may not be able to stay engaged • If attention is wandering, take their hand, touch arm or make other physical contact • healthychildren.org

32. Effective Discipline (healthychildren.org)

33. Effective Discipline • Discipline means teaching self-control. • It is important to respond immediately and consistently. • Do not spank or slap your child, may contribute to negative self-image and resentment. Teaches the child to hit when angry. • healthychildren.org

34. The Classroom- Structure is Key! • Children with ADHD make significantly better progress when classroom is structured • Clear rules and limits • Immediate, appropriate enforcement, predictable routines • Desks facing forward • Small class size • healthychildren.org

35. Ideal Teacher • Engaging, fun, interesting, and exciting • Structure, but can also be flexible • Able and willing to use multiple approaches to teaching • healthychildren.org

36. Good Habits for Academic Success • Use a daily planner or handheld computer • Use a backpack as the location for all schoolwork and supplies • Organize an assigned locker • Make lists of tasks to be accomplished, ideas for an essay, people to call about a project • Use an outline or flowchart format to take notes • Preview • Break up large tasks into a series of small steps • Set aside a routine time and lace for doing homework • healthychildren.org

37. Closing the Gap between School and Home • Daily Report Cards and Journal • Have meeting and agree upon measureable goals • Teacher to check off items and send home daily • Record detailed observations or requests in a journal • Parent to provide home-based incentives • If parent and teacher disagree, may need to involve principal, counselor, pediatrician, or therapist • Comprehensive Treatment for Attention Deficit Disorder (CTADD) Web Site

38. ADHD and Homework • All children work differently • Some need quiet and isolated time • Others do better with some action, like at the kitchen table with the radio playing • Make sure child has brought home homework and has all necessary materials • May need help checking over work and putting in folder to make sure it gets turned in • healthychildren.org

39. Daily Routines • Success of rules and strategies in home is influenced by the quality of the relationship that the parent has with child/teen • Keep child on daily schedule • Time of waking up, eating, bathing, leaving for school, going to sleep same each day • Give warnings for event or activity • Give 15, 10, 5 minute warnings for changes in activity • healthychildren.org

40. Daily Routines • Cut down on distractions • Develop a homework plan with your child • Create homework space, stock with supplies • Homework incentive chart with rewards • Second set of schoolbooks at home • Divide homework into small working parts with breaks • Use special timers to keep on track • Share homework detail with other family members • Have spot near door to keep backpack • healthychildren.org

41. Daily Routines • Organize your house • Less likely to lose items if put in designated place • Develop ‘house rules,’ monitor daily, reward for compliance • Provide a safe space in the home for active play • healthychildren.org

42. Daily Routines • Use charts and checklists • Friendly reminders: checklists of things to take to school each day and bring home • Post on morning exit door • Focus on effort child made to do work and chores, not just completion of task • healthychildren.org

43. Daily Routines • Limit choices • Give only 2-3 options at a time • Foster ‘best outcomes’ by creating and encouraging a sense of resiliency and participation • Validate positive plans, even if you feel some things should be done differently • Express empathy for concerns and problems • Include teen in decision-making process and problem-solving issues • Encourage involvement in family activity planning and outings • Provide sincere praise, even for the small things • healthychildren.org

44. Daily Routines • Set small, reachable goals • Aim for step-by-step progress • Succeed by taking small steps • Keep plan child-centered! • healthychildren.org

45. Cognitive Behavioral Approach • Especially helpful if coexisting disorders (ODD, CD, mood, anxiety disorders) • Aggressive behavior, poor tolerance for frustration, inflexibility, poor problem solving skills • Significant family conflict • healthychildren.org

46. Collaborative Problem-Solving approach • Developed by Dr. Ross Greene • Helps adults and children become proficient at resolving problems collaboratively • Defuses conflict and teaches kids cognitive skills they may lack • 3 options for problem solving: • 1. imposition of adult will (unilateral problem solving) • 2. collaborative problem-solving • 3. deferring resolution of the problem, at least for now • healthychildren.org

47. Cognitive Behavioral Approach, continued • Adults are helped to master the ‘ingredients’ involved in solving problems collaboratively • 1. achieving clearest possible understanding of child’s concern • 2. entering the adult’s concern or perspective • 3. brainstorming solutions that are realistic and mutually satisfactory • www.livesinthebalance.org

48. College Support Services • Special orientation programs • Specialized academic advisors or counselors • Priority scheduling • Reduced course loads • Private dorm room • Math labs, writing workshops, computer labs, and reading courses • healthychildren.org

49. College Support Services • Specialized tutoring • A ‘personal coach’ • Classroom technology • Academic aides • Special testing arrangements • Advocates • healthychildren.org

50. Myths and Misconceptions • “My preschooler is too young to have ADHD” • “He’s just lazy and unmotivated” • “He’s a handful- or, she’s a daydreamer-but that’s normal. They just don’t let kids be kids these days.” • “Treatment for ADHD will cure it. The goal is to get off medication as soon as possible.” • “He focuses on his video games for hours. He can’t have ADHD” • healthychildren.org