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ADHD Overview

ADHD Overview. Jeanette E. Cueva, M.D. Overview. ADHD history Perception and reality Diagnosis in the US and UK Etiology. ADHD in 1854: Fidgety Phil. “Let me see if he is able to sit still for once at the table. Thus Popa bade Phil behave and Mama looked very grave

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ADHD Overview

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  1. ADHD Overview Jeanette E. Cueva, M.D.

  2. Overview • ADHD history • Perception and reality • Diagnosis in the US and UK • Etiology

  3. ADHD in 1854: Fidgety Phil “Let me see if he is able to sit still for once at the table. Thus Popa bade Phil behave and Mama looked very grave But fidgety Phil, He won’t sit still…” http://www.fln.vcu.edu/struwwel/philipp_e.html

  4. History of ADHD

  5. Erroneous Beliefs/Assumptions About ADHD • Minor disorder if it even exists • Affects almost solely males • Has little impact beyond the classroom • Disappears spontaneously after grade school

  6. Erroneous Beliefs/Assumptions About ADHD • Overdiagnosed • Diagnosis made about any energetic or “different” child • Medication is only a form of chemical control • Misdiagnosed in cases of • Poor parenting • Rigid, misguided teachers • Overtreated by physicians who used powerful and potentially addicting drugs for a minor, temporary ailment

  7. Erroneous Beliefs/Assumptions About ADHD • Produced a pattern of treatment in which clinicians did not use medications OR • Used low doses of medications • (Only Monday through Friday) • (Only during school hours) • (Gave “drug holidays”) • Stopped medications in adolescence

  8. Erroneous Beliefs vs Evidence Erroneous Beliefs/Assumptions Are False ADHD Evidence Exists to Invalidate Them

  9. Evidence • In the beginning, the diagnosis of ADHD was unclear due to • Different names • Inconsistent nature of impairments • Feedback from 3rd parties (ie, children are poor historians) • Media controversy • Lack of validated diagnostic instruments • But by 1998, the AMA called ADHD “…one of the best-researched disorders in medicine, and the overall data on its validity are far more compelling than for many medical conditions.” Goldman et al. JAMA 1998;279:1100.

  10. N=6472 children, adolescents, and adults. Controlled Studies of Medication in ADHD Stimulants 21 Antidepressants 12 155 3 Neuroleptics Antihypertensives Spencer et al. JAACAP 1996;35:409.

  11. ADHD: Diagnosis • Based on coding systems • DSM-IV and DSM-IV TR (www.behavenet.com/capsules/disorders/adhd.htm) • US • 314.01 ADHD, Combined Type • 314.00 ADHD, Predominantly Inattentive Type • 314.01 ADHD, Predominantly Hyperactive-Impulsive Type • ICD 10 (www.mentalhealth.com/icd/p22-ch01.html) • EU/US • F90 Hyperkinetic disorders • F90.0 Disturbance of activity and attention • F91.1 Hyperkinetic CD

  12. ADHD: Core Symptom Areas Inattention Impulsivity/Hyperactivity

  13. Inattention to detail/makes careless mistakes Difficulty sustaining attention Seems not to listen Fails to finish tasks Difficulty organizing Avoids tasks requiring sustained attention Loses things Easily distracted Forgetful ADHD: DSM-IV Criteria Inattention Six or more of the following – manifested often

  14. Impulsivity Blurts out answers before question is finished Difficulty in awaiting turn Interrupts or intrudes on others Difficulty organizing Fidgets Unable to stay seated Inappropriate running/climbing Difficulty in engaging in leisure activities quitely On the go Talks excessively ADHD: DSM-IV Criteria Impulsivity/Hyperactivity Six or more of the following – manifested often

  15. ADHD: DSM-IV Diagnostic 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 • Symptoms lead to significant impairment • Social, academic, or occupational • Symptoms are not exclusionary due to other mental disorders

  16. ADHD: DSM-IV Subtypes • ADHD predominately inattentive type • Criteria met for inattention but not for impulsivity/hyperactivity • ADHD predominately hyperactivity/impulsivity type • Criteria met for impulsivity/hyperactivity • but not for inattention • ADHD combined type • Criteria met for inattention and impulsivity/hyperactivity

  17. DSM IV Diagnosis: Clinical Subtypes • Predominately inattentive • Easily distracted; not excessively hyperactive or impulsive • Combined type • Predominent presentation; exhibits all three classical signs • Predominately hyperactive-impulsive • Extremely hyperactive and impulsive; not highly inattentive Predominately inattentive Combined type Predominately hyperactive-impulsive

  18. ADHD: ICD 10 • Stresses HK disorders over “ADD” • Implies knowledge of psychological process and suggests anxious, preoccupied, or dreamy apathetic children • Inattention central feature • Cardinal features of DSM-IV • Vague • Diagnostic guidelines descriptive

  19. Impairment • DSM-IV-TR: ADHD symptoms must be consistently and persistently impairing in at least 2 areas of life functioning • Much more than personality traits and quirks • Must significantly impair major aspects of day-to-day life Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. 2000.

  20. Impairment in ADHD Psychiatric comorbidity School failure Poor peer relationships Legal difficulties Smoking and substance abuse Accidents and injuries Family conflict Parent stress

  21. ADHD: Variations in symptoms Pervasiveness Frequency of Occurrence Degree of impairment

  22. DSM-IV-Defined ADHD Population (Paediatric 3-19 yrs) Source: Decision Resources, “Attention Deficit Hyperactivity Disorder”, December 2001

  23. ADHD: World Wide Prevalence in School Aged Children Prevalence (per 1000)

  24. Diagnosis & Treatment Rates of ADHD Source: Decision Resources, “Attention Deficit Hyperactivity Disorder”, December 2001 *Europe = D,F,I,UK,E

  25. Neuroanatomic Neurochemical ADHD • CNS insults • Environmental factors ADHD: Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies • Genetic origins

  26. Adult ADHDGenetic Basis Twin Studies Family Studies Genetic Basis of ADHD Molecular Genetics Adoption Studies

  27. Schizophrenia Height Heritability of ADHD

  28. Neuroanatomic Neurochemical ADHD • Genetic origins • CNS insults • Environmental factors ADHD: Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies

  29. Pre- and Perinatal Risk Factors for ADHD

  30. Indicator of Adversity • Low social class • Maternal psychopathology • Paternal criminality • Family conflict • Placement outside the home

  31. Risk for Childhood Mental Disturbance 10 9 8 7 6 Odds Ratio 5 4 3 2 1 0 2 4 1 Number of Indicators of Adversity

  32. Rutters Indicators of Adversity and Risk for ADHD 5 Gender, parental ADHD Maternal smoking during pregnancy 4 3 Adjusted Odds Ratio 2 1 0 0 2 1 3 4 Number of Rutter’s Indicators

  33. ADHD: Diagnostic Considerations Inattention Comorbidity Impulsivity/Hyperactivity

  34. Risk Factors for ADHD Boys Girls

  35. ADHD: Adult Common Comorbid Diagnosis Male Female

  36. “It’s a guy thing.”

  37. Psychiatric Comorbidity Anxiety (34%) MD (20 to 30%) 7% 7% 23% 4% CD (8 – 20%) Non-comorbid (55%) 2%

  38. Neuroanatomic Neurochemical ADHD • CNS insults • Environmental factors ADHD: Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies • Genetic origins

  39. Affected area of brain

  40. MRI in Adults with ADHD MGH-NMR Center & Harvard- MIT CITP Bush G, et al. Biol Psychiatry. 1999;45(12):1542-1552.

  41. ADHD: Neurochemistry • ADHD best understood by the interaction of multiple neurotransmitters • Neurotransmitters most critical in ADHD • Norepinephrine (NE) • Dopamine (DA)

  42. OH OH OH NH2 NH2 CH2 CH CH2 CH Pemoline Amphetamine Methylphenidate OH OH O NH2 O NH2 CH2 CH COCH3 N CH3 O NH Neurotransmitters Dopamine Norepinephrine

  43. Presynaptic Neuron Storage vesicle Cytoplasmic DA DA Transporter Synapse Methylphenidate inhibits Probable Mechanism of Action of MethylphenidateWilens and Spencer. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513.

  44. Presynaptic Neuron AMPH AMPH Storage vesicle Cytoplasmic DA DA Transporter Protein Synapse The Mechanisms of Action of AmphetamineWilens and Spencer. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513. AMPH diffuses into vesicle causing DA release into cytoplasm AMPH blocks uptake into vesicle AMPH is taken up into cell causing DA release into synapse AMPH Inhibits

  45. Enhances signal Improves attention Focus On-task behavior On-task cognition Dopamine Neurotransmission Relative to ADHD Dopamine Nigrostriatal Pathway Mesolimbic Pathway Substantia nigra Mesocortical Pathway Ventral tegmental area Solanto. Stimulant Drugs and ADHD. Oxford; 2001.

  46. Frontal Limbic Locus Ceruleus Norepinephrine Neurotransmission Relative to ADHD Norepinephrine • Dampens noise • Executive operations • Increases inhibition Solanto. Stimulant Drugs and ADHD. Oxford; 2001.

  47. Striatal - Prefrontal Enhances Signal Improves Attention Focus Vigilance Acquisition On-task behavior On-task cognitive Perception(?) Prefrontal Dampens Noise Distractibility Shifting Executive operations Increases Inhibition Behavioral Cognitive Motoric Catecholaminergic Neurotransmission Relative to ADHD Dopamine Norepinephrine Solanto. Stimulant Drugs and ADHD. Oxford; 2001.

  48. Questions

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