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Diagnosis and Management of ADHD

Diagnosis and Management of ADHD

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Diagnosis and Management of ADHD

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  1. Diagnosis and Management of ADHD

  2. ADHD “Attention deficit hyperactivity disorder (ADHD) is a pattern of behaviour which is the most recent in a series of American attempts to characterise inattentive restlessness as a condition. It is effectively a syndrome encompassing hyperactivity, poor concentration and marked impulsive, impatient, excitable behaviour. Most, but not all, instances are predominantly genetic in origin, with various inherited deficiencies of the dopamine neurotransmitter system.” Hill, P. Child & Adolescent Mental Health in Primary Care 2003; 1(1):2-4

  3. Symptoms of ADHD Inattention Hyperactivity Impulsivity

  4. ADHD: Prevalence and Demographics • Overall prevalence 3% to 10% in school-aged children • Diagnosed in boys 3 to 4 times more often thanin girls • Persists in 30% to 50% of patients into adolescence and adulthood (symptom profile may change)

  5. Nerve Impulse Neurochemical Pathophysiology of ADHD Noradrenaline Dopamine Transporter Synapse Receptors

  6. Patients Poor academic achievement Social impairment Low occupational status Increased risk of substance abuse Increased risk of injury Family Increased stress levels Increased depression Increased marital discord Changed work status Impact of ADHD on Patientsand Family

  7. Impact of ADHD onSchool Performance • Poor classroom behaviour • Poor academic achievement • Special education requirements (tutoring and special educational programmes) • School exclusion (either suspension or expulsion) • Repetition of grades • Failure to gain external qualifications

  8. Effects of ADHD on Behavioural Development • Problems with productivity and motivation • Reduced ability to express ideas and emotions • Decreased working memory • Problems with social interaction • Impairments in speech • Problems with verbal reasoning

  9. Developmental Impact of ADHD Occupational failure Self-esteem issues Relationship problems Injury/accidents Substance abuse Academic problems Difficulty with social interactions Self-esteem issues Legal issues, smoking and injury Behavioural disturbance Pre-school Adolescent Adult School-age College-age Behavioural disturbance Academic problems Difficulty with social interactions Self-esteem issues Academic failure Occupational difficulties Self-esteem issues Substance abuse Injury/accidents

  10. Defining Comorbidity • ADHD is highly comorbid • Comorbidity is defined as two different diagnoses present in an individual patient • It is important to recognise comorbid disorders • Comorbidities may require treatment independent from and different to therapy for ADHD

  11. Co-occurring Disorders in Children (n = 579) Oppositional Defiant Disorder 40% Tics 11% ADHD alone 31% Anxiety Disorder 34% Conduct Disorder 14% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096 Mood Disorders 4%

  12. Common Associated Comorbidities 60 40 20 0 (%) Oppositional defiant disorder Anxiety disorder Learning disorder Mood disorder Conduct disorder Smoking Substance use disorder Tics Milberger et al. Am J Psychiatry1995; 152: 1793–1799 Biederman et al. J Am Acad Child Adolesc Psychiatry 1997; 36: 21–29 Castellanos. Arch Gen Psychiatry 1999; 56: 337–338 Goldman et al. JAMA 1998; 279: 1100–1107 Szatmari et al. J Child Psychol Psychiatry 1989; 30: 219–230

  13. Input Needed to Make a Diagnosis Teacher Parent Diagnosis Child

  14. Inattention Does not attend Fails to finish tasks Can’t organise Avoids sustained effort Loses things, ‘forgetful’ Easily distracted Hyperactivity Fidgets Leaves seat in class Runs/climbs excessively Cannot play/work quietly Always ‘on the go’ Talks excessively * Impulsivity Talks excessively † Blurts out answers Cannot await turn Interrupts others Intrudes on others Symptom Groups * ‘Talks excessively’ is one of the DSM-IV criteria for hyperactivity but not one of the ICD-10 criteria † ‘Talks excessively’ is one of the ICD-10 criteria for impulsiveness but not one of the DSM-IV criteria DSM-IV – Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association, 1994) ICD-10 – International Classification of Diseases, 10th Edition (World Health Organisation, 1993)

  15. DSM-IV ADHD Diagnostic Criteria • List of symptoms must be present for past 6 months • Must have six (or more) symptoms of inattention and/or hyperactivity–impulsivity • Some symptoms present before 7 years of age • Some impairment from symptoms must be present in two or more settings (e.g. school and home) • Significant impairment: social, academic or occupational • Exclude other mental disorders

  16. DSM-IV Subtypes of ADHD • Predominantly inattentive • Predominantly hyperactive–impulsive • Mixed/combined • In partial remission • Not otherwise specified (NOS)

  17. ICD-10 HKD Diagnostic Criteria • Used to diagnose hyperkinetic disorder (HKD), a more severe form of ADHD • List of symptoms must be present for at least six months • Must have: at least six symptoms of inattention AND at least three symptoms of hyperactivity AND at least one symptom of impulsivity • Onset of symptoms no later than 7 years of age • Impairment of symptoms must be present in two or more settings (e.g. school and home) • Significant impairment: social, academic or occupational

  18. Important Rating Tools for ADHD • Conners Parent Rating Scale – assesses and monitors response to treatment • IOWA Conners – measures dimensions of behaviour associated with ADHD • SKAMP Measures – measures the classroom manifestation of ADHD • SNAP-IV Scale – derived from descriptions in DSM-IV • Continuous Performance Test (CPT) – measures the attention span in children with ADHD • C-DISC – computer-assisted diagnostic interview schedule for children

  19. Therapy Options as Part of a Total Treatment Programme • Behavioural treatment • Medication management • Combining medication/behavioural treatment • Educating parents/patient about ADHD • Educational support services

  20. Tools Used in Behavioural Treatment • Specific strategies • Reward system • Time out • Social reinforcement • Behaviour modelling • Support for parents • Family and patient education • Group problem-solving • Sports skills • Social skills training Cunningham, Barkley. Child Dev 1979; 50: 217–224

  21. Behavioural Treatment in the Home • Identify problem situations and the precipitating factors • Enhance positive parent–child interactions • Limit negative parent–child interactions • Use cost systems to reduce problem behaviours • Use time outs as punishment for serious problem behaviours

  22. Behavioural Treatment in the Classroom • Behavioural treatment in school setting similar to the approach used in home with parents • Goal: Reduce inattention and disruptive behaviour • Specific school accommodations: • Ensure structure and predictable routines • Employ cost–response token economy systems • Use daily report cards • Teach organisational and work/study skills Atkins, Pelham. 1992:69–88; Barkley, Cunningham. Arch Gen Psychiatry 1979; 36: 201–208

  23. Effectiveness of Behavioural Therapy • Parent training is generally regarded as the most effective behavioural therapy • Parent training combined with medication management increases parent acceptability of medication • School-based treatment is more effective than individual strategies, however benefits are only seen during treatment programmes • Individual treatment approaches have not been shown to be effective

  24. Pharmacological Agents Usedin Treatment of ADHD* StimulantsMethylphenidate (Recommended Amphetamine compounds first-line therapy)Dextroamphetamine Pemoline AntidepressantsTricyclicantidepressants Bupropion AntihypertensivesClonidine Guanfacine * Not all agents are available in some countries Wilens T, et al. ADHD, In Annual Review of Medicine, 2002: 53 Greenhill L. Childhood attention deficit hyperactivity disorder: pharmacological treatments. In: Nathan PE, Gorman J, eds. Treatments that Work. Philadelphia, PA: Saunders; 1998:42-64

  25. ADHD Pharmacotherapy – Responsiveness Methylphenidate Amphetamine Pemoline Tricyclicantidepressants Bupropion MAOI Clonidine/ Guanfacine 0 20 40 60 80 100 %Responders Wilens TE, Spencer TJ. Presented at Massachusetts General Hospital’s Child and Adolescent Psychopharmacology Meeting, March 10-12, 2000, Boston, MA