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ADHDStephanie Stockburger, MD FAAPAssistant ProfessorAdolescent Medicine ClinicUniversity of Kentucky
Objectives1. Review Diagnostic Criteria of
ADHD2. Summarize ADHD Evaluation3. Describe Current ADHD
Treatment
ADHD: PrevalenceAffects 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_wADHD in children and adolescents. Epidemiology and pathogenesis. www.uptodate.com
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
Comorbid DisordersChildren 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
Diagnosed Attention Deficit Hyperactivity Disorder and Learning Disability: United States, 2004-2006 http://www.cdc.gov/ncbddd/adhd/data.html
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.
Brain ChangesChildren with ADHD have differences in
brain structuresChanges especially noted in anterior
brain areas◦Smaller prefrontal cortical volumes ◦Reduced thickness of the anterior cingulate
cortex◦Cortical thinning in bilateral superior frontal
brain regionsFrontal 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.
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.
Neurotransmitter ChangesChildren 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.
Environmental FactorsDietary 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.
ADHD: DiagnosisADHD 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
ADHD: DiagnosisChildren must have at least six
symptoms from the subtypeOlder 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
ADHD: DiagnosisSymptoms 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
Diagnostic Criteria: HyperactivityHyperactivity-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
Diagnostic Criteria: ImpulsivityImpulsivity
◦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
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
Differential DiagnosisDevelopmental variations
◦ Gifted, intellectual disabilityNeurologic 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
TreatmentPreschool 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.
TreatmentSchool-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.
MedicationLong and short-acting stimulantsShort 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)
MedicationsShort acting medications must be
taken 2-3 times per dayLong-acting medications taken in
the morningPeak at 30-40 minutesDelayed peak if taken with high
fat meal
Medication Side EffectsDecreased appetitePoor growthCardiovascularDizzinessInsomnia/nightmaresMood labilityReboundTicsPsychosisDiversion and misuse
Medication MythsAt 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
Medication DangersMedication does have abuse
potentialStimulant medications are
controlled substancesWhen doctors prescribe
stimulants, a Kasper report must be run every 90 days
Prognosis for children and adolescents with ADHDgreater risk for incurring intentional
and unintentional injury 2-4x more likely to have a motor
vehicle accidentImpaired 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
ADHD in Adolescence: Impulsive behaviorMay 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
ADHD in AdolescenceMinor 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
ADHD in Adolescence: Overall ProblemsDifficulty focusing and organizingProblems with long-term planningLow self-esteemIndependence issues
healthychildren.org
Persistance into Adulthood?1/3 to 2/3 continue to manifest ADHD
symptoms into adult lifeOne study found lower status jobs Increased risk to develop antisocial
personality disorder in adulthoodBy 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
Daily LifeCommunication 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
Effective Discipline (healthychildren.org)
Child's Behavior* Your Responses Effective Constructive
Temper Tantrums Walk away.
Discuss the incident in an age-appropriate manner when child is calm.
Overexcitement Distract with another activity.
Talk about his behavior in an age-appropriate manner when he's calm.
Hitting or biting
Immediately remove him from situation or in anticipation of this behavior.
Discuss consequences of his actions (pain, damage, bad feelings) to himself and others in an age-appropriate manner. Try one-word time-out after brief response.
Not paying attention
Establish eye contact to hold his attention.
Make sure your expectations are age-appropriate for your child's developmental level (ask him to listen to a story for three minutes instead of ten; don't insist he sit through a full church service).
Refuses to pick up toys
Don't let him play until he does his job.
Show him how to do the task and help him with it; praise him when he finishes.
HCPROD
Effective DisciplineDiscipline 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
The Classroom- Structure is Key!Children with ADHD make
significantly better progress when classroom is structured
Clear rules and limitsImmediate, appropriate
enforcement, predictable routinesDesks facing forward Small class size healthychildren.org
Ideal TeacherEngaging, fun, interesting, and
excitingStructure, but can also be flexibleAble and willing to use multiple
approaches to teaching
healthychildren.org
Good Habits for Academic SuccessUse a daily planner or handheld computerUse a backpack as the location for all
schoolwork and suppliesOrganize an assigned lockerMake lists of tasks to be accomplished, ideas for
an essay, people to call about a projectUse an outline or flowchart format to take notesPreviewBreak up large tasks into a series of small stepsSet aside a routine time and lace for doing
homework healthychildren.org
Closing the Gap between School and HomeDaily Report Cards and JournalHave meeting and agree upon measureable
goalsTeacher to check off items and send home
dailyRecord detailed observations or requests in
a journalParent to provide home-based incentivesIf parent and teacher disagree, may need to
involve principal, counselor, pediatrician, or therapist
Comprehensive Treatment for Attention Deficit Disorder (CTADD) Web Site
ADHD and HomeworkAll children work differentlySome need quiet and isolated timeOthers do better with some action, like at
the kitchen table with the radio playingMake 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
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
Daily RoutinesCut down on distractionsDevelop 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
Daily RoutinesOrganize 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
Daily RoutinesUse 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
Daily RoutinesLimit 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
Daily RoutinesSet small, reachable goals
◦Aim for step-by-step progress◦Succeed by taking small steps◦Keep plan child-centered!
healthychildren.org
Cognitive Behavioral ApproachEspecially 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
Collaborative Problem-Solving approachDeveloped by Dr. Ross GreeneHelps adults and children become proficient
at resolving problems collaborativelyDefuses conflict and teaches kids cognitive
skills they may lack3 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
Cognitive Behavioral Approach, continuedAdults 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
College Support ServicesSpecial orientation programsSpecialized academic advisors or
counselorsPriority schedulingReduced course loadsPrivate dorm roomMath labs, writing workshops,
computer labs, and reading courses healthychildren.org
College Support ServicesSpecialized tutoringA ‘personal coach’Classroom technologyAcademic aidesSpecial testing arrangementsAdvocates
healthychildren.org
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
Resources 1. CDC – ADHD, Data and Statistics. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 9/23/2013. 2. CDC-ADHD, Symptoms and Diagnosis. http://www.cdc.gov/ncbddd/adhd/diagnosis.html. Accessed 9/23/2013. 3. 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. 4. Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children --- United States,
2003 and 2007. Weekly. November 12, 2010 / 59(44);1439-1443 5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w. Accessed 9/23/13. 6. Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com
Accessed 6/5/2013. 7. ADHD Long-term Outcomes: Comorbidity, Secondary Conditions, and Health Risk Behaviors. CDC.
http://www.cdc.gov/ncbddd/adhd/workshops/outcomes.html. Accessed 9/23/13. 8. Biederman, Faraone. Attention-deficit hyperactivity disorder. The Lancet. Volume 366, Issue 9481, 16–22 July
2005, Pages 237–248. 9. Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications.
www.uptodate.com. Accessed 6/5/2013. 10. Healthychildren.org. Multiple articles about ADHD. Accessed 7/1/2013. 11. Age, Academic Performance, and Stimulant Prescribing for ADHD: A Nationwide Cohort Study. Zoega,
Valdimarsdottir, Hernandez-Diaz. Pediatrics. 2012;130. 12. Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation.
www.uptodate.com. Accessed 6/5/2013. 13. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis.
www.uptodate.com. Accessed 6/5/2013. 14. The Diet Factor in Attention-Deficit/Hyperactivity Disorder. Millichap and Yee. Pediatrics 2012;129:330-7. 15. 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. 16. 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.
17. Progress and Promise of Attention-Deficit Hyperactivity Disorder Pharmacogenetics. Froehlich TE, McGough JJ, Stein MA. CNS Drugs. 2010 February;24(2):99-117.