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Attention-Deficit Hyperactivity Disorder Melissa Stern, M.S.

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1 Attention-Deficit Hyperactivity Disorder Melissa Stern, M.S.

2 A Day in the life of….

3 Attention-Deficit/Hyperactivity Disorder ADHD is a neurodevelopmental disorder of childhood that is characterized by developmentally inappropriate levels of: ADHD is a neurodevelopmental disorder of childhood that is characterized by developmentally inappropriate levels of: Hyperactivity Hyperactivity Impulsivity Impulsivity Inattention Inattention

4 ADHD: Prevalence 3-9% of the elementary school population 3-9% of the elementary school population more often in males than females, with the sex ratio being about 3:1 to 9:1 more often in males than females, with the sex ratio being about 3:1 to 9:1 most common disorders of childhood accounting for a large number of referrals to pediatricians, family physicians and child mental health professionals most common disorders of childhood accounting for a large number of referrals to pediatricians, family physicians and child mental health professionals

5 ADHD Risk Factors Maternal cigarette use Maternal cigarette use Maternal alcohol use Maternal alcohol use Unusually long or short labor Unusually long or short labor Forceps delivery Forceps delivery Toxemia Toxemia Meconium staining Meconium staining Birth during the month of September Birth during the month of September Minor physical anomalies Minor physical anomalies

6 History of ADHD Characteristics of this disorder have been recognized for at least a century Characteristics of this disorder have been recognized for at least a century The disorder has been referred to by a variety of labels: The disorder has been referred to by a variety of labels: Minimal Brain Dysfunction (MBD) Minimal Brain Dysfunction (MBD) Hyperkinetic Reaction of Childhood Hyperkinetic Reaction of Childhood Attention Deficit Disorder (ADD) Attention Deficit Disorder (ADD) Attention Deficit Hyperactivity Disorder (ADHD) Attention Deficit Hyperactivity Disorder (ADHD)

7 History of ADHD Characteristics of this disorder have been recognized for at least a century Characteristics of this disorder have been recognized for at least a century The disorder has been referred to by a variety of labels: The disorder has been referred to by a variety of labels: Minimal Brain Dysfunction (MBD) Minimal Brain Dysfunction (MBD) Hyperkinetic Reaction of Childhood Hyperkinetic Reaction of Childhood Attention Deficit Disorder (ADD) Attention Deficit Disorder (ADD) Attention Deficit Hyperactivity Disorder (ADHD) Attention Deficit Hyperactivity Disorder (ADHD)

8 History of ADHD 1980’s: 1980’s: DSM III & DSM III-R stimulates ADHD research DSM III & DSM III-R stimulates ADHD research development of new assessment methods development of new assessment methods new treatment methods new treatment methods increased focus on biological factors. increased focus on biological factors. 1990’s: 1990’s: Neuroimaging Neuroimaging genetics genetics reevaluation of DSM reevaluation of DSM

9 DSM-IV: Hyperactivity Often fidgets with hands or feet, squirms in seat Often fidgets with hands or feet, squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected 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 Often runs about or climbs excessively in situations in which it is inappropriate Often has difficulty playing or engaging in leisure activities quietly Often has difficulty playing or engaging in leisure activities quietly

10 DSM-IV Hyperactivity Is often "on the go" or often acts as if "driven by a motor” Is often "on the go" or often acts as if "driven by a motor” Often talks excessively when inappropriate to the situation Often talks excessively when inappropriate to the situation 6 or more of hyperactive and/or impulsive symptoms required for diagnosis 6 or more of hyperactive and/or impulsive symptoms required for diagnosis

11 More on Hyperactivity Children with ADHD are more active, restless, and fidgety than normal children during the day and during sleep Children with ADHD are more active, restless, and fidgety than normal children during the day and during sleep There are different types of hyperactivity: There are different types of hyperactivity: Gross Motor Activity Gross Motor Activity Restless/Squirmy Restless/Squirmy Verbal hyperactivity Verbal hyperactivity Hyperactivity often varies according to situation Hyperactivity often varies according to situation Degree of hyperactivity may vary with age Degree of hyperactivity may vary with age

12 DSM-IV: Impulsivity Often blurts out answers before questions have been completed Often blurts out answers before questions have been completed Often has difficulty awaiting turn Often has difficulty awaiting turn Often interrupts or intrudes on others Often interrupts or intrudes on others Six symptoms of hyperactivity and impulsivity are required for diagnosis

13 DSM-IV: Inattention Often fails to give close attention to details or makes careless mistakes Often fails to give close attention to details or makes careless mistakes Often has difficulties sustaining attention in tasks or play activities Often has difficulties sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish homework, chores, or duties in the workplace Often does not follow through on instructions and fails to finish homework, chores, or duties in the workplace

14 DSM-IV: Inattention Often has difficulty organizing tasks and activities Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Often loses things necessary for tasks or activities Often loses things necessary for tasks or activities Is often easily distracted by extraneous stimuli. Is often easily distracted by extraneous stimuli. Is often forgetful in daily activities Is often forgetful in daily activities 6 or more symptoms needed for diagnosis 6 or more symptoms needed for diagnosis

15 More on Inattention “Attentional" problems may be most obvious on specific types of attentional tasks: “Attentional" problems may be most obvious on specific types of attentional tasks: sustained attention: responding to tasks, being vigilant sustained attention: responding to tasks, being vigilant situations requiring the child to attend over time to dull, boring, and repetitive tasks situations requiring the child to attend over time to dull, boring, and repetitive tasks

16 Diagnostic Criteria Overview Symptom Criteria - Core Symptoms of Hyperactivity & Impulsivity and/or Inattention (Six or More Symptoms of either category) Symptom Criteria - Core Symptoms of Hyperactivity & Impulsivity and/or Inattention (Six or More Symptoms of either category) Duration Criterion - Symptoms have Persisted for at Least 6 Months Duration Criterion - Symptoms have Persisted for at Least 6 Months Developmental Criterion - Symptoms are Inconsistent with Developmental Level Developmental Criterion - Symptoms are Inconsistent with Developmental Level Impairment Criterion - Clear Evidence of Clinically Significant Impairment in Social, Academic, or Occupational Functioning Impairment Criterion - Clear Evidence of Clinically Significant Impairment in Social, Academic, or Occupational Functioning

17 Diagnostic Criteria Age Criterion - Some Symptoms that Cause Impairment Were Present Before Age 7 Age Criterion - Some Symptoms that Cause Impairment Were Present Before Age 7 Situation Criterion - Some Impairment from Symptoms is Present in Two or More Settings Situation Criterion - Some Impairment from Symptoms is Present in Two or More Settings

18 Types of ADHD Combined Type Combined Type Symptoms of hyperactivity, impulsivity and inattention Symptoms of hyperactivity, impulsivity and inattention Hyperactive/Impulsive Type Hyperactive/Impulsive Type Symptoms of hyperactivity and impulsivity Symptoms of hyperactivity and impulsivity Predominately Inattentive Type Predominately Inattentive Type Symptoms of inattention Symptoms of inattention

19 Impairment in ADHD Social Impairment – What does it look like? Social Impairment – What does it look like? Academic Impairment – Long term outcomes for children with ADHD not so good Academic Impairment – Long term outcomes for children with ADHD not so good Family Impairment Family Impairment Occupational Impairment Occupational Impairment Driving Impairment Driving Impairment

20 ADHD Across the Lifespan ADHD is a chronic disorder ADHD is a chronic disorder 60%-80% of children continue to meet diagnostic criteria in Adolescence 60%-80% of children continue to meet diagnostic criteria in Adolescence 50%-70% of children will continue to meet diagnostic criteria in Adulthood 50%-70% of children will continue to meet diagnostic criteria in Adulthood ADHD in childhood is different from adolescence and different from adulthood ADHD in childhood is different from adolescence and different from adulthood

21 Presentation of ADHD in Adolescence Gross motor activity tends to disappear Gross motor activity tends to disappear Predominance of Inattention, Restlessness (rather than hyperactivity) and impulsivity Predominance of Inattention, Restlessness (rather than hyperactivity) and impulsivity What is a developmentally appropriate level of impulsivity in adolescence? What is a developmentally appropriate level of impulsivity in adolescence?

22 ADHD in Adults More similar to adolescent presentation More similar to adolescent presentation Mainly problems with inattention and impulsivity Mainly problems with inattention and impulsivity How much inattention and impulsivity affect an adult male? A father? A store clerk? How much inattention and impulsivity affect an adult male? A father? A store clerk? Impairment is key Impairment is key

23 Occupational Impairment Similar problems to those seen in the academic environment Similar problems to those seen in the academic environment Often unprepared, untimely, easily distracted Often unprepared, untimely, easily distracted “Under Achievers” “Under Achievers”

24 Social Impairment Still there in adolescence and adulthood! Still there in adolescence and adulthood! If you don’t attend when people talk, they often think you aren’t interested If you don’t attend when people talk, they often think you aren’t interested

25 Sensation Seeking/Substance Use Adolescents and adults with ADHD are more likely than those with out to engage in risky behavior including: Adolescents and adults with ADHD are more likely than those with out to engage in risky behavior including: Marijuana use Marijuana use Alcohol Use Alcohol Use Drunk Driving Drunk Driving This is true even when accounting for the presence of oppositional defiant disorder and/or conduct disorder This is true even when accounting for the presence of oppositional defiant disorder and/or conduct disorder

26 Driving impairment Leading cause of death in year olds are motor vehicle accidents Leading cause of death in year olds are motor vehicle accidents Adolescents and adults with ADHD are more likely to have an accident, to have more accidents, to speed, to receive traffic citations, to receive more traffic citations, to have their licenses suspended/revoked, to drive without a license, to drive under the influence Adolescents and adults with ADHD are more likely to have an accident, to have more accidents, to speed, to receive traffic citations, to receive more traffic citations, to have their licenses suspended/revoked, to drive without a license, to drive under the influence

27 Driving Impairment One of the most common causes of MVAs is plain old inattention One of the most common causes of MVAs is plain old inattention Adolescents in particularl are more likely to speed, to not use a seatbelt, and to drink and drive Adolescents in particularl are more likely to speed, to not use a seatbelt, and to drink and drive Hmm….what does this mean for people with ADHD Hmm….what does this mean for people with ADHD

28 Virtual Reality Researchers are using virtual reality to simulate driving situations and assess performance Here at UF we have a high tech simulator

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31 Shameless Plug Driving Impairment in ADHD is my area of research Driving Impairment in ADHD is my area of research I am going to need an RA or two to help with my dissertation starting in the Spring or next fall I am going to need an RA or two to help with my dissertation starting in the Spring or next fall If you are a sophomore or junior and are interested in getting into research, ME! If you are a sophomore or junior and are interested in getting into research, ME!

32 But What About Cognitive Impairment It’s a NEUROdevelopmental disorder, right? It’s a NEUROdevelopmental disorder, right? So why hasn’t this lady mentioned cognitive problems? So why hasn’t this lady mentioned cognitive problems?

33 ADHD & Neuropsychological Deficits Results from research involving neuropsychological testing has often suggested that children with ADHD have problems: Results from research involving neuropsychological testing has often suggested that children with ADHD have problems: inhibiting behavioral responses inhibiting behavioral responses with working memory with working memory with planning and organization with planning and organization with verbal fluency with verbal fluency with perserveration with perserveration in motor sequencing in motor sequencing with other frontal lobe functions with other frontal lobe functions

34 Neurological Findings Siblings of children with ADHD who do not have ADHD, have milder yet significant impairments in executive functions Siblings of children with ADHD who do not have ADHD, have milder yet significant impairments in executive functions This suggests a possible genetic risk for executive function deficits in families This suggests a possible genetic risk for executive function deficits in families

35 Other Neurological Findings Differences in cerebral blood flow Differences in cerebral blood flow Differences in cerebral metabolism Differences in cerebral metabolism Differences in the corpus collosum Differences in the corpus collosum

36 Neurotransmitter Deficits Neurotransmitter dysfunction in children with ADHD has been suggested for many years Neurotransmitter dysfunction in children with ADHD has been suggested for many years Originated from observations of the response of children with ADHD to different type of stimulant drugs Originated from observations of the response of children with ADHD to different type of stimulant drugs The fact that stimulant drugs have an impact on ADHD and that they increase dopamine has contributed to the neurotransmitter dysfunction hypothesis The fact that stimulant drugs have an impact on ADHD and that they increase dopamine has contributed to the neurotransmitter dysfunction hypothesis

37 Comorbidity & ADHD Why is it essential to consider the possibility of comorbid conditions in assessing children with ADHD? Why is it essential to consider the possibility of comorbid conditions in assessing children with ADHD? Importance of distinguishing between comorbid conditions and mimicry Importance of distinguishing between comorbid conditions and mimicry What is the frequency of comorbidities in children with ADHD? What is the frequency of comorbidities in children with ADHD?

38 Comorbidities Learning Disabilities - 19 to 26% Learning Disabilities - 19 to 26% Oppositional Defiant Disorder - 40% Oppositional Defiant Disorder - 40% Conduct Disorder - 25% children; 45-50% adolescents Conduct Disorder - 25% children; 45-50% adolescents Anxiety Disorders - 30% Anxiety Disorders - 30% Depressive Disorder % Depressive Disorder % Bipolar Disorder – up to 20% Bipolar Disorder – up to 20% Tics and Tourette’s Disorder – 7% of children with ADHD have a tic disorder Tics and Tourette’s Disorder – 7% of children with ADHD have a tic disorder 40 to 50% of those with Tourette’s disorder have ADHD 40 to 50% of those with Tourette’s disorder have ADHD

39 Onto Assessment and Diagnosis!

40 American Academy of Pediatrics Guidelines Only governing organization with guidelines for ADHD assessment Only governing organization with guidelines for ADHD assessment Designed for pediatricians Designed for pediatricians Move toward guidelines in APA Move toward guidelines in APA

41 The Interview Structured or semi-structured Structured or semi-structured Gold Standard is “The Barkley” Gold Standard is “The Barkley” Parent and Self-Report versions Parent and Self-Report versions Mostly used in research Mostly used in research Goal is to assess for the three main symptom areas and evidence of impairment which meets DSM criteria Goal is to assess for the three main symptom areas and evidence of impairment which meets DSM criteria

42 Behavioral Observations This isn’t technically recommended by AAP This isn’t technically recommended by AAP However, if a child is literally climbing the walls, it might be good to note that However, if a child is literally climbing the walls, it might be good to note that Always remember that children may be inclined to be on their “best behavior” in new situations Always remember that children may be inclined to be on their “best behavior” in new situations Coding systems available for looking at hyperactive and inattentive behaviors Coding systems available for looking at hyperactive and inattentive behaviors

43 Parent-Report Rating Scales Shorter measures which ask parents about frequency, severity, etc. of various behaviors Shorter measures which ask parents about frequency, severity, etc. of various behaviors Recommended by AAP but not required Recommended by AAP but not required Conners’ Parent Rating scale the “Gold Standard” form Conners’ Parent Rating scale the “Gold Standard” form Assesses various aspects of inattention, hyperactivity, impulsivity Assesses various aspects of inattention, hyperactivity, impulsivity

44 CPRS Items are rated on a four-point scale from “Not at all true” to “Very much true” Items are rated on a four-point scale from “Not at all true” to “Very much true” 87 questions 87 questions Each question is part of one or more subscales Each question is part of one or more subscales The parents’ rating on a given question corresponds to a number 0-3 The parents’ rating on a given question corresponds to a number 0-3 You sum the numbers for that scale You sum the numbers for that scale You plot subscale sums on the profile chart You plot subscale sums on the profile chart Scores in the red area are indicative of greater problems Scores in the red area are indicative of greater problems

45 Parent-Report “Broadband” Measure Broadband measures assess a wide array of social, emotional, and behavioral problems Broadband measures assess a wide array of social, emotional, and behavioral problems They are not recommended for AAP for ADHD diagnosis They are not recommended for AAP for ADHD diagnosis However, they are USEFUL for identifying comorbid areas of concern (aggression/conduct problems, depression) However, they are USEFUL for identifying comorbid areas of concern (aggression/conduct problems, depression)

46 Teacher Reports These are essential in assessing for ADHD These are essential in assessing for ADHD Need to identify impairment in MULTIPLE SETTINGS Need to identify impairment in MULTIPLE SETTINGS Most children with ADHD will have academic impairment Most children with ADHD will have academic impairment Teachers may have the best knowledge of “developmentally appropriate” levels because they work with so many children Teachers may have the best knowledge of “developmentally appropriate” levels because they work with so many children

47 Teacher Reports There is a teacher version of the CPRS, called the Conners’ Teacher Rating Scale (CTRS) There is a teacher version of the CPRS, called the Conners’ Teacher Rating Scale (CTRS) Modified for the classroom setting but scored the same way Modified for the classroom setting but scored the same way There are also teacher equivalents of broadband measures There are also teacher equivalents of broadband measures

48 Problems with Parent and Teacher Report Always the issue of informant bias (wanting to look like a good parent, like a teacher who can “handle” kids) Always the issue of informant bias (wanting to look like a good parent, like a teacher who can “handle” kids) Sometimes difficult to get in contact with teachers and they often don’t return forms Sometimes difficult to get in contact with teachers and they often don’t return forms CPRS and BASC may be biased towards non-European-American Children CPRS and BASC may be biased towards non-European-American Children

49 Detour: Multicultural Issues in ADHD ADHD is not limited to the U.S. ADHD is not limited to the U.S. It is seen cross-culturally It is seen cross-culturally However, there is concern it is over-diagnosed in Low SES and minority children However, there is concern it is over-diagnosed in Low SES and minority children Compared to parents of Caucasian children, parents of African-American and Hispanic children have reported significantly more often feeling as though their children are over- diagnosed and over-medicated Compared to parents of Caucasian children, parents of African-American and Hispanic children have reported significantly more often feeling as though their children are over- diagnosed and over-medicated

50 Detour: Multicultural Issues In ADHD Parents of African-American children less likely to associate school problems with ADHD and are less likely to request behavioral interventions compared to parents of Caucasian children Parents of African-American children less likely to associate school problems with ADHD and are less likely to request behavioral interventions compared to parents of Caucasian children Parents of African-American children more likely to report not knowing the etiology of ADHD and where to go to receive treatment for the disorder compared to parents of Caucasian children Parents of African-American children more likely to report not knowing the etiology of ADHD and where to go to receive treatment for the disorder compared to parents of Caucasian children

51 Detour: Multicultural Issues In ADHD In studies looking at cross-cultural validity of several ADHD assessments, found that parents of African-American children had significantly higher scores compared to parents of Caucasian children. Similar findings for teacher ratings In studies looking at cross-cultural validity of several ADHD assessments, found that parents of African-American children had significantly higher scores compared to parents of Caucasian children. Similar findings for teacher ratings Unclear as to whether this is due to informant biases, cultural biases of the measure, or actual ethnic differences Unclear as to whether this is due to informant biases, cultural biases of the measure, or actual ethnic differences This continues to be an area needing research This continues to be an area needing research

52 Detour: Multicultural Issues In ADHD What we do know: What we do know: African-American Children respond equally well to medication treatment compared to Caucasian children African-American Children respond equally well to medication treatment compared to Caucasian children Generally no differences in doses of medication Generally no differences in doses of medication Multimodal treatment superiority effect for minority children (we will get back to this in a moment) Multimodal treatment superiority effect for minority children (we will get back to this in a moment)

53 Cognitive Measures Not recommended for use in diagnosis Not recommended for use in diagnosis Most evaluators use them in combination with many other measures. Most evaluators use them in combination with many other measures. These are lab measures that directly assess impulsivity, inattention, and executive function These are lab measures that directly assess impulsivity, inattention, and executive function

54 The CPT Measures attention and impulsivity Measures attention and impulsivity Various ways to administer it, but here we use the “everything but X paradigm” Various ways to administer it, but here we use the “everything but X paradigm” Let’s see what this looks like Let’s see what this looks like

55 TREATMENT ADHD treatment

56 Treatment of ADHD Stimulant Medications Stimulant Medications Other Medications Other Medications Psychosocial Treatments Psychosocial Treatments Educational Accommodations Educational Accommodations

57 Stimulant Medications Ritalin Ritalin Dexadrine Dexadrine Adderall Adderall Concerta Concerta % of children with ADHD respond well to stimulant drugs % of children with ADHD respond well to stimulant drugs Stimulant drugs represent an empirically supported treatment for core symptoms of ADHD Stimulant drugs represent an empirically supported treatment for core symptoms of ADHD Stimulants are a trial and error method Stimulants are a trial and error method

58 Stimulant Side Effects loss of appetite, weight loss, sleeping problems, irritability loss of appetite, weight loss, sleeping problems, irritability restlessness, stomachache, headache, rapid heart rate, elevated blood pressure, sudden deterioration of behavior restlessness, stomachache, headache, rapid heart rate, elevated blood pressure, sudden deterioration of behavior symptoms of depression with sadness, crying, and withdrawn behavior symptoms of depression with sadness, crying, and withdrawn behavior intensification of tics (muscle twitches of the face and other parts of the body), possible Tourette’s, and growth suppression intensification of tics (muscle twitches of the face and other parts of the body), possible Tourette’s, and growth suppression Long term effects? Long term effects?

59 Stimulant Side Effects Side effects are often: Side effects are often: transient in nature transient in nature result of inappropriate medication levels result of inappropriate medication levels If one medication results in side effects, another might be used without side effects If one medication results in side effects, another might be used without side effects Other medications are used to minimize side effects Other medications are used to minimize side effects Good clinical judgment by the clinician may help to minimize side effects Good clinical judgment by the clinician may help to minimize side effects

60 Non-stimulant Medications Non-Stimulant ADHD Medication Non-Stimulant ADHD Medication Straterra - a norepinephrine reuptake inhibitor- selectively blocks the reuptake of norepinephrine, which increases its availability Straterra - a norepinephrine reuptake inhibitor- selectively blocks the reuptake of norepinephrine, which increases its availability Other Non Stimulant Drugs Other Non Stimulant Drugs Anti-depressants (e.g., Tofranil, Wellbutrin) Anti-depressants (e.g., Tofranil, Wellbutrin) Anti-hypertensives (Clonidine) Anti-hypertensives (Clonidine)

61 Psychosocial Treatments Parent Training Parent Training Social Skills Training Social Skills Training Cognitive Behavioral Treatments Cognitive Behavioral Treatments Psychotherapy for comorbid conditions Psychotherapy for comorbid conditions NEED FOR MULTIMODAL TREATMENT!

62 Educational Interventions Special Education Services for existing learning problems Special Education Services for existing learning problems Classroom accommodations Classroom accommodations Classroom behavior modification programs Classroom behavior modification programs 504 Plan 504 Plan

63 The Daily Report Card Specific set of behaviors relevant to the specific child Specific set of behaviors relevant to the specific child Everyday teacher marks how the child did on these behaviors Everyday teacher marks how the child did on these behaviors Child is rewarded (or not) based on performance at school Child is rewarded (or not) based on performance at school Integrates the classroom and home Integrates the classroom and home

64 ADHD Treatment: Conclusions It is essential to treat the full range of difficulties that impact on child and family functioning It is essential to treat the full range of difficulties that impact on child and family functioning Treatment of ADHD needs to be “multimodal” Treatment of ADHD needs to be “multimodal” Findings from the Multimodal Treatment Study suggest that: Findings from the Multimodal Treatment Study suggest that: Stimulant medication is effective in reducing core symptoms Stimulant medication is effective in reducing core symptoms Psychosocial treatments are of value in addressing associated comorbidities Psychosocial treatments are of value in addressing associated comorbidities


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