3 Attention Deficit/Hyperactivity Disorder Changes from DSM IVAge of onset of impairing symptoms by age 7 to age 12Increase number of adult diagnosesChanges the three subtypes to three current presentationsAdd a fourth presentation for restrictive inattentionChange to accommodate a lifespan relevance of each symptom (change in examples without changing the DSM IV wording)
4 Attention Deficit/Hyperactivity Disorder Changes from DSM IVModify to indicate the information must be obtained from two different informantsParentsTeachersSignificant other adult
5 Attention Deficit/Hyperactivity Disorder PresentationsCombined Presentation: Inattention and Hyperactivity-Impulsivity criteria metPredominantly Inattentive: Inattention criteria met and Hyperactivity-Impulsivity criteria not met but 3 or more symptoms present for the last 6 monthsInattentive Presentation (Restrictive): Inattentive criteria met but no more than 2 symptoms from Hyperactivity-Impulsivity criteria present for the past 6 monthsPredominantly Hyperactive/Impulsive: Hyperactivity-Impulsivity criteria met but Inattentive is not met
6 Attention-Deficit/Hyperactivity Disorder Dopamine and Norepinephrine play role in attention and thinkingNE is critical to reasoning, learning, problem solving, priority setting and organizational thoughtNE functions in maintaining arousal, regulating excitability related to danger, contributes to memory storage and retrievalDA is involved in motor control and interacts with NE in the frontal lobes to maintain attention
7 Attention-Deficit/Hyperactivity Disorder Linked to several brain areasPREFRONTAL AND FRONTAL LOBESCONTROL BEHAVIOR AND SYNTHESIZE THOUGHTS AND MOTOR ACTS INTO PURPOSEFUL SEQUENCESCONNECTIONS TO BASAL GANGLIATHEIR RELATIONSHIP WITH THE CEREBELLUMIn severe cases the frontal lobes were 3-4% smallerTemporal gray matter, caudate nucleus and cerebellum were smaller
8 Attention-Deficit/Hyperactivity Disorder Substance-Related Disorders are familial3-5% in school-age kidsAnother 15-20% of school-aged population show transient behaviors suggestive of ADHDBoys are 3 times more likely than girls to have ADHDSymptoms decrease with age but 50-65% of children still manifest symptoms into adulthood (Korn & Weiss, 2003)
9 Attention-Deficit/Hyperactivity Disorder IMPACT (Barkley, 2002)32-40% WILL DROP OUT OF SCHOOLONLY 5-10% WILL COMPLETE COLLEGE50-70% WILL HAVE FEW OR NO FRIENDS70-80% WILL UNDERPERFORM AT WORK40-50% WILL ENGAGE IN ANTISOCIAL ACTIVITIESMORE LIKELY TO EXPERIENCE TEEN PREGNANCY & SEXUALLY TRANSMITTED DISEASESHAVE MORE ACCIDENTSEXPERIENCE DEPRESSION
10 Attention-Deficit/Hyperactivity Disorder CO-OCCURRING-CHILDREN & ADOLESCENTS54-84%-Oppositional Defiant DisorderSubstance Abuse problemsConduct DisorderAnxiety DisordersAffective DisordersHarvard Mental Health Letter, “Treating ADHD in Children and Adolescents”, Vol 25, No. 4, October, 2008.
12 Attention-Deficit/Hyperactivity Disorder INATTENTION-DISTRACTIBILITYDoesn’t seem to listenFails to finish assigned tasksOften loses thingsDifficulty concentratingEasily distractedDaydreamsRequires frequent redirectionCan be very quiet and withdrawn
13 Attention-Deficit/Hyperactivity Disorder IMPULSIVITYRushing into thingsCareless errorsRisk takingTaking daresAccident/injury proneImpatientInterruptions
14 Attention-Deficit/Hyperactivity Disorder RestlessCan’t sit stillTalks excessivelyFidgetingAlways on the goEasily over-stimulated
15 Attention-Deficit/Hyperactivity Disorder CHANGING PRESENTATION3-6 YEAR OLDSMotor restlessnessInsatiable curiosity“Dangerously daring”Vigorous, aggressive (breaks toys, accidents)Demanding, argumentativeNoisy, interruptsLow levels of compliance
16 Attention-Deficit/Hyperactivity Disorder CHANGING PRESENTATION6-12 YEAR OLDSEasily distractedHomework poorly organized, incomplete with careless errorsPerforms below expectationsBlurts out answers before question is completedInterrupts othersDifficulties in peer relationshipsFails to wait turn“Immaturity”
17 Attention-Deficit/Hyperactivity Disorder CHANGING PRESENTATION12-18 YEAR OLDSSense of inner restlessnessPoor follow-throughFails to work independently“Risky” behaviors-sex, drugs, drivingPoor self-esteemPoor peer relationshipsDifficulty with authority figures
18 Attention-Deficit/Hyperactivity Disorder RULE OUTGifted childIQ TestingLearning DisabilityAcademic/Perceptual testing by psychologistNeurological Condition (seizures, Tourettes, etc.)Pediatric Neurologist-EEG, 24 hr EEG, MRI, etc.Behavioral and Emotional problems secondary to anxiety and depressionPsycho-Social history & personality testing
19 Attention-Deficit/Hyperactivity Disorder RULE OUTEarly Life Developmental TraumaVision Acuity ProblemHearing Problem including intermittent middle ear infectionsMetabolic ProblemFood allergies, signs of metabolic illness like Failure to Thrive, Thyroid, etc.
20 Attention-Deficit/Hyperactivity Disorder PreschoolComprehensive AssessmentFollowed by at least 8 weeks of behavioral interventionBefore consider the initiation of pharmacotherapyShort –acting methylphenidate
22 Attention-Deficit/Hyperactivity Disorder STIMULANTS-FDA APPROVEDBeaded delivery system (30% immediate and 70% 3hrs later)- (Metadate CD)Can sprinkle beads into soft foodBeaded delivery system (50% immediate release and 50% released 4 hrs later)- (Ritalin LA, Focalin XR, Adderall XR, Dexedrine Spansule)Osmotic-release system (OROS)- (18% immediate and 82% gradually released, replicates tid dosing)Methylphenidate- ConcertaPatchesMethylphenidate (Daytrana)-worn up to 9 hours per day (skin rash)Lisdexamfetamine (Vyvanse-Adderall patch)
23 Attention-Deficit/Hyperactivity Disorder NON-STIMULANT-FDA APPROVEDImmediate-releaseAtomoxetine (Strattera)Potential severe liver damage (www.fda.gov)Possible suicidal thoughtsExtended-releaseGuanfacine ER (Intuniv)Binds selectively to alpha 2A-adrenoreceptors in prefrontal cortexLinked to attention and executive function
24 Attention-Deficit/Hyperactivity Disorder NON-STIMULANT-NOT FDA APPROVEDImmediate ReleaseGuanfacine IR (Tenex)Clonidine (Catapres)Buproprion (Wellbutrin/Zyban)Imipramine (Tofranil)Nortryptiline (Aventil/ Pamelor)Modafinil (Provigil)Not FDA approved FOR CHILDREN OR ADOLESCENTS-Stevens-Johnson Syndrome concerns
25 Attention-Deficit/Hyperactivity Disorder NON-STIMULANT-NOT FDA APPROVEDSustained ReleaseBuproprion (Wellbutrin SR)Buproprion (Wellbutrin XL)OTHEROmega-3 and Omega-6 fatty acids (http://www.medscape.com/viewarticle/514770_print)
26 Attention-Deficit/Hyperactivity Disorder STIMULANTS AS FIRST-LINE THERAPY ESPECAILLY WHEN NO CO-OCCURRING DISORDER EXISTSATOMOXETINE MAY BE BETTER IF ANXIETY OR SUBSTANCE ABUSE EXIST OR IF FAMILY CONCERNED ABOUT ADDICTIONMULTIMODAL TREATMENT STUDY OF CHILDREN WITH ADHD (MTA) SHOWED THE RELATIVE ADVANTAGE OF DRUG THERAPY BEGAN TO FADE AT 24 MONTHS AND SOMETIMES DISAPPEARED AT 36 MONTHSCLASSROOM INTERVENTIONS AND PARENT TRAINING TECHNIQUES HELPFUL WITH CHILDREN BUT LITTLE DATA EXISTS REGARDING EFFECTS ON ADOLESCENTS
27 Attention-Deficit/Hyperactivity Disorder Stimulants-Side Effects (greater with AMPH vs. MPH)Delayed sleep onsetReduced appetite (most common sustained)CAN ALSO SEE WITH STRATTERAAbdominal painJitterinessHeadacheMotor and vocal tics (controversial)Growth effectsNo adult variation in height or weight (NIH)May be dose-related
28 Attention-Deficit/Hyperactivity Disorder FINE TUNINGMORNING PERSON-RUNS OUT OF MENTAL ENERGY IN AFTERNOONAvoid difficult afternoon classesEncourage afternoon physical activityHomework may require supplemental medication after schoolRebound symptoms more likely without supplementalConcerta , Daytrana, Adderall XR
29 Attention-Deficit/Hyperactivity Disorder FINE TUNINGAFTERNOON PERSON-HARD TO GET STARTED IN MORNINGSchedule difficult classes in mid-dayWake-up early to give medication (short acting) and sustained release laterEncourage morning physical activityEvaluate sleep patternsRitalin LA, Focalin XR, Adderall XR, Daytrana
30 ADHD: Management Instruction to patient Behavioral Assess abilities- Structured environmentTraining parentsParent-Child Interaction Therapy (PCIT)Originally used with Child-Onset Conduct DisorderMay be effective with severe behavioral problemsZisser, A., & Eyberg, S.M. (2010). Treating oppositional behavior in children using parent-child interaction therapy. In A.E. Kazdin & J.R. Weisz (Eds.) Evidence-based psychotherapies for children and adolescents (2nd ed., pp ). New York:
31 Parent-Child Interaction Therapy (PCIT) Parent-Child Interaction Therapy (PCIT) is an empirically-supported treatment for conduct-disordered young children that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns. In PCIT, parents are taught specific skills to establish a nurturing and secure relationship with their child while increasing their child’s prosocial behavior and decreasing negative behavior. This treatment focuses on two basic interactions: Child Directed Interaction (CDI) is similar to play therapy in that parents engage their child in a play situation with the goal of strengthening the parent-child relationship; Parent Directed Interaction (PDI) resembles clinical behavior therapy in that parents learn to use specific behavior management techniques as they play with their child.
32 ADHD: Management Communication with teacher CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) is the nation's leading non-profit organization serving individuals with AD/HD and their families. CHADD has over 16,000 members in 200 local chapters throughout the U.S. Chapters offer support for individuals, parents, teachers, professionals, and others.Attention MagazineFree Discount Prescription Card offered by CHADDCommunication with teacherDaily Behavioral Report Cards (school-home notes)School report invokes home-based contingencies
33 Children and Adults With Attention Deficit/Hyperactivity Disorder
35 BEHAVIORAL CONTINGENCIES To Reduce Unwanted BehaviorPresent something undesirable (additional chores)“Positive Punishment”Keep something desirable (restrict access to video games)“Negative Punishment”To Increase Desired BehaviorProvide something desirable (borrow the car)“Positive Reinforcement”Remove or reduce aversive conditions“Negative Reinforcement”
36 Other ApproachesI've seen some patients benefit from LENS, a form of neurofeedback. I've seen other patients benefit from iLs, Integrated Listening Systems, a music-based therapeutic listening program. I'm a big fan of the Cogmed program for improving working memory, because it has more research behind it than other alternative therapies. My favorite "alternative treatments" are free: sleep, exercise, nutrition, meditation, stretching your brain with stimulating exercises, and positive human contact — known as love.
37 Other Approaches Mindfulness Training Social Skills Training UCLA study-reduction in impulsivitySocial Skills TrainingFailed to show effectivenessMay be failure to generalize skillsHomework Management PlanSecondary school youthSpecific amount of time each evening for homework even if youth states “no homework”Pilot data indicates improvementIn-sight Driven IndividualGenerally less effective
38 Structure AM Protocol Daily schedule “SAFE” places White board or check-off sheetDaily scheduleConsistent wake-up timeConsistent home work timeConsistent “high energy” timeConsistent bed time“SAFE” places