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ADHD Overview Jeanette E. Cueva, M.D.. Overview ADHD history Perception and reality Diagnosis in the US and UK Etiology.

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Presentation on theme: "ADHD Overview Jeanette E. Cueva, M.D.. Overview ADHD history Perception and reality Diagnosis in the US and UK Etiology."— Presentation transcript:

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…”

4 History of ADHD DateMilestone 1902Still: Description of ADHD symptoms 1937 Bradley: Benzadrine. Conceptualization of ADHD involved testing response to stimulants 1955MPH 1960Minimal Brain Dysfunction 1980ADD – DSM-III; adults acknowledged 1987ADHD – DSM-III R 1994DSM-IV

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

9 Evidence In the beginning, the diagnosis of ADHD was unclear due to – Different names – Inconsistent nature of impairments – Feedback from 3 rd 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 Antihypertensives Neuroleptics Antidepressants Stimulants N=6472 children, adolescents, and adults. Controlled Studies of Medication in ADHD Spencer et al. JAACAP 1996;35:

11 ADHD: Diagnosis Based on coding systems DSM-IV and DSM-IV TR (www.behavenet.com/capsules/disorders/adhd.htm) – US ADHD, Combined Type ADHD, Predominantly Inattentive Type 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 Inattention Impulsivity/Hyperactivity ADHD: Core Symptom Areas

13 Inattention ADHD: DSM-IV Criteria 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 Six or more of the following – manifested often

14 ADHD: DSM-IV Criteria 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 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 Combined type Predominatelyhyperactive-impulsive Predominately inattentive

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

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

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

22 DSM-IV-Defined ADHD Population (Paediatric 3-19 yrs) Growth (%/Yr) Growth (%/Yr) United States 10,362,90010,391,60010,225,2000.1(0.3) Europe9,795,6009,396,6008,900,300(0.8)(1.1) France2,185,1002,133,2002,082,000(0.5) Germany2,581,5002,471,3002,270,800(0.9)(1.7) Italy1,637,2001,565,2001,480,300(0.9)(1.1) Spain1,222,7001,108,2001,052,800(1.9)(1.0) United Kingdom 2,169,1002,118,7002,014,400(0.5)(1.0) Japan3,432,0003,265,6003,233,300(1.0)(0.2) Major Market Total 23,590,50023,053,80022,358,800(0.5)(0.6) 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 ADHD: Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies ADHD NeuroanatomicNeurochemical CNS insults Genetic origins Environmental factors

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

27 Heritability of ADHD HeightSchizophrenia

28 ADHD: Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies ADHD NeuroanatomicNeurochemical CNS insults Genetic origins Environmental factors

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 Number of Indicators of Adversity Odds Ratio

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

33 Inattention Impulsivity/Hyperactivity ADHD: Diagnostic Considerations

34 Risk Factors for ADHD Girls Boys

35 ADHD: Adult Common Comorbid Diagnosis Female Male

36 “It’s a guy thing.”

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

38 ADHD: Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies ADHD NeuroanatomicNeurochemical CNS insults Genetic origins Environmental factors

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):

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

42 Neurotransmitters CH 2 NH 2 OH Dopamine CH NH 2 OH Norepinephrine CH 2 CH NH 2 CH 3 Amphetamine O NH 2 N OPemolineMethylphenidate COCH 3 O NH

43

44 Storage vesicle DA Transporter Cytoplasmic DA Methylphenidate inhibits Presynaptic Neuron Synapse Probable Mechanism of Action of Methylphenidate Wilens and Spencer. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;

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

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

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

48 Catecholaminergic Neurotransmission Relative to ADHD 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 NorepinephrineDopamine Solanto. Stimulant Drugs and ADHD. Oxford; 2001.

49 Questions


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