Diagnosis and Management of ADHD

ADHD Hill, P. Child & Adolescent Mental Health in Primary Care 2003; 1(1):2-4 “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.”

InattentionHyperactivity Impulsivity Symptoms of ADHD

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

Neurochemical Pathophysiology of ADHD Receptors Synapse Nerve Impulse Transporter Noradrenaline Dopamine

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

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

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

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

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

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

Common Associated Comorbidities (%) Milberger et al. Am J Psychiatry 1995; 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– Oppositional defiant disorder Anxiety disorder Learning disorder Mood disorder Conduct disorder SmokingSubstance use disorder Tics

Input Needed to Make a Diagnosis Diagnosis Teacher Child Parent

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

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

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

ICD-10 HKD Diagnostic Criteria Used to diagnose hyperkinetic disorder (HKD), a more severe form of ADHD Used to diagnose hyperkinetic disorder (HKD), a more severe form of ADHD List of symptoms must be present for at least six months List of symptoms must be present for at least six months Must have: at least six symptoms of inattention AND 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 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) Impairment of symptoms must be present in two or more settings (e.g. school and home) Significant impairment: social, academic or occupational Significant impairment: social, academic or occupational

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

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

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

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

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

Effectiveness of Behavioural Therapy Parent training is generally regarded as the most effective behavioural therapy Parent training is generally regarded as the most effective behavioural therapy Parent training combined with medication management increases parent acceptability of medication 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 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 Individual treatment approaches have not been shown to be effective

Stimulants Methylphenidate (RecommendedAmphetamine compounds first-line therapy)Dextroamphetamine Pemoline Antidepressants Tricyclic antidepressants Bupropion Antihypertensives Clonidine Guanfacine Guanfacine 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 Pharmacological Agents Used in Treatment of ADHD* * Not all agents are available in some countries

ADHD Pharmacotherapy – Responsiveness % Responders Methylphenidate Amphetamine Pemoline Tricyclic antidepressants Bupropion MAOI Clonidine/ Guanfacine Wilens TE, Spencer TJ. Presented at Massachusetts General Hospital’s Child and Adolescent Psychopharmacology Meeting, March 10-12, 2000, Boston, MA