1. ADHD, Executive Functions and PKU Kevin M. Antshel, Ph.D. Associate Professor of Psychiatry / Licensed Psychologist State University of New York – Upstate Medical University

2. Outline ADHD basics Executive functioning ADHD and PKU Questions

3. ADHD Is characterized by pervasive and often occurring… Impairing inattentive symptoms AND/OR Impairing hyperactive / impulsive symptoms

4. Inattention symptoms DSM-IV SYMPTOM Typical ADHD No attention to details 6.069.5 Can’t sustain attention 10.377.0 Doesn’t listen 7.668.3 No follow-through 5.077.7 Disorganized 3.376.0 Avoids sustained tasks 7.362.7 Loses things 13.979.2 Easily distracted 14.586.1 Forgetful 5.368.1 Antshel et al., 2007

5. Hyperactive / Impulsive symptoms DSM-IV SYMPTOM Typical ADHD Fidgets 16.669.5 Leaves seat 6.763.6 Runs/Climbs 0.691.3 Loud 1.946.8 Driven by a motor 5.255.1 Talks too much 19.763.6 Blurts out answers10.265.3 Can’t wait turn 4.356.9 Interrupts16.780.1 Antshel et al., 2007

6. ADHD diagnosis Symptoms present before 7 years of age Symptoms must be present in 2 or more settings (e.g., school, work, home) Symptoms must have persisted for at least 6 months The disturbance causes clinically significant impairment in functioning Is not better accounted for by another disorder

7. ADHD “facts” Prevalence: 5 – 7 % 2:1 – 9:1 male: female ratio Co-occurs with multiple other psychiatric disorders Strong heritability 60+% continue to have ADHD as adults

8. Research-supported treatments Medications Stimulants (e.g., Ritalin, Adderall, etc.) Noradrenergic (Strattera) Anti-hypertensives (e.g., Clonidine, Tenex) Parent Training in Child Management Children (<11 yrs., 65-75% respond) Adolescents (25-30% show reliable change) Teacher Training in Behavior Management

9. The Usual Questions… Nigg, 2006

10. ADHD affects two primary brain areas Toga et al., 2006

12. Executive Functions Planning Organization Self-Monitoring Prioritizing Goal-oriented, problem solving behavior

13. Low Dopamine Availability Links PKU and ADHD

18. Decision Tree for Diagnosing ADHD in PKU Do ADHD symptoms dramatically lessen / become less impairing with better phenylalanine control? Probably not ADHD – no real need for an evaluation

19. Decision Tree (cont’d) Do ADHD symptoms lessen with tighter phenylalanine control yet continue to impair functioning? Could be worth considering an evaluation

20. Decision tree (cont’d) Do impairing ADHD symptoms continue in the presence of historically and currently well- treated PKU? Should have an evaluation

21. Conclusions ADHD and PKU share neurochemical (dopamine), neurological (prefrontal, striatal) and psychological (executive function deficits) characteristics To reliably diagnose ADHD, however, ADHD symptoms need to persist and impair functioning in the context of well-treated PKU