Attention Deficit Hyperactivity Disorder (ADHD)

By

Shokry Alemam, MD

Agenda1.Definition

2.Clinical picture

3.Diagnosis

4.Epidemiology

5.Comorbidities

6.Prognosis

7.Management

1. Definition Attention-deficit/hyperactivity disorder (AD/HD or ADHD) •It is a neurobehavioral developmental disorder, affecting preschoolers, children, adolescents, and adults, characterized by impulsiveness and inattention, with or without a component of hyperactivity.(1)

(1) American Psychiatric Association. Attention-deficit/hyperactivity disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.59.

2. Clinical picture

3. Diagnosis (DSM V) A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

d. Often does not follow through on instructions and fails to finish schoolwork, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

3. Diagnosis (cont) 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have per sisted for at least 6

months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

a. Often fidgets with or taps hands or feet or squirms in seat.

b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)

d. Often unable to play or engage in leisure activities quietly.

e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

f. Often talks excessively.

g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).

h. Often has difficulty waiting his or her turn (e.g., while waiting in line).

i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving per mission; for adolescents and adults, may intrude into or take over what others are doing).

3. Diagnosis (cont)B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal). Specify whether:314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months.314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months. 314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. Specify if:in partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning. Specify current severity:

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.

Moderate: Symptoms or functional impairment between “mild” and “severe” are present.

Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

3. Diagnosis (cont)• MRI studies reported decreased volume of

( cerebellar regions, splenium of corpus callosum, total and right cerebral volumes, and right caudate nucleus.(2)

• fMRI studies reported hypoactivation of right inferior frontal cortex which is associated with motor response inhibition in adult ADHD. (3)

(2) Marten H. Onninka, Marcel P. Zwiers. Brain alterations in adult ADHD: Effects of gender, treatment and comorbid depression.European Neuropsychopharmacology (2014) 24, 397–409

(3) Sharon Morein-Zamir, Chris Dodds. Hypoactivation in Right Inferior Frontal Cortex is Specifically Associated With Motor Response Inhibition in Adult ADHD. Human Brain Mapping (2014)

35:5141–5152

Changes in DSM V• Symptoms must be present by the age of 12

years instead of age of 7 years.• There are 3 subtypes instead of 2, combined,

predominant inattentive, and predominant hyperactive/impulsive.

• DSM V permits diagnosis of ADHD with comorbid autistic spectrum.

• In DSM V for adolescents 17 years and older, and for adults, only 5 symptoms rather than 6 are required.

4. Epidemiology • Population surveys suggest that ADHD occurs in most cultures

in about 5-8% of children and about 2.5% of adults.(4)

• symptoms are difficult to distinguish from highly variable normative behaviors before age 4 years.

• ADHD is more frequent in males than in females in the general population, with a ratio of approximately 2:1 in children and 1.6:1 in adults. Females are more likely than males to present primarily with inattentive features.

(4) Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA: The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 2007, 164:942–948.

7. Comorbidities • ADHD exists alone in only about 1/3 of the

children diagnosed with it.

• Studies in adults with substance use disorder (SUD) shows higher prevalence of adult ADHD compared to general population, with more severe course and poorer treatment outcome (5)

(5) Geurt van de Glind, Maija Konstenius. Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: Results from an international multi-center study exploring DSM-IV and DSM-5 criteria. Drug and Alcohol Dependence 134 (2014) 158–166

7. Comorbidities

• Patients with adult ADHD and early use of cannabis have more severe deficit in their executive functions(6)

(6) Leanne Tamm, Jeffery N. Epstein. Impact of ADHD and cannabis use on executive functioning in young adults. Drug and Alcohol Dependence 133 (2013) 607–614

7. Comorbidities • A study on a sample of older youth (21-29) in

adult Scottish prisons reported that The prevalence of ADHD was found to be 7%, which is consistent with previous research, and higher than that found in the general population(7)

(7)Vicki Gordon , Peter D. Donnelly, Damien J. Williams. Relationship between ADHD symptoms and anti-social behaviour in a sample of older youths in adult Scottish prisons, Personality and

Individual Differences 58 (2014) 116–121

9. Prognosis • The diagnostic criteria for ADHD dropped by

about 50% over three years after the diagnosis.

• It persists in about 60-85% in adolescence, and up to 60% of cases in adulthood.

• People with ADHD tend to work better in less structured environments with fewer rules .

• Hyperactive types are likely to change jobs often.

10. Management Behavioral interventions:

• Psychological therapies use to treat ADHD include psychoeducation , behavior therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy,

school-based interventions, social skills training, and parent management training.

• Parent training and education have been found to have short term benefits.

10. Management (cont)

Pharmacological treatment:

•Stimulant medications are the most clinically and cost effective method of treating ADHD.

•No significant differences between the various drugs in terms of efficacy or side effects have been found

10. Management (cont)Stimulant MedicationsMethylphenidate, inhibits the reuptake of dopamine and norepinephrine through inhibition of the dopamine transporter system.

The amphetamines, diffuse into storage vessicles and cause the release of dopamine to the cytoplasm and blocks reuptake into the vessicle.

Mixed amphetamine salts include Adderall and Adderall XR. It was reported in UK 2005 to cause sudden cardiac arrest and increase risk of suicide.

10. Management (cont)common side effects • rebound• insomnia• irritable mood• tics • decreased appetite which can lead

to weight loss and decelerated growth in some children.

10. Management (cont)• There may be persistent cognitive

impairments (especially attention) in adult ADHD despite medications, and the benefit of stimulants seems to be reduced under cognitive fatigue.(8)

(8) Jun Maruta, Lisa A. Spielman. Possible Medication-Resistant Deficits in Adult ADHD, Journal of Attention Disorders ,(2014) 1- 11

10. Management (cont)

• Memantine was found to help in improvement of executive functions of patients with adult ADHD, by modulation of prefrontal glutamate and dopamine(9)

(9) van Wageningen, H., Jorgensen, H. A., Specht, K., & Hugdahl, K.

(2010). A 1H-MR spectroscopy study of changes in glutamate and glutamine (Glx) concentrations in frontal spectra after administration of memantine. Cerebral Cortex, 20, 798-803.

10. Management (cont)• Early age at initiation of methylphenidate

treatment in children with ADHD doesn’t increase for negative outcomes, and even in non ADHD children, no relationship between exposure to methylphenidate and substance use disorder in adulthood.(10)

(10) Salvator Mannuzza S, Klein, Nuhan L. Truong: Age of methylphenidate treatment initiation in children with ADHD and later substance abuse. Am J psychiatry 2008; 165: 604-609

10. Management (cont)Nonstimulant MedicationsAtomoxetine (Strattera) is a non stimulant medication

that works by blocking the norepinephrine pump on the presynaptic membrane which increases the availability of intrasynaptic norepinephrine.

Antidepressant medications as a class, are used as

"second line" treatment for the ADHD disorders. The two types used are buproprion and tricyclics (SSRI's are not used to treat ADHD). Buproprion blocks the reuptake of norepinephrine and dopamine. Tricycylic antidepressants (Nortriptyline) work by inhibiting the reuptake of norepinephrine and serotonin

10. Management (cont)

Dietary Supplements and Experimental Treatments:

Dietary supplements and specialized diets For example, Omega-3 supplementation may reduce

ADHD symptoms for a subgroup of children and adolescents with ADHD "characterized by inattention and associated neurodevelopmental disorders.“

• The effectiveness of these dietary supplements and specialized diets is debated

• In the United States, no dietary supplement has been approved for the treatment for ADHD by the FDA.

ADHD and pregnancy• A study of 19 pregnant women, they

performed better on verbal memory tasks after delivery than 2 months before delivery, while no association between sex hormones and cognitive impairments. (11)

(11) Buckualter JG, Stanczy K F Z, McCleary C A: pregnancy, the postpartum, and steroid hormones: effects on cognition and mood. Psychoneuroendocrinology 1999; 24: 69-84

ADHD and pregnancy

Recommendations are:•Medication free trial•Use of stimulant medications in severe cases. (12)

(12) Marlene P. Freeman: ADHD and pregnancy. Am J psychiatry 2014; 171: 723-728

10. Management (cont)

Binaural auditory beats(13)

(13) Susan Kennel PhD, RN, CPNP, Ann Gill Taylor RN, EdD, FAAN, Debra Lyon PhD, RN, FNP, Cheryl Bourguignon RN, PhD (2010). Pilot Feasibility Study of Binaural Auditory Beats for Reducing

Symptoms of Inattention in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Journal of Pediatric Nursing (2010) 25, 3–11