Attention-Deficit / Hyperactivity Disorder

Ross Andelman, M.D.Contra Costa Children’s Mental

Health

CCRMC Noon Lecture SeriesSeptember 8th 2009

ADHD Diagnosis

“A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at comparable level of development.”

DSM IV, APA 1994

ADHD: Current Perspective

Highly prevalent in community studiesExtremely prevalent in clinical samplesDevelopmental disorder Presents in childhood (before age 7) Persists into adolescence and into adulthood

Neurobiological disorder Disorder of executive functionSpectrum ‘heterogeneous’ disorderHighly inheritableResponsive to appropriate treatment

ADHD Etiology-Genetics

Up to 92% concordance in monozygotic twinsHeritability - .75 (twin studies) Comparable to schizophrenia Panic - .48; Height - .92

Siblings - 26-50% in full; 9% in halfFirst degree family members – 20-25%Dopamine transporter gene (DAT1), chr 5Dopamine receptor D4 (DRD4*7), chr 11

ADHD: D/O of Executive Fxn

Shifting from one mindset to another - flexibilityOrganization - anticipating needs & problemsPlanning - goal settingWorking memory (short-term) - receiving, storing, retrieving informationSeparating affect from cognition - detaching emotions from reasonInhibiting and regulating verbal and motoric action - jumping to conclusions too quickly, difficulty waiting in line in an appropriate fashion

ADHD, DSM IV Diagnosis 6 of 9 Sxs of inattention and/or

6 of 9 Sxs of hyperactivity-impulsivity

Sxs present for more than 6 months

Presence of some Sxs before age 7

Impairment in 2 or more settings

Clear evidence of significant social, academic, or occupation impairment

Symptoms not secondary to other Dx

ADHD, DSM IV–Inattentive Symptoms

Fails to give close attention; makes careless mistakes Has difficulty sustaining attention Does not seem to be listening when spoken to Does not follow through; fails to finish tasks Difficulty organizing tasks Avoids tasks requiring sustained mental effort Often loses things Easily distracted by extraneous stimuli Forgetful in daily activities

ADHD, DSM IV-Hyperactivity-Impulsivity

Symptoms Fidgets or squirms

Unable to stay in seat

Runs and climbs excessively

Difficulty playing quietly

On the go (driven by a motor)

Talks excessively

Blurts out answers

Difficulty waiting turn

Interrupts or intrudes on others

ADHD, Presentation-Preschool

Hyperactivity the rule Frequent temper tantrums Impulsive aggression toward peers Fearlessness with frequent injuries Noncompliance with preschool rules & decorum Demanding and argumentative with parents Sleep disturbance Delays in motor-language development

ADHD, Presentation-Elementary Age

Difficulty, especially with challenging work Homework disorganized, messy, with careless errors

Easily distracted, unable to sustain attention Difficulty forming & keeping peer relationships Denny Cantwell's 'lack of social savoir-faire' Perceived as poorly controlled, disrespectful, disruptive, class clown, immature, bad Impulsivity and noncompliance now result in trips to the principal's office

ADHD, Presentation-Adolescence

From 'on the go' to fidgety and restless

School performance inconsistentIf not yet diagnosed, likely to be intelligentPoor organization & poor follow through

Persistent high risk behaviorBike and auto accidentsDrug and alcohol use

Lack of social skills now impacts on both same-sex and opposite-sex

relationships

Failure to meet educational and career goals

Poor organization, time management, and Procrastination

Interpersonal instability at home and at work

Poor social skills 'grown up‘Short fuse, irritabilityInability to maintain long-term relationships

May still be restless or fidgety May be drawn to high risk activities &

substance abuse May have legal problems May have low self-esteem

ADHD, Presentation-Adults

ADHD - Assessment

Diagnostic Bottom Line Diagnostic interviews with parents &

child or adult +/- spouse/ co-worker Rating scales – e.g. SNAP, Vanderbilt,

Conners, & Adult ADHD checklists

Frills and Extras Observation of behavior in natural

contexts Medical and / or neurological evaluation Cognitive, psycholinguistic, and psycho-

educational testing

ADHD, Initial Assessment-Goals

Determine presence of core symptoms (Sxs)

Rule out alternate explanations for symptoms

Assess for co-morbid conditions

Obtain baseline ratings of symptom severity and functional impairment

Educate family about disorder

Dispel myths and normalize condition

ADHD, Initial Assessment-Interview and History

Symptom & impairment history How long / how bad / where / when Family’s understanding of problem What has helped? What has not?

Past mental health history Birth, development, and medical history Social and educational history Family and home environment Family psychiatric history Individual and family strengths and resources

ADHD, Treatment-Goals

Reduce core symptoms of ADHD Establish individual target symptoms

Improve functioning in all areas of impairment Assess for and attend to co-occurring conditions Minimize adverse effects of therapy

ADHD, TreatmentTreatment is Multimodal!

Psycho-Education Psycho-Pharmacology Psycho-Social Educational Interventions Parent Training and Support Social Skills Training Recreational Mainstreaming Individual and Group Psychotherapies

ADHDPsychopharmacology

ADHD, Treatment-Psychopharmacology

Symptoms likely to respond to medication Inattention Impulsivity Hyperactivity Non-compliance with authority Impulsive aggression Social deficits Academic performance

ADHD, Treatment-Psychopharmacology

ADHD, Treatment-Psychopharmacology

Psychostimulants MPH, dextroamphetamine, mixed amphetamines>200 double-blind random controlled trials (RCTs)Typical investigations of efficacy usually quite brief

Other medications found effective in RCTs Tricyclic Antidepressants (>18 trials)AtomoxetineBuproprionalpha-2 agonists

Promising, efficacy not yet fully establishedVenlafaxine, Nicotine, modafinil, donepezil

ADHD, Psychopharmacology

-? Adverse effects of stimulants

Weight loss; Sleep disturbance; Mood lability ? Risk of sudden death ? Induce tics ? Height suppression ? Dependence ? Drug abuse

ADHD, Psychopharmacology

-Stimulants The Andelman (Cantwell-UCLA) Algorithm Trial of one of the long-acting formulations,

titrating dose weekly, and monitoring benefits and side effects through parent and child interviews, and teacher serial checklists Concerta 18mg – 36 mg – 54 mg qAM; Metadate CD 20mg – 40 mg - 60mg qAM; Dexadrine Spansule 10 mg – 20 mg - 30mg qAM; Adderall XR 10 mg – 20 mg -30mg qAM Vyvance 20mg – 30 mg – 40 mg – 50 mg qAM

ADHD, Psychopharmacology

-Beyond Stimulants

Atomoxetine (Strattera) Initiate 0.5mg/kg/D qAM or 10mg Titrate alt weekly to 1.2mg/kg or 80mg Max

Bupropion (Wellbutrin [SR]) Initiate 3mg/kg/D qAM to TID [BID for SR] Titrate weekly to 7mg/kg/D or 400mg Max

Clonidine (Catapres) or Guanfacine (Tenex) Initiate 0.05mg qHS (.5mg Guanfacine) Titrate weekly to .05mg TID (.5mg Guanfacine),

then to .1mg TID Max (1mg TID Guanfacine)

ADHD, Treatment-Psychosocial interventions

• Behavioral parent support & training• Bibliotherapy / Organizational support

• Behavioral classroom interventions

• Social skills group therapy

• Individual psychotherapy• Unfortunately not all that useful

ADHD, Treatment-Parent training

ADHD, Psychosocial Treatment

-Parent Training

Normalize hygiene – food and sleep Consistency in expectations / discipline Positive reinforcement Homework & Chores

Provide structure and predictability Modeling good organizational skills Home-school-clinician communication Exercise & relaxation

ADHD, Psychosocial Treatment

-Parent Training –Behavioral Mod Positive attending

Catch the child doing good: Be specific!

Contingency contracting Identifying “target behaviors”

Establishing behavioral baseline Ignoring low-level negative behaviors

Creating positive reward systems Selected use of “punishment” Shaping, cueing, modeling

Parent Training-Creating positive rewards

Parent Training-Creating positive rewards

-Parent TrainingSelective ignoring

ADHD, Psychosocial Treatment

-School-based interventions

ADHD, Psychosocial Treatment

- Self Discipline (Adult)

Normalize hygiene Food and sleep Exercise & relaxation

Structure and predictability Developing good organizational skills Attention to schedule, deadlines, &

priorities

ADHD, Treatment-Psycho-Education:

Bibliotherapy Driven to Distraction: Recognizing and Coping with

Attention Deficit Disorder from Childhood through Adulthood,

Hallowell and Ratey, 1995. Attention Deficit Hyperactivity Disorder: What Every

Parent Wants To Know, Wodrich, 1994. ADHD 102: Practical Strategies for Reducing the

Deficit, Frank and Smith, 2001.

Getting a Grip on ADD: A Kids Guide to Understanding and Coping With Attention Disorders, Frank and Smith, 1994.

I Would If I Could : a Teenagers Guide ADHD Hyperactivity, Gordon, 1992.

ADHD Treatment

QUESTIONS?