Diagnosis and Diagnosis and Management of ADHDManagement of ADHD

ADHDADHD

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

““Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder (ADHD) is a pattern of behaviour which is (ADHD) is a pattern of behaviour which is the most recent in a series of American the most recent in a series of American attempts to characterise inattentive attempts to characterise inattentive restlessness as a condition. It is effectively a restlessness as a condition. It is effectively a syndrome encompassing hyperactivity, poor syndrome encompassing hyperactivity, poor concentration and marked impulsive, concentration and marked impulsive, impatient, excitable behaviour. Most, but not impatient, excitable behaviour. Most, but not all, instances are predominantly genetic in all, instances are predominantly genetic in origin, with various inherited deficiencies of origin, with various inherited deficiencies of the dopamine neurotransmitter system.”the dopamine neurotransmitter system.”

InattentionInattention HyperactivityHyperactivity

ImpulsivityImpulsivity

Symptoms of ADHDSymptoms of ADHD

ADHD: Prevalence and ADHD: Prevalence and DemographicsDemographics

Overall prevalence 3% to 10% in school-Overall prevalence 3% to 10% in school-aged childrenaged children

Diagnosed in boys 3 to 4 times more often Diagnosed in boys 3 to 4 times more often thanthanin girlsin girls

Persists in 30% to 50% of patients into Persists in 30% to 50% of patients into adolescence and adulthood (symptom adolescence and adulthood (symptom profile may change)profile may change)

Neurochemical Neurochemical Pathophysiology of ADHDPathophysiology of ADHD

Receptors

Synapse

NerveImpulse

Transporter

Noradrenaline Dopamine

Impact of ADHD on PatientsImpact of ADHD on Patientsand Familyand Family

PatientsPatients Poor academic Poor academic

achievementachievement Social impairmentSocial impairment Low occupational Low occupational

statusstatus Increased risk of Increased risk of

substance abuse substance abuse Increased risk of Increased risk of

injuryinjury

FamilyFamily Increased stress Increased stress

levelslevels Increased Increased

depressiondepression Increased marital Increased marital

discorddiscord Changed work Changed work

statusstatus

Impact of ADHD onImpact of ADHD onSchool PerformanceSchool Performance

Poor classroom behaviourPoor classroom behaviour Poor academic achievementPoor academic achievement Special education requirements (tutoring Special education requirements (tutoring

and special educational programmes)and special educational programmes) School exclusion (either suspension or School exclusion (either suspension or

expulsion)expulsion) Repetition of gradesRepetition of grades Failure to gain external qualificationsFailure to gain external qualifications

Effects of ADHD on Effects of ADHD on Behavioural DevelopmentBehavioural Development

Problems with productivity and motivationProblems with productivity and motivation Reduced ability to express ideas and Reduced ability to express ideas and

emotionsemotions Decreased working memoryDecreased working memory Problems with social interactionProblems with social interaction Impairments in speechImpairments in speech Problems with verbal reasoningProblems with verbal reasoning

Developmental Impact of Developmental Impact of ADHDADHD

Pre-school Adolescent AdultSchool-age College-age

Behaviouraldisturbance

Behavioural disturbanceAcademic problemsDifficulty with social interactionsSelf-esteem issues

Academic problemsDifficulty with social interactionsSelf-esteem issuesLegal issues, smoking and injury

Academic failureOccupational difficultiesSelf-esteem issuesSubstance abuseInjury/accidents

Occupational failureSelf-esteem issuesRelationship problemsInjury/accidentsSubstance abuse

Defining ComorbidityDefining Comorbidity

ADHD is highly comorbidADHD is highly comorbid Comorbidity is defined as two different Comorbidity is defined as two different

diagnoses present in an individual patientdiagnoses present in an individual patient It is important to recognise comorbid It is important to recognise comorbid

disordersdisorders Comorbidities may require treatment Comorbidities may require treatment

independent from and different to therapy independent from and different to therapy for ADHDfor ADHD

Co-occurring Disorders in Co-occurring Disorders in Children (Children (n n = 579)= 579)

ADHDalone31%

AnxietyDisorder

34%

Mood Disorders 4%MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096

OppositionalDefiant

Disorder40%

Tics11%

Conduct Disorder14%

Common Associated Common Associated ComorbiditiesComorbidities

(%)

Milberger et al. Am J Psychiatry 1995; 152: 1793–1799Biederman et al. J Am Acad Child Adolesc Psychiatry 1997; 36: 21–29Castellanos. Arch Gen Psychiatry 1999; 56: 337–338Goldman et al. JAMA 1998; 279: 1100–1107Szatmari et al. J Child Psychol Psychiatry 1989; 30: 219–230

60

40

20

0Oppositional

defiant disorder

Anxiety disorder

Learning disorder

Mood disorder

Conductdisorder

Smoking Substance use

disorder

Tics

Input Needed to Make Input Needed to Make a Diagnosisa Diagnosis

DiagnosisDiagnosisTeacherTeacher

ChildChild

ParentParent

ImpulsivityImpulsivityTalks excessively Talks excessively ††

Blurts out answersBlurts out answersCannot await turnCannot await turnInterrupts othersInterrupts othersIntrudes on othersIntrudes on others

DSM-IV – Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association, 1994)ICD-10 – International Classification of Diseases, 10 th Edition (World Health Organisation, 1993)

HyperactivityHyperactivityFidgetsFidgets

Leaves seat in classLeaves seat in classRuns/climbs Runs/climbs excessivelyexcessivelyCannot play/work Cannot play/work quietlyquietlyAlways ‘on the go’Always ‘on the go’Talks excessively *Talks excessively *

InattentionInattentionDoes not attendDoes not attendFails to finish Fails to finish taskstasksCan’t organiseCan’t organiseAvoids sustained Avoids sustained efforteffortLoses things, Loses things, ‘forgetful’‘forgetful’Easily distractedEasily 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 GroupsSymptom Groups

DSM-IV ADHD Diagnostic DSM-IV ADHD Diagnostic CriteriaCriteria

List of symptoms must be present for past 6 List of symptoms must be present for past 6

monthsmonths Must have six (or more) symptoms of Must have six (or more) symptoms of

inattention inattention and/orand/or hyperactivity–impulsivity hyperactivity–impulsivity Some symptoms present before 7 years of ageSome symptoms present before 7 years of age Some impairment from symptoms must be Some impairment from symptoms must be

present in two or more settings (e.g. school present in two or more settings (e.g. school and home)and home)

Significant impairment: social, academic or Significant impairment: social, academic or occupationaloccupational

Exclude other mental disordersExclude other mental disorders

DSM-IV Subtypes of ADHDDSM-IV Subtypes of ADHD

Predominantly inattentivePredominantly inattentive Predominantly hyperactive–impulsivePredominantly hyperactive–impulsive Mixed/combined Mixed/combined In partial remissionIn partial remission Not otherwise specified (NOS)Not otherwise specified (NOS)

ICD-10 HKD Diagnostic ICD-10 HKD Diagnostic CriteriaCriteria

Used to diagnose hyperkinetic disorder (HKD), a Used to diagnose hyperkinetic disorder (HKD), a more severe form of ADHDmore severe form of ADHD

List of symptoms must be present for at least List of symptoms must be present for at least six monthssix months

Must have:Must have: at least six symptoms of inattention at least six symptoms of inattention ANDANDat least three symptoms of hyperactivity at least three symptoms of hyperactivity ANDAND at least one at least one symptom of impulsivitysymptom of impulsivity

Onset of symptoms no later than 7 years of ageOnset of symptoms no later than 7 years of age Impairment of symptoms must be present in Impairment of symptoms must be present in

two or more settings (e.g. school and home)two or more settings (e.g. school and home) Significant impairment: social, academic or Significant impairment: social, academic or

occupationaloccupational

Important Rating Tools for Important Rating Tools for ADHDADHD

Conners Parent Rating Scale – assesses and Conners Parent Rating Scale – assesses and monitors response to treatmentmonitors response to treatment

IOWA Conners – measures dimensions of IOWA Conners – measures dimensions of behaviour associated with ADHDbehaviour associated with ADHD

SKAMP Measures – measures the classroom SKAMP Measures – measures the classroom manifestation of ADHDmanifestation of ADHD

SNAP-IV Scale – derived from descriptions in SNAP-IV Scale – derived from descriptions in DSM-IVDSM-IV

Continuous Performance Test (CPT) – measures Continuous Performance Test (CPT) – measures the attention span in children with ADHD the attention span in children with ADHD

C-DISC – computer-assisted diagnostic interview C-DISC – computer-assisted diagnostic interview schedule for childrenschedule for children

Therapy Options as Part of a Therapy Options as Part of a Total Treatment Programme Total Treatment Programme Behavioural treatmentBehavioural treatment Medication managementMedication management Combining medication/behavioural Combining medication/behavioural

treatmenttreatment Educating parents/patient about ADHD Educating parents/patient about ADHD Educational support servicesEducational support services

Cunningham, Barkley. Child Dev 1979; 50: 217–224

Tools Used in Behavioural Tools Used in Behavioural TreatmentTreatment

Specific strategiesSpecific strategies Reward systemReward system Time outTime out Social reinforcementSocial reinforcement Behaviour modellingBehaviour modelling

Support for parentsSupport for parents Family and patient educationFamily and patient education

Group problem-Group problem-solvingsolving

Sports skillsSports skills Social skills trainingSocial skills training

Behavioural Treatment in the Behavioural Treatment in the HomeHome

Identify problem situations and the Identify problem situations and the precipitating factorsprecipitating factors

Enhance positive parent–child interactionsEnhance positive parent–child interactions Limit negative parent–child interactionsLimit negative parent–child interactions Use cost systems to reduce problem Use cost systems to reduce problem

behavioursbehaviours Use time outs as punishment for serious Use time outs as punishment for serious

problem behavioursproblem behaviours

Atkins, Pelham. 1992:69–88; Barkley, Cunningham. Arch Gen Psychiatry 1979; 36: 201–208

Behavioural Treatment in the Behavioural Treatment in the ClassroomClassroom

Behavioural treatment in school setting Behavioural treatment in school setting similar to the approach used in home with similar to the approach used in home with parentsparents

Goal: Reduce inattention and disruptive Goal: Reduce inattention and disruptive behaviourbehaviour

Specific school accommodations:Specific school accommodations: Ensure structure and predictable routinesEnsure structure and predictable routines Employ cost–response token economy systemsEmploy cost–response token economy systems Use daily report cardsUse daily report cards Teach organisational and work/study skillsTeach organisational and work/study skills

Effectiveness of Behavioural Effectiveness of Behavioural TherapyTherapy

Parent training is generally regarded as Parent training is generally regarded as the most effective behavioural therapythe most effective behavioural therapy

Parent training combined with medication Parent training combined with medication management increases parent management increases parent acceptability of medicationacceptability of medication

School-based treatment is more effective School-based treatment is more effective than individual strategies, however than individual strategies, however benefits are only seen during treatment benefits are only seen during treatment programmesprogrammes

Individual treatment approaches have not Individual treatment approaches have not been shown to be effective been shown to be effective

StimulantsStimulants MethylphenidateMethylphenidate(Recommended(Recommended Amphetamine compounds Amphetamine compounds first-line therapy)first-line therapy) DextroamphetamineDextroamphetamine

PemolinePemoline AntidepressantsAntidepressants TricyclicTricyclic antidepressantsantidepressants

BupropionBupropion

AntihypertensivesAntihypertensives ClonidineClonidine Guanfacine Guanfacine

Wilens T, et al. ADHD, In Annual Review of Medicine, 2002: 53Greenhill 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 UsedPharmacological Agents Usedin Treatment of ADHD*in Treatment of ADHD*

* Not all agents are available in some countries

ADHD Pharmacotherapy – ADHD Pharmacotherapy – ResponsivenessResponsiveness

0 10080604020% Responders

Methylphenidate

Amphetamine

PemolineTricyclic

antidepressantsBupropion

MAOIClonidine/

Guanfacine

Wilens TE, Spencer TJ. Presented at Massachusetts General Hospital’s Child and Adolescent Psychopharmacology Meeting, March 10-12, 2000, Boston, MA