ADHDStephanie Stockburger, MD FAAPAssistant ProfessorAdolescent Medicine ClinicUniversity of Kentucky

Objectives1. Review Diagnostic Criteria of

ADHD2. Summarize ADHD Evaluation3. Describe Current ADHD

Treatment

ADHD: PrevalenceAffects 2-18% of children

◦Depends on diagnostic criteria and population studied

◦CDC: 9.5% of children ages 4-17 years affected

◦Affects 8-10% of school aged children One of the most common disorders of childhood

◦More common in males than females Predominantly hyperactive 4:1 (males:females) Predominantly inattentive 2:1 (males:females)

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_wADHD in children and adolescents. Epidemiology and pathogenesis. www.uptodate.com

State-based Prevalence Data of ADHD Diagnosis

Percent of Youth 4-17 ever Diagnosed with Attention-Deficit/Hyperactivity Disorder by state: National Survey of Children's Health, 2007

http://www.cdc.gov/ncbddd/adhd/prevalence.html

Comorbid DisordersChildren and Adolescents with ADHD

frequently have comorbid psychiatric disorders◦Oppositional Defiant Disorder (ODD)◦Conduct Disorder ◦Depression◦Anxiety Disorder◦Learning disabilities

May be primary or secondary (exacerbated by ADHD)

http://www.cdc.gov/ncbddd/adhd/workshops/outcomes.html

Diagnosed Attention Deficit Hyperactivity Disorder and Learning Disability: United States, 2004-2006 http://www.cdc.gov/ncbddd/adhd/data.html

Pathogenesis: What causes ADHD?Not definitely known.Genetic imbalance of catecholamine

metabolism in the cerebral cortex (illustrated by structural and functional brain imaging, animal studies, and the response to drugs with noradrenergic activity like methylphenidate)

Twin studies: concordance as high as 92 percent in monozygotic twins and 32 percent in dizygotic twins

Number of genes appear to play a role.

Biederman, Faraone. Attention-deficit hyperactivity disorder. The Lancet. Volume 366, Issue 9481, 16–22 July 2005, Pages 237–248.

Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013.

Brain ChangesChildren with ADHD have differences in

brain structuresChanges especially noted in anterior

brain areas◦Smaller prefrontal cortical volumes ◦Reduced thickness of the anterior cingulate

cortex◦Cortical thinning in bilateral superior frontal

brain regionsFrontal cortex monitors impulse control! Attention-deficit hyperactivity disorder. J Biederman, S.V. Faraone. The Lancet. Volume 366, Issue 9481, 16–22 July 2005, Pages 237–248.

Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013 .

Cortical abnormalities in children and adolescents with attention-deficit hyperactivity disorder. E.R. Sowell, P.M. Thompson, S.E. Welcome, A.L. Henkenius, A.W. Toga, B.S. Peterson. The Lancet. Vol 362. 2013.

What do the brain changes mean?Neuropsychologic testing suggests

that patients with ADHD have:◦ Impaired executive functions (processes

involved in forward planning, including abstract reasoning, mental flexibility, working memory)

◦And/or difficulties with response inhibition

This goes along with the parts of the brain that are affected!

Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013.

Impact of Executive Function Deficits and Attention-Deficit/Hyperactivity Disorder (ADHD) on Academic Outcomes in Children. Biederman J, Monuteaux MC, Doyle AE, Seidman LJ, Wilens TE, Ferrero F, et al. Journal of Consulting and Clinical Psychology. Vol 72, No. 5;2004, 757-66.

Neurotransmitter ChangesChildren and Adolescents with

ADHD have an increase in dopamine transporter density◦This may clear dopamine from the

synapse too quickly

Methylphenidate increases extracellular dopamine in the brain (why the medication helps!)

Progress and Promise of Attention-Deficit Hyperactivity Disorder Pharmacogenetics. Froehlich TE, McGough JJ, Stein MA. CNS Drugs. 2010 February;24(2):99-117.

Environmental FactorsDietary influences (controversial)

◦Food additives (artificial colors, artificial flavors, preservatives)

◦Refined sugar intake◦Food sensitivity (allergy or intolerance)◦Essential fatty acid deficiency◦Iron and zinc deficiency

Prenatal exposure to tobacco Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013.

The Diet Factor in Attention-Deficit/Hyperactivity Disorder. Millichap and Yee. Pediatrics 2012;129:330-7.

ADHD: DiagnosisADHD is characterized by a pattern of

behavior, (several symptoms)* present in multiple settings (e.g., school and home), that can result in performance issues in social, education, or work settings.

Two subtypes:◦ Hyperactivity and Impulsivity◦ Inattention

DSM 5 Diagnostic Criteria*change from DSM IV. “Several symptoms”

instead of “impairment.” www.cdc.gov/ncbddd/adhd/diagnosis.html

ADHD: DiagnosisChildren must have at least six

symptoms from the subtypeOlder adolescents and adults (over

17) must have five.Symptoms must be present before

age 12 years*

*change from DSM IV. Previously before age 6.

www.cdc.gov/ncbddd/adhd/diagnosis.html

ADHD: DiagnosisSymptoms interfere with, or reduce

the quality of, social, school, or work functioning

Symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

Symptoms are not better explained by another mental disorder (mood d/o, anxiety d/o, dissociative d/o, or personality d/o)

www.cdc.gov/ncbddd/adhd/diagnosis.html

Diagnostic Criteria: HyperactivityHyperactivity-Impulsivity subtype (children

must have 6, over age 17 must have 5)◦ Hyperactivity

Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or in other situations in

which remaining seated is expected Often runs about or climbs excessively in situations in

which it is inappropriate (in adolescents or adults, may be limited to feelings of restlessness)

Often has difficulty playing or engaging in leisure activities quietly

Is often “on the go” or often acts as if “driven by a motor”

Often talks excessively www.cdc.gov/ncbddd/adhd/diagnosis.html

Diagnostic Criteria: ImpulsivityImpulsivity

◦Often blurts out answers before questions have been completed

◦Often has difficulty awaiting turn◦Often interrupts or intrudes on

others (eg, butts into conversations or games)

www.cdc.gov/ncbddd/adhd/diagnosis.html

Diagnostic Criteria: Inattention (children must have 6; over age 17 must have 5)

Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

Often has difficulty sustaining attention in tasks or play activities Often does no seem to listen when spoken to directly Often does not follow through on instructions and fails to finish

schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that

require sustained mental effort (such as schoolwork or homework) Often loses things necessary for tasks or activities (eg, toys, school

assignments, pencils, books, keys, paperwork, cell phones, eyeglasses or tools)

Is often easily distracted by extraneous stimuli Is often forgetful in daily activities www.cdc.gov/ncbddd/adhd/diagnosis.html

Differential DiagnosisDevelopmental variations

◦ Gifted, intellectual disabilityNeurologic or developmental conditions

◦ Learning disability, language or communication disorder, autism

Emotional and behavior disorders◦ Anxiety, ODD, OCD, PTSD

Psychosocial and environmental factors◦ Maternal depression, stressful home environment

Medical conditions◦ Lead poisoning, thyroid abnormality, hearing or

vision impairment, sleep disorders

TreatmentPreschool children (ages 4-5)

◦Initially: behavioral therapy◦If behaviors do not improve consider

medication.◦Methylphenidate is treatment

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. Volume 128, Number 5, November 2011.

TreatmentSchool-aged children (age 6 and

older) and adolescents◦ Initial treatment with behavioral therapy

combined with stimulant medication.◦Non-stimulants may be appropriate for

certain children◦Co-morbid conditions must be considered

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. Volume 128, Number 5, November 2011.

MedicationLong and short-acting stimulantsShort acting: Focalin, Methylphenidate,

Ritalin, Adderall

Long acting: Focalin XR, Concerta, Adderall XR, Vyvanse, Daytrana patch

Non-stimulant: Atomoxetine (Strattera), Clonidine, Guanfacine (Intuniv, Tenex), Wellbutrin (unlabeled use)

MedicationsShort acting medications must be

taken 2-3 times per dayLong-acting medications taken in

the morningPeak at 30-40 minutesDelayed peak if taken with high

fat meal

Medication Side EffectsDecreased appetitePoor growthCardiovascularDizzinessInsomnia/nightmaresMood labilityReboundTicsPsychosisDiversion and misuse

Medication MythsAt therapeutic doses,

medications do not sedate or tranquilize children

Medications do not increase the risk of addiction if taken as directed

Stimulants are not ‘gateway’ drugs leading to illegal drug or alcohol abuse

Medication DangersMedication does have abuse

potentialStimulant medications are

controlled substancesWhen doctors prescribe

stimulants, a Kasper report must be run every 90 days

Prognosis for children and adolescents with ADHDgreater risk for incurring intentional

and unintentional injury 2-4x more likely to have a motor

vehicle accidentImpaired academic functioning

(completion of less schooling, lower achievement scores, failure of more courses)

Increased risk of substance use if also with conduct or antisocial disorders

ADHD in Adolescence: Impulsive behaviorMay have more difficulty than

other teens in regulating their impulses

May act first and think later-but stakes are higher than when younger child

Substance abuse, aggressive behavior, unprotected sex, reckless driving or other high-risk situations

healthychildren.org

ADHD in AdolescenceMinor impulsive behavior like

interrupting others and fidgeting at desk may cause academic or social problems.

More ‘mature’ behavior may be expected

Work with adolescent on ways to minimize potentially damaging effects of this behavior

healthychildren.org

ADHD in Adolescence: Overall ProblemsDifficulty focusing and organizingProblems with long-term planningLow self-esteemIndependence issues

healthychildren.org

Persistance into Adulthood?1/3 to 2/3 continue to manifest ADHD

symptoms into adult lifeOne study found lower status jobs Increased risk to develop antisocial

personality disorder in adulthoodBy developing strengths and

structuring environment, adults with ADHD can lead very productive lives!

In some careers having high-energy behavior is an asset!

healthychildren.org

Daily LifeCommunication Style with a child

with ADHD:◦Pause to get attention◦Maintain eye contact◦Have child repeat back or explain what

you have said to make sure they understand

◦Avoid interrupting frequently as child may not be able to stay engaged

◦ If attention is wandering, take their hand, touch arm or make other physical contact

healthychildren.org

Effective Discipline (healthychildren.org)

Child's Behavior* Your Responses  

  Effective Constructive

Temper Tantrums Walk away.

Discuss the incident in an age-appropriate manner when child is calm.

Overexcitement Distract with another activity.

Talk about his behavior in an age-appropriate manner when he's calm.

Hitting or biting

Immediately remove him from situation or in anticipation of this behavior.

Discuss consequences of his actions (pain, damage, bad feelings) to himself and others in an age-appropriate manner. Try one-word time-out after brief response.

Not paying attention

Establish eye contact to hold his attention.

Make sure your expectations are age-appropriate for your child's developmental level (ask him to listen to a story for three minutes instead of ten; don't insist he sit through a full church service).

Refuses to pick up toys

Don't let him play until he does his job.

Show him how to do the task and help him with it; praise him when he finishes.

HCPROD

Effective DisciplineDiscipline means teaching self-

control.It is important to respond

immediately and consistently.Do not spank or slap your child,

may contribute to negative self-image and resentment. Teaches the child to hit when angry.

healthychildren.org

The Classroom- Structure is Key!Children with ADHD make

significantly better progress when classroom is structured

Clear rules and limitsImmediate, appropriate

enforcement, predictable routinesDesks facing forward Small class size healthychildren.org

Ideal Teacher

Engaging, fun, interesting, and exciting

Structure, but can also be flexibleAble and willing to use multiple

approaches to teaching

healthychildren.org

Good Habits for Academic SuccessUse a daily planner or handheld computerUse a backpack as the location for all schoolwork

and suppliesOrganize an assigned lockerMake lists of tasks to be accomplished, ideas for

an essay, people to call about a projectUse an outline or flowchart format to take notesPreviewBreak up large tasks into a series of small stepsSet aside a routine time and lace for doing

homework healthychildren.org

Closing the Gap between School and HomeDaily Report Cards and JournalHave meeting and agree upon

measureable goalsTeacher to check off items and send home

dailyRecord detailed observations or requests

in a journalParent to provide home-based incentivesIf parent and teacher disagree, may need

to involve principal, counselor, pediatrician, or therapist

Comprehensive Treatment for Attention Deficit Disorder (CTADD) Web Site

ADHD and HomeworkAll children work differentlySome need quiet and isolated timeOthers do better with some action, like at

the kitchen table with the radio playingMake sure child has brought home

homework and has all necessary materials

May need help checking over work and putting in folder to make sure it gets turned in

healthychildren.org

Daily Routines Success of rules and strategies in

home is influenced by the quality of the relationship that the parent has with child/teen◦Keep child on daily schedule

Time of waking up, eating, bathing, leaving for school, going to sleep same each day

Give warnings for event or activity Give 15, 10, 5 minute warnings for

changes in activity healthychildren.org

Daily RoutinesCut down on distractionsDevelop a homework plan with your child

◦Create homework space, stock with supplies◦Homework incentive chart with rewards◦Second set of schoolbooks at home◦Divide homework into small working parts

with breaks◦Use special timers to keep on track◦Share homework detail with other family

members◦Have spot near door to keep backpack

healthychildren.org

Daily RoutinesOrganize your house

◦Less likely to lose items if put in designated place

◦Develop ‘house rules,’ monitor daily, reward for compliance

◦Provide a safe space in the home for active play

healthychildren.org

Daily RoutinesUse charts and checklists

◦Friendly reminders: checklists of things to take to school each day and bring home

◦Post on morning exit door◦Focus on effort child made to do

work and chores, not just completion of task

healthychildren.org

Daily RoutinesLimit choices

◦ Give only 2-3 options at a time◦ Foster ‘best outcomes’ by creating and

encouraging a sense of resiliency and participation

◦ Validate positive plans, even if you feel some things should be done differently

◦ Express empathy for concerns and problems◦ Include teen in decision-making process and

problem-solving issues◦ Encourage involvement in family activity

planning and outings◦ Provide sincere praise, even for the small things

healthychildren.org

Daily RoutinesSet small, reachable goals

◦Aim for step-by-step progress◦Succeed by taking small steps◦Keep plan child-centered!

healthychildren.org

Cognitive Behavioral ApproachEspecially helpful if coexisting

disorders (ODD, CD, mood, anxiety disorders)

Aggressive behavior, poor tolerance for frustration, inflexibility, poor problem solving skills

Significant family conflict

healthychildren.org

Collaborative Problem-Solving approachDeveloped by Dr. Ross GreeneHelps adults and children become proficient

at resolving problems collaborativelyDefuses conflict and teaches kids cognitive

skills they may lack3 options for problem solving:

◦1. imposition of adult will (unilateral problem solving)

◦2. collaborative problem-solving◦3. deferring resolution of the problem, at least

for now healthychildren.org

Cognitive Behavioral Approach, continuedAdults are helped to master the

‘ingredients’ involved in solving problems collaboratively◦1. achieving clearest possible

understanding of child’s concern◦2. entering the adult’s concern or

perspective◦3. brainstorming solutions that are

realistic and mutually satisfactory

◦ www.livesinthebalance.org

College Support ServicesSpecial orientation programsSpecialized academic advisors or

counselorsPriority schedulingReduced course loadsPrivate dorm roomMath labs, writing workshops,

computer labs, and reading courses

healthychildren.org

College Support ServicesSpecialized tutoringA ‘personal coach’Classroom technologyAcademic aidesSpecial testing arrangementsAdvocates

healthychildren.org

Myths and Misconceptions“My preschooler is too young to have

ADHD”“He’s just lazy and unmotivated”“He’s a handful- or, she’s a daydreamer-

but that’s normal. They just don’t let kids be kids these days.”

“Treatment for ADHD will cure it. The goal is to get off medication as soon as possible.”

“He focuses on his video games for hours. He can’t have ADHD”

healthychildren.org

Resources 1. CDC – ADHD, Data and Statistics. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 9/23/2013. 2. CDC-ADHD, Symptoms and Diagnosis. http://www.cdc.gov/ncbddd/adhd/diagnosis.html. Accessed 9/23/2013. 3. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of

Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. Volume 128, Number 5, November 2011.

4. Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children --- United States, 2003 and 2007. Weekly. November 12, 2010 / 59(44);1439-1443

5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w. Accessed 9/23/13. 6. Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis.

Uptodate.com Accessed 6/5/2013. 7. ADHD Long-term Outcomes: Comorbidity, Secondary Conditions, and Health Risk Behaviors. CDC.

http://www.cdc.gov/ncbddd/adhd/workshops/outcomes.html. Accessed 9/23/13. 8. Biederman, Faraone. Attention-deficit hyperactivity disorder. The Lancet. Volume 366, Issue 9481, 16–22 July

2005, Pages 237–248. 9. Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications.

www.uptodate.com. Accessed 6/5/2013. 10. Healthychildren.org. Multiple articles about ADHD. Accessed 7/1/2013. 11. Age, Academic Performance, and Stimulant Prescribing for ADHD: A Nationwide Cohort Study. Zoega,

Valdimarsdottir, Hernandez-Diaz. Pediatrics. 2012;130. 12. Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation.

www.uptodate.com. Accessed 6/5/2013. 13. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis.

www.uptodate.com. Accessed 6/5/2013. 14. The Diet Factor in Attention-Deficit/Hyperactivity Disorder. Millichap and Yee. Pediatrics 2012;129:330-7. 15. Cortical abnormalities in children and adolescents with attention-deficit hyperactivity disorder. E.R. Sowell,

P.M. Thompson, S.E. Welcome, A.L. Henkenius, A.W. Toga, B.S. Peterson. The Lancet. Vol 362. 2013. 16. Impact of Executive Function Deficits and Attention-Deficit/Hyperactivity Disorder (ADHD) on Academic

Outcomes in Children. Biederman J, Monuteaux MC, Doyle AE, Seidman LJ, Wilens TE, Ferrero F, et al. Journal of Consulting and Clinical Psychology. Vol 72, No. 5;2004, 757-66.

17. Progress and Promise of Attention-Deficit Hyperactivity Disorder Pharmacogenetics. Froehlich TE, McGough JJ, Stein MA. CNS Drugs. 2010 February;24(2):99-117.