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Recent Findings in Neurobiology, Clinical Manifestations and Diagnosis
MA. ROCHELLE BUENAVISTA - PACIFICO, MD, FPPS, FPSDBP
Philippine Society for Developmental and Behavioral Pediatrics 9th Biennial ConventionNovotel, Quezon City, September 5, 2017
DIVERSITY IN ADHD
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A brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that is inconsistent with a child’s
level of development. • are more severe• occur more often• interfere with or reduce the quality of how
they functions socially, at school, or in a job
National Institute of Mental Health
ATTENTION DEFICIT / HYPERACTIVITY DISORDER
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Evolution of nomenclature used to describe ADHD
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Prevalence of ADHD in children and adolescents by geographical location (n=102 studies)
Polanczyk G, de Lima MS, Horta BL, et al. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 2007; 164: 942-948.
Worldwide estimates = 5 – 7%MRBPacifico_05SEP2017
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Philippine Estimates of AD/HD Prevalence
Prevalence: 3 - 5%
Population: 103.3 M
AD/HD: 3-5.1 M
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0
2
4
6
8
10
12
2003 2007 2011
Maternal and Child Health Bureau and the National Center for Health Statistics of the U.S. Centers for Disease Control and Prevention in a National Children's Survey from 2003-2011
Prevalence rates of ADHD Diagnosis among children and adolescents aged 4 to 17 years
55% increase in diagnosis among girls from 2003 to 2011
M:F ( 4:1)
52% increase among adolescents
50% increase among younger children
%
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"Mild" ADHD diagnosed at 7 years,
"Moderate" ADHD diagnosed at 6.1 years
"Severe" ADHD diagnosed at 4.4 years.
The more severe the symptoms, the younger they are identified and the earlier intervention can be started
Thomas, Rae et al. (April 2015). Prevalence of Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis. Pediatrics, 135(4), pp. e994–e1001.
Pastor, Pastor N. et al. (2015). Association between diagnosed ADHD and selected characteristics among children aged 4–17 years: United States, 2011–2013. NCHS data brief, no 201. Hyattsville, MD: National Center for Health Statistics.MRBPacifico_05SEP2017
Average age of diagnosis = 6.2 yrs old
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ETIOLOGY
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EPIGENETIC BASIS OF ADHD
ADHD
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EPIGENETIC BASIS OF ADHD
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Screens and ADHD ….Overstimulation hypothesis :
Christakis D. Rethinking ADHD. JAMA Pediatrics.2016; 170(2):109-110MRBPacifico_05SEP2017
Overstimulating the brain in the first years of life will condition it to expect high levels of input leading to shorter attention spans later
”I’m bored!”
“aren’t youalways?!”
TOYS
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Attentional and Self-regulatory Problems from early screen exposure:
10% increase for every hour of television viewing per day in children < 3 yrs old
Further increase with fast-paced videos
110% increase if violent games
Christakis D. Rethinking ADHD. JAMA Pediatrics.2016; 170(2):109-110Zimmerman etal. Association between content type of early media exposure and
subsequent attentional problems. Pediatrics, 2007. 120(5) MRBPacifico_05SEP2017
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Children who can’t pay ATTENTION
can’t LEARN!
Christakis 2004, Small 2008 as cited in Rowan, 2015MRBPacifico_05SEP2017
“High speed media content can contribute to ATTENTION
DEFICIT, as well as decreased concentration and memory, due
to the brain pruning neuronal tracks to the frontal cortex."
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How Neurotransmission Workshttps://www.youtube.com/watch?v=p5zFgT4aofA
Neurobiology OF ADHD
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Basal ganglia (putamen, nucleus accumbens)
Cerebellum
Frontal Lobe
Amygdala
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NEUROBIOLOGY OF ADHD
Hippocampus
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Basal ganglia (putamen, nucleus accumbens)Frontal Lobe
NEUROBIOLOGY OF ADHD
Hoogman M, et al. Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis. Lancet Psychiatry. Feb. 15, 2017,
Shaw P, etal. Development of cortical surfaces and gyrification in AD/HD.. Biological Psychiatry, 2012
“HOW”
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Basal ganglia (putamen, nucleus accumbens)
Cerebellum(vermis)
Frontal Lobe
NEUROBIOLOGY OF ADHD
Hoogman M, et al. Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis. Lancet Psychiatry. Feb. 15, 2017,
Shaw P, etal. Development of cortical surfaces and gyrification in AD/HD.. Biological Psychiatry, 2012
“WHEN”
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Frontal Lobe
Amygdala
NEUROBIOLOGY OF ADHD
Hoogman M, et al. Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis. Lancet Psychiatry. Feb. 15, 2017,
Shaw P, etal. Development of cortical surfaces and gyrification in AD/HD.. Biological Psychiatry, 2012
Hippocampus
“WHY”
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*Lighter colored areas indicate peak
cortical maturation
FrontalLobe
Brain Imaging Studies comparing maturation of Frontal Lobes of Individuals with and without ADHD
Courtesy of ADHD Institute MRBPacifico_05SEP2017
NEUROBIOLOGY OF ADHD
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> Frontal Lobe size reduction> Temporal lobe size reduction> Decreased activity in both
MRI Differences between ADHD and Control brains
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NEUROBIOLOGY OF ADHD
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MRI Studies show less blood flow in regions of the brain while working on a task in individuals with ADHD vs. Non-ADHD
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NEUROBIOLOGY OF ADHD
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DIAGNOSIS and
CLASSIFICATION
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CORE SYMPTOMS OF AD/HD:
(EXECUTIVE FUNCTIONS)2. Hyperactivity 3. Impulsivity
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Emotional Dysregulation
1. Inattentiveness(SELF-REGULATION)
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AD/HD Mimickers
Sudden change in the child’s life (ex: death of a parent, divorce, parent’s job loss)
Undetected seizures Intermittent hearing problems
(ex: middle ear infection)
Other medical disorders that affect brain functioning
Underachievement caused by Learning Disability
Anxiety or depression
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DSM – 5 (American Psychiatric Association)ICD-10( World Health Organization )
Rating scales:• ADHD-RS• Vanderbilt• SNAP-IV• Conners• SKAMP• ACE
Diagnosis and Assessment
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Comprehensive Assessment tools
Neuroimaging Studies (ex: MRI, PET Scans)
Diagnosis and Assessment
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(ex: Intelligence/Mental Development tests, Educational Achievement tests)
Electrometric Tests (ex: EEG)
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Diagnostic and Statistical Manual of Mental Disorders Published by the American
Psychiatric Association Provides standard diagnostic criteria First edition (DSM-1) published in
1952 Most recent edition: DSM-5 (2013)
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• Examples added for almost all criterion items• Age of onset: 12 (7 in DSM-IV)• Subtypes replaced with presentation specifiers
Combined presentationPredominantly inattentive presentationPredominantly hyperactive/impulsive presentation
• Comorbidity with ASD is allowed• Symptom threshold: 5 for adults, 6 for younger persons• Several symptoms (not impairment) present in more
than one settingMRBPacifico_05SEP2017
ADHD: Changes in the DSM-5CHANGES IN THE DSM-5
Examples added especially for adult presentationAge of onset: Before 12 years old (7 years old in DSM-IV)Subtypes replaced with presentation specifiers: Combined presentation Predominantly inattentive presentation Predominantly hyperactive/impulsive presentationComorbidity with ASD is allowedSymptom threshold: 5 for > 17 years, 6 for younger personsSeveral symptoms (not impairment) present in more than one setting
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MRBPacifico_05SEP2017American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. 2013.
DSM – 5 CLASSIFICATION for a DIAGNOSIS OF AD/HD
Before 12 years
At least 6 months
Present in > 2 settings
Impact on social, academic and occupational functioning
Not better accounted for by another mental disorder
Requires indication of severity
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DISTRIBUTION ACCORDING TO AD/HD PRESENTATION
Faraone SV, Biederman J, Weber W, et al. Psychiatric, neuropsychological, and psychosocial features of DSM-IV subtypes of attention-deficit/hyperactivity disorder: results from a clinically
referred sample. J Am Acad Child Adolesc Psychiatry 1998; 37: 185-193.MRBPacifico_05SEP2017
COMBINED
INATTENTIVE
HYPERACTIVE-IMPULSIVE
61%30% 9%
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Prevalence of AD/HD presentations according to age range
Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics 2012; 9: 490-499.MRBPacifico_05SEP2017
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Diagnosed with only AD/HD
Diagnosed with 1 co-morbiddisorder
Diagnosed with 2 co-morbiddisorders
Diagnosed with 3 or moreco-morbid disorders
33%33%
18%16%
N = 5000 children
MedPage TodayMRBPacifico_05SEP2017
Distribution of Children with AD/HD in association with Co-morbid conditions
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Cuffe, S.P., etal. Attention-Deficit/Hyperactivity Disorder and Psychiatric Comorbidity: Functional Outcomes in a School-Based Sample of Children. Journal of Attention Disorders.
Published online before print, November 25, 2015, doi: 10.1177/1087054715613437MRBPacifico_05SEP2017
Percent of children with certain problems, by disorder group
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AD/HD will persist in approximately 50 – 75% of children diagnosed with the
condition
Caye A, etal. Predictors of persistence of ADHD into adulthood: a systematic review of literature and meta-analysis. Eur Child Adolesc Psychiatry. 2016 Nov;25(11):1151-1159.
Predictors of Persistence of ADHD into Adulthood
Severity
Need for treatment
Co-morbid conduct disorders
Co-morbid major depressive disorder
Kessler ,RC et al. Arch Gen Psychiatry 2010; 67:1168-1178
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https://www.ncbi.nlm.nih.gov/pubmed/27021056
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Associated Conditions1.Learning Disabilities ( 30-60%)
a. Dyslexiab. Dyscalculiac. Dysgraphia
2. Problems in Fine Motor Coordination (Dyspraxia) (50%)
3. Externalizing behavior Problems (50-60%)a. Oppositional Defiant Disorderb. Conduct Disorder
4. Internalizing Behavior Disorder (30%)a. Anxiety/Mood disorder
5. Language/Communication Disorder (Dysphasia)6. Tic Disorder7. Nocturnal Enuresis/Encopresis
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Impact of ADHD across the lifespan
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Executive Functions Impaired in ADHD
Executive Functions(Work together in various combinations)
Organizing, prioritizing
and activating to work
Focusing, sustaining
and shifting
attention to tasks
Regulating alertness, sustaining effort, and processing
speed
Utilizing working memory
and accessing
recall
Managing frustration
and modulatingemotions
Monitoring and self-
regulating action
1. Activation
2. Focus
3. Effort
4. Memory
5. Emotion
6. Action
TE Brown (2001) Manual for Attention Deficit Disorder Scales for Children and Adolescents
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Problem Behaviors associated with ADHD compared to those without ADHD
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Perceived negative impact of ADHD on everyday life of children and adolescents
Caci H, et al. Daily life impairments associated with self-reported childhood/adolescent AD/HD and experiences of diagnosis and treatment: results from the European Lifetime Impairment Survey. Eur Psychiatry 2014; 29: 316-323MRBPacifico_05SEP2017
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Harpin V. 2005. The Effect of AD/HD on the Life of an Individual, their Families and Community from Pre-school to Adult life. Arch of Dis in Childhood MRBPacifico_05SEP2017
Developmental Impact of ADHD
PreschoolSchool-age
AdolescentCollege-age
Adult
BehavioralDisturbance
Behavioral DisturbanceAcademic Problems
Difficulty with social interactionSelf esteem issues
Academic ProblemsDifficulty with social interaction
Self esteem issuesLegal Issues, smoking and injury
Academic FailureSelf esteem issuesSubstance abuseInjury, accidents
Occupational difficulties
Self esteem issuesRelationship problems
Substance abuseInjury, accidents
Occupational Failure
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Some Positive AD/HD Traits
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ProductiveMulti-taskResourcefulAchieverAmbitious Broad mindedConceptualizes wellTenaciousTolerantDrivenOptimisticEmpathetic
Some Positive AD/HD Traits
HYPER-FOCUSED
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AdaptiveCollaborativeAdventurous CourageousConfidentEloquent speakersUnconventionalCreativeInnovativeImaginativeVersatileMulti-talented
Some Positive AD/HD Traits
HYPER-FOCUSED
IMPULSIVE UNINHIBITED
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Out goingWittyFunnyExcitingLivelyGood story-tellerAttractive personality CharismaticSociableSpontaneousPragmatic
Some Positive AD/HD Traits
HYPER-FOCUSED
IMPULSIVE UNINHIBITED
ATTENTION-SEEKING
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ADHD
To Conclude:
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