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

thanthan

in 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

0

Oppositionaldefiant

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 answers

Cannot await turnCannot await turn

Interrupts othersInterrupts others

Intrudes 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 class

Runs/climbs Runs/climbs excessivelyexcessively

Cannot play/work Cannot play/work quietlyquietly

Always ‘on the go’Always ‘on the go’

Talks excessively *Talks excessively *

InattentionInattentionDoes not attendDoes not attend

Fails to finish Fails to finish taskstasks

Can’t organiseCan’t organise

Avoids sustained Avoids sustained efforteffort

Loses 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), Used to diagnose hyperkinetic disorder (HKD), a more severe form of ADHDa more 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 ANDAND

at least three symptoms of hyperactivity at least three symptoms of hyperactivity ANDAND at least one symptom of impulsivityat least one symptom 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 antidepressantsantidepressantsBupropionBupropion

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

Pemoline

Tricyclic antidepressants

Bupropion

MAOI

Clonidine/Guanfacine

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