1、Attention-Deficit Hyperactivity Disorder,Melissa Stern, M.S. mksternphhp.ufl.edu,A Day in the life of.,Attention-Deficit/Hyperactivity Disorder,ADHD is a neurodevelopmental disorder of childhood that is characterized by developmentally inappropriate levels of: Hyperactivity Impulsivity Inattention,A
2、DHD: Prevalence,3-9% of the elementary school population more often in males than females, with the sex ratio being about 3:1 to 9:1 most common disorders of childhood accounting for a large number of referrals to pediatricians, family physicians and child mental health professionals,ADHD Risk Facto
3、rs,Maternal cigarette use Maternal alcohol use Unusually long or short labor Forceps delivery Toxemia Meconium staining Birth during the month of September Minor physical anomalies,History of ADHD,Characteristics of this disorder have been recognized for at least a century The disorder has been refe
4、rred to by a variety of labels: Minimal Brain Dysfunction (MBD)Hyperkinetic Reaction of ChildhoodAttention Deficit Disorder (ADD)Attention Deficit Hyperactivity Disorder (ADHD),History of ADHD,Characteristics of this disorder have been recognized for at least a century The disorder has been referred
5、 to by a variety of labels: Minimal Brain Dysfunction (MBD)Hyperkinetic Reaction of ChildhoodAttention Deficit Disorder (ADD)Attention Deficit Hyperactivity Disorder (ADHD),History of ADHD,1980s: DSM III & DSM III-R stimulates ADHD research development of new assessment methods new treatment methods
6、 increased focus on biological factors. 1990s: Neuroimaging genetics reevaluation of DSM,DSM-IV: Hyperactivity,Often fidgets with hands or feet, 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 situa
7、tions in which it is inappropriate Often has difficulty playing or engaging in leisure activities quietly,DSM-IV Hyperactivity,Is often “on the go“ or often acts as if “driven by a motor”Often talks excessively when inappropriate to the situation6 or more of hyperactive and/or impulsive symptoms req
8、uired for diagnosis,More on Hyperactivity,Children with ADHD are more active, restless, and fidgety than normal children during the day and during sleep There are different types of hyperactivity: Gross Motor Activity Restless/Squirmy Verbal hyperactivity Hyperactivity often varies according to situ
9、ation Degree of hyperactivity may vary with age,DSM-IV: Impulsivity,Often blurts out answers before questions have been completed Often has difficulty awaiting turn Often interrupts or intrudes on othersSix symptoms of hyperactivity and impulsivity are required for diagnosis,DSM-IV: Inattention,Ofte
10、n fails to give close attention to details or makes careless mistakes Often has difficulties sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish homework, chores, or duties in the wor
11、kplace,DSM-IV: Inattention,Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Often loses things necessary for tasks or activities Is often easily distracted by extraneous stimuli. Is often forgetful in
12、 daily activities 6 or more symptoms needed for diagnosis,More on Inattention,“Attentional“ problems may be most obvious on specific types of attentional tasks: sustained attention: responding to tasks, being vigilant situations requiring the child to attend over time to dull, boring, and repetitive
13、 tasks,Diagnostic Criteria Overview,Symptom Criteria - Core Symptoms of Hyperactivity & Impulsivity and/or Inattention (Six or More Symptoms of either category) Duration Criterion - Symptoms have Persisted for at Least 6 Months Developmental Criterion - Symptoms are Inconsistent with Developmental L
14、evel Impairment Criterion - Clear Evidence of Clinically Significant Impairment in Social, Academic, or Occupational Functioning,Diagnostic Criteria,Age Criterion - Some Symptoms that Cause Impairment Were Present Before Age 7 Situation Criterion - Some Impairment from Symptoms is Present in Two or
15、More Settings,Types of ADHD,Combined Type Symptoms of hyperactivity, impulsivity and inattention Hyperactive/Impulsive Type Symptoms of hyperactivity and impulsivity Predominately Inattentive Type Symptoms of inattention,Impairment in ADHD,Social Impairment What does it look like? Academic Impairmen
16、t Long term outcomes for children with ADHD not so good Family Impairment Occupational Impairment Driving Impairment,ADHD Across the Lifespan,ADHD is a chronic disorder 60%-80% of children continue to meet diagnostic criteria in Adolescence 50%-70% of children will continue to meet diagnostic criter
17、ia in AdulthoodADHD in childhood is different from adolescence and different from adulthood,Presentation of ADHD in Adolescence,Gross motor activity tends to disappear Predominance of Inattention, Restlessness (rather than hyperactivity) and impulsivity What is a developmentally appropriate level of
18、 impulsivity in adolescence?,ADHD in Adults,More similar to adolescent presentation Mainly problems with inattention and impulsivity How much inattention and impulsivity affect an adult male? A father? A store clerk?Impairment is key,Occupational Impairment,Similar problems to those seen in the acad
19、emic environment Often unprepared, untimely, easily distracted “Under Achievers”,Social Impairment,Still there in adolescence and adulthood! If you dont attend when people talk, they often think you arent interested,Sensation Seeking/Substance Use,Adolescents and adults with ADHD are more likely tha
20、n those with out to engage in risky behavior including: Marijuana use Alcohol Use Drunk DrivingThis is true even when accounting for the presence of oppositional defiant disorder and/or conduct disorder,Driving impairment,Leading cause of death in 15-24 year olds are motor vehicle accidents Adolesce
21、nts and adults with ADHD are more likely to have an accident, to have more accidents, to speed, to receive traffic citations, to receive more traffic citations, to have their licenses suspended/revoked, to drive without a license, to drive under the influence,Driving Impairment,One of the most commo
22、n causes of MVAs is plain old inattention Adolescents in particularl are more likely to speed, to not use a seatbelt, and to drink and driveHmm.what does this mean for people with ADHD,Virtual Reality,Researchers are using virtual reality to simulate driving situations and assess performance Here at
23、 UF we have a high tech simulatorhttp:/driving.phhp.ufl.edu/,Shameless Plug,Driving Impairment in ADHD is my area of research I am going to need an RA or two to help with my dissertation starting in the Spring or next fall If you are a sophomore or junior and are interested in getting into research,
24、 EMAIL ME! mksternphhp.ufl.edu,But What About Cognitive Impairment,Its a NEUROdevelopmental disorder, right? So why hasnt this lady mentioned cognitive problems?,ADHD & Neuropsychological Deficits,Results from research involving neuropsychological testing has often suggested that children with ADHD
25、have problems: inhibiting behavioral responseswith working memorywith planning and organizationwith verbal fluencywith perserverationin motor sequencingwith other frontal lobe functions,Neurological Findings,Siblings of children with ADHD who do not have ADHD, have milder yet significant impairments
26、 in executive functions This suggests a possible genetic risk for executive function deficits in families,Other Neurological Findings,Differences in cerebral blood flow Differences in cerebral metabolism Differences in the corpus collosum,Neurotransmitter Deficits,Neurotransmitter dysfunction in chi
27、ldren with ADHD has been suggested for many years Originated from observations of the response of children with ADHD to different type of stimulant drugs The fact that stimulant drugs have an impact on ADHD and that they increase dopamine has contributed to the neurotransmitter dysfunction hypothesi
28、s,Comorbidity & ADHD,Why is it essential to consider the possibility of comorbid conditions in assessing children with ADHD? Importance of distinguishing between comorbid conditions and mimicry What is the frequency of comorbidities in children with ADHD?,Comorbidities,Learning Disabilities - 19 to
29、26% Oppositional Defiant Disorder - 40% Conduct Disorder - 25% children; 45-50% adolescents Anxiety Disorders - 30% Depressive Disorder - 10 - 30% Bipolar Disorder up to 20% Tics and Tourettes Disorder 7% of children with ADHD have a tic disorder 40 to 50% of those with Tourettes disorder have ADHD,
30、Onto Assessment and Diagnosis!,American Academy of Pediatrics Guidelines,Only governing organization with guidelines for ADHD assessment Designed for pediatricians Move toward guidelines in APA,The Interview,Structured or semi-structured Gold Standard is “The Barkley” Parent and Self-Report versions
31、 Mostly used in research Goal is to assess for the three main symptom areas and evidence of impairment which meets DSM criteria,Behavioral Observations,This isnt technically recommended by AAP However, if a child is literally climbing the walls, it might be good to note that Always remember that chi
32、ldren may be inclined to be on their “best behavior” in new situations Coding systems available for looking at hyperactive and inattentive behaviors,Parent-Report Rating Scales,Shorter measures which ask parents about frequency, severity, etc. of various behaviors Recommended by AAP but not required
33、 Conners Parent Rating scale the “Gold Standard” form Assesses various aspects of inattention, hyperactivity, impulsivity,CPRS,Items are rated on a four-point scale from “Not at all true” to “Very much true” 87 questions Each question is part of one or more subscales The parents rating on a given qu
34、estion corresponds to a number 0-3 You sum the numbers for that scale You plot subscale sums on the profile chart Scores in the red area are indicative of greater problems,Parent-Report “Broadband” Measure,Broadband measures assess a wide array of social, emotional, and behavioral problems They are
35、not recommended for AAP for ADHD diagnosis However, they are USEFUL for identifying comorbid areas of concern (aggression/conduct problems, depression),Teacher Reports,These are essential in assessing for ADHD Need to identify impairment in MULTIPLE SETTINGS Most children with ADHD will have academi
36、c impairment Teachers may have the best knowledge of “developmentally appropriate” levels because they work with so many children,Teacher Reports,There is a teacher version of the CPRS, called the Conners Teacher Rating Scale (CTRS) Modified for the classroom setting but scored the same way There ar
37、e also teacher equivalents of broadband measures,Problems with Parent and Teacher Report,Always the issue of informant bias (wanting to look like a good parent, like a teacher who can “handle” kids) Sometimes difficult to get in contact with teachers and they often dont return forms CPRS and BASC ma
38、y be biased towards non-European-American Children,Detour: Multicultural Issues in ADHD,ADHD is not limited to the U.S. It is seen cross-culturally However, there is concern it is over-diagnosed in Low SES and minority children Compared to parents of Caucasian children, parents of African-American a
39、nd Hispanic children have reported significantly more often feeling as though their children are over-diagnosed and over-medicated,Detour: Multicultural Issues In ADHD,Parents of African-American children less likely to associate school problems with ADHD and are less likely to request behavioral in
40、terventions compared to parents of Caucasian children Parents of African-American children more likely to report not knowing the etiology of ADHD and where to go to receive treatment for the disorder compared to parents of Caucasian children,Detour: Multicultural Issues In ADHD,In studies looking at
41、 cross-cultural validity of several ADHD assessments, found that parents of African-American children had significantly higher scores compared to parents of Caucasian children. Similar findings for teacher ratings Unclear as to whether this is due to informant biases, cultural biases of the measure,
42、 or actual ethnic differences This continues to be an area needing research,Detour: Multicultural Issues In ADHD,What we do know: African-American Children respond equally well to medication treatment compared to Caucasian children Generally no differences in doses of medication Multimodal treatment
43、 superiority effect for minority children (we will get back to this in a moment),Cognitive Measures,Not recommended for use in diagnosis Most evaluators use them in combination with many other measures. These are lab measures that directly assess impulsivity, inattention, and executive function,The
44、CPT,Measures attention and impulsivity Various ways to administer it, but here we use the “everything but X paradigm”Lets see what this looks like,TREATMENT ADHD treatment,Treatment of ADHD,Stimulant Medications Other Medications Psychosocial Treatments Educational Accommodations,Stimulant Medicatio
45、ns,Ritalin Dexadrine Adderall Concerta 70-80 % of children with ADHD respond well to stimulant drugs Stimulant drugs represent an empirically supported treatment for core symptoms of ADHD Stimulants are a trial and error method,Stimulant Side Effects,loss of appetite, weight loss, sleeping problems,
46、 irritability restlessness, stomachache, headache, rapid heart rate, elevated blood pressure, sudden deterioration of behavior symptoms of depression with sadness, crying, and withdrawn behavior intensification of tics (muscle twitches of the face and other parts of the body), possible Tourettes, an
47、d growth suppression Long term effects?,Stimulant Side Effects,Side effects are often: transient in nature result of inappropriate medication levels If one medication results in side effects, another might be used without side effects Other medications are used to minimize side effects Good clinical
48、 judgment by the clinician may help to minimize side effects,Non-stimulant Medications,Non-Stimulant ADHD Medication Straterra - a norepinephrine reuptake inhibitor- selectively blocks the reuptake of norepinephrine, which increases its availability Other Non Stimulant Drugs Anti-depressants (e.g.,
49、Tofranil, Wellbutrin) Anti-hypertensives (Clonidine),Psychosocial Treatments,Parent Training Social Skills Training Cognitive Behavioral Treatments Psychotherapy for comorbid conditions,NEED FOR MULTIMODAL TREATMENT!,Educational Interventions,Special Education Services for existing learning problems
50、 Classroom accommodations Classroom behavior modification programs 504 Plan,The Daily Report Card,Specific set of behaviors relevant to the specific child Everyday teacher marks how the child did on these behaviors Child is rewarded (or not) based on performance at school Integrates the classroom and home,
