ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Definition:

A neuropsychiatry disorder characterized by

Inattentiveness

Impulsiveness

Hyperactivity

Causing impairment in functioning at home, school, or with peers.

Epidemiology:

Prevalence: 2.5% of children (ADHD)

Incidence: 1-6% of school-age children (ADD/ADHD)

Age of onset: Before age 7

Risk factors:

M > F

Familial

Coexisting conditions

1)      oppositional defiant disorder

2)      conduct disorder

3)      language impairment

4)      anxiety disorder

5)      depression

6)      learning disability

7)      demoralization

8)      encopresis

9)      enuresis

10)  tic disorders (Tourette syndrome)

11)  substance abuse

Differential diagnosis of hyperactivity:

1)      acting out behavior (due to emotional disturbance)

2)      age-appropriate over activity

3)      Attention-Deficit Disorder (ADD)

4)      inadequate environmental parenting

5)      mental retardation

6)      mood disorder

7)      Pervasive Developmental Disorder

8)      primary learning disorder with secondary inattention

9)      specific medical disorders

10)  hearing-impairment

11)  lead toxicity

12)  hyperthyroidism

Clinical features (DSM-III R) (DSM = Diagnostic and Statistical Manual of Mental Disorders.)

A. Inattentiveness

1. Difficulty to carry out instructions – eg in class does not write or do maths

2. Difficulty sustaining attention in tasks or play activities

3. Does not seem to listen to what is being said to them

4. looses things necessary for tasks or activities at school or at home

5. Easily distracted by extraneous stimuli

B. Impulsive

6. difficulty awaiting turn in games or group situations

7. blurts out answers to questions before the question has been completed

8. shifts from one uncompleted activity to another

9. interrupts or intrudes on others, e.g. in games

10. engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill seeking)

C. Hyperactive

11. fidgets with hands or feet or squirms in seat

12. difficulty remaining seated when required to do so

13. difficulty playing quietly

14. talks excessively

Note: must have 8/14 criteria for diagnosis, onset less than 7 years of age, and have symptoms for longer than 6 months

sometimes ADHD presents as part of a triad:

ADHD, Tourette's Syndrome, and oppositional conduct disorder

the symptoms of ADHD and the comorbid conditions may change as the patients age:

1. Hyperactive/Impulsive

1. Preschool

wanders off alone

inappropriate touching and handling objects

trouble staying seated

demands attention

rapidly shifts from one activity to another

sleep problems

resists passive activities

2. Children/Adolescents

Difficult to be sedentary

Fidgety, wound up

Uncomfortable with inactivity

Quick mood shifts

Poor self control

Non-reflective

in the family history look for:

1. Paternal History of:

Childhood history of ADHD

ADHD in partial remission

Substance abuse

Antisocial behavior

Impulse control problems

2. Maternal History of:

Somatization disorder

INVESTIGATIONS:

1. Cognitive Testing

1. Psychometric Testing

1. Ability

Stanford Binet

Wechsler Intelligence Scale for Children-Revised

Wisconsin Card Sort

2. Achievement

Wide Range Achievement Test (WRAT)

Woodcock/Johnson

2. Attention

Conners rating scale

Continuous performance task

Porteus maze

3. Impulsivity

Kagan's matching familiar figure test

4. Attention and Impulsivity

Paired associated learning

Choice reaction time tasks

2. Behavior Rating Scales

Yale Child Checklist

Conners Teacher/Parent R.S.

Child Behaviour Checklist (Teacher/Parent)

3. Imaging Studies

1. Positron Emission Tomography (PET)

Focal hypoperfusion and diminished glucose use in the pre-motor cortex and superior prefrontal cortex

2. CT (Head)

If indicated, i.e., seizures (with EEG)

3. Evoked Potentials

4. Speech and Language Assessment

if indicated, i.e., suspected communication problems

MANAGEMENT:

I. APPROACH

1. Diagnosis

2. Education

3. Goals of Therapy

4. Non-Pharmalogical  Behavioural Modification  Psychotherapy

5. Pharmalogical

            1. Stimulant Medications (long & short acting)

            Methylphenidate (Ritalin)

            Dextroamphetamine (Dexedrine)

            Methamphetamine (Desoxyn)

            Pemoline (Cylert)

            2. Non-Stimulant Medications

            1. Tricyclic Antidepressants

                        Imipramine, Desipramine

            2. Antipsychotic Agents

                        Phenothiazines, Haloperidol, Lithium

            3. Clonidine

1. Diagnosis (Clinical)

information from school, parents, other care-givers, etc.

school records - cognitive test results

teacher report - day-care report

8/14 criteria from DSM-IIIR

secondary causes of hyperactivity ruled out

Behavior is not due to an associated learning disability or other condition (i.e., visual or auditory deficit)

Evidence that hyperactivity is of a cognitive impairment

2. Education

Counseling of parents and teacher

Review diagnosis, epidemiology, and prognosis

A developmental handicap

Chronic in 60% of patients

No treatment but symptoms can be successfully managed

Review management strategies

Non-pharmalogical

Pharmalogical

Importance of follow-up

Remember that ADHD may be associated with significant parental morbidity

Provide information in the form of books, videotapes, handouts, support groups, etc.

3. Goals of Therapy

To improve functioning at home, in school, and with peers through the modification of the inattention, impulsiveness, and hyperactivity

To maximize cognitive functioning and social/behavior skills with minimal side effects

4. Non-Pharmacological Therapy

1. Behavior Modification

Using conditioning therapy, control of the environment and maximizing communication with the patient - mild cases may need behavioural modification only without medical therapy

1. Parent

1. Conditioning Therapy

Immediate positive and negative reinforcement

Increase positive reinforcement for compliance with commands and rules (i.e., attention, praise, privileges)

Decrease but continue to use negative reinforce-meant for non-compliance (i.e., time out, loss of privileges, etc.)

2. Altering the Environment

Decrease stimulants in the home (i.e., a regular study area with very little distractions)

Anticipate settings in which the patient may misbehave

3. Maximizing Communication

Deliver commands more effectively

Give simple instructions

Set time limits for compliance

Reduce length and complexity of work assignments

2. Teacher

1. Conditioning Therapy

As above for parents

2. Altering the Environment

Alter classroom to improve supervision of and feedback to patient (i.e., move patient closer to the teacher and decrease distractions in the classroom)

3. Maximizing Communication

Decrease the length of work assignments

one-student-one-teacher teaching  

use a consistent education plan agreed upon by the parents, teacher, and school personnel - consistent evaluation of school and home work and progress

2. Psychotherapy

Individual or family therapy especially in those patients with associated symptoms, i.e., conduct disorder

5. Pharmacological Therapy- Ritalin, Dextroamphetamine, Pemoline

1. Stimulant Therapy

drugs act to increase certain neurotransmitters (i.e., catecholamines) interacting in certain areas of the brain

common side effects

abdominal pain

appetite suppression

increased anxiety

insomnia

headaches

loss of spontaneity

mood change/irritability

rebound phenomena

picking of fingers

tics

contraindications to use

hypersensitivity reaction

assessment of effects

parent and teacher ratings of cognitive functioning and social/behavioural skills before therapy, during placebo, and while medicated (at different dosages) also noting the degree of side effects

1. Ritalin (short-acting)

starting dose of 0.3 mg/kg/dose orally bid and increasing to a maximum of 0.7 mg/kg/dose if necessary - levels peak 1-2.5 hours postingestion with optimal therapeutic effect within 4 hours and lasting up to 7 hours

effective in 75-80% of patients

may attempt a discontinuation trial annually every spring and/or drug holidays

2. Dextroamphetamine

0.15-0.5 mg/kg/dose po qid

3. Pemoline

0.8-0.9 mg/kg/dose po od

moniter liver function tests as pemoline can cause a hypersensitivity reaction involving the liver

2. Non-Stimulant Therapy

indicated in those cases where stimulant therapy is contra-indicated, ineffective, or cause adverse effects

1. Tricyclic Antidepressants

imipramine or desipramine

add to stimulant therapy if tics become a problem

side effects: arrhythmias (do a baseline ECG), sudden death (desipramine)

70% response rate

2. Antipsychotic Agents

Phenothiazines, Haloperidol, Lithium

3. Clonidine

best to use the patch preparation

improves social/behavioural skills but not cognitive function

Prognosis

60% of children with ADHD are still symptomatic as young adults and thus considered chronic

risks in untreated patients –

increased incidence of:

aggressive behaviour - divorce

anti-social personality disorder –

school drop-out

conduct disorder - substance abuse (59%)

depression –

 thefts

risk factors for non-compliance with medications:

seen in 40-60% of patients

older patient

adolescent girls

oppositional conduct disorder

Some Coping Strategies for Teens with ADHD

When necessary, ask the teacher or boss to repeat instructions rather than guess.

Break large assignments or job tasks into small, simple tasks. Set a deadline for each task and reward yourself as you complete each one.

Each day, make a list of what you need to do. Plan the best order for doing each task. Then make a schedule for doing them. Use a calendar or daily planner to keep yourself on track.

Work in a quiet area. Do one thing at a time. Give yourself short breaks.

Write things you need to remember in a notebook with dividers. Write different kinds of information like assignments, appointments, and phone numbers in different sections.

Keep the book with you all of the time.

Post notes to yourself to help remind yourself of things you need to do. Tape notes on the bathroom mirror, on the refrigerator, in your school locker, or dashboard of your car -- wherever you're likely to need the reminder.

Store similar things together. For example, keep all your text books in one place, and note books in another. Keep uniform in one place, and casual wear in another.

Create a routine. Get yourself ready for school or work at the same time, in the same way, every day.

Exercise, eat a balanced diet and get enough sleep.

INTERNET LINKS:

Attention Deficit Disorder Resources for Adults and Teens

ADD WWW Archive

DSM IV Diagnostic Criteria

Canadian Professionals' ADD Page

Toronto Sick Children's Hospital ADD Page

Books for Parents:

Anderson, W.; Chitwood, S.; and Hayden, D. Negotiating the Special Education Maze: A Guide for Parents and Teachers. 2d ed. Rockville, MD: Woodbine House, 1990.

Bain, L. A Parent's Guide to Attention Deficit Disorders. New York: Dell Publishing, 1991.

Barkley, R. Defiant Children. New York: Guilford Press, 1987.

Child Psychopharmacy Center, University of Wisconsin. Stimulants and Hyperactive Children. Madison: 1990. (Order by calling (608) 263-6171.)

Copeland, E., and Love, V. Attention, Please!: A Comprehensive Guide for Successfully Parenting Children with Attention Disorders and Hyperactivity. Atlanta, GA: SPI Press, 1991.

Fowler, M. Maybe You Know My Kid: A Parent's Guide to Identifying, Understanding, and Helping your Child with ADHD. New York: Birch Lane Press, 1990.

Goldstein, S., and Goldstein, M. Hyperactivity: Why Won't My Child Pay Attention? New York: J. Wiley, 1992.

Greenberg, G.; Horn, S.; and Wade F. Attention Deficit Hyperactivity Disorder: Questions & Answers for Parents. Champaign, IL: Research Press, 1991.

Ingersoll, B., and Goldstein, S. Attention Deficit Disorder and Learning Disabilities: Realities, Myths, and Controversial Treatments. New York: Doubleday, 1993.

Kennedy, P.; Terdal, L.; and Fusetti, L. The Hyperactive Child Book. New York: St. Martrin's Press, 1993.

Moss, R., and Dunlap, H. Why Johnny Can't Concentrate: Coping with Attention Deficit Problems. New York: Bantam Books, 1990.

Silver, L. Dr. Silver's Advice to Parents on Attention-Deficit Hyperactivity Disorder. Washington, DC: American Psychiatric Press, 1993.

Vail, P. Smart Kids with School Problems. New York: EP Dutton, 1987.

Wilson, N. Optimizing Special Education: How Parents Can Make a Difference. New York: Insight Books, 1992.

Windell, J. Discipline: A Sourcebook of 50 Failsafe Techniques for Parents. New York: Collier Books, 1991.