Attention Attention Deficit/HyperactivityDeficit/Hyperactivity Disorder Disorder

Christopher Lever, MD, FRCP(C)Christopher Lever, MD, FRCP(C)

Objectives.

Define attention disorders.Define attention disorders. Appreciate how to Appreciate how to ““diagnosediagnose”” an attention an attention

disorder.disorder. Be aware of the medical problems that may mimic Be aware of the medical problems that may mimic

primary attention disorders.primary attention disorders. List some of the other List some of the other ““co-existingco-existing”” diagnoses with diagnoses with

attention disorders.attention disorders. Have some awareness of the treatment options for Have some awareness of the treatment options for

children with attention disorders.children with attention disorders. Discuss when referral for an attention difficulty is Discuss when referral for an attention difficulty is

appropriate.appropriate.

Case 1

A 7-year-old boy in grade II presents with academic and A 7-year-old boy in grade II presents with academic and behavior problems.behavior problems.

He was asked to leave two day homes because he harmed He was asked to leave two day homes because he harmed other children.other children.

His parents struggle with getting him ready in the morning His parents struggle with getting him ready in the morning and for bedtime. He behaves better when heand for bedtime. He behaves better when he’’s outside s outside playing, but is known to get overexcited. Parenting classes playing, but is known to get overexcited. Parenting classes have been helpful, but both parents feel somewhat have been helpful, but both parents feel somewhat stressed looking after him when his two siblings are stressed looking after him when his two siblings are around. He is thoughtful, curious, and enjoyable when he around. He is thoughtful, curious, and enjoyable when he is alone with one of his parents.is alone with one of his parents.

Teachers are concerned because his literacy skills are Teachers are concerned because his literacy skills are delayed more than one year, and he is frequently removed delayed more than one year, and he is frequently removed from the classroom for disrupting the work of others.from the classroom for disrupting the work of others.

Case 2

A 14-year-old girl with a known learning disability [literacy A 14-year-old girl with a known learning disability [literacy skills delayed] presents because she is irritable with her skills delayed] presents because she is irritable with her parents and they feel she is depressed.parents and they feel she is depressed.

Her learning disability was diagnosed in grade 3. She Her learning disability was diagnosed in grade 3. She received special assistance for literacy skills. She did received special assistance for literacy skills. She did improve, but several teachers suggested she could do improve, but several teachers suggested she could do better. She remains in a modified educational program that better. She remains in a modified educational program that is now failing all of her academic subjects. She is is now failing all of her academic subjects. She is frequently known to be doodling during class time and does frequently known to be doodling during class time and does not hand in most of her assignments.not hand in most of her assignments.

Her parents find her irritable and reclusive. She is not Her parents find her irritable and reclusive. She is not managing regular chores at home. She has spent more managing regular chores at home. She has spent more time involved in electronic chat and listening to music.time involved in electronic chat and listening to music.

She is smoking marijuana three to five times per week.She is smoking marijuana three to five times per week.

Case 3

A 9-year-old boy diagnosed with AD\HD; combined type at A 9-year-old boy diagnosed with AD\HD; combined type at BC ChildrenBC Children’’s Hospital at five years old presents for s Hospital at five years old presents for renewal of stimulant medication.renewal of stimulant medication.

Medications include Ritalin SR 20 mg once in the morning, Medications include Ritalin SR 20 mg once in the morning, and melatonin 3-6 mg in the evening.and melatonin 3-6 mg in the evening.

Improved attention and decreased hyperactivity is noted Improved attention and decreased hyperactivity is noted two hours after administration and lasts for a total of 5 two hours after administration and lasts for a total of 5 hours. Hyperactivity is increased around transition in spite hours. Hyperactivity is increased around transition in spite of regular medication administration.of regular medication administration.

Growth is good, sleep is better with melatonin. His blood Growth is good, sleep is better with melatonin. His blood pressure is normal.pressure is normal.

He is zinc deficient and has asthma. He also wears He is zinc deficient and has asthma. He also wears glasses.glasses.

It’s about perspective.

Who in this room thinks they have attention Who in this room thinks they have attention problems?problems?

Who feels restless?Who feels restless? Who has had a speeding ticket?Who has had a speeding ticket? Who has ever missed a spelling error in the final Who has ever missed a spelling error in the final

draft of a document?draft of a document? Who has ever bought something on sale that Who has ever bought something on sale that

theythey’’ve only used once? (not a condom or a coffin)ve only used once? (not a condom or a coffin) Who has ever asked for instructions to be Who has ever asked for instructions to be

repeated because they repeated because they ““missed a stepmissed a step””??

SPECTRUMS .

Attention disorders represent a grouping of children with similar traits. Most do not have a hard

pathologic diagnosis. It is simply a pattern of similar clinical

characteristics that are maladaptive for the child’s

current setting and expectations.

A brief controversy.

Attention difficulties are described between 4-8% of North Attention difficulties are described between 4-8% of North American children, but much less in most other parts of the American children, but much less in most other parts of the world.world.

It depends who you ask. There is inherent bias in any It depends who you ask. There is inherent bias in any behavioral symptom.behavioral symptom.

It depends on context for that child. If the world were about It depends on context for that child. If the world were about better soccer players, the story writers would be doing better soccer players, the story writers would be doing remedial throw-ins at recess.remedial throw-ins at recess.

The pharmaceutical industry and medical education has The pharmaceutical industry and medical education has directly created more public awareness.directly created more public awareness.

Attention and impulse/movement regulation are only part of Attention and impulse/movement regulation are only part of the whole person. A disorder exclusive to inattention, the whole person. A disorder exclusive to inattention, hyperactivity, or impulsivity is naïve.hyperactivity, or impulsivity is naïve.

What is ADHD?

Cultural. Cultural. ““WhatWhat’’s my age again?s my age again?”” Pathological. Well, it is getting less clear. It is Pathological. Well, it is getting less clear. It is

mostly about frontal cortex dopamine. mostly about frontal cortex dopamine. Functional MRI data are accumulating, but Functional MRI data are accumulating, but the results are not easy to summarize. There the results are not easy to summarize. There are likely multiple reasons for ADHD are likely multiple reasons for ADHD phenotype.phenotype.

Academic. But 65 % in math is a definite Academic. But 65 % in math is a definite pass. pass.

Dotted line – dopamine, dashed line - norepinephrineDotted line – dopamine, dashed line - norepinephrine

= NT = neurotransmitter; dopamine or norepinephrine

Adapted from Wilens & Spencer. Child Adolesc Psych Clin N Am 2000;9:573.

NT Transporter(reuptake pump)

Presynaptic Neuron

Postsynaptic Neuron

Neurotransmitter Transporter

Neurotransmitter Output

Storage VesicleAMPH

AMPH = amphetamineMPH = methylphenidate

StimulantsStimulants’’ Proposed Mechanism of Proposed Mechanism of ActionAction

MPH & AMPH

DSM-IV-TR A Six or more of the following symptoms of inattention have

been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention Often does not give close attention to details or makes careless

mistakes in schoolwork, work, or other activities. Often has trouble keeping attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow instructions and fails to finish schoolwork,

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

Often has trouble organizing activities. Often avoids, dislikes, or doesn't want to do things that take a lot of

mental effort for a long period of time (such as schoolwork or homework).

Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

Is often easily distracted. Is often forgetful in daily activities.

DSM-IV-TR B Six or more of the following symptoms of hyperactivity-

impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity Often fidgets with hands or feet or squirms in seat. Often gets up from seat when remaining in seat is expected. Often runs about or climbs when and where it is not appropriate

(adolescents or adults may feel very restless). Often has trouble playing or enjoying leisure activities quietly. Is often "on the go" or often acts as if "driven by a motor". Often talks excessively. Impulsivity Often blurts out answers before questions have been finished. Often has trouble waiting one's turn. Often interrupts or intrudes on others (e.g., butts into

conversations or games).

DSM-IV-TR

Some symptoms that cause impairment were present before age 7 years.

Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

There must be clear evidence of significant impairment in social, school, or work functioning.

The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified: ADHD, Combined Type: if both criteria 1A and 1B are met for the

past 6 months ADHD, Predominantly Inattentive Type: if criterion 1A is met but

criterion 1B is not met for the past six months  ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is

met but Criterion 1A is not met for the past six months.

DSM-V revisions.

No exclusion for ASD. Other mental health disorders can exist, but

ADHD symptoms must not be primarily seen during mental health exacerbations or intoxication or withdrawal.

First symptoms before age 12 (not 7) years. Five of nine criteria can diagnose anyone over

17 years of age.

http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf

Information gathering.

From parent, both if possible. From teachers. From anybody else who spends time

directly observing this child and has expectations of the child.

From a trained school observation.

Is it a disorder?

Academic failure. Social failure. Family disharmony. Emerging negative self-concept. A Six or more of the following symptoms of inattention have

been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

B Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

There must be clear evidence of significant impairment in social, school, or work functioning.

Why bother with this diagnosis?

Understand origin of current difficulty. Educate parents and teachers about the

nature of attention difficulties. Offer medically proven therapies to

improve attention disorder symptoms. Discuss the natural history of attention

disorders.

Medical differential diagnosis.

Serious chronic symptomatic medical health issue.

Obstructive sleep apnea. Absence epilepsy. Thyroid disease. Rarely iron and zinc

deficiency. Serious head injury. Sensory impairment. Association with preterm delivery.

Psychologic concomitant diagnoses.

Cognitive impairment. Unique learning profile, “learning disability”. Autistic spectrum disorder. Opposition defiant disorder. Conduct disorder. Obsessive-compulsive disorder. Primary anxiety. Substance abuse. Major depression.

Comorbidity of Adult ADHD with Other Comorbidity of Adult ADHD with Other DSM-IV Disorders in the National DSM-IV Disorders in the National

Comorbidity Survey Replication (n=154)Comorbidity Survey Replication (n=154)

Kessler, Adler, Barkley, Biederman, Conners, Demler, Faraone, Greenhill, Howes, Secnik, Spencer, Ustun, Walters, Zaslavsky – The American Journal of Psychiatry, April 2006, pgs. 716-723

Comorbid Disorder During Previous 12 Comorbid Disorder During Previous 12 MonthsMonths

Among Respondents With Among Respondents With ADHDADHD

Major Depressive DisorderMajor Depressive Disorder 18.6%18.6%DysthymiaDysthymia 12.8%12.8%

Bipolar DisorderBipolar Disorder 19.4%19.4%Generalized Anxiety DisorderGeneralized Anxiety Disorder 8%8%

PTSDPTSD 11.9%11.9%AgoraphobiaAgoraphobia 8.9%8.9%

Social phobiaSocial phobia 29.3%29.3%

Alcohol abuseAlcohol abuse 5.9%5.9%Alcohol dependenceAlcohol dependence 5.8%5.8%

Drug dependenceDrug dependence 4.4%4.4%

Any substance use disorderAny substance use disorder 15.2%15.2%

Intermittent explosive disorderIntermittent explosive disorder 19.6%19.6%

2929

National Comorbidity Survey Replication: National Comorbidity Survey Replication: Mood Disorders in Adult ADHDMood Disorders in Adult ADHD

N=3199

Bipolar Disorder

19.4%

Major Depression

18.6%

Dysthymia 12.8%

AdultAdultADHDADHD Any Mood

Disorder 38.3%

Kessler RC et al. Am J Psychiatry. 2006;163:716-723.

National Comorbidity Survey Replication: National Comorbidity Survey Replication: Anxiety Disorders in Adult ADHDAnxiety Disorders in Adult ADHD

N=3199

AdultAdultADHDADHD PTSD

11.9%

Obsessive-compulsive

Disorder2.7%

Agoraphobia

4%

Generalized Anxiety Disorder

8%

Panic Disorder

8.9%

Social Phobia29.3%

Any Anxiety Disorder

47%

Kessler RC et al. Am J Psychiatry. 2006;163:716-723.

Stress and attention skill.

Child abuse. Witnessing violent acts. Medically ill or dying caregiver. [Poor role modeling]- the genetics of

ADHD. Chaos – variable and multiple caregivers,

foster care, and transiency.

Treatment.

Education. Balanced diet. Good sleep hygiene. Regular physical activity. [decreased video game playing] Specific behavioral strategies. Medication.

Psychostimulant medication.

Methylphenidate. Ritalin, Ritalin SR, Concerta, Biphentin.

Dextro-amphetamine. Dexedrine (tablet and Spansule).

Mixed amphetamine salts. Adderall XR. Lisdexamfetamine- L-lysine-L-lysine-

dextroamphetamine dimesylatedextroamphetamine dimesylate. Vyvanse.

Non-stimulant medication.

Atomoxetine. (Strattera) Tricyclic antidepressants. Alpha adrenergic agonists. (Clonidine and

Guanfacine – Intuniv XR) Buproprion. (Zyban, Wellbutrin XR)

When to refer?

Complex cases have a role for input from psychology, occupational therapy, and occasionally psychiatry.

Lack of comfort with diagnostic process. Inadequate time for evaluation process. Discussion of medication options.

Take Home Message

Attention difficulties are a subjective group of disorders defined by Attention difficulties are a subjective group of disorders defined by semi-objective questionnaires rating a particular person in a specific semi-objective questionnaires rating a particular person in a specific setting with certain expectations.setting with certain expectations.

Significantly different attention skills in at least two settings combined Significantly different attention skills in at least two settings combined with academic and/or social failure and the impression of negative self with academic and/or social failure and the impression of negative self concept lead to the diagnosis of ADHD.concept lead to the diagnosis of ADHD.

Medical health reasons need to be excluded.Medical health reasons need to be excluded. Psychological problems need to be recognized and accounted for.Psychological problems need to be recognized and accounted for. Each child requires a thoughtful and comprehensive evaluation prior to Each child requires a thoughtful and comprehensive evaluation prior to

labeling or discussion of treatment. Referral may be required for this labeling or discussion of treatment. Referral may be required for this purpose.purpose.

Treatment includes: education, healthy lifestyle, behavioral strategies, Treatment includes: education, healthy lifestyle, behavioral strategies, and medication.and medication.

In adolescence, encourage condom use and driving a 5 speedIn adolescence, encourage condom use and driving a 5 speed..