ADHD

Question 1

Prevalence of ADHD in children

Answer 1

Prevalence of ADHD in children
Not enough child psychiatrists to diagnose and treat ADHD

As a group these children have well-known risk factors and show abnormal neuro-psychological functioning and neurobiological correlates

Question 2

History

Answer 2

Der Struwwelpeter, an illustrated book portraying children misbehaving (“Impulsive Insanity/Defective Inhibition”) by Heinrich Hoffman (1854).

ADHD has long been described in the medical literature. Heinrich Hoffmann (1809-1894), a German psychiatrist, was the first to describe children whose behavior was marked by impulsivity and hyperactivity. He named this behavioral problem “impulsive insanity” or “defective inhibition”.

Question 3

History

Answer 3

1902 Lancet article
1920’s “minimal brain damage”
1930’s “hyperkinetische Erkrankung”
1960’s “minimal brain dysfunction”
1937 Benzedrine discovered
Hyperkinetic Syndrome of Childhood” in ICD-9
1980 inattention recognized
DSM-III Attention-Deficit Disorder with or without Hyperactivity

Question 4

ADHD

Answer 4

common in all cultures

Question 5

ADHD can be serious:

Answer 5

untreated it can lead to educational failure, accidents and unfair harsh punishments that may worsen the behaviour and outcome.

Question 6

Severe ADHD can persist into adulthood with risk of :

Answer 6

marriage breakdowns, unemployment, accidents, other psychiatric disorders

Question 7

ADHD is stigmatizing:

Answer 7

Patients or their families may be blamed for the behaviours, suffering social exclusion

Question 8

ADHD is treatable with:

Answer 8

several evidence based treatments

Question 9

Core Symptoms

Answer 9

Inattention, hyperactivity, impulsivity
Present in more than one context
Leading to functional impairment

Question 10

Subtypes in DSM

Answer 10

Combined subtype
Predominantly hyperactive
Predominantly inattentive

Question 11

Changes to ADHD Dx in DSM-V

Answer 11

Symptoms must be present < 12 years old
(not 7 years old)

Adult symptoms similar to child symptoms, but lower threshold
(e.g. 5+ symptoms needed, not 6+)

No exclusion criteria for autism spectrum disorders, now considering ADHD as a co-morbid disorder

Question 12

Prevalence

Answer 12

6% for children
3% for adolescents

Male > Female

Question 13

Clinical Pictures Across Ages

Pre-school:

Answer 13

play < 3minutes, not listening “whirlwind”, no sense of danger

Question 14

Clinical Pictures Across Ages

Primary school:

Answer 14

activities < 10minutes, forgetful, distracted, restless, intrusive, disruptive

Question 15

Clinical Pictures Across Ages

Adolescence:

Answer 15

attention< 30 mins, no focus/planning, fidgety, reckless

Question 16

Clinical Pictures Across Ages

Adults:

Answer 16

incomplete details, restless, forgetful, impatient, accidents

Question 17

Associations with Durability of Symptoms

Answer 17

Lower academic achievement
Marital problems and dissatisfaction
Divorce
Difficulties dealing with offspring
Lower job performance
Unemployment
Employment below potential
Traffic accidents
Other psychiatric disorders

Question 18

Etiology & Risk Factors

Answer 18

Strong genetic component (76%)

Perinatal factors – some evidence

Neurobiological deficits – growing evidence

Deprivation and family factors – important for course and outcome (maybe not causation)

Question 19

Neurobiology

Answer 19

Frontal-striatal dysfunction
mediated by GABA
modulated by catecholamines
(DA, NE)

Catecholaminergic dysregulation

Delay in cortical maturation

Question 20

Associated Features

Answer 20

Defiant, aggressive antisocial behaviors
Problems with social relationships
IQ tends to be lower than in the general population
Specific learning problems
Co-ordination problems
Specific developmental delay
Poor emotional self-regulation

Question 21

Genetics:

Answer 21

proportion of variance attributed to additive genetic factors 76%

Negative results in genome wide association studies and most associated candidate genes only responsible for small increase in risk.

Most genes implied related to catecholaminergic system (DAT 1 – dopamine transporter gene)

Question 22

Perinatal Factors

Answer 22

most evidence for association with prematurity, low birth weight and Intra-uterine tobacco exposure

Question 23

Neurobiological deficits

Answer 23

(slight differences in mean values not brain damage)
Fronto-striatal dysfunction (executive function and inhibitory control)
Catecholaminic dysregulation
Delay in cortical maturation

Question 24

Deprivation and family factors:

Answer 24

implied by epidemiological studies: more common in low SES, institutions etc. but may also be related to course and outcome rather than causation

Question 25

Popular explanations that students may be confronted with by parents (e.g. through newspaper and internet articles) should be explored and discussed

Answer 25

i.g. food allergies (some evidence for some cases) computer games (no evidence) environmental toxins (inconclusive) but also any other culturally relevant explanatory models

Question 26

Comorbid Disorders in Brazilian Community Samples

Answer 26

Children with ADHD often suffer from other psychiatric conditions; systematic screening for the presence of other mental disorders is essential. Figure D.1.4 shows the prevalence of comorbid disorders in two Brazilian cohorts of children with ADHD; oppositional defiant disorder, anxiety disorders, conduct disorders and depression are among the most frequent (Souza et al, 2004).

Question 27

Oppositional Defiant Disorder

Answer 27

Three categories of symptoms Includes both emotional & behavioral symptomatology – 6 months No longer exclusion criteria for conduct disorder

Question 28

Three categories of symptoms

Answer 28

Angry/irritable mood Argumentative/defiant behavior Vindictiveness

Question 29

Angry/Irritable Mood

Answer 29

Often loses temper. Is often touchy or easily annoyed. Is often angry and resentful.

Question 30

Argumentative/Defiant Behavior

Answer 30

Often argues with authority figures or, for children and adolescents, with adults. Often actively defies or refuses to comply with requests from authority figures or with rules. Often deliberately annoys others. Often blames others for his or her mistakes or misbehavior.

Question 31

Vindictiveness

Answer 31

Has been spiteful or vindictive at least twice within the past 6 months.

Question 32

Oppositional Defiant Disorder

Answer 32

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

Question 33

Specify current severity:

Answer 33

Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers). Moderate: Some symptoms are present in at least two settings. Severe: Some symptoms are present in three or more settings.

Question 34

ADHD Clinical Presentation & Diagnosis

Answer 34

``` Inattention Hyperactivity Impulsivity Pervasive symptoms Duration/age of onset Impairment or distress ```

Question 35

Inattention:

Answer 35

Distractibility, forgetfulness, inability to finish what they start etc.

Question 36

Hyperactivity:

Answer 36

On the go all the time, restlessness, fidgeting, talking too much, inability to play quietly etc.

Question 37

Impulsivity:

Answer 37

Difficulty in delaying gratification, taking turns in play, acting without thinking

Question 38

Pervasive symptoms

Answer 38

Symptoms need to be pervasive | need for multiple informants! School!

Question 39

Clinical Assessment

Answer 39

Always obtain information from at least two contexts (e.g., home, school) Perform medical and psychiatric assessment History, family functioning, parenting style etc. Patient might be well behaved during the clinical interview Assess medical and psychiatric DD/co-morbidity No additional tests necessary for diagnosis.

Question 40

Neuropsychological Testing

Answer 40

Only for research use The majority of neuropsychological tests are copyrighted and expensive, which restricts their use, although specific tests can be of help. Intelligence tests (e.g., Wechsler) can be useful in clarifying intellectual deficits or IQ level and its implications. The Continuous Performance Test (CPT-II), Wisconsin Cart- Sorting test, STROOP test, and “Go/no go” tests are useful for research.

Question 41

Stroop test

Answer 41

The stroop test is used to measure attention. It takes advantage of our ability to read words more quickly and automatically than naming colors. The cognitive mechanism involved in this task is called directed attention: one has to manage one’s attention, inhibit or stop one response in order to say or do something else. It is one of the tests that, despite not being diagnostic, provides data about attentional ability.

Question 42

Differential Diagnosis

Answer 42

``` Situational hyperactivity Behavioral disorders (ODD/CD) Emotional disorders Tics, chorea or other dyskinesias Misuse of substances Autism Spectrum Disorder Intellectual Disability ```

Question 43

Further Differential Considerations

Answer 43

``` Parental mental health issues Severe marital discord or recent divorce Domestic violence Child abuse or neglect Severe bullying or exclusion by peers Severe deprivation or poverty ```

Question 44

Rating Scales

Answer 44

SNAP IV: http://www.adhd.net/snap-iv-form.pdf SDQ : http://www.sdqinfo.org SWAN: http://www.adhd.net/SWAN_SCALE.pdf Vanderbilt: http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-assessment-scales Many other proprietary (not free) scales

Question 45

Rating Scales | Cont.

Answer 45

Not necessary for diagnosis but very useful for monitoring symptoms during treatment While diagnosis cannot be made on the basis of rating scale data alone, using rating scales is good clinical practice for screening purposes, to measure symptom severity and to monitor response to treatment and outcome. There are numerous rating scales that can be either specific for ADHD or for general psychopathology, most have a child, parent and teacher versions.

Question 46

Aims of Treatment

Answer 46

Individually tailored Reduce symptoms Improve educational outcomes Reduce family and school-based problems

Question 47

What works?

Answer 47

Evidence Based Treatments: Best evidence for stimulant medication Behavior treatments also effective in mild to moderate cases Psycho-education for parents and school

Question 48

Psychosocial Treatments

Answer 48

Behavior therapy Generally effective, but smaller effect size than medication First line treatment in younger children or milder cases

Question 49

Behavior therapy

Answer 49

Individual, not always generalize Parent management training: particularly useful in younger children and for associated behavior problems School based: child in front of class, short tasks etc.

Question 50

Stimulant Medications

Answer 50

``` Methylphenidate or Amphetamines Efficacy and safety well-established ES 0.8-1.1; clinical response in 70% Dose: titrate for optimum response Short/long acting (sustained release) available ```

Question 51

Stimulant Medications | cont.

Answer 51

Methylphenidate or Amphetamines Common side effects: nausea, weight loss, insomnia, agitation More serious side effects: tics, psychotic symptoms, raised blood pressure, growth retardation Concern raised for risk of sudden cardiac death – raised in 2005, but has not panned out in the bigger studies. No EKG required for cases, but it is reasonable to get one if your history and physical exam suggests one.

Question 52

Atomoxetine (Strattera)

Answer 52

``` Noradrenergic reuptake inhibitor Can be given once or twice daily Less pronounced effects on appetite and sleep than stimulants May have more nausea / sedation Takes about 6 weeks to work ```

Question 53

Indications for Atomoxetine

Answer 53

Helps with patients with co-morbid anxiety but recommendation is still 1st line stimulant with added SSRI Consider if active substance abuse problems, co-morbid anxiety or tics, and severe side effects to stimulants

Question 54

Atomoxetine Side Effects

Answer 54

Appetite suppression, nausea, sedation Rare hepatotoxicity Rare suicidality

Question 55

Meds used Off-label

Answer 55

Antidepressants | Alpha-2 agonists

Question 56

Antidepressants

Answer 56

Buproprion (Wellbutrin) Imipramine Nortriptyline

Question 57

Alpha-2 agonists

Answer 57

Clonidine / Kapvay (extended-release) | Guanfacine / Intuniv (extended-release)

Question 58

When to Refer

Answer 58

If no response and severe impairment after pharmacological treatment combined with behavioral approaches Re-evaluate diagnosis and co-morbidity Check for undetected social adversity or abuse If still no response after 6 months consult with specialist

Question 59

Clonidine and guanfacine are

Answer 59

alpha-2 agonists with demonstrated efficacy in the treatment of ADHD These medications can also be used for patients with comorbid tic disorders or Tourette’s syndrome, in which its efficacy seems to be higher. There are now long-acting formulations for both clonidine and guanfacine available.

Question 60

Guanfacine

Answer 60

is more selective than clonidine causing fewer adverse effects such as somnolence.

Question 61

Tricyclic antidepressants such as

Answer 61

imipramine, have also been shown to reduce ADHD symptoms. Nevertheless tricyclic antidepressants are associated with significant side effects, are less effective than stimulant medications and should be used only after failure to respond to two or three stimulants and atomoxetine (AAP, 2011). Tricyclic antidepressants can interfere with cardiac conduction and can cause sudden death; it is important that patients are monitored with electrocardiogram before and during treatment.

Question 62

Bupropion

Answer 62

Bupropion is considered a third line treatment for ADHD; it can be tried in case of failure of stimulants, atomoxetine and alpha-2 agonists. Bupropion lowers seizure threshold in a dose dependent fashion.