Understanding, Diagnosing and Treating ADHD

Presenters:Tom W. Breyer, ANP, PMHNP-BC

Susan Gillette, PMHNP-BC

We have no disclosures or conflicts of Interest and receive no support from the pharmaceutical Industry

Objectives1.Examine historical descriptions of ADHD as diagnosis evolvedWorld Journal of Psychiatry December 22, 2015 Martinez-Badia & Martinez-Raga

Is the diagnosis real?Schwartz, Alan (2016) ADHD Nation : Children, Doctors, Big Pharma, and the Making of an American Epidemic New York Scribner

Understanding diagnostic criteria for ADHD

• American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Health Disorders 5th ed.

Barkley, R.A. (2013) Taking Charge of ADHD. 3rd ed. New York The Guillford Press pp. 253-254

2. Explore different presentations of the disorder base on gender ,age and with comorbidities

• • Nøvik TS, Hervas A, Ralston SJ, et al. Influence of gender on attention-deficit/hyperactivity disorder in Europe–ADORE. Eur Child Adolesc Psychiatry 2006; 15(Suppl 1): I15-I24.

• • Biederman J, Faraone SV, Monuteaux MC, et al. Gender effects on attention-deficit/hyperactivity disorder in adults, revisited. Biol Psychiatry 2004; 55: 692-700.

• Biederman J, Mick E, Faraone SV, et al. Influence of gender on attention deficit hyperactivity disorder in children referred to a psychiatric clinic. Am J Psychiatry 2002; 159: 36-42. •Biederman J, Faraone SV. The Massachusetts General Hospital studies of gender influences on attentiondeficit/hyperactivity disorder in youth and relatives. Psychiatr Clin North Am 2004; 27: 225-232.

3. Familiarize and evaluate assessment tools, their usefulness and validity

• CHADD.org CBCL 6-18American Psychiatric Association (2013) Desk Reference to the Diagnostic Criteria from DSM V 5th ed. pp.31-35

4.Therapies, Medications, their classes, long acting vs. short acting, common side effects.Wilens, Timothy E, & Hamerness, Paul Graves (2016) Straight Talk About Psychaitric Medications for Kids 4th ed. New York, Ny The Guilford Press

5. Family addiction problems- should I or should I not prescribe a stimulant?

• . Wilens TE, Spencer TJ. Understanding attention-deficit/hyperactivity disorder from childhood to adulthood. Postgrad Med. 2010 Sep;122(5):97–109. This review provides a comprehensive discussion pertaining to the co-occurring disorders, diagnoses, and treatment modalities of ADHD.

• Frodl T. Comorbidity of ADHD and substance use disorder (SUD): a neuroimaging perspective. J Atten Disord. 2010 Sep;14(2):109–20. This review of the literature identifies neurobiological similarities between ADHD and SUD.]

• Charach A, Yeung E, Climans T, Lillie E. Childhood attention-deficit/hyperactivity disorder and future substance use disorders: comparative meta-analyses. J Am Acad Child Adolesc Psychiatry. 2011 Jan;50(1):9–21.

6. 504 plans, IEP’s, ODS , IDEA, ADA-working with schools & parents

• Barkley, R.A. (2013) Taking Charge of ADHD. 3rd ed. New York The Guillford Press pp. 258-260

•

7. Questions?

Who says this is a modern disorder? The early history of attention deficit hyperactivity disorder

• Hippocrates 460-375 BC described patients with “quickened responses to sensory experience, but less tenaciousness because the soul moves on quickly to the next impression”

• German Physician Weikard 1775 Described adults and children suffering form a lack of attention…being easily distracted by anything, even his or her imagination…lacking perseverance and persistence…overactive and impulsive generally…unwary, carelss, flighty and bacchanal. These inattentive indivduals “will be shallow everywhere, mostly reckless and imprudent and inconsistent in execution”

• Sir Alexander Crichton 1798 In his book “An inquiry into the nature and origin of mental derangement” in a chapter ‘On attention and its diseases’ described a disorder characterized by abnormal degrees of inattention and distractibility….an incapacity to attend with the necessary degree of constancy to any object and associated with impulsivity, restlessness and emotional reactivity. He further noted the disorder can “be born with a person and evident at a very early period of life”

• Scottish Psychiatrist Sit Thomas Clouston 1899-reported “neurotic children who are hyperexcitable, hypersensitive…ceaseless active but everchanging in activitiy suffering from ‘undue brain reactiveness

• 1902 British Pediatrician Sir George Still noted “an abnormal defect of moral control in children”

• 1936 Dr Charles Bradley administered a new medication, Benzedrine,(an early amphetamine) to problem children in a residential facility in an attempt to alleviate headaches-he noted improved behavior and performance in the home and in School

• 1952 First Diagnostic and statistical Manual of Mental Disorders (DSM) released by the American Psychiatric Association-no diagnosis of ADD or ADHD

• 1968 DSM II listed a disorder called “hyperkinetic impulse control disorder” a developmental disorder of intrinsic motivation, characterized by poor appreciation of the contingencies between behavior and environmental events. Characteristics of H.I.D. children, including apparent over activity, impulsivity, impersistence, inattention, and underachievement in academic and social skills.

• 1980 DSM III Attention Deficit Disorder, with and without hyperactivity• 1987 DSM III-R ADHD, no subtypes• 2000 DSM IV: ADHD -3 subtypes-combined, predominately inattentive,

predominately hyperactive and impulsive• Reference World Journal Psychiatry Dec 22 2015 Martinez-Badia &

Martinez-Raga

Diagnostic Criteria DSM V

• Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

• Often has trouble holding attention on 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 schoolwork, chores, or duties in

the workplace (e.g., loses focus, side-tracked).• Often has trouble organizing tasks and activities.• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of

time (such as schoolwork or homework).• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools,

wallets, keys, paperwork, eyeglasses, mobile telephones).• Is often easily distracted• Is often forgetful in daily activities.

•Hyperactivity and Impulsivity: •Six or more symptoms of hyperactivity-impulsivity for children up to age 16, •or five or more for adolescents 17 and older and adults; •symptoms of hyperactivity-impulsivity have been present for at least 6 months• to an extent that is disruptive and inappropriate for the person’s developmental level:•Often fidgets with or taps hands or feet, or squirms in seat. •Often leaves seat in situations when remaining seated is expected. •Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeli •Often unable to play or take part in leisure activities quietly. •Is often “on the go” acting as if “driven by a motor”. •Often talks excessively. •Often blurts out an answer before a question has been completed. •Often has trouble waiting his/her turn. •Often interrupts or intrudes on others (e.g., butts into conversations or games)

Presentations of ADHD

• Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

• Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months

• Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

• Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.

• Because symptoms can change over time, the presentation may change over time as well.

https://www.cdc.gov/-available in Spanish

• DSM-5 Criteria for ADHD• People with ADHD show a persistent pattern of inattention and/or

hyperactivity–impulsivity that interferes with functioning or development:

Diagnosis ADHD in Adults

• ADHD often lasts into adulthood. To diagnose ADHD in adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children. Symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity.

• For more information about diagnosis and treatment throughout the lifespan, please visit the websites of the National Resource Center on ADHDExternal and the National Institutes of Mental HealthExternal.

• Reference• American Psychiatric Association: Diagnostic and Statistical Manual of

Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.

references

• J Am Acad Child Adolesc Psychiatry. Author manuscript; available in PMC 2011 May 25.• Published in final edited form as:• J Am Acad Child Adolesc Psychiatry. 2010 Mar; 49(3): 217–28.e1-3. • PMCID: PMC3101894• NIHMSID: NIHMS291682• PMID: 20410711• Sex and age differences in Attention-Deficit/Hyperactivity Disorder symptoms and

diagnoses: Implications for DSM-V and ICD-11• Dr. Ujjwal P. Ramtekkar, M.D., M.P.E., Dr. Angela M. Reiersen, M.D., M.P.E., Dr. Alexandre

A. Todorov, Ph.D., and Dr. Richard D. Todd, Ph.D., M.D.• Author information Copyright and License information Disclaimer• The publisher's final edited version of this article is available at J Am Acad Child Adolesc

Psychiatry

Prevalence of ADHD in US and World Wide

• Results• Overall prevalence of current DSM-IV-like ADHD was 9.2% with a male:female

ratio of 2.28:1. The prevalence of DSM-IV-like ADHD was highest in children. Gender differences in DSM-IV-like ADHD subtype prevalences were highest in adolescents. On average, individuals with lifetime DSM-IV-like ADHD diagnoses had elevated current ADHD symptoms even as adolescents or adults.

• Conclusions• Lower male:female ratios than reported in some clinic-based studies suggest that

females are under-diagnosed in the community. Although they may no longer meet the full symptom criterion, young adults with a history of lifetime DSM-IV-like ADHD maintain higher levels of ADHD symptoms compared to the general population. The use of age-specific diagnostic criteria should be considered for DSM-V and ICD-11.

ADHD Nation -Alan SchwartzChildren, Doctors, Big Pharma and the Making of an American Epidemic• In this investigative book the author notes that while ADHD is real, 1

in 7 (14%)American Children are diagnosed. He cites Keith Connors one of the pioneers of ADHD as stating it is a national disaster of dangerous proportions” driven by big Pharma over promoting medications and manipulating patients to demand these medications

• Worldwide estimates are 7.2% of the population regardless of ethnicity or nationality and education- CHADD.org

William Osler

•“It is much more important to know what sort of patient has a problem than what sort of problem a patient has.”

THE 3 types of Attention Deficit Hyperactivity Disorder: What are the differences?(Excerpted from Medical News Today Timothy J. Legg, PhD, CRNP June 7, 2017)

Estimated 6.4 million children between 6 and 17 in US

Combined Presentation: most common type, individual will exhibit impulsive and hyperactive behaviors in addition to inattention and distractibility. More often seen in males

Predominately impulsive/hyperactive: least common type, individual is hyperactive with need to move or fidget constantly, impulsive behaviors but does not show signs of distractibility or inattention

Predominately inattentive: (often referred to as ADD, attention deficit disorder), individual does not exhibit signs of hyperactivity or impulsivity but is easily distracted and struggles with focus and attention. More often seen in females

What are the Early Signs of ADHD?(Excerpted Medical World News April 16 2018 Bethany Cadman)

Signs differ in Adults and Children

Children: Inattention, not paying attention in class, making careless mistakes in homework, appearing to not listen(not selective hearing), unable to follow multistep instructions, procrastination, unable to finish homework, difficulty with organization, avoiding tasks that require focus, such as homework, easily distracted by surroundings, losing or forgetting items

Hyperactivity/Impulsivity, fidgeting, inability to remain seated, constantly in motion, running or climbing on things or in places where it is not allowed, interrupting the teacher or others talking, talking excessively, difficulty with playing quietly, intruding in other children’s play, difficulty waiting their turn

Adults: 60% of children diagnosed will have symptoms as adults. Many have difficulty in relationships, careers, time management forgetfulness and impatience and frustration tolerance

Your Child’s ADHD Is an IcebergPenny Williams - Additude Magazine CHADD.org July 2019(Ms. Williams is a parenting coach and author numerous books on ADHD)

Symptoms of ADHD are visible and the tip of the “iceberg”

Beneath the water:

1. Poor self esteem

2. Developmental delays, often 2-3 years behind in social skills maturation emotional IQ executive functioning executive functioning (problem solving, black and white thinking, inability to abstract)

3. Inflexibility

4. Intensity, extreme emotions

5. Emotional dysregulation-not age appropriate

6. Co-existing conditions-estimated 50-60% have this, may be mood disorder, anxiety, autism, learning disabilities, (my least favorite ‘oppositional defiant disorder’)

7. Skill deficits-time management, planning, organization, problem solving flexibility

8. Executive Functioning deficits-day to day planning, task initiation, organization

9. Time Blindness-distorted view of time, ie a simple task will take ‘forever’

Your Child’s ADHD Is an Iceberg

Your Child’s ADHD Is an Iceberg

10. Meltdown (different than a tantrum) A child will stop a tantrum if he gets what he wants, meltdowns are caused by sensory overload, perseveration, feeling misunderstood, no longer in control of what he is doing or saying , may harm himself or others

11. School incompatibility-schools designed for conformity students required to be quiet, sit still remain seated and remain attentive for long periods of time

12. Pills don’t teach skills, they help put the individual in a better space to focus and attend longer to develop skills and overcome deficits. The earlier the diagnosis and effective treatment the less symptoms below the water develop

Emily Dickenson (1864)

• I felt a Cleaving in my Mind• As if my Brain had split• I tried to match it-Seam by Seam• But could not make them fit

• The thought behind. I strove to join• Unto the thought before• But Sequence raveled out of Sound• Like Balls-upon a Floor

Environmental Factors contributing to ADHD

Risk factor Proposed mechanism for ADHD-related neurobehavioral effects

Copper deficiency Decreased availability of DA and NE, as copper is an essential co-factor in their production [48]

Electronic media exposure Frequent stimulus changes in TV and video games may interfere with ability to stay focused on less attention-grabbing tasks [2]

Folate deficiency in pregnancy Impaired cellular growth and replication, leading to net reduction in cells and loss of progenitor cells in fetal brain [77]

Food additives exposure Sodium benzoate: downregulation of tyrosine hydoxylase and DA transporter expression in DA neurons [78]

Food dyes: neuron membrane dysfunction preventing the uptake of DA and other neurotransmitters, although postmortem tissue analyses of animals fed a blend of all 7 food, drug, and cosmetic (FD & C) dyes showed no effect on brain levels of DA, NE, or Ser [79]

Psychosocial deprivation Interference with cortical maturation (particularly in the frontal, temporal, and occipital areas) [80]

Iron deficiency Changes in cortical fiber conduction, DA and Ser systems, and myelin formation [45, 47]

Lead exposure Disruption of synapse formation; derangements to brain DA system, including reduction of DA neuron branching and length [81]

Manganese exposure Accumulation of manganese in DA neurons; exposure associated with reduced striatal DA levels [81]

Mercury exposure Disruption of synaptic transmission; decrease in Ach release and DA levels in striatum and hypothalamus [82]

Obesity during pregnancy Maternal leptin derangements may affect maintenance and differentiation of neural stem cells in fetal cerebral cortex, including the cingulate cortex [83]; alterations in insulin and interleukin-6 levels may impair neurodevelopment [84]

Omega-3 fatty acid deficiency Reduced neuronal size and branching; disruption of DA, Ser, and Ach neuronal release; altered membrane localization and activity for DA receptors and DA, NE, and Ser transporters [85]

Organochlorine exposure Disruption of brain DA levels and function; possible reduction in circulating thyroid hormone levels [31]

Organophosphate exposure Disruption of DNA replication and axonal and dendritic growth; perturbation of DA, NE, Ser, and Ach systems [35]

Phthalate exposure Thyroid hormone derangements; suppression of nerve cell proliferation; downregulation of DA systems [86]

Polyfluoroalkyl chemical exposure Changes in neuron cell differentiation, brain proteins tau and synaptophysin, thyroid hormone levels, and Ach system [39, 87]

Prenatal alcohol use Reduction in neurons; reduced DA synthesis, uptake sites, and receptor-binding sites in mesolimbic/cortical areas [88, 89]

Prenatal antidepressant use Inhibition of DA reuptake in fetal brain causing abnormalities in the DA system [20]

Prenatal antihypertensive use Alteration of placental blood flow; increased risk of SGA birth and neonatal bradycardia, which may affect neurodevelopment [19]

Prenatal caffeine use Upregulation of adenosine receptors; enhanced DA-induced changes in motor behavior [16]

Prenatal heroin use Alteration of neuronal cell division/migration; increased fetal neuron apoptosis [90]; altered function of NE and opioid systems [91]

Prenatal tobacco use Overexpression/desensitization of fetal brain nAChRsaffecting the release of DA, Ach, NE, Ser, Glu, and GABA [10, 92]

Stress during pregnancy Changes in offspring hypothalamo-pituitary-adrenal axis feedback, including altered hippocampus and locus coeruleus neuronal activation [93]

Trauma exposure Altered development of frontal cortex, cerebellum, hippocampus, and amygdala [2]

Zinc deficiency Increase in DA transporter activity, as zinc is a noncompetitive inhibitor of substrate (DA) translocation via the DA transporter [94]

Patient Presentations:

Excerpt from Driven to Distraction

Astronaut lady

Duct Tape person

Locked keys in car student

Forget appointments

Forget medications

Screening ToolsComputerized assessment tools:

Connors CPT-III

TOVA

Forms:

Likert Rated DSM Criteria- teachers, parents, & SO’s should fill out along with patient

Copeland Screening Tool

All of the above may be repeated to help evaluate medication efficacy and duration of action

Screening Questions in HistoryThe disorder really is global !!!

Ask questions about frustrations in daily life, i.e.:

Losing things

Procrastination-(homework the night before it is due)

Inability to read and retain

Numerous unfinished projects

Never enough time

Frustration- can’t ever get anything done

Poor sleep

Forgetting engagements

Relationship difficulties

Okay, so they have ADHD, now what?

How much is it impacting their life and impairing their performance in all domains.

Family or personal problems with addictive behaviors?

Medication Choices:

Stimulant, non-stimulant, off label medications choices, see handout

Co-morbid disorders in addition to addictive behaviors that may influence medication choices: TBI, anxiety, depression, bipolar, PTSD, FADE, Developmental delays, foster care

Oppositional Defiant Disorder-Really?

Overview of Medication Options and what guides the choice (see handout)

Help for School Age Children (college too!)IEP’s

504 Plans

Testing Accommodations

Office of Disability Services

Helping at HomeQuiet defined area for studying

Structure

Routine

Consistency of expectations

Single step instructions

Age appropriate rewards and consequences

Token system, not all or nothing

Questions?