Lecture 1: ADHD
Behav med
Terms
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- ADHD def
- *Neurobehavioral disorder characterized by:*** -Inattention -Hyperactivity -Impulsivity *Symptoms must: -Cause greater impairment in affected patients than in age-matched peers -Present before age seven*** -Manifest in multiple settings, such as school and home -Cause significant** impairment NOTE: ADD no longer used
- ADHD prevalence
- -Up to ~ 6 % of school-age children -75-80% of children with ADHD have symptoms as adolescents = don't grow out of it; chronic persistent dz -60% have symptoms and impairment as adults -Prevalence is ~ 4% in adults
- 3 types of ADHD
- *Combined Type -At least six symptoms of inattention and six symptoms of hyperactivity-impulsivity for six months Most children and adolescents have combined type *Predominantly Inattentive Type -At least six symptoms of inattention but fewer than six symptoms of hyperactivity-impulsivity for six months *Predominantly Hyperactive-Impulsive Type -At least six symptoms of hyperactivity-impulsivity but fewer than six symptoms of inattention for six months
- Criteria for inattentive type in children
- Inattention to details / makes careless mistakes Difficulty sustaining attention Seems not to listen Fails to finish tasks Difficulty organizing Avoids tasks requiring sustained attention Loses things Easily distracted Forgetful
- Criteria for the inattentive type in adults
- Has difficulty sustaining attention Is easily distracted and forgetful Poor concentration Manages time poorly Misplaces things Difficulty finding things
- Criteria for hyperactive impulsive in children
- *Six or more manifestations of: *Impulsivity Blurts out answers before question is finished Difficulty wasting time Interrupts or intrudes on others *Hyperactivity Fidgets Unable to stay seated Inappropriate running, climbing (restlessness) Difficulty engaging in leisure activities quietly "On the go" Talks excessively
- Criteria for hyperactive impulsive type in adults
- *Impulsivity -drives too fast, traffic accidents -impulsively changes jobs -irritable or quick to get angry *Hyperactive -shows inner restlessness -fidgets when seated -self-selects active jobs -talks excessively -feels overwhelmed
- Hyperactivity vs. inattentive in schools
- -schools often pick out hyperacitve children without picking out inattentive ones -BUT kids who are hyperactive are MORE likely to graduate than inattentive kids
- Impact of untreated ADHD in adults
- Academic Underachievement Interpersonal Problems Deficits in Occupational Functioning Substance Use Disorders Increased Accident Rates
- Difficulties making accurate ADHD dx
- -Subjectivity of diagnostic criteria -Testing objective but not specific -Diagnosis dependent on social and educational circumstances -"In vogue" diagnosis -Pharmaceutical marketing -Symptoms overlap with other psychiatric illness
- Things more likely to occur in bipolar disorde vs ADHD
- Grandiosity (85% vs 7%) Elevated mood (87% vs 5%) Daredevil acts (70% vs 13%) Uninhibited people-seeking (68% vs 21%) Silliness/laughing (68% vs 21%)
- ADHD: pathophysiology
- -core deficits remain TBD and variation exists -mostly related to diff in functioning in prefrontal cortex basal ganglia -Catecholiminergic CNS pathways play a role: NE and dopamine are important modulators of attnetion and psychomotor act
- What should not be used in dx
- neuroimaging techniques - lack specificity and sensitivity
- ADHD and genetics
- -Strong genetic component -90% concordance in monozygotic twins -Heritability of 0.75 -Molecular studies have implicated the human thyroid receptor-beta gene, the dopamine transporter gene (DAT-1), and the D4 receptor gene (DRD4)
- ADHD eval/assessment
- *Standard History and Physical *Screening Neuro Exam *History from parents/caregivers Inattention/hyperactivity/impulsivity Multiple settings Age of onset Duration of symptoms Degree of functional impairment *Information from school Inattention/hyperactivity/impulsivity Classroom behavior and response to interventions Learning and attendance Degree of functional impairment Examples of schoolwork Report card/teacher evaluation *Assess for associated conditions Impaired vision/hearing Learning/speech/language disorder Seizures; tics; migraines Medical illnesses, malnutrition Sleep disorders Medication/lead toxicity/pica/substance abuse Psychiatric disorders (Oppositional deficant DO, Intermittent Explosive DO, Mood/anxiety Disorders) Anxiety: realistic fears, depression Sequelae of abuse/neglect
- ADHD: cont eval and assessment
- *Identify target behaviors *Collect previous treatment data -Target behavior => response -Medication => dosage, duration, side effects, adverse events; did it work?
- Standardized assessment measures
- Preschool Early Childhood Attention Deficit Disorder Evaluation Scale (ECADDS) Elementary School Child Behavioral Checklist (CBCL) Connors Parent and Teacher Rating Scale (CPRS and CTRS) Adolescent Connors/Wells Adolescent Self-Report of Symptoms Adolescent Symptoms Inventory (ASI-4) Adults Connors Adult Attention Deficit Rating Scale (CAARS) Adult ADHD Self-Report Scale can be biased
- Neuropsych testing
- -Objective measure -Not diagnostic - lacks specificity -May be useful to determine patterns of strength and weakness and for screening for possible cognitive deficits -Continuous Performance Test, Wisconsin Card-Sorting Test, Stroop Word Color Association Test, Test of Working Memory, others
- ADHD and follow up
- -Target behavior outcome -Academic progress -Adverse effects of medications -Response to medications does not validate a diagnosis of ADHD***** -Children and adults without the disorder have cognitive and behavioral responses similar to those of patients with ADHD***
- Non-pharm treatment
- *Coaching = Problem-solving skills *Cognitive/Behavioral = Correct negative belief systems *Conflict Resolution / Anger Management / Interpersonal Skills -May be more effective when taught in group settings -Results are inconsistent *dec workload to match ability *establish explicit house/class rules *coordinate btwn school and home *set time limits for work completions
- Behavioral interventions
- *Reinforcement -Rewards/privileges provided contingent on performance of desired behavior -Increased frequency and immediacy of re *Time-out -Access to positive reinforcement removed contingent on performance of unwanted/problem behavior *Response Cost *Token Economy System **JK behavioral interventions exist
- Stimulant treatment
- -can be used in tx - often structurally similar to dopamine and NE (D-enantiomers more effective) *amphetamines and methylphenidate= MC -safe -good tolerability -robust response = work right away -equal response rates -no predictors of preferential response to one or the other
- Stimulants found to improve
- *all 3 core symptoms** -inattention, impulsivity, hyperacitivty *other sx's = noncompliance, impulsive aggression, social interaction, academic productivity and accuracy
- SE of stimulants and CI
- SE = -dec appetite, insomnia, headache, stomachache, irritability CI = cardiac abn
- Insomnia relaed to stimulants
- -sleep hygiene -avoid evening meds -adjunctive pharmacotherapy
- headache/stomach ache related to stimulants
- -dec dose -switch to diff stimulant -switch to another agent
- Irritablity related to stimulants
- -dec dose -try longer acting agent -assess for other disorder
- Growth suppression related to stimulant
- -weight = usu limited to clinical course, give meds with meals, snacks, consider drug holidays -height = some studies show dec 1-3cm other dont, deficits MC in prepubertal kids not adolescents, catch-up gains in height even with continued sitmulant tx
- Tic
- *9% have transient tics < 1% have chronic tics *When tics occur: Decrease dose Switch stimulants Adjust treatment of tics Try nonstimulant medication
- Non-stimulant meds
- 1) Atomoxetine = nonstimulant**, NE reuptake inhibitor, suicide warning 2) Modafinil - but not FDA app 3) TCAs = imipramine and desipramine - block reuptake of NE 4) Bupropion = if depression + ADHD 5) Alpha adrenergic agents - clonidine and guanfacine -
- ADHD and substance abuse disorder
- *Youth -earlier onset SUD + inc risk -earlier onset of smoking *Adults -more prolonged course of SUD -marijuana MC used *Stimulants ok to use but try non-stimulant first - pharmacotherapy of ADHD reduces risk of SUD
- Comorbid depression and anxiety
- -Prioritize treatment -Combination therapy often required -Noradrenergic agents may treat ADHD and depressive symptoms -SSRI's may be effective in treating depression and anxiety but not ADHD -Stimulants effective in treating ADHD but not mood and anxiety disorders -Consider buspirone and benzodiazepines -Psychotherapy and behavior therapy may be particularly important