Attention-Deficit Hyperactivity Disorder
W. Alexander Ellis, MS III
Psychiatry Rotation, April 22, 2011
Diagnosing Attention Deficit
Hyperactivity Disorder
• Attention Deficit Hyperactivity Disorder
(ADHD) is a diagnosis based on a set
of symptoms of behavior patterns.
"There are no laboratory tests, neurological
assessments, or attentional assessments that have
been established as diagnostic in the clinical
assessment of Attention-Deficit/Hyperactivity
Disorder.“
-Diagnostic and Statistical Manual of
Mental Disorders Fourth Edition Text Revision
DSM-IV Criteria for ADHD
ADHD is defined by five categories
labeled A, B, C, D, E.
Category A is further subdivided into two
sections with multiple criteria
DSM-IV Criteria for ADHDCategory A
• A. “Persistent pattern of inattention and/or
hyperactivity-impulsivity that is more frequently
displayed and is more severe than is typically
observed in individuals at comparable level of
development.” Individual must meet criteria for either
(1) or (2):
DSM-IV Criteria for ADHDCategory A (cont.)
(1) Six (or more) of the following symptoms of inattention have persisted
for at least six months to a degree that is maladaptive and inconsistent
with developmental level:
Inattention
(a) often fails to give close attention to details or makes careless
mistakes in schoolwork, work or other activities
(b) often has difficulty sustaining attention in tasks or play activity
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish
schoolwork, chores or duties in the workplace (not due to oppositional
behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
(g) often looses things necessary for tasks or activities (e.g., toys,
school assignments, pencils, books or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
DSM-IV Criteria for ADHDCategory A (cont.)
(2) Six (or more) of the following symptoms of hyperactivity-impulsivity
have persisted for at least six months to a degree that is maladaptive
and inconsistent with developmental level:
Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which
remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective
feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often “on the go” or often acts as if “driven by a motor”
(f) often talks excessively
Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations
or games)
DSM-IV Criteria for ADHDCategories B, C, D, E
B. Some hyperactive-impulsive or inattentive symptoms must
have been present before age 7 years.
C. Some impairment from the symptoms is present in at least
two settings (e.g., at school [or work] and at home).
D. There must be clear evidence of interference with
developmentally appropriate social, academic or occupational
functioning.
E. The disturbance does not occur exclusively during the
course of a Pervasive Developmental Disorder, Schizophrenia,
or other Psychotic Disorders and is not better accounted for by
another mental disorder (e.g., Mood Disorder, Anxiety Disorder,
Dissociative Disorder, or a Personality Disorder).
DSM-IV Criteria for ADHD
3 Types
• Attention deficit hyperactivity disorder,
combined type:
– If both Criteria A1 and A2 are met for the past 6
months
• Attention deficit hyperactivity disorder,
predominantly inattentive type:
– If Criterion A1 is met but Criterion A2 is not met for the
past 6 months
• Attention deficit hyperactivity disorder,
hyperactive-impulsive type:
– If Criterion A2 is met but Criterion A1 is not met for the
past 6 months
» DSM IV-TR as quoted in Kaplan & Sadock
Epidemiology
• Reported incidence in school-age children
varies from 2 to 20 percent
• First-degree relatives are at increased risk of
developing it as well as other disorders, e.g.,
disruptive behavior disorders and learning
disorders
• “Parents of children with ADHD show an
increased incidence of hyperkinesis,
sociopathy, alcohol use disorders and
conversion disorder.”
» Kaplan & Sadock (2007)
Epidemiology- Gender
• Prevalence: boys more than girls; ratios
range from 2 to 1 to 9 to 1 (Kaplan & Sadock, 2007)
• However a published summary of a 1996
National Institute of Mental Health (NIMH)
conference that considered gender
differences in children with ADHD examined
the literature and raised questions about the
validity of the accepted differences in the
ratios
Epidemiology- Gender (cont.)
• “The consensus was that part of the higher male-tofemale ratio in clinical samples results from boys
being more likely to be referred for their comorbid
conduct or oppositional disorder and aggression
(Biederman, 1994; Gaub & Carlson, in press; Lahey,
1994). Even after correction for comorbidity,
however, there remained some referral bias favoring
referral of boys (Lahey, 1994)”
– Arnold, LE (1996). Sex Differences in ADHD, Journal of Abnormal Psychiatry, 24(5)
Etiology
•
•
•
•
•
•
Possibly multifactorial causes that
increase a child’s susceptibilty to
developing ADHD
Genetic Factors
Developmental Factors
Brain Damage
Neurochemical Factors
Neurophysiological Factors
Pyschosocial Factors
Genetic Factors
• Greater concordance between monozygotic twins
than dizygotic twins
• Siblings of affected child have twice the risk of
acquiring the disorder compared to the general
population
• Greater incidence of ADHD in biological parents than
adoptive parents of affected child
• Children with ADHD more commonly have parents
with alcohol use disorders and antisocial personality
disorder than children in the general population
» Kaplan & Sadock (2007)
Developmental Factors
• September is the peak month for births
of children with ADHD
– Possible contributing factor is 1st trimester
exposure to winter infections
• Question: May there be an as yet
undiscovered TORCH-like virus or fungus that
increases the risk for any fetus regardless of
family history?
Brain Damage
• Hypothesis is of “subtle damage” to the CNS
during fetal and perinatal development:
“associated with circulatory, toxic, metabolic,
mechanical, or physical insult to the brain
during early infancy caused by infection,
inflammation, and trauma.”
» Kaplan & Sadock (2007)
Neurochemical Factors
• The fact that the most effective drugs used to treat
ADHD are stimulants that affect dopamine and
norepinephrine has contributed to neurotransmitters
hypotheses of dysfunction in the dopaminergic and
adrenergic systems.
• Studies have determined that the locus ceruleus is
integral to attention
• Possibly a dysregulation of the peripheral
noradrenergic system causes an accumulation of
epinephrine and a subsequent homoeostatic reset of
the centrally-located locus ceruleus
Neurophysiological Factors
• Some children with delays in the normal post natal
growth spurts that the brain undergoes display
symptoms of ADHD.
• This is often accompanied by abnormal nonspecific
EEG patterns
• Positron emission tomography (PET) scans have
revealed comparatively “lower cerebral blood flow
and metabolic rates in the frontal lobes of children
with ADHD than in controls.” (Kaplan & Sadock, 2007)
• Because cerebral structures maintain an inhibitory
control on lower structures, one theory holds that the
frontal lobes of affected children is not performing
adequately leading to disinhibition.
Psychosocial Factors
• Children subjected to emotional deprivation
display signs of overactivity and poor
attention similar to ADHD that disappear
when the deprivation is corrected
• Genetically or temperamentally predisposed
children may develop ADHD due to stressful
psychic events, abuse, disrupted family
dynamics, or other anxiety-inducing factors
Comorbidities
• Possible developmental disorders
–
–
–
–
language
arithmetic
reading
coordination
• High incidence of
–
–
–
–
–
mood disorders
anxiety disorders
personality disorders
Oppositional Defiant Disorder (30-40%)
conduct disorders (30-50%)
Clinical Features
• Onset may occur in infancy but is seldom
recognized before toddler age
– Infants may either be hypersensitive and easily
agitated by changes in external stimuli such as
light, temperature or may by unusually
unresponsive, sleep a lot and be slow to develop
– Usually infants belong to the former group and
sleep little
Clinical Features (cont.)
• School age children have learning and behavioral
problems characterized by hyperactivity, emotional
lability, lack of focus, poor concentration, easy
distractibility, impulsivity, memory deficits, and
learning disabilities.
– Comorbid learning disorders may be the primary cause of
learning difficulties, not ADHD
• A large majority of children with ADHD additionally
have increased irritability and may display
aggression and defiance.
• The resulting negative response to their behavior
affects their self-esteem and may trigger them to
act out, thereby creating a self-defeating cycle.
Clinical Features (cont.)
• “A meta-analysis (Gaub & Carlson, in press)
suggested that clinic-referred girls with
ADHD had more severe attentional and
intellectual impairment across all IQ scales
than clinically referred boys with ADHD, but
less hyperactivity and conduct disorder, and
a similar degree of impairment in most other
domains of function.”
» Arnold, LE (1996). Sex Differences in ADHD, Journal of Abnormal Psychiatry,
24(5)
Clinical Features (cont.)
“Females with ADHD symptoms may go unidentified
during childhood and adolescence (Quinn & Nadeau,
2000). One possible explanation is that most
referrals for ADHD during childhood are triggered by
the display of hyperactivity, impulsivity, and
aggression. Females are less likely to be hyperactive
and aggressive and more likely to manifest
inattentive symptoms.”
–
Lee, D.H., Oakland T., Jackson, G. & Glutting, J. (2008). Estimated prevalence of Attention-Deficit/
Hyperactivity disorder symptoms among college freshmen: Gender, race and rater effects. Journal
of Learning Disabilities, 41(371)
Differential Diagnosis
• Normal active child with a child’s short attention
span
• Anxiety- in a child can manifest as “overactivity
and easy distractibility” (Kaplan & Sadock, 2007)
• Mania- shares features with ADHD
– “children with bipolar I exhibit more waxing and
waning of symptoms than those with ADHD” (Kaplan &
Sadock, 2007)
– However, having ADHD does not preclude having or
developing bipolar disorder
• Conduct disorder and ADHD may coexist
Course and Prognosis
• Course is variable
• ADHD symptoms may persist into
adulthood in up to 60% of childhood cases
– Decreased attention span and impulse
control may be the dominant symptoms
with a loss of hyperactivity with age
• Impulsivity > hyperactive
• Remission, when it does occur, usually
happens after age 11 years, between the
the ages of 12 and 20
Course and Prognosis (cont.)
• Adolescents with ADHD risk developing
conduct disorder
• In cases that do remit, most remission
is partial.
• Sequelae:
– Antisocial behavior
– Substance use disorders
– Mood disorders
– Learning problems persist
» (Kaplan & Sadock, 2007)
Course and Prognosis (cont.)
“Because of the prominence of hyperactivity and impulsivity
at the younger ages, symptoms more common in children
may be overrepresented in the DSM–IV criteria (Barkley,
2006), thus requiring college students to present with more
severe symptoms in order to be diagnosed. In addition,
ADHD symptoms may manifest differently in adulthood than
in childhood, whereas the core ADHD symptoms of
inattention, hyperactivity, and impulsivity are overt in
children. For example, college students and other adults with
ADHD may be more likely to display difficulties with internal
distractions (e.g., daydreaming or a constant flow of taskrelevant and irrelevant ideas; Conners et al., 1999; Downey,
Stelson, Pomerleau, & Giordani, 1997; Weyandt, Iwaszuk, &
Fulton, 2003).”
–
Lee, D.H., Oakland T., Jackson, G. & Glutting, J. (2008). Estimated prevalence of Attention-Deficit/
Hyperactivity disorder symptoms among college freshmen: Gender, race and rater effects. Journal
of Learning Disabilities, 41(371)
Course and Prognosis (cont.)
“A growing number of studies indicate that
biased samples might underlie extreme
gender effects on the prevalence of ADHD in
clinically referred paediatric study samples…
Compared with paediatric and adolescent
studies, adult ADHD studies have generally
shown a more balanced distribution of
prevalence in men and women.”
» Simon, V., Czobar P., Balint S., Meszaros A. & Bitter, I., (2009). Prevalence and
correlates of adult attention-deficit hyperactivity disorder: a meta-analysis. The
British Journal of Psychiatry 194, 208.
Treatment
• Medication is the most effective
treatment for ADHD but should be part
of an overall treatment plan that may
include nonpharmacologic treatment
• Psychopharmacological therapy for
adults with ADHD may continue
indefinitely
Pharmacologic Treatments
• Central nervous system stimulants are first
line
– Methylphenidate compounds
• Ritalin, Ritalin-SR, Concerta, Metadate CD, Metadate
ER, Focalin
– Dextroamphetamine
• Dexidrine,Dexidrine Spansules, DextroStat
– Dextroamphetamine and amphetamine salts
• Adderall, Aderall XR
Pharmacologic Treatments (cont.)
• Non CNS stimulants
– Norepinephrine uptake inhibitor
• Atomoxetine (Stratera)
– Antidepressants
• Buproprion (Welbutrin, Welbutrin SR)
• Venlafaxine (Effexor, Efexor XR)
– α-adrenergic receptor agonists
• Clonidine (Catapres), Guanfacine (Tenex)
Non-Pharmacologic Treatments
• Family, individual and group
psychotherapy
– Behavior modification techniques and
social skill training
• Parent psychoeducation
• Educational Interventions
– Teacher and classroom modifications
» Stead, L. G., Kaufman, M. S. & Yanofski, J. (2011). First aid for the psychiatry
clerkship (3rd ed.). New York, NY: McGraw-Hill.
Attention Deficit Hyperactivity
Disorder Not Otherwise Specified
• This category is for symptoms of inattention or
hyperactivity-impulsivity that do not meet criteria for
attention-deficit/ hyperactivity disorder. Examples
include:
1. Individuals whose symptoms and impairment meet the
criteria for attention-deficit/ hyperactivity disorder,
predominantly inattentive type but whose age of onset is 7
years or after
2. Individuals with clinically significant impairment who
present with inattention and whose symptom pattern does
not meet the full criteria for the disorder but have a
behavioral pattern marked by sluggishness, daydreaming,
and hypoactivity
»
DSM IV-TR, 2000 as quoted in Kaplan & Sadock, 2007
Utah Criteria for Adult Attention Deficit
Hyperactivity Disorder
I.
Retrospective childhood ADHD diagnosis
A.
B.
Narrow criterion: met DSM-IV criteria in childhood by parent
interview
Broad criterion: both (1) and (2) are met as reported by patient
1.
2.
II.
Childhood hyperactivity
Childhood attention deficits
Adult characteristics: five additional symptoms, including
ongoing difficulties with inattentiveness and hyperactivity and
at least three other symptoms:
A.
B.
C.
D.
E.
F.
G.
Inattentiveness
Hyperactivity
Mood lability
Irritability and hot temper
Impaired stress tolerance
Disorganization
impulsivity
III. Exclusions: not diagnosed in presence of severe depression,
psychosis, or severe personality disorder
References
• Sadock, B. J., Sadock, V. A. (2007) Kaplan and
Sadock’s synopsis of psychiatry: Behavioral
sciences/ clinical sciences (10th ed.). Philadelphia,
PA: Lippincot Williams & Wilkins.
• Arnold, LE (1996). Sex Differences in ADHD,
Journal of Abnormal Psychiatry, 24(5)
• Lee, D.H., Oakland T., Jackson, G. & Glutting, J.
(2008). Estimated prevalence of Attention-Deficit/
Hyperactivity disorder symptoms among college
freshmen: Gender, race and rater effects. Journal
of Learning Disabilities, 41(371)
References (cont.)
• Simon, V., Czobar P., Balint S., Meszaros A. &
Bitter, I., (2009). Prevalence and correlates of
adult attention-deficit hyperactivity disorder: a
meta-analysis. The British Journal of Psychiatry
194
• Stead, L. G., Kaufman, M. S. & Yanofski, J.
(2011). First aid for the psychiatry clerkship (3rd
ed.). New York, NY: McGraw-Hill.
THANK YOU
Questions?