Diagnosis and Management
of ADHD
ADHD
“Attention deficit hyperactivity disorder (ADHD) is
a pattern of behaviour which is the most recent in
a series of American attempts to characterise
inattentive restlessness as a condition. It is
effectively a syndrome encompassing hyperactivity,
poor concentration and marked impulsive,
impatient, excitable behaviour. Most, but not all,
instances are predominantly genetic in origin, with
various inherited deficiencies of the dopamine
neurotransmitter system.”
Hill, P. Child & Adolescent Mental Health in Primary Care 2003; 1(1):2-4
Symptoms of ADHD
Inattention
Hyperactivity
Impulsivity
ADHD: Prevalence and
Demographics

Overall prevalence 3% to 10% in school-aged
children

Diagnosed in boys 3 to 4 times more often than
in girls

Persists in 30% to 50% of patients into
adolescence and adulthood (symptom profile
may change)
Neurochemical Pathophysiology
of ADHD
Noradrenaline
Dopamine
Nerve
Impulse
Transporter
Synapse
Receptors
Impact of ADHD on Patients
and Family

Patients





Poor academic
achievement
Social impairment
Low occupational
status
Increased risk of
substance abuse
Increased risk of injury

Family




Increased stress levels
Increased depression
Increased marital
discord
Changed work status
Impact of ADHD on
School Performance

Poor classroom behaviour

Poor academic achievement


Special education requirements (tutoring and
special educational programmes)
School exclusion (either suspension or
expulsion)

Repetition of grades

Failure to gain external qualifications
Effects of ADHD on Behavioural
Development

Problems with productivity and motivation

Reduced ability to express ideas and emotions

Decreased working memory

Problems with social interaction

Impairments in speech

Problems with verbal reasoning
Developmental Impact of ADHD
Behavioural
disturbance
Academic problems
Difficulty with social interactions
Self-esteem issues
Legal issues, smoking
and injury
Pre-school
Adolescent
School-age
Behavioural disturbance
Academic problems
Difficulty with social
interactions
Self-esteem issues
Occupational failure
Self-esteem issues
Relationship problems
Injury/accidents
Substance abuse
Adult
College-age
Academic failure
Occupational difficulties
Self-esteem issues
Substance abuse
Injury/accidents
Defining Comorbidity

ADHD is highly comorbid

Comorbidity is defined as two different
diagnoses present in an individual patient

It is important to recognise comorbid disorders

Comorbidities may require treatment
independent from and different to therapy for
ADHD
Co-occurring Disorders in Children
(n = 579)
ADHD
alone
31%
Tics
11%
Conduct
Disorder
14%
Mood Disorders 4%
Oppositional
Defiant
Disorder
40%
Anxiety
Disorder
34%
MTA Cooperative Group.
Arch Gen Psychiatry 1999;
56:1088–1096
Common Associated
Comorbidities
60
40
(%)
20
0
Oppositional Anxiety Learning
defiant
disorder disorder
disorder
Mood Conduct Smoking Substance
disorder disorder
use
disorder
Milberger et al. Am J Psychiatry 1995; 152: 1793–1799
Biederman et al. J Am Acad Child Adolesc Psychiatry 1997; 36: 21–29
Castellanos. Arch Gen Psychiatry 1999; 56: 337–338
Goldman et al. JAMA 1998; 279: 1100–1107
Szatmari et al. J Child Psychol Psychiatry 1989; 30: 219–230
Tics
Input Needed to Make
a Diagnosis
Teacher
Diagnosis
Child
Parent
Symptom Groups
Inattention
Hyperactivity
Impulsivity
Does not attend
Fidgets
Talks excessively †
Fails to finish tasks
Leaves seat in class
Blurts out answers
Can’t organise
Runs/climbs
excessively
Cannot await turn
Avoids sustained
effort
Loses things,
‘forgetful’
Easily distracted
Cannot play/work
quietly
Interrupts others
Intrudes on others
Always ‘on the go’
Talks excessively *
* ‘Talks excessively’ is one of the DSM-IV criteria for hyperactivity but not one of the ICD-10 criteria
† ‘Talks excessively’ is one of the ICD-10 criteria for impulsiveness but not one of the DSM-IV criteria
DSM-IV – Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association, 1994)
ICD-10 – International Classification of Diseases, 10th Edition (World Health Organisation, 1993)
DSM-IV ADHD Diagnostic Criteria






List of symptoms must be present for past 6
months
Must have six (or more) symptoms of inattention
and/or hyperactivity–impulsivity
Some symptoms present before 7 years of age
Some impairment from symptoms must be
present in two or more settings (e.g. school and
home)
Significant impairment: social, academic or
occupational
Exclude other mental disorders
DSM-IV Subtypes of ADHD

Predominantly inattentive

Predominantly hyperactive–impulsive

Mixed/combined

In partial remission

Not otherwise specified (NOS)
ICD-10 HKD Diagnostic Criteria






Used to diagnose hyperkinetic disorder (HKD), a
more severe form of ADHD
List of symptoms must be present for at least six
months
Must have:
at least six symptoms of inattention AND
at least three symptoms of hyperactivity AND
at least one symptom of impulsivity
Onset of symptoms no later than 7 years of age
Impairment of symptoms must be present in two or
more settings (e.g. school and home)
Significant impairment: social, academic or
occupational
Important Rating Tools for ADHD






Conners Parent Rating Scale – assesses and
monitors response to treatment
IOWA Conners – measures dimensions of behaviour
associated with ADHD
SKAMP Measures – measures the classroom
manifestation of ADHD
SNAP-IV Scale – derived from descriptions in DSM-IV
Continuous Performance Test (CPT) – measures the
attention span in children with ADHD
C-DISC – computer-assisted diagnostic interview
schedule for children
Therapy Options as Part of a Total
Treatment Programme

Behavioural treatment

Medication management

Combining medication/behavioural treatment

Educating parents/patient about ADHD

Educational support services
Tools Used in Behavioural
Treatment

Specific strategies






Reward system
Time out
Social reinforcement
Behaviour modelling



Group problem-solving
Sports skills
Social skills training
Support for parents
Family and patient education
Cunningham, Barkley. Child Dev 1979; 50: 217–224
Behavioural Treatment in the
Home

Identify problem situations and the precipitating
factors

Enhance positive parent–child interactions

Limit negative parent–child interactions

Use cost systems to reduce problem behaviours

Use time outs as punishment for serious
problem behaviours
Behavioural Treatment in the
Classroom



Behavioural treatment in school setting similar to
the approach used in home with parents
Goal: Reduce inattention and disruptive
behaviour
Specific school accommodations:




Ensure structure and predictable routines
Employ cost–response token economy systems
Use daily report cards
Teach organisational and work/study skills
Atkins, Pelham. 1992:69–88; Barkley, Cunningham. Arch Gen Psychiatry 1979; 36: 201–208
Effectiveness of Behavioural
Therapy




Parent training is generally regarded as the most
effective behavioural therapy
Parent training combined with medication
management increases parent acceptability of
medication
School-based treatment is more effective than
individual strategies, however benefits are only
seen during treatment programmes
Individual treatment approaches have not been
shown to be effective
Pharmacological Agents Used
in Treatment of ADHD*
Stimulants
Methylphenidate
Amphetamine compounds
Dextroamphetamine
Pemoline
Antidepressants
Tricyclic antidepressants
Bupropion
Antihypertensives
Clonidine
Guanfacine
(Recommended
first-line therapy)
* Not all agents are available in some countries
Wilens T, et al. ADHD, In Annual Review of Medicine, 2002: 53
Greenhill L. Childhood attention deficit hyperactivity disorder: pharmacological treatments. In: Nathan PE, Gorman J, eds.
Treatments that Work. Philadelphia, PA: Saunders; 1998:42-64
ADHD Pharmacotherapy –
Responsiveness
Methylphenidate
Amphetamine
Pemoline
Tricyclic
antidepressants
Bupropion
MAOI
Clonidine/
Guanfacine
0
20
40
60
% Responders
80
Wilens TE, Spencer TJ. Presented at Massachusetts General Hospital’s Child and Adolescent Psychopharmacology
Meeting, March 10-12, 2000, Boston, MA
100