ADHD, Executive Functions and
PKU
Kevin M. Antshel, Ph.D.
Associate Professor of Psychiatry / Licensed Psychologist
State University of New York – Upstate Medical University
Outline
• ADHD basics
• Executive functioning
• ADHD and PKU
• Questions
ADHD
Is characterized by pervasive and often occurring…
Impairing inattentive symptoms
AND/OR
Impairing hyperactive / impulsive symptoms
Inattention symptoms
DSM-IV SYMPTOM
No attention to details
Can’t sustain attention
Doesn’t listen
No follow-through
Disorganized
Avoids sustained tasks
Loses things
Easily distracted
Forgetful
Typical
6.0
10.3
7.6
5.0
3.3
7.3
13.9
14.5
5.3
Antshel et al., 2007
ADHD
69.5
77.0
68.3
77.7
76.0
62.7
79.2
86.1
68.1
Hyperactive / Impulsive
symptoms
DSM-IV SYMPTOM
Fidgets
Leaves seat
Runs/Climbs
Loud
Driven by a motor
Talks too much
Blurts out answers
Can’t wait turn
Interrupts
Typical
16.6
6.7
0.6
1.9
5.2
19.7
10.2
4.3
16.7
Antshel et al., 2007
ADHD
69.5
63.6
91.3
46.8
55.1
63.6
65.3
56.9
80.1
ADHD diagnosis
• Symptoms present before 7 years of age
• Symptoms must be present in 2 or more
settings (e.g., school, work, home)
• Symptoms must have persisted for at least 6
months
• The disturbance causes clinically significant
impairment in functioning
• Is not better accounted for by another disorder
ADHD “facts”
• Prevalence: 5 – 7 %
• 2:1 – 9:1 male: female ratio
• Co-occurs with multiple other psychiatric
disorders
• Strong heritability
• 60+% continue to have ADHD as adults
Research-supported treatments
• Medications
•Stimulants (e.g., Ritalin, Adderall, etc.)
•Noradrenergic (Strattera)
•Anti-hypertensives (e.g., Clonidine, Tenex)
• Parent Training in Child Management
•Children (<11 yrs., 65-75% respond)
•Adolescents (25-30% show reliable change)
• Teacher Training in Behavior Management
The Usual Questions…
Nigg, 2006
ADHD affects two primary brain areas
Toga et al., 2006
Executive Functions
• Planning
• Organization
• Self-Monitoring
• Prioritizing
• Goal-oriented, problem solving behavior
Low Dopamine Availability Links PKU and ADHD
Decision Tree for Diagnosing
ADHD in PKU
Do ADHD symptoms dramatically lessen / become
less impairing with better phenylalanine control?
Probably not ADHD – no real need for an
evaluation
Decision Tree (cont’d)
Do ADHD symptoms lessen with tighter
phenylalanine control yet continue to impair
functioning?
Could be worth considering an evaluation
Decision tree (cont’d)
Do impairing ADHD symptoms continue in the
presence of historically and currently welltreated PKU?
Should have an evaluation
Conclusions
• ADHD and PKU share neurochemical
(dopamine), neurological (prefrontal, striatal)
and psychological (executive function deficits)
characteristics
• To reliably diagnose ADHD, however, ADHD
symptoms need to persist and impair
functioning in the context of well-treated PKU