ADHD
Stephanie Stockburger, MD FAAP
Assistant Professor
Adolescent Medicine Clinic
University of Kentucky
Objectives
1. Review Diagnostic Criteria of ADHD
 2. Summarize ADHD Evaluation
 3. Describe Current ADHD Treatment

ADHD: Prevalence

Affects 2-18% of children
◦ Depends on diagnostic criteria and population
studied
◦ CDC: 9.5% of children ages 4-17 years affected
◦ Affects 8-10% of school aged children
 One of the most common disorders of childhood
◦ More common in males than females
 Predominantly hyperactive 4:1 (males:females)
 Predominantly inattentive 2:1 (males:females)
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w
ADHD in children and adolescents. Epidemiology and pathogenesis. www.uptodate.com
State-based Prevalence Data
of ADHD Diagnosis


Percent of Youth 4-17 ever Diagnosed with AttentionDeficit/Hyperactivity Disorder by state: National Survey of
Children's Health, 2007
http://www.cdc.gov/ncbddd/adhd/prevalence.html
Comorbid Disorders

Children and Adolescents with ADHD
frequently have comorbid psychiatric
disorders
◦
◦
◦
◦
◦


Oppositional Defiant Disorder (ODD)
Conduct Disorder
Depression
Anxiety Disorder
Learning disabilities
May be primary or secondary (exacerbated
by ADHD)
http://www.cdc.gov/ncbddd/adhd/workshops/outcomes.html
Diagnosed Attention Deficit Hyperactivity
Disorder and Learning Disability: United
States, 2004-2006

http://www.cdc.gov/ncbddd/adhd/data.html
Pathogenesis: What causes ADHD?
Not definitely known.
 Genetic imbalance of catecholamine
metabolism in the cerebral cortex (illustrated

by structural and functional brain imaging, animal studies, and the response
to drugs with noradrenergic activity like methylphenidate)
Twin studies: concordance as high as 92
percent in monozygotic twins and 32
percent in dizygotic twins
 Number of genes appear to play a role.


Biederman, Faraone. Attention-deficit hyperactivity disorder. The Lancet. Volume 366, Issue 9481, 16–22 July 2005, Pages 237–248.

Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013.
Brain Changes


Children with ADHD have differences in
brain structures
Changes especially noted in anterior brain
areas
◦ Smaller prefrontal cortical volumes
◦ Reduced thickness of the anterior cingulate
cortex
◦ Cortical thinning in bilateral superior frontal
brain regions

Frontal cortex monitors impulse control!

Attention-deficit hyperactivity disorder. J Biederman, S.V. Faraone. The Lancet. Volume 366, Issue 9481, 16–22 July 2005, Pages 237–248.

Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013.

Cortical abnormalities in children and adolescents with attention-deficit hyperactivity disorder. E.R. Sowell, P.M. Thompson, S.E. Welcome, A.L. Henkenius, A.W. Toga, B.S. Peterson. The
Lancet. Vol 362. 2013.
What do the brain changes mean?

Neuropsychologic testing suggests that
patients with ADHD have:
◦ Impaired executive functions (processes involved
in forward planning, including abstract reasoning,
mental flexibility, working memory)
◦ And/or difficulties with response inhibition

This goes along with the parts of the brain
that are affected!

Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013.

Impact of Executive Function Deficits and Attention-Deficit/Hyperactivity Disorder (ADHD) on Academic Outcomes in Children. Biederman J, Monuteaux MC, Doyle AE, Seidman LJ, Wilens
TE, Ferrero F, et al. Journal of Consulting and Clinical Psychology. Vol 72, No. 5;2004, 757-66.
Neurotransmitter Changes

Children and Adolescents with ADHD
have an increase in dopamine transporter
density
◦ This may clear dopamine from the synapse
too quickly


Methylphenidate increases extracellular
dopamine in the brain (why the
medication helps!)
Progress and Promise of Attention-Deficit Hyperactivity Disorder Pharmacogenetics. Froehlich TE, McGough JJ, Stein MA. CNS Drugs. 2010
February;24(2):99-117.
Environmental Factors

Dietary influences (controversial)
◦ Food additives (artificial colors, artificial
flavors, preservatives)
◦ Refined sugar intake
◦ Food sensitivity (allergy or intolerance)
◦ Essential fatty acid deficiency
◦ Iron and zinc deficiency

Prenatal exposure to tobacco

Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed 6/5/2013.

The Diet Factor in Attention-Deficit/Hyperactivity Disorder. Millichap and Yee. Pediatrics 2012;129:330-7.
ADHD: Diagnosis
ADHD is characterized by a pattern of behavior,
(several symptoms)* present in multiple settings
(e.g., school and home), that can result in
performance issues in social, education, or work
settings.
 Two subtypes:

◦ Hyperactivity and Impulsivity
◦ Inattention



DSM 5 Diagnostic Criteria
*change from DSM IV. “Several symptoms”
instead of “impairment.”
www.cdc.gov/ncbddd/adhd/diagnosis.html
ADHD: Diagnosis
Children must have at least six symptoms
from the subtype
 Older adolescents and adults (over 17)
must have five.
 Symptoms must be present before age 12
years*



*change from DSM IV. Previously before
age 6.
www.cdc.gov/ncbddd/adhd/diagnosis.html
ADHD: Diagnosis




Symptoms interfere with, or reduce the
quality of, social, school, or work functioning
Symptoms do not happen only during the
course of schizophrenia or another
psychotic disorder.
Symptoms are not better explained by
another mental disorder (mood d/o, anxiety
d/o, dissociative d/o, or personality d/o)
www.cdc.gov/ncbddd/adhd/diagnosis.html
Diagnostic Criteria: Hyperactivity

Hyperactivity-Impulsivity subtype (children must
have 6, over age 17 must have 5)
◦ Hyperactivity
 Often fidgets with hands or feet or squirms in seat
 Often leaves seat in classroom or in other situations in which
remaining seated is expected
 Often runs about or climbs excessively in situations in which
it is inappropriate (in adolescents or adults, may be limited to
feelings of restlessness)
 Often has difficulty playing or engaging in leisure activities
quietly
 Is often “on the go” or often acts as if “driven by a motor”
 Often talks excessively

www.cdc.gov/ncbddd/adhd/diagnosis.html
Diagnostic Criteria: Impulsivity

Impulsivity
◦ Often blurts out answers before questions
have been completed
◦ Often has difficulty awaiting turn
◦ Often interrupts or intrudes on others (eg,
butts into conversations or games)

www.cdc.gov/ncbddd/adhd/diagnosis.html
Diagnostic Criteria: Inattention

(children must have 6; over age 17 must have 5)


Often fails to give close attention to details or makes careless mistakes in schoolwork,
work, or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does no 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 (not due to oppositional behavior or failure to understand
instructions)
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or homework)
Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils,
books, keys, paperwork, cell phones, eyeglasses or tools)
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities

www.cdc.gov/ncbddd/adhd/diagnosis.html

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Differential Diagnosis

Developmental variations
◦ Gifted, intellectual disability

Neurologic or developmental conditions
◦ Learning disability, language or communication
disorder, autism

Emotional and behavior disorders
◦ Anxiety, ODD, OCD, PTSD

Psychosocial and environmental factors
◦ Maternal depression, stressful home environment

Medical conditions
◦ Lead poisoning, thyroid abnormality, hearing or vision
impairment, sleep disorders
Treatment

Preschool children (ages 4-5)
◦ Initially: behavioral therapy
◦ If behaviors do not improve consider
medication.
◦ Methylphenidate is treatment

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in
Children and Adolescents. Pediatrics. Volume 128, Number 5, November 2011.
Treatment

School-aged children (age 6 and older) and
adolescents
◦ Initial treatment with behavioral therapy
combined with stimulant medication.
◦ Non-stimulants may be appropriate for certain
children
◦ Co-morbid conditions must be considered

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and
Adolescents. Pediatrics. Volume 128, Number 5, November 2011.
Medication


Long and short-acting stimulants
Short acting: Focalin, Methylphenidate,
Ritalin, Adderall

Long acting: Focalin XR, Concerta, Adderall
XR, Vyvanse, Daytrana patch

Non-stimulant: Atomoxetine (Strattera),
Clonidine, Guanfacine (Intuniv, Tenex),
Wellbutrin (unlabeled use)
Medications
Short acting medications must be taken 23 times per day
 Long-acting medications taken in the
morning
 Peak at 30-40 minutes
 Delayed peak if taken with high fat meal

Medication Side Effects

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Decreased appetite
Poor growth
Cardiovascular
Dizziness
Insomnia/nightmares
Mood lability
Rebound
Tics
Psychosis
Diversion and misuse
Medication Myths
At therapeutic doses, medications do not
sedate or tranquilize children
 Medications do not increase the risk of
addiction if taken as directed
 Stimulants are not ‘gateway’ drugs leading
to illegal drug or alcohol abuse

Medication Dangers
Medication does have abuse potential
 Stimulant medications are controlled
substances
 When doctors prescribe stimulants, a
Kasper report must be run every 90 days

Prognosis for children and
adolescents with ADHD
greater risk for incurring intentional and
unintentional injury
 2-4x more likely to have a motor vehicle
accident
 Impaired academic functioning
(completion of less schooling, lower
achievement scores, failure of more
courses)
 Increased risk of substance use if also
with conduct or antisocial disorders

ADHD in Adolescence: Impulsive
behavior
May have more difficulty than other teens
in regulating their impulses
 May act first and think later-but stakes are
higher than when younger child
 Substance abuse, aggressive behavior,
unprotected sex, reckless driving or other
high-risk situations


healthychildren.org
ADHD in Adolescence
Minor impulsive behavior like interrupting
others and fidgeting at desk may cause
academic or social problems.
 More ‘mature’ behavior may be expected
 Work with adolescent on ways to
minimize potentially damaging effects of
this behavior


healthychildren.org
ADHD in Adolescence: Overall
Problems
Difficulty focusing and organizing
 Problems with long-term planning
 Low self-esteem
 Independence issues


healthychildren.org
Persistance into Adulthood?






1/3 to 2/3 continue to manifest ADHD
symptoms into adult life
One study found lower status jobs
Increased risk to develop antisocial
personality disorder in adulthood
By developing strengths and structuring
environment, adults with ADHD can lead
very productive lives!
In some careers having high-energy behavior
is an asset!
healthychildren.org
Daily Life

Communication Style with a child with
ADHD:
◦ Pause to get attention
◦ Maintain eye contact
◦ Have child repeat back or explain what you have
said to make sure they understand
◦ Avoid interrupting frequently as child may not be
able to stay engaged
◦ If attention is wandering, take their hand, touch
arm or make other physical contact

healthychildren.org
HCPROD
Effective Discipline (healthychildren.org)
Child's Behavior*
Your Responses
Effective
Constructive
Temper Tantrums
Walk away.
Discuss the incident in
an age-appropriate
manner when child is
calm.
Overexcitement
Distract with another
activity.
Talk about his behavior
in an age-appropriate
manner when he's calm.
Hitting or biting
Discuss consequences
of his actions (pain,
Immediately remove
damage, bad feelings) to
him from situation or in himself and others in an
anticipation of this
age-appropriate
behavior.
manner. Try one-word
time-out after brief
response.
Not paying attention
Establish eye contact to
hold his attention.
Make sure your
expectations are ageappropriate for your
child's developmental
level (ask him to listen
to a story for three
minutes instead of ten;
don't insist he sit
through a full church
service).
Refuses to pick up toys
Don't let him play until
he does his job.
Show him how to do
the task and help him
with it; praise him when
he finishes.
Effective Discipline
Discipline means teaching self-control.
 It is important to respond immediately
and consistently.
 Do not spank or slap your child, may
contribute to negative self-image and
resentment. Teaches the child to hit when
angry.


healthychildren.org
The Classroom- Structure is Key!
Children with ADHD make significantly
better progress when classroom is
structured
 Clear rules and limits
 Immediate, appropriate enforcement,
predictable routines
 Desks facing forward
 Small class size


healthychildren.org
Ideal Teacher
Engaging, fun, interesting, and exciting
 Structure, but can also be flexible
 Able and willing to use multiple
approaches to teaching


healthychildren.org
Good Habits for Academic Success

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Use a daily planner or handheld computer
Use a backpack as the location for all schoolwork
and supplies
Organize an assigned locker
Make lists of tasks to be accomplished, ideas for
an essay, people to call about a project
Use an outline or flowchart format to take notes
Preview
Break up large tasks into a series of small steps
Set aside a routine time and lace for doing
homework
healthychildren.org
Closing the Gap between School
and Home
Daily Report Cards and Journal
Have meeting and agree upon measureable
goals
 Teacher to check off items and send home
daily
 Record detailed observations or requests in
a journal
 Parent to provide home-based incentives
 If parent and teacher disagree, may need to
involve principal, counselor, pediatrician, or
therapist



Comprehensive Treatment for Attention Deficit Disorder (CTADD) Web Site
ADHD and Homework
All children work differently
 Some need quiet and isolated time
 Others do better with some action, like
at the kitchen table with the radio playing
 Make sure child has brought home
homework and has all necessary materials
 May need help checking over work and
putting in folder to make sure it gets
turned in


healthychildren.org
Daily Routines

Success of rules and strategies in home is
influenced by the quality of the
relationship that the parent has with
child/teen
◦ Keep child on daily schedule
 Time of waking up, eating, bathing, leaving for
school, going to sleep same each day
 Give warnings for event or activity
 Give 15, 10, 5 minute warnings for changes in
activity

healthychildren.org
Daily Routines


Cut down on distractions
Develop a homework plan with your child
◦
◦
◦
◦
Create homework space, stock with supplies
Homework incentive chart with rewards
Second set of schoolbooks at home
Divide homework into small working parts with
breaks
◦ Use special timers to keep on track
◦ Share homework detail with other family
members
◦ Have spot near door to keep backpack

healthychildren.org
Daily Routines

Organize your house
◦ Less likely to lose items if put in designated
place
◦ Develop ‘house rules,’ monitor daily, reward
for compliance
◦ Provide a safe space in the home for active
play

healthychildren.org
Daily Routines

Use charts and checklists
◦ Friendly reminders: checklists of things to
take to school each day and bring home
◦ Post on morning exit door
◦ Focus on effort child made to do work and
chores, not just completion of task

healthychildren.org
Daily Routines

Limit choices
◦ Give only 2-3 options at a time
◦ Foster ‘best outcomes’ by creating and encouraging a
sense of resiliency and participation
◦ Validate positive plans, even if you feel some things
should be done differently
◦ Express empathy for concerns and problems
◦ Include teen in decision-making process and problemsolving issues
◦ Encourage involvement in family activity planning and
outings
◦ Provide sincere praise, even for the small things

healthychildren.org
Daily Routines

Set small, reachable goals
◦ Aim for step-by-step progress
◦ Succeed by taking small steps
◦ Keep plan child-centered!

healthychildren.org
Cognitive Behavioral Approach
Especially helpful if coexisting disorders
(ODD, CD, mood, anxiety disorders)
 Aggressive behavior, poor tolerance for
frustration, inflexibility, poor problem
solving skills
 Significant family conflict


healthychildren.org
Collaborative Problem-Solving
approach
Developed by Dr. Ross Greene
Helps adults and children become proficient
at resolving problems collaboratively
 Defuses conflict and teaches kids cognitive
skills they may lack
 3 options for problem solving:


◦ 1. imposition of adult will (unilateral problem
solving)
◦ 2. collaborative problem-solving
◦ 3. deferring resolution of the problem, at least
for now

healthychildren.org
Cognitive Behavioral Approach,
continued

Adults are helped to master the
‘ingredients’ involved in solving problems
collaboratively
◦ 1. achieving clearest possible understanding
of child’s concern
◦ 2. entering the adult’s concern or perspective
◦ 3. brainstorming solutions that are realistic
and mutually satisfactory
◦ www.livesinthebalance.org
College Support Services
Special orientation programs
 Specialized academic advisors or
counselors
 Priority scheduling
 Reduced course loads
 Private dorm room
 Math labs, writing workshops, computer
labs, and reading courses


healthychildren.org
College Support Services
Specialized tutoring
 A ‘personal coach’
 Classroom technology
 Academic aides
 Special testing arrangements
 Advocates


healthychildren.org
Myths and Misconceptions






“My preschooler is too young to have
ADHD”
“He’s just lazy and unmotivated”
“He’s a handful- or, she’s a daydreamer-but
that’s normal. They just don’t let kids be kids
these days.”
“Treatment for ADHD will cure it. The goal
is to get off medication as soon as possible.”
“He focuses on his video games for hours.
He can’t have ADHD”
healthychildren.org
Resources

1. CDC – ADHD, Data and Statistics. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 9/23/2013.

2. CDC-ADHD, Symptoms and Diagnosis. http://www.cdc.gov/ncbddd/adhd/diagnosis.html. Accessed 9/23/2013.

3. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in
Children and Adolescents. Pediatrics. Volume 128, Number 5, November 2011.

4. Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children --- United States, 2003 and
2007. Weekly. November 12, 2010 / 59(44);1439-1443

5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w. Accessed 9/23/13.

6. Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Uptodate.com Accessed
6/5/2013.

7. ADHD Long-term Outcomes: Comorbidity, Secondary Conditions, and Health Risk Behaviors. CDC.
http://www.cdc.gov/ncbddd/adhd/workshops/outcomes.html. Accessed 9/23/13.

8. Biederman, Faraone. Attention-deficit hyperactivity disorder. The Lancet. Volume 366, Issue 9481, 16–22 July 2005, Pages 237–
248.

9. Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications. www.uptodate.com. Accessed
6/5/2013.

10. Healthychildren.org. Multiple articles about ADHD. Accessed 7/1/2013.

11. Age, Academic Performance, and Stimulant Prescribing for ADHD: A Nationwide Cohort Study. Zoega, Valdimarsdottir,
Hernandez-Diaz. Pediatrics. 2012;130.

12. Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation. www.uptodate.com.
Accessed 6/5/2013.

13. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. www.uptodate.com.
Accessed 6/5/2013.

14. The Diet Factor in Attention-Deficit/Hyperactivity Disorder. Millichap and Yee. Pediatrics 2012;129:330-7.

15. Cortical abnormalities in children and adolescents with attention-deficit hyperactivity disorder. E.R. Sowell, P.M. Thompson, S.E.
Welcome, A.L. Henkenius, A.W. Toga, B.S. Peterson. The Lancet. Vol 362. 2013.

16. Impact of Executive Function Deficits and Attention-Deficit/Hyperactivity Disorder (ADHD) on Academic Outcomes in Children.
Biederman J, Monuteaux MC, Doyle AE, Seidman LJ, Wilens TE, Ferrero F, et al. Journal of Consulting and Clinical Psychology. Vol
72, No. 5;2004, 757-66.

17. Progress and Promise of Attention-Deficit Hyperactivity Disorder Pharmacogenetics. Froehlich TE, McGough JJ, Stein MA. CNS
Drugs. 2010 February;24(2):99-117.