Back to Basics
Review of ADHD, Learning
Disabilities, and Pervasive
Developmental Disorders
Dhiraj Aggarwal, MD, FRCP (C )
Child and Youth Psychiatrist, Children’s Hospital of
Eastern Ontario
Assistant Professor, University of Ottawa
daggarwal@cheo.on.ca
April 9nd , 2014
Disclosures
• No affiliations to disclose
Causes/Sources of School Refusal
1.
2.
3.
4.
5.
6.
Separation Anxiety Disorder (50%-80%)
Truancy
Mood Disorders (Major depressive Disorder/Bipolar Disorder)
Other Anxiety Disorders
Overt Psychotic Disorder
Realistic fear of bodily harm in a dangerous school setting
(bullying, gangs)
7. Academic Underachievement
(Learning disabilities, ADHD, Developmental delay)
3
Pervasive Developmental Disorders
Outline
• Diagnosis
• Epidemiology
• Etiology
• Assessment
• Treatment
–Non medication treatments
–Medication treatments
Back to Basics – Dr. D. Aggarwal
Classification of Pervasive Developmental
Disorders (PDDs) According to DSM-IV TR
Pervasive
Developmental
Disorders
Autistic
Disorder
Asperger’s
Disorder
PDD-NOS
Autism Spectrum Disorders
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Childhood
Disintegrative
Disorder
Rett’s
Disorder
Pervasive Developmental Disorder
• Prevalence 1% (1/88) (2010, Can. J. Psych. 55(11) 71520; Arch Gen Psyc 2011, 68(5), 459-65)
• Male to female ratio: 5: 1
• < 40% are mentally retarded (intellectual
disability)
• Affects social interactions +/- communication,
play, interests and behaviour
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Autistic Disorder
• Problems in all 3 core
domains
– Social abnormality
– Language abnormality
– Stereotyped repetitive pattern
of behavior
• Onset of symptoms before 3
yrs of age
• Most severely affected
group of ASD
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Diagnostic criteria for Autism
• require the presence of 6 symptoms from 3
categories:
– Impaired reciprocal social interaction (at
least 2/4 symptoms)
– Impaired communication (1/4)
– Restricted, repetitive and stereotyped
behaviors (1/4)
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Qualitative impairment in Social Interaction
Qualitative impairment in Social Interaction
- Impairment in the use of multiple nonverbal
behaviors: eye to eye gaze (eye contact), facial
expression, body postures and gestures to regulate
social interaction
- Failure to develop peer relationships appropriate to
developmental level
- Lack of spontaneous seeking to share enjoyment,
interests or achievements with other people (not
showing, bringing or pointing out objects of
interests)
- Absence of social or emotional reciprocity
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Qualitative impairment in Communication
– Delay in or total lack of development of spoken
language (no attempt to compensate with
gestures or mime)
– If speech present, marked impairment in the
ability to initiate or sustain conversation with
others
– Stereotyped and repetitive use of language or
idiosyncratic language
– Lack of varied, spontaneous make-believe play
or social imitative play appropriate to
developmental level
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Restricted repetitive and stereotyped patterns of behavior,
interest and activities
– Encompassing preoccupation with one or more
stereotyped and restricted patterns of interest
that is abnormal either in intensity or in focus
– Inflexible adherence to specific, nonfunctional
routines or rituals
– Stereotyped and repetitive motor mannerisms:
hand or finger flapping or twisting, complex
whole-body movements
– Persistent preoccupation with parts of objects
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Etiology
• Genetic - increased risk in siblings and in twins
– Twin concordance, monozyg. 60% vs 5% dizygotic
– ASDs tend to occur more often in people who
have certain genetic or chromosomal conditions.
About 10% of children with autism are also
identified as having Down syndrome, fragile X
syndrome, tuberous sclerosis, and other genetic
and chromosomal disorders
• Environmental, toxins, gastrointestinal,
immunological factors inconclusive
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Unproved Theories
• Vaccines containing thimerosal are not
associated with autism.
• No association between MMR vaccine and
autism (MMR vaccine producing enterocolitis,
causing “leaky gut”, which then leads to
increased absorption of peptides with
bioactive properties of endogenous opioids
that produce the symptoms of autism.)
Consider Evaluation if by:
• 12 months: No babbling or gesturing (pointing, waving byebye), not responding to own name
• 16 months: No single words
• 24 months: No spontaneous 2 word phrases
(i.e. not echolalia or repeating someone else’s words)
• Any age: any loss of any language or social skills
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Asperger’s Disorder
-Hans Asperger 1944 (1980’s)
-Diagnosed later than Autism
-IQ within normal range
-Qualitative impairment in Social
Interaction
-Restricted repetitive and
stereotyped patterns of
behavior, interest and activities
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Language in Aspergers “Unusual but not Absent”
• There is no clinically significant general delay in
language
• Normal language milestones but atypical:
– Language is one sided (lecture)
– Perseverates on topic of interest
– Pragmatics- turn taking, facial expression, body
language, overly formal “little professor”
– Prosody- intonation, volume, rhythm
– Conversational intent- sarcasm, metaphors
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
PDD-NOS
• Symptoms/impairment :
– Social interaction and
– Communication OR Behavior
• That do not reach threshold for diagnosis of
a specific PDD.
• Most common but least studied
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Differential Diagnosis for PDD
•
•
•
•
•
•
•
•
•
•
•
Specific Developmental Disorder eg language
Mental Retardation not associated with PDD
OCD, Social Phobia, and other anxiety disorders
Tourette’s and tic disorders
ADHD, oppositional defiant disorder (ODD)
Giftedness/precocity
Selective mutism
Reactive attachment disorder, PTSD
Schizophrenia of childhood onset
Schizotypal/schizoid personality disorder
Specific medical/neurological conditions
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Evaluation
• History
– Pregnancy, neonatal and developmental hx, medical hx, family and
psychosocial factors, intervention hx.
• Direct interaction and behavioural observations of
child
• Collateral of observations of child in social settings
• Screening and diagnostic questionnaires
• Psychological evaluation
• Speech/language/communication assessment
• OT evaluation
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Autism-Specific Questionnaires
• M-CHAT (Modified Checklist for Autism in
Toddlers)
• CARS (Childhood Autism Rating Scale)
• GARS (Gillian Autism Rating Scale)
• Autism Diagnostic Interview-revised (ADI-R)
• Autism Diagnostic Observation ScheduleGeneric (ADOS-G)
Medical Evaluation
• Physical exam to identify dysmorphic physical
features
• Audiology/visual evaluation
• Chromosomal microarray analysis recommended:
submicroscopic chromosome deletions, duplications
(copy number variant) detected in 10%% of people
with ASD.
• Metabolic testing based on clinical features.
• EEG if history of seizure or history of significant
regression in social or communication functioning.
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Goals of treatment
• In order to optimize outcome, it is important to
screen/diagnose early and to initial intensive
behavioral therapy.
• Promote functional conversational language.
• Promote social interactions while mitigating
repetitive, self-stimulatory behaviors, tantrums,
aggression and self-injurious behaviors.
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Interventions
• Applied Behavior Analysis (ABA). Uses the principles of
operant conditioning to teach specific social, communicative,
and behavioral skills to children with ASD. It involves teaching
new behaviors by explicit reinforcement of these behaviors,
• Typical Target Behaviors
• Attentional skills
• Imitation skills
• Adaptive and self help skills
• Social skills
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
Medications
• No medication is available to treat the core
symptoms of autism (deficits in communication and
social interaction).
• Risperidone and aripiprazole are approved and
helpful to assist in irritability, managing tantrums,
aggression and self-injurious behaviors.
• Stimulant (eg methylphenidate) medication is helpful
to assist with inattentive, impulsive and hyperactive
behaviors.
– ADHD not diagnosed in presence of PDD
according to DSM-IV, but ADHD symptoms are
common in PDD (>50%)
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
References
• www.autism-society.org
• www.teacch.com
• http://www.nichd.nih.gov/health/topics/autism/Pages/def
ault.aspx
• http://www.aspergers.com/
• http://www.asatonline.org/
• ASD video glossary: Autism Speaks
http://www.autismspeaks.org/video/glossary.php
• Management of Children With Autism Spectrum Disorders SM
Myers, CP Johnson, Pediatrics, 120 (5), 1162-1182 (2007)
Unit 3 – Autism Spectrum Disorders – Dr. D. Aggarwal
ADHD Outline
• Diagnosis
• Assessment
• Co-morbidity
• Epidemiology
• Etiology
• Natural History
• Treatment
– Non medication options
– Medication options
Case
10 year old boy Joshua presents with difficulty
sitting still, distractibility and aggressive
behaviour.
Mother “The teacher thinks he has ADHD and
she told me to put him on Ritalin….I told the
school he is just an active boy and the school
should be able to manage him…..Dr. what do
you think is going on?”
Differential Diagnosis of ADHD
• Not every inattentive or disruptive child has
ADHD
• A child may be inattentive or act out because of:
–
–
–
–
–
Learning problems, Mental Retardation
Mood (Depression or Bipolar)
Anxiety, including OCD
Autism Spectrum Disorder
Substance related disorder NOS
– Sleep problems
– Impaired hearing or vision
– Personality Change Due to a GMC (ie head injury)
– Age appropriate behaviours in active child
– Understimulating environment (gifted child)
APA, DSM-IV TR, 2000
DSM-IV-TR Symptoms for ADHD
Inattention
Hyperactivity
1.
1.
2.
3.
4.
5.
6.
2.
3.
4.
5.
6.
7.
8.
9.
Doesn’t attend to details in
schoolwork
Difficulty sustaining attention
in tasks/play
Doesn’t listen
Doesn’t complete tasks
Difficulty organizing
Avoids tasks requiring focus
Loses things
Distractible
Forgetful
Fidgets
Leaves seat
Runs about
Doesn’t play quietly
“On the go”
Talks excessively
Impulsivity
7.
8.
9.
Blurts out answers
Doesn’t await turn
Interrupts or intrudes
(APA, DSM-IV TR, 2000)
DSM-IV-TR Diagnostic Criteria for ADHD
• Threshold:
Symptoms of inattention and/or hyperactivity-impulsivity for
≥6 months:
– At least 6/9 inattentive symptoms: ADHD, inattentive type
– At least 6/9 hyperactive-impulsive symptoms: ADHD, hyperactiveimpulsive type
– At least 6/9 in each category*: ADHD, combined type
• Onset before age 7 years*
• Impairment in at least two settings
• Exclusion: Symptoms do not occur in the context of PDD* or psychosis,
and are not better accounted for by another mental disorder
*May be changed in the new DSM-5
(APA, DSM-IV TR, 2000)
What part of the assessment is the least helpful
in making the dx of ADHD in a 15year old teen?
a) Parent interview
b) Teen interview
c) Teen mental status
d) Rating scale completed by parent
e) Rating Scales completed by teacher
What part of the assessment is least helpful in
making the dx of ADHD in a 15year old teen?
a) Parent interview
b) Teen interview
c) Teen mental status
d) Rating scale completed by parent
e) Rating Scales completed by teacher
What part of the assessment is the most helpful
in making the dx of ADHD in a 15year old teen?
a) case conference with teachers and parents to
get a better understanding of the teens
behaviour at school
b) interview with parent about developmental
history and past academic history
c ) interview with the teen
d) observing the teen in class
e) rating scales completed by teacher and parent
What part of the assessment is the most helpful
in making the dx of ADHD in a 15year old teen?
a) case conference with teachers and parents to
get a better understanding of the teens
behaviour at school
b) interview with parent about developmental
history and past academic history
c ) interview with the teen
d) observing the teen in class
e) rating scales completed by teacher and parent
Assessment in Children and Adolescents
• Parent interview including developmental
history
• Child/adolescent interview
• Information from teachers and other sources
• Rating Scales
-useful to support clinical evaluation and monitor progress,
but should not be used on their own to make a diagnosis
• Conners Rating Scale-Revised (Parent/Teacher)
• SNAP-IV Teacher/Parent Rating Scale (available at
www.caddra.ca)
Assessment (cont.)
• Medical evaluation:
– History and physical examination
– Hearing and vision tests
– Laboratory and imaging tests only if
indicated by the clinical evaluation
• Consider a psychoeducational
evaluation, including both
cognitive and academic testing, to
assess for learning problems
Co-morbidity
• Children with ADHD have high rates of comorbid psychiatric disorders
• Almost 70% of children with ADHD had at
least one co-morbid condition
• Disorders that are frequently co-morbid with
ADHD:
–
–
–
–
–
Learning disorders
Anxiety & depressive disorders
Oppositional defiant disorder & conduct disorder
Substance use disorders
Tic disorders
Pliszka et al., 2007; Spencer et al., 2007; Spencer et
al., 1999; MTA Cooperative Group, 1999
Father “How common is ADHD? What causes
ADHD? Will Joshua outgrow ADHD ? “
Prevalence of ADHD
• School age children: 6-9% (Wolraich et al., 1998; CDC,
2010; Ontario Child Health Study, 1989)
• Gender differences: 9.0% in boys (4-16 yrs
old) and 3.3% in girls (OCHS, 1989)
• Adult : 4.4% (NCS-R, 2006)
• ADHD accounts for 30-50 % of mental health
referrals (MTA Cooperative Group, 1999)
• ADHD Subtypes in children: (Polanczyk et al., 2007)
–
–
–
Combined (50-75%)
Inattentive (20-40%)
Hyperactive-impulsive (<5-15%)
Etiology
• Genetic factors are most important:
– Heritability is about 75%
– Implicated genes: DAT1, DRD4.7, DRD5,
DBH, 5-HTT, HTR1B, SNAP-25
• Nongenetic factors:
–
–
–
–
Perinatal stress & low birth weight
Traumatic brain injury
Maternal smoking during pregnancy
Severe early deprivation
Faraone et al., 2005; Pliszka et al., 2007
Etiology (cont.)
• Neurobiology:
– Implicated brain regions: prefrontal
cortex, basal ganglia, corpus callosum,
and cerebellum
– Implicated neurotransmitter systems:
dopamine and norepinephrine
• No evidence that ordinary variations
in child-rearing practices contribute to
the etiology of ADHD
Krain & Castellanos, 2006; Pliszka et al., 2007
ADHD Persists from Childhood to Adulthood
Children
with ADHD
Prevalence in juvenile
population
6%-9%
60% will
exhibit
symptoms
into
adulthood
Adults with
ADHD
Prevalence in adult
population 3%-5%
(Biederman et al., 2000; Rasmussen et al., 2000; Weiss et al., 1993)
ADHD Course of the Disorder
- Hyperactive-impulsive
symptoms are more likely to
improve or become
internalized (e.g. changed
into nervous tension)
Hyperactivity
-inattentive symptoms are
more likely to persist
Impulsivity
Inattention
--Time--
(Faraone et al., 2005)
Father “I think my wife has ADHD. I made a
video to show you. what do you think ?”
Mother “ How do you treat ADHD? Are there
any side effects with medications? Are there
any long-term side effects of medications?
Behavioural Management vs.
Medication for ADHD
Non-Medication Interventions
• Psychoeducation
• Behavioural Parent Management Training
• Behavioural School and Academic Intervention
AACAP ADHD Practice parameter. JAACAP. 2007
American Academy of Pediatrics. Pediatrics. 2011
Stimulants
•
•
Duration of Action (hours)
Methylphenidate
• Ritalin
• Ritalin SR
• Biphentin
• Concerta
4 (3-4)
8 (4-6?)
8-10
12 (8-14)
Amphetamines
• Dexedrine
• Dexedrine spansule
• Adderall XR
• Lisdexamfetamine (Vyvanse)
4 (3-6)
10-12 (5-8?)
10-12
12-13
Pharmacodynamics
• Methylphenidate:
–Blocks DA and NE transporters in the
presynaptic neuron, thus inhibiting reuptake
and resulting in increased synaptic
concentrations of these neurotransmitters
•Amphetamines:
–Stimulate release of DA and, to a lesser
extent, NE, from presynapticsites
–Have secondary effects on inhibiting DA
reuptake
Lisdexamfetamine (Vyvanse)
• Lisdexamfetamine dimesylate (LDX) is a
pharmacologically inactive prodrug
>>Low abuse potential
• Clinical effect for 12 hours or more (12h:
monograph information, 13h in a clinical trial in
children and 14h in adults)
• Can be diluted in water if the child has difficulties
swallowing
Stimulant Adverse Effects
•
•
•
•
•
•
•
Initial insomnia
Decreased appetite, weight loss
Small increases in HR and diastolic BP
Nausea/vomiting, abdominal pain
Headache
Thirst
Palpitations
• Anxiety
• Social withdrawal, decreased spontaneity
• Increased activity, aggression, irritability,
dsyphoria
• Tics
• Risk of growth supression
Monitoring for Stimulants
• Height and weight on growth charts
• HR and BP at baseline, with dose changes
and periodically thereafter
• Use parent and teacher rating scales to
monitor response and side effects at
different doses
Atomoxetine (non stimulant)
• Atomoxetine has been studied as a potential
treatment for depression, but was found to be
ineffective
• Selective norepinephrine (NE) reuptake
inhibitor (NRI)
Health Canada (October 2011)
• A safety announcement which warns of the risk of increased
blood pressure and increased heart rate with the use of
atomoxetine
• Atomoxetine should not be prescribed to patients with
symptomatic cardiovascular diseases, moderate to severe
hypertension or severe cardiovascular disorders whose
condition would be expected to deteriorate if they
experienced clinically important increases in blood pressure
or heart rate
• Following similar principles for stimulants with respect to
cardiac work up and monitoring
2012 CADDRA Guidelines Medical Treatment of ADHD
1st line
2nd line
Long Acting
Short Acting
XR®)
MAS (Adderall
CR MPH MLR (Biphentin ®)
OROS MPH (Concerta ®)
Atomoxetine (Strattera ®)
Lisdexamphetamine
(Vyvanse ®)
Dexedrine®
Dexedrine ® Spansules
Ritalin ® IR
Ritalin ® SR
3rd line
off label
Imipramine
Modafinil
Wellbutrin®
(CADDRA ,2011)
Suggested Pharmacological Algorithm for ADHD
1a. Stimulants* (try methylphenidate and at least one
amphetamine before moving on)
1b. Atomoxetine*
2. α-2 agonists** (clonidine, clonidine XR, guanfacine XR)
3a. Bupropion
3b. Tricyclic antidepressants
4. Modafinil
5. Other medications and medication combinations
*Only the stimulants and atomoxetine are approved by Health Canada to
treat ADHD in youth and adults
** Clonidine XR and guanfacine XR are approved by the FDA to treat ADHD in
youth (neither agent is available in Canada)
(Wilens, AACAP 57th Annual Meeting, 2010)
(Slide by Dr. D. Gorman, 2011)
(CADDRA, 2011)
(CADDRA, 2011)
Mother “what should I tell the school?”
Online ADHD Resources
• www.teachadhd.ca
This site is designed specifically for teachers, but the
information and down-loadable materials are also of interest
for parents and clinicians. This website is developed and
maintain by The Hospital for Sick Children, Toronto.
• http://www.aacap.org/galleries/defaultfile/adhd_parents_medication_guide_english.pdf
• www.caddac.ca
– Centre for ADHD Awareness Canada
– national, umbrella organization providing leadership in
education and advocacy for ADHD organizations and
individuals across Canada.
Questions ?