Attention-Deficit/Hyperactivity
Disorder
Dispelling Myths is Good Medicine
Karen J. Kraus, M.D.
UCSF Fresno Psychiatry Residency
Program
Introduction
• ADHD is a complex disorder of higher brain
functioning, characterized by inattention,
motor over-activity and difficulty inhibiting
impulsive behaviors
• ADHD is one of the most prevalent disorders
in childhood and adolescence, affecting an
estimated 3-9% of school-age children
Introduction
• Symptoms occur at an early age, occur in
most areas of a child’s life, and persist over
time, frequently into adulthood
• The precise constellation of symptoms
changes as children grow and develop
Introduction
• ADHD is often inherited
• Imaging, electrophysiological and
neuropsychological tests, and now, genetic
analysis, all point to disturbances in specific
neurotransmitter systems, affecting specific
areas of the brain
Introduction
• ADHD is frequently associated with other
psychiatric and learning problems, which
complicate diagnosis, treatment and
prognosis
• ADHD is a heterogeneous disorder with many
known causes, all of which mediate similar
or identical effects on brain functioning
“There is no such thing as
ADHD”
Myth #1
• Psychiatric disorders do not
occur in children.
Myth #2
• ADHD is nothing more than
applying a diagnostic label to
normal childhood behavior.
Myth #3
• If ADHD really existed, wouldn’t
it be obvious?
“The medicines used to treat
ADHD are dangerous and
addictive”
Efficacy and dosing guidelines have not been
established for children
Use of these medications may actually exacerbate
the underlying disorder
Associated with high rates of significant side
effects such as irritability, restlessness,lethargy,
hallucinations, hypertension & severe muscle
stiffness, even death
In one study, more than 50% of mothers
interviewed had administered this medication
within the past month
During an investigative hearing, one congressman
made the comment, “The sad fact is, much of the
billion dollar medication industry is based more
on hype then health care.”
According to the American Association of
Poison Control Centers:
These medications are the frequent targets of
unintentional ingestions in young children
They rank #2 for intentional ingestions
In 1988, they accounted for 58,000
exposures & 77% of all ingestions
In 1990, they accounted for 73,680
exposures (calls to poison control centers
In the case of one medicine, tracking
mechanisms reported a 60% annual increase in
use, abuse and medical contacts for toxicity
Stimulant medications, doses and
pharmacological activity
Non-stimulant Medications in ADHD
Efficacy
• More than 200 randomized and/or
placebo controlled studies
demonstrate that stimulants are
effective in reducing the core
symptoms of ADHD
• Approximately 70% of children with
ADHD demonstrate a robust response
to stimulants
Medication Effects
•  fidgetiness
• interrupting
• physical
aggressiveness
• antisocial
behavior
• compliance
• peer acceptance
• efficiency
• on-task
behavior
• accuracy
• short term
memory
• problem-solving
• parent-child
interactions
• performance of
motor tasks
Efficacy
• The MTA study demonstrated the
superior efficacy of medications over
other kinds of treatment in school age
children.
• There is less evidence to support the
long term use of stimulants (>14
months), or their use with preschool
children, adolescents, and adults.
Myth #4
• The medications used to treat
ADHD are very dangerous
Myth #5
• The medications used to treat
ADHD are addictive
Rates of psychotropic medication use by children
in the United States
Substance Abuse & ADHD
• A individual with ADHD persisting into
adulthood is at increased risk to
develop a substance abuse disorder;
that risk increases substantially in the
presence of concurrent Conduct
Disorder
• ADHD is associated with earlier onset
of substance abuse disorders, and a
shortened time from use to frank
abuse
Substance Abuse & ADHD
• Substance abuse disorders in
individuals with ADHD persisting into
adulthood appear to be more chronic
with lower rates of remission
• Overall, there is a 2-fold increased risk
of developing a substance abuse
disorder
Substance Abuse & ADHD
• The core rate of substance abuse in
adolescents with ADHD is 10-15%
• Teens who were medicated with
stimulants showed no increased risk
as compared to “normal” teens
• Teens with ADHD who were not
medicated have a 3-4 fold increased
risk, as compared with affected teens
who were treated
Abuse of Stimulants
• There are only 5 case reports of
stimulant abuse in the literature
• Epidemiological studies involving
adolescents have found rates of nonprescription use of Methylphenidate
ranging from a low of .1% in 1992, to
a peak of 2.8% in 1997 & 1998, to a
rate of 2.2% in 2000.
Abuse of Stimulants
• A survey of 6000 students in Mass.
reported that 13% of high school
students and 4% of junior high school
students had used Methylphenidate
without a prescription
• A 1999 report on drug-abuse related
visits to EDs revealed 1,478 notations
of Methylphenidate abuse, down from
1,728 in 1998
Abuse of Stimulants
• A 7 year study of incidents involving
Methylphenidate called into poison control
centers revealed:
– Out of 11,149 cases involving MPH, 1,244
(11.2%) were related to intentional abuse.
– The data indicated an increasing rate of
abuse, with 17 cases in 1993 and 158
cases in 1998
– Most were boys between the ages of 14-15
Abuse of Stimulants
• Continued:
– 70% involved MPH only; the remainder
involved the co-consumption of 1-2
additional drugs.
– Use was coded “acute” in over 87% of
cases, meaning there was no ongoing use
of the stimulant either illicitly or
therapeutically,
– Use in a “chronic” context was more likely
to occur in older adolescents
– The most common route was ingestion.
Advice to Parents, Kids and
other Interested Observers
Inattention
• Difficulty initiating and sustaining
attention, characterized by:
– difficulty persisting in tasks, especially if they are
uninteresting, tedious, sedentary or demanding
– switching from one unfinished task to another
– failure to complete tasks, chores, schoolwork, etc.
Inattention
• Difficulty initiating and sustaining
attention, characterized by:
– difficulty following through with
directions
– “daydreaming”, or appearing as if one isn’t
listening or is unable to hear
Inattention
• Avoidance of, or aversion to, tasks
that require sustained attention, such
as:
– tasks that require perseverance or
sustained, intense mental effort
– tasks that tax limited organizational skills
Inattention
• Distractibility, characterized by:
– sensory distractibility, described as the
inability to filter out unimportant,
extraneous stimuli from important,
relevant stimuli
– motor distractibility, described as the
inability to inhibit responses to stimulus
or, the inability to control the allocation
of attention.
Inattention
• Distractibility, characterized by:
– difficulty shifting attention from one task
or activity to another
– difficulty attending to more than one task
at a time
– sometimes manifest as an extraordinary
awareness of detail, however irrelevant
Inattention
• Difficulty with organization and
prioritization (impaired executive functions),
characterized by:
– loses or misplaces belongings or necessary
things such as homework, school materials,
toys, etc.
– difficulty prioritizing tasks in terms of
importance or planning objectives
– procrastination
– forgetfulness, e.g., misses appointments,
fails to remember gym clothes, etc.
– poor awareness of time, with similarly poor
time management skills
Inattention
• Difficulty with organization and
prioritization (impaired executive functions),
characterized by:
– deficits in working memory - the ability to keep
certain information “in mind” over short periods of
time in the absence of environmental stimuli –
manifested by:
- difficulty recalling complex instructions, such
as game rules
- forgetting information that has just been read
- difficulty transferring information
- difficulty with math functions such as
transposing numbers or computational errors.
Hyperactivity
• Excessive motor activity,
described as:
– constantly moving or “on the go”
– fidgety or restless
– difficulty remaining seated when
required to do so
Hyperactivity
• Subjective sense of motor
restlessness
– A subtle finding more common in
girls, and frequently found in
adolescents and adults
Hyperactivity
• Over-talkativeness, described as:
– excessive, continuous talking
(“blabbermouth”)
– poor modulation of speech, with loud
speech
– verbosity
– blurts out answers, interrupts
conversation
Hyperactivity
• Poor motor control, characterized by:
– difficulty engaging in leisure activities quietly
– work, particularly handwriting, is often messy
– poor physical boundaries, with socially
inappropriate, intrusive behavior
– aggressiveness or clumsiness, related to poor
modulation of motor activities (e.g., breaks toys,
hurts others unintentionally)
Impulsivity
• Difficulty inhibiting responses
(“Ready, fire, aim!), manifested
by:
– intrusiveness
– impatience, manifested by:
- difficulty with turn taking in games
- similarly manifest in conversation, with
interruption and comments out of turn
- inappropriate behavior
Impulsivity
• Risk taking/Novelty-seeking
behavior
– engagement in physically dangerous
activities without consideration of
potential consequences
– often described as “ accident
prone”, with a history of injuries
– tendency to become easily bored
and seek external stimulation
Impulsivity
• Altered responsiveness to behavioral
rewards, consequences and
contingencies
– resistance to conditioning effects of
reward or punishment
– failure to apply past experiences to
current situations, resulting in repetitive
mistakes
– neurophysiological basis
Associated Features
• Altered response to social reinforcement
– Because of inattentiveness, negativism, or
resistance to the conditioning effects of
reward or punishment, many ADHD
children are difficult to socialize. They
are described as obstinate, impervious,
stubborn or negativistic, although they are
not necessarily “conduct disordered”
Associated Features
• Altered emotional responsiveness
– Children with ADHD are easily excited and
easily upset, and tend to react to
situations in an exaggerated,
disproportionate way, with dramatic
(albeit usually short-lived) shifts in
emotions
– They also tend to exhibit poor frustration
tolerance (a “short fuse”), particularly with
delay/denial of gratification,
developmental challenges or interpersonal
conflicts
Associated Features
• Differences in interpersonal relationships
– Children with ADHD tend to be intense,
controlling, socially imperceptive and
intolerant.
– They are often described as immature and
in fact, often exhibit delayed social
development.
– Chronically antagonistic interpersonal
interactions can lead to social isolation,
and later on, to depression and angry
defiance.
Associated Features
• Behavioral dyscontrol
– Problematic behavior may signal the
presence of a co-morbid psychiatric
disorder, but may also stem from the core
neuropsychiatric deficits seen in ADHD.
– The gap between the normal
developmental aspirations of children with
ADHD and their maturity and judgement
further complicates the picture .
Associated Features
• Behavioral dyscontrol
– Examples include:
- lying and stealing may be indicative
underlying impulsivity
- aggressive behavior may be an
expression of poorly regulated physical
force
- temper tantrums are often seen in the
context of sensory or affective overstimulation
Associated Features
• Demoralization
– The “curious dissociation between knowing and
doing” often frustrates children with ADHD.
Despite talent and skills, and often despite
prodigious effort, children with ADHD chronically
fall short of expectations
– As a result their inefficient cognitive styles,
children with ADHD must often work harder and
longer than their peers to obtain the same
outcome.
– Over time children with ADHD fatigue, and in the
context of repeated failures, become demoralized,
lose motivation and develop a posture of defensive
defiance