Attention-Deficit/Hyperactivity Disorder (ADHD)

R. KAAN OZBAYRAK, MD ASSISTANT PROFESSOR OF PSYCHIATRY UMASS MEDICAL SCHOOL

ADHD
ADHD i a developmental disorder. is d l t l di d Etiology:

factors Maternal drug use (smoking, alcohol, lead, cocaine) Low birth weight Asphyxiation at or near birth p y Affects 3%-7% of the population More common in males (4:1 to 2:1) Impaired frontal lobe functions

Genetic

Frontal Lobe Functions

Sh i Shutting unimportant stimuli out i i li Impulse control Slowing motor activity down g y Planning Sequencing Executing

Major Symptoms of ADHD j y p

Inattention Impulsiveness Hyperactivity

P d Predominantly i tl

inattentive type Predominantly hyperactive/impulsive type Combined type yp

Diagnosing ADHD g g
ADHD is a clinical diagnosis i e good history taking diagnosis, i.e. taking,

asking about common symptoms, eliciting the time course of the problem, understanding how it interferes with daily tasks and activities There is no testing for ADHDno psychological o e e s o test g o o psyc o og ca or neuropsychological tests, no attention testing (test for learning disabilities or mental retardation) What passes for testing is asking the parent and the teacher, to rate the frequency of ADHD symptoms, f from DSM IV TR DSM-IV-TR Often and very often are considered positive

DSM-IV-TR Criteria for ADHD

Inattention 1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities 2. often has difficulty sustaining attention in tasks or play activities k l i ii 3. often does not seem to listen when spoken to directly 4. often does not follow through on instructions and fails to finish schoolwork, chores or schoolwork chores, duties in the workplace (not due to oppositional behavior or failure to understand instructions) 5. often has difficulty organizing tasks and activities 6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) 7 7. often loses things necessary for tasks or g y activities (e.g., toys, school assignments, pencils, books, or tools) 8. is often easily distracted by extraneous stimuli 9. 9 is often forgetful in daily activities Hyperactivity/Impulsivity 1. often fidgets with hands or feet or squirms in seat 2. often leaves seat in classroom or in other situations in which remaining seated is expected 3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) 4. often has difficulty playing or engaging in leisure activities quietly 5. is often "on the go" or often acts as if "driven by a motor" 6. often talks excessively 7. often blurts out answers before questions have been completed 8. often has difficulty awaiting turn 9. 9 often interrupts or intrudes on others (e.g., (e g butts into conversations or games)

Eliciting ADHD Symptoms g y p

S Symptoms are most prominent d i monotonous, t t i t during t

repetitive or boring tasks We d not need much assistance f do d h i from our f frontal l lobes if the task is fun, interesting, captivating or exciting iti This makes it difficult to observe ADHD symptoms in h doctors or therapists office, until the child i the d h i ffi il h hild becomes familiar/bored with the environment This explains absence of ADHD while playing video games

Relationship with other diagnoses p g

Wh t needs t b ruled-out or t What d to be l d t treated b f t d before

diagnosing ADHD:

Anxiety A i t Depression Bipolar disorder Drug dependence/withdrawal

High comorbidity with ADHD: Bipolar disorder Autistic spectrum disorders (Pervasive Developmental Disorders PDD) Oppositional Defiant Disorder & Conduct Disorder pp

Growing out of ADHD g

70% of children who were diagnosed as having

ADHD will meet the di A ill h diagnostic criteria f A i i i for ADHD as adolescents 70% of adolescents who were diagnosed as having ADHD will meet the diagnostic criteria for ADHD as adults d l 49% of children who were diagnosed as having ADHD will meet the diagnostic criteria for ADHD as adults

Is ADHD a real disorder?

O i it a fi Or is figment of current W t t f t Western society? i t ? It is true that some of us (3%-7%) have significantly

poorer frontal lobe f f l l b functions than the rest of us i h h f This group seem to fail some of the cultural expectations:

Being able to sit still for extended periods of time Being able to listen to and understand boring material Being able to read and understand boring material

We can make every task interesting and fun We can lend our frontal lobes (structure)

How do we treat ADHD?

Manipulate the environment to minimize the

monotonous, repetitive, boring aspects Bring external structure into the picture (he does great when you work with him 1 to 1) Send dopamine to frontal lobes so that they start g job (psychostimulant medications doing their j (p y stimulate the lazy frontal lobes, not the patient)

Should we treat ADHD or not?

What are the costs of treating

ADHD? What are the costs of NOT treating ADHD?

Potential costs of treating ADHD g

Educating parents, teachers, administrators, policy

makers, makers physicians and other healthcare workers Smaller classrooms; higher teacher/student ratio Better educational materials and planning Labor intensive parenting Medication id ff t like developmental d l M di ti side effects lik d l t l delays, decreased appetite and weight loss, insomnia, moodiness and agitation, flaring up motor tics, agitation tics heart-related problems, suicidal ideation

Potential costs of NOT treating ADHD g

O Oppositional-defiant disorder iti l d fi t di d Low self-esteem and depression Drug and alcohol use Traffic violations and accidents Dropping out of college Poor job performance; more blue collar jobs Legal problems I Increased rates of STD d f STDs Having children early on but 50% losing custody

Medication treatment of ADHD

Psychostimulants Methylphenidate group vs. amphetamine group Short acting vs. longer acting D Dexmethlyphenidate and li d hl h id d lisdexamfetamine f i Atomoxetine (Strattera) Bupropion (Wellbutrin) Tricyclic antidepressants y p Alpha-2 agonists (clonidine, guanfacine)