Adolescent ADHDAdolescent ADHD

長庚兒童醫院 兒童心智科長庚兒童醫院 兒童心智科張學岑醫師張學岑醫師

EtiologyEtiology

ADHD is a heterogeneous behavioral disoADHD is a heterogeneous behavioral disorder with multiple possible etiologiesrder with multiple possible etiologies

Neuroanatomic/ NeurochemicalNeuroanatomic/ Neurochemical CNS InsultsCNS Insults Genetic OriginsGenetic Origins Environmental factorsEnvironmental factors

Core Symptoms AreasCore Symptoms Areas

InattentioInattentionn

Impulsivity/HyperactivityImpulsivity/Hyperactivity

DSM-IV CriteriaDSM-IV CriteriaInattentionInattention

Six or moreSix or more of the following—manifested often: of the following—manifested often:

Inattention to details/Inattention to details/

makes careless mistakesmakes careless mistakes Difficulty sustaining Difficulty sustaining

attentionattention Seems not to listenSeems not to listen Fails to finish tasksFails to finish tasks

Difficulty organizationDifficulty organization Avoids tasks requiring Avoids tasks requiring

sustained attentionsustained attention Loses thingsLoses things Easily distractedEasily distracted ForgetfulForgetful

ADHD: DSM-IV CriteriaADHD: DSM-IV CriteriaImpulsivity/HyperactivityImpulsivity/Hyperactivity

Six or moreSix or more of the following-manifested often: of the following-manifested often:

ImpulsivityImpulsivity Blurts out answer Blurts out answer

before questions is before questions is finishedfinished

Difficulty awaiting Difficulty awaiting turnturn

Interrupts or intrudes Interrupts or intrudes on otherson others

HyperactivityHyperactivity FidgetsFidgets Unable to stay seatedUnable to stay seated Inappropriate Inappropriate

running/climbing running/climbing (restlessness)(restlessness)

Difficulty in engaging in Difficulty in engaging in leisure activities quietlyleisure activities quietly

““On the go”On the go” Talks excessivelyTalks excessively

Variation in symptomsVariation in symptoms

Symptoms vary inSymptoms vary in PervasivenessPervasiveness Frequency of occurrenceFrequency of occurrence Degree of impairmentDegree of impairment

DSM-IV Diagnosis CriteriaDSM-IV Diagnosis Criteria

Symptom criteria must be met for past Symptom criteria must be met for past 6 months6 months Some symptoms must be present Some symptoms must be present before 7 yearsbefore 7 years

of ageof age Some impairment from symptoms must be Some impairment from symptoms must be

present in present in 2 or more2 or more settings settings The symptoms lead to significant The symptoms lead to significant impairmentimpairment Symptoms are not exclusively due to other Symptoms are not exclusively due to other

mental disordersmental disorders

DSM-IV SubtypesDSM-IV Subtypes

ADHD Predominantly Inattentive TypeADHD Predominantly Inattentive Type– Criteria met for Inattentive but note for Criteria met for Inattentive but note for

impulsivity/hyperactivityimpulsivity/hyperactivity

ADHD Predominantly Hyperactivity/Impulsivity TypeADHD Predominantly Hyperactivity/Impulsivity Type– Criteria met for impulsivity/hyperactivity but not for Criteria met for impulsivity/hyperactivity but not for

InattentionInattention

ADHD Combined TypeADHD Combined Type– Criteria are met for both inattention and Criteria are met for both inattention and

impulsivity/hyperactivityimpulsivity/hyperactivity

Impact and cost of ADHDImpact and cost of ADHD

ADHD in adult prison inmates:25%ADHD in adult prison inmates:25% More drivers with ADHD:More drivers with ADHD:

– Drove without a licenseDrove without a license– Had license revoked or suspendedHad license revoked or suspended– Had multiple crashes(2+)Had multiple crashes(2+)– Had multiple traffic citations(3+)Had multiple traffic citations(3+)– Subgroups of ADHD with comorbid ODD/CD Subgroups of ADHD with comorbid ODD/CD

were at highest riskwere at highest risk

Impact and cost of ADHDImpact and cost of ADHD

Despite similar educational levels and IQ Despite similar educational levels and IQ scores, individuals with ADHD not taking scores, individuals with ADHD not taking medication display significantly more medication display significantly more academic problems in school (25% repeat a academic problems in school (25% repeat a grade) and lower occupation attainmentgrade) and lower occupation attainment

Impact and cost of ADHDImpact and cost of ADHD

Parents of children with ADHD experience Parents of children with ADHD experience higher level of stress, self blame, social higher level of stress, self blame, social isolation, depression and marital discordisolation, depression and marital discord

63% of 144 caregivers after diagnosis of 63% of 144 caregivers after diagnosis of child’ s ADHD changed work statuschild’ s ADHD changed work status

過去過去 4040 年的變化年的變化 Laufer (1962): “The behavior picture described tends tLaufer (1962): “The behavior picture described tends t

o disappear with maturation, anywhere between twelvo disappear with maturation, anywhere between twelve and eighteen years of age….”e and eighteen years of age….”

Mendelson et al (1971): “Our findings suggest that hyMendelson et al (1971): “Our findings suggest that hyperactive children are generally behaving in a more noperactive children are generally behaving in a more normal way by the time they enter their teens…” rmal way by the time they enter their teens…”

Wender (1995):”…the past decade researchers have bWender (1995):”…the past decade researchers have become convinced that…ADHD… is a common psychiecome convinced that…ADHD… is a common psychiatric disorder in adults…”atric disorder in adults…”

Gadow and Weiss (2001): ”…the validity of this disorGadow and Weiss (2001): ”…the validity of this disorder is now beyond controversy.”der is now beyond controversy.”

Diagnosis of Adolescent ADHDDiagnosis of Adolescent ADHD

Still an Still an observational diagnosisobservational diagnosis DSM-IV criteria thought threshold could be DSM-IV criteria thought threshold could be

too too highhigh– Likely 4/9 Likely 4/9 (Barkley et al., 2001)(Barkley et al., 2001)

– Shouldn’t apply age 7 criteria Shouldn’t apply age 7 criteria (Applegate et al., 1996)(Applegate et al., 1996)

– Semi-structured interview should be doneSemi-structured interview should be done– Measurement of impairmentMeasurement of impairment

Pitfall in the diagnosis of adolescent Pitfall in the diagnosis of adolescent ADHD --IADHD --I

Individuals (esp. girls) who tend to exhibit Individuals (esp. girls) who tend to exhibit fewer hyperactive symptomsfewer hyperactive symptoms

Individuals who exhibit mental rather than Individuals who exhibit mental rather than physical restlessnessphysical restlessness

The ubiquity of inattentive and impulsive The ubiquity of inattentive and impulsive behavior in normal adolescent lifebehavior in normal adolescent life

Developmental relativity, age Developmental relativity, age appropriatenessappropriateness

Pitfall in the diagnosis of adolescent Pitfall in the diagnosis of adolescent ADHD --IIADHD --II

Self report Vs parental reportSelf report Vs parental report Difficulty to obtain data from secondary schDifficulty to obtain data from secondary sch

ool teacherool teacher Uncooperative adolescentsUncooperative adolescents Multiple comorbid disorderMultiple comorbid disorder Shared features of other adolescent –onset pShared features of other adolescent –onset p

sychiatric disorderssychiatric disorders Life span with multiple stressesLife span with multiple stresses

Pitfall in the diagnosis of adolescent Pitfall in the diagnosis of adolescent ADHD --IIIADHD --III

The uncertain validity of applying DSM-IV The uncertain validity of applying DSM-IV diagnostic criteria for ADHD in adolescentdiagnostic criteria for ADHD in adolescent

The difficulty of establishing impairment in The difficulty of establishing impairment in functioning due to ADHD for adolescentfunctioning due to ADHD for adolescent

Different definition of remissionDifferent definition of remission– Syndromatic remissionSyndromatic remission– Symptomatic remissionSymptomatic remission– Functional remission Functional remission

Definition of ADHD RemissionDefinition of ADHD Remission

<8.0 ADHD<8.0 ADHD

symptomssymptoms

<4.5 ADHD<4.5 ADHD

symptomssymptoms

GAFGAF>=65>=65

SyndromaticSyndromatic

**SymptomaticSymptomatic

** * * FunctionalFunctional

** ** **

Adolescent and adult with ADHDAdolescent and adult with ADHDBackgroundBackground

A source of controversy and uncertainty in ADHD A source of controversy and uncertainty in ADHD is the marked differences that have been observed is the marked differences that have been observed in male to female ration between pediatric and in male to female ration between pediatric and adolescent samplesadolescent samples– Gender ration in pediatric sample heavily favors male Gender ration in pediatric sample heavily favors male

4:1– 9:14:1– 9:1

– Adolescent and adult samples have a more even gender Adolescent and adult samples have a more even gender distributiondistribution

– Differences in gender representation have threaten the Differences in gender representation have threaten the validity of the diagnosis of Adolescent and adult validity of the diagnosis of Adolescent and adult ADHDADHD

Adolescent and adult with ADHDAdolescent and adult with ADHDBackgroundBackground

Similar pattern of comorbidity had been docSimilar pattern of comorbidity had been documented in boys and girls with ADHDumented in boys and girls with ADHD– However, boys have>2 fold increased rates of dHowever, boys have>2 fold increased rates of d

isruptive behavior disorderisruptive behavior disorder– Disruptive behavior disorders drive clinical refeDisruptive behavior disorders drive clinical refe

rrals of children but not adultsrrals of children but not adults

Follow up studies in ADHDFollow up studies in ADHD

Montreal study by Weiss and Hechtman Montreal study by Weiss and Hechtman (1993) (1993)

New York Study by Mannuzza,Klein et al New York Study by Mannuzza,Klein et al (1998)(1998)

Swedish Study by Rasmussen and Gillberg Swedish Study by Rasmussen and Gillberg (2001) (2001)

Milwaukee Study by Barkley (2002)Milwaukee Study by Barkley (2002)

What predicts persistence of ADHD into What predicts persistence of ADHD into adolescence?adolescence?(Biederman, Farone et al;1996)(Biederman, Farone et al;1996)

Familiarity of the ADHD(OR 2) Familiarity of the ADHD(OR 2) Presence of psychiatry comorbidity (conduct Presence of psychiatry comorbidity (conduct

disorder, mood or anxiety disorder) (OR 3)disorder, mood or anxiety disorder) (OR 3) Family adversityFamily adversity (paternal mental illness, (paternal mental illness,

conflict in family) (OR 7)(p<0.001)conflict in family) (OR 7)(p<0.001)

Adolescent outcomeAdolescent outcome

decline in hyperactivity, improvement in decline in hyperactivity, improvement in attention span and impulse controlattention span and impulse control (Hart, (Hart,

Lahey, Loeber, Applegate& Frick, 1995)Lahey, Loeber, Applegate& Frick, 1995) 30-80% of ADHD children continue to 30-80% of ADHD children continue to

display symptoms in adolescencedisplay symptoms in adolescence (Gittelman, (Gittelman,

Mannuzza, 1985; Barkley, Fischer et al, 1990)Mannuzza, 1985; Barkley, Fischer et al, 1990) 25-45% display oppositional or antisocial 25-45% display oppositional or antisocial

behavior or CDbehavior or CD (Biederman, Faraone et al 1996, (Biederman, Faraone et al 1996, Biederman et al 1997)Biederman et al 1997)

How are ADHD adolescents doing in How are ADHD adolescents doing in school?school? 29.3% retained in a grade, 46.3% had been suspen29.3% retained in a grade, 46.3% had been suspen

ded, 10% dropped out.ded, 10% dropped out.(Barkley, Fischer,1990)(Barkley, Fischer,1990)

ADHD adolescents had more academic impairmenADHD adolescents had more academic impairments(compared to baseline), lower IQ and mathematits(compared to baseline), lower IQ and mathematics achievement scores and more learning disabilitics achievement scores and more learning disabilities.es.

Fail to work independently wellFail to work independently well Poor organization and planningPoor organization and planning Poor time management Poor time management Poor follow throughPoor follow through

Differential diagnosis of ADHDDifferential diagnosis of ADHD--comorbidity alter the clinical presentation and may --comorbidity alter the clinical presentation and may require multiple treatmentrequire multiple treatment

Coexisting conditionsCoexisting conditions– Conduct disorderConduct disorder– Learning disorderLearning disorder– Oppositional defiant disorderOppositional defiant disorder– Bipolar affective disorderBipolar affective disorder– EpilepsyEpilepsy– Tourette syndromeTourette syndrome

Comorbid disorders in ADHD adolescentsComorbid disorders in ADHD adolescents

High percentage of antisocial behavior, but low rates of High percentage of antisocial behavior, but low rates of mood and anxiety disorders.mood and anxiety disorders.(Weiss 1993; Mannuzza 1991)(Weiss 1993; Mannuzza 1991)

59% of ADHD adolescents had ODD, 43% had 59% of ADHD adolescents had ODD, 43% had CDCD(Barkley,1990)(Barkley,1990)

Baseline comorbid CD significantly increase the risk for CD Baseline comorbid CD significantly increase the risk for CD and ODD, Bipolar Disorder and alcohol and drug and ODD, Bipolar Disorder and alcohol and drug dependence on follow up. dependence on follow up.

Baseline comorbid major depression increased the risk for Baseline comorbid major depression increased the risk for ODD, Major Depression, Bipolar Disorder and Agoraphobia. ODD, Major Depression, Bipolar Disorder and Agoraphobia.

Multiple anxiety disorder at baseline increased the risk for Multiple anxiety disorder at baseline increased the risk for Anxiety Disorder. Anxiety Disorder.

Youngster with non-comorbid ADHD had an increased risk Youngster with non-comorbid ADHD had an increased risk for ODD, Tic Disorder, and Language disorder. for ODD, Tic Disorder, and Language disorder. (Biederman, (Biederman, Faraone et al, 1996)Faraone et al, 1996)

Comorbidity of adolescent ADHDComorbidity of adolescent ADHD

comorbiditycomorbidity Prevalence among Prevalence among ADHD adolescentsADHD adolescents

Prevalence in Prevalence in general populationgeneral population

Academic Academic impairmentimpairment

20%- 60%20%- 60% 5% -15%5% -15%

Major depressionMajor depression 9%- 32%9%- 32% 3%-5%3%-5%

Anxiety disordersAnxiety disorders 10%- 40%10%- 40% 3%- 10%3%- 10%

Conduct disorderConduct disorder 20%- 56%20%- 56% unknownunknown

ODDODD 20%- 67%20%- 67% 2% -16%2% -16%

BipolarBipolar 6% -10%6% -10% 3% -4%3% -4%

Overlapping Diagnostic CriteriaOverlapping Diagnostic Criteria

ADHDADHD GADGAD ManiaMania DepressionDepression CD/ODDCD/ODD

RestlessnessRestlessness** **

Poor attentionPoor attention** ** **

Increased Increased activityactivity ** **DistractibilityDistractibility

** **IrritabilityIrritability

** ** ** ** **

Psychiatry and Medical Disorders can Psychiatry and Medical Disorders can mimic ADHDmimic ADHD Mood DisorderMood Disorder Psychotic DisorderPsychotic Disorder Adjustment DisorderAdjustment Disorder Anxiety DisorderAnxiety Disorder Learning/language Learning/language

DisorderDisorder Stress-related DisorderStress-related Disorder Developmental Developmental

DisorderDisorder

Sleep ApneaSleep Apnea Substance Use Substance Use

DisorderDisorder Use of Other Use of Other

medicationsmedications Seizure DisorderSeizure Disorder Vision problemVision problem Hearing ImpairmentHearing Impairment

How does having ADHD affect self How does having ADHD affect self esteem?esteem?

ADHD individuals displayed lower self-ADHD individuals displayed lower self-esteem and psychosocial adjustment by esteem and psychosocial adjustment by adolescents and lower educational adolescents and lower educational achievement and occupational status. achievement and occupational status. (Mannuzza, Klein,1995)(Mannuzza, Klein,1995)

Lowered self esteem is part of the Lowered self esteem is part of the longitudinal outcome of ADHDlongitudinal outcome of ADHD

How are ADHD adolescents getting along How are ADHD adolescents getting along with their families?with their families?

Parent-adolescent relationship between Parent-adolescent relationship between ADHD teenagers and their parents are ADHD teenagers and their parents are generally characterized by increased generally characterized by increased conflict, negative communication, distorted conflict, negative communication, distorted beliefs, and more disengagement, especially beliefs, and more disengagement, especially when the adolescents are diagnosed with when the adolescents are diagnosed with ADHD+ODD.ADHD+ODD.

Adolescent ADHD and substance useAdolescent ADHD and substance use

Persistence of ADHD symptoms, family history Persistence of ADHD symptoms, family history and comorbid CD– high prediction of and comorbid CD– high prediction of drunkenness and daily smokingdrunkenness and daily smoking

Among different symptom cluster in ADHD, Among different symptom cluster in ADHD, inattentiveness is most predictive of substance inattentiveness is most predictive of substance use use

ADHD studiesADHD studies

Developmental outcome Developmental outcome studiesstudies

Developmental course Developmental course studiesstudies

Diagnostic retention Diagnostic retention studiesstudies

Symptom trajectory Symptom trajectory studiesstudies

Developmental outcome and Developmental outcome and developmental course researchdevelopmental course research

Developmental outcome studyDevelopmental outcome study:identifying a :identifying a cohort of children that meet diagnostic cohort of children that meet diagnostic criteria for ADHD and follow them criteria for ADHD and follow them prospectively to determine whether they are prospectively to determine whether they are at increased risk for any number of negative at increased risk for any number of negative developmental outcomedevelopmental outcome

Developmental course studyDevelopmental course study: whether the : whether the symptoms of ADHD persist into adolescentsymptoms of ADHD persist into adolescent

Developmental outcome studiesDevelopmental outcome studies

ThorleyThorley (1984)(1984):Childhood hyperactivity was associated with :Childhood hyperactivity was associated with an increased risk for PD, antisocial behavior, peer an increased risk for PD, antisocial behavior, peer relationship, educational difficulties,as well as continued relationship, educational difficulties,as well as continued HIA symptomsHIA symptoms

Clampit and PirkleClampit and Pirkle (1983)(1983): psychostimulants maybe effective : psychostimulants maybe effective in ADHD adolescentsin ADHD adolescents

Barkley et alBarkley et al (1993)(1993): children with ADHD are at increased risk : children with ADHD are at increased risk for a variety of negative developmental outcome in for a variety of negative developmental outcome in adolescence and adulthood.adolescence and adulthood.

Barkley et alBarkley et al (2002)(2002): “…the educational, occupational, and : “…the educational, occupational, and psychosocial risks are associated with a childhood diagnosis psychosocial risks are associated with a childhood diagnosis of ADHD relative to both normal and clinical control of ADHD relative to both normal and clinical control populations.”populations.”

Limitations of developmental outcome Limitations of developmental outcome studiesstudies

It remains unclear whether:It remains unclear whether:– ADHD symptomatology may ADHD symptomatology may interfereinterfere with with

normal development process, including parent-normal development process, including parent-child relationships, peer relationship and/or child relationships, peer relationship and/or academic performance that in turns increase the academic performance that in turns increase the risk of negative outcome, orrisk of negative outcome, or

– ADHD may ADHD may facilitatefacilitate the onset and persistence the onset and persistence of other behaviors/psychiatric disorder that of other behaviors/psychiatric disorder that increase the risk for negative outcome.increase the risk for negative outcome.

The importance of developmental The importance of developmental course studycourse study

Clarify the Clarify the mechanismmechanism linking childhood linking childhood ADHD to later negative developmental ADHD to later negative developmental outcomeoutcome

An improved understanding of the An improved understanding of the developmental coursedevelopmental course of ADHD of ADHD symptomatology would provide information symptomatology would provide information for the construction of developmentally for the construction of developmentally sensitive diagnostic criteriasensitive diagnostic criteria

Developmental course studiesDevelopmental course studies

Diagnostic retention studiesDiagnostic retention studies Symptom trajectory studiesSymptom trajectory studies

– MacCallum et al (2002): “…repeated measures data of MacCallum et al (2002): “…repeated measures data of a continuous variable provide more information than a a continuous variable provide more information than a dichotomous diagnosis…” dichotomous diagnosis…”

Diagnostic retention studiesDiagnostic retention studies

– Hill and Schoener (1996):meta-analysis of 9 Hill and Schoener (1996):meta-analysis of 9 diagnostic retention studies. Rate of ADHD diagnostic retention studies. Rate of ADHD desisted by 50% every 5 years(beginning at 9)desisted by 50% every 5 years(beginning at 9)

» Barkley(1998)’s criticize: 1. Many of the studies Barkley(1998)’s criticize: 1. Many of the studies included were initiated prior to the establishment of included were initiated prior to the establishment of formal diagnostic criteria for ADHD. 2. Not enough formal diagnostic criteria for ADHD. 2. Not enough studies were included.studies were included.

Symptom trajectory studiesSymptom trajectory studies

Hart et alHart et al(1995)(1995): 1. Hyperactive-impulsive symptoms : 1. Hyperactive-impulsive symptoms significantly declined with increasing age, whereas significantly declined with increasing age, whereas inattention symptoms did not. 2. Conduct problems inattention symptoms did not. 2. Conduct problems predicted persistence of ADHD symptom. predicted persistence of ADHD symptom. 3.Developmental changes in ADHD symptom did not 3.Developmental changes in ADHD symptom did not vary as a function of informants 4. Psychosocial and vary as a function of informants 4. Psychosocial and pharmacological interventions did not reduce ADHD pharmacological interventions did not reduce ADHD greatly.greatly.

BiedermanBiederman (1998)(1998):1.Children and adolescent ADHD did :1.Children and adolescent ADHD did not differ in the mean number of ADHD symptoms. not differ in the mean number of ADHD symptoms. 2.Clinical phenotype is the same in adolescent and 2.Clinical phenotype is the same in adolescent and children.children.

BiedermanBiederman (on the same sample,2000):(on the same sample,2000): HIA decreased HIA decreased significantly as age increased.significantly as age increased.

Developmental Trajectories of Brian Developmental Trajectories of Brian volume abnormalities in youth with ADHDvolume abnormalities in youth with ADHD

Design: MRI case control studyDesign: MRI case control study M=152 youth with ADHD and 139 controls M=152 youth with ADHD and 139 controls

of both gendersof both genders Objectives; assess volumetric changes overtObjectives; assess volumetric changes overt

ime in medicated vs unmedicated youth witime in medicated vs unmedicated youth with ADHD and controlsh ADHD and controls

Catellanous :JAMA 2002; 288-1740 Catellanous :JAMA 2002; 288-1740

Developmental Trajectories of Brian Developmental Trajectories of Brian volume abnormalities in youth with ADHDvolume abnormalities in youth with ADHD

Main FindingsMain Findings::1.1. Smaller brain volumes in all regions independenSmaller brain volumes in all regions independen

tly of medication statustly of medication status2.2. Smaller total cerebral (-3.2%)and cerebellar (-3.Smaller total cerebral (-3.2%)and cerebellar (-3.

5%) volumes5%) volumes3.3. Volumetric abnormalies(except caudate) persisteVolumetric abnormalies(except caudate) persiste

nt with agent with age4.4. No gender differencesNo gender differences5.5. Volumetric findings correlated with severity of Volumetric findings correlated with severity of

AHDHAHDH

Developmental Trajectories of Brian Developmental Trajectories of Brian volume abnormalities in youth with ADHDvolume abnormalities in youth with ADHD

ConclusionsConclusions

Genetic and or early environmental influeGenetic and or early environmental influences on brain development in ADHD are fnces on brain development in ADHD are fixed, nonprogressive and unrelated to stimixed, nonprogressive and unrelated to stimulant treatmentulant treatment

Maturation lag hypothesisMaturation lag hypothesis

Satterfield JHSatterfield JH(1973,1984)(1973,1984):ADHD children have more slow :ADHD children have more slow activity and less activity in the high frequency band---activity and less activity in the high frequency band---signs of immaturity reflecting a delayed brain signs of immaturity reflecting a delayed brain maturation that could be normalized with age,or a maturation that could be normalized with age,or a deviation of brain maturation.deviation of brain maturation.

Giedd JNGiedd JN(2001(2001):ADHD cerebellum is significantly ):ADHD cerebellum is significantly smaller than control.smaller than control.

LouLou (1984)(1984):SPECT finding—maturational lags of CNS :SPECT finding—maturational lags of CNS resulting from delayed myelination.resulting from delayed myelination.

CastellanosCastellanos (2002)(2002):gray matter shows complex :gray matter shows complex developmental curves with a preadolescent increase but developmental curves with a preadolescent increase but a post adolescent decrease.a post adolescent decrease.

Limitations of developmental course Limitations of developmental course studiesstudies

Sample characteristics: predominantly males in clinic Sample characteristics: predominantly males in clinic referred samplereferred sample

Course of ADHD symptomatology differs as a function of Course of ADHD symptomatology differs as a function of comorbidity?comorbidity?

The need to better understand whether reductions in The need to better understand whether reductions in ADHD(due either to sex and/or advancing age) are ADHD(due either to sex and/or advancing age) are associated with specific changes in functional impairment associated with specific changes in functional impairment that result from ADHD.that result from ADHD.

Design issues:Design issues:– Wide age rangeWide age range– Time adjacent study that did not consider the functional form that Time adjacent study that did not consider the functional form that

characterizes this change over timecharacterizes this change over time

More limitations…More limitations…

Heterogeneity:Heterogeneity: ADHD is not a homogenous ADHD is not a homogenous diseasedisease– Mendelson et al (1971):1/2 improved over time, ¼ Mendelson et al (1971):1/2 improved over time, ¼

partial improved, ¼unchangedpartial improved, ¼unchanged– Loney (1981):developmental delay, developmental Loney (1981):developmental delay, developmental

decay, continual display decay, continual display – Lambert (1987,community cases):20% remitters, Lambert (1987,community cases):20% remitters,

residuals 37%, persisters (43%)residuals 37%, persisters (43%)– Hechtman of Montreal sample(1993):1/3 normal Hechtman of Montreal sample(1993):1/3 normal

outcome, 1/2continual symptoms with function outcome, 1/2continual symptoms with function impairment, a minority experienced serious outcome.impairment, a minority experienced serious outcome.

ImplicationsImplications

Clinicians working with Clinicians working with substance abusesubstance abuse populations, populations, conduct disorderedconduct disordered populations populations and and head injuryhead injury populations should be alert populations should be alert for ADHD.for ADHD.

ADHD is a lifelong disorderADHD is a lifelong disorder

Treatment options in comorbid ADHDTreatment options in comorbid ADHD

Assess and treat all disordersAssess and treat all disorders Prioritized treatmentPrioritized treatment Treatment of ADHD almost always involves the trTreatment of ADHD almost always involves the tr

eatment of comorbidityeatment of comorbidity Order of treatmentOrder of treatment

– Most debilitating symptoms firstMost debilitating symptoms first– Consider interactions of symptoms and side effects of sConsider interactions of symptoms and side effects of s

timulantstimulants Simple case– monotherapySimple case– monotherapy Complex case- combined treatmentComplex case- combined treatment

Use of RitainUse of Ritain

Absolute range per Absolute range per dose:5-30 mgdose:5-30 mg

Weight-based dose Weight-based dose range per day: 0.3-range per day: 0.3-2.0mg/kg2.0mg/kg

There is no research to There is no research to indicate more medicine indicate more medicine with higher body weightwith higher body weight

Dose of medicine varied Dose of medicine varied with individual’s with individual’s metabolism, severity of metabolism, severity of ADHD symptoms, ADHD symptoms, presence of comorbid presence of comorbid conditions, behavior conditions, behavior characteristics and natural characteristics and natural environmentenvironment

Side effect of Ritalin and its managementSide effect of Ritalin and its management Anorexia(generally lunch)-give with meals, snacksAnorexia(generally lunch)-give with meals, snacks Insomnia- move dosing earlier, use of clonidine, TCAInsomnia- move dosing earlier, use of clonidine, TCA Mood disturbance- evaluate for mood disorder, assess Mood disturbance- evaluate for mood disorder, assess

timing of mood to r/o wear off effecttiming of mood to r/o wear off effect Tic disorder- assess for underlying tics, stop and rechTic disorder- assess for underlying tics, stop and rech

allengeallenge Headache- lower dose, change prep, consider beta bloHeadache- lower dose, change prep, consider beta blo

ckercker Psychosis- rare, reassess dose and comorbidPsychosis- rare, reassess dose and comorbid Delay growth spurt- drug holiday if inattentive formDelay growth spurt- drug holiday if inattentive form

Non-stimulant pharmacotherapyNon-stimulant pharmacotherapy

TCATCA– 60-70% effective, but generally less effective than stimulant60-70% effective, but generally less effective than stimulant

ss BupropionBupropion

– First line for ADHD+ substance abuse/cigarette useFirst line for ADHD+ substance abuse/cigarette use– Maybe helpful in ADHD+ mood labilityMaybe helpful in ADHD+ mood lability

ClonidineClonidine– Useful in ADHD +ticsUseful in ADHD +tics– Use at night for ADHD related sleep problemUse at night for ADHD related sleep problem– Concerns of sudden death: case report of 4 children(clonidineConcerns of sudden death: case report of 4 children(clonidine

+ MPH)+ MPH)

Treatment of ADHD with MDDTreatment of ADHD with MDD

Depression disorderDepression disorder– If MDD is severe, then it is the focus of treatmentIf MDD is severe, then it is the focus of treatment– If MDD is less severe or not primary, If MDD is less severe or not primary, use stimulant trial use stimulant trial

firstfirst– After stimulant trial, evaluate the depressive symptomsAfter stimulant trial, evaluate the depressive symptoms– If depressive symptoms continue, use antidepressant or If depressive symptoms continue, use antidepressant or

psychotherapeutic treatmentpsychotherapeutic treatment– SSRI effective for depression but not ADHDSSRI effective for depression but not ADHD– If depressive symptoms subsided, continue stimulantsIf depressive symptoms subsided, continue stimulants– Bupropion and TCA have antidepressant activity in adult, Bupropion and TCA have antidepressant activity in adult,

but utility in pediatric use had nor been established(5 but utility in pediatric use had nor been established(5 cases of sudden death in younger childrencases of sudden death in younger children) )

Treatment of ADHD with anxiety Treatment of ADHD with anxiety disorderdisorder

Differentiate the relationship between ADHD and Differentiate the relationship between ADHD and anxiety disorders anxiety disorders

Start with a stimulant trialStart with a stimulant trial If ADHD symptoms improve, but anxiety If ADHD symptoms improve, but anxiety

symptoms persisted, apply psychosocial symptoms persisted, apply psychosocial interventionintervention

If the anxiety symptoms does not improve with If the anxiety symptoms does not improve with the psychosocial intervention, consider adding the psychosocial intervention, consider adding SSRI to the stimulants.SSRI to the stimulants.

Treatment of ADHD with tics disorderTreatment of ADHD with tics disorder

High comorbidity of ADHD (50-70% TS patients)High comorbidity of ADHD (50-70% TS patients) Onset of ADHD before ticsOnset of ADHD before tics Stimulants are highly effective in the treatment of ADHD Stimulants are highly effective in the treatment of ADHD

in these patients and in the majority of patients tics do not in these patients and in the majority of patients tics do not increaseincrease

Start the stimulant treatment after proper informed consentStart the stimulant treatment after proper informed consent If tics worsen markedly, move on to an alternative If tics worsen markedly, move on to an alternative

stimulantsstimulants If tics do not worsen, and ADHD symptoms respond, If tics do not worsen, and ADHD symptoms respond,

remain on the stimulantsremain on the stimulants To treat the tics, consider combine medication, clonidine To treat the tics, consider combine medication, clonidine

and guanfacine may be tried firstand guanfacine may be tried first

Treatment of ADHD with conduct Treatment of ADHD with conduct disorder and aggressiondisorder and aggression

It stimulant did not reduce antisocial behavior despite It stimulant did not reduce antisocial behavior despite the attenuation of the ADHD symptoms, use mood the attenuation of the ADHD symptoms, use mood stabilizer(Li or divalproex sodium), or Clonidine in stabilizer(Li or divalproex sodium), or Clonidine in addition to stimulants(Frazier, 1999)(4 deaths with the addition to stimulants(Frazier, 1999)(4 deaths with the combination of Stimulants and Clonidine)combination of Stimulants and Clonidine)

Use of Clonidine:start with 0.05mg at bedtime, never Use of Clonidine:start with 0.05mg at bedtime, never more than 0.3 mg per day. more than 0.3 mg per day. Never use in patients with Never use in patients with family history of sudden death, repeated fainting or family history of sudden death, repeated fainting or arrhythmias.arrhythmias.

If aggression is severe, and is in immediate danger, use If aggression is severe, and is in immediate danger, use atypical neuroleptics, such as 0.5mg QD Risperidone, atypical neuroleptics, such as 0.5mg QD Risperidone, to the stimulantsto the stimulants

Prevention of Abuse potential of Prevention of Abuse potential of stimulants in adolescentsstimulants in adolescents

Locked the medicine, keep a recordLocked the medicine, keep a record Do not use one student’s medicine on Do not use one student’s medicine on

anotheranother Avoid sending medicine to schoolAvoid sending medicine to school Use Concerta: paste, taken once dailyUse Concerta: paste, taken once daily

Oslon, 1959Oslon, 1959

Those who surprised us seems to take a Those who surprised us seems to take a longer time to travel a given road, but that longer time to travel a given road, but that road has been kept open by parents and road has been kept open by parents and teachers who felt it worthwhile.”teachers who felt it worthwhile.”