ADHD

ADHD main idea

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development

Symptoms must present prior to age

12

Symptoms must present in what number of settings?

two or more

History of ADHD

Frequently thought to be a “21st century disorder” caused by the abundant stimuli from current information technology (smartphones, TV, social media) but there is little evidence for this

• However, ADHD symptoms were reported as early as 1902

• therefore current tech can be a component cause but not sufficient cause

Early reports of ADHD: Primarily focused on children’s malfunctioning

• Before DSM-2

  • Children were described as minimal brain damage

• DSM-4

  • Distinguished between subtypes

    • ADHD-I

      • Predominantly inattentive

    • ADHD-H

      • Predominantly hyperactive-impulsive

    • ADHD-C

      • Combined subtype

      • Both inattentive and hyperactive-impulsive

• DSM-5

  • Retains subtypes but now called presentations

  • Ongoing debate over validity

Prevalence

Most recent estimate is 6-7% of children worldwide, but varies from 1-20% based on study

• Some variation due to rise in clinical referrals and diagnoses over past twenty years

• ICD and DSM also use slightly different diagnostic criteria

• Many studies tend to apply diagnostic criteria too loosely

Sex differences

• Males are 2-3x more likely to be diagnosed than females

• Females more likely to have inattentive presentation

• Men more likely to have combined presentation

• Women may be underdiagnosed

Developmental course

Much easier to diagnose children bc diagnostic criteria is written for them

Suggests some symptoms persist into adulthood

• They learn to control external symptoms (climbing on things) and retain internal ones 

Functional impact on children

• Poorer social skills

• Low self esteem

• Adverse academic outcome

  • Approximately 7 to 15 points lower on IQ tests

• Injuries and accidents

• Burden on families

Functional impact on adolescents

• Started smoking earlier

• Engage in risky sexual behavior

Functional impact on adults

• Lower socioeconomic status

• Marital difficulties

• General health problems

Comorbidity

• Adults with lifetime ADHD

  • Highly increased occurrences of antisocial behaviors

    • Theft, assault, vandalism, disorderly conduct

  • Increased risk of depression, anxiety, substance abuse

  • In the workplace:

    • Poor productivity

    • Absenteeism

    • General occupational underachievement or unemployment

  • Substantial economic impact from loss of productivity

Standard treatment for ADHD

Behavioral therapy: uses positive and negative reinforcement to increase desired behavior and decrease undesired behavior

Medication recommended for severe symptoms, usually begin with behavioral therapy first

• Both are effective

Behavioral therapy

Well established, stand alone treatment for pediatric ADHD

• Mostly uses positive and negative reinforcement to increase desired behavior and decrease undesired behavior

  • ex.  setting timers as a way of operantly conditioning you to assess your attention level

• Types of evidence-based treatments target children with ADHD in different settings

  • Behavioral parent training

  • Classroom management

  • Peer interventions

• Meta analysis

  • Behavioral therapy ameliorates behavioral symptoms of the disorder

  • Has moderate effects on

    • Comorbid opposition and conduct behavior

    • Social behavior outcomes

Medication

• Stimulants

  • Enhances neurotransmission of dopamine in the brain (ritalin)

  • Prevalence of stimulants use has increased dramatically

• Nonstimulants

  • Enhances neurotransmission of norepinephrine in the brain (strattera)

• Well documented beneficial effects of stimulants and atomoxene

  • Ameliorates core symptoms of ADHD

  • Beneficial effects on comorbid

    • ODD

    • Cognitive functions

    • Productivity at school or work

    • But NO effect on academic achievement

• Little or inconsistent evidence for long-term beneficial effects of medication beyond 2 years of use

• In general, stimulants and atemoxine are well tolerated with mild symptoms

  • However, in children they can stunt growth

  • Recommends drug holidays - taking children off medication during weekends or holidays

Risk factors

Environmental risk factors

• Neurobiological factors

  • Maternal smoking or alcohol use during pregnancy

  • Eclampsia

  • Fetal distress

  • Premature birth

  • Poor maternal health

  • Higher maternal age

• Psychosocial factors

  • Low socioeconomic status

  • Family dysfunction

    • Includes maternal mental issues, paternal criminality, marital problems

  • Some have concerns that media might lead to ADHD-like behavioral problems

    • However there is little evidence for this

What percent of ADHD symptoms can be explained genetically

76

issues with diagnosing?

on a continuum - has arbitrary cutoffs (need 6 or more symptoms)

criteria are specifically written for children with things like “climbs on things” and must present before age 12