Attention Deficit Hyperactivity Disorder (ADHD)

It's frequently thought that ADHD is a

"twenty-first century disorder"

What term was used to describe children with ADHD before DSM-II?

Minimal brain damage (MBD)

What was the term nuanced from minimal brain damage (MBD) before DSM-II for ADHD?

Minimal brain dysfunctioning

DSM-II (1968)

"Hyperkinetic reaction of childhood" was the DSM-II diagnosis characterized by hyperactivity

DSM-III (1980)

Condition was renamed to "Attention Deficit Disorder"; first recognition of inattention as part of the disorder

DSM-IV (1994)

– Distinguished between subtypes

• ADHD-I

– Predominantly inattentive

• ADHD-H

– Predominantly hyperactive-impulsive

• ADHD-C

– Combined subtype

– Describes children showing both inattentive and hyperactive-impulsive symptoms

DSM-5 (2013)

Retains DSM-IV subtypes, which are now called presentations

Prevalence of ADHD

about 6% - 7% of children worldwide

Some of this variation is due to a

rise in clinical referrals and diagnoses over the past two decades

ICD and DSM focus on slightly different aspects of the disorder and have used

different diagnostic criteria

Males are

two to three times more likely to be diagnosed with ADHD than females

Females are more likely to meet criteria for the

inattentive presentation

Males are more likely to be diagnosed with the

combined presentation

Recent literature shows that at least

some symptoms persist into adulthood

Which gender may be underdiagnosed for ADHD

women

Approximately 15% of ADHD patients

still met full criteria at age 25

Approximately 65% of ADHD patients

still met criteria for "ADHD in partial remission"

Prevalence of ADHD in young adulthood

5%

Prevalence of ADHD in old age

3-4%

Functional Impact on children with ADHD

– Suffer from poor social skills

• Leading to conflicted peer relationships

– Low self-esteem

– Adverse academic outcome

– Injuries and accidents

– Frequently seen as a burden on their families

Functional Impact on adolescents with ADHD

– Start smoking at an earlier age and smoke more on a daily basis

– Engage in risky sexual behavior more often

Functional Impact on Adults with ADHD

– Lower socioeconomic status

– Marital difficulties

– General health problems

Children with ADHD

Score approximately 7 to 15 points lower in IQ tests

Adults with lifetime ADHD experience highly increased occurrences of

Antisocial behaviors including theft, assault, vandalism, or disorderly conduct

Comorbidity of ADHD

increased risk of depression, anxiety disorder, antisocial personality disorder, and substance use disorder

Both inattention and hyperactive/impulsive behavior should be seen as

continua ranging from normal to severely abnormal

It is important to strictly adhere to

standard diagnostic criteria for the diagnosis

Diagnostic criteria for ADHD were originally

defined to evaluate children's behavior

Treatment of ADHD

either behavioral therapy, medication, or a combination of both
is beneficial for most patients

Behavioral therapy is a well-established stand-alone treatment for pediatric ADHD that mostly uses positive and negative reinforcement to

increase desired behavior and decrease undesired behavior

What type of medication enhances neurotransmission of dopamine in the brain?

Stimulants (ex. Ritalin or methylphenidate)

What type of medication enhances neurotransmission of norepinephrine in the brain?

Nonstimulants (ex. atomoxetine or Strattera)

Prevalence of stimulus use has

increased dramatically

Benefits of stimulants

– Ameliorates core symptoms of ADHD

– Beneficial effects on comorbid

• Oppositional defiant behavior

• Cognitive functions

• Productivity at school or work

• (no effect on academic achievement, though :/

Evidence of benefits of stimulants long term

There is little and inconsistent evidence for the long-term beneficial effects of medication beyond 2-years of use

In general, stimulants and atomoxetine are

well-tolerated

Stimulants and atomoxetine sometimes lead to

reductions in weight and height gain in children

Drug Holidays

taking children off medication during weekends or holidays

Drug holidays are often advised because they may be helpful in

normalizing side effects such as reduction in height and weight gain

Heritability of ADHD

An average of 76% of the variance in ADHD symptoms are explained by genetic factors

Environmental risk factors for ADHD

Neurobiological factors, psychosocial factors

Neurobiological factors

– For a large part include complications during pregnancy or delivery

• Maternal smoking or alcohol use during pregnancy

• Eclampsia

• Fetal distress

• Premature birth

• Poor maternal health

• Higher maternal age

– Many of these factors can lead to hypoxia in the fetal brain

• The basal ganglia is often implicated in ADHD and particularly sensitive to the effects of hypoxia

Psychosocial risk factors for ADHD

Poor socioeconomic status, Family dysfunction

Family disfunction includes

maternal mental disorders, paternal criminality, marital problems, and in-home conflict

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

However, there is little evidence for this