OH, Adolescents and Attention Deficit Hyperactivity Disorder (ADHD) How do you deal with them? Presented By: Todd Twogood MD, FAAP

OH, Adolescents and Attention Deficit Hyperactivity Disorder (ADHD) How do you deal with them? Presented By: Todd Twogood MD, FAAP

Teenagers

Time of Transformation

Allergy to Parents

The Real Self

Looks are everything

How do you deal with it all

Don t lose your parental authority

Give them all your Love

ADD and ADHD

ADHD: Historical Timeline Hyperkinetic Reaction of Childhood (DSM-II) Minimal Brain Damage Attention Deficit Hyperactivity Disorder (DSM-III-R) 1902 1930 1960 1968 1980 1987 1994 ADHD-like syndrome first described Minimal Brain Dysfunction Attention Deficit Disorder + or - Hyperactivity (DSM-III) Attention Deficit/Hyperactivity Disorder (DSM-IV)

Worldwide Prevalence of ADHD Is 3% to 7% Studies of ADHD prevalence United States (Shaffer et al 1996) Tennessee (Wolraich et al 1996) Mannheim, Germany (Esser et al 1990) London, England (Esser et al 1990) Germany (Baumgaertel et al 1995) Iowa (Lindgren et al 1990) Pittsburgh, Pa (Costello et al 1988) US inner city (Newcorn et al 1989) Ontario (Szatmari et al 1989) New Zealand (Anderson et al 1997) Goldman, et al. JAMA.1998;279:1100-1107. 0 5 10 15 20 Prevalence of ADHD (%) in school-age children

ADHD: Core Symptom Areas Inattention Impulsivity/Hyperactivity

ADHD: Core Symptom Area Inattention Six or more of the following - manifested often*: Inattention to details/ makes careless mistakes Difficulty sustaining attention Seems not to listen Fails to finish tasks Difficulty organizing Avoids tasks requiring sustained attention Loses things Easily distracted Forgetful *DSM-IV, 1994.

ADHD: Core Symptom Areas Impulsivity/Hyperactivity Six or more of the following - manifested often* Impulsivity Blurts out answer before question is finished Difficulty awaiting turn Interrupts or intrudes on others Hyperactivity Fidgets Unable to stay seated Inappropriate running/climbing (restlessness) Difficulty in engaging in leisure activities quietly On the go Talks excessively *DSM-IV, 1994.

ADHD: Course of the Disorder Inattentio n Age

Comorbid Conditions in Children with ADHD Comorbidities Anxiety disorder Conduct disorder Oppositional-defiant disorder Affective disorder Tic disorder Mania/hypomania Learning/academic problems Range 8% 30% 8% 25% 45% 64% 15% 75% 8% 34% 0% 22% 10% 92% Spencer TJ, et al. Pediatr Clin North Am. 2000;46:915-927. Biederman J, et al. Arch Gen Psychiatry. 1996;53:437-446.

ADHD: Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies Environmental factors Neuroanatomical neurochemical ADHD CNS insults Genetic origins CNS = central nervous system

Neuroimaging and ADHD y = +21 mm Normal control 1 x 10-2 y = +21 mm ADHD 1 x 10-2 Anterior Cingulate Cortex 1 x 10-3 Frontal Striatal Insular network 1 x 10-3 fmri shows decreased blood flow to the anterior cingulate and increased flow in the frontal striatum PET imaging shows decreased cerebral metabolism in brain areas controlling attention SPECT imaging shows increased DAT protein binding MGH-NMR Center & Harvard-MIT CITP. Adapted from Bush, et al. Biol Psychiatry. 1999;45:1542-1552.

Twin Studies Show ADHD Is a Genetic Disorder Hudziak, 2000 Nadder, 1998 Levy, 1997 Sherman, 1997 Silberg, 1996 Gjone, 1996 Thapar, 1995 Schmitz, 1995 Edelbrock, 1992 Gillis, 1992 Goodman, 1989 Willerman, 1973 Breast cancer Asthma Schizophrenia 0 0.2 0.4 0.6 0.8 1 Average genetic contribution of ADHD based on twin studies Faraone. J Am Acad Child Adolesc Psychiatry. 2000;39:1455-1457. Hemminki. Mutat Res. 2001;25:11-21. Palmer. Eur Resp J. 2001;17:696-702. Height ADHD Mean

Molecular Genetics of ADHD Specific genes associated with ADHD Dopamine receptor D4 gene (DRD4) on chromosome 11 Dopamine transporter gene (DAT1) on chromosome 5 D2 dopamine receptor gene Dopamine-beta-hydroxylase gene Uncertain about the association of noradrenergic genes There are several genes involved and their effects are cumulative Sunohara G, et al. J Am Acad Adolesc Psychiatry. 2000;39:1537-1592. Giros B, et al. Nature. 1996;379:606-612.

Potential Areas of Impairment Academic limitations Occupational/ vocational Relationships Legal difficulties ADHD Low self esteem Motor vehicle accidents Injuries Smoking and substance abuse

ADHD Affects Socialization Children are stigmatized by their behavior Disruptive behavior Troublemakers Excessive talking Unfocused, not responsive to others aggression Immaturity and impulsiveness Center of attention Blurting out answers AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S. Barkley RA. J Am Acad Child Adolesc Psychiatry. 1991;30:752-762. Bad sportsmanship Cannot sit still Impulsive Breaks the rules Peer rejection Adolescents continue to demonstrate social problems Poor participation in group activities Few friends Vulnerable to antisocial groups, drug abuse

How ADHD Affects Parents Increased stress Worry Anxiety Frustration Anger Lower self-esteem Self-blame Depression Social isolation Increased employment disruption Increased marital disruption Increased alcohol/substance abuse Murphy D, Barkley B. Am J Orthopsychiatry. 1996;66:93-102.

Increased Smoking with ADHD 50% Adult patients with ADHD; n=71 48.5% Current smokers 40% 30% 20% 40.8% 25.8% 29% ADHD General population *P<0.01 10% 0% *Smokers Quit ratio Pomerleau, et al. J Subst Abuse. 1995;7:373-378.

Earlier Initiation of Smoking with ADHD 0.6 Smoking probability 0.5 0.4 0.3 0.2 0.1 ADHD n=128 Control n=109 6- to 17-year-old boys P<0.003 0 0 2 4 6 8 10 12 14 16 18 20 22 24 Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44.

Increased Lifetime Substance Abuse in Untreated Adults with ADHD Lifetime rate of substance abuse in referred ADHD adults 60 50 40 30 20 10 0 ADHD (n=239) 55% Control (n=268) P<0.001 27% Biederman, et al. Biol Psychiatry. 1998;44:269-273.

Increased Traffic Violations and Motor Vehicle Accidents in Adolescents and Adults with ADHD 90 80 P=0.004 ADHD n=25 Control n=23 P=0.07 Subjects (%) 70 60 50 40 30 P=0.07 P=0.01 20 10 0 Traffic violations Speeding violations Drunk driving License suspended Driver-caused accidents Barkley RA, et al. Pediatrics. 1996;98:1089-1095.

ADHD Is Associated with Increased Medical Costs Medical cost (1995 national avg. dollars) $4500 $4000 $3500 $3000 $2500 $2000 $1500 $1000 $500 $0 $4306 ADHD $1944 Non-ADHD Overall medical costs P<0.001 N=4119 % total cohort 90 80 70 60 50 40 30 20 10 0 ADHD (n=309) Non-ADHD (n=3810) 26% 18% Inpatient hospital admission 41% 33% Outpatient hospital admission 81% 74% Emergency admission P<0.001 P<0.006 P<0.005 1987 to 1995 Leibson CL, et al. JAMA. 2001;285:60-66.

ADHD Diagnosis

Proper Steps in Diagnosis Assessment History DSM-IV criteria Interview parents, teachers, and patient Determine functional impairment in home and school/job settings Rating scales to corroborate clinical diagnosis Physical exam, vital signs, physical explanation for disorder, secondary conditions, drug contraindications Make assessment for comorbid conditions AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S.

Diagnostic Criteria for ADHD: DSM-IV-TR Persistent symptoms of inattention Onset of symptoms before age 7 Impairment in 2 or more settings (eg, school, work, home) Evidence of clinically significant impairment in social, academic, or occupational functioning Symptoms not a result of other disorders APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.

ADHD: DSM-IV Subtypes ADHD Predominantly Inattentive Type Criteria met for inattention but not for impulsivity/hyperactivity Inattention ADHD Predominantly Hyperactive-Impulsive Type Criteria met for impulsivity/hyperactivity but not for inattention Impulsivity/Hyperactivity ADHD Combined Type Criteria are met for both inattention and impulsivity/hyperactivity Inattention Impulsivity/Hyperactivity

American Academy of Pediatrics: Guidelines for ADHD Assessment Evaluate children (age 6 to 12 years) who exhibit the following: Inattention Hyperactivity Impulsivity Academic underachievement Behavioral problems DSM-IV criteria Evidence from parents/caretakers and teachers/school professionals of core symptoms of ADHD in school, home, and social settings Assessment for co-existing conditions Other diagnostic tests are not routinely indicated AAP. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105:1158-1170.

ADHD Treatment Strategies

Three Components of ADHD Treatment Education Psychosocial interventions Pharmacotherapeutic interventions

Classes of Medication Used to Treat ADHD FDA-approved Stimulants (methylphenidate, amphetamine) Off-label Antidepressants (tricyclics, bupropion) α2-adrenergic agonists (clonidine) AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36(suppl):85S-121S.

Probable Mechanism of Action of Methylphenidate Presynaptic Neuron Cytoplasmic DA v v Storage vesicle DA Transporter Synapse Methylphenidate Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513.

In ADHD: Stimulants Found to Improve Core Symptoms Inattention Impulsivity Hyperactivity Other Symptoms Noncompliance Impulsive aggression Social interactions Academic efficiency Academic accuracy Family dynamics ADHD Practice Parameters. J Am Acad Child Adolesc Psychiatry. 1997;36:85S. Greenhill LL, et al. J Am Acad Child Adolesc Psychiatry. 1999;38:503-512.

Stimulants: Potential Side Effects Appetite loss, abdominal pain Insomnia Nervousness Mild increase in pulse, blood pressure Psychiatric effects, irritability, dysphoria, and rebound (Effects occurring in >5% of patients and >placebo) Controversies: growth deficits, tic exacerbation, seizures, abuse AACAP Clinical Practice Guidelines. J Am Acad Child Adolesc Psychiatry. 1997;36(suppl):85S-121S.

Treatment Strategies for ADHD The multimodal treatment study of children with ADHD (MTA) 14-month clinical trial of treatment strategies 579 children with ADHD Subjects randomized to one of 4 treatment conditions Medication management Behavior management Medication management and behavior management Community-based treatment MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-1086.

Long-term Outcomes of Therapies for ADHD in the MTA Study Improvement at 14 months (%) 70 65 60 55 50 45 40 35 30 2 20 5 15 10 5 0 Hyperactive Impulsive Symptoms (Teacher Reports) 56% Medication management 60% Combination therapy (medication + behavior therapy) 45% Behavioral treatment 36% Community-based treatment

Pharmacotherapy Significantly Reduces Substance Abuse in Adults with ADHD 40 Effect of pharmacotherapy % of study population 30 20 10 32 12 P<0.001 10 0 Unmedicated ADHD (N=19) Medicated ADHD (N=56) Control (N=137) Biederman J, et al. Pediatrics. 1999;104:e20-e25.

American Academy of Pediatrics: Guidelines for the Treatment of ADHD Establish a treatment program that recognizes ADHD as a chronic condition Specify appropriate target outcomes to guide management Prescribe stimulant medication and/or behavior therapy to improve target outcomes in children with ADHD If the treatment program has not met target outcomes, evaluate: Original diagnosis Use of all appropriate treatments Adherence to the treatment plan Presence of coexisting conditions Using information from parents, teachers, and the child, followup to evaluate target outcomes and adverse effects AAP. Pediatrics. 2001;108:1033-1043.