PayAttention:ADHDThrough theLifespan

AnthonyL.Rostain,MD,MA ProfessorofPsychiatryandPediatrics PerelmanSchoolofMedicineatthe UniversityofPennsylvania

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Week1:TheBasics

Background
WhyADHDisimportant
Mostcommonneurobehavioraldisorderofchildhood Immediateandlifelongimpactsondevelopment

WhyADHDiscontroversial
Challengesofdiagnosis changesinterminology Fearsofoverdiagnosisandofovermedicationofchildren

HowknowledgeofADHDisevolving
Fromcasedescriptionstocasestudiestoclinicaltrials Fromobservationsofbehaviortoadvancesinneuroscience

WhatisADHD?
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DiagnosticCriteria

DSMIVCriteriaforADHD
1. Coresymptoms*:
Inattention HyperactivityandImpulsivity

2.Chronicity ofADHDsymptoms 3.PervasivenessofADHDsymptoms 4. ImpairmentcausedbyADHDsymptoms * toadegreethatismaladaptiveandinconsistent

withdevelopmentallevel
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DSMIVDiagnosticCriteria
A1.Sixormoreofthefollowingsymptomsofinattention havepersistedforatleastsixmonthstoadegreethatis maladaptiveandinconsistentwithdevelopmentallevel:
a) b) c) d) Oftenfailstogivecloseattentiontodetailsormakescareless mistakesinschoolwork,workorotheractivities Oftenhasdifficultysustainingattentionintasksorplayactivity Oftendoesnotseemtolistenwhenspokentodirectly Oftendoesnotfollowthroughoninstructionsandfailstofinish schoolwork,chores,ordutiesintheworkplace(notdueto oppositionalbehaviororfailuretounderstandinstructions)

Departments of Psychiatry and Pediatrics, University of Pennsylvania School of Medicine

DSMIVDiagnosticCriteria
Inattention(cont.)
e) f) g) h) i) Oftenhasdifficultyorganizingtasksandactivities Oftenavoids,dislikesorisreluctanttoengageintasksthatrequire sustainedmentaleffort(suchasschoolworkorhomework) Oftenlosesthingsnecessaryfortasksoractivities(e.g.toys,school assignments,pencils,booksortools) Isofteneasilydistractedbyextraneousstimuli Isoftenforgetfulindailyactivities

Departments of Psychiatry and Pediatrics, University of Pennsylvania School of Medicine

DSMIVDiagnosticCriteria
A2.Sixormoreofthefollowingsymptomsofhyperactivity impulsivity havepersistedforatleastsixmonthstoa degreethatismaladaptiveandinconsistentwith developmentallevel:
a) b) c) Oftenfidgetswithhandsorfeetorsquirmsinseat Oftenleavesseatinclassroomorinothersituationsinwhich remainingseatedisexpected Oftenrunsaboutorclimbsexcessivelyinsituationsinwhichitis inappropriate(inadolescentsoradults,maybelimitedto subjectivefeelingsofrestlessness) Oftenhasdifficultyplayingorengaginginleisureactivitiesquietly

d)

Departments of Psychiatry and Pediatrics, University of Pennsylvania School of Medicine

DSMIVDiagnosticCriteria
Hyperactivity(cont.)
e) f) Isoftenonthegooroftenactsasifdrivenbyamotor Oftentalksexcessively

Impulsivity
g) h) i) Oftenblurtsoutanswersbeforequestionshavebeencompleted Oftenhasdifficultyawaitingturn Ofteninterruptsorintrudesonothers(e.g.buttsinto conversationsorgames

Departments of Psychiatry and Pediatrics, University of Pennsylvania School of Medicine

DSMIVDiagnosticCriteria
B. Somehyperactiveimpulsiveorinattentivesymptomsmusthavebeen presentbeforeage7years C. Someimpairmentfromthesymptomsispresentinatleasttwosettings (e.g.atschool[orwork]andathome)

D. Theremustbeclearevidenceofinterferencewithdevelopmentally appropriatesocial,academicoroccupationalfunctioning E. Thedisturbancedoesnotoccurexclusivelyduringthecourseofother seriousmentaldisorders(e.g.pervasivedevelopmental disorder/autism,schizophrenia,otherpsychoticdisorder)

Departments of Psychiatry and Pediatrics, University of Pennsylvania School of Medicine

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DSMIVDiagnosticCriteria
314.01AttentionDeficit/HyperactivityDisorder,CombinedType:ifboth CriteriaA1andA2aremetforthepast6months 314.00AttentionDeficit/HyperactivityDisorder,Predominantly InattentiveType:ifCriterionA1ismetbutCriterionA2isnotmetforthe past6months 314.01AttentionDeficit/HyperactivityDisorder,Predominantly HyperactiveImpulsiveType:ifCriterionA2ismetbutCriterionA1isnot metforthepast6months Codingnote:Forindividuals(especiallyadolescentsandadults)who currentlyhavesymptomsthatnolongermeetfullcriteria,InPartial Remissionshouldbespecified

Departments of Psychiatry and Pediatrics, University of Pennsylvania School of Medicine

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MidLectureQuiz

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StrengthsofDSMIVCriteria
Usesrigorousandempiricallyderivedcriteria Committeeofexpertsdevelopedthecriteria LiteraturereviewofADHDconducted Existingratingscaleswerereviewed&studied Fieldtrialconducted(416yearoldsubjects)
Diagnosticcutoffpointsbasedonreliabilityandabilityto discriminateADHDfromnonADHD

Impairmentcriteriongivengreateremphasis

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WeaknessesofDSMIVCriteria
Ageofonsetcriterionmaynotbejustified Diagnosticitemsetsmaynotbeappropriatefor differentdevelopmentalperiods Diagnosticthresholds maynotapplytoolderage groups(>16years) Nogenderdistinctionindiagnosticthresholds Noloweragelimitdefined(<4years) Developmentalinappropriatenessisneitherclearly stipulatednorquantified
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ControversiesofDSMIVCriteria
Heterogeneityofsubtypesisproblematic
ADHD,PIType:differencesinsymptomsandlifecourse ADHD,PHIType:oftenconfusedwithotherdisorders

Setting(school,home)andsourceofinformation (teacher,parent)areconfounded
Peoplebehavedifferentlyindifferentcontexts Ratershavedifferentcriteriaforjudgingbehavior

Lowcorrelationbetweenparentandteacherratings (0.30 0.50)leadstodisagreementsandconfusion

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ControversiesofDSMIVCriteria
WhatistherelativeimportanceofInattentionindetermining thediagnosisADHD?
Attentionisnotaunitaryconstruct Inattentionisoftendifficulttodetectandmeasure InattentionmaybeduetofactorsotherthanADHDandcanbeseenin otherdisorders

WhatistherelativeimportanceofHyperactivityvs.Impulsivity indeterminingthediagnosisofADHD?
HyperactivitysymptomsoutnumberImpulsivitysymptomsincriteria Theoverlapbetweenthesesymptomsandthoseseeninother disorders(e.g.oppositionaldefiantdisorder)canleadtomisdiagnosis

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ADHDPotentialChangesinDSM5
Ageofonset willbeincreasedtoage12 Intent:Leavecore18Acriteriaunchanged,but contextualizedandillustratedtofitlifespan Impulsivitypoorlycovered Addingupto4new criteriabeingconsidered #ofcriterianeededforadolescents/adultslikelyto berevised datasuggest23fromall3dimensions wouldbebest compromiseis4from2dimensions concernthatprevalencewillincreasedramatically ASDexclusionisbeingremoved
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EndofLectureQuiz

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Prevalence,epidemiology

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WorldwidePrevalenceofADHD
Am J Psychiatry. 2007;164(6):942-948.

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ADHDintheUnitedStates
ADHDprevalenceamong8 to15yearolds:8.7%1 PercentageofchildrenwithADHDwhohavebeen treatedconsistentlyduringthepastyear:32%1 ADHDprevalenceamong18 to44yearolds:4.4%2 PercentageofadultswithADHDwhoreceived treatmentwithintheprevious12months:11%2
1. Froehlich et al. Arch Pediatr Adolesc Med. 2007;161(9):857-864. 2. Kessler et al. Am J Psychiatry. 2006;163:716-723.

Departments of Psychiatry and Pediatrics, University of Pennsylvania School of Medicine

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PrevalenceofADHD:Summary
9%ofchildren;7%ofadolescents;4.5%ofadults Malefemale:6:1,3:1,1:1 AlllevelsofIQ Alllevelsofsocioeconomicstatus Familygenetictransmission:0.75 Inheritancenotspecifictosubtype

CDC, 2008. Gaub M, Carlson CL. J Am Acad Child Adolesc Psychiatry. 1997;36(8):10361045. Levy F, et al. J Am Acad Child Adolesc Psychiatry. 1997;36(6):737-744. Smalley SL, 22 et al. J Am Acad Child Adolesc Psychiatry. 2000;39(9):1135-1143.

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MidLectureQuiz

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TheManyFacesofADHD: CasePresentations

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CaseStudy:TornadoTommy
6yearoldboyin1st grade
Presentingcomplaints
Troublefocusingandsustainingattention(esp.inschool) Easydistractibility(alwayslookingaround) Restlessnessandfidgetiness(squirmyinhisseat) Alwaysonthego neversitsstill Talksincessantlyandloudly Interruptsothersconversations Cantwaithisturn
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CaseStudy:SpacySteve
8yearoldboyin3rd grade
Presentingproblems
Inattention(Doesntlisten,alwaysinhisownworld) Forgetfulness(Cantrememberwhathesbeentold) Dawdlesandhastroublegettingstartedonthings Takesforevertogetthingsdone Lackseffortinschoolworkandhomework Poororganizationalskills Forgetstoturninhomeworkassignments
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CaseStudy:OrneryArnold
10yearoldboyin5th grade
Presentingproblems
Troublefocusing&sustainingattention(esp.inschool) Veryrestless,fidgetyinhisseat Argumentative(Alwayssaysnoandchallengesrules) Obnoxious(Getsonotherpeoplesnerves) Dislikesschoolintensely(Hethinksitsawasteoftime) Resistscompletinghomework(Procrastinatesandputs offgettingstarteduntillateatnight)
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CaseStudy:BabblingBrooke
12yearoldgirlin7th grade
Presentingproblems
Excessivetalking(Neverkeepsquiet arealchatterbox) Highenergyandfunloving(Lifeoftheparty sociable) Highlydistractible(Hastoseeeverythingthatsgoingon) Losesthings(e.g.eyeglasses,clothes,assignments) Verydisorganized(Bookbagisacompletemess) Avoidsdoingherhomework

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CaseStudy:AbsentmindedAnna
16yearoldgirlin11th grade
Presentingcomplaints
Troublefocusingandsustainingattention(esp.inschool) Easydistractibility(alwayslookingaround) Restlessnessandfidgetiness(squirmyinherseat) Alwaysonthego neversitsstill Talksincessantlyandloudly Interruptsothersconversations Cantwaitherturn
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CaseStudy:DizzyDavid
20yearoldcollegejunior
Presentingcomplaints
Shortattentionspan(cantreadmorethan5minutes) Verydistractible(mymindcantstayonthelecturer) Organizationalissues(troublegettingstufftogether) Timemanagementproblems(assignmentsalwayslate) Makescarelessmistakes(e.g.onexams) Notmotivatedtostudy

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CaseStudy:BoisterousBill
30yearoldunemployedmarriedman Presentingcomplaints
Irresponsibilityathome doesntgetthingsdone Lackofconsiderationforothers interrupts,argues Troublekeepingjobs
Changedjobs6timesinpast4years Firedfortardiness,inefficiency,troublefollowingdirectionsand argumentswithhisbosses

Lowselfselfesteem,feelslikeafailure ADHDsymptoms:poorconcentration,troublecompleting tasks,restlessness

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CaseStudy:LostLouise
50yearoldmarriedwoman Presentingcomplaints
Alwayshadtoworkextrahardtogetassignmentsdone, butlately,itstakingevenlongertofinishthings Mindwandersatwork spacesoutduringmeetings Veryimpatient,cantwait,getsangryeasily Cantremembermoviesshesseen,booksshesreador conversationssheshadwithimportantpeople Getslosteasily,poorsenseofdirection

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LookingAhead
Topicfornextweek:CausalFactors Readingsfornextweek:
NIMHADHDOverview: http://www.nimh.nih.gov/health/publications/att entiondeficithyperactivitydisorder/index.shtml CDCDataandStatistics: http://www.cdc.gov/ncbddd/adhd/data.html

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EndofLectureQuiz

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