ADHD Inattentive type DSMV Diagnostic Criteria: A persistent pattern of inattention that interferes with functioning or development, as characterized by six (or more) of the following symptoms AND symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Inattentive Symptoms Criterian A1 Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities. Often has difficulty sustaining attention in tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish homework, chores, or duties in the workplace. Inattentive Symptoms cont. Often has difficulty organizing tasks and activities. Often avoids, dislikes, or is reluctant to engage in tasks that requires sustained mental effort. Often loses things necessary for tasks or activities. Is often easily distracted by extraneous stimuli. Is often forgetful in daily actitivies. Hyperactivity and Impulsivity Criterion A2 Diagnostic Criteria: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: NOTE: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least 5 symptoms are required. Hyperactive/Impulsive Symptoms Often fidgets with or taps hands or feet or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is inappropriate. Often unable to play or engage in leisure activities quietly. Hyperative/Impulsive Symptoms cont. Is often on the go, acting as if driven by a motor. Often talks excessively. Often blurts out an answer before a question has been completed. Often has difficulty waiting his or her turn. Often interrupts or intrudes on others. 1
Additional Criteria to be met: Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings. The is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder. ADHD Types and Coding Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity- impulsivity) are met for the past 6 months. 314.01 (ICD 9) F90.2 (ICD 10) Attention Deficit Hyperactivity Disorder, combined presentation ADHD Types and Coding cont: Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months. 314.00 (ICD 9) F90.0 (ICD 10) Attention deficit hyperactivity disorder, predominantly inattentive presentation. ADHD Types and Coding cont: Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivityimpulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. 314.01 (ICD 9) F90.1 (ICD 10) Attention deficit hyperactivity disorder, predominantly hyperactive/impulsive presentation. Specify if: In partial remission: DSM V Change When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning. DSM V Change: Severity Mild: if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. Md Moderate: Symptoms or functional impairment i between mild and severe are present. Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning. 2
DSM IV versus DSM V DSM IV: Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. DSM V: Several inattentive or hyperactiveimpulsive symptoms were present prior to age 12 years. Why the change? ADHD begins in childhood. The requirement that several symptoms be present before age 12 years conveys the importance of a substantial clinical presentation during childhood. At the same time, an earlier age at onset is not specified because of difficulties in establishing precise childhood onset retrospectively. Adult recall of childhood symptoms tends to be unreliable, and it is beneficial to obtain ancillary information. Prevalence and Risk Factors ADHD is elevated in first-degree biological relatives of individuals with ADHD. Population surveys suggest that ADHD occurs in most cultures in about 5% of children and about 2.5% of adults. Very low birth weight (less than 1,500 grams) conveys a two to three fold risk for ADHD, but most children with low birth weight do not develop ADHD. Prevalence and Risk Factors cont. Although ADHD is correlated with smoking during pregnancy, some of this association reflects common genetic risk. A minority of cases may be related to reactions to aspects of diet. There may be a history of child abuse, neglect, multiple foster placements, neurotoxin exposure (e.g., lead), infections (e.g., encephalitis), or alcohol exposure in utero. Exposure to environmental toxicants has been correlated with subsequent ADHD, but it is not known whether these associations are causal. Development and Course Many parents first observe excessive motor activity when the child is a toddler, but symptoms are difficult to distinguish from highly variable normative behaviors before age 4 years. ADHD is most often identified during elementary school years, and inattention becomes more prominent and impairing. Development and Course cont. The disorder is relatively stable through early adolescence, but some individuals have a worsened course with development of antisocial behaviors. In most individuals with ADHD, symptoms of motoric hyperactivity become less obvious in adolescence and adulthood, but difficulties with restlessness, inattention, poor planning, and impulsivity persist. A substantial proportion of children with ADHD remain relatively impaired into adulthood. 3
Development and Course cont. In preschool, the main manifestation is hyperactivity. Inattention becomes more prominent during elementary school. During adolescence, signs of hyperactivity (e.g., running and climbing) are less common and may be confined to fidgetiness or an inner feeling of jitteriness, restlessness, or impatience. In adulthood, along with inattention and restlessness, impulsivity may remain problematic even when hyperactivity has diminished. Gender-Related Diagnostic Issues ADHD is more frequent in males than in females in the general population, with a ratio of approximately 2:1 in children and 1.6:1 in adults. Females are more likely than males to present primarily with inattentive features. ADHD Screening Tools Adult ASRS Symptom Checklist Adult ADHD Self-Report Scale (ASRS) Symptom Checklist National Institute t for Children's Health Quality (NICHQ) Vanderbilt Assessment Scales (Used for diagnosing ADHD) Provide the symptom checklist to patient, PART A: 1. How often do you make careless mistakes when you have to work on a boring or difficult project? 2. How often do you have difficulty keeping you attention when you are doing boring or repetitive work? 3. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 4. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? Adult ASRS Symptom Checklist cont. 5. How often do you have difficulty getting things in order when you have to do a task that requires organization? 6. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 7. How often do you misplace or have difficulty finding things at home or at work? 8. How often are you distracted by activity or noise around you? 9. How often do you have problems remembering appointments or obligations? Adult ASRS Symptom Checklist cont. PART B: 10. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 11. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 12. How often do you feel restless or fidgety? 13. How often do you have difficulty unwinding and relaxing when you have time to yourself? 14. How often do you feel overly active and compelled to do things, like you were driven by a motor? 4
Adult ASRS Symptom Checklist cont. 15. How often do you find yourself talking too much when you are in social situations? 16. When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17. How often do you have difficulty waiting your turn in situations when turn taking is required? 18. How often do you interrupt others when they are busy? Scoring Adult ASRS On each of the 18 questions circle the correct number that best describes how you have felt and conducted yourself over the past 6 months. 0 never 1 rarely 2 sometimes 3 often 4 very often Score Scoring Adult ASRS Evaluation 0-16 Unlikely to have ADHD 17-23 Likely to have ADHD 24 or > Highly likely to have ADHD Scoring Adult ASRS cont. If the score is in the likely or highly likely category for either Part A or Part B, the patient has symptoms consistent with ADHD and a more thorough clinical evaluation to understand impairments and history if warranted. If the score is in the likely category for either Part A or Part B, but you still suspect ADHD, consider evaluating them for impairments based on the symptoms present. Sometimes adults with ADHD suffer significant impairment due to only a few symptoms. Reliability and Validity of the Adult ASRS The Adult ADHD Self-Report Scale (ASRS) Symptom Checklist and scoring system were developed in conjunction with the World Health Organization (WHO), and the Workgroup on Adult ADHD that included a team of psychiatrists and researchers. Reliability and Validity of the Adult ASRS Background: The Adult ADHD Self-Report Scale-V1.1 (ASRS-V1.1) is a validated, 6-question screen for adult ADHD. Our purpose was to analyze this tool for evaluating patients in a busy primary care setting. Methods: The ASRS-V1.1 was administered to patients in 8 busy primary care practices. All with a positive score and a random sample of those with a negative screening score were asked to complete the Adult ADHD Rating Scale Self Report Short Version. Each was administered within the clinic setting during the same session. Sensitivity, specificity, and positive/negative predictive values were calculated. Data were evaluated for site-specific differences. 5
Reliability and Validity of the Adult ASRS Results: It took an average of 54.3 seconds (range, 22 252 seconds) to complete the ASRS-V1.1. There was an inconsistency-adjusted sensitivity of 1.0, a specificity of 0.71, a positive predictive value of 0.52, and a negative predictive value of 1.0. No site-specific differences were found. Conclusions: Because of its ease of use, short time to administer, high sensitivity, and moderate specificity, the ASRS-V1.1 is an effective adult ADHD screening to guide further evaluations for ADHD. The initial assessment scales, parent and teacher, have 2 components: symptom assessment and impairment in performance. On both the parent and teacher initial scales, the symptom assessment screens for symptoms that meet criteria for both inattentive (items 1-9) and hyperactive ADHD (items 10-18). cont. Inattentive Questions To meet DSM-V criteria for the diagnosis, one must have at least 6 positive responses to either the inattentive 9 or hyperactive 9 core symptoms, or both. A positive response is a 2 or 3 (often, very often). The initial scales also have symptoms also have screens for 3 other co-morbidities: Oppositional Defiant, Conduct, and Anxiety/Depresion. 1. Does not pay attention to details or makes careless mistakes with, for example homework. 2. Has difficulty keeping attention ti to what needs to be done. 3. Does not seem to listen when spoken to directly. 4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand). Inattentive Questions cont. Hyperactive/Impulsive Questions 5. Has difficulty organizing tasks and activities. 6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort. 7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books). 8. Is easily distracted by noises or other stimuli. 9. Is forgetful in daily activities. 10. Fidgets with hands or feet or squirms in seat. 11. Leaves seat when remaining seated is expected. 12. Runs about or climbs too much when remaining seated is expected. 13. Has difficulty playing or beginning quiet play activities. 6
Hyperactive/Impulsive Questions cont. 14. Is on the go or often acts as if driven by a motor. 15. Talks too much. 16. Blurts out answers before questions have been completed. 17. Has difficulty waiting his or turn. 18. Interrupts or intrudes in on others' conversations and/or activities. Performance Parent Informant Questions 48. Overall school performance 49. Reading 50. Writing 51. Mathematics 52. Relationship with parents 53. Relationship with siblings 54. Relationship with peers 55. Participation in organized activities (eg, teams) Performance (Parent Informant) Question Scoring 1 Excellent 2 Above Average 3 Average 4 Somewhat of a problem 5 Problematic A score of 4 or 5 on any of the questions 48-55 would be indicative of an impairment in performance. Performance Teacher Informant Questions Academic Performance 36. Reading 37. Mathemathics 38. Written expression Performance Teacher Informant Questions Classroom Behavioral Performance 39. Relationships with peers 40. Following directions 41. Disrupting class 42. Assignment completion 43. Organizational skills Performance (Teacher Informant) Question Scoring 1 Excellent 2 Above Average 3 Average 4 Somewhat of a problem 5 Problematic A score of 4 or 5 on any of the questions 36-43 would be indicative of an impairment in performance. 7
Predominantly Inattentive subtype Question Scoring Parent Informant - Must score a 2 or 3 on 6 out of 9 items on questions 1-9 AND - Score a 4 or 5 on any of the Performance questions 48-55. Teacher Informant - Must score a 2 or 3 on 6 out of 9 items on questions 1-9 AND - Score a 4 or 5 on any of the Performance questions 36-43. Predominantly Hyperactive/Impulsive subtype Question Scoring Parent Informant - Must score a 2 or 3 on 6 out of 9 items on questions 10-18 AND - Score a 4 or 5 on any of the Performance questions 48-55. Teacher Informant - Must score a 2 or 3 on 6 out of 9 items on questions 10-18 AND - Score a 4 or 5 on any of the Performance questions 36-43. ADHD Combine Inattention/Hyperactive Question Scoring Parent and Teacher Informant Requires the above criteria on both inattention and hyperactivity/impulsivity. Follow-up scales: the parent and teacher follow-up scales have the first 18 core ADHD symptoms, not the co-morbid symptoms. The follow-up scale also has a side-effects reporting scale that can be used to both assess and monitor the presence of adverse reactions to medications prescribed, if any. Reliability and Validity of the NICHQ Vanderbilt ADHD Assessment Scales OBJECTIVE: To examine the psychometric properties of the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) using a community-based sample of primarily elementary and middle schoolaged children. METHOD: Participants were initially recruited from 41 elementary schools in 5 Oklahoma school districts including urban, suburban, and rural students. Vanderbilt rating scales were obtained from all teachers (n = 601) and sampled parents (n = 587) of the participating children. Construct validity was assessed by confirmatory factor analysis of the 45 items that made up the 4 scales of inattention, hyperactivity, conduct/oppositional problems, and anxiety/depression problems. Reliability was evaluated from internal consistency, test-retest, and inter-rater agreement perspectives. Criterion validity was evaluated via comparisons to a structured psychiatric interview with the parents using the Diagnostic Interview Schedule for Children-IV. Reliability and Validity of the NICHQ Vanderbilt ADHD Assessment Scales RESULTS: A 4-factor model (inattention, hyperactivity, conduct/oppositional problems, and anxiety/depression problems) fit the data well once discarding conduct items that were infrequently endorsed. The estimates of coefficient alpha ranged from.91 to.94 and the analogous KR20 coefficient for a binary item version of the scale ranged from.88 to.91. Test-retest reliability exceeded.80 for all summed scale scores. The VADPRS produced a sensitivity of.80, specificity of.75, positive predictive value of.19, and negative predictive value of.98 when predicting an attention-deficit hyperactivity disorder (ADHD) case definition that combined teacher's Vanderbilt ADHD Diagnostic Teacher Rating Scale and parent diagnostic interview responses. CONCLUSION: The confirmation of the construct and concurrent criterion validities found in this study further support the utility of the VADPRS as a diagnostic rating scale for ADHD. Treatment options for ADHD Behavior therapy, including parent training Mdi Medications School/Work accommodations and interventions 8
Behavior Therapy Research shows that behavior therapy is an important part of treatment for children with ADHD. ADHD affects not only a child s ability to pay attention or sit still at school, it also affects relationships with family and other children. Children with ADHD often show behaviors that can be very disruptive to others. Behavior therapy is a treatment option that can help reduce these behaviors. It is often helpful to start behavior therapy as soon as a diagnosis is made. Behavior Therapy The 2011 clinical practice guidelines from the American Academy (AAP) recommend that doctors prescribe behavior therapy as the first line of treatment for preschool-aged children (4 5 years of age) with ADHD. Behavior management training for parents has the most evidence of being effective, but teachers and early childhood caregivers can use behavior therapy in the classroom as well. What does behavior therapy involve? The goals of behavior therapy are to learn or strengthen positive behaviors and eliminate unwanted or problem behaviors. Behavior therapy can include behavior therapy with parents, with children, or a combination. Teachers can also use behavior therapy to help reduce problem behaviors in the classroom. What does behavior therapy involve? In behavior therapy with parents, parents learn new skills or strengthen their existing skills to teach and guide their children and to manage their behavior. Behavior management training for parents has been shown to strengthen the relationship between the parent and child, and to decrease children s negative or problem behaviors. Behavior management training for parents is also known as parent behavior therapy, behavioral parent training or just parent training. What does behavior therapy involve? In behavior therapy with children, the therapist works with the child to learn new behaviors to replace behaviors that don t work or cause problems. The therapist may also help the child learn to express feelings in ways that do not create problems for the child or other people. The Agency for Health Care Research and Quality (AHRQ) conducted a review in 2010 of all existing studies on treatment options for children younger than 6 years of age. The review found enough evidence to recommend behavior management training for parents as a good treatment option for children under 6 with ADHD symptoms and for disruptive behavior, in general. Specific behavioral therapy programs The Agency for Health Care Research and Quality (AHRQ)review also identified four programs for parents of young children with ADHD that reduced symptoms and problem behaviors related to ADHD: Triple P (Positive Parenting Program), Incredible Years Parenting Program Parent-Child Interaction Therapy New Forest Parenting Programme Developed specifically for parents of children with ADHD 9
Adult Psychological Therapy for ADHD Counseling for adult ADHD can be beneficial and generally includes psychological counseling (psychotherapy) and education about the disorder. Psychotherapy may help you: Improve you time management and organizational skills Learn how to reduce your impulsive behavior Adult Psychological Therapy for ADHD Develop better problem-solving skills Cope with past academic and social failures Improve your self-esteem Learn ways to improve relationships with your family, co-workers and friends Develop strategies for controlling your temper Common types of psychotherapy for ADHD Cognitive Behavioral therapy. This structured type of counseling teaches specific skills to manage your behavior and change negative thinking patterns into positive ones. It can help you deal with life challenges, such as school, work or relationship problems, and help address other mental health conditions, such as depression or substance abuse. This therapy can be done one-on-one or in a group. Common types of psychotherapy for ADHD Marital counseling and family therapy. This type of therapy can help loved ones cope with the stress of living with someone who has ADHD and learn what they can do to help. Such counseling can improve communication and problem solving skills. Make a list of tasks Break down tasks Use sticky pads Practical suggestions Keep an appointment book Carry a notebook or electronic device with you Take time to set up systems to file and organize information Follow a routine Ask for help Alternative treatments Yoga or meditation Special diets Vitamin or mineral supplements Herbal supplements Essential fatty acids Neurofeedback training 10
Other resources Support groups Social support Colleagues, supervisors, and teachers ADHD coaches Stimulants ADHD Medications These medications appear to boost and balance levels of brain chemicals called neurotransmitters. Stimulant medications are available in short-acting and long-acting forms. They are available in pill, capsule, liquid, and patch forms. Amphetamines Stimulants - Vyvanse (lisdexamfetamine) - Adderall (dextroamphetamine/amphetamine) - Adderall XR (dextroamphetamine/amphetamine) Some immediate effects can be seen with first dosing, can take several weeks to attain maximum therapeutic benefit Amphetamine Vyvanse is a prodrug of dextroamphetamine and is thus not active until after it has been absorbed by the intestinal tract and converted to dextroamphetamine (active component) and l-lysine Once converted to dextroamphetamine, it increases norepinephrine and especially dopamine actions by blocking their reuptake and facilitating their release Stimulants Methylphenidate - Concerta - Ritalin/Ritalin LA/Ritalin SR - Daytrana - Focalin/Focalin XR - Quillavant XR Increases norepinephrine and especially dopamine actions by blocking their reuptake Some immediate effects can be seen with first dosing, can take several weeks to attain maximum therapeutic benefit ADHD Medications Non-stimulants (alpha-2 agonist) These drugs work by tricking the presynaptic neuron into thinking that t there are adequate amounts of brain norepinephrine. Over time, this trickery results in a lower level of norepinephrine synthesis and release. 11
Non-stimulant medication Catapress (clonidine) Kapvay (clonidine) Tenex (guanfacine) Intuniv (guanfacine) For ADHD, can take a few weeks to see maximum therapeutic effect Blood pressure should be checked regularly, may be lowered 30-60 minutes after first dose; greatest reduction seen after 2-4 hours. Non-stimulant continued Strattera (atomoxetine) Boosts neurotransmitter norepinephrine/noradrenaline and may also increase dopamine in prefrontal cortex Blocks norepinephrine reuptake pumps Monitor blood pressure and pulse when initiating treatment until dosage increments have stabilized Child/Adolescent Children ages 3-5: The only FDA approved stimulants are immediate release forms Children ages 6 and older are FDA approved for IR extended release stimulants Vyvanse capsule may be opened and mixed with water Quillivant XR is a liquid form of methylphenidate Avoid afternoon/evening dosing due to insomnia Long-term stimulant use may be associated with growth suppression in children (controversial) Schedule II drug Stimulants Patients may develop psychological dependence Tolerance to therapeutic effects may develop in some patients t Theoretically less abuse potential with vyvanse than other stimulants when taken as directed because it is inactive until it reaches the gut and thus has delayed time to onset as well as long duration of action (10-12 hours) Common side effects of stimulants Insomnia Headache Exacerbation of tics Nervousness Irritability Overstimulation Tremor Dizziness Contraindications to stimulants History of substance abuse Elevated blood pressure Severe cardiac disease Cardiac structural abnormalities Severe arrhythmias Coronary artery disease Cardiomyopathy 12
ADHD versus? Intellectual Disability Autism Spectrum Disorder Depression Oppositional Defiant Disorder Bipolar/Mood Disorder Anxiety Case Study Questions 13