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A Brief History of ADHD

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A Brief History of ADHD A Brief History of ADHD 1967: 1980: 1902: 1937: 1995: LEARNING OBJECTIVES Sir George DSM‐II defines a DSM‐III defines Benzedrine Wender publishes Frederic Still “Hyperkinetic Attention Deficit (amphetamine) Attention‐Deficit describes 20 Reaction of Disorder (ADD) with shown to be Childhood” Hyperactivity cases of children and without st effective for MBD characterized by hyperactivity Disorder in Adults (1 with attention book about adult and disruptive overactivity and behaviors with an short attention span ADHD) • Identify clinical symptoms of ADHD in children, adolescents and adults organic cause vs “bad parenting” • Understand the developmental course of ADHD, the impairments it may produce in various major life activities, and implications for treatment planning. 1997: • Identify comorbid conditions 1976: 1987: 1917-1928: 1957: Barkley defines ADHD • Encephalitis Methylphenida Wender DSM‐III‐R removes concept of symptoms and behaviors Review key genetic and neuroimaging concepts epidemic leads to te (MPH) describes MBD 2 subtypes and defines across the lifespan “organic brain approved for in adults Attention deficit‐ (symptom of impaired damage” MBD (foundation for Hyperactivity Disorder impulse control added) • Discuss the MOA comparative efficacy of medical versus psychosocial eventually ADHD in adults) (ADHD) becomes “Minimal interventions Brain Dysfunction” or MBD • Considerations for selection of pharmacotherapeutic interventions 1798: Sir Alexander Crichton is first to describe a “disease of attention” causing “unnatural degree of mental restlessness" TREATMENT CHALLENGES FOR ADHD OVERVIEW OF DSM‐5 CRITERIA FOR ADHD A. A persistent pattern of inattention and/or hyperactivity‐impulsivity that interferes with functioning or development, as characterized by inattention and/or hyperactivity/impulsivity B. Several inattentive or hyperactive‐impulsive symptoms were present prior to age 12 years. Attempting to understand the burden of psychiatric illness C. Several inattentive or hyperactive‐impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or across the lifespan is often complicated because with the relatives; in other activities). progression of time and parallel developmental maturation, D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. the core features of a disorder may present differently. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal). Reference: https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_ADHD.pdf ADHD: A LIFELONG DISORDER CLINICAL PRESENTATION: AGES 13 TO 18 • Excessive motor activity tends to decrease • Engaging in “risky” behaviors (speeding and 75% 50% driving mishaps) persists persists Children • May have a sense of inner restlessness into into (rather than hyperactivity) • Difficulty with authority figures with ADHD adolescence adulthood • Schoolwork disorganized and shows poor • Poor self‐esteem follow‐through; fails to work independently • Poor peer relationships Adolescents • Comments: “Not living up to with ADHD potential,” “spacey,” “hyper” • Anger, emotional lability Adults with ADHD • Behavioral issues: “Class clown” Prevalence in juvenile population Prevalence in adult 6%-9% population 3%-5% Greenhill LL. J Clin Psychiatry. 1998;59(suppl 7):31-41. Conners CK, Jett JL. ADHD in Adults and Children. Compact Clinicals;1999. Wilens TE. Psychiatr Clin North Am. 2004;27:283-301. Barkley RA, et al. Psychiatr Clin N Am. 2004;27:233-260. Persistence of ADHD Symptoms in Adulthood ADHD PERSISTENCE INTO ADULTHOOD • Common myth: that children with ADHD “grow out of it” • It is generally accepted that children with ADHD face academic and behavioral challenges, have difficulty making friends, and navigating stressful situations • Often clinicians are not aware of the serious consequences of adult ADHD • An estimated 4.4% of adults aged 18‐44 years have ADHD* *According to results from the National Comorbidity Survey Replication in 3199 respondents aged 18 to 44 years. 1. US Census 2000; 2. Kessler RC et al. Am J Psychiatry. 2006;163:716-723. Stahl S (2009). Stahl’s Illustrated Attention Deficit Hyperactivity Disorder. CORE SYMPTOMS OF ADHD: HYPERACTIVITY, IMPULSIVITY, AND INATTENTIVENESS ADHD IN ADULTS MAY LEAD TO POTENTIALLY SERIOUS Symptom Typically Seen in Children Typically seen in Adults CONSEQUENCES Hyperactivity • Talks excessively • Talks excessively • Squirms and Fidgets • Inner restlessness • Run/Climbs excessively • Feelings of being overwhelmed • Cannot work or play • Chose active jobs quietly • Inability to enjoy quiet leisure time 1 • Always “on the go” • Sense of being “driven” • 2x more likely to have been arrested * • Nearly 2x as likely to have been divorced1* Impulsivity • Blurts out answers • Irritability and quick to anger 2† • Cannot wait turn • Blurts out rude or insulting thoughts • 4x more likely to have contracted a sexually transmitted disease • Interrupts others • Reckless driving • Impulsively changes jobs 2† • Quits new projects • 3x more likely to be currently unemployed • Impulsive sexuality Inattentiveness • Difficulty with homework • Complain what they read doesn’t register 1 • Doesn’t listen • Frustrated over inability to organize • 2x more likely to have been involved in 3 or more car crashes * • Forgetful • Poor time management • Problems prioritizing • Loses things • Misplace belongings • Easily distracted • Easily distracted • Prefers to multitask *Results from a population survey of 500 adults with ADHD and 501 gender- and age-matched adults without ADHD that investigated characteristics of ADHD • Inefficient and its impact on multiple domains of functioning; †Data compiled from a study comparing the young adult adaptive outcomes of an original population of 158 children diagnosed as hyperactive and 81 controls followed concurrently for at least 13 years. 1. Biederman J et al. J Clin Psychiatry. 2006;67:524-540; 2. Barkley RA et al. J Am Acad Child Adolesc Psychiatry. 2006;45:192-202. Weiss M , Murray C (2003) Assessment and management of attention-deficit hyperactivity disorder in adults . CMAJ 18: 715-722 ADHD: COMORBID CONDITIONS IN CHILDREN COEXISTING PSYCHIATRIC DISORDERS IN ADULTS 60 55 50 Prevalence in Prevalence in patients 45 Disorder patients with ADHD without ADHD 40 40% 35 30–35% Major Depression 18.6% 7.8% 30 (%) Bipolar Disorder 19.4% 3.1% 25 20–25% 15–25% 20 15–20% 20% 19% Generalized Anxiety 8.0% 2.6% 15 15% Disorder 10 5 Any Anxiety Disorder 47.1% 19.5% 0 Any Substance Use 15.2% 5.6% Disorder Oppositional Language Anxiety Learning Mood Conduct Smoking4 Substance defiant disorder2 disorders3 difficulties2 disorders2 disorder3 use disorder1 disorder5 Impulse Control Disorders 19.6% 6.1% 1MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1076–1086. 2Barkley R. Attention-deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment, 2nd ed. New York: Guilford Press, 1993. Kessler, R C, et al. “The Prevalence and Correlates of Adult ADHD in the United States: Results from the National 3Biederman J, et al. Am J Psychiatry 1991; 148:565–577. Comorbidity Survey Replication.” American Journal of Psychiatry, vol. 4, Apr. 2006, pp. 716–723., 4Milberger S, et al. J Am Acad Child Adolesc Psychiatry 1997;36:37–44. doi:10.1176/ajp.2006.163.4.716. 5Biederman J, et al. J Am Acad Child Adolesc Psychiatry 1997;36:21–29. HERITABILITY OF ADHD IS ADHD A “REAL” DIAGNOSIS? Panic Disorder Schizophrenia Height Martin 2002 Kuntsi 2001 Coolidge 2000 Willcutt 2000 Hudziak 2000 Nadder 1998 Levy 1997 Sherman 1997 Silberg 1996 Gjone 1996 Thapar 1995 Schmitz 1995 Stevenson 1992 Edelbrock 1992 Gillis 1992 Goodman 1989 Matheny 1980 Willerman 1973 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Mean heritability of ADHD = 0.77 POTENTIAL ETIOLOGICAL FACTORS • Average heritability of .80 ‐ .85 ETIOLOGY FACTORS CONTINUED • Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions • Possible differences in size of brain structures • Dysfunction in prefrontal lobes • Prefrontal cortex, • Involved in inhibition, executive functions • corpus callosum • Genes involved in dopamine regulation • caudate nucleus • Dopamine transporter (DAT1) gene implicated • Abnormal brain activation during attention & inhibition tasks • 7 repeat of dopamine receptor gene (DRD4) implicated • Gene x environment interactions Kieling, Gondaves. Tannock. & Castellanos. 2008; Mick &. Faraone, 2008 Genetics Parents with ADHD Dopamine genes: have >50% chance DA type 2 gene, DA of having a child transporter gene with ADHD (DAT1) About 25% of Dopamine receptor children with (DRD4, “repeater ADHD have parents gene”) is over‐ who meet the represented in formal diagnostic ADHD patients criteria for ADHD THE STROOP TEST DORSAL ANTERIOR CINGULATE CORTEX FUNCTIONS DIRECTIONS: Read the word. RED YELLOW GREEN BLUE • Target Anticipation • Error Detection • Target Selection/Attention • Reward based decision making GREEN RED BLUE YELLOW • Novelty Detection • Complex and effortful cognitive BLUE GREEN YELLOW RED • Response Selection processing • Response selection and inhibition • Working Memory YELLOW RED GREEN BLUE • Performance monitoring RED YELLOW
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