Chapter 39 Attention-Deficit Disorders JAMES T. MCCRACKEN, M.D.

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER Definition Attention-deficit/hyperactivity disorder (ADHD) is the most common psychiatric disorder among school-age children and the best understood. Children with ADHD display the early onset of symptoms consisting of developmentally inappropriate overactivity, inattention, academic underachievement, and impulsive behavior. Etiology 1. Neurochemistry - monoamines dopamine and norepinephrine imbalance 2. differences in brain structure 3. Genetics 4. pregnancy and delivery complications, low birth weight, traumatic brain injury, and prenatal substance exposure Diagnosis and Clinical Features DSM-IV Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder A. Either (1) or (2): (1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has difficulty organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities (2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be linked to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often "on the go" or often acts as if "driven by a motor"

(f)

often talks excessively Impulsivity (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games) B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). Code based on type: Attention-deficit/hyperactivity disorder, combined type: if the criteria A1 and A2 are met for the past 6 months Attention-deficit/hyperactivity disorder, predominantly inattentive type: if criterion A1 is met but criterion A2 is not met for the past 6 months Attention-deficit/hyperactivity disorder, predominantly by active-impulsive type: if criterion A2 is met but criterion A1 is not met for the past 6 months Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "in partial remission" should be specified. Reprinted with permission from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. American Psychiatric Association, Washington, DC, 1994. Case example: Bill was an 8-year-old boy who lives with his adoptive parents and younger sister. After his school teacher raised concerns over his poor adjustment to his second grade classroom, his parents sought out a consultation. Bill was the product of an apparently normal pregnancy and delivery. He was adopted at age 3 months by his current adoptive parents. Early development was normal except for the description of Bill's temperament as hard to soothe and irregular sleep patterns in the first year of life. After he began preschool at 30 months, staff noted that he had difficulty sitting still for group activities and needed frequent reminders to resist hitting peers over disagreements during play. Later, a supportive first grade teacher described Bill as active but learning normally without concerns. However, soon after Bill entered second grade, his teacher called parents to express concerns that Bill showed problems listening in class and completing assignments without multiple reminders. He also frequently rose from his chair in class during quiet study activities. Overall, he was performing below expectations, and multiple reprimands had not led to sustained improvement. Bill's parents noted that for about 9 months prior to evaluation, he had become more challenging to his parents at home; in particular, he was frequently argumentative and resistant to requests. Daily struggles over simple routines and limits ensued. Bill's mother

had attempted to restrict his intake of sugar but without significant change in behavior. On examination, Bill appeared restless and shifted frequently from one item to another. He acknowledged difficulty listening to his teacher "sometimes." Psychomotor activity was increased. Mood and affect were normal. Teacher ratings on behavior rating scales were above the 95th percentile, with no indication of a learning disorder. Parent ratings on the Child Behavior Checklist confirmed attention problems and aggresion. A physical examination performed 5 months earlier by Bill's pediatrician showed no abnormalities. Results of the consultation were consistent with attention-deficit hyperactivity disorder and oppositional defiant disorder. Recommendations included a trial of methylphenidate (Ritalin) at 5, 10, and 15 mg given three times a day over 3 weeks and referral to a parent training program for behavioral management. Differential Diagnosis 1. disruptive behavior disorders - Descriptions of inattention, overactivity, and impulsivity should be evident across situations and to multiple observers is prominent in ADHD 2. mood or anxiety disorders on concentration, school adjustment, and performance ADHD is distinguished by its chronicity and early onset rather than an episodic pattern 3. autistic disorder and other pervasive developmental disorders, schizophrenia, and mental retardation Course and Prognosis children with ADHD should be considered at increased risk for adverse outcomes deliquent behaviors, poorer self-esteem, lower academic achievement, new diagnoses of conduct disorder, and greater substance abuse. On average, about 60 to 80 percent of children with ADHD continue to manifest the full syndrome well into adolescence. Importance of intervention in an effort to prevent these adverse outcomes. Treatment short-acting psychostimulants remain the first-line choice for the pharmacotherapy of ADHD, principally because of their ability to improve both behavioral and cognitive aspects of the disorder in 70 to 80 percent of children. The safety profile for the stimulants is also excellent. Medications for the Treatment of ADHD and Suggested Monitoring Medication Preparation Approximate Dosage Range First-line agents Methylphenidate (Ritalin) 5-, 10-, and 20-mg scored 0.31.0 mg/dose, t.i.d.; daily tablets dose < 60 mg SR (sustained release): 20-mg tablet Dextroamphetamine (Dexedrine) 5- and 10-mg scored 0.150.5 mg/kg/dose, b.i.d.; tablets total daily dose < 40 mg Spansules (sustained release) 5-, 10-, and

15-mg capsules Dextroamphetamine and 5-, 10-, 20-, 30-mg tablets amphetamine salts (Adderall)

0.150.5 mg/kg dose, q.a.m. or b.i.d.; total daily dose < 4 mg

Combined Approaches - medication treatment combined with home and school behavioral interventions. ATTENTION-DEFICIT DISORDER NOT OTHERWISE SPECIFIED DSM-IV Diagnostic Criteria for Attention-Deficit Disorder Not Otherwise Specified Category is for disorders with prominent symptoms of inattention or hyperactivityimpulsivity that do not meet criteria for attention-deficit/hyperactivity disorder. Reprinted with permission from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. American Psychiatric Association, Washington, DC, 1994.