Transcript Document 7114609

ADHD –Comorbidity Issues
Regina Bussing, M.D., M.S.H.S.
Chief, Division of Child and
Adolescent Psychiatry
ADHD: Etiology and Prevalence
Etiology
• No single cause
• Many possible etiologies
Prevalence
• Estimates in school-age children: 3% to 9%
• More commonly diagnosed in boys (4:1 to 9:1)
• Girls may be under-represented in clinical populations
• More prevalent in 1st degree biologic relatives
Ref: Greenhill 1993; Biederman 1989; Safer 1988; Lambert 1981
ADHD: Core Symptoms
Varying degrees of:
• Inattention
• Hyperactivity
• Impulsivity
Symptoms also vary in:
• Degree of impairment
• Frequency of occurrence
• Pervasiveness
Ref: Greenhill 1993; Swanson 1992; Cantwell 1985
DSM-IV ADHD Criteria:
Inattention Symptoms
Behaviors manifested often:
• 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
Ref: APA 1994
DSM-IV ADHD Criteria:
Hyperactivity/Impulsivity Symptoms
Hyperactivity behaviors manifested often:
• Difficulty engaging in leisure activities quietly
• Fidgeting
• Unable to stay seated
• Moving excessively (restlessness)
• “On the go”
• Talking excessively
Impulsivity behaviors manifested often:
• Blurting out answer before question is completed
• Difficulty waiting turn
• Interrupting/intruding upon others
Ref: APA 1994
ADHD: DSM-IV General Criteria and
Subtypes
Inattention and hyperactivity-impulsivity symptoms:
• Onset before age 7
• Present for > 6 months
• Present in  2 settings (e.g., home, school, work)
Subtypes:
• AD/HD, combined type: criteria from both dimensions
– 6 of 9 from both symptom lists
• AD/HD, predominantly inattentive type: inattentive
criteria
– 6 of 9 inattentive symptoms
• AD/HD, predominantly hyperactive-impulsive type:
hyperactive-impulsive criteria
– 6 of 9 hyperactive-impulsive symptoms
Ref: APA 1994
ADHD: Overview of Assessment
Process
• What is the child’s developmental level?
• Does the child meet the criteria for ADHD?
• What are the areas of functional impairment?
• Is comorbidity present?
• What are the strengths of the child, family, and
prosocial environment?
• What treatment is indicated?
ADHD: Patient Evaluation Procedures
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Parent/child interviews
Parent-child observation
Behavior rating scales
Physical examination (include neurologic)
Cognitive testing (if indicated?)
Laboratory studies
– Check on audiology/vision testing
– are not pathognomonic
Ref: Reiff 1993
ADHD Domains of Impairment
• Peer
relationships
• Adult
relationships
• Family
relationships
• School
functioning
• Leisure
activities
Ref: Mannuzza 1993; Pelham 1982; Shaywitz 1988
Differential Diagnosis
of ADHD in Children
Developmental
Disorders
Psychiatric
Disorders
 Learning disorders  Conduct
 Mental
Retardation
Ref: Reiff 1993; Barkley 1990
Medical
Disorders
 Anxiety
 Post traumatic
encephalopathy
 Seizures (e.g., absence)
 Mood
 Drug-induced change
 Environmental  Chronic Illness
(e.g., hypo/hyperthyroid)
 Stress
 Sensory Deficits
(e.g., hearing loss)
ADHD: Comorbidities in
Children/Adolescents
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Learning disorders
Language and communication disorders
Oppositional defiant disorder
Conduct disorders
Anxiety disorders
Mood disorders
Tourette’s syndrome; chronic tics
Ref: Biederman 1991; Hinshaw 1987
ADHD and Other Disruptive
Disorders
• ODD
– Diagnosis:
• Similar age of onset, course
• Likely most frequent comorbidity encountered
• Prompts specialty mental health referral (over-represented)
– Treatment implications
• Family and patient education
• Raises caregiver stress more than ADHD or CD
• Psychotherapy choices (PCIT; parenting interventions)
• Medication implications (stimulants; non-stimulant ADHD
treatments)
ADHD and Other Disruptive
Disorders
• CD
– Diagnosis:
• Variations in age of onset, course
• Comorbidity with significant prognostic impact (increased risk
of drug abuse; antisocial behaviors)
– Treatment implications
• Family likely has significant other risk factors
• Psychotherapy choices (PCIT; parenting interventions)
• Medication implications (stimulants; non-stimulant ADHD
treatments; atypical neuroleptics; possibly mood stabilizers
for anti-aggressive effects)
ADHD and Anxiety
Disorders
• GAD and SAD
– Diagnosis:
• Tease out age of onset and course of symptoms
• “Shared” symptoms (inattention, hyperactivity; academic
performance problems; sleep problems)
• Unique features (worry; fears; significant somatic
complaints)
– Treatment implications
• Families may be reinforcing avoidances and fears
• Psychotherapy choices
• Medication implications (stimulants; non-stimulant ADHD
treatments; antidepressant options)
ADHD and Anxiety Disorders
• PTSD
– Diagnosis:
• Identify stressor event
• Tease out age of onset and course of symptoms
• “Shared” symptoms (inattention, hyperactivity; academic
performance problems; sleep problems)
– Treatment implications
• Families often have significant other stressors
• Psychotherapy choices
• Medication implications (stimulants; non-stimulant ADHD
treatments; antidepressant options)
ADHD and Mood Disorders
• Major Depression/Dysthymia
– Diagnosis:
• Differentiate age of onset, course
• “Shared” symptoms (inattention, academic performance
problems; sleep problems)
– Treatment implications
• Family and patient education
• Psychotherapy choices
• Medication implications (stimulants; non-stimulant ADHD
treatments; antidepressant options)
ADHD and Mood
Disorders
• Bipolar Disorder
– Diagnosis:
• Differentiate age of onset, course (issues of mixed
presentation and of rapid cycling)
• “Shared” symptoms (attention problems; hyperactivity;
increased speech output; loud; sleep problems; academic
performance problems)
• Unique symptoms (grandiosity; psychotic symptoms; severe
mood lability
– Treatment implications
• Family and patient education
• Medication implications (mood stabilizers; atypical
neuroleptic medications; issue of stimulants; non-stimulant
ADHD treatments; antidepressant options)
ADHD and Tic Disorders
• Chronic Tics or Tourette’s Disorder
– Onset of ADHD often precedes onset of Tics or TS
– Important to inquire about family history and educate
parents about stimulants and tics/TS
• Treatment
– Stimulants were considered “contraindicated” in past
– Focus now on improving functioning – ADHD may be
more impairing than tics
– Complex regimens may be used, combining ADHD
medications with alpha-agonists and/or atypical
neuroleptic medications
A Norepinephrine Reuptake
Inhibitor (NRI)
Mechanism of Action
Strattera: Effects on Dopamine
Case Example
• XY presented to child psychiatrist for ADHD, SLD,
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expressive language disorder
Family history + ADHD, depression
Treated with stimulants, school interventions as
preadolescent
Developed severe aggression, mood instability, some
seasonal variations in mood in early adolescence
Repeated inpatient crisis stabilization, family therapy,
medication adjustments
Developed psychotic symptoms with hypomanic
component
Residential treatment pursued
XY follow-up
• Temporarily stopped ADHD medication
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treatment, used antipsychotic medications
Moved into mood stabilization, resumed ADHD
medications once had remained free of psychotic
symptoms for 3 months
Continued family intervention (“the explosive
child”)
Able to resume regular school attendance, with
partial special education services, continued
ADHD treatment, ongoing mood stabilization, off
all antipsychotic medications
Continues to experience social isolation, but
markedly improved overall functioning