Uniformed Services University of the Health Sciences
March 8 and April 12, 2001
What is ADHD?
How do you diagnose and treat ADHD?
What do you need to consider in the differential diagnosis of ADHD?
What comorbidities should you be aware of?
Attention Deficit Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.
First described systematically by George Still in 1902
There have been 25 different name changes for the clinical symptom complex
A specific neuroanatomic, physiologic, biochemical or psychologic origin has not been identified, despite extensive investigation
5-10 prevalence in the US
41 boys to girls for hyperactive-impulsive and 21 for inattentive type
Intense public scrutiny
Many controversial alternative treatments have flourished without scientific evidence of clinical benefit
Basic diagnostic and treatment approaches have changed little over the past 20 years
1902 defect in moral control
1930-1950s Minimal Brain Damage- looked at history of toxins, injuries, etc
1950-1960s Minimal Brain Dysfunction- recognized most individuals had no evidence of damage, also coined hyperkinetic reaction of childhood
1960s Use of stimulant medications became widespread, although use since 1930s was recognized to improve symptoms
1970s Renamed ADD/ADHD
1980-1990s Investigation of processing problems
ADHD has long been recognized to run in families
1st and 2nd degree relatives are at highest risks
Concordance rates are higher in full siblings than ½ siblings and in monozygotic than dizygotic twins
Research is ongoing on 3 associated genes
Toxins lead, alcohol, cigarette smoke can contribute to ADHD symptoms
A small proportion of children are affected by food additives and allergenic whole foods
Studied but not proven Iron deficiency, deficiency in essential fatty acids, Zinc and other minerals
45 of children with ADHD have 1 comorbid condition
30 have 2 comorbid conditions
10 have 3 comorbid conditions
Common comorbid conditions include ODD, Anxiety, Learning Disability, Mood, Conduct, Smoking, Substance Use and Tics
19 ADHDAssociated Conditions
Impaired Adaptive Function
Motor Development Deficits
Impaired Task Performance
Medical Problems (h/o trauma, prematurity, sleep disturbances)
20 ADHDClinical Management
Fit treatment to the patient
Educate parents and patients regarding ADHD
Discuss behavioral treatment
Ensure educational support
Methylphenidate HCL (Concerta)
Dextro and Levoamphetamine (Adderall)
Tricyclic anti-depressants- Usually a second line alternative treatment for 10-20 of patients unresponsive to any psychostimulants. Maximal benefits are primarily observed in depressed or angry patients. Potential for lethal overdose. Need for screening labs and EKG.
SSRIs May be preferred adjunctive therapy for depressed adolescents with ADD even though they have not been approved for an ADD indication.
Bupropion (Wellbutrin)- an anxiolytic drug that blocks uptake of serotonin and norepinephrine. Occasionally prescribed for off-label non-responders. May exacerbate tics.
Clonidine (Catapres)- alpha-adrenergic agonist of particular benefit in patients who are hyperaroused, extremely overactive and those with ODD or conduct disorder. Occasionally used at bedtime to counteract insomnia of stimulants. May cause hypotension and should be withdrawn slowly to avoid rebound hypertension. Transdermal patches may enhance compliance.
26 ADHDStimulant Dosing
Ritalin SR 20mg for slow release
Dexedrine Spansule available for slow release
Of 70 of children with ADHD
1/3 respond to Ritalin
1/3 respond to Adderall
1/3 respond to Dexedrine
Trial of multiple psychostimulants may be warranted
Idiosyncratic dosing is not dependent on weight
Frequent Side Effects
Infrequent Side Effects
Long term use of stimulants may increase heart rate, blood pressure but these increases do not approach clinical significance
Children treated with stimulants are at no higher risk for substance abuse than their untreated peers with ADHD
In children for whom behavior problems are cross-situational, stimulants must be considered on a daily basis. Consider drug holidays during summer if height and weight is of concern
Careful clinic follow-up is recommended every 3-4 months
Recommend treatment be discontinued on an annual basis for a short period of time during the school year to assess behavior and symptoms
30 ADHDBehavioral Management
The main emphases in parent training are on understanding the antecedents of undesirable behaviors, modifying the environment to alter those antecedents, and establishing positive incentives before using punishment.
Emphasis on quality attention to positive behaviors.
Teach appropriate use of time out and other disciplinary methods
Enable parents to create an environment that maximizes the childs potential to behave appropriately
31 ADHDBehavioral Management
Discuss use of structure and routine and minimizing distractions
Suggest the use of an assignment sheet or day planner to be reviewed by teachers and parents
Consider a second set of textbooks at home
Family psychotherapy may be indicated to address family dysfunction
Consider to a parent support group if available
32 ADHDEducational Placement
Federal law PL 94-142 (1975 Education for All Handicapped Children Act) requires school systems to test any child within 30 days after a written, signed request has been presented to them
Section 504 of the Rehabilitation Act requires that children who are underperforming relative to their expected level should receive classroom modifications to improve their academic progress
33 ADHDEducation Placement
Modifications may include appropriate classroom placement, resource education, additional time for taking tests, not penalizing for misspelling or neatness, and additional instruction, including supplemental auditory learning and computer time
Under the Individual Disabilities Educational Act, ( PL101-476), these patients may further qualify for special education assistance in organization, work completion, listening, planning and following directions
34 ADHDAlternative Treatments
Publications on alternative treatments for ADHD are sparse in the peer-reviewed literature, but abound in the popular press.
Practitioners must be prepared to provide accurate information and answer questions
35 ADHDAlternative Treatments
Feingold Diet- Dr. Ben Feingold, in 1975, contended that artificial colors, flavors and preservatives as well as naturally occurring salicylates were the primary cause of ADHD. Studies showed only 1 with consistent improvement after strict elimination diets.
36 ADHDAlternative Treatments
Prinz hypothesized that the positive effects of the Feingold diet may have been due to it higher protein-sugar ratio rather than to salicylates and additives.
Multiple well-designed studies discounted his theory and showed no significant behavioral effects of sugar in either normal or ADHD study populations.
37 ADHDAlternative Treatments
Aspartame appeared on the market in 1981 and was used as a placebo in many of the studies on the effects of sugar on behavior. No independent neurologic, metabolic, or behavioral-cognitive effects related to aspartame have been found.
38 ADHDAlternative Treatments
The Yeast Connection
Dr. William Cook, an allergist and pediatrician, claimed a success rate in reducing hyperactive behavior in his patients with ADHD using strict elimination diets
He maintained that frequent antibiotic treatment results in chronic candidiasis and candida toxin production. This is responsible for metabolic and behavioral disturbances including hyperactivity, irritability, and learning disorders
His treatment included oral antifungal agents and a diet strictly eliminating sources of sugar and any foods made with molds and yeast
His claims are based on experience and have not been scientifically validated
39 ADHDAlternative Treatments
Children who initially were noted to have improved classroom attention while on megavitamins in an open trial, did not show any improvement in the double blind cross over placebo control phase
In fact, they showed 25 more disruptive behavior
4 had elevation of liver enzymes
Therefore, Megavitamins are of little benefit in treating ADHD, and may cause harm
40 ADHDAlternative Treatments
Symptoms of iron deficiency anemia include decreased attention, arousal, and social responsiveness. Iron deficiency should be suspected on the basis of dietary history and then verified. There is no indication form iron supplementation in non-deficient individuals.
41 ADHDAlternative Treatments
Magnesium- a required co-factor of many enzyme systems. Only isolated reports of improvement with supplementation.
Pyridoxine- essential for neurotransmitter synthesis and normal brain development. Some studies suggest behavior improvement, but no replication has proven link.
Zinc- essential for normal growth, immune functions and neurologic development. No good controlled studies have been performed. Zinc is potentially toxic and not indicated in the absence of deficiency.
42 ADHDAlternative Treatments
Essential Fatty Acids- Linoleic and Linolenic acid are essential to brain development and neuronal functioning. Role in ADHD is unclear and still being studied.
Anitoxidants and Herbs- Most of these agents are used in folk and traditional medicine. None have been studied systematically in ADHD. (e.g. Pycnogenol,melatonin, gingko biloba, chamomile, kava, hops, valerian, lemon balm and passion flower) Caution should be used because of possible potentiation of effects. No clinical trials have proven there effectiveness in ADHD
43 ADHDAlternative Treatments
Vision Therapy and Oculovestibular Treatment- Impairment in visual acuity, oculomotor function and visuospatial perception has been implicated in the etiology of dyslexia and secondary attention problems. Introduction of lenses have anecdotally shown improvements, but any concerns regarding a childs vision should prompt a referral to an ophthalmologist
44 ADHDAlternative Treatments
Homeopathy- based on the concept of vital energies and using dilutions of plant, animal and mineral extracts to restore those energies. Widespread use in Europe, but unknown mechanisms of action. Therefore, more studies are needed.
Auditory Stimulation- Tomatis method of sound training uses high frequency modifications of human voice and music. Requires 75 sessions and no controlled studies have shown improvement.
Biofeedback- methods of hypnotherapy, relaxation, and biofeedback are most effective when integrated into a multimodal treatment plan.
Conners' Rating Scales, Toronto, MultiHealth Systems, 1997 Tel 800-456-3003
Achenbach, Child Behavior Checklist, 1 South Prospect Street, Burlington, Vt. 05401-3456, Tel 802-656-8313
American Academy of Child and Adolescent Psychiatry Practice parameters for the assessment and treatment of children, adolescents and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 36 (suppl 10)085S-121S, 1997