Attention-Deficit / Hyperactivity Disorder (ADHD) Attention-Deficit / Hyperactivity Disorder (ADHD) Trouble du déficit de l’attention/hyperactivitéTrouble du déficit de l’attention/hyperactivité

((TDAH)TDAH)

Claude Jolicoeur. m.d.Claude Jolicoeur. m.d.

DSM-IDSM-IV Criteria for ADHDV Criteria for ADHD

Symptoms of ADHD ; Topic ContentsSymptoms of ADHD ; Topic Contents

The year 2000 Diagnostic & Statistical Manual for Mental The year 2000 Diagnostic & Statistical Manual for Mental Disorders (DSM-IV-TR) provides criteria for diagnosing Disorders (DSM-IV-TR) provides criteria for diagnosing ADHD. ADHD.

The criteria are presented here in modified form to make The criteria are presented here in modified form to make them more accessible to the general public. They are listed them more accessible to the general public. They are listed here for information purposes and should be used only by here for information purposes and should be used only by trained health care providerstrained health care providers

InattentionInattention

I. Either A or B:I. Either A or B: A. Six or more of the following symptoms of inattention A. Six or more of the following symptoms of inattention

have been present for at least 6 months to a point that is have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:disruptive and inappropriate for developmental level:

1. Often does not give close attention to details or makes 1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.careless mistakes in schoolwork, work, or other activities.

2. Often has trouble keeping attention on tasks or play 2. Often has trouble keeping attention on tasks or play activitiesactivities

3. Often does not seem to listen when spoken to directly.3. Often does not seem to listen when spoken to directly. 4. Often does not follow instructions and fails to finish 4. Often does not follow instructions and fails to finish

schoolwork, chores, or duties in the workplace (not due to schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).oppositional behavior or failure to understand instructions).

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5. Often has trouble organizing activities.5. Often has trouble organizing activities. 6. Often avoids, dislikes, or doesn't want to do 6. Often avoids, dislikes, or doesn't want to do

things that take a lot of mental effort for a long things that take a lot of mental effort for a long period of time (such as schoolwork or homework).period of time (such as schoolwork or homework).

7. Often loses things needed for tasks and 7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, activities (e.g. toys, school assignments, pencils, books, or tools).books, or tools).

8. Is often easily distracted.8. Is often easily distracted. 9. Is often forgetful in daily activities.9. Is often forgetful in daily activities.

Hyperactivity/impulsivityHyperactivity/impulsivity

BB- Six or more of the following symptoms of - Six or more of the following symptoms of hyperactivity-impulsivity have been present for at hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and least 6 months to an extent that is disruptive and inappropriate for developmental level:inappropriate for developmental level:

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1. Often fidgets with hands or feet or squirms in 1. Often fidgets with hands or feet or squirms in seat.seat.2. Often gets up from seat when remaining in seat 2. Often gets up from seat when remaining in seat is expected.is expected.3. Often runs about or climbs when and where it is 3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel not appropriate (adolescents or adults may feel very restless).very restless).

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4. Often has difficulty playing or enjoying leisure 4. Often has difficulty playing or enjoying leisure activities quietly. activities quietly. 5. Is often "on the go" or often acts as if "driven by 5. Is often "on the go" or often acts as if "driven by a motor". a motor". 6. Often talks excessively6. Often talks excessively

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7.7. Often blurts out answers before questions Often blurts out answers before questions have been completedhave been completed

8.8. Often has difficulty waiting one's turn.Often has difficulty waiting one's turn. 9.9. Often interrupts or intrudes on others (e.g., Often interrupts or intrudes on others (e.g.,

butts into conversations or games).butts into conversations or games).

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BB. Some hyperactive, impulsive or inattentive symptoms . Some hyperactive, impulsive or inattentive symptoms that cause impairment were present before 7 years of age.that cause impairment were present before 7 years of age.

CC. Some impairment from the symptoms is present in two . Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).or more settings (e.g. at school/work and at home).

DD. There must be clear evidence of clinically significant . There must be clear evidence of clinically significant impairment in social, school, or occupational functioning.impairment in social, school, or occupational functioning.

EE The symptoms do not happen exclusively during the The symptoms do not happen exclusively during the course of a pervasiven developmental disorder, course of a pervasiven developmental disorder, schizophrenia, or other psychotic disorder, and are not schizophrenia, or other psychotic disorder, and are not better accounted for by another mental disorder (e.g. mood better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a disorder, anxiety disorder, dissociative disorder, or a personality disorder).personality disorder).

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Based on these criteria, three types of ADHD are identified:Based on these criteria, three types of ADHD are identified: 1.1. ADHD, ADHD, Combined Combined Type: if both criteria 1A and 1 B are Type: if both criteria 1A and 1 B are

met for the past 6 monthsmet for the past 6 months 2.2. ADHD, ADHD, Predominantly Predominantly Inattentive Type: if criterion 1A is Inattentive Type: if criterion 1A is

met but criterion 1 B is not met for the past six monthsmet but criterion 1 B is not met for the past six months 3.3. ADHD, ADHD, Predominantly Predominantly Hyperactive-Impulsive Type: if Hyperactive-Impulsive Type: if

Criterion 1 B is met but Criterion 1A is not met for the past six Criterion 1 B is met but Criterion 1A is not met for the past six months.months.

American Psychiatric Association: Diagnostic and Statistical American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.Washington, DC, American Psychiatric Association, 2000.

[ADHD.._Referençes][ADHD.._Referençes]

The most common disorderThe most common disorder

- emotional- emotional

- cognitive- cognitive

- behavioral- behavioral

With a high rate comorbidityWith a high rate comorbidity

- oppositional defiance: 40-70%- oppositional defiance: 40-70%

- anxiety: 10-40% - conduct disorder: 20-56%- anxiety: 10-40% - conduct disorder: 20-56%- bipolar disorders:0-27% - bipolar disorders:0-27% - conduct disrder: 20-56%- conduct disrder: 20-56%- delinquent/Antisocial Activities: 18-30%- delinquent/Antisocial Activities: 18-30%- academic Problems: 90%- academic Problems: 90%

BarkleyBarkley

Social costSocial cost

Academic underacheivementAcademic underacheivement Conduct problemsConduct problems UnderemploymentUnderemployment Vehicle accidentsVehicle accidents Bad personnal relationsBad personnal relations

PrevalencePrevalence

More thanMore than- schizophrenia- schizophrenia- obsessive-compulsive D- obsessive-compulsive D- panic disorder- panic disorder

At 4% to 12% Shool-age (USA)At 4% to 12% Shool-age (USA)

Sex ratioSex ratio

More boys than girl - ratio 3:1More boys than girl - ratio 3:1

Adults- ratio 1:1Adults- ratio 1:1

Clinical Clinical Presentation (6-12 years)Presentation (6-12 years)

Easily distractedEasily distracted Homework poorly organizedHomework poorly organized Blurts out answers before questionBlurts out answers before question Often interruptsOften interrupts Fails to waitFails to wait Often out of seatOften out of seat Perceived « immature »Perceived « immature »

Based GreenhillBased Greenhill

Clinical Presentation (13-18 years)Clinical Presentation (13-18 years)

Inner reslessness more than agitationInner reslessness more than agitation Shoolwork disorganizedShoolwork disorganized Engages in risky behaviorsEngages in risky behaviors Poor self-esteemPoor self-esteem Poor peers relationsPoor peers relations Confront with authorityConfront with authority

Based Greenhill, Conners and JettBased Greenhill, Conners and Jett

NeurobiologyNeurobiology

Maybe, the dysfunction Maybe, the dysfunction

- is intrinsic to the - is intrinsic to the

frontal lobefrontal lobe

- is influenced by brains areas with subcortical - is influenced by brains areas with subcortical projections.projections.

fMRI, PET studies:fMRI, PET studies:

- circuits controling attention: less active and smaller- circuits controling attention: less active and smaller

Main Neurotransmittors in ADHDMain Neurotransmittors in ADHD

DopamineDopamine EpinephrineEpinephrine

To regulate the inhibitory influences in theTo regulate the inhibitory influences in the

frontal-cortical processing of informationfrontal-cortical processing of information

DopamineDopamine

May May - enhances signals - enhances signals - improves: - improves:

. attention,. attention, . focus vigilance, . focus vigilance, . acquisition, . acquisition, . on-task behavior and cognition . on-task behavior and cognition

NorepinephrineNorepinephrine

MayMay- dampen « noise »- dampen « noise »- decrease distractibility and shifting- decrease distractibility and shifting

- improve executive operations- improve executive operations- increase behevioral, cognitive, motoric- increase behevioral, cognitive, motoricinhibitioninhibition

Cognitive functionsCognitive functions

PlanningPlanning AnticipatingAnticipating OrganizingOrganizing Working memory:Working memory:

- maintaining attention - maintaining attention - focusing on task- focusing on task

PsychostimulantsPsychostimulants

Acting primarily by blocking the reuptake of dopamineActing primarily by blocking the reuptake of dopamine

Méthylphénidate:Méthylphénidate:

. old - ritalin 5, 10, 20 mg (3-4 hours), ritalin 20 mg Sr, 6-7 . old - ritalin 5, 10, 20 mg (3-4 hours), ritalin 20 mg Sr, 6-7 hourshours

. new - concerta (long acting 10-12 hours)18, 27, 36, 54 mg.. new - concerta (long acting 10-12 hours)18, 27, 36, 54 mg. Amphetamine:Amphetamine:

. old - dexedrine, short & long acting. old - dexedrine, short & long acting

. new - adderall xr (long acting 10 hours), 5, 10, 15, 20, 25, . new - adderall xr (long acting 10 hours), 5, 10, 15, 20, 25, 30 mg.30 mg.

NonstimulantNonstimulant

Atomoxetine (strattera), primarily blocking Atomoxetine (strattera), primarily blocking epinephrine reuptakeepinephrine reuptake

Buproprion (wellbutrin)Buproprion (wellbutrin) Tricycliques (norpramine-desipramine)Tricycliques (norpramine-desipramine) SSRIs (fluoxetine, paroxetine, sertraline)SSRIs (fluoxetine, paroxetine, sertraline) Venlafaxine (Effexor)Venlafaxine (Effexor) Antipsychotics (risperdone-Risperdal)Antipsychotics (risperdone-Risperdal) Antihypertensives (guanafacine, clonidine)Antihypertensives (guanafacine, clonidine)