Attention-Deficit/Hyperactivity Disorder

Dispelling Myths is Good Medicine

Karen J. Kraus, M.D.UCSF Fresno Psychiatry Residency

Program

Introduction• ADHD is a complex disorder of higher

brain functioning, characterized by inattention, motor over-activity and difficulty inhibiting impulsive behaviors

• ADHD is one of the most prevalent disorders in childhood and adolescence, affecting an estimated 3-9% of school-age children

Introduction• Symptoms occur at an early age, occur in

most areas of a child’s life, and persist over time, frequently into adulthood

• The precise constellation of symptoms changes as children grow and develop

Introduction• ADHD is often inherited

• Imaging, electrophysiological and neuropsychological tests, and now, genetic analysis, all point to disturbances in specific neurotransmitter systems, affecting specific areas of the brain

Introduction• ADHD is frequently associated with other

psychiatric and learning problems, which complicate diagnosis, treatment and prognosis

• ADHD is a heterogeneous disorder with many known causes, all of which mediate similar or identical effects on brain functioning

“There is no such thing asADHD”

Myth #1• Psychiatric disorders do not

occur in children.

Myth #2• ADHD is nothing more than

applying a diagnostic label to normal childhood behavior.

Myth #3• If ADHD really existed,

wouldn’t it be obvious?

“The medicines used to treat ADHD are dangerous

and addictive”

Efficacy and dosing guidelines have not been established for childrenUse of these medications may actually exacerbate the underlying disorderAssociated with high rates of significant side effects such as irritability, restlessness,lethargy, hallucinations, hypertension & severe muscle stiffness, even deathIn one study, more than 50% of mothers interviewed had administered this medication within the past monthDuring an investigative hearing, one congressman made the comment, “The sad fact is, much of the billion dollar medication industry is based more on hype then health care.”

According to the American Association of Poison Control Centers:

These medications are the frequent targets of unintentional ingestions in young childrenThey rank #2 for intentional ingestionsIn 1988, they accounted for 58,000 exposures & 77% of all ingestionsIn 1990, they accounted for 73,680 exposures (calls to poison control centersIn the case of one medicine, tracking mechanisms reported a 60% annual increase in use, abuse and medical contacts for toxicity

Stimulant medications, doses and pharmacological activity

Non-stimulant Medications in ADHD

Efficacy• More than 200 randomized and/or

placebo controlled studies demonstrate that stimulants are effective in reducing the core symptoms of ADHD

• Approximately 70% of children with ADHD demonstrate a robust response to stimulants

Medication Effects• fidgetiness• interrupting• physical

aggressiveness

• antisocial behavior

• compliance• peer

acceptance• efficiency

• on-task behavior

• accuracy• short term

memory• problem-

solving• parent-child

interactions• performance

of motor tasks

Efficacy• The MTA study demonstrated the

superior efficacy of medications over other kinds of treatment in school age children.

• There is less evidence to support the long term use of stimulants (>14 months), or their use with preschool children, adolescents, and adults.

Myth #4• The medications used to treat

ADHD are very dangerous

Myth #5• The medications used to treat

ADHD are addictive

Rates of psychotropic medication use by children in the United States

Substance Abuse & ADHD• A individual with ADHD persisting

into adulthood is at increased risk to develop a substance abuse disorder; that risk increases substantially in the presence of concurrent Conduct Disorder

• ADHD is associated with earlier onset of substance abuse disorders, and a shortened time from use to frank abuse

Substance Abuse & ADHD• Substance abuse disorders in

individuals with ADHD persisting into adulthood appear to be more chronic with lower rates of remission

• Overall, there is a 2-fold increased risk of developing a substance abuse disorder

Substance Abuse & ADHD• The core rate of substance abuse in

adolescents with ADHD is 10-15%• Teens who were medicated with

stimulants showed no increased risk as compared to “normal” teens

• Teens with ADHD who were not medicated have a 3-4 fold increased risk, as compared with affected teens who were treated

Abuse of Stimulants• There are only 5 case reports of

stimulant abuse in the literature• Epidemiological studies involving

adolescents have found rates of non-prescription use of Methylphenidate ranging from a low of .1% in 1992, to a peak of 2.8% in 1997 & 1998, to a rate of 2.2% in 2000.

Abuse of Stimulants• A survey of 6000 students in Mass.

reported that 13% of high school students and 4% of junior high school students had used Methylphenidate without a prescription

• A 1999 report on drug-abuse related visits to EDs revealed 1,478 notations of Methylphenidate abuse, down from 1,728 in 1998

Abuse of Stimulants• A 7 year study of incidents involving

Methylphenidate called into poison control centers revealed:– Out of 11,149 cases involving MPH,

1,244 (11.2%) were related to intentional abuse.

– The data indicated an increasing rate of abuse, with 17 cases in 1993 and 158 cases in 1998

– Most were boys between the ages of 14-15

Abuse of Stimulants• Continued:

– 70% involved MPH only; the remainder involved the co-consumption of 1-2 additional drugs.

– Use was coded “acute” in over 87% of cases, meaning there was no ongoing use of the stimulant either illicitly or therapeutically,

– Use in a “chronic” context was more likely to occur in older adolescents

– The most common route was ingestion.

Advice to Parents, Kids and other Interested Observers

Inattention• Difficulty initiating and sustaining

attention, characterized by:

– difficulty persisting in tasks, especially if they are uninteresting, tedious, sedentary or demanding

– switching from one unfinished task to another

– failure to complete tasks, chores, schoolwork, etc.

Inattention• Difficulty initiating and sustaining

attention, characterized by:

– difficulty following through with directions

– “daydreaming”, or appearing as if one isn’t listening or is unable to hear

Inattention• Avoidance of, or aversion to, tasks

that require sustained attention, such as:– tasks that require perseverance or

sustained, intense mental effort

– tasks that tax limited organizational skills

Inattention• Distractibility, characterized

by:– sensory distractibility, described as the

inability to filter out unimportant, extraneous stimuli from important, relevant stimuli

– motor distractibility, described as the inability to inhibit responses to stimulus or, the inability to control the allocation of attention.

Inattention• Distractibility, characterized

by:

– difficulty shifting attention from one task or activity to another

– difficulty attending to more than one task at a time

– sometimes manifest as an extraordinary awareness of detail, however irrelevant

Inattention• Difficulty with organization and

prioritization (impaired executive functions), characterized by:

– loses or misplaces belongings or necessary things such as homework, school materials, toys, etc.

– difficulty prioritizing tasks in terms of importance or planning objectives

– procrastination– forgetfulness, e.g., misses

appointments, fails to remember gym clothes, etc.

– poor awareness of time, with similarly poor time management skills

Inattention• Difficulty with organization and

prioritization (impaired executive functions), characterized by:– deficits in working memory - the ability to keep

certain information “in mind” over short periods of time in the absence of environmental stimuli – manifested by:

- difficulty recalling complex instructions, such as game rules

- forgetting information that has just been read

- difficulty transferring information- difficulty with math functions such as

transposing numbers or computational errors.

Hyperactivity• Excessive motor activity,

described as:– constantly moving or “on the

go”– fidgety or restless– difficulty remaining seated when

required to do so

Hyperactivity• Subjective sense of motor

restlessness

– A subtle finding more common in girls, and frequently found in adolescents and adults

Hyperactivity• Over-talkativeness, described

as:– excessive, continuous talking

(“blabbermouth”)– poor modulation of speech, with loud

speech– verbosity– blurts out answers, interrupts

conversation

Hyperactivity• Poor motor control, characterized

by:– difficulty engaging in leisure activities quietly

– work, particularly handwriting, is often messy

– poor physical boundaries, with socially inappropriate, intrusive behavior

– aggressiveness or clumsiness, related to poor modulation of motor activities (e.g., breaks toys, hurts others unintentionally)

Impulsivity• Difficulty inhibiting responses

(“Ready, fire, aim!), manifested by:– intrusiveness– impatience, manifested by:

- difficulty with turn taking in games- similarly manifest in conversation,

with interruption and comments out of turn

- inappropriate behavior

Impulsivity• Risk taking/Novelty-seeking

behavior– engagement in physically

dangerous activities without consideration of potential consequences

– often described as “ accident prone”, with a history of injuries

– tendency to become easily bored and seek external stimulation

Impulsivity• Altered responsiveness to

behavioral rewards, consequences and contingencies – resistance to conditioning effects of

reward or punishment– failure to apply past experiences to

current situations, resulting in repetitive mistakes

– neurophysiological basis

Associated Features• Altered response to social reinforcement

– Because of inattentiveness, negativism, or resistance to the conditioning effects of reward or punishment, many ADHD children are difficult to socialize. They are described as obstinate, impervious, stubborn or negativistic, although they are not necessarily “conduct disordered”

Associated Features• Altered emotional responsiveness

– Children with ADHD are easily excited and easily upset, and tend to react to situations in an exaggerated, disproportionate way, with dramatic (albeit usually short-lived) shifts in emotions

– They also tend to exhibit poor frustration tolerance (a “short fuse”), particularly with delay/denial of gratification, developmental challenges or interpersonal conflicts

Associated Features• Differences in interpersonal relationships

– Children with ADHD tend to be intense, controlling, socially imperceptive and intolerant.

– They are often described as immature and in fact, often exhibit delayed social development.

– Chronically antagonistic interpersonal interactions can lead to social isolation, and later on, to depression and angry defiance.

Associated Features• Behavioral dyscontrol

– Problematic behavior may signal the presence of a co-morbid psychiatric disorder, but may also stem from the core neuropsychiatric deficits seen in ADHD.

– The gap between the normal developmental aspirations of children with ADHD and their maturity and judgement further complicates the picture .

Associated Features• Behavioral dyscontrol

– Examples include:- lying and stealing may be indicative

underlying impulsivity- aggressive behavior may be an

expression of poorly regulated physical force

- temper tantrums are often seen in the context of sensory or affective over-stimulation

Associated Features• Demoralization

– The “curious dissociation between knowing and doing” often frustrates children with ADHD. Despite talent and skills, and often despite prodigious effort, children with ADHD chronically fall short of expectations

– As a result their inefficient cognitive styles, children with ADHD must often work harder and longer than their peers to obtain the same outcome.

– Over time children with ADHD fatigue, and in the context of repeated failures, become demoralized, lose motivation and develop a posture of defensive defiance