| ADHD and Suicide Definition: Simply defined, ADHD (attention-deficit hyperactivity disorder) is a developmentally inappropriate level of inattention, hyperactivity-impulsivity present by the age of 7 years that produces significant impairment in two or more settings. History: 1902 - oldest description of ADHD given in the medical journal, Lancet. 1937 - first use of benzedrine as treatment.
1955 - methylphenidate (Ritalin) was manufactured. 1960 - called “minimal brain dysfunction”, with the main symptom for diagnosis being hyperactivity. 1966 - inattentiveness was added as another main symptom of ADHD. 1980 - DSM-III defined the diagnosis as: ADD with or without hyperactivity. It also provided the first definition of ADHD in adults. 1987 - DSM-III R revised the definition of ADD and renamed it ADHD. 1994 - DSM-IV revised the definition to the one currently in use (see above). Prevalence: ranges from 4-12% in the general population of 6- to 12- year olds. These figures are based on data from countries across the globe, including USA, New Zealand, Canada, Germany, and Brazil. Neurobiologic basis of ADHD: Norepinephrine and dopamine: the interaction of these compounds modulate attention and impulse control. Med Hypotheses 1989;29:33. Brain Size: Children with ADHD have smaller cerebral and cerebellar volume than children without ADHD. Brain volumes correlate with parent and clinician ratings of ADHD severity. The smaller brain volumes are not caused by medication. JAMA 1998; 279:1100. Brain Glucose Metabolism: is reduced in adults with ADHD by 8%. The regions of the brain most effected are the premotor cortex and the superior prefrontal cortex - areas that have been shown to relate to the control of attention and motor activity. JAMA 2002;288:1740. Genetics: Children with ADHD are 5-6 times more likely than other children to have a parent with ADHD. Diagnositc Criteria: Developmentally inappropriate level of inattention/distractability, hyperactivity, impulsivity. Symptoms must be present by the age of 7 years. (Usually observed by 3-4 years of age). Symptoms must produces clinically significant impairment in two or more settings (home, school, work). Impairments may be social, academic, or occupational. Symptoms must be present at least six months. Symptoms cannot be accounted for by other psychopathologic conditions. ADHD types: (given in order of prevalence) Combined: child has all three symptoms of the disorder. Predominantly inattentive: easily distracted but not excessively hyperactive or impulsive. Predominantly hyperactive-impulsive: extremely hyperactive and impulsive but not excessively inattentive. Complications: (when left unmanaged or untreated) See also under “Impairments” below. Preschool: Low self-esteem and disruptions in the family. School age: Disruptive behaviors poor social skills school failure learning delays low self-esteem. Teen: variety of academic and interpersonal difficulties oppositional behaviors lack of motivation depression increased risk of suicide increased risk of traffic tickets and motor vehicle accidents antisocial behaviors and activities smoking substance abuse sexually transmitted disease early pregnancy Adults: difficulty organizing responsibilities frequent job changes marital and social problems increased risk of suicide, alcohol and drug use depression 50-80% of ADHD children continue to have ADHD into early adulthood. Coexisting Disorders: Almost 90% of ADHD children will have at least one, and about 67% will have two: Learning Disabilities Depression Oppositional Defiant Disorder Tics, Tourette’s Syndrome High Anxiety Personality Conduct Disorder Pervasive Development Disorder Bipolar Disorder Fetal Alcohol Effect or Syndrome Protective factors: Positive family environment Healthy lifestyle Access to educational resources High intelligence Risks for ADHD: A child’s vulnerability to ADHD depends on the interaction of genetic, medical, and environmental risks, the child’s temperament, and protective factors. Genetic risks: A child has a greater risk of ADHD if s/he has relatives with: hyperactivity mood disorders conduct disorders alcoholism learning disorders anxiety disorders sociopathy minor physical anomalies Children with ADHD are more likely than other children to have parents who smoke. First-degree relatives of children with ADHD are more likely to have substance abuse, affective disturbances, antisocial behaviors, school problems, and high levels of anxiety. Medical risks: The 2 biggest risk factors for ADHD are: If mother smoked during pregnancy If mother drank alcohol in the first trimester Other pregnancy and delivery risk factors: Preeclampsia Low Birth Weight Premature labor C-section with complications Other medical risk factors: Meningitis chronic illness seizures severe allergies or asthma head injury with loss of consciousness Temperament risks (A child has a greater risk of ADHD if s/he): is impulsive, difficult to control, or fearful seeks novelty has eating and sleeping problems is rigid and tense (not easy to cuddle) has extremes of temperament (reacts intensely to stimuli, so shy s/he’s barely approachable, etc) Environmental risks implicated, not proven: Lead carbon monoxide a variety of heavy metals dietary factors, family stress, economic problems Impairments: (adverse effects of ADHD symptoms - not all are seen in every ADHD child. Impairments also change with the individual’s age and stage of development). Preschool years: Always on the go, as if “driven by a motor” Fearless and energetic Impulsively aggressive and disruptive High level of oppositionalism Tends to spill and/or break things Demanding, argumentative, noisy during play Insatiable curiosity Interrupts others, impatient, low tolerance for frustration School-aged child: Disruptive behaviors have caused a lot of distress to parents, leading to family problems. Inappropriate behaviors cause difficulties at school and often alienate child from teachers and peers Struggles with homework, fails to complete it or its full of careless errors. Blurts out answers in class and is disruptive. Unwilling and/or unable to do assigned chores at home. Unable to wait turns in games or can’t play cooperatively with schoolmates, who may perceive child as bossy. Easily frustrated Coaches may think child has an “attitude problem” and may not be able to participate in sports as much. Difficult to establish regular sleeping and eating patterns. Lying and stealing are much more common in ADHD children. Also higher than average levels of setting fires, being cruel to people and animals, carrying or using a weapon, and deliberately destroying property. 35% of ADHD children also have ODD (oppositional defiant disorder) 25% of ADHD children also have conduct disorder Adolescence: Inner sense of restlessness may replace hyperactivity, giving false impression that the ADHD has improved. Angry outbursts and quick changes of mood, above and beyond the average adolescent. Becomes frustrated easily and is impatient - which can fuel temper outbursts. Continues to be disorganized at school. Persistence of learning disabilities and lack of motivation. Has trouble following through on responsibilities. Difficulties in relationships with peer and adults. Clashes with authority. Antisocial activities (juvenile delinquency) Risky behaviors such as smoking, alcohol and substance abuse. Increased rate of sexually transmitted diseases and early pregnancy. Increased rate of traffic violations and driving accidents (more and worse than peers, and more are their fault). Plagued with overall feeling of low self-worth, and increased incidence of depression and suicide. Adulthood: Occupational difficulties caused by poor planning and organization, difficulty managing time, poor memory, emotional distress, feelings of frustration, and bad temper. More likely to lose and change jobs. More likely to have family and marital problems, resulting in higher rates of separation, divorce, and multiple marriages. ADHD is a risk factor for suicidal thoughts, substance abuse, depression, alcoholism. ADHD symptoms and impairments fuel and exacerbates various psychiatric conditions. Treatment of ADHD: Needs to be individualized and constantly reevaluated. ADHD is a chronic condition that can seriously disrupt the functioning of an individual throughout his or her lifetime. Left unmanaged, it is likely to give rise to ever-increasing complications as a child matures. ADHD is a complicated mixture of symptoms (inattention, hyperactivity, impulsivity) that lead to impairments (poor academic performance) which lead to functional outcomes (poor self-esteem and troubled relationships with family and peers). The presence of co-existing disorders, protective factors and risk factors, also effect how ADHD appears in different children, and how they respond to treatment. Treatment should result in decreased impairments and improved functional outcomes. The Multimodal Treatment Study of Children with ADHD, an extremely large clinical trial, showed that using both medication and behavior modification gave the best outcomes. Second was medication alone, and third was behavior modification alone. Arch Gen Psychiatry 1999;56:1073. Behavior Modification: Important to be used for both academic performance as well as to improve child’s interaction with peers and in the family. Must be used by both parents and teachers. Should be provided consistently. It is effective when used. It lessens the impairments that result from ADHD symptoms. And it is for behavior management (it doesn’t “train” and “fix” the child over a few months time). As the ADHD child matures, s/he will slowly incorporate this training into his/her own ability to regulate his/her ADHD symptoms. Techniques include: Positive reinforcement in the form of rewards or privileges given for desired behaviors. Negative reinforcement Time outs (about 1 minute for each year of age) for undesirable behaviors. Withdrawing rewards and privileges for unwanted or problem behavior. When young, these can be combined in a “token economy” where child earns or loses stickers, depending on behavior. After so many stickers over a certain amount of time, a prize is awarded. In school, teachers can give periodic report cards (daily is best). Parents can add these to the “token economy” at home. Environmental changes such as increasing structure in child’s home and school activities, providing more supervision, limiting distractions where possible. Ideally, parents and teachers should participate in training sessions with a therapist, meeting weekly for 8-12 weeks, and then keeping in contact with the therapist as needed for help with special problems or as child goes through developmental transitions. These may be needed for 2-3 years. Where such support is not available, parents and teachers must self-educate through books, videos, and joining organizations such as CHADD (Children and Adults with Attention Deficit Disorder) www.chadd.org or 1-800-233-4050. Counseling: Many ADHD patients and their families can benefit from counseling. Behavior modification is difficult to learn and implement. A therapist can greatly help families with this. Family problems: An ADHD child causes a lot of additional stress in a family and the resultant problems may be overwhelming and difficult to solve without the help of a counselor. Impairments of ADHD: An ADHD child may need help from a counselor in understanding his/her own ADHD, and in dealing with low self esteem, depression, and control of anger and other oppositional behaviors. Co-existing disorders: May be very difficult to manage without the help of a counselor. Medication: Stimulants: (FDA approved for ADHD): Methylphenidate (Ritalin, Metadate, Concerta, Focalin) Amphetamines (Adderall, Dexedrine, DextroStat) Non Stimulants: Atomoxetine (Strattera) - the only non-stimulant with FDA approval for ADHD Antihypertensives: Clonidine (Catapres) Guanfacine (Tenex) Antidepressants: Bupropion (Wellbutrin), Venlafaxine (Effexor), Tricyclics (Imipramine) Stimulants (methylphenidate and amphetamines) have been used for ADHD since 1937(amphetamines) and 1957 (methylphenidate). They stimulate the parts of the brain that increase attention and control impulses, using the dopamine pathway. They are not addicting. They do not sedate. They do not change the child’s personality. They have been proven effective: in reducing inattention, impulsivity, and hyperactivity. in helping with impulsive aggression, poor social interactions, academic productivity and accuracy, and with compliance to therapy, Parents are used to their ADHD child as “bouncy, flighty, distracted, argumentative, careless,” etc. The only time they see their child calm is when s/he is sick. On medication, their child is calmer and able to focus, and often initially is perceived as “zoned, spacey, or sedated”. 70% of patients will respond to treatment with any one stimulant, and both types of stimulants are equally effective. If the first class of stimulant does not work, 66% of children will respond to the second. Side effects: insomnia irritability decreased appetite weight loss may exacerbate tics and
anxiety Medications: Requires multiple dosing because their effects last for only 4-10 hours. There are short-, intermediate- and long-acting forms available. No benefit from medication in the morning before the dose is absorbed and in the late afternoon and evening when the dose wears off. Some patients rebound as the medicine wears off, making them extra hyper and/or irritable. They are controlled substances which makes prescribing tedious, and gives them a stigma that may not be deserved, but does create concern. Non stimulants Antidepressants: Tricyclics (Imipramine) have been shown to be effective, but are not commonly used. Once a day dosing. Effective through 24 hours. Side effects: dry mouth, constipation, sedation, can seriously effect the heart. Venlafaxine (Effexor) - also used as an anti-anxiety medication. Bupropion (Wellbutrin) - Both Effexor and Wellbutrin seem to help with oppositional and aggressive behaviors of ADHD, but limited studies are available. Both are well tolerated and have minimal side effects. Antihypertensives: Clonidine (Catapres) and Guanfacine (Tenex) Used to treat ADHD that does not respond to stimulants. Clonidine has been studied more, but Tenex causes less side effects (drowsiness). Clonidine is most often used for ADHD-related insomnia which is often made worse by stimulant use. Atomoxetine (Strattera) Newest medication - received FDA approval in late 2002. Studies show it to be as effective in treating ADHD as the stimulants. Inhibits the reuptake of norepinephrine. So rather than adding an artificial compound, it increases the natural norepinephrine and its effects in regulating attention and controlling impulses. Side effects: Most commonly reported is drowsiness, but because its effects last 24 hours, it can be taken in the evening rather than in the morning. It can effect appetite in some patients: Weight decreases at first, and then begins to catch up. Diastolic blood pressure and heart rate increase slightly in some
children, but not in a significant manner. Advantages: More specific than stimulants in effecting the brain’s areas that regulate attention and impulse control. Less effect on the nucleus accumbens, which is thought to be related to abuse potential. Less effect on the striatum, which is thought to be related to tic generation. Does not increase anxiety, in fact it may help relieve anxiety. Does not cause insomnia. 24 hour coverage with once a day dosing, so better than stimulants for social and home interactions. It is not a controlled substance, so prescribing is easier and less stigma is attached. Disadvantage: Must be taken daily. Benefits may not be seen for 1-2 weeks. http://www.elkokidsdoc.com/Pages/adhd.htm  
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