PayAttention:ADHDThrough

theLifespan
AnthonyL.Rostain,MD,MA
ProfessorofPsychiatryandPediatrics
PerelmanSchoolofMedicineatthe
UniversityofPennsylvania
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Week1:TheBasics

Background
WhyADHDisimportant
Mostcommonneurobehavioraldisorderofchildhood
Immediateandlifelongimpactsondevelopment

WhyADHDiscontroversial
Challengesofdiagnosis changesinterminology
Fearsofoverdiagnosisandofovermedicationofchildren

HowknowledgeofADHDisevolving
Fromcasedescriptionstocasestudiestoclinicaltrials
Fromobservationsofbehaviortoadvancesinneuroscience

WhatisADHD?
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DiagnosticCriteria

DSMIVCriteriaforADHD
1. Coresymptoms*:
Inattention
HyperactivityandImpulsivity

2.Chronicity ofADHDsymptoms
3.PervasivenessofADHDsymptoms
4. ImpairmentcausedbyADHDsymptoms
* toadegreethatismaladaptiveandinconsistent
withdevelopmentallevel

DSMIVDiagnosticCriteria
A1.Sixormoreofthefollowingsymptomsofinattention
havepersistedforatleastsixmonthstoadegreethatis
maladaptiveandinconsistentwithdevelopmentallevel:
a)
b)
c)
d)

Oftenfailstogivecloseattentiontodetailsormakescareless
mistakesinschoolwork,workorotheractivities
Oftenhasdifficultysustainingattentionintasksorplayactivity
Oftendoesnotseemtolistenwhenspokentodirectly
Oftendoesnotfollowthroughoninstructionsandfailstofinish
schoolwork,chores,ordutiesintheworkplace(notdueto
oppositionalbehaviororfailuretounderstandinstructions)

Departments of Psychiatry and Pediatrics,

University of Pennsylvania School of Medicine

DSMIVDiagnosticCriteria
Inattention(cont.)
e)
f)
g)
h)
i)

Oftenhasdifficultyorganizingtasksandactivities
Oftenavoids,dislikesorisreluctanttoengageintasksthatrequire
sustainedmentaleffort(suchasschoolworkorhomework)
Oftenlosesthingsnecessaryfortasksoractivities(e.g.toys,school
assignments,pencils,booksortools)
Isofteneasilydistractedbyextraneousstimuli
Isoftenforgetfulindailyactivities

Departments of Psychiatry and Pediatrics,

University of Pennsylvania School of Medicine

DSMIVDiagnosticCriteria
A2.Sixormoreofthefollowingsymptomsofhyperactivity
impulsivity havepersistedforatleastsixmonthstoa
degreethatismaladaptiveandinconsistentwith
developmentallevel:
a)
b)
c)

d)

Oftenfidgetswithhandsorfeetorsquirmsinseat
Oftenleavesseatinclassroomorinothersituationsinwhich
remainingseatedisexpected
Oftenrunsaboutorclimbsexcessivelyinsituationsinwhichitis
inappropriate(inadolescentsoradults,maybelimitedto
subjectivefeelingsofrestlessness)
Oftenhasdifficultyplayingorengaginginleisureactivitiesquietly

Departments of Psychiatry and Pediatrics,

University of Pennsylvania School of Medicine

DSMIVDiagnosticCriteria
Hyperactivity(cont.)
e)
f)

Isoftenonthegooroftenactsasifdrivenbyamotor
Oftentalksexcessively

Impulsivity
g)
h)
i)

Oftenblurtsoutanswersbeforequestionshavebeencompleted
Oftenhasdifficultyawaitingturn
Ofteninterruptsorintrudesonothers(e.g.buttsinto
conversationsorgames

Departments of Psychiatry and Pediatrics,

University of Pennsylvania School of Medicine

DSMIVDiagnosticCriteria
B. Somehyperactiveimpulsiveorinattentivesymptomsmusthavebeen
presentbeforeage7years
C.

Someimpairmentfromthesymptomsispresentinatleasttwosettings
(e.g.atschool[orwork]andathome)

D. Theremustbeclearevidenceofinterferencewithdevelopmentally
appropriatesocial,academicoroccupationalfunctioning
E.

Thedisturbancedoesnotoccurexclusivelyduringthecourseofother
seriousmentaldisorders(e.g.pervasivedevelopmental
disorder/autism,schizophrenia,otherpsychoticdisorder)

Departments of Psychiatry and Pediatrics,

University of Pennsylvania School of Medicine

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DSMIVDiagnosticCriteria
314.01AttentionDeficit/HyperactivityDisorder,CombinedType:ifboth
CriteriaA1andA2aremetforthepast6months
314.00AttentionDeficit/HyperactivityDisorder,Predominantly
InattentiveType:ifCriterionA1ismetbutCriterionA2isnotmetforthe
past6months
314.01AttentionDeficit/HyperactivityDisorder,Predominantly
HyperactiveImpulsiveType:ifCriterionA2ismetbutCriterionA1isnot
metforthepast6months
Codingnote:Forindividuals(especiallyadolescentsandadults)who
currentlyhavesymptomsthatnolongermeetfullcriteria,InPartial
Remissionshouldbespecified

Departments of Psychiatry and Pediatrics,

University of Pennsylvania School of Medicine

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MidLectureQuiz

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StrengthsofDSMIVCriteria

Usesrigorousandempiricallyderivedcriteria
Committeeofexpertsdevelopedthecriteria
LiteraturereviewofADHDconducted
Existingratingscaleswerereviewed&studied
Fieldtrialconducted(416yearoldsubjects)
Diagnosticcutoffpointsbasedonreliabilityandabilityto
discriminateADHDfromnonADHD

Impairmentcriteriongivengreateremphasis

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WeaknessesofDSMIVCriteria
Ageofonsetcriterionmaynotbejustified
Diagnosticitemsetsmaynotbeappropriatefor
differentdevelopmentalperiods
Diagnosticthresholds maynotapplytoolderage
groups(>16years)
Nogenderdistinctionindiagnosticthresholds
Noloweragelimitdefined(<4years)
Developmentalinappropriatenessisneitherclearly
stipulatednorquantified
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ControversiesofDSMIVCriteria
Heterogeneityofsubtypesisproblematic
ADHD,PIType:differencesinsymptomsandlifecourse
ADHD,PHIType:oftenconfusedwithotherdisorders

Setting(school,home)andsourceofinformation
(teacher,parent)areconfounded
Peoplebehavedifferentlyindifferentcontexts
Ratershavedifferentcriteriaforjudgingbehavior

Lowcorrelationbetweenparentandteacherratings
(0.30 0.50)leadstodisagreementsandconfusion
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ControversiesofDSMIVCriteria
WhatistherelativeimportanceofInattentionindetermining
thediagnosisADHD?
Attentionisnotaunitaryconstruct
Inattentionisoftendifficulttodetectandmeasure
InattentionmaybeduetofactorsotherthanADHDandcanbeseenin
otherdisorders

WhatistherelativeimportanceofHyperactivityvs.Impulsivity
indeterminingthediagnosisofADHD?
HyperactivitysymptomsoutnumberImpulsivitysymptomsincriteria
Theoverlapbetweenthesesymptomsandthoseseeninother
disorders(e.g.oppositionaldefiantdisorder)canleadtomisdiagnosis

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ADHDPotentialChangesinDSM5
Ageofonset willbeincreasedtoage12
Intent:Leavecore18Acriteriaunchanged,but
contextualizedandillustratedtofitlifespan
Impulsivitypoorlycovered Addingupto4new
criteriabeingconsidered
#ofcriterianeededforadolescents/adultslikelyto
berevised datasuggest23fromall3dimensions
wouldbebest compromiseis4from2dimensions
concernthatprevalencewillincreasedramatically
ASDexclusionisbeingremoved
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EndofLectureQuiz

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Prevalence,epidemiology

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WorldwidePrevalenceofADHD
Am J Psychiatry. 2007;164(6):942-948.

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ADHDintheUnitedStates
ADHDprevalenceamong8 to15yearolds:8.7%1
PercentageofchildrenwithADHDwhohavebeen
treatedconsistentlyduringthepastyear:32%1
ADHDprevalenceamong18 to44yearolds:4.4%2
PercentageofadultswithADHDwhoreceived
treatmentwithintheprevious12months:11%2
1. Froehlich et al. Arch Pediatr Adolesc Med. 2007;161(9):857-864.
2. Kessler et al. Am J Psychiatry. 2006;163:716-723.

Departments of Psychiatry and Pediatrics,

University of Pennsylvania School of Medicine

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PrevalenceofADHD:Summary
9%ofchildren;7%ofadolescents;4.5%ofadults
Malefemale:6:1,3:1,1:1
AlllevelsofIQ
Alllevelsofsocioeconomicstatus
Familygenetictransmission:0.75
Inheritancenotspecifictosubtype

CDC, 2008. Gaub M, Carlson CL. J Am Acad Child Adolesc Psychiatry. 1997;36(8):10361045. Levy F, et al. J Am Acad Child Adolesc Psychiatry. 1997;36(6):737-744. Smalley SL,22
et al. J Am Acad Child Adolesc Psychiatry. 2000;39(9):1135-1143.

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MidLectureQuiz

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TheManyFacesofADHD:
CasePresentations

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CaseStudy:TornadoTommy
6yearoldboyin1st grade
Presentingcomplaints

Troublefocusingandsustainingattention(esp.inschool)
Easydistractibility(alwayslookingaround)
Restlessnessandfidgetiness(squirmyinhisseat)
Alwaysonthego neversitsstill
Talksincessantlyandloudly
Interruptsothersconversations
Cantwaithisturn
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CaseStudy:SpacySteve
8yearoldboyin3rd grade
Presentingproblems

Inattention(Doesntlisten,alwaysinhisownworld)
Forgetfulness(Cantrememberwhathesbeentold)
Dawdlesandhastroublegettingstartedonthings
Takesforevertogetthingsdone
Lackseffortinschoolworkandhomework
Poororganizationalskills
Forgetstoturninhomeworkassignments
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CaseStudy:OrneryArnold
10yearoldboyin5th grade
Presentingproblems

Troublefocusing&sustainingattention(esp.inschool)
Veryrestless,fidgetyinhisseat
Argumentative(Alwayssaysnoandchallengesrules)
Obnoxious(Getsonotherpeoplesnerves)
Dislikesschoolintensely(Hethinksitsawasteoftime)
Resistscompletinghomework(Procrastinatesandputs
offgettingstarteduntillateatnight)
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CaseStudy:BabblingBrooke
12yearoldgirlin7th grade
Presentingproblems

Excessivetalking(Neverkeepsquiet arealchatterbox)
Highenergyandfunloving(Lifeoftheparty sociable)
Highlydistractible(Hastoseeeverythingthatsgoingon)
Losesthings(e.g.eyeglasses,clothes,assignments)
Verydisorganized(Bookbagisacompletemess)
Avoidsdoingherhomework

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CaseStudy:AbsentmindedAnna
16yearoldgirlin11th grade
Presentingcomplaints

Troublefocusingandsustainingattention(esp.inschool)
Easydistractibility(alwayslookingaround)
Restlessnessandfidgetiness(squirmyinherseat)
Alwaysonthego neversitsstill
Talksincessantlyandloudly
Interruptsothersconversations
Cantwaitherturn
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CaseStudy:DizzyDavid
20yearoldcollegejunior
Presentingcomplaints

Shortattentionspan(cantreadmorethan5minutes)
Verydistractible(mymindcantstayonthelecturer)
Organizationalissues(troublegettingstufftogether)
Timemanagementproblems(assignmentsalwayslate)
Makescarelessmistakes(e.g.onexams)
Notmotivatedtostudy

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CaseStudy:BoisterousBill
30yearoldunemployedmarriedman
Presentingcomplaints
Irresponsibilityathome doesntgetthingsdone
Lackofconsiderationforothers interrupts,argues
Troublekeepingjobs
Changedjobs6timesinpast4years
Firedfortardiness,inefficiency,troublefollowingdirectionsand
argumentswithhisbosses

Lowselfselfesteem,feelslikeafailure
ADHDsymptoms:poorconcentration,troublecompleting
tasks,restlessness
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CaseStudy:LostLouise
50yearoldmarriedwoman
Presentingcomplaints
Alwayshadtoworkextrahardtogetassignmentsdone,
butlately,itstakingevenlongertofinishthings
Mindwandersatwork spacesoutduringmeetings
Veryimpatient,cantwait,getsangryeasily
Cantremembermoviesshesseen,booksshesreador
conversationssheshadwithimportantpeople
Getslosteasily,poorsenseofdirection

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LookingAhead
Topicfornextweek:CausalFactors
Readingsfornextweek:
NIMHADHDOverview:
http://www.nimh.nih.gov/health/publications/att
entiondeficithyperactivitydisorder/index.shtml
CDCDataandStatistics:
http://www.cdc.gov/ncbddd/adhd/data.html

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EndofLectureQuiz

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