ATTENTION DEFICIT HYPERACTIVITY

DISORDER AND COMORBIDITY

• SEMINAR PRESENTATION
• PRESENTER : DR LUKEMAN SHA M. P.
• CHAIRPERSON: DR SANJAY PATTANAYAK
• VIMHANS, DEPARTMENT OF PSYCHIATRY
• 03/07/23
DSM-5 Criteria for ADHD
Inattentive Symptoms (6/9 Age < 17 Years; 5/9 ≥ 17 Years)
 IMPULSIVITY / HYPERACTIVITY SYMPTOMS
DSM-5 Criteria for ADHD
Inattentive Symptoms (6/9 Age < 17 Years; 5/9 ≥ 17 Years)
On the go, as if driven by a
motor

Fidgets with hands/ feet,

Talks excessively
squirms in seat

Impulsive or Blurts out answers before

Leaves seat when remaining
hyperactivity question has been completed
seated is expected symptoms
Runs about or climbs
Difficulty awaiting turn
excessively; restlessness

Unable to engage in leisure Interrupts or intrudes on

activities quietly others
 DSM-V ADHD Criteria Continued:
•Patients must have symptoms from <
either the inattentive or
At least six symptoms of inattention
hyperactive/impulsive categories, or
and/or hyperactivity and impulsivity
both. And have:
• Some ADHD symptoms before
age 12
• Current symptoms in 2 or more areas
(home, school, work) At least five symptoms of inattention
• Reduced quality of function in the 3 and/or hyperactivity and impulsivity
settings mentioned above
• The symptoms are not better
accounted for by another diagnosis
 ADHD: Associated Symptoms
Autism Traits

Behavioral
Dysregulation Inattention

Learning
Disabilities
Hyper-
ADHD activity

Emotional
Dysregulation

Impulsivity
Psychosocial
Symptoms

Sleep Issues
ADHD Is Prevalent in All Age Groups

2.5% of
adults

60% CHILDREN CONTINUE TO EXPERIENCE THE PERSISTENT

IMPAIREMENT FROM SYMPTOMS INTO ADULTHOOD
Adult Onset or Adult Diagnosis of ADHD
MTA Study Followed Into Adulthood

• 30% of children experienced full remission at some

point during follow up period
• 60% of them experienced recurrence after initial
period of remission
 RISK FACTORS FOR PERSISTENCE

• FAMILY HISTORY OF ADHD

• DEPRESSION
• CONDUCT DISORDER
• ANXIETY DISORDERS
• ADVERSE LIFE EVENTS

SOCIALLY DYSFUNCTIONAL CHILDREN HAVE HIGHER RATES OF COMORBID

PSYCHIATRIC DISORDER AND BEHAVIOURAL PROBLEMS

Kaplan and sadock’s,Synopsis of psychiatry,12th edition

ADHD and Coexisting Psychiatric Conditions
COMMON ADHD COMORBIDITIES

Children Adults
• Anxiety • Depression
• Tics • Anxiety
• Oppositional Defiant • Bipolar
Disorder (ODD) • Substance Use
• Conduct disorder Disorders
 ADHD Comorbidities Change with Age

Percentag
e

Kooij JJ et al,J Atten Disord.2012

NCS-R
Mood Disorders in Adult ADHD
NCS-R
Anxiety Disorders in Adult ADHD
A Case for Diagnostic Achromatopsia:
Comorbidities or ADHD?
Mood and Anxiety Disorders Not Responding to Treatment?
ADHD May Be Hiding in the Background
Prevalence of Probable ADHD Increases in
Advanced Treatment Stages of MDD
The Primary Wechsler Intelligence Scale for
Children-V (WISC-V) Scales
Psychiatric Comorbidities Increase the Risk
of Premature Mortality in Adults With ADHD
Underdiagnosis
Overlooked and Nonreferred
Underreporting by Adults With Childhood History of
ADHD
Pittsburgh ADHD Longitudinal Study
 BARRIERS IN ADULT ADHD DIAGNOSIS

• Screening : You don’t see what you don’t look for

• Chief complaints
• Normalisation : I have been this way all my life
• Comorbidities
Currently Approved ADHD Medications Reflect
Limited Distinct Approaches for Adult Patients
A Holistic Approach to ADHD and
Comorbidities
 Updated Jan. 2020 SDBP Guidelines
The clinician with specialized training or expertise should initiate a
comprehensive assessment and develop an interprofessional,
multimodal treatment plan for any child or adolescent through age
18 years with suspected or diagnosed complex ADHD upon
referral from primary care clinician.

Treatment of complex ADHD should include evidence-based

approaches that address ADHD and account for coexisting
conditions.

SDBP : SOCIETY FOR DEVELOPMENTAL AND BEHAVIOURAL PEDIATRICS

Complex ADHD Is Defined By Any
Of The Following:
• Presence or suspicion of coexisting disorders and
complicating factors (LD, neurodevelopmental or mental health
disorders, medical conditions, genetic disorders)

• Moderate to severe functional impairment

• Diagnostic uncertainty
• Inadequate response to treatment (or uncertainty
about treatment planning)
• Aged <4 years or >12 years at initial
symptom presentation
ADHD and Depression
 Set the Treatment Table for Success

1. Pharmacotherapy
Patient/Family
ADL’s: nutrition, sleep, exercise
2. ADD and Executive
Function Coaching

Accommodations
3. Academic/Workplace (school/workplace)
Accommodations
ADD Coaching
Pharmacotherapy
(Physician, NP)
4. Therapy (Individual, Psychotherapy
Couples, Family) (Therapist)
 Diagnostic Rating Scales
ADHD
• ADHD Rating Scale-5 (ADHD RS-5)
• (PHQ-9)
Adolescent
• Conners Self-Report
Parent (CPRS), Scales
Teacher,
• Brown Attention/Executive
Function Scales
• Before School Functioning
Questionnaire (BSFQ)
• Vanderbilt Parent and Teacher
(VARS)
• World Health Organization
Adult
Self-Report Scale (ASRS)
Comorbidities
Patient Health Questionnaire
• Behavior Assessment System for
Children (BASC)
Mood Disorder Questionnaire
(MDQ)
• Children’s Depression Inventory
(CDI)
• Generalized Anxiety Disorder 7
item (GAD-7)
• Social Responsiveness Scale-2
(SRS-2)
Which Is the 'BEST' Scale to Detect
Inadequate Response to an ADHD Medication?
Breaking Down Stigma and Misperceptions
Key Elements of Therapy
 Joined at the Root
Genetic Composition of Psychiatric Disorders

GENOME WIDE ASSOCIATION STUDIES

Polygenic Risk for ADHD and Associated
Traits
Relationship Between Genetic Risk for ADHD
and Important Clinical and Functional Outcomes
Phenotypic-Genetic Similarity
Emotional Dysregulation May Be a Manifestation of Genetic
Risk
for ADHD
Evidence of Emotional Dysregulation in
ADHD
Associations of PGS With Childhood, Persistent, and
Late-Diagnosed ADHD
NEUROANATOMY
 Dorsolateral

Ventrolateral
Prefrontal
Cortex

Ventromedial
 Functional Brain Networks in ADHD
• Salience network: straitum,thalamus,anterior
cingulate , VLPFC, insula. emotion regulating network
-positive/ negative emotion and rewards. Monitor
behaviourally salient event in environment, inhibit
prepotent response.
• Any stimulus,SN receives the emotional
representation
• FPN: (Central executive network) DLPFC,post.
Parietal cortex organise response, active
maintenance and manipulation of task relevant
information
• DMN: post.cingulate cortex, medial prefrontal cortex
mentalising, self reflecting, processing social
information
Symptoms of Depression Reflect Aberrant
Functional Network Connectivity in MDD
Altered Functional Network Activity in
Anxiety Disorders
5-HT and DA Have a Role in Networks Associated
With ADHD
Catecholamine Regulation of PFC Activity and Sensory
Circuits
Reflective to Reactive
Catecholamine Regulation of Prefrontal Cortex, Limbic and Paralimbic
Areas
Summary
THANK YOU
What's the Newest Adult ADHD Treatment?
Viloxazine XR
Viloxazine XR Short- and Long-Term Adult
Data
Viloxazine XR
Adult Adverse Events
Centanafadine Is a Triple Reuptake Inhibitor
Phase 3 Trial: Centanafadine SR for Adult ADHD
Efficacy - AISRS Total Score
Phase 3 Trial: Centanafadine SR for Adult ADHD
Safety - Most Common TEAEs (> 5%)