THE ADHD SPECTRUM
Professor Hans-Christoph Steinhausen
Department of Child and Adolescent Psychiatry
University of Zurich,...
Inattention Hyperactivity Impulsivity
Definition
Core symptoms
Classification
Dimensional approach
• ADHD...
• … is not like tuberculosis or epilepsy
(categorical with clear symptoms fo...
Epidemiology
Prevalence rates according to criteria
• DSM-III-R: 3 - 11 per cent
• DSM-IV: 8 - 18 per cent
• ICD-10: (?) 2...
Aetiology / Neuroanatomy
• Smaller brain (~4%): right frontal lobe (~8%)
• Smaller basal ganglia (~6%)  normalisation (~1...
•ADHD: activity remains reduced (less attention, van Leeuwen et al 1998)
• younger age: activity is stronger (increased at...
¡
¡
• Analyse data
• Prepare for response
• Noradrenaline
• Dopamine
• Anterior
• (eg frontal)
• Disengage from stimuli
• ...
ADHD involves dysfunction in a widely distributed neural network
Aetiology
Neuropsychology
Anterior
attentional
system
Fro...
 Inhibition (motor, cognitive and emotional)
 Planning
 Working memory
 Speech fluency
 Selective and sustained atten...
Aetiology / Genetics
Twin Studies
• Correlations and concordance rates for ADHD-traits and
-symptoms are higher in MZ than...
Aetiology / Genetics
Molecular Genetics
• Associations of ADHD with variations in certain genes,
e.g.dopamine transporter ...
Aetiology / Genetics
Clinical Implications
• ADHD is highly heritable
• Most children with DNA variants do not have ADHD
•...
Risk factorsRisk factors
Genetic dispositionGenetic disposition
Acquired biological factorsAcquired biological factors
Adv...
Symptom domains
 Inattention
 Hyperactivity
 Impulsivity
Symptom domains
 Inattention
 Hyperactivity
 Impulsivity
Ps...
Over 85% of patients have at least one comorbidity and
approximately 60% of patients have at least two comorbidities
Comor...
Clinical Assessment
• Interviews with parents and child
• Behavioural observation
• Questionnaires and rating scales
• Neu...
Treatment
Interventions
Patient-focusedPatient-focused
Parent-focusedParent-focused
School-focusedSchool-focused
Cognitive...
Clinical Course
Conclusion
• ADHD is a chronic disorder, the clinical picture changes over
the lifespan of the patient
• D...
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  • <number>
    Educational intent:
    to illustrate the three core symptoms of ADHD - inattention, hyperactivity and impulsivity
    SPEAKERS’ NOTES
    Complicating comorbidity should be raised. Explain that the core symptoms will be covered in more detail in module 2. Additionally, supplement with the following case-studies (Julia, inattentive, and Joe, combined/ predominantly impulsive) if you wish.
    Julia, 14 years old, is being presented by both of her parents because her school performance is getting worse and she doesn’t feel like doing her homework or studying for school. Julia thinks that studying is not worth it, and classes and, especially, teachers are only getting on her nerves. Her parents bother her the whole day and she can’t please anybody at all.
    Her parents explain that she always had problems at school. Even in her first year at primary school it was obvious that Julia was day-dreaming, that she did not follow the teacher, and that she needed much more time than everybody else because she was always doing something different. Reading and writing were especially difficult for her right from the beginning.
    Her current teacher explains that she has always known Julia as a kind of dreamer. She seems to tire very quickly, and the latter parts of her written tests are full of careless mistakes - and not only in dictation. Julia used to be quite an open person who tried very hard to fulfil everybody’s expectations. Now, however, there is a growing realisation that Julia does not feel like trying anymore. Her attitude is worsening and she seems very unhappy. She complains that everybody always complains about her. She always resolves to concentrate more at home and at school, and to try to finish things, but she finds this very hard – other things are always coming into her mind. The problem is compounded because she’s always looking for things – she lives in absolute chaos and loses things all the time.
    In a recent test, Julia scored an average IQ. She does try very hard but gets distracted easily. She interrupts frequently, asking how much longer things will take, and seems focused on failure.
    Joe, 7 years old, charming and bright, has earned the reputation of ‘class clown’, mostly because he answers questions before the teacher has completed them. He can’t wait to get his ice-cream at school dinner, but, on one occasion, dropped it on another child’s head.
    Joe was a lot of fun in nursery school, but his teachers and friends are now annoyed by his stampeding habits and frequent interruptions. His mother describes him as ‘a bull in a china shop’ and finds it very hard to take him shopping. He is so unpredictable and impetuous that he often makes irrelevant comments to strangers.
    His teachers now find him a nuisance and, on two occasions, he has been excluded from school. He is losing friends and becoming increasingly miserable and lonely as a result.
  • <number>
    Educational intent:
    to illustrate the differences between a categorical and a dimensional approach to ADHD classification, and to demonstrate that the dimensional approach is more appropriate
    SPEAKERS’ NOTES
    In some disorders, like tuberculosis, epilepsy or malaria, the presence of symptoms clearly permits diagnosis.
    Although ADHD is also defined by a number of symptoms that have to be present for diagnosis to be made, the cut-off is somewhat arbitrary. In other words, there is a continuum between normal behaviour and the disorder.
    ADHD is therefore another ‘dimension’ rather than a ‘category’.
    However, the use of diagnostic categories such as those defined by ICD-10/ DSM-IV is helpful because categories are easier to handle (eg for health insurance companies).
    In summary, ADHD can be viewed as both a categorical concept (DSM-IV diagnosis) and a dimension (continuum of ADHD behaviours in the population). Valid diagnostic entities are useful for communication and in the prediction of treatment response and outcome.
  • <number>
    Educational intent:
    to clarify noradrenaline and dopamine involvement in ADHD
     
    SPEAKERS’ NOTES
    Noradrenaline and dopamine are the two most important neurotransmitters related to the pathophysiology and drug treatment of ADHD. Both are involved in attentional function and dopamine also plays a major role in motor regulation, reward and reinforcement mechanisms.
  • <number>
    Educational intent:
    to highlinght that the neuronal dysfunction associated with ADHD is widespread, and thus introduce the neuropsychology of ADHD
     
    SPEAKERS’ NOTES
    Attention is controlled by three networks: the orienting network, the executive network and the vigilance network (see next three slides).
  • <number>
    Educational intent:
    to list the ways in which disturbed executive functioning is manifest in ADHD
    SPEAKERS’ NOTES
    Practical examples of the executive functioning disturbances listed might relate to:
    inhibition – stopping at traffic lights, waiting one’s turn
    planning – using one’s agenda, organising a five-course dinner for six friends
    working memory – pertains to two functions:
    maintenance, eg retaining the telephone number of a stranger
    manipulation, eg being instructed to remember a number (eg 149682573) and then to perform the following calculation: add up the last two digits, add up the first two digits, subtract the sum of the last two digits from the sum of the first two digits (answer is 5)
    fluency – ability to name all the animals that begin with the letter ‘p’
    selective attention – ability to listen to one conversation in a crowded restaurant
    sustained attention – ability to maintain attention for a long period of time, eg drive for several hours at night without falling asleep
    cognitive flexibility – ability to switch from one task to another and back again, eg make the dinner, answer the telephone and be able to return to the cooker knowing what to do next
    interference control – ability to write a letter efficiently while TV is on.
    Manifestation of the three core symptoms of ADHD:
    Distraction (inattention) refers to a breakdown in selective attention. This can occur as a result of failure to:
    divide attention - can’t switch attention from the phone to cooking the dinner
    focus attention - misses new stimuli, while concentrating on current task.
    Hyperactivity is an inappropriate level of motor activity for the current situation eg leg swinging while sitting at table or fidgeting constantly with desktop materials while performing a task. 
    Impulsivity is manifest as responding too quickly and consequently making errors eg subject blurts out first answer that comes to mind.
  • <number>
    Educational intent:
    to suggest an integrated aetiological model for ADHD
     
    SPEAKERS’ NOTES
    This integrated aetiological model summarises the possible risk factors for ADHD and the processes affected by these risk factors at the neurobiological, neuropsychological and behavioural levels; it also summarises the level of interaction and co-existing problems.
    Empirical evidence suggests that genetic factors are the most important aetiological factors.
    The role of adverse conditions in the family or at school is less clear. The latter may have some impact on the intensity of ADHD symptoms, the level of negative interaction in daily life and on the development of associated problems such as conduct disorder.
    The precise causal pathways from risk factors to processes are not yet known.
  • <number>
    Educational intent:
    to illustrate that functional impairment occurs when the core symptoms are associated with various psychiatric comorbidities
    SPEAKERS’ NOTES
    …contd
    The clinical diagnosis of ADHD is based on developmentally inappropriate behaviour within two symptom domains: inattention and impulsivity/ hyperactivity.
    These symptom domains combined with the influence of comorbid conditions result in various functional impairments in everyday life.
    Family stress, psychiatric comorbidity, socialisation deficits and academic underachievement are just a few of the many difficulties ADHD patients face.
    The symptom domain of inattention is more closely related to academic and achievement opportunities, while hyperactivity/impulsivity are the antecedents of problems concerning social relationships and ‘psychiatric’ outcomes.
    NB. Adverse outcomes can also occur without comorbidities and ADHD is a precursor of conduct disorder.
  • <number>
    Educational intent:
    to illustrate the frequency of comorbidities
    SPEAKERS’ NOTES
    Comorbidity is the rule rather than the exception.
    ADHD plus conduct disorder and ADHD plus anxiety disorder and probably ADHD plus tic disorder may be sufficiently distinct to warrant classification as ADHD subtypes distinct from pure ADHD.
  • <number>
    Educational intent:
    to illustrate the broad types of intervention that may be applied at different levels 
     
    SPEAKERS’ NOTES
    Because different problems are usually present in different arenas – ie child, family, school – different interventions may be used to target the child himself (child-focused), the parent or family (parent-/ family-focused), or the nursery/ school.
    Patient-focused intervention may comprise psychoeducation of the child, cognitive behaviour therapy with the child and psychopharmacotherapy.
    Parent- and family-focused intervention may comprise psychoeducation of the parents and parent training (and treatment of the parents if necessary).
    Teacher- and school-focused intervention may comprise psychoeducation of the teachers and behavioural interventions in the nursery school, school or classroom.
    In most cases a combination of interventions - so-called ‘multimodal’ treatment - is required.
  • <number>
  • Kein Folientitel

    1. 1. THE ADHD SPECTRUM Professor Hans-Christoph Steinhausen Department of Child and Adolescent Psychiatry University of Zurich, Switzerland The Social Brain 2 Glasgow 3-2006
    2. 2. Inattention Hyperactivity Impulsivity Definition Core symptoms
    3. 3. Classification Dimensional approach • ADHD... • … is not like tuberculosis or epilepsy (categorical with clear symptoms for diagnosis) • … is rather like hypertension or being overweight (dimensional with spectrum of symptoms) One can have more or less of it; the borders blur; however, its classification (ICD-10 or DSM-IV) is categorical
    4. 4. Epidemiology Prevalence rates according to criteria • DSM-III-R: 3 - 11 per cent • DSM-IV: 8 - 18 per cent • ICD-10: (?) 2 per cent
    5. 5. Aetiology / Neuroanatomy • Smaller brain (~4%): right frontal lobe (~8%) • Smaller basal ganglia (~6%)  normalisation (~18 years) • Smaller cerebellum (12%)  more pronounced (~18 years) • Volumetric differences: manifest early (~6 years) correlate with ADHD severity are irrespective of medication status are irrespective of comorbidities Age (years) 900 1000 1100 5 7 9 11 13 15 17 19 21 ml Control males ADHD males Control females ADHD females Controls > ADHD P<0.003 Total brain volume
    6. 6. •ADHD: activity remains reduced (less attention, van Leeuwen et al 1998) • younger age: activity is stronger (increased attentional demand) y8 10 12 P300 µV Cue P300: longitudinal Cue P300: posterior sources Aetiology / Neurophysiology EEG based: ADHD ≠ maturational lag ADHD n=12 controls n=11 Year 1 / Age11 Year 2 / Age12 ADHD t-maps: ADHD - controls Maturational Lag t-maps: year 1 - year 2 +7µV/ t -7µV/ t ^ ^ ^ ^ ^ ^ ^ ^ ^ (Manova: ADHD X cue/distractor p<.01, year p<.05)
    7. 7. ¡ ¡ • Analyse data • Prepare for response • Noradrenaline • Dopamine • Anterior • (eg frontal) • Disengage from stimuli • Change focus to new stimuli • Engage attention to new stimuli • Noradrenaline• Posterior • (eg parietal) • Activity• Neurotransmitter involved • Attentional systems Regions rich in dopamine (DA) and noradrenaline (NA) are consistently implicated Aetiology / Neurochemistry
    8. 8. ADHD involves dysfunction in a widely distributed neural network Aetiology Neuropsychology Anterior attentional system Frontal lobe Striatum Posterior attentional system CerebellumAnterior Attention System Posterior Attention System
    9. 9.  Inhibition (motor, cognitive and emotional)  Planning  Working memory  Speech fluency  Selective and sustained attention  Cognitive flexibility or interference control These findings are not specific to ADHD Aetiology / Neuropsychology Disturbance of executive functioning
    10. 10. Aetiology / Genetics Twin Studies • Correlations and concordance rates for ADHD-traits and -symptoms are higher in MZ than in DZ. • Heritability estimates range from 0.39 to 0.91 • Parental (maternal) contrast effects account for the low DZ correlations.
    11. 11. Aetiology / Genetics Molecular Genetics • Associations of ADHD with variations in certain genes, e.g.dopamine transporter gene DAT1 (positive and negative reports) and dopamine receptor genes DRD-4 and -5 (positive and negative reports) • Significant associations with ADHD but small effect sizes (not more than 5 per cent of the variance)
    12. 12. Aetiology / Genetics Clinical Implications • ADHD is highly heritable • Most children with DNA variants do not have ADHD • Most children with ADHD do not have the known DNA variants • Further work is needed before results can be incorporated into clinical practice
    13. 13. Risk factorsRisk factors Genetic dispositionGenetic disposition Acquired biological factorsAcquired biological factors Adverse conditions in family/ school Adverse conditions in family/ school Altered neuronal networksAltered neuronal networks Altered self-regulationAltered self-regulation Inattention, Hyperactivity, Impulsivity Inattention, Hyperactivity, Impulsivity Negative interactions with caregivers Negative interactions with caregivers Associated disorders/ problemsAssociated disorders/ problems ProcessesProcesses Neuroanatomy • chemistry • physiology Neuroanatomy • chemistry • physiology Neuro- psychology Neuro- psychology BehaviourBehaviour InteractionsInteractions Coexisting problems Coexisting problems LevelsLevels Döpfner et al 2002 Aetiology / Integrated Framework
    14. 14. Symptom domains  Inattention  Hyperactivity  Impulsivity Symptom domains  Inattention  Hyperactivity  Impulsivity Psychiatric comorbidities  Disruptive behavioural disorders (conduct disorder and oppositional defiant disorder)  Anxiety and mood disorders Psychiatric comorbidities  Disruptive behavioural disorders (conduct disorder and oppositional defiant disorder)  Anxiety and mood disorders Lead to+ Functional impairments Self  Low self-esteem  Accidents and injuries  Smoking/ substance abuse  Delinquency School/ work  Academic difficulties/ underachievement  Employment difficulties Home  Family stress  Parenting difficulties Social  Poor peer relationships  Socialisation deficit  Relationship difficulties Functional impairments Self  Low self-esteem  Accidents and injuries  Smoking/ substance abuse  Delinquency School/ work  Academic difficulties/ underachievement  Employment difficulties Home  Family stress  Parenting difficulties Social  Poor peer relationships  Socialisation deficit  Relationship difficulties Clinical Picture Psychosocial impairments
    15. 15. Over 85% of patients have at least one comorbidity and approximately 60% of patients have at least two comorbidities Comorbidity • Autism spectrum disorders, Mental retardation Infrequent • Tic disorders, Depressive disorder Less frequent (up to 20%) • Specific learning disorders, Anxiety disorder, Developmental coordination disorder Frequent (up to 50%) • Oppositional defiant or conduct disorder Very frequent (more than 50%)
    16. 16. Clinical Assessment • Interviews with parents and child • Behavioural observation • Questionnaires and rating scales • Neuropsychological testing • Physical examination and neuromotor testing • Laboratory tests • Differential diagnosis Multidimensional approach
    17. 17. Treatment Interventions Patient-focusedPatient-focused Parent-focusedParent-focused School-focusedSchool-focused Cognitive behaviour therapyCognitive behaviour therapy PsychopharmacotherapyPsychopharmacotherapy PsychoeducationPsychoeducation PsychoeducationPsychoeducation Behavioural interventionsBehavioural interventions Parent trainingParent training PsychoeducationPsychoeducation
    18. 18. Clinical Course Conclusion • ADHD is a chronic disorder, the clinical picture changes over the lifespan of the patient • Diagnostics and treatment must be adapted throughout the patient‘s lifespan: • Preschoolers - early intervention, behavioural methods preferred • Schoolchildren - combination of drug and behavioural therapy • Adolescents/adults - treatment modification needed (associated problems)

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