ADHD is a complex neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity. Symptoms appear early in life and persist into adulthood. While its exact causes are unknown, genetic and neurological factors are involved. Stimulant medications are effective in reducing ADHD symptoms in about 70% of children, with benefits including improved behavior and academic performance. Contrary to myths, ADHD is not due to poor parenting alone, medications are not generally dangerous or addictive when used as prescribed, and the disorder can cause significant impairment without treatment.

1. Attention-Deficit/Hyperactivity Disorder Dispelling Myths is Good Medicine Karen J. Kraus, M.D. UCSF Fresno Psychiatry Residency Program

2. 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

3. 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

4. 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

6. 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

7. “ There is no such thing as ADHD”

8. Myth #1 Psychiatric disorders do not occur in children.

9. Myth #2 ADHD is nothing more than applying a diagnostic label to normal childhood behavior.

10. Myth #3 If ADHD really existed, wouldn’t it be obvious?

11. “ The medicines used to treat ADHD are dangerous and addictive”

12. Efficacy and dosing guidelines have not been established for children Use of these medications may actually exacerbate the underlying disorder Associated with high rates of significant side effects such as irritability, restlessness,lethargy, hallucinations, hypertension & severe muscle stiffness, even death In one study, more than 50% of mothers interviewed had administered this medication within the past month During 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.”

13. According to the American Association of Poison Control Centers: These medications are the frequent targets of unintentional ingestions in young children They rank #2 for intentional ingestions In 1988, they accounted for 58,000 exposures & 77% of all ingestions In 1990, they accounted for 73,680 exposures (calls to poison control centers In the case of one medicine, tracking mechanisms reported a 60% annual increase in use, abuse and medical contacts for toxicity

14. Stimulant medications, doses and pharmacological activity

16. Non-stimulant Medications in ADHD

18. 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

19. 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

20. 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.

21. Myth #4 The medications used to treat ADHD are very dangerous

22. Myth #5 The medications used to treat ADHD are addictive

24. Rates of psychotropic medication use by children in the United States

25. 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

26. 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

27. 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

28. 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.

29. 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

30. 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

31. 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.

32. Advice to Parents, Kids and other Interested Observers

33. 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.

34. 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

35. 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

36. 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.

37. 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

38. 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

39. 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.

40. Hyperactivity Excessive motor activity, described as: constantly moving or “on the go” fidgety or restless difficulty remaining seated when required to do so

41. Hyperactivity Subjective sense of motor restlessness A subtle finding more common in girls, and frequently found in adolescents and adults

42. Hyperactivity Over-talkativeness, described as: excessive, continuous talking (“blabbermouth”) poor modulation of speech, with loud speech verbosity blurts out answers, interrupts conversation

43. 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)

44. 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

45. 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

46. 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

47. 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 ”

48. 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

49. 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.

50. 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 .

51. 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

52. 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