University of California
ADHD: Current Research Assessment and Treatment Status
UC Davis Mind Institute, Summer 2010
Dr. Julie Schweitzer and Dr. Faye Dixon
· Rate of ADHD in general population is 3 – 10% of children depending on what diagnostic measures are used
· Environmental factors in pregnancy shown to increase the risk of ADH:
o Pesticide exposure
o Maternal eating disorders
· Academic problems associated with ADHD
o 56% need tutoring
o 30% repeat a grade
o 30-40% in special education
· Impulsivity and inattention continues with 70-80% adolescents, while hyperactivity declines
· Teen behavior problems include
o Anti-social behavior
o Greater frequency of suspensions or dropping out
o Heavier alcohol and cigarette use
o Riskier sexual behavior
o Higher risk of driving accidents
· Adults commonly continue to have symptoms but their symptoms are different because they are in a different environment
o More problem maintaining jobs
o Higher underemployment – earn $9,00 - $15,000 less than non-ADHD
o More marital problems
o Depression, substance abuse and anti-social behavior problems continue
· Evaluations should include:
o ADHD is a very complicated diagnosis. It can’t just be done in the pediatrician’s office. It must involve collaboration and interviews with child, parents, caregivers, teachers, school
o Look at co-occurring conditions
o Look at medical history to see what else is contributing or may be looking like ADHD
o Family stress
o Family medical history – ADHD looks like it is hereditary
o Look at academic and intellectual performance
o Problems need to exist in all settings – home and school and across time
o Brain imaging is not a necessary diagnostic tool. (used purely for research purposes). Blood tests are also not required. CPT tests are also not diagnostic tools.
o Standardized forms – Vanderbilt is free, Connors and Children’s Symptom Inventory are a few of the best. The Children’s Symptom Inventory is best for people who have ASD.
o Not just rating scales and interviews that inform us. Need input from people who see the children over time – especially teachers.
o Review what else has been tried
o Sleep is a common ADHD problem, but can also affect attention
o Performance in the clinic may be dramatically different from home or school performance. That’s why we always rely on an observer to also screen adults. “Collateral” information is very important.
o Self-report of teens and young adults is a very ineffective diagnostic tool
· DSM-IV criteria is very subjective and will be changing soon
o Hyperactivity is most observable
o Impulsivity gets kids in trouble the most, most problematic. DSM-V thinking of breaking Impulsivity and Hyperactivity apart as symptom areas
o Problem behaviors must be evident before the age of 7 (this may change with DSM-V)
· DSM-V due out in 2013
· ADHD Sub-Groups:
o personal theory – subgroups due to different neurotransmitter systems and brain regions involvement and treatment should be different.
o Norepinepherine and dopamine are key
o Behavioral intervention and medication are the two standards of treatment
o Behavior intervention doesn’t treat the core symptoms, medication does
o Insufficient evidence that the following treatments are effective: neurofeedback and cognitive therapy. Need replicable, randomized placebo studies.
· Cultural attitudes
o Hispanics and Af. Americans are less informed as a group and more concerned about stigma
· A child’s behavior at 6 significantly influences their performance level at age 17
o Best prediction of performance in math and reading is attentional focus (not conduct)
· High school dropout rate dramatically affected by ADHD
o 30,000 people study, control for age, sex, parental mental disorders and childhood adversity
o 15% of all people don’t graduate.
o Conduct disorder, ADHD (even the inattentive type) are much less likely to graduate. (about 30% drop out rate)
o Drop outs have a poorer life expectancy, higher social cost, incarceration, less productive
· Children with ADHD have variable levels of performance
o One day they are able to do it, the next they aren’t
o Often mistaken for laziness
o Perhaps a physiological root to this behavior
o People with ADHD do better with non-routine tasks – nearly as well as non-ADHD kids.
o These kids are consistently inconsistent
o Working memory is known to be a problem for ADHD. Some of this has to do with slow response time. This looks like inattention.
o The kids who are the most hyperactive also are the most variable
o Kids with ADHD are less able to quiet some areas of their brain when they need to sustain focus on a task
· Kids with ADHD don’t respond the same way to mistakes, leading to them not learning from their errors
· There is also neural evidence that inattentive ADHD and hyperactive/impulsive ADHD types respond differently to different circumstances
o Ritalin has been shown to increase brain efficiency (measured by glucose usage)
o We know it works, but
o People don’t adhere to medication prescription
o Within 6 months to a year, many people have stopped taking their medication
o Most people respond to a stimulant and most pediatricians should be able to prescribe one. But in complicated cases, prescribing medications is a complex art form and needs to be done by a psychiatrist comfortable and well versed in working with this population.
· Video-psychiatry (i.e. skype) has been shown to be as effective as in person treatment.
· Treatment recommendations for young adults
o Important to have a partner to work on behavior therapy
o Set long term goals, break into smaller tasks and build a system to support them in sustaining focus on their goals.
· Executive functioning and ADHD
o We know that people with ADHD have executive function problems
o But you can have executive function issues without ADHD
o It’s become too broad and over used a term
o Executive function is not the answer. It’s an easy way to talk about it but not always the most specific way.
o Brain regions and processing is a better place to focus our attention.
· Teaching students to understand what areas they are weak in is an important part of treatment. Because they are consistently inconsistent, it’s hard for a person to recognize why they are having problems in certain areas because some of the time they are able to function in that area.
· ADHD learners are usually multi-sensory learners
o Strategies that work with children who have multi-sensory learning disabilities also work with ADHD
o We should be designing curriculum that is visual, auditory and hands-on
o And people with ADHD should also look for careers that combine these sensory experiences.