Attention Deficit Disorders

 

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - James Vardeman, Nathan Smith, Kim Jackson, Shaimaa Eldib, Rucha Gadgil, Uchechukwu Chukwuemeka, Vidya Acharya, Shreya Pavaskar, Elaine Lonnemann, Simisola Ajeyalemi, Eugenie Lamprecht, 127.0.0.1 and WikiSysop  

Definition/Description

According to the National Institute of Mental Health, Attention-deficit/hyperactivity disorder (ADHD) is defined as “a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development”. In adults, this disorder may cause trouble getting organized, remembering appointments, or even have trouble keeping a job. Activities of Daily Living are affected due to the inability to keep attention on one task at a time. Chronic condition affecting millions of children and often continues into adulthood. Children with ADHD may also struggle with low self-esteem, troubled relationships, and poor performance in school. Symptoms experienced by these individuals sometimes diminish as one ages. For those who's symptoms persists, coping strategies can be learned in order to be successful

Prevalence

The onset of this condition typically occurs according to a common trend in children, with boys being 2 to 3 times more likely to show signs and symptoms
Average age of onset: 7 years old
12 month prevalence: 4.1% of U.S adult population

Prevalence of ADHD

Percentage of children 5-17 years old diagnosed	10.2%
Percentage of boys 5-17 years old diagnosed	14.1%
Percentage of girls 5-17 years old diagnosed	6.2%

Characteristics/Clinical Presentation

ADHD symptoms start before age of 12, and sometimes as noticeable as young as 3 y.o. Symptoms can range from mild to severe and can continue into adulthood

In children, symptoms include

•Excessive daydreaming

•Forgetfulness

•Squirming/fidgeting excessively

•Talking excessively

•Trouble getting along with peers

•Poor academic performance

•Trouble with organizing tasks and activities

•Easily distracted

ADHD usually presents in 3 different ways in children:

•Predominantly Inattentive: wandering off task, difficulty sustaining focus, disorganized

•Predominantly Hyperactive-Impulsive: Hyoeractivity means a person moves constantly, or is restless; impulsivity means a person makes hasty actions that occur in the moment

•Combined

To be diagnosed with ADHD as an adult, several factors must be taken into account. According to the National Institute of Mental Health, four factors must be taken into consideration:

•Several symptoms must be present before the age of twelve.

•A person must have at least five symptoms of either inattention and/or hyperactivity-impulsivity.

•The symptoms must be present in two or more settings, such as at home and at work

•There must be evidence the symptoms interfere with the person’s functioning in these settings.

Symptoms of ADHD in adults include:

•Failure to pay attention to details/makes careless mistakes

•Difficulty keeping attention on tasks

•Difficulty organizing tasks and activities

•Avoids activities requiring sustained mental effort

•Easily distracted

•Forgetfulness in activities of daily living

•Fidgety/squirms

•Unable to remain still for extended periods of time

Associated Co-morbidities

There are multiple co-morbidities associated with ADHD. There is a high rate of anxiety in those diagnosed with ADHD, along with depressive disorder. Having the diagnosis of ADHD doubles the likelihood of having depression. Bipolar disease has a growing association as well, with 22% of those with ADHD having bipolar disorder as well.
There is data to indicate that youth with ADHD are at an increased risk for cigarette smoking and substance abuse during their teenage years, and are twice as likely as their non-ADHD counterparts for this to occur. Those with this disorder also tend to maintain their addictions for longer.

Medications

Stimulants

Class: Amphetamines

•Adderall (mixed amphetamine salts)

•Adderall XR (Extended release mixed amphetamine salts)

•Dexedrine (Dextroamphetamine)

•Dexedrine Spansule (Dextroamphetamine)

•Vyvanse (Lisdexamfetamine (extended release))

• Several heart-related deaths have occurred in children and teenagers taking stimulants. Although unproven at this point as to why this is, it’ believed that people who already have heart disease or heart defect are at greater risk for this

Class: Methylphenidate

•Concerta (Methylphenidate)

•Daytrana (Methylphenidate (patch))

•Focalin (dexmethylphenidate)

•Focalin XR (extended release dexmethylphenidate)

•Metadate ER extended release methylphenidate)

•Metadate CD (extended release methylphenidate)

•Methylin (Methylphenidate hydrochloride)

•Quillivant XR (extended release methylphenidate)

•Ritalin (Methylphenidate)

•Ritalin LA (extended release methylphenidate)

•Ritalin SR (extended release methylphenidate)

Non-stimulants

Class: Norepinephrine Uptake Inhibitor

•Strattera (Atomoxetine)

Class: Alpha Adrenergic Agents

•Intuniv (extended release guanfacine)

•Kapavay (extended release clonidine)

Concerns have been raised threat there may be a slightly increased risk of suicidal thoughts in children and teenagers taking nonstimulant medication or antidepressants. Contact your child’s doctor if you notice any signs of depression or suicidal thought.

Diagnostic Tests/Lab Tests/Lab Values

First off, a child should only receive a diagnosis of ADHD if the core symptoms start before the age of 12 and create significant problems at home and at school repeatedly. Also, to be diagnosed with ADHD, a person must show symptoms for more than six months, and in more than one setting. Although the signs and symptoms of ADHD can sometimes manifest themselves in children of preschool age or even younger, diagnosis at a very young age is difficult. The reason for this is because developmental problems, like language delays, can be mistaken for ADHD. Therefore, children at the preschool age or younger suspected of having ADHD are more likely to need evaluation from a specialist (ie psychologist, psychiatrist, speech pathologist, developmental pediatrician). Although there is no specific diagnostic test for ADHD, diagnosis will usually include:
-medical exam: ruling out other possible causes of the symptoms
-medical history, school records, and subjective history
-interviews/questionnaires distributed to family members, teachers, and other who know the child well (coaches, babysitters, etc.)
-DSM-5: ADHD Criteria from the diagnostic and statistical manual of mental disorders
-ADHD rating scales

Etiology/Causes

The exact cause of ADHD is not clear but research continues on the topic. Possible factors that are thought to play a role include:

-Genetics: ADHD can run in families, and studies show that genes may play a role.

-Environment: Factors, such as lead exposure may increase the risk

-Development: Problems with the central nervous system at key moments of development may play a role.

Risk factors for ADHD may include:

-Blood relatives with ADHD or other mental health disorders

-Maternal drug use such as alcohol or smoking during pregnancy.

-Premature birth.

-Sugar is a suspect in causing hyperactivity, but there is no reliable proof that this directly causes ADHD. Although it may play a role in one’s sustain attention, it is not considered to be a cause of ADHD.

Systemic Involvement

Cognitive/Mental:
- Concentrating problems: inattention to details as well as careless mistakes. Difficulties sustaining    attention with activities or games.
- Difficulty controlling impulses
- Executive function: difficulties in planning, organizing, and performing strategies.
- Memory function: forgetful, and difficulty recalling information, no matter how intense the effort put forth.
Motor¹⁷
- Difficulty remaining seated, when staying seated is expected, which can be seen in the classroom.
- Difficulty awaiting turn or standing in line. The child tends to run about or climb excessively when it’s inappropriate.
- Excessive talking: Blurting out answers, or disrupting the classrooom.
- Feelings of always being “in a hurry”
GI:
- Bowel and bladder dysfunction

Medical Management (current best evidence)

Treatment varies with age of the individuals with ADHD. For children 4 to 5 years old, treatment consists of parent and/or teacher administered behavior therapy. If the symptoms have a well founded manifestation, the doctor may prescribe medication, although this is not the most desirable course of action. Initially, attempting behavioral therapy can give the parents skills and strategies to help their child, relatively no side effects in comparison to medication presrcription, and the long term effects of ADHD medication on young children have not been widely studied. ADHD medications can cause sleeping problems, decreased appetite, delayed growth, headaches/stomachaches, rebound irritability, tics, and moodiness/irritability

For children who are 6-11 years of age, then the physician should prescribe medication (usually stimulant medications), along with possible parent and/or teacher behavioral therapy. The medication is more important here, although the behavioral therapy is an important part of management as well.

For the adolescents who are defined as 12-18 yrs old, medication is the primary method of management. It is also recommended that behavior therapy is also prescribed.

Stimulant medications are highly effective for reducing ADHD symptoms. Other medications including selective norepinephrine-reuptake inhibitors and selective alpha-adrenergic agonists have also been shown to be effective.

Behavior therapy is a broad, non-specific intervention. Its goal is to modify both the physical and social environment to change the behaviors of those with ADHD. This is done by using rewards and consequences for certain behaviors. 

Physical Therapy Management (current best evidence)

Exercise has been shown to reduce stress, anxiety, and depressive symptoms as well as improve cognitive function. Research exists to show that regular exercise can alter brain functions both emotionally and cognitively. For those with ADHD, it has been shown that moderate to high-intensity exercise improved parent-teacher behavior reports and levels of information processing.
With moderate to high-intensity training, it has also been shown that motor performance was improved as well. Physical activity improves social skills and behavior as well in those with ADHD, especially children. The ability to maintain attention is improved with physical exercise as well, with better sustained auditory attention.
Another possible intervention for those with ADHD is yoga. Studies have been conducted that show that an eight-week yoga intervention improved both selective and sustained attention in children with ADHD. It has also been suggested by studies that yoga can reduce impulsivity, anxiety, and social problems in all individuals with ADHD.
Executive Function (EF) training program was feasible and acceptable to children with ADHD and parents. This type of training with multiple EF focus and parent involving in real-life activities could be a potentially promising intervention associated with significant EF and ADHD symptoms improvements. Specifically, for children with ADHD, is important and useful to reduce the EF developmental gap by teaching children appropriate coping skills and strategies.

Differential Diagnosis

Medical conditions that can mimic ADHD include:

-learning/language problems

-Mood disorders (depression, anxiety)

-psychiatric disorders

-seizure disorders

-vision/hearing problems

-Tourette’s Syndrome

-cognitive and behavioral disorders

-sleep disorders

-thyroid issues

-substance abuse

-Brain injury

Case Reports/ Case Studies

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

¹National Institute of Health
²Mayo Clinic.
³The Center for International Rehabilitation Research Information and Exchange. University of Buffalo.   
⁴Centers for Disease Control and Prevention..
⁵Journal of Pediatric Psychology..

⁶American Academy of Pediatrics
⁷WebMD. 
⁸ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2011;128(5):1007-1022. doi:10.1542/peds.2011-2654. http://pediatrics.aappublications.org/content/128/5/1007
¹⁸Archer T, Kostrzewa RM. Physical Exercise Alleviates ADHD Symptoms: Regional Deficits and Development Trajectory. Neurotoxicity Research. 2011;21(2):195-209. doi:10.1007/s12640-011-9260-0.
¹⁹Verret C, Guay M-C, Berthiaume C, Gardiner P, Beliveau L. A Physical Activity Program Improves Behavior and Cognitive Functions in Children With ADHD: An Exploratory Study. Journal of Attention Disorders. 2010;16(1):71-80. doi:10.1177/1087054710379735.
²⁰Chou C-C, Huang C-J. Effects of an 8-week yoga program on sustained attention and discrimination function in children with attention deficit hyperactivity disorder. PeerJ. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5237364/. Published January 12, 2017. Accessed March 2017.
²¹Chinese Medical Journal.
²³ International Medical Journal of Experimental and Clinical Research.

²⁴Chen VC, Yang YH, Liao YT, et al. Medscape Log In. Medscape Log In. http://www.medscape.com/medline/abstract/28296941. Published 2017. Accessed March 2017.
²⁵Wiesner CD, Molzow I, Prehn-Kristensen A, Baving L. Sleep-Dependent Consolidation of Rewarded Behavior Is Diminished in Children with Attention Deficit Hyperactivity Disorder and a Comorbid Disorder of Social Behavior. Frontiers in Psychology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5296295/. Published February 8, 2017. Accessed March 2017.
²⁶Yang T-xiao, Allen RJ, Holmes J, Chan RCK. Impaired Memory for Instructions in Children with Attention-Deficit Hyperactivity Disorder Is Improved by Action at Presentation and Recall. Frontiers in Psychology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5258743/. Published January 24, 2017. Accessed March 2017.
²⁷Shin J-Y, Roughead EE, Park B-J, Pratt NL. Cardiovascular safety of methylphenidate among children and young people with attention-deficit/hyperactivity disorder (ADHD): nationwide self controlled case series study. The BMJ. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4887614/. Published May 31, 2016. Accessed March 2017.

Recent Related Research (from Pubmed)

Significant differences in hematologist parameters in terms of Vitamin D and Vitamin B12 in those who have been diagnosed with ADHD or ASD (Autism Spectrum Disorder). In ADHD group, negative correlation between both vitamins and mean platelet volume. Therefore, both ADHD and ASDs may accompany increased risk for cardiovascular disease due to presence of vitamin deficiencies.

Methylphenidate treatment exceeding 180 days or greater was linked to nearly 25% lower risk for fracture comparing to those who never received methylphenidate. Also, shorter duration of medicine treatment doesn’t mitigate the risk for fracture. Although the foregoing collection of observations suggests that psychostimulant prescription mitigates the risk for fracture, data wasn’t provided on whether they treatment duration further moderated risk reduction. The high lifetime prevelance and persistence of ADHD, as well as personal costs associated with fracture and other unintentional injuries, underscores the public health significance of this topic.

Sleep promotes the consolidation of declarative memory in healthy children but not in children with ADHD. Sleep seems to foster the consolidation of rewarded behavior in healthy children but not in children suffering from ADHD+CD/ODD (contact disorder; oppositional defiant disorder). Severely affected patients pose a great challenge for therapeutic and pedagogical interventions. Behavioral therapy using reward is the main approach in these patients. Therefore, the consolidation of behavior learned by reward is a topic of high clinical relevance. In conclusion, healthy children consolidate rewarded behavior better during. Night of sleep than during a day of awake. Sleep dependent consolidation of rewarded behavior is diminished in children with ADHD and doesn’t correlate with sleep. This helps explain why children suffering from ADHD often display impaired learning and memory and are at risk of school failure. Take into account poor sleep quality when treating children with ADHD and a comorbid disorder of social behavior. Sleep hygiene training might help to improve both sleep as well as social behavior in children with ADHD.

The classroom is a predominantly verbal environment, placing heavy demand on children to retain spoken or written instruction. Teacher demonstration may improve the retention of important information both for children with and without developmental difficulties. This provides a possible target for training and intervention.

Significantly increased overall risk of arrhythmia she associated with treatment with methylphenidate in children with ADHD. Risk of MI not significant overall; but, increased risk after the first week of treatment, remaining significantly raised for the first two months of continuous treatment.