ADHD, Executive Functions and PKU

Kevin M. Antshel, Ph.D.Associate Professor of Psychiatry / Licensed Psychologist

State University of New York – Upstate Medical University

Outline

• ADHD basics• Executive functioning• ADHD and PKU• Questions

ADHD

Is characterized by pervasive and often occurring…

Impairing inattentive symptoms

AND/OR

Impairing hyperactive / impulsive symptoms

Inattention symptoms

DSM-IV SYMPTOM Typical ADHDNo attention to details 6.0 69.5Can’t sustain attention 10.3 77.0Doesn’t listen 7.6 68.3No follow-through 5.0 77.7Disorganized 3.3 76.0Avoids sustained tasks 7.3 62.7Loses things 13.9 79.2Easily distracted 14.5 86.1Forgetful 5.3 68.1

Antshel et al., 2007

Hyperactive / Impulsive symptoms

DSM-IV SYMPTOM Typical ADHDFidgets 16.6 69.5Leaves seat 6.7 63.6Runs/Climbs 0.6 91.3Loud 1.9 46.8Driven by a motor 5.2 55.1Talks too much 19.7 63.6Blurts out answers 10.2 65.3Can’t wait turn 4.3 56.9Interrupts 16.7 80.1

Antshel et al., 2007

ADHD diagnosis

• Symptoms present before 7 years of age• Symptoms must be present in 2 or more settings (e.g., school, work, home)• Symptoms must have persisted for at least 6 months• The disturbance causes clinically significant impairment in functioning• Is not better accounted for by another disorder

ADHD “facts”

• Prevalence: 5 – 7 % • 2:1 – 9:1 male: female ratio• Co-occurs with multiple other psychiatric disorders• Strong heritability• 60+% continue to have ADHD as adults

Research-supported treatments

• Medications•Stimulants (e.g., Ritalin, Adderall, etc.) •Noradrenergic (Strattera)•Anti-hypertensives (e.g., Clonidine, Tenex)

• Parent Training in Child Management •Children (<11 yrs., 65-75% respond)•Adolescents (25-30% show reliable change)

• Teacher Training in Behavior Management

The Usual Questions…

Nigg, 2006

ADHD affects two primary brain areas

Toga et al., 2006

Executive Functions

• Planning• Organization• Self-Monitoring• Prioritizing• Goal-oriented, problem solving behavior

Low Dopamine Availability Links PKU and ADHD

Decision Tree for Diagnosing ADHD in PKU

Do ADHD symptoms dramatically lessen / become less impairing with better phenylalanine control?

Probably not ADHD – no real need for an evaluation

Decision Tree (cont’d)

Do ADHD symptoms lessen with tighter phenylalanine control yet continue to impair

functioning?

Could be worth considering an evaluation

Decision tree (cont’d)

Do impairing ADHD symptoms continue in the presence of historically and currently well-

treated PKU?

Should have an evaluation

Conclusions

• ADHD and PKU share neurochemical (dopamine), neurological (prefrontal, striatal) and psychological (executive function deficits) characteristics• To reliably diagnose ADHD, however, ADHD symptoms need to persist and impair functioning in the context of well-treated PKU