Phenomenology & Diagnostic Classification of ADHD Across
Life Span Prof. Fatima AlHaidar Professor & Consultant Child
& Adolescent Psychiatrist College of Medicine\ KSU
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ADHD is a lifespan condition that affects children,
adolescents, and adults of all ages.
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Definition: The official definition of ADHD describes the
essential features of the disorder as persistent pattern of
inattention, & /or hyperactivity impulsivity that is more
frequent & severe than typically observed in individuals at a
comparable level of development. These problems have to be chronic,
they must have existed before age of 7 years & they must be
pervasive; occurring in two or more settings.
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The Evolving Concepts of ADHD 100 years ago, the concept
started as a description of behavior. Before 1940s, children who
had difficulty in learning were described as: Mentally retarded,
emotionally disturbed, and socially & culturally disadvantaged.
In early 1940s minimal brain damage. In 1950s MBD had evolved: 1-
learning difficulty due to dysfunction in CNS. 2- Problems with
hyperactivity & distractibility 3- Emotional & family
problems due to 1 or 2. In 1968; hyperkinetic reaction of childhood
: overactivity, restlessness, distractibility & short attention
span ( DSM II )
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The Evolving Concepts of ADHD cont. In 1980s; attention deficit
disorder ADD ; ADD- H & ADD- WH ( DSM-III ). A residual
category for adult has been described; ADD-residual type. In 1987;
ADHD ( DSM-III-R ). In 1994, ADHD continues as a term but
distractibility had changed to inattention ( DSM-IV ). 3 subtypes
were described: 1- Mixed type. 2- Inattentive type. 3- Hyperactive-
impulsive type. In 2000, ADHD continues as a term with the 3
subtypes. Coding note: ADHD in partial remission; for adolescent
& adults who currently have symptoms that no longer meet full
criteria ( DSM-IV-TR ).
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Clinical Findings Suggestive of ADHD in Children Hyperactivity:
Clear Hyperactivity fidgety or squirmy behavior or something always
in motion. Hyperactivity appears to diminish in overt severity as
individual mature to adolescence and later adulthood.
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Impulsivity: Being unable / difficulty stopping before speaking
or acting. They know what to do, but they do not stop long enough
for that knowledge to influence their behavior. People evaluate
their action as purposeful, non-caring or oppositional when in
reality it reflects their immediate need for gratification &
inability to stop and think. Adolescents & adults realize the
problem but children do not.
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Inattention: This term is used interchangeably with
distractibility. External distractibility: - Auditory - Visual
Internal distractibility
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Difficulty with gratification: Not working well for long- term
rewards. Reinforcers do not change behavior in the long term.
Children with ADHD receive high rates of repeated negative
reinforcement. Behavioral intervention may manage immediate
behavior but do not produce long-term modification, sense of
responsibility or build independence.
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Other Aspects: Children with hyperactive-impulsive type
demonstrate more behavioral problems, conduct difficulty and mild
depression. Most children with hyperactive-impulsive type are
younger than those with inattentive type. Those with inattentive
type are described to be shy, withdrawn, with more academic and
learning problems, low academic motivation, weak self concept,
greater problem with depression. They used to be referred later
because of school performance, shyness and social difficulty. of
urban children with ADHD are reported to display symptoms of
inattention. of rural children with ADHD are reported to display
symptoms of behavioral and oppositional disturbance. Some of
children with initial diagnosis of hyperactive-impulsive type ended
later to have combined type.
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What is so difficult in making the diagnosis of ADHD?
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Inattention. Children, adolescents or adults might have
difficulty maintaining attention for many reasons. ADHD is but one
cause. 3 broad tasks are involved with attention: 1- The ability to
seek out what one wants to attend and focus on it. 2- The ability
to maintain ones focus. 3- Once the task is done, the ability to
stop attending and to move on to something else.
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The difficulty with (1) is avoidance The difficulty with (2) is
related to several themes. The difficulty with (3) is related to
many factors.. Not all individuals who are inattentive have
ADHD.
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Hyperactivity-Impulsivity. Anxiety ( cant sit still, pay
attention, irritability ) Depression ( restlessness, unable to stay
focus ) Learning Disability ( cant finish class work, difficulty
doing homework, appear not listening ) ADHD.. Not all individuals
who are hyperactive or impulsive have ADHD.
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The Official Diagnostic Criteria of ADHD The clinical history
is the only current means to finalize the proper diagnosis.
Information obtained from the individual, parents, teachers,
others, & previous medical and school records leads to the
diagnosis. The official guidelines used by health and mental
professionals to diagnose ADHD are found in DSM-IV-TR. These
guidelines reflect ICD-10-CM. No formal tests are available to
establish the diagnosis of ADHD, no physical, laboratory, or
neurological findings are associated with the disorder. However,
doing these examination and tests are important to exclude other
disorders.
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Formal instruments used in the diagnostic process 1- Rating
scales. These scales operationalize the DSM criteria. The Conners
series for parents and teachers rating scales are the most popular
ones. New rating sheets are being created all the time Some
professionals have their own sheets. 2- Computer-Based Tests CBT.
Several tests have been developed that use computer to assess the
individuals ability to pay sustained attention and whether there is
evidence of impulsivity 3- Internet Self-rating Scales There are
many Internet sites about AD/HD that offer various types of
questionnaires and lists of symptoms. These questionnaires are not
standardized or scientifically validated
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Developmental Course
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Developmental course 10% of infants & toddlers have history
of difficult childhood temperament. Preschoolers with ADHD might
present initially with speech & linguistic problems.75% of them
meet full criteria for ADHD on follow up. Majority of children with
ADHD achieve as well as the normal population in elementary school.
However, by later school years, the commutative effect of ADHD on
students ability to complete tasks hurts academic achievement.
During primary and secondary schools, children with ADHD are
described as daydreaming and disinterested in tasks leading to more
nonproductive activities which continue as adult poor performance
at workplace.
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Developmental Course cont. As children with ADHD become
adolescents they fall behind one or more years academically. they
have impairment in social competence and have more behavioral and
emotional adjustment difficulty. It has been suggested that many of
primary symptoms of ADHD diminished by adolescence. Now, it is
clear that the majority of children with ADHD continue to adulthood
experience some if not all symptoms consistent with ADHD. Children
with high impulsive behavior progress to more serious adulthood
behavior.
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Developmental Course cont. Concurrence of ADHD & other
family adversity ( depressed mother, alcoholic father ) increase
the risk of conduct disorder during childhood and adolescence and
later on antisocial behavior during adulthood. Deficient social
skills appear to be the most lasting & disabling co- morbid
aspects of adult ADHD. Presence of combined type of ADHD &
aggression in preadolescents, predict later risk for substance
abuse.
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Clinical Findings Suggestive of ADHD in Adolescents
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80% of children with ADHD continue to report symptoms of ADHD
during adolescence. They might present with self reporting
attention difficulty without overt behavioral problem. They were
described as day dreaming or not there. They might present with
poor self esteem or academic difficulty. internal distractibility
rather than external distractibility. impulsivity ( speech or acts
)
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Irresponsible behavior, annoying acts or overt aggression. They
receive more traffic citations. Delinquent behavior. 20% of
adolescents with ADHD has antisocial behavior. Those usually
continue to have ADHD as adults. substance abuse. 50% of
adolescents with ADHD continue to have ADHD as adults.
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Clinical Findings Suggestive of ADHD in Adults Mental health
professionals who work only with adults might not know to consider
this possibility. Therefore adults with ADHD might have difficulty
to find a professional to evaluate them. Some adults realize the
possibility of having ADHD when their child is diagnosed with ADHD;
Thats me ! For others, a newspaper or magazine article, a book, or
TV program might make them aware that there is a reason for the
problems they have had most of their lives.
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Prevalence. It is estimated that about 50% of adolescents with
ADHD will continue to have this possibility as adults. Current
estimate that 3%-6% of youth have ADHD. Therefore, 1.5%- 3% of
adults might have ADHD.
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Diagnosis. Diagnosis of ADHD in adulthood should include: 1. A
childhood history with evidence that the child met criteria for
DSM-IV-TR or ICD- 10. 2. Current ADHD symptoms with cutoff scores
of 4\ 9 of inattention & 5\9 of hyperactivity- impulsivity or (
at least total of 6 DSM-IV-TR symptoms ) for adults below 50 years
of age. For those older than 50 years old the sample is too small
to conclude. 3. Symptoms producing impairment in many area; job,
school, social acceptance, daily responsibilities, relationships,
marriage and emotional adjustment. 4. Other co-morbid problems are
understood and delineated. 5. Assessment conducted by a
well-trained person in the field
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Diagnosis cont. Many scales & questionnaires have been
developed to aid the diagnosis: BAAD= Brown Attention Activation
Disorder scale Wender Adult Questionnaire Conners Adult
Questionnaire.
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Relationship Between Childhood ADHD and Adulthood ADHD About
1/2 of adults with ADHD had ADHD as children. Those who have ADHD
as children have worse adult picture of ADHD. Adults with ADHD who
are not identified in childhood as ADHD have milder problems and
less areas of dysfunction. Some people usually come asking for help
for mood, anxiety or problems at work, marital or interpersonal
problems and sometimes, they come at the request of spouse. At that
time the diagnosis of ADHD is established. The first degree
relatives of children with ADHD have high rates of ADHD and
antisocial problems.
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Major Complaints of Adults Seeking Assessment for ADHD 1.
Difficulty sustaining attention. 2. Difficulty concentrating.
3.Forgetfulness. 4. Feelings of poor memory. 5. Reporting of
difficulty thinking clearly. 6. Low frustration threshold 7.
Impulsiveness. 8. Restlessness. 9. Intolerance of boredom. 10.
Worry excessively. 11. Feeling of depression.
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Major Complaints of Adults Seeking Assessment for ADHD 12. poor
self esteem. 13. Poor self disciplines. 14. Lack of organization.
15. Difficulty establishing & maintaining rules. 16. Strong
feeling of underachievement. 17. Crave stimulation. 18. Impairment
of social & occupational functioning. 19.Difficulty locating
& maintaining vocation. 20. Performing below level of
competence vocationally. 21. Significantly more accidents. 22.
Significantly more geographical move. 23. More court
referrals.
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ADHD Behaviors in Adults. Hyperactivity: Seeking certain types
of job. Difficulty to sit for long time to finish tasks. Start with
marriage/ having children. Noticed with work promotion.
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Inattention: The main problem is with internal distractibility.
Career demands, marriage and children demands increase this
problem.
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Impulsivity: Like children & adolescents, Adults might
speak or act before thinking. The difference is that adults are
aware of the problem & concentrate on controlling. Stealing,
gambling, laying and poor driving are reported more with them. They
have more traffic accidents and more traffic tickets.
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Organizational Problems: Organization means the ability to
organize pieces of information together into concept, or the
ability to break concept into its parts. The ability to organize
ones thoughts, materials & time is included as well. Therefore,
these problems might relate to organization of time, schedules,
material at home or work. Their life is one big organizational
problem. Possible reasons for that might include: 1. Result of
inattention & distractibility. 2. Result of learning disability
& executive function... intervention should be related to
reason.
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Problems Related to ADHD in Adults 1. Less formal schooling. 2.
90% employed but their jobs were of lower occupational ranking. 3.
20%- 30% of adults with ADHD have of co-morbid substance abuse;
particularly alcohol and cocaine. 4. High rates of personality
disorders & mood disorders. 5. Higher rates of stuttering,
enuresis, speech & language disorder. 6. Only 28% have no other
psychiatric disorders. 7. More traffic accidents. 8. More marital,
family and interpersonal problems.
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ADHD is a lifespan condition that affects children,
adolescents, and adults of all ages. ?