Sammendrag av forelesningsnotater av

Professor Christopher Gillberg

( A brief summary of Prof. Gillberg’s lecture)

ADHD – foreningens jubileumskonferanse i Oslo

23. – 24. september 2004

ADHD deles inn i to ulike begreper:

( ADHD is divided into two different concepts)

AD= attention deficit

HD= hyperactivity disorder

Minst seks av følgende ”tistander” må kunne påvises før diagnosen kan fastslås:

( At least six of the following “conditions” has to be proven before a diagnosis can be stated)

AD:

Ø     Fails to give close attention to daily careless mistakes

Ø     Difficulty sustaining attention

Ø     Does not seem to listen when spoken to

Ø     Does not follow through on instruction

Ø     Difficulty tasks requiring mental efforts

Ø     Loses things necessary for tasks

Ø     Easily distracted

Ø     Forgetful

HD:

    Fidgets with hands / squirms in seat

    Leaves seat

    Runs about or climbs excessively

    Difficulty doing things quietly

    Often on the go / driven by motor

    Often talks excessively

    Blurt out answers

    Difficulty await turn

    Interrupts or intrudes others

 ADHD:

 Ø     Overlap with cognitive problems

o       50% spiseforstyrrelser  (bulimia)

o       Stort forbruk av sigaretter (consuming a great number of cigarettes)

o       Autisme

o       65% or more have dyslexsia

o       Dyscalculia

o       Other learning disorder

o       Usually associated with 5 – 10 points IQ reduction

§        Low IQ “mistaken” for ADHD

o       Depressions

o       Even extreme IQ might cause cognitive problems!

 v    Neurophysiology

o       Executive function problems (achieve a goal, fulfil a plan etc.)

§        Mangler tidsoppfatning (rekkefølge av handlinger) (missing the time sight; ranking the number of actions)

o       Central coherence problems in DAMP

§        Ser ikke helheter eller detaljer i helheten

o       Prolonged reaction times

o       Commisions on CPT  (HD)

o       Commisions on ATP  (AD)

o       Relationship to non-verbal learning disability? Relation to autism spectrum

 ADHD:  Pathogenesis

 ü     ADHD usually familiar / hereditary (64 – 91% variance explained by genes), lowest for dimensional ADHD, highest for categorical ADHD.

ü     ADHD sometimes associated with pre- or prenatal adversity

o       (prematurity, FAS, smoking, fatal alcohol substance)

ü     Interaction gene-environment in many cases

ü     DAMP rather than often associated with pre- or prenatal adversity

ü     (prematurity, smoking, reduced optimality)

ü     Both ADHD and DAMP associated with low class

o       Social class can not explain ADHD / DAMP

ü     Dopamine transporters gene and dopamine D4 receptor gene variant in significant proportion of cases.

ü     Other developmental genes affected

ü     Dopamine function enhanced (brain damage) and learning increased when stimulant treatment combined with interesting (but not uninteresting) cases.

ü     Brain volume reduced

o       Overall, frontal, basal ganglia, cerebellum

ü     Brain growth affected by stimulant treatment???????

ü     Atomoxetine for one year leading to remission of ADHD in subgroup? Stimulants affective only if continued for several years.

ADHD work-up for optimal intervention:

    Correct and detailed diagnosis

o       Child examination

o       Parent examination

o       Questionnaires

    ADHD – work – up

o       Detailed statement very important,  coordination disorder

o       Possibly:

§        EEG- moderate increase of low frequencies, epileptogenic, paroxysmal activity on activation, sleep abnormity

§        DNA – and / or karetype

§        MRI – migration defects with matters lesions

§        OTHER: thyroid, neuromentabolic, neuromuscular

ADHD outcome:

Ø     ADHD has poor outcome in 40 – 60% of cases; unmedicated individuals appear to have higher rates of later drug abuse

Ø     Persistence of ADHD diagnosis into adult age in 50%, persistence of symptoms of ADHD in 90%.

Ø     Antisocial PD, other PD and psychiatric disorder, substance use disorder, academic failure, unemployment, accidents, criminality, anstisitc feature, early sick pension.

ADHD “costs”:

ü     Often chronic, 50% into adult age

ü     Considerable suffering for child, family

ü     Great early costs to society

ADHD interventions to faster optimal learning:

v    Psycho education first and foremost

v    Psychological support (including support groups, interests groups and parent organizations) and parent training but ineffective if mother has untreated ADHD- family approach!

v    Special education measures at school (dysexec syndrome)

o       Teacher training, small groups, coach

v     Working memory training

o       Use of computers, almost as good as central stimulus

o       Working memory

o       Self immage

v    Psychical exercise (in particular when DCD present)

v    Training in “real - life” settings. Long periods linked to a theme (subject)

v    Medication if other measures not sufficient

v    Sometimes financial support for family/respite care

Psycho education probably makes a positive difference:

ADHD medication:

Ø     Always consider medication if:

o       Extreme problems, combined AD/HD or severe DAMP

o       Severe variants of ADHD/ODD

o       In-patient, school removal, social authorities

o       When other interventions have proved ineffective for 3 - 6 months or longer

o       Central stimulants à easy to medicate; easy to remove, few side effects

·        Redusere bruken av: (reduction in use of)

·        Melk (milk)

·        Nøtter nuts)

·        Gluten (?????, ikke dokumentert)  (No documentation)

·        Sukker; ikke dokumentert (sugar, no documentation)

·        Noen fargeemner E-stoffer ( some E-marked paintadditive)

·        Coca – cola

·        Kaffe (Coffee)

·                         Lavt blodtrykk à ADHD? Ingen dokumentasjon

                                                               (Low blood pressure à ADHD? No documentation)

·                         Medisinering med sentralstimulià høgt blodtrykk

·                         Foreldre med ADHD + barn med ADHD à behandling til       alle parter

(If you have parents with ADHD + children with ADHD à treatment to all of them, not just one part)

·                         Røking under svangerskapet øker risikoen for at barnet kan få ADHD 2 – 4 ganger à tydeligst av alle funn!!!!

( Smoking during a pregnancy increase the risk of having a baby with ADHD 2 – 4 times à the most significant of all test results)

·                         Alle som jobber i fengsel må / bør få kunnskap om ADHD

(All persons who are working in a prison should have the knowledge of ADHD)

·                         Ved bruk av Stratera bør man ta en pause i medisineringen etter ca ett år

(If you use the medication STRATERA a break is recommended after one year)

·                         Sengevæting kan ha relevans til ADHD (arvelig)

(Bed-wetting might have a relevance to ADHD)