ATTENTION –DEFICIT HYPER ACTIVITY DISORDER

DR.A.GODSONMD - PSYCHIATRY

What is ADHD? A pattern of diminished sustained attention

and high impulsivity in child or adolescent than expected for someone of that age and developmental level

Three types: Combined Type, Predominantly Inattentive Type, and Predominantly Hyperactive-Impulsive Type.

ADHD-STATISTICS: 5-10% of the entire U.S. population Males are 3 to 6 times more likely

than females. At least 50% of ADHD sufferers

have another diagnosable mental disorder.

3-5% of all school-age children are estimated to have this disorder

First degree biological relatives are at high risk

Parents shows increased incidence of –hyperkinesis,sociopathy,alcohol abuse,conversion disorder

Symptoms often present by 3 years,but diagnosis made only at school setting

Minimal Brain Dysfunction

Minimal Brain Damage

Hyperkinetic Reaction of Childhood (DSM-II)

Attention Deficit Disorder + or - Hyperactivity (DSM-III)

Attention Deficit Hyperactivity Disorder (DSM-III-R)

19601960 1980198019681968 19871987 19941994

Attention Deficit/Hyperactivity Disorder (DSM-IV)Attention Deficit/Hyperactivity Disorder (DSM-IV)

19301930

ADHD-TIME LINE:

ADHD-likesyndromefirst described

19021902

Etiology--? Prenatal toxic exposure Mechanical insults to

CNS Prematurity Food aditives,

colorings,preservatives But ………….no

scientific evidences

CAUSES OF ADHD:

CNSinsults

Geneticorigins

Neuroanatomicalneurochemical

ADHD

Environmentalfactors

Genetic factors

Twin studies-great concordance in monozygotic twins

Two times risk in siblings Adoption studies-higher incidence in

biological parents than adoptive parents

Developmental factors

Winter infections during first trimester

Subtle damage to CNS during

development

High rate of soft neurological signs

Neurochemical factors Peripheral nor-

adrenergic system dysfunction

Possible dopamine system dysfunction

Both evidenced by effect of stimulant drugs in improving symptoms

Psycho-social factors Prolonged emotional

deprivation Stressful psychic

events Family disequilibrium Demands from

society Childs temperement

Diagnosis-assessment History, History, and History, History, and more History!! History!! School historySchool history Teachers reportsTeachers reports Academic performanceAcademic performance Clinic based psychological tests Individually administered intelligence tests Pediatric exam to check for an alternate

disorder

DSM-IV-TR CRITERIAInattention pervasive and persistent for more than 6

months At least 6 symptoms in the listHyperactivity-impulsivity pervasive and persistent for more than 6

months At least 6 symptoms in the list

Some symptoms onset before 7 years Some symptoms should present in two

settings Social ,occupational ,academic function

impairment Symptoms not better accounted for

pervasive developmental disorder, schizophrenia , any other mental disorder

Inattention Often has difficulty

sustaining attention in tasks

Often fails to give close attention to details/ makes mistakes in schoolwork, work, and other activities

Often does not seem to listen when spoken to directly

Inattention Often does not follow

through on instructions and fails to finish schoolwork, chores or duties in work

Often has difficulty organizing tasks and activities

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

Often loses things necessary for tasks or activities

Often easily distracted by extraneous stimuli

Often forgetful in daily activities

Hyperactivity Often leaves seat in

class/ situation where staying seated is expected

Often fidgets with hands or feet or squirms in seat

Often runs about/climbs excessively in situations where it is inappropriate

Often has difficulty playing/engaging in leisure activities quietly

Cont.. Often on the go or

acts as if driven by a motor

Talks excessively

Impulsivity Often blurts out

answers before questions have been completed

Often has difficulty waiting to take turns

Often interrupts or intrudes on others

Differential diagnosis Sensory impairment. Epilepsy and related states-TLE Effects of head injury Acute or chronic medical Illness Poor nutrition. Sleep disorders. Side effects of medication

Psychiatric conditions Autism Spectrum Disorder Obsessive Compulsive Disorder Tic Disorders Conduct Disorders Attachment disorders. Depression and emotional disorders. Anxiety disorder Psychosis

Course and prognosis Persistent symptoms at

adult/adolescent age-50% Remission at puberty/early

adulthood-50% Remission unlikely before-12 years Over activity-first to remit Distractibility-last to remit

Course of partial or non remittance in adolescent life Antisocial behavior Conduct disorder Substance abuse disorder Mood disorder Social difficulties Learning difficulties

Pharmacotherapy First line treatment Stimulants are first choice-

methylphenidate, amphetamine preparations

Second line agents-Atomoxetine, bupropion, venlafaxine, clonidine

Methylphenidate Dopamine agonist Dexmethylphenidate –maximum effect,

minimal side effect 0.3-1 mg/kg tid, upto 60 mg/day Sustained release preparations allowed

once daily dose, less rebound effects FDA recommendation-should use in

children >6 years

Side effects Head ache GI upset Insomnia Exacerbate tic

disorder Growth suppression

Amphetamine preparations

Second choice when methylphenidate not useful

FDA recommend for child >3 years 0.15-0.5 mg/kg bd, upto 40 mg/day Once daily sustained release useful

Non stimulants-Atomoxetine

Nor-epinephrine reuptake inhibitor FDA-use in 6 years and above Effective for inattention and impulsivity 0.5-1.8 mg/kg bd dose,upto 40-80

mg/day Side effects-decreased

appetite ,dizziness, irritability, increase in BP & HR

others Bupropion – beware of seizure Clonidine - useful in pts with tic

disorder Modafinil – once daily,useful in

adolescents Reboxetine – used in methylphenidate

resistant cases

Psychosocial intervention Teacher’s attitude MUST

be positive, upbeat, flexible

praise liberally Provide more direct

instruction and as much one-on-one instruction as possible

Lecture less Challenge but don't

overwhelm

Design tasks of low to moderate frustration levels

Pair the student with a exemplary student

frequent communication between home and school

Provide frequent feedback Provide frequent and

regularly scheduled breaks Teach conflict resolution

and peer mediation skills

Adult manifestation of ADHD

Prevalence- 4% Difficult to diagnose – lack of school

and observer information SPECT - Increases dopamine

transporter binding sites in striatum Premature birth , maternal use of

nicotine, increased serum lead

Diagnosis-utah criteria Retrospective

childhood diagnosis of ADHD

At least 3 of following Inattentiveness Hyperactivity Mood lability Irritability, hot ember Low stress tolerance Disorganization impulsivity

DD – hypomania , anxiety disorder Treatment – similar to childhood

ADHD Therapy needed indefinitely

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