Transcript Attention Deficit Hyperactive Disorder

Attention Deficit Hyperactive
Disorder
Monica Arora M.D.
Attention Deficit Hyperactive Disorder
ADHD is a neurobehavioral syndrome that is
characterized by developmentally inappropriate
degrees of inattentiveness, impulsivity and
hyperactivity.
History:
End of 19th century and early 20th century-
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morbid defect of moral control (Still 1902)
Post WW-I – organic nature of the ADHD was
postulated
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Influenza epidemic encephalitis lethargica  survivor children
exhibited similar symptoms as described by Still.
“Minimal Brain Syndrome” – 1950’s (Clements and
Peter)
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Damage to the central nervous system was considered to be minimal that
only manifestations were behavioral in nature.
History:
Hyper kinetic syndrome of childhood”- DSM- II (APA
1968)
 “ Attention deficit disorder with or without
hyperactivity”DSM- III (APA 1980).
 “ Attention Deficit Hyperactive Disorder”- DSM-III-R
(1987).
8/14 symptoms required for diagnosis.
 “Attention Deficit Hyperactive Disorder”- DSM-IV
(1994)- inattentive, hyperactive- impulsive,
combined.

Epidemiology:
Prevalence - 5-7% (1.7-17.8%)
 Gender difference- 2-3: 1 (community based samples)
 Most common in first-born males.
 Manifest in children, usually by the age 3.
 Most common diagnosis in children 4-11yrs of age.
 ADHD – related outpatient visits to primary care
increased from 1.6 to 4.2 million per year during
the years 1990-1993.
 There has been a five-fold increase in the number of
adults diagnosed with ADHD in the past 5 years.

Etiology:
1) Genetics:
Twin studies:
Hereditability of 0.75 ,Concordance rate MZ >DZ.
Family studies: 2-3 fold increase in 1st degree relatives.
ASPD, drug and alcohol abusing parents are significantly
higher in children with ADHD with or without
conduct d/o.
Molecular genetic studies: Implicate dopamine
transporters (DAT1) gene and the D4 receptor gene
(DRD4) in association with ADHD
Etiology:
2) Neurochemical: Dysfunction of the adrenergic and
dopaminergic systems.
3) Imaging: PET scan show
Decreased cerebral blood flow
Moderate reduction (~10%) in the size of
the BG, corpus callosum and frontal lobes.
4) Psychosocial:
Stressful psychic events and emotional
deprivation.
Diagnosis:
Diagnosis is clinical, based upon detailed
developmental and symptomatic history.
Several informants are required.
DSM IV Criteria
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6 (or more)/9 of the symptoms of inattention or
hyperactivity-impulsivity have persisted for at least
6 months to a degree that is maladaptive and
inconsistent with developmental level.
Present before age 7 years.
Impairment in two or more settings
Significant impairment in social, academic, or
occupational functioning.
Not better accounted for by another mental disorder.
DSM IV Criteria
Inattention
(a) Often fail to give close attention to details or makes
careless mistakes in school work, work, or other
activities.
(b) Often has difficulty in sustaining attention in task or
play activities.
(c) Often does not seem to listen when spoken to
directly.
(d) Often does not follow through with instructions and
fails to finish schoolwork, chores or duties in the
workplace.
DSM IV Criteria
(e) Often has difficulty organizing tasks and activities
(f) Often avoids, dislikes or is reluctant to engage in
tasks that require sustained mental efforts
(schoolwork or homework)
(g) Often looses things necessary for task or activities
(toys, books, pencils, school assignments or tools)
(h) Is often easily distracted by extraneous stimuli
(i) Is often forgetful in daily activities
DSM IV Criteria
Hyperactivity:
(a) Often fidgets with hands or feet or squirms in seat
(b) Often leave seat in classroom
(c) Often runs about or climbs excessively in situations
in which
it is inappropriate
(d) Often has difficulty playing or engaging in leisure
activities quietly
(e) Is often “on the go” or often acts as if “driven by a
motor”.
(f) Often talks excessively
DSM IV Criteria
Impulsivity:
(a) Often blurts out answers before questions
have been completed
(b) Often has difficulty awaiting turns
(c) Often interrupts or intrudes on others (e.g.,
butts into conversations or games)
DSM IV Criteria
TYPES:
 ADHD-combined type: if criteria A1 and A2 are met
for the past 6 months
 ADHD, predominantly inattentive type: if criteria A1
is met for the past 6 months
 ADHD, predominantly hyperactive-impulsive type:
if criteria A2 are met for the past 6 months.
Characteristics
Context specific variability in symptom expression is
typical of the disorder.
 Symptoms are more likely to appear when
stimulus salience is low, as doing math
homework, than when stimulus salience is
high, as playing Nintendo.
 Children with symptoms most often show up in
the situations that demand sustained attention,
are repetitive, boring, and are hard.
Characteristics
Children with ADHD symptoms do better in
high structured settings or with one to
one attention by an adult.
All symptoms are normal to the certain extent at
certain ages. - Avoid misdiagnosis
 High co morbidity
66% of elementary school aged children
have at least one co morbid psychiatric
diagnosis.
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P
R
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S
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N
T
A
T
I
O
N
Preschool
Middle
Childhood
Inattentive
Excitable
Unduly sensitive to
stimuli
Hyperactive
(Running all the time,
climbing on things)
Fidgety
Spills things
Insatiable curiosity
Destructive play
Noisy
Interrupts
Aggressive
Stubborn
Temper tantrums
Accidents
Distractible
Difficulty sitting still
in the chair
Poorly Organized
Fails to complete
Careless errors
Disruptive in class
Bored all the time
Difficulty getting
along
Interrupts or intrudes
Cannot wait turns
Engage in physically
dangerous activities
School
underachievement
Unwilling or inability
to complete house
hold chores
Adolescence
Day dream
Poorly Organized
Sense of Restless
Poor follow
through
Require directions
Forgetful
Risky behavior
Low self esteem
School
underachievement
Poor peer
relationships.
Adult
Disorganization –
failure to plan
ahead
Poor concentration
Incomplete work
Forgetful
Procrastinates
Impulsive
Affective
dysregulation
Anxious
Substance abuse
Antisocial
behavior
Job instability and
marital conflicts
Poor anger control
Co-morbidity:
66% of elementary school aged children have at least
one co morbid psychiatric diagnosis.
ODD/ conduct d/o ~ 50%
Major depression ~ 9-38%
Anxiety disorders ~ 25%
Learning disorders ~ 20-30%
Bipolar Disorder ~ 6%
Tourette Syndrome ~ 2%
Course and Prognosis:
A. Persistence into Adolescence/ adulthood:
80% will continue to exhibit symptoms in
adolescence and young adulthood.
50-60% display behavior problems and
symptoms of the disorder well in to the adult
life.
B. Functional impairment across multiple settings
Pattern of academic, familial and social
dysfunction
Course and Prognosis:
C. Adolescents – When untreated are more prone to be
Involved in auto accidents
Be cited for traffic violation
Use illicit drugs (32% vs. 14%)
D. Adults with persistent symptoms often complete
less formal education, lower status jobs, high
rates of ASPD
Course and Prognosis:
With growing age, hyperactivity is replaced by
restlessness, physical impulsivity often replaced by
verbal impulsivity. In contrast to hyperactivity,
symptoms of inattention often don’t diminish over time.
Predictors for persistence into adolescence and
adulthood include
1. Family history of ADHD
2. Psychosocial adversity
3. Co morbid disorders like CD, ODD,
mood disorders and anxiety disorders.
Components of diagnostic
evaluation
Prior to office visit, review information gathered from
the following:

Parent rating scales sent to parent/guardians
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Teacher rating scales sent to school via
parent/guardians (including instructions). Try to
obtain from at least two teachers.
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Report cards and report of standardized intelligence
tests if available
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Previous medical and psychiatric history, reports of
hearing and vision tests.
Components of diagnostic
evaluation
During the office visit:
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Clinical interview
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Use of behavior rating scales
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Physical examination- Height, weight, blood
pressure, Neurological examination, Vision and
hearing screen
Additional assessment tools
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Psychological tests
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Neuropsychological testing
Psychosocial treatment
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Parent education and training
Social Skill therapy
School Interventions
Classroom Interventions
Daily Report Cards
Academic Skills
Pharmacological treatment
Stimulants
Mixed salt Amphetamine (Adderall, Adderall SR)
Dextroamphetamine (Dexedrine, Dexedrine
spansule)
Methylphenidate (Ritalin, Ritalin SR, Concerta,
Metadate)
Methamphetamine (Desoxyn)
Pemoline (Cylert)
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Stimulants-Time Action Profile
Short acting stimulants (3-4 hrs)
Methylphenidate- Ritalin
Dextroamphetamine- Dexedrine
 Mid range stimulants (5-7 hrs)
Mixed salt amphetamine- Adderall
 Longer acting stimulant (6-8 hrs)
Methylphenidate- Ritalin SR, Metadate
Dextroamphetamine- Dexedrine SR
 Long acting stimulant (12 hrs)
Methylphenidate- Concerta
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Non stimulants
AntidepressantsTricyclic antidepressants
Bupropion
Venlafaxine
 Alpha 2 agonistsClonidine
Guanfacine
Atomoxetine
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Resources:
CHADD
Children and Adults with Attention Deficit
Disorder
-http://www.chadd.orgNational ADDA
National Attention Deficit Disorder Organization
-http://add.comLearning Disability Disorder of America
-http://idanatl.org-