Transcript Attention Deficit Hyperactivity Disorder: anxiety phenomena in

Attention Deficit/
Hyperactivity Disorder
Dr. Ernest S L Luk
Adjunct Professor
Department of Psychiatry
The Chinese University of Hong Kong
Attention Deficit, Hyperactivity &
Impulsiveness (AHI)
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AHI is a pattern of cognitive and behavioural deviation
from the norm
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Genetic factors are strong
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AHI presents with a behavioural style of overactivity,
inattention and impulsiveness
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Inattention or hyperactivity/impulsiveness may present on
its’ own
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AHI is usually recognisable in the pre-school period
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A diagnosis of ADHD requires the criterion of impairment
to the development of the child
The Concept of Attention Deficit/Hyperactivity
Disorder
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Inattention behaviour
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Hyperactivity (overactivity)
3.
Impulsive behaviour
Must be maladaptive and inconsistent with developmental level
Persistent for at least six months
Onset no later than seven years old
Does not occur exclusively during the course of a Pervasive
Developmental disorder, Schizophrenia or other psychotic disorder
Not better accounted for by a Mood Disorder or Anxiety Disorder
Pervasive
The disturbance causes clinically significant distress or impairment
in social, academic, or occupational functioning
Prevalence
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ADHD in school aged children
(DSM III, IIIR, IV Manual)
3 - 5% (6% boys, 2% girls).
2.
Hyperkinetic disorder in school
boys according to ICD 10.
1.7% in UK
(Taylor, et al., 1991)
1.3% in Sweden (Gill berg, et al., 1983)
0.78% in HK
(Leung, et al., 1996)
Biological Basis of AD/HD
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Genetic studies: familial, adoption, twin,
association, linkage and candidate gene studies
 Imaging studies:
– Structural: whole brain, particularly prefrontal, basal
ganglia and cerebella
– Functional: hypofrontality, compensatory pattern
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Neuropsychological functions
– Executive functions (planning, organization), working
memory and inhibition (delay reward)
From gene to behaviour
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Multiple genes are involved
 Neuro-biological mechanisms: frontal striatal, cerebral
thalamic cerebellar circuit
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Neuropsychological mechanisms: inhibition, working
memory, executive function
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Functional impairments: overactive, impulsive, inattentive,
motor coordination, learning problems
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Psychosocial aspects: parent child interaction, cognitiveemotional factors
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Behavioural pattern: inattentive / hyperactive impulsive
Causes of ADHD
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Heritability: 75%
 Genes with small effect:
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DRD4 (Dopamine 4 receptor)
DRD5 (Dopamine 5 receptor)
SLC6A3 (Dopamine Transporter)
DBH (Dopamine Beta-hyproxylase
SNAP25 (synaptic vesicle transport and release)
SLC6A4 (serotonin transporter gene)
HTR1B (serotonin 1B receptor)
Environmental risk factors: pregnancy exposure
and complications, family conflict
Differential Diagnosis of
Disruptive Behaviour
1.
Age appropriate
phenomenon
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Difficult Temperament
3.
Conduct Problems/
Disorder
7. Anxiety State/Disorder
8. Pervasive Developmental
Disorders
9. Organic Brain Syndrome
10. Multiple Tics
4.
ADHD/Hyperkinetic
Syndrome
5.
Learning Disabilities
6.
Mood Problems/Disorder
11. Psychosis
12. Consequence of Deprivation
or Abuse
Diagnosis
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Good history from the parents
Information from teachers
Observation data
No biological test that can replace the above.
Common co-existing
conditions
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Specific Learning Disorder
Oppositional Defiant Disorder/Conduct Disorder
High Anxiety
High aggression
Symptoms of Pervasive Developmental Disorder
Attachment disorder
High Intelligent
Tics
Other organic conditions
Untreated AD/HD
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Initial effects
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Learning problem
Parental frustration
Sibling frustration
Family frustration
Teacher frustration
Classmates’ frustration
The child has repeated negative experience
Untreated AD/HD
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By around the age of 8
– School complain leading to rejection
– Parent child relationship problem
– Sibling rivalry problem
– Underachievement
– Increasing Oppositional Defiant Behaviour
– Low self esteem problem
– At risk for conduct problems, conduct disorder and
personality disorder
Untreated AD/HD
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Later childhood presentation
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Severe Oppositional Behaviour
Severe learning problem
Aggressive behaviour
Emotional problem
Adolescence presentation
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ODD/CD
Education failure
Depression
Substance Abuse
Risk taking behaviour
ADHD continues into adulthood
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Up to 60% of people with childhood AD/HD continue to
have significant symptoms in adulthood
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The behavioural symptoms will change: overactivity will
subside; inattention persists in the form of
disorganisation and inability to concentrate when facing
a demanding task; poor impulse control occurs when
they are frustrated
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May present with anxiety, depression, substance
abuse/dependence, aggressive behaviour, parental and
marital problem
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Short term benefits from psycho-stimulants have been
established
Management of AD/HD
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Psycho-education
Understanding the child’s emotion, thinking and development
Parents support / parenting training
Drug treatment
Behavioural management at home and outside home
Intervention at school level
Skills training in language, reading and motor skills
Individual work with the child
Family work
Group work
Community treatment
Long term monitoring and support
Monitoring of medication
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Half-hour monthly medication maintenance
visits
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Support, encouragement and practical advice
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Identify coexisting conditions
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Assess and address developmental issues
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Address parenting issues
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Provide reading material
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Adjustment of medication
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Monitoring should be long term
Psycho-education and parents
support
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Explanation
Reading material
Support group
Parent management training
Advocate
Disability Allowance
Respite
Some parents have ADHD and need help
themselves
Conclusion
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AD/HD is a developmental neuropsychiatric
disorder which is not confined to childhood.
 It is a handicap that is often unrecognised.
 Early detection is important.
 Treatment can reduce its impairment.
 Management should be multi-modal,
coordinated and long term.
 Collaboration of services is essential.