Attention Deficit Hyperactivity Disorder (ADHD)

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• Attention Deficit Hyperactivity Disorder (ADHD)

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ADHDDefinition

• Attention Deficit Hyperactivity Disorder is a
  persistent pattern of inattention and/or
  hyperactivity that is more frequent and severe
  than is typically observed in individuals at a
  comparable level of development.
• DSM IV

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ADHD

Definition
Developmentally inappropriate degree of
3 core symptoms See criteria chart
in the school or home setting
(American Psychiatric Association)
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Etiology
Hypothesis

• Genetic Hypothesis
• Factors affecting brain development during
  prenatal early
• postnatal.
• Environmental factors
• Social disadvantages (Large family size over
  crowding)
• Catecholamine hypothesis (Dopamine deficiency)
• Experimental studies
• Abnormal dopamine turnover in CNS low dopamine
• concentration in CSF.
• Norepinephrine Serotonin hypothesis
• Stimulants increase the release of such neuro
  transmitters.

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Epidemiology
Incidence
One of the most common chronic conditions of
childhood
10 using DSM IV 4-12 among school aged
group

• Male
• Hyperactive type

Female inattentive type (academic under
achievement)
Male / female 31
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Etiology

• ADHD is primarily a genetic disorder
• Runs in families with different degrees of
• severity
• The role of environmental factors (e.g. dietary
  food additives and colorations)is unknown

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ADHDMedical Assessment

• There are no confirmatory lab tests
• Detailed History, comprehensive Physical Exam,
  functional neurodevelopmental assessment
• Rating scales e.g. DSM- IV checklist - Conners -
  CAAS)
• Use tests for both parents and teachers

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ADHDPhysical Exam

• Comprehensive Physical Exam
• General Observation of behavior and interactions
• Exam Growth parameters and plot on growth curves
• Vital signs to include blood pressure
• Vision and hearing screens
• Physical exam including neurologic exam

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ADHDDSM-IV

• ADHD-H ADD with predominant hyperactivity and
  impulsivity
• ADHD-I ADD with predominant inattentiveness
• ADHD-C ADD combined type with both
  hyperactivity and inattention

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ADHDDSM- IV

• In order to diagnose ADD, the clinician must
  also ascertain the following
• Onset before age 7 years
• Behaviors present for at least 6 months
• Functional impairment must be present in two or
  more settings
• The exclusion of pervasive developmental
  disorder, schizophrenia, mood and anxiety
  disorders, mental retardation, and learning
  disability

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ADHDComorbidities

• 45 of children with ADHD have at least one
  comorbid condition
• Common comorbid conditions include Obssessive
  compulsive disorder, oppositional defiant
  disorder, Anxiety, Learning Disability, Mood,
  Conduct, Smoking, Substance Use and Tics

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ADHDClinical Management

• Fit treatment to the patient
• Educate parents and patients regarding ADHD
• Discuss behavioral treatment
• Medication management
• Ensure educational support

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ADHD Primary goals of treatment

• Maximize function.
• Improve inter-relationships with parents,
  sib-lings, teachers, and peers
• Reduce mechanisms of ADHD.
• Improve ability to follow order.
• Decrease emotion over activity.
• Decrease disruptive behaviors

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Treatment

• 1. Drug based Approaches
• both stimulants (methylphenidate) and
  non-stimulants (atomoxetine) are used
• Given to improve overall behavior specially
  impulsivity and hyperactivity

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Treatment

• 2. Behavior Management
• The main emphases in parent training are on
  understanding the antecedents of undesirable
  behaviors, modifying the environment to alter
  those antecedents, and establishing positive
  incentives before using punishment.
• Emphasis on quality attention to positive
  behaviors.
• Teach appropriate use of time out and other
  disciplinary methods
• Enable parents to create an environment that
  maximizes the childs potential to behave
  appropriately

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Treatment

• 3. Educational Placement
• Modifications may include appropriate classroom
  placement, resource education, additional time
  for taking tests, not penalizing for misspelling
  or neatness, and additional instruction,
  including supplemental auditory learning and
  computer time

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Treatment

• 3. Dietary Management
• Removal of artificial colors, flavors and
  preservatives as well as naturally occurring
  salicylates.
• Use of megavitamins zinc antioxidants
• Treatment of iron deficiency

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Treatment

• 4. Neurofeedback
• A method used through training of brain waves to
  be modified to improve attention and
  concentration during playing games or reading or
  drawing or other cognitive tasks