Attention Deficit Hyperactivity Disorder

Dr Arya Jith

Contents• Introduction• Etiology• Description of the disorder• Differential Diagnosis and

comorbidities• Treatment• Adult ADHD

Introduction • Also called as attention deficit

disorder• Affect 3-5 % of school age

population• Boys out number girls-3:1

Myths

AetiologyGenetics- If u have a…. Your risk for having

ADHD is..Parent with ADHD More than 50%

Brother or sister with ADHD 41%

Child with ADHD 21%

Identical twin with ADHD 80%

Aetiology……Molecular Genetic Studies- Thyroid receptor B gene-Not a major

cause Dopamine Type 2 receptor

gene(DRD2) Dopamine Transport Gene(DAT1) Dopamine 4 Receptor Gene(DRD4)

Aetiology…Neuroanatomy-Decreased cerebellar

volume.

Aetiology……Neurotransmitters – Dopamine System-very important Noradrenergic System Serotonin system-weak association

AetiologyHigh exposure to lead, heavy metalsNutritional deficiency-zinc, iron, omega

3 fatty acidMaternal smokingPregnancy and delivery complications

Diagnosis

Based on DSM 4 criteriaCriteria A----Inattention Criteria B-----Hyperactivity-Impulsivity

Fails to give close attention to detailsDifficulty sustaining attention in tasksDoes not seem to listen when spoken to directlyOften does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplaceOften has difficulty organizing tasks and activitiesOften loses things necessary for tasks or activitiesIs often easily distractedOften forgetful in daily activities

Hyperactivity -often fidgets with hands or feet or squirms in seat -often leaves seat in classroom or in other situations in which remaining seated is expected -often runs about or climbs excessively -often has difficulty playing or engaging in leisure activities -often is “on the go” or as if “driven by a motor” -talks excessivelyImpulsivity -often blurts out answers before questions are completed -has difficulty awaiting turn -interrupts or intrudes on others

Diagnostic criteria• A: Six or more of the previously noted

symptoms persisting for 6 months or longer qualifies for a diagnosis of ADHD in either the inattentive category or hyperactivity-impulsive category. If both inattentive and hyperactive-impulsive symptoms are present then a combined type diagnosis is given.

B: One of the symptoms needs to have been present before the age of 7.

C: Some impairment from the symptoms is present in two or more settings, such as school or home.D: There must be clear and significant evidence of a social, academic, or occupational impairmentE: The symptoms are not better accounted for by another mental disorder

Based on these criteria-3 types of ADHD are identified

COMBINED TYPE-if criteria for bothA and B are present for 6 months

Hyperactive RestlessnessDisorganizedInattentionimpulsivity

Diagnosis

• 2. Predominantly Inattentive Type: if criterion A is met but criterion B is not met for the past six months- Inattentive,– sluggish, – slow-moving, – unmotivated,– daydreamer

3. Predominantly Hyperactive-Impulsive Type: if Criterion B is met but Criterion A is not met for the past six months.

over focused, obsessive, argumentative

Organic disorders-Sensory disorders Medication induced attention deficit seizure disorder Thyroid abnormality Learning Disability Frontal lobe –abscess/neoplasm substance abuse Lead intoxication

Differential Diagnosis

Functional disorders-Oppositional DisorderConduct DisorderMood DisorderAnxiety DisorderBipolar disorderPersonality disorder

Differential Diagnosis

Developmental Disorder-Age appropriate over activity

Situation-Inappropriate school placement

Family and social disruption Abuse or neglect

Differential Diagnosis

ADHD and comorbid oppositional defiant disorder coexist in 30 -40 percent of ADHD patients

Children with ADHD and conduct disorder have more severe ADHD symptoms, higher aggresion, anxiety,peer rejection .

Extensive family historyF/h of psychiatric disordersLevel of parental stress Psychosocial adversityAntisocial behaviour,substance use

and internalizing disorders

Clinical Assessment

Complete pre natal perinatal post natal developmental history of accident, head trauma , eye

and ear infection

Medical Evaluation

Regarding behaviour Learning attendenceSocial functioning-both from teacher

and parents

School Related assessment

Structured interview-P ,C

Diagnostic Interview schedule for children(DISC 3.0) rating scale-P,C

Strength and Difficulty Questionnaire

Childs behaviour check list-CBCL- P,T

Screening

Conners rating scaleAttention deficit disorder evaluation

scale(ADDES)Behavioural Assessment for children

(BASC)- teacher,Parent and childSKAMP –classroom behaviourCLAM-conners loney milch scale

Rating scales

Conners Rating scale

Treatment

Dextro amphetamine and Methylphenidate-

Improve impulsivityinattention

Stimulants

MOA-Increases nor epinephrine and dopamine actions and will improve attention, concentration, executive function

Dosage-5-40mg/day in divided dosesfor immediate release tablets and once

daily morning dose for extended release

(5mg,10mg,15mg,30mg)

Stimulants

Is a mixture of d amphetamine and l amphetamine salts in the ratio of 3:1

Controlled release should not be chewedBut swallowedNo lunch time dosingHalf life-9 and 11 hours

MOA-Increases nor epinephrine and dopamine reuptake

Dosage-ADHD-2mg/kg/day in children above 6 years

Maximum dose-60mg/day

Methyl Phenidate

-immediate release tablet of methyl phenidate(5mg,10mg,20mg)

-refined form of Ritalin isolating only effective D isomer 3times more potent,less toxic-

-oral osmotic release system Methyl phenidate preperation

Tic disorderSeizure DisorderAggression and conduct disorderAnxiety disorderMood DisorderDevelopmental disorder-MR,autism

Stimulants-in other comorbidities

Stimulants-side effectsInsomnia, Headache, Exacerbation of

tics, nervousness, irritability, anorexia, dry mouth, diarrhea ,constipation

Can temporarily slow normal growth in children-Drug holiday in summer

Rebound- deterioration occurs in late afternoon or evening after day time administration of stimulant medication

Also produce choreiform movements, lip licking, lip biting

Rare-Toxic psychosis-with tactile delusions, thought disorganization, pressured speech, marked anxiety

ATOMOXETINE HCL:-Norepinephrine reuptake inhibitorWell absorbed.Minimally affected by food.Maximum plasma conc-1-2 hours after

ingestion.

Non stimulant medication

Side effects-abdominal discomfort, decreased appetite, dizziness, vertigo irritability and mood swings

Metabolized by cyp450 enzymeDOSAGE-0.5-1.2mg/kgper day inchildren

Imipramine,Nortryptiline,Amitryptiline have been found to be effective in ADHD patients

Lower dosages are required when compared to depression

TID dosageCI- cardiac conduction problem

Tricyclic Antidepressants

Side effects-Fatigue and sedationCVS S/E-Slowing of cardiac conduction

problems,thus increasing PR and QRS intervals and thus increase the risk of cardiac arrythmia and thus heart block

BASELINE ECG SUGGESTED BEFORE STARTING MEDICATION

Non TCA anti depressantsLess effective than TCA or stimulants75 mg twice a dayMedication can be increased to

maximum of 200mg to 300mg per dayS/e- fatigue dry mouth insomnia

headacheN,V,C tremor and skin rash

BUPROPION

Clonidine and GuanfacineEffective in children with ADHDDecrease impulsivity and hyperactivityStart at 0.025mgS/E-Daytime Sedation- stop the drugBP and pulse should be monitored

Alpha Adrenergic Antagonists

Watch For Rebound adrenergic Over drive

CI-pre existing cardiac and vascular disease

Guanfacine is slightly less seadating than clonidine

PsychoeducationAcademic Organizational Skills and

RemediationParent training in Behavior therapyFamily therapyCBTIndividual Psychotherapy

Psychosocial Treatment of children

Refers to educating the child and family about ADHD

Intervention in school designed to improve school behaviour, academic productivity and achievement

Psychoeducation

ADHD children will have comorbid learning disability.

Education designed to assist students in order to achieve expected competencies in core academic skills.

Remedial Tutoring

Teaches the parent how to implement a Contingency management behavioral

programmeParent group –small(<8)Training session held weekly -8-20

weeksMore effective in younger(preschoolers)

Parent Training in Behavior therapy

ADHD is frequently associated with family conflicts

Barkley: Structured family therapy Communication Training Problem solving trainingNot much improvement in adolescents.

Family Therapy

Programs were designed to teach children about problem solving, dealing with anger and frustration ,persistence and social skills

It was not successful

Cognitive Behavioural Therapy

Poor social functioning12 weekly sessions-conversational

skillsGroup entry, handling, teasing

rejection ,praising othersParents were taught coaching

strategies

Social Skill Training

Good sportsmanshipAccepting consequencesAssertionsIgnoring mild provocationProblem solvingRecognizing and dealing with feeling

Unlikely therapy for ADHD symptomsBut child can be made to understand

what ADHD is

Individual Psychotherapy

Study showed that combined medical and behavior treatment was best followed by medication treatment alone.

Multimodel Treatment

Nice guidelines for children

18 year old male presented with complaints of difficulty to remain attentive in class from the age of 8 years, changing seats frequently, bunking classes, blurting out answers during class, teachers made him sit in the library and read then also he found it diificult to remain there.

CASE discussion

He started showing irritability towards friends who started mocking him because of his behavior. During tenth standard exam also he found it difficult to sit and write exam for 3 hours.He started having frequent fights with family members. He started demanding many things.

Also started physically abuse his parents. wandering away episodes

ADULT ADHD

Retrospective childhood ADHD diagnosis

Narrow criterion: met DSM4 criteria in childhood by parent interview

Broad criterion: both 1 and 2 are met as reported by patient

1.Childhood hyperactivity2.Childhood attention deficit

Utah Criteria for adult ADHD

5 additional symptoms including ongoing difficulties with inattention and hyperactivity and at least 3 other symptoms

Adult charecteristics

InattentionHyperactivityMood LabilityIrritability and hot temperImpaired stress intoleranceDisorganizationImpulsivity

DSM4 criteria-1.Either 6 or more symptoms of

inattention or 6 more symptoms of hyperactivity –impulsivity have persisted atleast for 6 months

LimitationSymptom field inappropriateNo scientific basis for establishing 6

symptoms

Limitations of DSM4 criteria for adult ADHD

DSM4 criteria-some hyperactive-impulsive or

inattentive symptoms that caused impairment were present before the age of 7 years.

LimitationNo scientific rationale for age onset

criterion

DSM4 criteria-some impairement from symptoms present in two or more settings(school,home,work)

Limitations:No mention of alternative domains of

functioning ore relevant to adults

Brown adult ADHD interviewConners Adult ADHD diagnostic

interview

Diagnostic instruments –adult ADHD

Prevalence declines with ageADHD adult reveal high childhood

conduct disorder with a subset of patients exhibiting anti sociality personality disorder

High rate of psychoactive substance use.

Course and prognosis

Adult ADHD exhibit lower self esteem poor lifetime acheivement,Less successful work history, more failures in long term relationships

Medications used in childhood adhd can be effective in adults also

Treatment

NICE GUIDELINES

Methyl Phenidate should be used firstConsider Atomexetine/dexamfetamine

if person shows no response to methyl phenidate(trial-6 weeks)

DO NOT USE ANTIPSYCHOTICS TO TREAT ADULT ADHD

NICE GUIDELINES

Methyl phenidate-begin with low dose5mg tid.Increase the dose upto 100mg/dayAtomoxetine-Upto 70 kg body weight-Total starting dose-0.5 mg /kg/body

weightIncrease dose after 7 days upto 1.2

mg/kg/day

Atomoxetine-over 70 kg body weightTotal starting dose-40mg/dayIncrease after 7 days up to maximum

maintenance dose of 100mg/dayDextro amphetamine-Begin with low

dose of 5mg bdIncrease the dose up to maximum of

60mg/day

Atomexetine-agitation,Irritabillity suicidal thinking

Liver damage in rare case.

Monitor side effects

Height –every 6 monthsWeight-Every 3 months and later on every

6 monthsHeart rate and BP-every 3 monthsMonitor- dysmenorrhoea,erectile

dysfunction,ejaculatory dysfunctionSeizures-consider dextro amphetamineTicsPsychotic symptomsAnxiety

Monitor

ADHD is not outgrown

HomeSchoolWork placeRelationshipsFinancialsociety

Consequences