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attention deficit and hyperkinetic disorder

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  • This slide gives a brief overview of how attention deficit hyperactivity disorder (ADHD) has evolved over the years Symptoms first described as early as 1902 by Dr. Still in Lancet The core symptoms of ADHD have always been defined on the basis of behavioral characteristics At first the symptoms were viewed as identical to those that would follow an insult to the brain, such as a head injury or a CNS infection. When these behavioral characteristics were seen in children with no history of such an insult, the damage to the CNS was considered to be so minimal that the only manifestations were behavioral. Hence the term “minimal brain damage” In the early 1960s, the term “minimal brain dysfunction,” or MBD, was used to describe a cluster of symptoms that included specific learning disabilities, hyperkinesis, impulsivity, and short attention span. But MBD was a vague, overinclusive diagnostic label, and it lacked predictive validity In 1968, DSM-II described this constellation of symptoms—overactivity, restlessness, distractibility, short attention span—as a specific syndrome: “hyperkinetic reaction of childhood.” The emphasis in this diagnostic label was on the motoric symptoms, which, we now know, represents only 1 part of this disorder Our more recent classifications—those in DSM-III, DSM-III-R, and DSM-IV—have described the signs and symptoms of the disorder without implying a specific etiology, as we saw that the “minimal brain damage” diagnosis did. Our current criteria emphasize 3 main behavioral areas: inattention, impulsivity, and hyperactivity
  • ADHD is most likely caused by a complex interplay of factors Biologic factors that predispose an individual for ADHD include post-traumatic or infectious encephalopathy, lead poisoning, and fetal alcohol syndrome Environmental influences include abuse or neglect, family adversity, and situational stress Emerging literature provides support for the hypothesis that abnormalities in frontal networks or frontal-striatal dysfunction and catecholamine dysregulation are involved Family and twin studies reveal compelling data regarding the genetic origin of ADHD; and recent advances in neuroimaging techniques have promoted closer study of neuroanatomic correlates
  • ADHD

    2. 2. What is ADHD? <ul><li>A pattern of diminished sustained attention and high impulsivity in child or adolescent than expected for someone of that age and developmental level </li></ul><ul><li>Three types: Combined Type, Predominantly Inattentive Type, and Predominantly Hyperactive-Impulsive Type . </li></ul>
    3. 3. ADHD-STATISTICS: <ul><li>5-10% of the entire U.S. population </li></ul><ul><li>Males are 3 to 6 times more likely than females. </li></ul><ul><li>At least 50% of ADHD sufferers have another diagnosable mental disorder. </li></ul><ul><li>3-5% of all school-age children are estimated to have this disorder </li></ul>
    4. 4. <ul><li>First degree biological relatives are at high risk </li></ul><ul><li>Parents shows increased incidence of –hyperkinesis,sociopathy,alcohol abuse,conversion disorder </li></ul><ul><li>Symptoms often present by 3 years,but diagnosis made only at school setting </li></ul>
    5. 5. ADHD-TIME LINE: 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) 1960 1980 1968 1987 1994 Attention Deficit/Hyperactivity Disorder (DSM-IV) 1930 ADHD-like syndrome first described 1902
    6. 6. Etiology--? <ul><li>Prenatal toxic exposure </li></ul><ul><li>Mechanical insults to CNS </li></ul><ul><li>Prematurity </li></ul><ul><li>Food aditives, colorings,preservatives </li></ul><ul><li>But ………….no scientific evidences </li></ul>
    7. 7. CAUSES OF ADHD: CNS insults Genetic origins Neuroanatomical neurochemical ADHD Environmental factors
    8. 8. Genetic factors <ul><li>Twin studies-great concordance in monozygotic twins </li></ul><ul><li>Two times risk in siblings </li></ul><ul><li>Adoption studies-higher incidence in biological parents than adoptive parents </li></ul>
    9. 9. Developmental factors <ul><li>Winter infections during first trimester </li></ul><ul><li>Subtle damage to CNS during development </li></ul><ul><li>High rate of soft neurological signs </li></ul>
    10. 10. Neurochemical factors <ul><li>Peripheral nor-adrenergic system dysfunction </li></ul><ul><li>Possible dopamine system dysfunction </li></ul><ul><li>Both evidenced by effect of stimulant drugs in improving symptoms </li></ul>
    11. 11. Psycho-social factors <ul><li>Prolonged emotional deprivation </li></ul><ul><li>Stressful psychic events </li></ul><ul><li>Family disequilibrium </li></ul><ul><li>Demands from society </li></ul><ul><li>Childs temperement </li></ul>
    12. 12. Diagnosis-assessment <ul><li>History, History, and more History!! </li></ul><ul><li>School history </li></ul><ul><li>Teachers reports </li></ul><ul><li>Academic performance </li></ul><ul><li>Clinic based psychological tests </li></ul><ul><li>Individually administered intelligence tests </li></ul><ul><li>Pediatric exam to check for an alternate disorder </li></ul>
    13. 13. DSM-IV-TR CRITERIA <ul><li>Inattention </li></ul><ul><li>pervasive and persistent for more than 6 months </li></ul><ul><li>At least 6 symptoms in the list </li></ul><ul><li>Hyperactivity-impulsivity </li></ul><ul><li>pervasive and persistent for more than 6 months </li></ul><ul><li>At least 6 symptoms in the list </li></ul>
    14. 14. <ul><li>Some symptoms onset before 7 years </li></ul><ul><li>Some symptoms should present in two settings </li></ul><ul><li>Social ,occupational ,academic function impairment </li></ul><ul><li>Symptoms not better accounted for pervasive developmental disorder, schizophrenia , any other mental disorder </li></ul>
    15. 15. Inattention <ul><li>Often has difficulty sustaining attention in tasks </li></ul><ul><li>Often fails to give close attention to details/ makes mistakes in schoolwork, work, and other activities </li></ul><ul><li>Often does not seem to listen when spoken to directly </li></ul>
    16. 16. Inattention <ul><li>Often does not follow through on instructions and fails to finish schoolwork, chores or duties in work </li></ul><ul><li>Often has difficulty organizing tasks and activities </li></ul><ul><li>Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort </li></ul>
    17. 17. <ul><li>Often loses things necessary for tasks or activities </li></ul><ul><li>Often easily distracted by extraneous stimuli </li></ul><ul><li>Often forgetful in daily activities </li></ul>
    18. 18. Hyperactivity <ul><li>Often leaves seat in class/ situation where staying seated is expected </li></ul><ul><li>Often fidgets with hands or feet or squirms in seat </li></ul>
    19. 19. <ul><li>Often runs about/climbs excessively in situations where it is inappropriate </li></ul><ul><li>Often has difficulty playing/engaging in leisure activities quietly </li></ul>
    20. 20. Cont.. <ul><li>Often on the go or acts as if driven by a motor </li></ul><ul><li>Talks excessively </li></ul>
    21. 21. Impulsivity <ul><li>Often blurts out answers before questions have been completed </li></ul><ul><li>Often has difficulty waiting to take turns </li></ul>
    22. 22. <ul><li>Often interrupts or intrudes on others </li></ul>
    23. 23. Differential diagnosis <ul><li>Sensory impairment. </li></ul><ul><li>Epilepsy and related states-TLE </li></ul><ul><li>Effects of head injury </li></ul><ul><li>Acute or chronic medical Illness </li></ul><ul><li>Poor nutrition. </li></ul><ul><li>Sleep disorders. </li></ul><ul><li>Side effects of medication </li></ul>
    24. 24. Psychiatric conditions <ul><li>Autism Spectrum Disorder </li></ul><ul><li>Obsessive Compulsive Disorder </li></ul><ul><li>Tic Disorders </li></ul><ul><li>Conduct Disorders </li></ul><ul><li>Attachment disorders. </li></ul><ul><li>Depression and emotional disorders. </li></ul><ul><li>Anxiety disorder </li></ul><ul><li>Psychosis </li></ul>
    25. 25. Course and prognosis <ul><li>Persistent symptoms at adult/adolescent age-50% </li></ul><ul><li>Remission at puberty/early adulthood-50% </li></ul><ul><li>Remission unlikely before-12 years </li></ul><ul><li>Over activity-first to remit </li></ul><ul><li>Distractibility-last to remit </li></ul>
    26. 26. Course of partial or non remittance in adolescent life <ul><li>Antisocial behavior </li></ul><ul><li>Conduct disorder </li></ul><ul><li>Substance abuse disorder </li></ul><ul><li>Mood disorder </li></ul><ul><li>Social difficulties </li></ul><ul><li>Learning difficulties </li></ul>
    27. 27. Pharmacotherapy <ul><li>First line treatment </li></ul><ul><li>Stimulants are first choice-methylphenidate, amphetamine preparations </li></ul><ul><li>Second line agents-Atomoxetine, bupropion, venlafaxine, clonidine </li></ul>
    28. 28. Methylphenidate <ul><li>Dopamine agonist </li></ul><ul><li>Dexmethylphenidate –maximum effect, minimal side effect </li></ul><ul><li>0.3-1 mg/kg tid, upto 60 mg/day </li></ul><ul><li>Sustained release preparations allowed once daily dose, less rebound effects </li></ul><ul><li>FDA recommendation-should use in children >6 years </li></ul>
    29. 29. Side effects <ul><li>Head ache </li></ul><ul><li>GI upset </li></ul><ul><li>Insomnia </li></ul><ul><li>Exacerbate tic disorder </li></ul><ul><li>Growth suppression </li></ul>
    30. 30. Amphetamine preparations <ul><li>Second choice when methylphenidate not useful </li></ul><ul><li>FDA recommend for child >3 years </li></ul><ul><li>0.15-0.5 mg/kg bd, upto 40 mg/day </li></ul><ul><li>Once daily sustained release useful </li></ul>
    31. 31. Non stimulants-Atomoxetine <ul><li>Nor-epinephrine reuptake inhibitor </li></ul><ul><li>FDA-use in 6 years and above </li></ul><ul><li>Effective for inattention and impulsivity </li></ul><ul><li>0.5-1.8 mg/kg bd dose,upto 40-80 mg/day </li></ul><ul><li>Side effects-decreased appetite ,dizziness, irritability, increase in BP & HR </li></ul>
    32. 32. others <ul><li>Bupropion – beware of seizure </li></ul><ul><li>Clonidine - useful in pts with tic disorder </li></ul><ul><li>Modafinil – once daily,useful in adolescents </li></ul><ul><li>Reboxetine – used in methylphenidate resistant cases </li></ul>
    33. 33. Psychosocial intervention <ul><li>Teacher’s attitude MUST be positive, upbeat, flexible </li></ul><ul><li>praise liberally </li></ul><ul><li>Provide more direct instruction and as much one-on-one instruction as possible </li></ul><ul><li>Lecture less </li></ul><ul><li>Challenge but don't overwhelm </li></ul>
    34. 34. <ul><li>Design tasks of low to moderate frustration levels </li></ul><ul><li>Pair the student with a exemplary student </li></ul><ul><li>frequent communication between home and school </li></ul><ul><li>Provide frequent feedback </li></ul><ul><li>Provide frequent and regularly scheduled breaks </li></ul><ul><li>Teach conflict resolution and peer mediation skills </li></ul>
    35. 35. Adult manifestation of ADHD <ul><li>Prevalence- 4% </li></ul><ul><li>Difficult to diagnose – lack of school and observer information </li></ul><ul><li>SPECT - Increases dopamine transporter binding sites in striatum </li></ul><ul><li>Premature birth , maternal use of nicotine, increased serum lead </li></ul>
    36. 36. Diagnosis-utah criteria <ul><li>Retrospective childhood diagnosis of ADHD </li></ul><ul><li>At least 3 of following </li></ul><ul><li>Inattentiveness </li></ul><ul><li>Hyperactivity </li></ul><ul><li>Mood lability </li></ul><ul><li>Irritability, hot ember </li></ul><ul><li>Low stress tolerance </li></ul><ul><li>Disorganization </li></ul><ul><li>impulsivity </li></ul>
    37. 37. <ul><li>DD – hypomania , anxiety disorder </li></ul><ul><li>Treatment – similar to childhood ADHD </li></ul><ul><li>Therapy needed indefinitely </li></ul>
    38. 38. THANK YOU
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