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Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
Attention Deficit
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Attention Deficit

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  • 1. ATTENTION DEFICITHYPERACTIVITY DISORDER<br />Jose David Gamez Godoy, M.D.<br />
  • 2. ADHD<br />Most common neurobehavioral disorder of childhood<br />Inattention, including increased distractibility and difficulty sustaining attention<br />Poor impulse control and decreased self inhibitory capacity<br />Motor over activity and motor restlessness<br />American Psychiatric Association’s Diagnostic and Statistical Manual (DMS-IV)<br />
  • 3.
  • 4. ETIOLOGY<br />Birth complications<br />Maternal drug use<br />Maternal smoking and alcohol<br />Genetic component<br />Exposure to toxins<br />High sensitivity to food colorings and additives<br />Eigenmann PA, Haenggeli CA: Food colorings, preservatives and hyperactivity. Lancet 370:2007<br />Abnormal brain structures<br />Severe traumatic brain injury<br />Psychosocial family stressors<br />Family history approximately 80%<br />Maternal stress<br />Grizenko et al, Relation of maternal strees during pregnancy to symptom severity and response to treatment in children with ADHD, Rev PsychiatrNeurosci 2008<br />
  • 5. EPIDEMIOLOGY<br />Prevalence 2-18% school aged children<br />2-6% adolescents<br />4.4 million children aged 4-17 years<br />11% boys and 4.4% girls<br />4:1 hyperactive and 2:1 inattentive<br />56.3% treated with medication<br />Health care costs $3.3 billion annually<br />Comorbid psychiatric diagnoses<br />CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003<br />
  • 6. EPIDEMIOLOGY<br />Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder: National Survey of Children&apos;s Health, 2003<br />CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003<br />
  • 7. EPIDEMIOLOGY<br />Percent of Youth 4-17 ever diagnosed and currently medicated for Attention-Deficit/Hyperactivity Disorder: National Survey of Children&apos;s Health, 2003<br />CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003<br />
  • 8. PATHOGENESIS<br />Smaller brain volumes, prefrontal cortex and basal ganglia (5-10%)<br />Increased gray matter in the posterior temporal and inferior parietal cortices<br />Atypical frontal-striatal function<br />Increase in dopamine transporter density<br />
  • 9. PATHOGENESIS<br />Ellison-Wright et al, Structural brain change in Attention Deficit Hyperactivity Disorder identified by meta-analysis, BMC Psychiatry. 2008<br />
  • 10. PATHOGENESIS<br />Volkow et al, Depressed Dopamine Activity in Caudate and Preliminary Evidence of Limbic Involvement in Adults With Attention-Deficit/Hyperactivity Disorder, Arch Gen Psychiatry. 2007<br />
  • 11. CLINICAL MANIFESTATIONS<br />Inattention<br />Hyperactivity<br />Impulsivity<br />Developmentally inappropriate<br />Before 7 years of age<br />At least 6 months<br />2 or more settings<br />Impairment in social, academic or occupational functioning<br />Not be secondary to another disorder<br />
  • 12. HYPERACTIVITY<br />Difficulty remaining seated<br />Difficulty playing quietly<br />Frequent restlessness<br />Always “on the go”<br />Peak 7-8 years of age<br />
  • 13. IMPULSIVITY<br />Difficulty waiting turns<br />Blurting out answers too quickly<br />Disruptive classroom behavior<br />Interrupting other’s activities<br />Peer rejection<br />Unintentional injury<br />Greater risk of engaging in drug use<br />Impulse buying<br />
  • 14. INATTENTION<br />Forgetfulness<br />Easily distracted<br />Losing or misplacing things<br />Disorganization<br />Academic underachievement<br />Poor follow-through with assignments or tasks<br />Poor concentration<br />Poor attention to detail<br />
  • 15. SUBTYPES<br />Inattentive<br />Hyperactive-impulsive<br />Combined<br />
  • 16. DIAGNOSIS<br />Clinical interview and history<br />School assessment<br />Behavioral rating scales<br />Physical examination and laboratory findings<br />
  • 17. DIAGNOSIS<br />
  • 18.
  • 19. DIFFERENTIAL DIAGNOSIS<br />Dimensional<br />Psychosocial<br />Medical<br />Coexisting conditions<br />Diagnoses with associated ADHD behaviors<br />Neurologic <br />
  • 20. TREATMENT GOALS<br />improvements in relationships with parents, siblings, teachers, and peers<br />decreased disruptive behaviors<br />improved academic performance<br />increased independence in self-care or homework<br />improved self-esteem<br />enhanced safety in the community<br />
  • 21. TREATMENT<br />Behavioral/psychologic interventions<br />Daily schedule<br />Distractions to a minimum<br />Specific places for toys, schoolwork and clothes<br />Small goals<br />Rewarding positive behavior<br />Checklists<br />Limiting choices<br />Activities in which the child can be successful<br />
  • 22. TREATMENT<br />Medications<br />Psychostimulant (70%)<br />Amphetamine<br />Atomoxetine<br />Antidepressants<br />Investigational<br />
  • 23.
  • 24. TREATMENT<br />Common side effects:<br />Anorexia (80%)<br />Sleep disturbances (3-85%)<br />Weight loss (10-15%)<br />Cardiovascular<br />Psychiatric (psychosis, mania)<br />Tics<br />Diversion and misuse<br />
  • 25. TREATMENT<br />Alternative therapies<br />Vision training<br />Diets<br />Megavitamins<br />Herbal supplements<br />Mineral supplements<br />EEG biofeedback<br />Kinesiology <br />
  • 26. PROGNOSIS<br />
  • 27. PROGNOSIS<br />60-80% symptoms in adolescence<br />40-60% symptoms in adulthood<br />Increased risk for antisocial personality disorder (12-23% vs 2-3%)<br />Risk taking behaviors (substance use, injuries, driving)<br />Educational underachievement<br />Employment difficulties<br />Relationship difficulties<br />
  • 28. REFERENCES<br />Nelson textbook of pediatrics (18th edition)<br />CDC Mental Health in the United States, 2003<br />Up to Date: Evaluation and diagnosis of attention deficit hyperactivity disorder in children, Dec 2007<br />Up to Date: Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents, Jun 2008<br />Up to Date: Pharmacotherapy for attention deficit hyperactivity disorder in children and adolescents, Jun 2008<br />Clinical Pediatric Guideline: Diagnosis and Evaluation of the child with ADHD, Pediatrics 2000<br />Treatment of Attention-Deficit/Hyperactivity Disorder: Overview of the Evidence, Pediatrics 2005<br />Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder, Pediatrics 2001<br />

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