Attention Deficit

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Attention Deficit

  1. 1. ATTENTION DEFICITHYPERACTIVITY DISORDER<br />Jose David Gamez Godoy, M.D.<br />
  2. 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. 3.
  4. 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. 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. 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. 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. 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. 9. PATHOGENESIS<br />Ellison-Wright et al, Structural brain change in Attention Deficit Hyperactivity Disorder identified by meta-analysis, BMC Psychiatry. 2008<br />
  10. 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. 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. 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. 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. 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. 15. SUBTYPES<br />Inattentive<br />Hyperactive-impulsive<br />Combined<br />
  16. 16. DIAGNOSIS<br />Clinical interview and history<br />School assessment<br />Behavioral rating scales<br />Physical examination and laboratory findings<br />
  17. 17. DIAGNOSIS<br />
  18. 18.
  19. 19. DIFFERENTIAL DIAGNOSIS<br />Dimensional<br />Psychosocial<br />Medical<br />Coexisting conditions<br />Diagnoses with associated ADHD behaviors<br />Neurologic <br />
  20. 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. 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. 22. TREATMENT<br />Medications<br />Psychostimulant (70%)<br />Amphetamine<br />Atomoxetine<br />Antidepressants<br />Investigational<br />
  23. 23.
  24. 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. 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. 26. PROGNOSIS<br />
  27. 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. 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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