Attention Deficit
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Attention Deficit Attention Deficit Presentation Transcript

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