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  1. 1. ADHDASHRAF TANTAWYProfessor of Psychiatry Suez Canal University Ismailia, Egypt.
  2. 2. A developmental disorder of self control(Executive function of the brain).Symptoms arise from brainabnormalities.Their main problems are:– Attention span.– Impulse control.– Activity level.A real disorder & often a real obstacle.
  3. 3. Symptoms of InattentionFails to pay close attention to details.Makes careless mistakes.Has difficulty maintaining attention in tasks or play.Does not seem to listen when spoken to directly.Does not follow directions.Fails to complete schoolwork or chores.Has difficulty organizing tasks or activities.Avoids/ dislike task that require sustained mental effort.Losses things necessary for task or activities.Easily distracted.Often forgetful in daily activities.
  4. 4. Symptoms of HyperactivityFidgets with hands or feet or squirms in seat.Leaves seat in classroom or in other situation in whichremaining seated is expected.Runs or climbs excessively when inappropriate.Has difficulty playing or engaging in leisure activitiesquietly.Always on the go or act as if driven by a motor.Often talks excessively.Exhibit feeling of restlessness in adolescence.
  5. 5. Symptoms of ImpulsivityBlurts out answers before questions havebeen completed.Has difficulty waiting in turn.Interrupts or intrudes onothers (for example buttsinto conversations or games).
  6. 6. TYPES OF ADHD1. INATTENTIVE TYPE: At least 6 symptoms of inattention. (20-30%)2. HYPERACTIVE IMPULSIVE TYPE: At least 6 symptoms of hyperactivity/ impulsivity. (1-15%)3. COMBINED TYPE: At least 6 symptoms both of inattention & hyperactivity-impulsivity. (50-75%)
  7. 7. Lifetime Course of ADHD Symptoms: Inattention Domain Childhood AdultDifficulty sustaining attention Difficulty sustaining attention (Meetings, Reading, Paperwork)Doesn’t listen Paralyzing procrastinationNo follow through Slow, inefficientCan’t organize Poor time managementLoses important items Disorganized APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000. Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.
  8. 8. Lifetime Course of ADHD Hyperactivity/ Impulsivity Domain Childhood AdultSquirming, fidgeting Inefficiencies at workCan’t stay seated Can’t sit through meetingsCan’t wait turn Can’t wait in lineRuns/ climbs excessively Drives too fastCan’t play/ work quietly Selects very active jobOn the go/ driven by motor Can’t tolerate frustrationTalks excessively Talks excessivelyBlurts out answers Makes inappropriate commentsIntrudes/ interrupts others Interrupts others APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000. Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.
  9. 9. Prevalence of ADHD Prevalence of ADHD1,2,3 – ADHD affects 3-6% of children & adolescents, with some estimates as high as 16.1%. – Boys 3 - 4 times more than girls. Prevalence of ADHD is underestimated4,5 – Comorbidities may mask diagnosis. – Girls are under-recognized & undertreated. – Difficult diagnosis in the adolescent.1. Goldman LS et al. JAMA. 1998;279:1100-1107; 2US Department of Health and Human Services, 1999 3Scott-Levin Inc.Physician Drug and Diagnosis Audit (PDDA), 2001. 4. Datamonitor report DMHC2008, published 9/2004; 5. Biederman J et al.J Am Acad Child Adolesc Psychiatry. 1999;38:966-975;
  10. 10. Potential Impact of Untreated ADHD Across the Lifespan Low self- Academic Smoking and Legal esteem limitations substance abuse problems Childhood Adolescence Adulthood Injuries Impaired family and Motor vehicle Occupational peer relationships accidents difficultiesAmerican Academy of Pediatrics. Pediatrics. 2000;105:1158-1170; Kelly PC et al. Pediatrics. 1989;83:211-217; MurphyK et al. Compr Psychiatry. 1996;37:393-401; Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7; Barkley RA et al.Pediatrics. 1996;98:1089-1095; Swensen A et al. J Adolesc Health. 2004;35:346.e1-9.
  11. 11. Developmental Impact of ADHD Academic problems Self-esteem issues Difficulty with social interactions Relationship problems Self-esteem issues Injury/ accidentsBehavioural Legal issues, smoking Substance abusedisturbance and injury Occupational failurePre-school Adolescent Adult School-age College-age Academic failure Behavioural disturbance Self-esteem issues Academic problems Substance abuse Difficulty with social interactions Injury/ accidents Self-esteem issues Occupational difficulties
  12. 12. Pathophysiology of ADHD (DA & NE Neurotransmission) Abnormal DA & NE neurotransmitters in frontal/ striatal areas of ADHD (1,2) Cortico-striatal circuits play an important role in ADHD (1,3,4) Efficacy of ADHD Medications affecting DA & NE support to the theory of monoamine dysfunction in ADHD(3)DA = dopamine; NE = norepinephrine.1. Mercugliano M. Ment Retard Dev Disabil Res Rev. 1995;1:220-226; 2. Krause K-H et al. Neurosci Let.2000;285:107-110; 3. Markowitz JS et al. Pharmacotherapy. 2003;23:1281-1299; 4. Zametkin AJ et al. J ClinPsychiatry. 1998;59(suppl 7):17-23.
  13. 13. Preorbital Frontal Cortex Reticular FormationThe Reticular Formation: It was believed that RF, whichregulates arousal & attention, was dysfunctional in ADHD.The Pre-orbital Frontal Cortex: Functional MagneticResonance Imaging research has revealed that POFCfunctions differently in individuals with ADHD.
  14. 14. The Preorbital Frontal Cortex: Planning (Time Management). Sequencing. Organizing. Self-Control. Other Executive Functions. Individuals with ADHD, with or without impulsivity or hyperactivity, have difficulties with executive functions.
  15. 15. PET Scan of Adult Brain Glucose Metabolism with ADHDRate at which brain uses glucose is lower in ADHD than Normal (Zametkin, et al., 1990). Adult with ADHD Normal Adult
  16. 16. Co-Occurring Disorders• Speech & Language Delays: 30%.• Learning Disabilities: 25%.• Smoking & Substance Abuse: 20%. 1. Oppositional Defiant Disorder 50% ADHD 2. Conduct alone Disorder 40% 30% 5. Tics 10% 4. Mood Disorders 20% 3. Anxiety Disorder 25% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096
  17. 17. ADHD Diagnostic Evaluation1. Physical Examination.2. Parent-Rated Child Behavior Scales.3. Teacher-Rated Child Behavior Scales.4. Parent & Child Interviews.5. Parent Self Report Measures.6. Clinic-Based Psychological Test.7. Review of Prior School & Medical Reports.8. IQ & Educational Achievement Tests.
  18. 18. Differential Diagnosis Vision & Hearing Problems. Chronic Illness; Breathing & Sleep Disorders. Developmental or Learning Problems. Absence Seizures. Acute change in living situation. Grief. Family conflict. Recent trauma. Substance Abuse; Side Effect of Medications. Stress. Frequent Co-Morbidities:(Mood/ anxiety/ psychotic/ adjustment disorders)- Fixing them can solve most of the problem.
  19. 19. ADHD VS. BIPOLAR ADHD BIPOLARChildhood onset. Later onset.Constant. Cyclical.Moods triggered. Moods not triggered.Difficulty in going to sleep. Decrease need for sleep.Thoughts jumping. Thoughts racing.Family history of ADHD. Family history of mood D.
  20. 20. Rule Outs for Diagnosis of ADHDRule Out’s Diagnosis Evaluation by use of:Gifted (MR) IQ Testing (Psychologist)Learning Disability Academic/ Perceptual Testing (Psychologist)Neurological Conditions: EEG, 24 hr EEG, MRI etcSeizures, Tourette’s etc. (Neurologist)Behavioral or Emotional: Psycho-Social History &Anxiety & Depression Personality Testing
  21. 21. Management1. Pharmacotherapy (FDA approved); Stimulants: Methylphenidate [Ritalin]). Non stimulants: Atomoxetine [Strattera]).2. Psychotherapy.3. Family Therapy/ Guidance: A- Home Management. B- Parenting. C- Stress Management.4. Classroom Management.
  22. 22. ADHD & Stimulant Medication Stimulants improve:Core Symptoms Inattention AND Impulsivity Hyperactivity Impulsive Aggression Social Interactions Academic Productivity & Accuracy Swanson et al. Except Child 1993;60:154.
  23. 23. Stimulant Users - Tomorrow’s Abusers? Harvard study 80% of substance abuse 70 no ADHD tx ADHD 60 non tx ADHD 50 40 Use of medications in ADHD 30 provides an 84% risk reduction in 20 developing of 10 a substance abuse disorder 0 J. Biederman, Pediatrics, Aug. 1999;104(2)
  24. 24. Nutrition In ADHDProtein & Omega-3 fatty acidsare important for ADHD, as wellas iron & magnesium.Eat a high-protein diet.Eat more Omega-3 fatty acids.Eat complex carbs at night(may aid sleep).Eat fewer simple carbohydrates.
  25. 25. ConclusionADHD is developmental disorder of self control(Executive function of the brain).The main problems are: Attention span, Impulsecontrol and Activity level.A real disorder & often a real obstacle.ADHD affects 3-6% of children & adolescents, withsome estimates as high as 16.1%.Prevalence of ADHD is underestimated.Management includes Pharmacotherapy,Psychotherapy, Family Therapy/ Guidance, ClassroomManagement & Nutrition.