ADHD, Causes, Incidence, prevalence, diagnostic criteria by DSM V, characteristics of ADHD

2. CONTENTS
• Labels of ADHD
• Definition by DSM V and ICD 10
• Difference between DSM IV and DSM V
• Prevalence (Global)
• Prevalence (India)
• Causes Of ADHD
• Characteristics

3. Introduction:
• Definition: Attention Deficit Hyperactivity Disorder (ADHD) is a
neurodevelopmental disorder characterized by persistent pattern of
inattention and/or hyperactivity-impulsivity, interfering with functioning
and development. (APA, 2013).

4. ACTIVITY: Find the difference??

5. History( Labels)
Year Label
1930s and l940s; brain damaged or brain injured
1950s and 1960s, Minimal Brain Dysfunction
1960’s Hyperactive or Hyperkinetic
DSM-II, 1968, Hyperkinetic Reaction of Childhood”
1980 DSM-III Attention Deficit Disorder” : with hyperactivity (ADD + H), and
without hyperactivity (ADD-H).
1987, DSM-III-R “Attention Deficit Disorder” to “Attention Deficit
Hyperactivity Disorder” (ADHD)

6. DSM-IV R, May of 1994, Attention-Deficit/Hyperactivity Disorder
4 types:
ADHD, Combined Type
ADHD, Predominantly Inattentive Type
ADHD, Predominantly Hyperactive-impulsive
Type
ADHD, Not Otherwise Specified

7. DSM IV
The diagnostic criteria
the three main types
specify that symptoms
must have been
present before
age seven and have
persisted for at least six
months to a degree that
is maladaptive and
inconsistent with the
child’s developmental
level
Inattention Criteria:
(a) Often fails to give close attention to details or makes
careless mistakes in schoolwork,
work, or other activities
(b) Often has difficulty sustaining attention in tasks or play
activities
(c) Often does not seem to listen when spoken to directly
(d) Often does not follow through on instructions and fails to
finish schoolwork, chores,
or duties in the workplace (not due to oppositional behavior or
failure to understand
instructions)
(e) Often has difficulty organizing tasks and activities
(f) Often avoids, dislikes, or is reluctant to engage in tasks
which require sustained
mental effort (such as schoolwork or homework)

8. Hyperactivity Criteria:
(a) Often fidgets with hands or feet or squirms in seat
(b) Often leaves seat in classroom or in other situations in which
remaining seated is
expected
(c) Often runs about or climbs excessively in situations in which
it is inappropriate (in
adolescents or adults, may be limited to subjective feelings of
restlessness)
(d) Often has difficulty playing or engaging in leisure activities
quietly
(e) Is often ‘on the go’ or often acts as if “driven by a motor”
(f) Often talks excessively
Impulsivity Criteria:
(g) Often blurts out
answers before questions
have been completed
(h) Often has difficulty
awaiting turn
(i) Often interrupts or
intrudes on others (e.g.,
butts into conversations
or games)

9. Criteria of DSM IV
• Some symptoms present before age 7 years.
• Symptoms is present in two or more settings (e.g. at school/work and at home).
• There must be clear evidence of clinically significant impairment in social, school, or
work functioning.
• The symptoms do not happen only during the course of a Pervasive Developmental
Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better
accounted for by another mental disorder (e.g. Mood Disorder, AnxietyDisorder,
Dissociative Disorder).

10. Subtypes
Of ADHD
( DSM IV)
• ADHD, Combined Type-
6 or more Inattention criteria ,
6 or more of the symptoms under Hyperactivity -
Impulsivity
• ADHD, Predominantly Inattentive Type-
6 or more under Inattention,
Less than 6 symptoms under Hyperactivity-Impulsivity
• ADHD, Predominantly Hyperactive-impulsive
Type-
six or more symptoms Hyperactivity-Impulsivity criteria
fewer than 6 symptoms under Inattention
• ADHD, Not Otherwise Specified
In which there are prominent symptoms from the
Inattention and/or Hyperactivity-Impulsivity criteria
lists, but these are not sufficient to meet criteria for
ADHD

11. Definition by DSM V
• Neurodevelopmental disorder and defines it as ‘a persistent pattern of
inattention and/or hyperactivity-impulsivity that interferes with functioning
or development…. And negatively impacts directly on social and
academic/occupational activities.

12. Diagnosing ADHD: DSM-V
• Six (or more) of the following symptoms have persisted for at least 6 months
• Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
• Older adolescents and adults (age 17 and older), at least five symptoms are required.
• Several inattentive or hyperactive-impulsive symptoms are present in two or more settings.
• There must be clear evidence of clinically significant impairment in social, academic, or
occupational functioning.
• Symptoms do not occur exclusively during the course of a pervasive developmental
disorder, schizophrenia, or other psychotic disorder.

13. Presentation Of ADHD ( DSM V)
• Combined type (ADHD C), which requires children to display at least six of nine
inattention and six of nine hyperactivity- impulsivity symptoms
• Predominantly inattentive type (ADHD, IA), which requires at least six of nine in
attention symptoms and fewer than six hyperactivity- impulsivity symptoms
• Hyperactivity- Impulsive type (ADHD, HI), which requires at least six of nine
hyperactivity- impulsivity symptoms and fewer than six inattention symptoms.

14. Changes from DSM IV to DSM V
 DSM-IV required documenting symptoms before the age of 7.
 In diagnosing ADHD, DSM-5 raises the age of when symptoms should be
documented to middle childhood (age 12 years)
 The new criteria describe and gives examples of how the disorder appears in
adults and adolescents
 DSM-IV, the three types of ADHD were referred to as “subtypes." This has
changed; subtypes are now referred to as “presentations."

15. Continued..
• Clinicians can specify whether a individual has mild, moderate or severe
ADHD. (DSM V)
• symptoms of ADHD need to be present in more than one setting rather
than just some symptoms in more than one setting.
• In making the diagnosis, children still should have six or more symptoms of
the disorder.
In people of age 17 and older the DSM-5 states they should have at least five
symptoms.

16. ICD 10
• The International Classification of Mental and Behavioural Disorders 10th revision
(ICD-10) was published by the WHO in 1992.
• Definition: Hyper Kinetic Disorder as a persistent and severe impairment of
psychological development, characterised by “early onset; a combination of overactive,
poorly modulated behaviour with marked inattention and lack of persistent task
involvement; and pervasiveness, over situations and persistence over time of these
behavioural characteristics.

17. Overview of the ICD-10 medical classification
system for ADHD
• Main symptoms of HKD are impaired attention and overactivity
• Impaired attention – manifested by a lack of persistent task involvement and tendency to
move from one activity to another without completion
• Overactivity – characterised by restlessness, talkativeness, noisiness and fidgeting,
particularly in situations requiring calm
• Early onset -(present prior to 6 years of age)
• Impairment must be present in two or more settings
• Diagnosis of HKD may also be made in adult life using the same criteria; however, attention
and activity must be judged with reference to developmentally appropriate norms

18. Characteristics according to ICD 10
• Disinhibition in social relationships
• Recklessness in dangerous situations
• Non-adherence to social norms (interrupting, intruding on others,
prematurely answering questions, difficulty in waiting in turn).

19. Prevalence in global
• Article1:The Worldwide Prevalence of ADHD: A Systematic Review and
Metaregression Analysis (2007)
• Article 2:ADHD in Tunisian Adolescents: Prevalence and Associated Factors
• Sweden based study(2018)
• The Prevalence of DSM-IV Attention-Deficit/ Hyperactivity Disorder: A Meta-
Analytic Review (2012)
• Prevalence of Attention-Deficit/Hyperactivity Disorder: A Systematic
Review and Meta-analysis (2014)

20. Prevalence in INDIA
• Certain Analysis on Attention-Deficit
Hyperactivity Disorder Among Elementary
Level School Children in Indian Scenario (2018)
• Prevalence in India: ADHD research in India: A
narrative review (2017)
• Prevalence of Attention Deficit Hyperactivity
Disorder in primary school children (2013)

21. Author Place Study setting Age in
years
Assessment
tool used
Prevale
nce
Manjunath et
al., 2016)
Mysore Primary school 6–10 DSM-IV 14.4%
Jaisoorya
et al., 2016)
Kerala School based study 12–19 BAARS-IV
Childhood
Symptoms self
report
4.3%
Jhambh et
al., 2014)
Chandigarh Medical,Dental,commerce
arts and engineering
colleges
19.46 ±
1.16
ASRS
WURS
5.48%
Juneja et
al., 2014)
New delhi School (6th to 10th class) 13 DSM-IV
based,ADHDq
uestionnaire
7.2%

22. Venkatesh
et al., 2012)
Chenna
i
Hospital – Child
guidance clinic
5.7 DSM 1V –
TR criteria-
Modified
SNAP
IV
rating
scale
20.3%
Chawla et
al., 1981)
New
Delhi
Primary school 6–12 Modified
behaviour
checklist
based
on
ICD-
10
hyperactive
syndrom
e was
4.7%

23. CAUSES FOR ADHD
ADHD
Pre- and
perinatal
factors
Psychosocial
adversity
Environmental
toxins
Brain Damage

24. BIOLOGICAL CONTRIBUTORS TO ADHD
• SELECTIVE ATTENTION: Superior and inferior temporal cortices and
corpus callosum
• SHIFTING ATTENTION: Prefrontal cortex
• SUSTAINED ATTENTION: reticular thalamic nuclei
• The frontal lobe: executive center , developing plans , organizing ideas,
inhibiting behaviors necessary for attention

25. Article: Biological contributors t Imaging Functional and Structural Brain
Connectomic in Attention-Deficit/Hyperactivity Disorder o ADHD:
• Author; Miao Cao et al (2014)
• In this review, we summarized recent findings of brain connectomics in
ADHD using EEG, R-fMRI, and dMRI data
• 11 published brain network studies in ADHD employing the noninvasive
neurophysiological and neuroimaging data

26. Small corpus callosum and cerebellum
Decreased activities in striatal areas and substriatal structures eg: Thalamus and
Hippocampus.
Smaller and less active Globus Pallidus and Caudate Nucleus
Decreased size and activity in the frontal lobes
Development of gray matter thickness especially in the prefrontal cortex was
significantly slower in ADHD patients compared with healthy children
Hechtman (1998)

27. Children with ADHD show decreased metabolic activity in the cortical
areas of the brain that are thought to be responsible for the regulation of
inhibition and attention (Durston et al,2003)
In Children with ADHD , brain size is smaller with the cortex being
thinner.
Overall physical and functional maturation is delayed by two to five years.
Ewen (2012)

28. Neurotransmitters:
• An abnormally low level of dopamine can cause the three symptoms of
ADHD: inattention, impulsiveness and hyperactivity
• Most of the molecular genetic studies to date have focussed on dopamine
related genes (eg:DRD2,DRD1 etc).
• Post treatment MR spectroscopy studies revealed ADHD-related
glutamatergic alterations happened in the prefrontal cortex, striatum, and
frontal lobes.

29. Article: Subcortical brain volume differences in
participants with
attention defi cit hyperactivity disorder in
children and
adults: a cross-sectional mega-analysis

30. Article: Practitioner Review: What have we
learnt about the causes of ADHD? (2012)
• Authors: Anita Thapar et.al

31. Pre- and perinatal
factors
Environmental
toxins
Dietary factors Psychosocial
adversity
Maternal smoking,
alcohol and substance
misuse.
Polychlorinated
biphenyls
Nutritional deficiencies eg
zinc, magnesium,
polyunsaturated fatty acids
Family adversity &
low income
Maternal stress Lead Conflict/parent–child
hostility
Low birth weight
<2500g
Organophosphate
pesticides
Prematurity Mercury
Hypoxic- anoxic brain
injury
Epilepsy
Traumatic brain injury

32. - Mash & Wolfe, 2007
GENETIC RISK
Prenatal alcohol or
tobacco exposure,
pregnancy
complications
Disturbances in
dopamine
transmission
Abnormalities in the
frontal lobes and basal
gangliaFailure to adequately
suppress inappropriate
response
Cognitive deficits in
working memory,self-
directed speech
Behavioral symptoms
of inattention,
hyperactivity ,
Impulsivity.

33. CHARACTERISTICS OF
ADHD

34. Inattention
• Inattentive behaviors in Preschool and Early School-
Age classrooms
• Difficulty paying attention when given directions by the teachers.
• Difficulty staying focused on a school task or play activity for an extended period of time
compared with other children in the classroom.
• Do not seem to be listening when spoken to or given directions.
• Often does not complete school tasks.
• Is often forgetful and fails to remember daily rules or activities.
• Inattentive in classroom discussions and need constant reminders to ‘join the group’.
• Plays alone and is often “in his or her own world”.
• Frequently daydreams.

35. Inattention and Play:
• Attentional differences in play are most prominent in “Free Play” and
“Structured Play” activities.
• In structured-play activities such as table work, they leave their seats more
often, tend to be more aggressive, demonstrating behaviors such as hitting,
biting, throwing things, and kicking.

36. Hyperactivity
• Often fidgets with hands or feet or squirms in seat or falls out of seat.
• Often leaves seat during lesson when remaining seated is expected.
• Often runs about or climbs excessively in situations where it is inappropriate.
• Has difficulty playing or engaging in leisure activities quietly.
• Often talks excessively or makes noises.
• Often is “on the go” or often acts as if “driven by a motor” (DSM IV)
• Often tosses toys or other objects.

37. Impulsivity:
• Blurts out answers before questions have been completed.
• Has difficulty waiting his or her turn.
• Interrupts or intrudes on others.
• Cannot wait for the teacher to call his/her name or pay attention to the teacher.
• Needs constant reinforcement and has difficulty with delayed gratification.
• Makes several errors on an assignment in an effort to finish quickly.
• Begin assignments without waiting for directions.
• Difficulty tempering unhappy feelings (inappropriate language, yelling, throwing
things)

38. LANGUAGE CHARACTERISTICS
• Speech-language pathology findings in Attention Deficit
Hyperactivity Disorder: a systematic literature review
• Year: 2015
• Review of articles published from 2008 to 2013

39. STUDIES FINDINGS
Tannock,Martinussen and Frijters
(2000)
deficits in naming speed
Alt and Gutman,( 2010) difficulties rapidly accessing the
lexicon
Tannock and Schachar, 1996). delayed in the onset of their first
words
Geurts (2004) Did not appear to experience
more syntactic problems
Van Lambalgen, Van Kruistum
and Parigger (2008)
Avoiding tense markers, tense
verbs
Preference for direct speech

40. Pragmatics
• Problems with inappropriate initiation, interruption,
• Difficulty maintaining a topic, and responding with appropriate amounts of
information are more likely to be evident. (Mikami et al., 2010).
• Children with ADHD (5-14 years of age) were found to have significantly lower
scores than control children, particularly in pragmatic aspects of language.
• Their stories were, for example, less coherent. Moreover, they conversed in a more
stereotyped way and made less use of the context of the conversation.
Geurts et al. (2004)

41. • Kim and Kaiser (2000) found that children with ADHD (6-8 years of age)
produced more pragmatically incorrect utterances than control children.
• The five most common errors were:
• Not answering questions or requests.
• Interrupting others.
• Failing to give feedback to the conversation partner.
• Making use of non-specific vocabulary (i.e. overuse of unspecified referents
that results in ambiguity of the message; also includes inappropriate choice
of lexical items)
• Producing utterances which lacked cohesion.

42. Auditory processing:
• Short term auditory memory weakness
• Problems following instructions
• Slow speed of processing written and spoken language
• Difficulties listening in distracting environments eg; classroom
• Difficulty in reading comprehension
• Problems with classroom discourse
• Poor writing skills
• Tangential narratives and conversations
• Word finding difficulties
• Difficulties inferring meaning

43. Video :https://www.youtube.com/watch?v=Nls3wxRZEoE
Video

44. Association Of ADHD and LD
• Most common comorbid condition,
• One third of children with ADHD also have LD
• Article 1:Association Between Attention Deficit-Hyperactivity Disorder
and Learning Disorders
• Article 2: Time perception, phonological skills and executive function
in children with dyslexia and/or ADHD symptoms