Attention Deficit disorder with its etiology, types and pathophysiology clinical features, Diagnosis, Assessment, differential Diagnosis and treatment , Medical Treatment and prognosis

1. ATTENTION DEFICIT/HYPER
ACTIVITY DISORDER
BY
Dr. NERUSU. SAI PRIYANKA
MPT NEUROSCIENCES

2. INTRODUCTION
•According to DSM-IV ADHD is characterized by
oInattention ,including increased distractability
and difficulty sustaining situations.
oPoor Impulse control and decreased self-
inhibitory capacity
oMotor Overactivity and motor restlessness

3. ETIOLOGY
• Evidences suggest that there is no single factor that determines the
expression of ADHD.
• Mothers of children with ADHD are more likely to experience birth
complications such as toxemia, lengthy labor and complicated delivery.
• Maternal drug use can be a risk factor.
• Maternal smoking and alcohol use are commonly linked to attention
deficits associated with ADHD.
• Genetic studies have primarily implicated 2 candidate genes .yje dopamine
transporter gene (DAT1) , and a particular form of the dopamine 4 receptor
gene (DRD4) in the development of ADHD

4. ETIOLOGY
• postnatal exposure to lead has traditionally been corelated with ADHD.
• Abnormal brain structures are linked to an increased risk of ADHD, because
1/5 of children with severe TBI are reported to have subsequent onset of
substantial symptoms of impulsivity and inattention.
• Structural abnormalities include dysregulation of the frontal subcortical
circuits ,small cortical volumes in this region ,small volume reduction
throughout the brain and abnormalities of the cerebellum have been
identified in children with ADHD without existing identifiable brain injury.
• Psychosocial family stressors may contribute or exacerbate the symptoms
of ADHD.

5. PATHOGENESIS
• MRI studies indicate loss of normal asymmetry in the brain , in
addition to smaller brain volumes of specific structures such as
prefrontal cortex and basal ganglia of 5-10% reduction.
• Functional MRI findings suggest low blood flow to the striatum.
• Dopamine Hypothesis : Disturbances in the dopamine system may be
related to the onset of ADHD.
• Fluorodopa Positron Emission Topography scans have also supported
the dopamine hypothesis through the identification of low levels of
dopamine activity in adults.

6. CLINICAL MANIFESTATIONS
• The current DSM –IV criteria state that the behaviour must be
developmentally inappropriate must begin before 7 years of age , must be
present for at least 6 months ,must be present in 2 or more settings and
must not be secondary to another disorder.
• Types of ADHD:
oAttention deficit /Hyperactivity Disorder –Inattentive type often includes
cognitive impairment.
oAttention deficit /Hyperactivity Disorder – Hyperactivity type
oAttention deficit / Hyperactivity Disorder- combined type – commonly seen
in males

7. CLINICAL MANIFESTATIONS
• Symptoms may vary from motor restlessness & aggressive &
disruptive behaviour common in preschool children, to
• disorganized, distractible, and inattentive symptoms -older
adolescents and adults.
• ADHD is often difficult to diagnose in preschoolers because
distractibility and inattention are often considered developmental
norms during this period.
• Impaired fine motor movement and poor coordination and other
soft signs (finger tapping, alternating movements, finger-to-
nose, skipping, tracing a maze, cutting paper) are common

9. ASSESSMENT
Clinical Interview and History
• The clinical interview allows a comprehensive understanding of whether the symptoms meet the
diagnostic criteria for ADHD.
• History of the presenting problems
• Childs overall health and development
• Social history
• Family History
• Factors that might affect the development or integrity of the central nervous system or reveal
chronic illness
• Sensory impairments
• Medication use that might affect the child ’ s functioning.
• Disruptive social factors : such as family discord, situational stress, and abuse or neglect, can
result in hyperactive or anxious behaviors.
• A family history of 1st-degree relatives with ADHD, mood or anxiety disorders, abuse might
indicate an increased risk of ADHD and/or comorbid conditions.

10. ASSESSMENT
• Behavior Rating Scales
• Behavior rating scales are useful in establishing the magnitude and pervasiveness of the
symptoms, but are not sufficient alone to make a diagnosis of ADHD.
• Well established behavior rating scales :Vanderbilt ADHD Diagnostic Rating Scale, the Conner
Rating Scales (parent and teacher)ADHD Index
o Swanson, Nolan, and
o Pelham Checklist (SNAP); and
o ADD-H: Comprehensive Teacher Rating Scale (ACTeRS).
o Other broadband checklists, such as the Achenbach Child Behavior Checklist (CBCL), are useful,
particularly in instances where the child may be experiencing co-occurring problems in other
areas (anxiety, depression, conduct problems).

11. Physical Examination and Laboratory Findings
• There are no laboratory tests available to identify ADHD in children.
• The presence of hypertension, ataxia, or a thyroid disorder should prompt further diagnostic
evaluation.
• Impaired fine motor movement and poor coordination and other soft signs (finger tapping,
alternating movements, finger-to-nose, skipping, tracing a maze, cutting paper) are common, but
they are not sufficiently specific to contribute to a diagnosis of ADHD.
• The clinician should also identify any possible vision or hearing problems.
• The clinician should consider testing for elevated lead levels in
• children who present with some or all of the diagnostic criteria, if these children are exposed to
environmental factors that might put them at risk (substandard housing, old paint).

12. Differential Diagnosis
• Chronic illnesses, such as migraine headaches, absence seizures, asthma and allergies, hematologic disorders,
diabetes, childhood cancer, affect up to 20% of children in the U.S. and can impair children ’ s attention and school
performance, either because of the disease itself or because of the medications used to treat or control the underlying
illness (medications for asthma, steroids, anticonvulsants, antihistamines) .
• In older children and adolescents, substance abuse can result in declining school performance and inattentive
behavior.
• Sleep disorders, including those secondary to chronic upper airway obstruction from enlarged tonsils and adenoids,
often result in behavioral and emotional symptoms, although such problems are not likely to be principal contributing
causes of ADHD .
• Behavioral and emotional disorders can cause disrupted sleep patterns.
• Depression and anxiety disorders can cause many of the same symptoms as ADHD (inattention, restlessness, inability
to focus and concentrate on work, poor organization, forgetfulness), but can also be comorbid conditions.
• Adjustment disorders secondary to major life stresses (death of a close family member, parents ’ divorce, family
violence, parents ’ substance abuse, a move) or parent-child relationship disorders involving conflicts over discipline,
overt child abuse and/or neglect, or overprotection can result in symptoms similar to those of ADHD.
• Although ADHD is believed to result from primary impairment of attention, impulse control, and motor activity, there is a
high prevalence of comorbidity with other psychiatric disorders
• Of children with ADHD, 15-25% have learning disabilities, 30-35% have language disorders, 15-20% have diagnosed
mood disorders, and 20-25% have coexisting anxiety disorders.
• Children with ADHD can also have co-occurring diagnoses of sleep disorders, memory impairment, and decreased
motor skills.

14. TREATMENT
Psychosocial Treatments
• Once the diagnosis of ADHD has been established, the parents and child should be educated with
regard to the ways ADHD can affect learning, behavior, self-esteem, social skills, and family
function. The clinician should set goals for the family to improve the child ’ s interpersonal
relationships, develop study skills, and decrease disruptive behaviors.
Behaviorally Oriented Treatments
• Treatments geared toward behavioral management often occur in the time frame of 8-12 sessions.
The goal of such treatment is for the clinician to identify targeted behaviors that cause impairment in
the child ’ s life (disruptive behavior, difficulty in completing homework, failure to obey home or
school rules) and for the child to work on progressively improving his or her skill in these areas.
• The clinician should guide the parents and teachers in implementing rules, consequences, and
rewards to encourage desired behaviors.
• In short-term comparison trials, stimulants have been more effective than behavioral treatments
used alone;
• behavioral interventions are only modestly successful at improving behavior, but they may be
particularly useful for children with complex comorbidities and family stressors, when combined with
medication.

15. Medications
• The most widely used medications for the treatment of ADHD are the psychostimulant medications,
including methylphenidate (Ritalin, Concerta, Metadate, Focalin, Daytrana), amphetamine, and/or various
amphetamine and dextroamphetamine preparations (Dexedrine, Adderall, Vyvanse) .
• The clinician should prescribe a stimulant treatment, either methylphenidate or an amphetamine
compound.
• If a full range of methylphenidate dosages is used, approximately 25% of patients have an optimal
response on a low ( < 20 mg/day), medium (20-50 mg/day), or high ( > 50 mg/day) daily dosage; another
25% will be unresponsive or will have side effects, making that drug particularly unpalatable for the family.
• Over the first 4 wk, the physician should increase the medication dose as tolerated (keeping side effects
minimal to absent) to achieve maximum benefit. If this strategy does not yield satisfactory results, or if
side effects prevent further dose adjustment in the presence of persisting symptoms
• If a methylphenidate compound is unsuccessful, the clinician should switch to an amphetamine product.
• If satisfactory treatment results are not obtained with the 2nd stimulant, clinicians may choose to prescribe
atomoxetine, a noradrenergic reuptake inhibitor that is superior to placebo in the treatment of ADHD in
children, adolescents, and adults and that has been approved by the U.S Food and Drug
Administration(FDA) for this indication. Atomoxetine should be initiated at a dose of 0.3 mg/kg/day and
titrated over 1-3 wk to a maximum dosage of 1.2-1.8 mg/kg/day.
• Guanfacine, an antihypertension agent, is also FDA approved for the treatment of ADHD.

17. PROGNOSIS
• A childhood diagnosis of ADHD often leads to persistent ADHD throughout the life span. From 60-
80% of children with ADHD continue to experience symptoms in adolescence, and up to 40-60%
of adolescents exhibit ADHD symptoms into adulthood.
• In children with ADHD, a reduction in hyperactive behavior often occurs with age.
• Other symptoms associated with ADHD can become more prominent with age, such as
inattention, impulsivity, and disorganization, and these exact a heavy toll on young adult
functioning.
• A variety of risk factors can affect children with untreated ADHD as they become adults.
• These risk factors include engaging in risk-taking behaviors (sexual activity, delinquent behaviors,
substance use), educational underachievement or employment difficulties, and relationship
difficulties.
• With proper treatment, the risks associated with the disorder can be significantly reduced.

18. REFERENCES
•Jan Stephen Tecklin, PEDIATRIC
PHYSICAL THERAPY.FIFTH EDITION.
pgno:108-112