3. INTRODUCTION
Definition - persistent pattern of inattention and/or hyperactivity/impulsivity that is sore severe than typical of a child of the same level
of development.
Most common neurobehavioural disorder of childhood
Among the most prevalent chronic health conditions affecting school aged children
Most extensively studied mental disorder of childhood
Characterized by inattention, hyperactivity and impulsivity
Prevalence - occurs in most cultures in about 5% of children and 2.5% of adults
Male:female ratio - 2:1 children and 1.6:1 adults
Females tend to be under diagnosed - present primarily with inattentive features
4. AETIOLOGY
No single factor determines expression of ADHD
A. Genetic and hereditary factors -
Accounts for 80% of cases - 1s degree biological relatives
dopamine transporter gene (DAT1) and dopamine 4 receptor gene (DRD4)
B. Pregnancy factors
Smoking and drinking pregnancy
Perinatal infections low birth weight
Premature babies
Post natal cerebral complications
C. Brain injury
D. Chemicals - lead
E. Psychosocial family stressors - contribute or exacerbate symptoms
5. PATHOGENESIS
Decreased activity/ neurotransmitters DA and NE in brain regions associated with executive function - frontostrital
circuit
Frontostriatal circuit
Connects the prefrontal cortex and regions of the basal ganglia
Mediates motor, cognitive and behavioral functions within the brain.
Executive function abilities:
• Selection and perception of important information
• Manipulation of information in working memory
• Planning and organization
• Behavioral control
• Adaptation to changes
• Decision making
Smaller brain volume in prefrontal cortex, caudate nucleus and vermis of cerebellum
6. DEVELOPMENT & COURSE
Childhood - motor hyperactivity is predominant
Inattention becomes more prominent and impairing
Restlessness, inattention, poor planning and impulsivity persist
Relatively stable through adolescence
Substantial proportion of children with ADHD remain relatively impaired into adulthood
Functional consequences:
• Reduced school performance
• Social rejection
• Poor occupational performance
• Higher probability of unemployment
• Elevated interpersonal conflict - incarceration
• Substance use disorders
8. DIAGNOSTIC CRITERIA
A. Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development,
as characterized by (1) and/or (2):
1. Inattention - 6 or more of following symptoms have persisted for at least 6 months to a degree that is
inconsistent with developmental level and that negatively impacts directly on social and
academic/occupational activities.
a. Failure to give close attention to details
b. Difficulty sustaining attention in tasks or play activities
c. Does not seem to listen when to directly
d. Does not follow through on instructions
e. Difficulty organizing tasks and activities
f. Avoids/ dislikes or is reluctant to engage in tasks that require sustained mental effort
g. Often looses things necessary for tasks or activities
h. Easily distracted by extraneous stimuli
i. Forgetful in daily activities
9. DIAGNOSTIC CRITERIA
2. Hyperactivity and impulsivity - 6 or more
a. Often fidgets with or taps hands or feet or squirms in seat
b. Leaves seat in situations when remaining seated is expected
c. Runs about or climbs in situations where it is inappropriate
d. Unable to play or engage on leisure activities quietly
e. Is often ‘on the go’ , acting as if ‘driven by a motor’
f. Talk excessively
g. Blurts out an answer before question has been completed
h. Difficulty waiting his/her turn
i. Interrupts or intrudes on others
10. B. Several inattentive or hyperactive-impulsive symptoms were present prior to 12 years
of age
C. Symptoms were present in 2 or more settings
D. Symptoms interfere with or reduce the quality of social, academic or occupational
functioning
E. Symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder
DIAGNOSTIC CRITERIA
11. DIAGNOSTIC CRITERIA
TYPES
1. Combined presentation
2. Predominantly inattentive presentation
3. Predominantly hyperactive/impulsive presentation
Severity - mild, moderate and severe
In partial remission - full criteria were previously met, fewer than the full criteria have been
met for the past 6 months and the symptoms still results in impairment in social, academic/
occupational functioning
12. DIAGNOSIS
Made primarily in clinical settings after a
thorough evaluation
Important to gather and evaluate information
from a variety of sources
Child
Parents
Teachers
Physicians
Caretakers
1. Clinical interview
2. Physical examination
3. Investigations
13. DIAGNOSIS - HISTORY
• History of presenting problems
• Growth and development
• Pregnancy complications
• Maternal smoking, alcohol or illicit drug use
• Perinatal period - labour and delivery complications, prematurity, jaundice and LBW
• Disruptive social factors - family discord, situational stress, abuse and neglect
• Family history of ADHD - particularly 1st degree relatives with ADHD
CLINICAL INTERVIEW
16. TREATMENT
GENERAL AND SUPPORTIVE MEASURES
1. Parent counseling
Rules and limit-setting
Positive reinforcement of pro-social behavior
Consistent routine
2. Behavior-based interventions
Reward positive behavior
Improve social awareness and adjustment
3. Social skills
4. Identify learning difficulties and refer to educational support services
19. METHYLPHENIDATE - RITALIN
Dose - 1mg/kg/day PO
Initial dose - 5mg 2-3 times daily
Every 3- 3.5 hours
Breakfast, lunch/noon
Increase dose at weekly intervals by 5-
10mg until symptoms are controlled
Use lowest effective dose
Maximum daily dose- 60mg
Mechanism of action
Exact MOA is unknown
Blocks re-uptake of norepinephrine and dopamine
into the pre-synaptic neuron
Increases NE and DA in extraneuronal space
Contraindications:
1. Hyperthyroidism
2. Glaucoma
3. Concomitant MAO inhibitor therapy
20.
21. References
• American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental
Disorders. [Fifth edition]. Arlington, VA: American Psychiatric Association.
• Burns, J. King, H. Saloojee, S. 2007. KwaZulu-Natal Treatment Protocols for Mental
Health Disorders. KwaZulu-Natal: UKZN Department of Psychiatry.
• Department of Health. 2017. Standard Treatment Guidelines and Essential Medicines
List For South Africa: Hospital Level Pediatrics. The National Department of Health:
Pretoria.
• Ganti, L. Kaufman, M S. Blitzstein, M S. 2016. First Aid for the Psychiatry Clerkship.
New York: McGraw-Hill Education.
• Levitt, S (ed). Rotenberg, M (ed). Thom, R (ed). 2015. Psychiatry:
Neurodevelopmental Disorders.
Editor's Notes
Failure to give close attention to details or often make a careless mistakes in schoolwork, at work or during other activities. these patients will overlook or miss details and their work is usually inaccurate
They often have difficulty sustaining attention in tasks or play activities. they have difficulty remaining focus during lectures,conversations or lengthy readings
They often don’t seem to listen when spoken to directly. their mind seems elsewhere, even in the absence of any obvious distraction
They do not follow through on instructions and failed to finish schoolwork chores or duties in the workplace.they will start tasks quickly and then lose focus and easily sidetracked
They often have difficulty organizing tasks and activities.they have difficulty managing sequential tasks difficult, keeping materials and belongings in order. they usually messy, disorganized work, have poor time management and fail to meet deadlines.
They often avoid dislike was reluctant to engage in tasks that require sustained mental effort for example schoolwork or homework.for all the adolescents and adults preparing reports completing forms and reviewing lengthy papers
They often lose things necessary for tasks or activities. for example school materials pencils books tools wallet Keys paperwork eyeglasses mobile telephones
They are easily distracted by extraneous stimuli. folder adolescents and adults this may include unrelated thoughts
They often forgetful in daily activities for example doing chores running errands for old adolescents and adults it’s returning calls paying bills and keeping appointments.
They often fidget with or tap their hands or feet or squirm in their seat
They often leave their seat in situations when remaining seated is expected for example they leave his or her place in the classroom in the office or workplace or another situation that require remaining in place
They often run about to climb in situations where is inappropriate and adolescents and adults this may be limited to feeling restless
Unable to play or engage and leisure Activities quietly
They often on the goal and acting as if driven by motor they’re unable to be or uncomfortable being still for extended time as in restaurants meetings maybe experience by others as being restless or difficult to keep up with
They talk excessively
They often blurt out an answer before a question has been completed they complete other people sentences cannot wait for turn in conversation
Difficulty waiting his or her turn for example waiting in a line
Often interrupt or intrude on others butts into conversations games or activities may start using other peoples things without asking or receiving permission for adolescents and adults may intrude into or take over what others are doing
All these drugs increase dopamine.
The difference between stimulants and illicit stimulants like methamphetamine is that stimulants cause a slow release of dopamine where is methamphetamine or illicit substances release dopamine very quickly
The surge of dopamine release disrupts normal communication between neurons to produce euphoria. Therefore addictive
Controlled or slow release of dopamine in stimulants help to improve focus and attention
