attention deficit hyperactivity disorder

1. ATTENTION-DEFICIT HYPERACTIVITY DISORDER

2. OVERVIEW
 Attention-Deficit Hyperactivity Disorder (ADHD)is a persistent pattern
of inattention, impulsivity and hyperactivity that interferes with
functioning.
 The underlying cause is unknown, although multiple factors thought to
increase the risk.
 Diagnosis is made by diagnostic and statistical manual of Mental
disorders (DSM-5) criteria, but requires several symptoms of both
inattention, impulsivity-hyperactivity, presence of symptoms for at
least six months and symptoms interfering with daily functions.

3. OVERVIEW
 Management is generally supportive ,offering guidance to families as
well as environmental modifications.
 In those for whom environmental modifications have not been
effective, medications can be started: the first line medicine of choice
is Methylphenidate.
 Symptoms generally improve with age, but up to 65 % children can
have symptoms that persist into adulthood.

4. EPIDEMIOLOGY
 Upto 3 % of school children meet the criteria for ADHD.
 Children are usually diagnosed between the ages of 6 to 12 years.
 It is more common in boys than girls (approximately 3:1) but girls are
often under diagnosed or misdiagnosed.

5. ETIOLOGY
The underlying cause of ADHD is unknown but factors thought to
increase risk include
 Family history of ADHD
 Prematurity and very low birth weight
 Exposure to tobacco, alcohol, smokes and drugs during pregnancy
 Lead exposure
 Acquired brain injury

6. ETIOLOGY
 Epilepsy
 Being a look after child
There is increased risk in those with a neurodevelopmental disorder,
which include
 Tic disorder
 Autistic spectrum disorder
 Intellectual disability
 Tuberous sclerosis and neurofibromatosis

7. PATHO-PHYSIOLOGY
The patho-physiology of ADHD is multi faceted, with a complex
interaction of environmental and genetic factors.
 Children with ADHD have 5-10 % reduction in brain volume.
 Disturbances in dopamine system
 Functional MRI shows low blood to the striatum
 Alteration in DAT1and DAT4 genes

8. CLINICAL PRESENTATION
Inattention
6 or more of the following symptoms-
 It is difficult to hold children’s attention to tasks or play activities
 Fail to give close attention in detail or make careless mistakes
 Often seems inattentive when spoken to directly
 Are easily distracted and forgetful in daily activities
 Have trouble organizing tasks and activities
 Often loose things necessary for tasks and activities
 Often doesn’t follow through instructions
 Often dislikes or avoids or is reluctant to engage in tasks that require
sustained mental effort
More common as presenting feature in girls

9. CLINICAL PRESENTATION
Hyperactivity and impulsivity
6 or more of the following symptoms-
 Often fidget with their hands and feet, squirm in their seats
 Will often leave the seat in situation where remain to be seated expected
 Run about or climb in situations where it is not appropriate
 Talk excessively
 Often blurt out the answer before a question has been fully asked
 Interrupt others
 Have trouble waiting their turn
 Are always on the go
 Are unable to take part in leisure activities quietly
More common as presenting feature in boys

10. DIAGNOSIS
Diagnosis is clinical, requires a detailed history from parents, school and
other professionals
For diagnosis DSM-V criteria requires
 Symptoms to have been present for > 6 months
 Symptoms are to an extent that hey are disruptive and inappropriate
for the child’s developmental level
 Several symptoms were present before the age of 12 years
 Symptoms are present in two or more settings such as home and
school
 Symptoms are not explained by another disorder such as anxiety or
mood disorder

11. MANAGEMENT
Non-pharmacological
 Child should be referred to specialist pediatrician or psychiatrist
 Children and their families offered detailed explanations and support
 In children < 5 years an ADHD focused group parenting program
should be used
 In children > 5 years, families should be given ADHD related advice
and support which should include:
-Education and information on the causes and impact of ADHD
-Advice on parenting strategies
-Liaison with school

12. MANAGEMENT
 Environmental modifications
 Changes made to physical environment to minimize the impact of
ADHD in daily life
 These can include:
-Changes to lightings and noise
-Changes to seating arrangements
-Reducing distractions
-Offering shorter periods of focus at school with movement breaks
-Teaching assistants

13. MANAGEMENT
 Pharmacological treatment
 Children under the age of five years should not be offered drugs
without specialist assessment
 Children over the age of five years should be offered medication if
condition is still causing a persistent, significant impairment in at least
one domain, despite environmental modifications
 The first line medication of choice is methylphenidate
 Starting dose is 0.2 mg/kg/day which can be up to 0.5 mg/kg/day
 Lisdexamphetamine can be used if there is no improvement after six
months of use

14. MANAGEMENT
 Nor-adrenergic reuptake inhibitor
 Atomoxetine should be initiated in a dose of 0.3 mg/kg/day and
titrated over 1-3 weeks to a maximal dose of 1.2-1.4 mg/kg/day
 The dose should be divided into twice daily portions
 Once daily dosing appears to be associated with a high incidence of
treatment failure
 Tab Axepta (10 mg,25 mg,40 mg)
 Tab Attentrol (18 mg , 25 mg )
 Cap Tomoxetin (10 mg,25 mg,40 mg)

15. PROGNOSIS
 Symptoms of ADHD generally improves with age
 However, for around 65 % of children, some symptoms can persist
into adulthood, with continuing functional impairment of psychosocial
and educational difficulties.
 Children are more likely to develop conduct or mood disorders
 Children are more likely to be involved in crime, develop substance
misuse or be unemployed in later life.

16. FLASH CARDS
 A very low _ _ _ _ _ _ _ _ _ _ _ , as well as, being in _ _ _ _ ,
predispose a child to ADHD.

17. FLASH CARDS
 Diagnosis of ADHD requires symptoms of both inattention and
hyperactivity–impulsivity for a period of at least _ _ _ months.

18. FLASH CARDS
 Differentials for ADHD include _ _ _ _ _ _ _ disease and _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ disorder.

19. FLASH CARD
 The first-line medication for ADHD is _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ; if
there is no improvement after six weeks, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ can be used.

20.  The behavioural changes in attention-deficit/hyperactivity disorder
(ADHD) should met all the following criteria EXCEPT
 A. developmentally inappropriately far comparing with other children
of the same age
 B. must begin before age 6 yr
 C. must be present for at least for 6 mo
 D. must be present in 2 or more settings
 E. must not be secondary to another disorder

21.  You are assessing an eight-year-old male child with attention-
deficit/hyperactivity disorder (ADHD). Of the following, the LEAST
useful test/investigation is
 A. thyroid function test
 B. lead level
 C. EEG
 D. Blood film
 E. polysomnography

22.  Of the following, the MOST common presenting behaviour in girls
with attention deficit/ hyperactivity disorder (ADHD) is
 A. inattentive
 B. hyperactive
 C. impulsive
 D. disruptive
 E. combined