2. To provide evidence-based guidelines in the
assessment and management ofADHD in
children and adolescents.
3. • What is ADHD?
•What are the risk factors?
• How is ADHD recognized and diagnosed?
•What are the associated co-morbidities?
• How is ADHD treated?
•What is the pharmacological treatment?
4. • How should pre-schoolers be managed?
•What are the non-pharmacological treatment
modalities?
• Is there a role for alternative therapy?
•When and to whom do primary care providers and
teachers refer?
•What is the follow-up plan?
• Can treatment be stopped?
5.
6. Attention Deficit Hyperactivity Disorder (ADHD) is
one of the most frequently encountered childhood-
onset neuro-behavioural disorders in primary care
settings.
It has defining features of inattention, over-activity
and impulsivity.The core symptoms co-exist with
other emotional, behavioural and learning
disorders.
7. Often primary care physicians, paediatricians,
psychiatrists and others are asked to evaluate and
treat a child who has disruptive relationships with
peers, defies parental discipline and does poorly in
school.
Early recognition, assessment, and management of
this condition can improve the educational and
psychosocial difficulties faced by the child and
adolescent.
8. Screening of children 5 – 15 years of age
Part of an extensive community survey
Prevalence rate of 3.9 %.
It is 3x more common in males compared to
females.
9. NEGERI KEBANGSAAN TERENGGANU KELANTAN PAHANG
Prevalence
(Psychiatric
morbidity
among
children and
adolescence)
20.3%
13%
(NHMS II)
26.6%
Ketiga selepas
Melaka dan
Negeri Sembilan
20.5% 21.1%
10. 25%
9%
11%
5% 5% 5%
3% 3%
0%
5%
10%
15%
20%
25%
Percentage
H
y
p
e
r
a
c
t
i
v
i
t
y
A
n
x
i
o
u
s
P
h
y
s
i
c
a
l
i
l
l
n
e
s
s
S
o
m
a
t
i
c
c
o
m
p
l
a
i
n
t
C
o
n
d
u
c
t
L
o
w
i
n
t
e
l
l
i
g
e
n
t
E
l
i
m
i
n
a
t
i
o
n
S
o
c
i
a
l
b
a
c
k
w
a
r
d
Psychological symptoms
11. DSM CLASSIFICATION : ADHD
Di UK: 3 – 7% kanak-kanak sekolah (Goldman et al.
1998)
Di USA: 5% kanak-kanak sekolah (APA, 1978,
Szatmari, Offord, & Boyle, 1989).
Kanak-kanak berusia muda > kanak-kanak dewasa
Bandaraya, kawasan setinggan, SES rendah, kanak-
kanak di institusi
30 – 50% akan berterusan ke zaman remaja dan
dewasa
13. Kaitan kukuh di antara genetik, biokimia dan
struktur otak yang tidak normal dengan ADHD
Berdasarkan bukti-bukti dari:
Neuro-Imaging
MRI
Brain mapping (Bush et al. 1998)
Dopamine transporter density
14. Kanak-kanak ADHD mempunyai risiko 2-8x
mempunyai ibubapa juga penghidap ADHD.
Anak lelaki boleh mendapat ADHD jika bapa
beliau seorang penghidap ADHD 3X
berbanding anak perempuan
15. Frontal Cortex yang lebih kecil (Hynd et al 1991)
Rt Prefrontal cortex yang lebih kecil (Castellanos
et al. 1996)
Corpus callosum; inf post vermis of
cerebellum yang lebih kecil (Mostofsky et al. 1998;
Berquin et al. 1998)
16. Kekangan sosial (SES rendah; Setinggan di bandar;
persekitaran kampung yang daif)
Merokok & pengambilan alkohol di kalangan ibu-
ibu semasa mengandung
Ibu yang menggunakan poly drug (heroin, cannabis,
ATS, benzodiazepines), terdedah kpd lead & PCB
(polychlorinated biphenyl).
Stress semasa mengandung (single parent, ibu yg
terlalu muda)
17. TV at age <3 yo associated with attention
problems at age 7yr.
TV <2yo should be discouraged.
TV limit 1-2 hr/day .
SUGAR does not affect in t the behavior or
cognitive performance.
Artificial color & preservative resulted in
hyperactivity
18.
19. SALAHTANGGAPAN
ADHD disebabkan oleh kegagalan ibubapa mengawal dan
mendisiplinkan anak mereka
Ramai ibubapa tertanya-tanya adakah mereka gagal
mendidik anak-anak mereka.
Mereka sering rasa bersalah kerana gagal mengawal
anak-anak mereka dari berkelakuan buas dan tidak
berdisiplin.(Cai, 2003).
FAKTA
ADHD adalah satu bentuk penyakit yang harus dirawat
secara berkesan dan bersepadu
20.
21. Assessment involves obtaining information from
parents, teachers and patients as well as conducting
a thorough clinical examination.
HISTORY
Detailed history including core symptoms of ADHD,
birth, developmental, family history. School
performance, functional impairment and
comorbidities.
22. PHYSICAL EXAMINATION
A comprehensive physical to exclude physical
conditions which mimic ADHD e.g.
hyperthyroidism, anaemia, visual and auditory
impairment, chronic adenoidal/ tonsillar
hypertrophy and obstructive sleep apnoea.
LABORATORY STUDIES
There is no diagnostic laboratory test for ADHD.
23.
24. No Questions Yes No Unsure
1 Does the child have difficulties paying attention?
2 Is the child forgetful?
3 Does the child often loses or misplaces things?
4 Does the child have poor academic performance?
5 Is the child easily distracted?
6 Does the child have difficulty in focusing on a task?
7 Does the child shift from task to task without completing any?
25. No Questions Yes No Unsure
8 Does the child often interrupt others?
9 Does the child tend to blurt answers even before the question is
completed?
10 Does the child have difficulty waiting for his/her turn in school and/
or social games?
11 Does the child frequently do dangerous things?
12 Does the child seem to be constantly on the move?
13 Does the child have difficulty remaining in his/her seat; fidgeting
excessively?
14 Does the child have difficulty engaging in quiet activities?
28. Terlalu aktif [Hyperactive]
Tiada daya tumpuan/ perhatian mudah
berubah- ubah [Inattentiveness]
Tindakan mendadak mengikut gerak hati
[Impulsive]
29. Terlalu Aktif Tiada daya tumpuan Tindakan mendadak
•Resah
•Gelisah
•Tidak boleh duduk diam
•Berlari
•Memanjat
•Tidak boleh bermain
secara senyap
•Sentiasa bergerak
•Banyak bercakap
Sukar mengurus kerja/
aktiviti
Sering lupa
Sering hilang barang-
barang kepunyaan
Aktiviti singkat dan
sering berubah-ubah
Sering berubah tumpuan
Cuai
Sukar mengekalkan
tumpuan
Tidak mendengar kata-
kata/ arahan
Tidak suka tugasan yang
memerlukan tumpuan
•Buat dulu baru fikir
•Sukar menunggu giliran
•Suka mengganggu orang
31. Mudah berfungsi secara satu-satu dari ramai-
ramai
Sukar berinteraksi dengan rakan sebaya atau
berada di dalam aktiviti berkumpulan
Sukar kekal dalam satu-satu aktiviti/
menghabiskan tugasan dengan baik/ sempurna
Sering kelihatan melanggar peraturan, engkar
atau bertindak di luar batas peraturan tanpa rasa
bersalah tetapi masih mendengar arahan
Cemerkap/ tidak cermat
32. Kurang peka terhadap masa
Sukar menghabiskan tugasan yang dikawal
dengan masa
Perkembangan emosi dan kebolehan terjejas
Gagal untuk merancang masa depan.
Masalah dengan daya ingatan jangka pendek
berbanding jangka panjang
33. Mudah meragam, meletup
Emosi yang sering berubah-ubah
Sukar mengawal tuturkata
34. Tidak begitu popular
Sukar berinteraksi dengam adik beradik, rakan sebaya,
ibubapa atau guru
Sukar mengekalkan perhubungan yang berpanjangan
Sukar memberi kerjasama yang baik
Sukar menghormati / mengikuti peraturan dalam
permainan
Sering dikritik orang (tidak peka, degil, suka mengarah)
Sering disisih atau dipulaukan
35. 6 or more of the following:
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 has difficulty organizing tasks and activities
e) Often avoids, dislikes or is reluctant to engage in
tasks that require sustained mental effort (such as
schoolwork or homework
36. f) Often loses things necessary for tasks or activities
g) Often does not follow through on instructions
and fails to finish school work, chores, or duties
in the workplace (not due to oppositional
behavior or failure to understand instructions
h) Is often easily distracted by extraneous stimuli
i) Is often forgetful in daily activities
37. 6 or more of the following:
HYPERACTIVITY
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
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
38. IMPULSIVITY
a) Often blurts out answers before questions have
been completed
b) Often has difficulty awaiting turn
c) Often interrupts or intrudes on others (e.g. butts
into conversations or games
39. A diagnosis [DSM-IV-TR] is based on whether
symptoms involve inattention
OR hyperactivity–impulsivity, OR both. It is necessary
that the symptoms:
• are present across different settings (rumah,
sekolah,klinik,tempat awam)
• result in significant impairment and are present
for at least six months
• began before seven years of age
• are not explained by other psychiatric disorders
(i.e. pervasive developmental disorder, mood
disorder)
40.
41.
42.
43.
44. The following may also be mistaken for ADHD
Bipolar disorder
Oppositional defiant disorder
Learning disorder
Mild mental retardation
Epilepsy, thyroid disease
Psychosocial problems- grief, child abuse etc.
45. Studies have shown that ADHD children with
comorbidities have significantly more difficulties,
and a lower quality of life.
76.2% of ADHD children have at least one
comorbidity while 20% have at least two
comorbidities.
Studies have shown boys are more susceptible to
conduct problems while girls have more depressive or
anxiety disorders.
54. Improves core ADHD Sx at home, in classroom
and social situation (Spencer T & Biederman J. 1996; Greenhill et
al. 1999; Miller et al. 1999)
Suppresses physical and non physical aggression
in ADHD children, improves ability to follow rules
and improves relationship with peers and family.
(SpencerT & Biederman J. 1996 ; Biederman J et al. 2003)
Reduces emotional lability and distractibility.
(Charach A et al. 2004; Miller et al. 1999)
55. Improves core ADHD Sx at home, in classroom and
social situation (Spencer T & Biederman J. 1996; Greenhill et al.
1999; Miller et al. 1999)
Suppresses physical and non physical aggression in
ADHD children, improves ability to follow rules and
improves relationship with peers and family. (SpencerT
& Biederman J. 1996 ; Biederman J et al. 2003)
Reduces emotional lability and distractibility. (Charach
A et al. 2004; Miller et al. 1999)
57. SIDE EFFECTS MANAGEMENT
Anorexia After / with meal dose; high caloric food after school/bedtime; drug holidays; refer
dietician
Insomnia Wind down time after school; administer dose earlier in day; no afternoon dose; change
to short acting; consider adjunctive medications (anti depressants)
Rebound irritability Step down dosing; try long acting or combination short/ long acting drugs
Agitation Assess timing of Sx; consider co-morbid condition; reduce dose /change long acting;
consider alternative adjunctive medication
Tics Monitor if mild/ infrequent; weigh benefit-risk; consider alternative / adjunctive
medication;
Headache Assess timing; reduce dose with gradual return to therapeutic dose; try long acting
preparation; consider alternative/ adjunctive medication
Linear growth impairment Limit stimulant to high priority needs (weekend; drug holidays); consider alternative
medication
58. • The use of stimulants in children younger than 6
years is considered off-label.
• Some of the most commonly reported side
effects were irritability, crying and increased
emotional outbursts.
• Therefore medication should be prescribed with
caution and if used, lower doses and slower
titration is recommended.
59.
60. (i) Administration
Dosage, titration and side effects of medication are
shown in Appendix 4.
(ii) Side effects
Mild growth suppression over 2 years has been
documented in children. However there is no height
deficit when these children are followed up to
adulthood. It is recommended that serial plotting of
height and weight on growth charts should be
considered once to twice a year.
61. (iii) Potential for abuse
There have been concerns of substance abuse with
the use of stimulants. However studies have shown
that stimulants do not contribute to risk for
substance experimentation, use, dependence or
abuse by the time adulthood is reached, and may in
fact protect against later substance misuse.
62. (iv) Drug holidays
Drug holidays refer to periods when patients are allowed
by their doctors to temporarily stop their medications.
A common reason for drug holidays is to avoid side effects
of medication (sleep delay, appetite suppression and
perceived or real tolerance to therapy).
Drug holidays’ should be initiated in low stress times such
as vacations. They should not be initiated at the
beginning of the school year and around examination
periods or during stressful situations.
63.
64. 1. Psychoeducation
2. Parent training and behavioral
interventions
3. School based intervention
4. Occupational therapy
5. Diet intervention
6. Alternative intervention
7. Support group
65. Around the kitchen Kitchen stove Electricity
Tuck cords safely behind
the kitchen appliances to
avoid being pulled
Use safety locks on
drawers and cupboards
Let the child use plastic
and paper cups instead
of breakable glasses or
china
Avoid using table cloth to
avoid grabbing by
children
Turn all saucepan
handles to the rear of the
stove
Remove stove knobs if
you can or tape them so
it can’t be turned on by
children
Cover outlet with either
strong clear tape or
pronged plastic caps
Wind up excess length
or plugged in cords and
fasten it with rubber
bands or twist ties
66. Bathroom Children room Door and windows
Keep handy outside the
door the key or tool with
which you can unlock it
Check often for loose
eyes on stuffed toys or
other parts of the toys
that might come off
Throw out any broken
toys for safety reason
Don’t place crib or other
furniture that can be
climbed on nearby a
window
Open window from top if
possible
Attach bell to the door to
give warning signs if
children open the door
and wander out.
Christmas bell look
practical and attractive
67. Outside the house In the car
Check all outdoor equipments
regularly to make sure it’s safe
Cover swing chain with sections of
garden hose to avoid torn clothes and
provide more comfortable grip
Teach the child auto safety routine
Pull over the side of the road if there is
screaming or fighting in the car. Stay
there till everyone settle down
All sharp or heavy objects are to be in
the trunk not in the passenger seat
Never leave children unattended in a
car
68.
69. It is recommended that the clinician provide periodic
follow-up for the child and adolescent diagnosed with
ADHD.
This would include monitoring height, weight, blood
pressure, pulse, emergence of comorbidity and
medical conditions monitoring target outcomes and
adverse effects.
Treatment of ADHD should continue as long as the
symptoms persist and cause impairment.
70. Children with ADHD are eligible for registration with
the Ministry ofWomen, Family and Community
Development using the “Borang pendaftaran dan
cadangan penempatan kanak–kanak keperluan
khas” (BPKK1 (Pindaan 2003).
ADHD children requiring special education should
be registered with the Education Department using
the same forms.
71. The decision to stop medication will depend on the
child/adolescent :
being symptom-free for at least 12 months while on
medication, and
not deteriorating, or have symptoms re-emerging
when doses are missed or reduced
able to concentrate while not on medication
72. Teachers and primary healthcare staff need to
refer the child for medical attention if there
is:
Suspicion of ADHD
Management difficulties
73. Consult with or refer to Child andAdolescent
Mental Health Professionals when:
There is uncertainty about diagnosis
Managing preschoolers
There is a lack of response to treatment
Prominent co morbidities exist (e.g. substance
abuse)
Severe side effects of medication are present
