1.
Attention Deficit
Hyperactivity Disorder
Dr. Santanu Ghosh, MD
Assistant Professor, Psychiatry
Tripura Medical College, Agartala

2.
The Difficult Child…..

3.
A mother brings her 8-year old son for evaluation after he is
suspended from the school for jumping on his seat, teasing
other children, and not following directions. He spends two to
three hours a night with homework that he never successfully
completes. His mother wants to know what is wrong with her
child.
The child is a victim of…………

4.
Attention Deficit
Hyperactivity Disorder

5.
ADHD ?
• A condition affecting children and adults
• Characterized by problems with:
Attention, Impulsivity Overactivity

6.
ADHD Prevalence
Physician office visits in 2001 9.7 L
Mental health referral for children 30-50%
Sex Ratio Male> Female
3-4:1
Children Prevalence : 7.5%
• 40- 70% of adolescence
Persists in • Up to 50% of adults

7.
Subtypes of ADHD
Predominately Predominately Combined type
Inattentive Hyperactive-Impulsive
Attention Deficit Hyperactivity Disorder

8.
ClinicalADHD: Etiology
Presentation
Inattentiveness
Difficulty sustaining Hyperactivity Impulsivity
attention
 Often fidgets
Makes careless mistakes in
Runs about/climbs Blurt s out answers
school work
Difficulty in obeying Difficulty awaiting turn
Fails to complete task
Often on the go Often interrupt others
Disinterest which requires
Talks excessively
mental effort
Forgetful, Often loses
things
• Impairment
• Duration >6 months

9.
ADHD Impact
ADHD Impact
Ch
Academic ild ren
limitations
Occupational/ Relationships
vocational
Adults
Low self
Legal
difficulties ADHD esteem
Motor vehicle
accidents Injuries
Smoking and
substance abuse
Adolescents

10.
ADHD: Etiology
Etiology
Neuroanatomical
Neurochemical
Environmental
(family) Genetic
ADHD origins
CNS
insults

11.
ADHD and the Brain
PET scan shows
Decreased blood flow to decreased glucose
prefrontal cortex and metabolism throughout
Diminished arousal of
pathways connecting to brain
the Nervous System
limbic system (caudate
nucleus and striatum)

12.
ADHD and the Brain
ADHD and the Brain cont..
MRIs of ADHD patients show:
Abnormal development in the frontal and striatal
Smaller anterior regions
right frontal lobe
Decreased communication and processing of
Significantly
information between hemispheres
smaller corpus
callosum
Immature basal ganglia
Smaller
caudate
nucleus

13.
Genetics
Dopamine genes
Parents with ADHD have > 50%
chance of having a child with ADHD •DA type 2 gene
•DA transporter gene (DAT1)
About 25% of children with
ADHD have parents who meet the Dopamine receptor (DRD4,
formal diagnostic criteria for “repeater gene”) is over-
ADHD represented in ADHD patients

14.
Genetics contd..
Learning of behavior
Motivation
Emotion
Working memory
Affects executive function & attention
DRD4 affect the post synaptic sensivity in the
prefrontal &frontal cortex.

15.
Catecholaminergic Neurotransmission
Catecholaminergic Neurotransmission
Relative to ADHD
Relative to ADHD
Dopamine Norepinephrine
• Striatal-prefrontal • Prefrontal
• Enhances signal • Dampens noises
• Improves attention - Distractibility
- Focus - Shifting
- Vigilance • Executive operations
- Acquisition • Increases inhibition
- On task behavior - Behavioral
- On task cognitive - Cognitive
- perception - Motoric
Solanto.Stimulant Drugs & ADHD. Oxford; 2001

16.
Dopamine in the Brain

17.
Other Causes
Brain insults such as injury to frontal
Environmental factors like Brain
insults such as injury to frontal
region, premature birth,
Injury complications during pregnancy, low
social class
Pb Zn
Sub clinical lead exposure: Serum Zinc- low levels in hyper
inattention, antisocial actives
behavior, Hyperactivity
(Bellinger 2004)

18.
Assessment & Diagnosis
 A good clinical history
A thorough developmental history
 Toddlers may be unable to be seated
 Pre school & school children may be hyperactive, naughty
 Older children are more inattentive.

19.
TOOLS - THE STROOP TEST to asses attention
Black Words
Black Words

20.
The Coloured words

21.
ADHD - Rating Scale
Prognosis of ADHD
Conner’s
Home School Teachers
Version Version Rating
Scale
• Contains a set of
• Contains a set of • Aged 3-17 years
18 questions
18 questions
• Addressing • Contains 28 or 39
• Addressing attention questions
learning abilities,
attention and • Addresses
organizing
behavior Conduct problem,
abilities,
hyperactivity,
behavior and inattentive-passive,
memory and hyperactivity

22.
Differential Diagnosis
Anxiety Conduct
disorder Opposition Disorder
Depression Defiant
Disorder

23.
Comorbidities:
ADHD
49%
11%
7%
Depression
11%
Conduct Disorder
Anxiety

24.
Prognosis of ADHD
With a
combination of
medication and
If not properly psychosocial and
treated individuals behavioral
across age-span are interventions most
at risk children’s
With increasing age symptoms are
•Hyperactivity decreases ameliorated
•Inattention, impulsivity,
80% of affected children disorganization &
symptoms of ADHD relationship difficulties
persist into adolescence persist
and adulthood
Nelson’s Textbook of Pediatrics, 17th Ed p 109-110

25.
Understanding Adult ADHD
Do you have difficulty concentrating or focusing your attention on
one thing?
Do you often start multiple projects at the same time, but rarely finish
them?
Do you have trouble with organization?
 Do you procrastinate on projects that take a lot of attention to detail?

26.
Understanding Adult ADHD contd..
 Do you have problems remembering appointments or obligations?
 Do you have trouble staying seated during meetings or other
activities?
 Are you restless or fidgety?
 Do you often lose or misplace things?

27.
Treatment Goals
• A child-specific, individualized treatment program should be
developed for children
• A goal of maximizing function to
– improve relationships and performance at school,
– decrease disruptive behaviors,
– promote safety,
– increase independence and
– improve self esteem.

28.
Treatment Options
Medication Behavioral Therapy Psychotherapy Educational
Techniques

29.
Treatment Options
• Medications are the first line of choice for ADHD management
– Help treating the core symptoms of ADHD
• Psychotherapy and behavioral therapies
– Effective in management of co morbid disorders with ADHD

30.
Childhood ADHD: Treatment
The Triangle principle
Pharmacotherapy
Parents
School
Education
Instruction
and BT

31.
Medications
• Stimulants
– Methylphenidate & derivatives
– Amphetamine & derivatives
• Non – Stimulants
– Antidepressants
– Antipsychotics
– Atomoxetine

32.
How do Stimulants Act?
• Non specific in action
• Increase levels of dopamine and
norepinephrine
• Increase dopamine levels in
– PFC
– Striatum
– Nucleus accumbens

33.
Stimulants – The Problem
•Abuse Potential
•Tics
•Anorexia
•Insomnia

34.
Stimulants - Methylphenydate
Methyl Phenydate
Blocks NT transporter
Decrease DA & NE uptake
Increased DA in striatum &
PFC
Improves hyperactivity &
attention

35.
Atomoxetine
• Initially developed as an antidepressant however found
more effective in ADHD
• Initially called as Tamoxetine but name changed to
atomoxetine to avoid confusion with tamoxifen (for
advanced breast cancer)

36.
Mode of Action of Atomoxetine
• Selective NE reuptake inhibitor
• Inhibits NE/DA re uptake in PFC (NET>DAT)
– DA taken up by NET in PFC
• Increase in extra-cellular NE (not DA) in subcortex (nucleus
accumbens/striatum)
• But no increase in DA in sub-cortex & hence no tics/abuse

37.
Mode of Action (cont’d…)
• A highly selective and a potent inhibitor of presynaptic NE
transporter
• Increases extracellular concentrations of DA 3 fold in
prefrontal cortex
• Does not alter DA concentrations in striatum and nucleus
accumbens
– No motoric or abuse potential
• Increases levels of catecholamines in PFC
Bymaster FP, et al, Neuropsychopharmacology, 2002, 27(5), 699 - 711

38.
Action on Dopamine
• In PFC Dopamine moves with the aid of NE transporter
• Lack of dopamine transporters in PFC
• Atomoxetine blocks NE transporter and increases DA in
synaptic cleft

39.
Atomoxetine
Release acetylcholine
Release acetylcholine
Improves attention ,cognition
Improves attention ,cognition
Dosage-0.5mg/kg-1.2mg/kg
Dosage-0.5mg/kg-1.2mg/kg
No abuse potential

40.
PRE-FRONTAL CORTEX
/DA /DA
Atemoxetine
Post- Post-

41.
Indications
• FDA approved in November 2002 for treatment of ADHD
• The first non stimulant drug for ADHD after debut of
methylphenidate for about 40 years

42.
Recent Warnings
• Atomoxetine increased the risk of suicidal ideation in short-term
studies in children or adolescents with Attention Deficit/Hyperactivity
Disorder (ADHD).
• Patients started on therapy should be monitored closely for suicidal
thinking and behavior.

43.
Precautions
• Suicidal thought
• Severe liver injury
– To be discontinued in patients with jaundice or
laboratory evidence of liver injury, and should not be
restarted

44.
Other agents
• TCAs (desipramine or imipramine) cardiotoxicity
• Bupropion – anti depressant activating than sedating, insomnia,
lower seizure threshold & tics

45.
NON PHARMACOLOGICAL TREATMENT
Parent behavior management training
•Parenting skills training to implement BT programme at home
•Contingency programme
•Positive reinforcement
•Time out
•To ignore negative behavior
Social skills training
•Aim is to develop social relationship
•Waiting for turn, sharing toys ,asking for help.

46.
Non pharmacological treatment
CBT - Cognitive Behavior Therapy
 helpful in adolescents, they recognizes social cues,
determines action in situations
Other behavioral
 Daily activity scheduling
Training teachers / school