ADHD

1. Attention DeficitHyperactivity 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 issuspended from the school for jumping on his seat, teasingother children, and not following directions. He spends two tothree hours a night with homework that he never successfullycompletes. His mother wants to know what is wrong with herchild.The child is a victim of…………

4. Attention DeficitHyperactivity 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 LMental 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 ADHDPredominately 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 vocationalAdults Low self Legal difficulties ADHD esteem Motor vehicle accidents Injuries Smoking and substance abuse Adolescents

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

11. ADHD and the Brain PET scan showsDecreased blood flow to decreased glucose prefrontal cortex and metabolism throughout Diminished arousal ofpathways connecting to brain the Nervous Systemlimbic 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 withADHD 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 ZnSub clinical lead exposure: Serum Zinc- low levels in hyperinattention, antisocial activesbehavior, 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 attentionBlack WordsBlack 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 DiagnosisAnxiety Conductdisorder Opposition Disorder Depression Defiant Disorder

23. Comorbidities: ADHD 49% 11% 7% Depression 11% Conduct DisorderAnxiety

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 difficultiespersist into adolescence persistand adulthood Nelson’s Textbook of Pediatrics, 17th Ed p 109-110

25. Understanding Adult ADHDDo you have difficulty concentrating or focusing your attention onone thing?Do you often start multiple projects at the same time, but rarely finishthem?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 OptionsMedication 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 EducationInstruction 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 PhenydateBlocks NT transporterDecrease DA & NE uptakeIncreased DA in striatum &PFCImproves 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 acetylcholineImproves attention ,cognition Improves attention ,cognitionDosage-0.5mg/kg-1.2mg/kgDosage-0.5mg/kg-1.2mg/kg No abuse potential

40. PRE-FRONTAL CORTEX /DA /DA AtemoxetinePost- 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 TREATMENTParent behavior management training•Parenting skills training to implement BT programme at home•Contingency programme•Positive reinforcement•Time out•To ignore negative behaviorSocial 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