3. 1. Definition
Attention-deficit/hyperactivity disorder
(AD/HD or ADHD)
•It is a neurobehavioral developmental
disorder, affecting preschoolers, children,
adolescents, and adults, characterized by
impulsiveness and inattention, with or without
a component of hyperactivity.(1)
(1)AmericanPsychiatricAssociation.Attention-deficit/hyperactivitydisorder.In:DiagnosticandStatisticalManualofMentalDisorders,FifthEdition,AmericanPsychiatricAssociation,Arlington,VA2013.p.59.
7. 3. Diagnosis (DSM V)
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or
development, as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the 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:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to
understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are
required.
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other
activities (e.g., overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during
lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any
obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, or duties in the workplace (e.g.,
starts tasks but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping
materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or
homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning
calls, paying bills, keeping appointments).
8. 3. Diagnosis (cont)
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have per sisted 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: Note: The symptoms are not solely a manifestation of oppositional
behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults
(age 17 and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the
classroom, in the office or other workplace, or in other situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be
limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for
extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep
up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences;
cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using
other people’s things without asking or receiving per mission; for adolescents and adults, may intrude into or
take over what others are doing).
9. 3. Diagnosis (cont)
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work;
with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational
functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better
explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder,
substance intoxication or withdrawal).
Specify whether:
314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met
for the past 6 months.
314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-
impulsivity) is not met for the past 6 months.
314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and
Criterion A1 (inattention) is not met for the past 6 months.
Specify if:
in partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months,
and the symptoms still result in impairment in social, academic, or occupational functioning.
Specify current severity:
Mild: Few, if any, symptoms in excess of those required to make the diagnosis are
present, and symptoms result in no more than minor impairments in social or occupational functioning.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe,
are present, or the symptoms result in marked impairment in social or occupational functioning.
10. 3. Diagnosis (cont)
• MRI studies reported decreased volume of
( cerebellar regions, splenium of corpus
callosum, total and right cerebral volumes,
and right caudate nucleus.(2)
• fMRI studies reported hypoactivation of right
inferior frontal cortex which is associated with
motor response inhibition in adult ADHD. (3)
(2)MartenH.Onninka,MarcelP.Zwiers. BrainalterationsinadultADHD:Effectsofgender,treatmentandcomorbiddepression.EuropeanNeuropsychopharmacology(2014)24,397–409
(3) SharonMorein-Zamir,ChrisDodds. HypoactivationinRightInferiorFrontalCortexis SpecificallyAssociatedWithMotorResponseInhibitioninAdultADHD.HumanBrainMapping(2014)
35:5141–5152
11. Changes in DSM V
• Symptoms must be present by the age of 12
years instead of age of 7 years.
• There are 3 subtypes instead of 2, combined,
predominant inattentive, and predominant
hyperactive/impulsive.
• DSM V permits diagnosis of ADHD with
comorbid autistic spectrum.
• In DSM V for adolescents 17 years and older,
and for adults, only 5 symptoms rather than 6
are required.
12. 4. Epidemiology
• Population surveys suggest that ADHD occurs in most cultures
in about 5-8% of children and about 2.5% of adults.(4)
• symptoms are difficult to distinguish from highly variable
normative behaviors before age 4 years.
• ADHD is more frequent in males than in females in the
general population, with a ratio of approximately 2:1 in
children and 1.6:1 in adults. Females are more likely than
males to present primarily with inattentive features.
(4) PolanczykG,deLimaMS,HortaBL,BiedermanJ,RohdeLA:TheworldwideprevalenceofADHD:asystematicreviewandmetaregressionanalysis.AmJPsychiatry2007,164:942–948.
13.
14. 7. Comorbidities
• ADHD exists alone in only about 1/3 of the
children diagnosed with it.
• Studies in adults with substance use
disorder (SUD) shows higher prevalence of
adult ADHD compared to general
population, with more severe course and
poorer treatment outcome (5)
(5) Geurt van de Glind, Maija Konstenius. Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: Results from an
internationalmulti-centerstudyexploringDSM-IVandDSM-5criteria. DrugandAlcoholDependence134(2014)158–166
15. 7. Comorbidities
• Patients with adult ADHD and early
use of cannabis have more severe
deficit in their executive functions(6)
(6)LeanneTamm,JefferyN.Epstein.ImpactofADHDandcannabisuseonexecutivefunctioninginyoungadults.DrugandAlcoholDependence133(2013)607–614
16. 7. Comorbidities
• A study on a sample of older youth (21-29) in
adult Scottish prisons reported that The
prevalence of ADHD was found to be 7%,
which is consistent with previous research,
and higher than that found in the general
population(7)
(7)VickiGordon,PeterD.Donnelly,DamienJ.Williams. RelationshipbetweenADHDsymptomsandanti-socialbehaviourinasampleofolderyouthsinadultScottishprisons,Personalityand
IndividualDifferences58(2014)116–121
17. 9. Prognosis
• The diagnostic criteria for ADHD dropped by
about 50% over three years after the
diagnosis.
• It persists in about 60-85% in adolescence,
and up to 60% of cases in adulthood.
• People with ADHD tend to work better in less
structured environments with fewer rules .
• Hyperactive types are likely to change jobs
often.
18. 10. Management
Behavioral interventions:
• Psychological therapies use to treat ADHD
include psychoeducation , behavior therapy,
cognitive behavioral therapy (CBT), interpersonal
psychotherapy (IPT), family therapy,
school-based interventions, social skills training,
and parent management training.
• Parent training and education have been
found to have short term benefits.
19. 10. Management (cont)
Pharmacological treatment:
•Stimulant medications are the most clinically and
cost effective method of treating ADHD.
•No significant differences between the various
drugs in terms of efficacy or side effects have
been found
20. 10. Management (cont)
Stimulant Medications
Methylphenidate, inhibits the reuptake of
dopamine and norepinephrine through inhibition
of the dopamine transporter system.
The amphetamines, diffuse into storage vessicles
and cause the release of dopamine to the
cytoplasm and blocks reuptake into the vessicle.
Mixed amphetamine salts include Adderall and
Adderall XR. It was reported in UK 2005 to cause
sudden cardiac arrest and increase risk of suicide.
21. 10. Management (cont)
common side effects
• rebound
• insomnia
• irritable mood
• tics
• decreased appetite which can lead
to weight loss and decelerated
growth in some children.
22. 10. Management (cont)
• There may be persistent cognitive
impairments (especially attention) in adult
ADHD despite medications, and the benefit of
stimulants seems to be reduced under
cognitive fatigue.(8)
(8) JunMaruta,LisaA.Spielman.PossibleMedication-ResistantDeficitsinAdultADHD, JournalofAttentionDisorders,(2014)1-11
23. 10. Management (cont)
• Memantine was found to help in
improvement of executive functions of
patients with adult ADHD, by modulation of
prefrontal glutamate and dopamine(9)
(9)vanWageningen,H.,Jorgensen,H.A.,Specht,K.,&Hugdahl,K.
(2010).A1H-MRspectroscopystudyofchangesinglutamateandglutamine(Glx)concentrationsinfrontalspectraafteradministrationofmemantine.CerebralCortex,20,798-803.
24. 10. Management (cont)
• Early age at initiation of methylphenidate
treatment in children with ADHD doesn’t
increase for negative outcomes, and even in non
ADHD children, no relationship between
exposure to methylphenidate and substance use
disorder in adulthood.(10)
(10)SalvatorMannuzzaS,Klein,NuhanL.Truong:AgeofmethylphenidatetreatmentinitiationinchildrenwithADHDandlatersubstanceabuse.AmJpsychiatry2008;165:604-609
25. 10. Management (cont)
Nonstimulant Medications
Atomoxetine (Strattera) is a non stimulant medication
that works by blocking the norepinephrine pump on the
presynaptic membrane which increases the availability
of intrasynaptic norepinephrine.
Antidepressant medications as a class, are used as
"second line" treatment for the ADHD disorders.
The two types used are buproprion and tricyclics
(SSRI's are not used to treat ADHD). Buproprion
blocks the reuptake of norepinephrine and
dopamine. Tricycylic antidepressants (Nortriptyline)
work by inhibiting the reuptake of norepinephrine
and serotonin
26. 10. Management (cont)
Dietary Supplements and Experimental
Treatments:
Dietary supplements and specialized diets
For example, Omega-3 supplementation may reduce
ADHD symptoms for a subgroup of children and
adolescents with ADHD "characterized by inattention
and associated neurodevelopmental disorders.“
• The effectiveness of these dietary supplements and
specialized diets is debated
• In the United States, no dietary supplement has been
approved for the treatment for ADHD by the FDA.
27. ADHD and pregnancy
• A study of 19 pregnant women, they
performed better on verbal memory tasks
after delivery than 2 months before delivery,
while no association between sex hormones
and cognitive impairments. (11)
(11)BuckualterJG,StanczyKFZ,McClearyCA:pregnancy,thepostpartum,andsteroidhormones:effectsoncognitionandmood.Psychoneuroendocrinology1999;24:69-84
28. ADHD and pregnancy
Recommendations are:
•Medication free trial
•Use of stimulant medications in severe cases. (12)
(12)MarleneP.Freeman:ADHDandpregnancy.AmJpsychiatry2014;171:723-728
29. 10. Management (cont)
Binaural auditory beats(13)
(13) Susan Kennel PhD, RN, CPNP, Ann Gill Taylor RN, EdD, FAAN, Debra Lyon PhD, RN, FNP, Cheryl Bourguignon RN, PhD (2010). Pilot Feasibility Study of Binaural Auditory Beats for Reducing
SymptomsofInattentioninChildrenandAdolescentswithAttention-Deficit/HyperactivityDisorder.JournalofPediatricNursing(2010)25,3–11
