Hyperactive Child

1. PRESENTER-Dr.Sri harsha
MODERATOR-Dr.Nirmala

2. 1
INTRODUCTION
2
EPIDEMIOLOGY & ETIOLOGY
3 PATHOGENESIS
4 CLINICAL FEATURES
5 DIFFRENTIAL DIAGNOSIS
6 APPROACH TO DIAGNOSIS
7
8
NUT SHELL
MANAGEMENT & PREVENTION

3. INTRODUCTION
• Attention-deficit hyperactivity disorder (ADHD) is
Neurobehavioural disorder characterized by developmentally
inappropriate motor hyperactivity, inattention and
impulsiveness leading to impairment at home and school.
• Impairment in academic and social functioning along with skill
deficits render such children to academic failures and social
isolation leading to demoralization, poor self-esteem,
delinquency and substance use.

4. TIMELINE OF EVOLUTION OF DIAGNOSIS
1960’s
“Hyperkinetic reaction of
childhood” enters the DSM-
2(1968)
1990’s
DSM-4(1994) evidence-based
redefinition of ADHD criteria
NIMH Conference to review
state of ADHD diagnosis and
treatment (1998).
1930’s
Clinical use of “minimal brain
damage” and then “ minimal
brain dysfunction”
1980’s
DSM-3(1980) “hyperkinetic
syndrome changed to
“attention deficit disorder with
or without hyperactivity” in
DSM-3-R(1987)
2000’s
AAP Practice guidelines for
primary care providers (2001)
DSM-5 criteria (2013)
1902
George Still published in
LANCET

5. EPIDEMIOLOGY
• Worldwide studies report prevalence of ADHD in children to be
between 3% and 9%.
• ADHD affects both genders with male to female ratio of up to 10:1.
• Prevalence rates of ADHD in the Indian subcontinent vary from 5% to
15.5% with the male to female ratio ranging from 3 to 6.4:1
• The Indian Council of Medical Research reported prevalence rate of
hyperkinetic disorders to be 1.6% among children aged 4–16 years
with higher rates in urban middle class (3.7%), than slum (1.2%) and
rural areas (0.5%).

6. FAMOUS PERSONALITIES WITH ADHD

7. ETIOLOGY
• Environmental factors:
• -Maternal
• -External factors
• Genetic factors:
•

8. ETIOLOGY

9. ETIOLOGY
• Genetic’s: Family studies have found two- to eight-fold higher rates of
ADHD in affected families in comparison to their healthy unaffected
relatives.
• Twin studies have observed higher concordance rates in monozygotic
compared to dizygotic twins.
•
• There is a strong genetic component to ADHD.
• Genetic studies have primarily implicated 2 candidate genes, the
dopamine transporter gene (DAT1) and a particular form of the
dopamine 4 receptor gene (DRD4), in the development of ADHD.

10. ETIOLOGY
• Genetic syndromes:
• Fragile X syndrome, tuberous sclerosis and Smith-
Magenis syndrome, and Fetal alcohol syndrome.
• Psychosocial family stressors can also contribute
to or exacerbate the symptoms of ADHD, including
poverty, exposure to violence, and malnutrition.

11. PATHOGENESIS
• Neuropsychological Studies:
• An alteration in the corticostriatal circuitry has been implicated in ADHD.
• This circuit includes the dorsolateral prefrontal cortex (DLPFC) and anterior
cingulate cortex (ACC), the dorsal striatum (especially the caudate nucleus)
and the thalamus, linking to the cerebellum.
• The DLPFC has role in response inhibition, working memory, planning and
organizing behavior.
• The ACC apart from its role in cognition and motor control, govern the
arousal/drive state.
• Dorsal striatum modulates responses and the cerebellum coordinates
motor activities and attention.

13. PATHOGENESIS
• Neurochemistry of ADHD:
• Dopaminergic neural circuits are suggested to play a
major role in altered reward processing mechanism
endorsed by ADHD.
• Other factors implicating dopamine hypothesis are: drugs
(like methylphenidate) utilized in managing ADHD act on
dopaminergic synapses; linkage of various dopamine
transporter and receptor genes to ADHD.

15. PATHOGENESIS
• Neurophysiological Studies:
• Few electroencephalograph (EEG) studies report
increased slow wave activity (predominantly theta) in
frontal region.
• whereas others have shown decreased delta and
increased beta percent power over the left hemisphere,
indicating both under-arousal and over-arousal in
ADHD.

18. PATHOGENESIS
• Structural Neuroimaging:
• Decrease in overall total brain size is the most consistent finding
being reported.
• Magnetic resonance imaging (MRI) studies report of decreased right
prefrontal cortex volume, reversal or loss of asymmetry of caudate
nucleus volume (usually right caudate nucleus is larger than the
left), lack of age-related decrease in caudate volume (usually
caudate nucleus volume decreases with age in males), smaller size
of globus pallidus, and decreased volume of corpus callosum.

20. CLINICAL FEATURES
• The core symptoms of ADHD are hyperactivity, impulsivity and
inattention.
• While teachers usually complain of creating nuisance in the
classrooms and deterioration of academic performance, parents
report a lack of interest in activities requiring sustained effort or child
being constantly “out of control”.
• The symptoms suggestive of the disorder need to be present in two or
more setting (at home, at school, during play, in social gatherings,
etc.); present for at least 6 months; and must be severe enough to
interfere with functioning in various settings.

21. CLINICAL FEATURES
• Symptoms of Hyperactivity:
• Excessive fidgetiness (e.g., tapping hands or feet,
squirming in seat)
• • Difficulty remaining still when sitting is expected
(e.g., at dinner, school, etc.)
• • Excessive talking, difficulty playing quietly
• • Run around a lot, always “on the go”.

22. CLINICAL FEATURES
• Symptoms of Impulsivity:
• Impatient, difficulty waiting turns, interrupt
conversations or others’ activities
• Blurt out inappropriate statements/answers too
quickly
• Express emotions without restraint
• Act without considering consequences.

23. CLINICAL FEATURES
• Symptoms of Inattention :
• Easily distractible, frequently switch from one task to another, forgetfulness in routine activities
(e.g., homework, chores, etc.)
• Difficulty in focusing on organizing and completing an activity or learning something new in play,
school, or home activities.
• Avoids tasks that require consistent mental effort.
• Gets easily bored, unless doing some enjoyable activity.
• Misses details, makes careless mistakes, often loses belongings (e.g., pencils, toys, books)
• Seems not to listen when spoken to
• Have difficulty in following instructions as quickly and accurately as others.

24. CLINICAL FEATURES
• The symptoms may secondarily dispose a child towards
difficulty in forming friendships, peer rejection, poor self-
esteem, and increased risk for depression and anxiety.
• The symptoms should also not be part of another
psychotic disorder.

25. PRESENTATION IN ADHD
• Based on the types of symptoms, three kinds (presentations) of ADHD can
occur:
• Combined Presentation: if enough symptoms of both criteria inattention
and hyperactivity-impulsivity were present for the past 6 months.
• Predominantly Inattentive Presentation: if enough symptoms of inattention,
but not hyperactivity-impulsivity, were present for the past six months.
• Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of
hyperactivity-impulsivity but not inattention were present for the past six
months.

26. DIFFRENTIAL DIAGNOSIS

27. DIFFRENTIAL DIAGNOSIS

28. DIAGNOSTIC CRITERIA
• DSM-5 Criteria for ADHD
• People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that
interferes with functioning or development:
• Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for
adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months:
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with
other activities.
• Often has trouble holding attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (e.g., loses focus, side-tracked).
• Often has trouble organizing tasks and activities.
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time
(such as schoolwork or homework).
• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets,
keys, paperwork, eyeglasses, mobile telephones).
• Is often easily distracted.
• Is often forgetful in daily activities.

29. DIAGNOSTIC CRITERIA
• 2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity
for children up to age 16, or five or more for adolescents 17 and older and adults;
symptoms of hyperactivity-impulsivity have been present for at least 6 months to
an extent that is disruptive and inappropriate for the person’s developmental
level:
• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may
be limited to feeling restless). Often unable to play or take part in leisure activities quietly.
• Is often "on the go" acting as if "driven by a motor".
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting his/her turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

30. DIAGNOSTIC CRITERIA
• In addition, the following conditions must be met:
• Several inattentive or hyperactive-impulsive symptoms were present before age 12
years.
• Several symptoms are present in two or more setting, (e.g., at home, school or work;
with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the quality of,
social, school, or work functioning.
• The symptoms do not happen only during the course of schizophrenia or another
psychotic disorder. The symptoms are not better explained by another mental
disorder (e.g. Mood Disorder, Anxiety Disorder, or a Personality Disorder).

31. BASED ON SEVERITY
• Mild: Few, if any, symptoms in excess of those required to make the
diagnosis are present, and if the symptoms result in no more than minor
impairments in social and 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.

32. APPROACH TO DIAGNOSIS
• Every child visiting the clinic should be assessed for ADHD.
• The evaluation comprises of medical, developmental,
behavioral, educational and psychosocial perspectives.
• The assessment should include careful and detailed medical,
social, and family history taking; clinical interviews and
observation of the child with and without the parent; gathering
information about functioning in child care center or school
(from teachers) and at home (from parents/ caregivers); and
assessment for coexisting emotional or behavioral disorders.

33. APPROACH TO DIAGNOSIS
• Medical Evaluation:
• An evaluation of child and family, dietary history and daily
sleep pattern should be undertaken before initiating
medications.
• The physical examination including a complete
neurological examination should be undertaken.
• Regular monitoring of vital signs, height, weight and head
circumference aids in assessment of medication effects.

34. APPROACH TO DIAGNOSIS
• Developmental and Behavioral Evaluation:
• A thorough assessment should be conducted regarding:
• Developmental history, particularly language
milestones.
• Onset, duration, course, and degree of functional
impact of ADHD symptoms.
• Behavior at home and school.

35. APPROACH TO DIAGNOSIS
• Open-ended questions or questionnaires may
be utilized to acquire historical information
regarding symptoms.
• Example of a questionare was developed by
INCLEN international Delhi and was being
followed in AIIMS

36. EXAMPLE

37. EXAMPLE

38. EXAMPLE

39. EXAMPLE

40. EXAMPLE

41. EXAMPLE

42. CASE 1
• A 9 year boy has been referred to a child Psychiatrist at
the request of his school teacher, because of the
difficulties he creates in class.
• His teacher complains that:
◦ He is so restless that the rest of the class is unable
to concentrate
◦ He is hardly ever in his seat and roams around in the
class
◦ Talks to other children while they are working
◦ He seems to have no control over his behavior which
is unpredictable and can even be quite outrageous

43. • His mother says that his behavior has been difficult since he
was a toddler
• Even when he was around 4-years old he was unbearably
restless, demanding and forgetful about his daily activities
• He required little sleep and awoke before anyone else
• When he was five, he had managed to unlock the door of the
house and wander off into a busy Main Street
• Fortunately, he was rescued from the oncoming traffic by a
passerby
• He was asked to leave a play school because of his difficulty
in following instructions and paying attention in class

44. • Presently he avoids doing his home work.
• He has minimal interest in TV (only a few selected
programs), and dislikes games or toys that require
prolonged concentration or patience.
• At home he prefers to be outdoors. However, he is not
popular with other children because he cannot await his
turn and picks up fights easily.
• Whenever he plays with toys, his games are messy and
destructive, and his mother cannot get him to keep his
things away tidily.

45. What symptoms of ADHD does this boy have? List out his
symptoms of inattention, hyperactivity & impulsivity separately?

49. • Only inattention.
His behavior typically demonstrates the
characteristic inattention symptoms of ADHD
(A1-a, b, d, e, f, i)

50. CASE 2

51. • An 8 year old boy was brought to the OPD with
complaints of pharyngitis
• Through the open door, the physician noted that the child
was pushing others, running about and jumping from one
bench to the other when he was waiting outside. His
mother was having trouble trying to restrain him
• However, on entering the doctor's room, he was an alert,
quiet child who however kept on getting distracted by
noises outside

52. • On inquiry, the parents said that the child has been like this
since 6 years of age and frequently engages in dangerous
activities like jumping from walls, running on the road and
breaking household objects
• His teachers also frequently complain that his behavior
disturbs others in the classroom during classes
• He often leaves the seat in class and when seated fidgets with
hands or feet
• Nobody wants to sit next to him
• Even while playing in school he cannot remain engaged in one
game for more than ten minutes
• While playing cricket near home he can not wait for his turn for
batting.

53. • She was concerned that, he has difficulty in
concentrating in the class and got easily distracted
• She had been noticing these behaviours during past six
months.
• She also felt that he talks too much and often made
careless mistakes in his home work book
• His mother complained that he often lost pencils and note
books in school
• However she said that he could organize his activities like
preparing his school bag and keeping his toys in their
place
• He could also get ready for school on his own including
tying shoe laces and buttoning

57. • He fulfills the following criteria A1-a,c,d,e,g,h
(inattention)
• A2- a, b, c, d, e (Hyperactivity) and h
• (Impulsivity)
• These symptoms have been persisting for about one
year and affecting his school performance.
• Onset of symptoms was around 6 years of age.
• Hence, a diagnosis of ADHD can be made.

58. APPROACH TO DIAGNOSIS
• Behavior rating scales:
• Scales are useful for acquiring structured information of behavior, estimating symptom severity,
measure treatment response and may add to the validity of the diagnosis.
• However, none of the global rating scales can provide a definitive diagnosis.
• Narrow band scales focus on the core symptoms of ADHD and have a high sensitivity and specificity.
They have parent, teacher and patient versions.
• These include Vanderbilt assessment scales: can be used in children more than or equal to 4 years
• Conners Comprehensive Behavior Rating Scales: validated in preschool children
• and
• ADHD Rating Scale IV: validated in preschool children.
• Broadband scales assess a broad variety of behavioral symptoms, e.g., Child Behavior Checklist. They can
help to recognize comorbid conditions and make the differential diagnosis narrow.

60. APPROACH TO DIAGNOSIS
• Educational evaluation:
• Assessment of the functional impact of ADHD symptoms in
academic setting should be conducted utilizing information
regarding grades, absences, learning pattern, report cards,
samples of schoolwork, etc.
• Details of parent-teacher meetings should also be sought.

62. APPROACH TO DIAGNOSIS
• Psychosocial evaluation
• It is prudent to assess the impact of symptoms on the
psychosocial environment and vice versa which may provide an
alternative explanation for the symptoms.
• Social responses at home and school—play activities, peer
relationship, etc.
• Psychosocial stressors (death, divorce, or economical
constrains in family).

63. APPROACH TO DIAGNOSIS
• Neuropsychological testing:
• It may be valuable in assessing coexisting
conditions (like learning disabilities), excluding
other disorders, planning interventions, and
charting treatment progress.
• It can also help to identify specific problem areas
in like reasoning, cognitive flexibility, planning and
working memory.

64. APPROACH TO DIAGNOSIS
• Comorbid evaluation
• Multiple conditions may mimic or coexist with ADHD such as reported in Indian literature are
developmental delays, temper-tantrums, enuresis, tics, parental discord and parental
psychiatric illness.
• After the complete evaluation, a thorough discussion of the clinician with the parents is
recommended regarding the child problematic behavior with its appropriate management
measures.
• which may entail implementing a daily report card procedure prior to initiating a medication
trial or other psychosocial intervention.

65. MANAGEMENT
• An effective treatment strategy includes pharmacological and psychosocial
approach, intervening in the personal, social, educational and
occupational spheres.
• Before initiating treatment, clinician should discuss the myths regarding
ADHD.
• Regular follow-ups should be ensured to increase treatment adherence.

66. MANAGEMENT
• Pharmacological Intervention
• Pharmacological treatment relies on agents targeting dopamine and/or
norepinephrine receptors.
• Stimulants imply the most extensively available first-line treatment option for
ADHD.
• Stimulant medications should be used as supervised treatment in patients 6 years or
older with no medical contraindications meeting the diagnostic criteria for ADHD.
• As being an activating drug, they should be given in daytime.
• The general rule of “start low and go slow” approach is followed during drug
titration.

68. MANAGEMENT
• Other drugs approved by FDA having less abuse potential than
stimulants are atomoxetine and extended release formulations
of clonidine and guanfacine, which recently were approved as
an adjunctive treatment to stimulant therapy for treating
pediatric ADHD.

69. MANAGEMENT
• Psychosocial Intervention
• Psychosocial treatment is beneficial in cases where pharmacological treatment, despite its
effectiveness, may lead to intolerable side effects.
• Psychosocial treatments include psychoeducation, parent training, academic organization
skill teaching and remediation, behavior modification, social skills training and individual
therapy.
• This modality is preferred in children with age less than 6 years, mild symptomatology,
uncertain diagnosis and when preferred by parents.
• Behavioral parent training has been the most widespread and effective intervention being
advised to preschool and school age children with oppositional and socially aggressive
behavior.

71. MANAGEMENT
• Adolescents generally respond well to behavior
techniques, academic interventions and family therapy.
• Though nonpharmacological treatment plays important
role in management of ADHD, the effect is modest.
• The most favorable treatment in general is individually
tailored psychosocial treatment plus pharmacotherapy.

73. OUTCOME
• With a family history of ADHD there are 50% increase chances of developing the
disorder if either parent has ADHD or 35% chances if one of the siblings have ADHD.
• Symptom onset can occur at 3–4 years age, though only half the cases develop the
disorder by 7 years of age and more than 90% develop by 12 years of age.
• With the child reaching 4 years of age, hyperactive and impulsive symptoms starts
appearing which continue to increase over next 3–4 years peaking at 7–8 years of
age with emergence of inattentive symptoms.
• Hyperactive symptoms start declining after 7–8 years of age with almost negligible
symptoms (in form of restlessness or inability to settle down) by the adolescence.
On the other hand, impulsive symptoms persist throughout life.

74. OUTCOME
• ADHD symptoms can persist up to adulthood in 60% of children.
• The prevalence rate of adult ADHD is 4%.
• It may manifest in form of drug and alcohol misuse and antisocial
behavior.
• Despite their poor overall performance in comparison to non- ADHD
counterparts, children with ADHD are capable of attaining high
educational and vocational objectives.
• Many children have negligible emotional or behavioral problems by the
time they reach mid-twenties.

75. PREVENTION
• Primary prevention
• includes promotion of maternal health during pregnancy, such as caution against use
of alcohol and cigarette.
• Initiative should be taken to reduce environmental toxins like lead, mercury, and
polychlorinated biphenyls.
• Though not accepted worldwide, an elimination diet has been proposed to lessen
hyperactivity which targets artificial colorings, flavorings and preservatives.
• Free fatty acids have some role in reducing ADHD symptoms.
• Couples with family history should be counseled regarding the risk of genetic loading
of ADHD.

76. PREVENTION
• Secondary prevention
• Includes early intervention of at risk children such as children with a family background
of ADHD,premature children, low birthweight babies, mothers with intake of toxic
substances during pregnancy and children with serious craniocerebral traumas.
• Making teacher and parents to work together to identify ADHD at early stage should be
a priority.
• Behavior management may be put forth through techniques such as focusing
attention, disciplinary classroom promulgation and anger management.
• Monitoring of academic performance via multiple measures such as class participation
and homework completion should also be incorporated.

77. PREVENTION
• Tertiary prevention is applied actively in symptomatic
children with provision of pharmacological
management and individual based therapy.

78. NUT SHELL
• ADHD, a neuropsychologically heterogeneous condition, is among the most
common disorders of childhood.
• It is highly prevalent worldwide with a long-term course and pervasive effects.
• Multiple factors may be responsible for its varied manifestations such as illness
severity, family history of the disorder, shifting impairment between home and
school setting, executive functioning deficits, comorbidity and developmental
stage.
• Recent studies provide more insight into the genetic, environmental, and
neurobiological causes of this disorder, thereby, further enhancing our
understanding of pathophysiologic processes, which, in turn, will bring about
novel prevention and intervention strategies.

79. NUT SHELL
• Promising pharmacotherapeutic options in form of stimulant as well as
nonstimulant medications offers new options for managing ADHD.
• Utmost treatment outcome may be achieved using a multimodal
management approach employing appropriate pharmacotherapy with
psychosocial intervention.
• A pragmatic, multifaceted management based around the establishment of
good working relationships with family and school should be incorporated.
• The disorder requires a long-term therapeutic alliance among clinician and
the patient along with their families improving their quality of life.

80. REFFRENCES
• NELSON
• PIYUSH GUPTHA
• DEVELOPMENTAL-BEHAVIORAL PEDIATRICS

81. THANK YOU.....