1. ADHD
ASHRAF TANTAWY
Professor of Psychiatry
Suez Canal University
Ismailia, Egypt.

2. A developmental disorder of self control
(Executive function of the brain).
Symptoms arise from brain
abnormalities.
Their main problems are:
– Attention span.
– Impulse control.
– Activity level.
A real disorder & often a real obstacle.

3. Symptoms of Inattention
Fails to pay close attention to details.
Makes careless mistakes.
Has difficulty maintaining attention in tasks or play.
Does not seem to listen when spoken to directly.
Does not follow directions.
Fails to complete schoolwork or chores.
Has difficulty organizing tasks or activities.
Avoids/ dislike task that require sustained mental effort.
Losses things necessary for task or activities.
Easily distracted.
Often forgetful in daily activities.

4. Symptoms of Hyperactivity
Fidgets with hands or feet or squirms in seat.
Leaves seat in classroom or in other situation in which
remaining seated is expected.
Runs or climbs excessively when inappropriate.
Has difficulty playing or engaging in leisure activities
quietly.
Always on the go or act as if driven by a motor.
Often talks excessively.
Exhibit feeling of restlessness in adolescence.

5. Symptoms of Impulsivity
Blurts out answers before questions have
been completed.
Has difficulty waiting in turn.
Interrupts or intrudes on
others (for example butts
into conversations or games).

6. TYPES OF ADHD
1. INATTENTIVE TYPE:
At least 6 symptoms of inattention. (20-30%)
2. HYPERACTIVE IMPULSIVE TYPE:
At least 6 symptoms of hyperactivity/
impulsivity. (1-15%)
3. COMBINED TYPE:
At least 6 symptoms both of inattention &
hyperactivity-impulsivity. (50-75%)

7. Lifetime Course of ADHD
Symptoms: Inattention Domain
Childhood Adult
Difficulty sustaining attention Difficulty sustaining attention
(Meetings, Reading, Paperwork)
Doesn’t listen Paralyzing procrastination
No follow through Slow, inefficient
Can’t organize Poor time management
Loses important items Disorganized
APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000.
Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.

8. Lifetime Course of ADHD
Hyperactivity/ Impulsivity Domain
Childhood Adult
Squirming, fidgeting Inefficiencies at work
Can’t stay seated Can’t sit through meetings
Can’t wait turn Can’t wait in line
Runs/ climbs excessively Drives too fast
Can’t play/ work quietly Selects very active job
On the go/ driven by motor Can’t tolerate frustration
Talks excessively Talks excessively
Blurts out answers Makes inappropriate comments
Intrudes/ interrupts others Interrupts others
APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000.
Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.

9. Prevalence of ADHD
Prevalence of ADHD1,2,3
– ADHD affects 3-6% of children & adolescents,
with some estimates as high as 16.1%.
– Boys 3 - 4 times more than girls.
Prevalence of ADHD is underestimated4,5
– Comorbidities may mask diagnosis.
– Girls are under-recognized & undertreated.
– Difficult diagnosis in the adolescent.
1. Goldman LS et al. JAMA. 1998;279:1100-1107; 2US Department of Health and Human Services, 1999 3Scott-Levin Inc.
Physician Drug and Diagnosis Audit (PDDA), 2001. 4. Datamonitor report DMHC2008, published 9/2004; 5. Biederman J et al.
J Am Acad Child Adolesc Psychiatry. 1999;38:966-975;

10. Potential Impact of Untreated
ADHD Across the Lifespan
Low self- Academic Smoking and Legal
esteem limitations substance abuse problems
Childhood Adolescence Adulthood
Injuries Impaired family and Motor vehicle Occupational
peer relationships accidents difficulties
American Academy of Pediatrics. Pediatrics. 2000;105:1158-1170; Kelly PC et al. Pediatrics. 1989;83:211-217; Murphy
K et al. Compr Psychiatry. 1996;37:393-401; Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7; Barkley RA et al.
Pediatrics. 1996;98:1089-1095; Swensen A et al. J Adolesc Health. 2004;35:346.e1-9.

11. Developmental Impact of ADHD
Academic problems Self-esteem issues
Difficulty with social interactions Relationship problems
Self-esteem issues Injury/ accidents
Behavioural Legal issues, smoking Substance abuse
disturbance and injury Occupational failure
Pre-school Adolescent Adult
School-age College-age
Academic failure
Behavioural disturbance
Self-esteem issues
Academic problems
Substance abuse
Difficulty with social interactions
Injury/ accidents
Self-esteem issues
Occupational difficulties

12. Pathophysiology of ADHD
(DA & NE Neurotransmission)
 Abnormal DA & NE neurotransmitters in
frontal/ striatal areas of ADHD (1,2)
 Cortico-striatal circuits play an important role in
ADHD (1,3,4)
 Efficacy of ADHD Medications affecting DA &
NE support to the theory of monoamine
dysfunction in ADHD(3)
DA = dopamine; NE = norepinephrine.
1. Mercugliano M. Ment Retard Dev Disabil Res Rev. 1995;1:220-226; 2. Krause K-H et al. Neurosci Let.
2000;285:107-110; 3. Markowitz JS et al. Pharmacotherapy. 2003;23:1281-1299; 4. Zametkin AJ et al. J Clin
Psychiatry. 1998;59(suppl 7):17-23.

13. Preorbital Frontal Cortex
Reticular Formation
The Reticular Formation: It was believed that RF, which
regulates arousal & attention, was dysfunctional in ADHD.
The Pre-orbital Frontal Cortex: Functional Magnetic
Resonance Imaging research has revealed that POFC
functions differently in individuals with ADHD.

14. The Preorbital Frontal Cortex:
 Planning (Time Management).
 Sequencing.
 Organizing.
 Self-Control.
 Other Executive Functions.
Individuals with ADHD, with or without
impulsivity or hyperactivity, have difficulties
with executive functions.

15. PET Scan of Adult Brain Glucose
Metabolism with ADHD
Rate at which brain uses glucose is lower in
ADHD than Normal (Zametkin, et al., 1990).
Adult with ADHD Normal Adult

16. Co-Occurring Disorders
• Speech & Language Delays: 30%.
• Learning Disabilities: 25%.
• Smoking & Substance Abuse: 20%. 1. Oppositional
Defiant
Disorder 50%
ADHD 2. Conduct
alone Disorder 40%
30% 5. Tics 10%
4. Mood
Disorders 20%
3. Anxiety
Disorder 25%
MTA Cooperative Group.
Arch Gen Psychiatry 1999;
56:1088–1096

18. ADHD Diagnostic Evaluation
1. Physical Examination.
2. Parent-Rated Child Behavior Scales.
3. Teacher-Rated Child Behavior Scales.
4. Parent & Child Interviews.
5. Parent Self Report Measures.
6. Clinic-Based Psychological Test.
7. Review of Prior School & Medical Reports.
8. IQ & Educational Achievement Tests.

19. Differential Diagnosis
Vision & Hearing Problems.
Chronic Illness; Breathing & Sleep Disorders.
Developmental or Learning Problems.
Absence Seizures.
Acute change in living situation.
Grief.
Family conflict.
Recent trauma.
Substance Abuse; Side Effect of Medications.
Stress.
Frequent Co-Morbidities:
(Mood/ anxiety/ psychotic/ adjustment disorders)
- Fixing them can solve most of the problem.

20. ADHD VS. BIPOLAR
ADHD BIPOLAR
Childhood onset. Later onset.
Constant. Cyclical.
Moods triggered. Moods not triggered.
Difficulty in going to sleep. Decrease need for sleep.
Thoughts jumping. Thoughts racing.
Family history of ADHD. Family history of mood D.

21. Rule Outs for Diagnosis
of ADHD
Rule Out’s Diagnosis Evaluation by use of:
Gifted (MR) IQ Testing (Psychologist)
Learning Disability Academic/ Perceptual
Testing (Psychologist)
Neurological Conditions: EEG, 24 hr EEG, MRI etc
Seizures, Tourette’s etc. (Neurologist)
Behavioral or Emotional: Psycho-Social History &
Anxiety & Depression Personality Testing

22. Management
1. Pharmacotherapy (FDA approved);
Stimulants: Methylphenidate [Ritalin]).
Non stimulants: Atomoxetine [Strattera]).
2. Psychotherapy.
3. Family Therapy/ Guidance:
A- Home Management.
B- Parenting.
C- Stress Management.
4. Classroom Management.

23. ADHD & Stimulant Medication
Stimulants improve:
Core Symptoms
Inattention AND
Impulsivity
Hyperactivity Impulsive Aggression
Social Interactions
Academic Productivity &
Accuracy
Swanson et al. Except Child 1993;60:154.

24. Stimulant Users -
Tomorrow’s Abusers?
Harvard study
80
% of substance abuse
70 no ADHD
tx ADHD
60
non tx ADHD
50
40
Use of medications in ADHD
30
provides an 84% risk reduction in
20
developing of
10
a substance abuse disorder
0
J. Biederman, Pediatrics, Aug. 1999;104(2)

25. Nutrition In ADHD
Protein & Omega-3 fatty acids
are important for ADHD, as well
as iron & magnesium.
Eat a high-protein diet.
Eat more Omega-3 fatty acids.
Eat complex carbs at night
(may aid sleep).
Eat fewer simple carbohydrates.

26. Conclusion
ADHD is developmental disorder of self control
(Executive function of the brain).
The main problems are: Attention span, Impulse
control and Activity level.
A real disorder & often a real obstacle.
ADHD affects 3-6% of children & adolescents, with
some estimates as high as 16.1%.
Prevalence of ADHD is underestimated.
Management includes Pharmacotherapy,
Psychotherapy, Family Therapy/ Guidance, Classroom
Management & Nutrition.