The document discusses attention deficit hyperactivity disorder (ADHD), including: 1) ADHD is characterized by diminished sustained attention and high impulsivity compared to others of the same age. It has three main types and affects 5-10% of the US population, predominantly males. 2) ADHD has genetic and neurological causes like central nervous system insults and dysfunction of the noradrenergic and dopamine systems. Stimulant medications are the first-line treatment as they target these systems. 3) Diagnosis involves assessing symptoms, impairment, history, and ruling out other conditions. Treatment includes medication, behavioral modifications, and accommodations at home and school to help manage symptoms.

1. ATTENTION –DEFICIT HYPER ACTIVITY DISORDER DR.A.GODSON MD - PSYCHIATRY

2. What is ADHD? A pattern of diminished sustained attention and high impulsivity in child or adolescent than expected for someone of that age and developmental level Three types: Combined Type, Predominantly Inattentive Type, and Predominantly Hyperactive-Impulsive Type .

3. ADHD-STATISTICS: 5-10% of the entire U.S. population Males are 3 to 6 times more likely than females. At least 50% of ADHD sufferers have another diagnosable mental disorder. 3-5% of all school-age children are estimated to have this disorder

4. First degree biological relatives are at high risk Parents shows increased incidence of –hyperkinesis,sociopathy,alcohol abuse,conversion disorder Symptoms often present by 3 years,but diagnosis made only at school setting

5. ADHD-TIME LINE: Minimal Brain Dysfunction Minimal Brain Damage Hyperkinetic Reaction of Childhood (DSM-II) Attention Deficit Disorder + or - Hyperactivity (DSM-III) Attention Deficit Hyperactivity Disorder (DSM-III-R) 1960 1980 1968 1987 1994 Attention Deficit/Hyperactivity Disorder (DSM-IV) 1930 ADHD-like syndrome first described 1902

6. Etiology--? Prenatal toxic exposure Mechanical insults to CNS Prematurity Food aditives, colorings,preservatives But ………….no scientific evidences

7. CAUSES OF ADHD: CNS insults Genetic origins Neuroanatomical neurochemical ADHD Environmental factors

8. Genetic factors Twin studies-great concordance in monozygotic twins Two times risk in siblings Adoption studies-higher incidence in biological parents than adoptive parents

9. Developmental factors Winter infections during first trimester Subtle damage to CNS during development High rate of soft neurological signs

10. Neurochemical factors Peripheral nor-adrenergic system dysfunction Possible dopamine system dysfunction Both evidenced by effect of stimulant drugs in improving symptoms

11. Psycho-social factors Prolonged emotional deprivation Stressful psychic events Family disequilibrium Demands from society Childs temperement

12. Diagnosis-assessment History, History, and more History!! School history Teachers reports Academic performance Clinic based psychological tests Individually administered intelligence tests Pediatric exam to check for an alternate disorder

13. DSM-IV-TR CRITERIA Inattention pervasive and persistent for more than 6 months At least 6 symptoms in the list Hyperactivity-impulsivity pervasive and persistent for more than 6 months At least 6 symptoms in the list

14. Some symptoms onset before 7 years Some symptoms should present in two settings Social ,occupational ,academic function impairment Symptoms not better accounted for pervasive developmental disorder, schizophrenia , any other mental disorder

15. Inattention Often has difficulty sustaining attention in tasks Often fails to give close attention to details/ makes mistakes in schoolwork, work, and other activities Often does not seem to listen when spoken to directly

16. Inattention Often does not follow through on instructions and fails to finish schoolwork, chores or duties in work Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

17. Often loses things necessary for tasks or activities Often easily distracted by extraneous stimuli Often forgetful in daily activities

18. Hyperactivity Often leaves seat in class/ situation where staying seated is expected Often fidgets with hands or feet or squirms in seat

19. Often runs about/climbs excessively in situations where it is inappropriate Often has difficulty playing/engaging in leisure activities quietly

20. Cont.. Often on the go or acts as if driven by a motor Talks excessively

21. Impulsivity Often blurts out answers before questions have been completed Often has difficulty waiting to take turns

22. Often interrupts or intrudes on others

23. Differential diagnosis Sensory impairment. Epilepsy and related states-TLE Effects of head injury Acute or chronic medical Illness Poor nutrition. Sleep disorders. Side effects of medication

24. Psychiatric conditions Autism Spectrum Disorder Obsessive Compulsive Disorder Tic Disorders Conduct Disorders Attachment disorders. Depression and emotional disorders. Anxiety disorder Psychosis

25. Course and prognosis Persistent symptoms at adult/adolescent age-50% Remission at puberty/early adulthood-50% Remission unlikely before-12 years Over activity-first to remit Distractibility-last to remit

26. Course of partial or non remittance in adolescent life Antisocial behavior Conduct disorder Substance abuse disorder Mood disorder Social difficulties Learning difficulties

27. Pharmacotherapy First line treatment Stimulants are first choice-methylphenidate, amphetamine preparations Second line agents-Atomoxetine, bupropion, venlafaxine, clonidine

28. Methylphenidate Dopamine agonist Dexmethylphenidate –maximum effect, minimal side effect 0.3-1 mg/kg tid, upto 60 mg/day Sustained release preparations allowed once daily dose, less rebound effects FDA recommendation-should use in children >6 years

29. Side effects Head ache GI upset Insomnia Exacerbate tic disorder Growth suppression

30. Amphetamine preparations Second choice when methylphenidate not useful FDA recommend for child >3 years 0.15-0.5 mg/kg bd, upto 40 mg/day Once daily sustained release useful

31. Non stimulants-Atomoxetine Nor-epinephrine reuptake inhibitor FDA-use in 6 years and above Effective for inattention and impulsivity 0.5-1.8 mg/kg bd dose,upto 40-80 mg/day Side effects-decreased appetite ,dizziness, irritability, increase in BP & HR

32. others Bupropion – beware of seizure Clonidine - useful in pts with tic disorder Modafinil – once daily,useful in adolescents Reboxetine – used in methylphenidate resistant cases

33. Psychosocial intervention Teacher’s attitude MUST be positive, upbeat, flexible praise liberally Provide more direct instruction and as much one-on-one instruction as possible Lecture less Challenge but don't overwhelm

34. Design tasks of low to moderate frustration levels Pair the student with a exemplary student frequent communication between home and school Provide frequent feedback Provide frequent and regularly scheduled breaks Teach conflict resolution and peer mediation skills

35. Adult manifestation of ADHD Prevalence- 4% Difficult to diagnose – lack of school and observer information SPECT - Increases dopamine transporter binding sites in striatum Premature birth , maternal use of nicotine, increased serum lead

36. Diagnosis-utah criteria Retrospective childhood diagnosis of ADHD At least 3 of following Inattentiveness Hyperactivity Mood lability Irritability, hot ember Low stress tolerance Disorganization impulsivity

37. DD – hypomania , anxiety disorder Treatment – similar to childhood ADHD Therapy needed indefinitely

38. THANK YOU