ADHD attention deficit hyperactivity disorder.pptx

Attention-deficit/Hyperactivity Disorder
Muhammad Saqib Siddique, Waleed Ahmad
1 Assistant Professor of Psychiatry, Pak International Medical College, Peshawar, KPK, PK
2 Consultant Psychiatrist, Peshawar Medical College, Peshawar
(c)
Justpsychiatry
5/20/2022

Scenario 1
“Musa is constantly forgetting things. His
homework is rarely finished, and his parents
describe homework time as “a nightmare.”
Children with ADHD frequently have difficulty
paying attention top tasks at hands.
5/20/2022 (c) Justpsychiatry

Impulsivity
• The under-control of motor behavior, poor sustained inhibition of behavior, the inability to delay a
response or defer gratification, or an inability to inhibit dominant responses in relation to ongoing
situational demands.
Cognitive impulsivity
• Disorganized, hurried thinking, and the need for supervision.
Behavioral impulsivity
• Have difficulty inhibiting their response when the situation requires it.
Emotional impulsivity
• Impatience, low frustration tolerance, hot temper, quickness to anger, and irritability.

Scenario 2
“Osman can hardly stay in his seat
during class and gets up as soon as
the bell rings. During lunchtime, he
grabs other students’ food and
frequently cuts in line”
Sitting still, or in one place, for a
long period of time is torture for
many kids with ADHD.

Terms
ADHD and ADD >> DSM-5,
• The American Psychiatric Association
• Hyperkinetic Disorder >> ICD-10
• World Health Organization

Definition
• ADHD is a behavioural disorder that presents with symptoms such as
inattentiveness, hyperactivity and impulsiveness.
• Second most common psychiatric disorder of Childhood.

Subtypes
• Predominantly Inattentive
• Hyperactive/Impulsive
• Combined Presentation

ADHD Diagnostic Criteria
in DSM-5

Inattention
1. Makes careless mistakes
2. Difficulty sustaining attention
3. Does not seem to listen when spoken
to directly
4. Fails to follow tasks and instructions
5. Exhibits poor organization
6. Avoids tasks requiring mental effort
7. Loses things necessary for
tasks/activities
8. Easily distracted
9. Seems forgetful in daily activities

Inattention
•An inability to sustain attention or stick to
tasks or play activities, to remember and
follow through on instructions or rules,
and to resist distractions.
Attentional capacity
•The amount of information we can
remember and attend to for a short
time.
•Intact in ADHD
Selective attention
•The ability to concentrate on relevant
stimuli and ignore task-irrelevant stimuli
in the environment.
Distractibility
•A term commonly used to indicate a
deficit in selective attention.
Sustained attention
•AKA vigilance. The ability to maintain
persistent focus overtime on
unchallenging, uninteresting tasks or
activities or when fatigued.
Alerting
•An initial reaction to a stimulus;
involves the ability to prepare for what
is about to happen.
•They respond too quickly in a situation
requiring a slow and careful approach
and too slowly in situations requiring a
quick response.
5/20/2022
(c) Justpsychiatry

• Most common presentation in the general population
• Predominantly inattentive presentation (ADHD-PI)
• Associated with problems with arousal
• Predominantly inattentive presentation (ADHD-PI)
• Sluggish Cognitive Tempo (SCT)

Sluggish
Cognitive
Tempo
• It is associated with Predominantly inattentive presentation (ADHD-PI). It
is characterised by a cluster that includes symptoms such as
• Daydreaming,
• Trouble staying alert,
• Mentally foggy/
• Easily confused,
• Slow processing of information,
• Stares a lot,
• spacey,
• Loses train of thought,
• Appearing lethargic.
• Hypoactive,
• Sleepy.

Diagnostic Sub-
groups Could Be
Contained
Under
Predominantly
Inattentive
Presentation
1. Child who displays both clinically significant
symptoms of inattention and sub-clinical,
but still substantial levels of hyperactivity-
impulsivity
2. ADHD-PI with SCT
3. Individuals who previously met the criteria
for ADHD-C presentation

Hyperactivity/Impulsivity
Fidgets with or
taps hands or feet,
turns in seat
Leaves seat in
situations when
remaining seated is
expected
Experience's
feelings of
restlessness
Has difficulty
engaging in quiet,
leisurely activities
Is “on-the-go” or
acts as if “driven by
a motor”
Talks excessively Blurts out answers
Has difficulty
waiting their turn
Interrupts or
intrudes on others

Other Criteria
9 symptoms in
each category.
6 required to make
the diagnosis.
Onset before 12
year of age.
persisting for 6
months.
Pervasive across
situations
(Home, Class,
Clinic)
Inappropriate for
developmental
age.
Impaired
functioning.
Not better
explained by any
other diagnosis.

Executive functions
1. Working memory,
holding information in
mind while
manipulating
information.
2. Mental computation.
3. Planning and
anticipation.
4. Flexibility of thinking.
5. Use of organizational
strategies.
Cognitive
processes.
1. Verbal fluency.
2. The use of self-
directed speech.
Language
processes.
1. Allocation of effort.
2. Following prohibitive
instructions.
3. Response inhibition.
4. Motor coordination
and sequencing.
Motor processes
1. Self-regulation of
arousal level.
2. Tolerating
frustration.
Emotional
processes.

Epidemiology
Prevalence: 3%
Male to Female ratio: 3:1
Socioeconomic association None

M:F Ratio of ADHD
75%
25%
Male Female

Age of Onset
Most diagnosed in 6-to-12-year-olds
Age of onset before 12 per DSM-5
Age of onset before 7 per ICD-10

Aetiology
Genetics
• Non-mendelian polygenic inheritance.
• Heritability estimates of ADHD are around 70-80%.
• Sibling with ADHD.
• If a parent has ADHD,
• Around 60%.likelihood that the child will develop ADHD
Genes affecting dopamine system
• DRD4 Gene
• Which had been linked to the personality trait of a sensation seeking
• high level of thrill-seeking, impulsive, exploratory, and excitable behaviour.
• It affects responsiveness to medication, and
• it affects parts of the brain associated with executive functions and attention.
• Other genes have been implicated
• Genes related to the regulation of dopamine and noradrenaline.

Aetiology
• Maternal smoking
• Prematurity, low birth weight
• Early psychosocial adversity
• (children raised in extreme deprivation
• Toxins such as pesticides
• Traumatic brain injury

Interrelated Theories of ADHD
1. Cognitive functioning deficits
2. Reward/motivation deficits
3. Arousal level deficits
4. Self-regulation deficits

Brain Structure
Abnormalities in ADHD
The frontostriatal circuitry of
the brain.
•A region consisting of the prefrontal
cortex and interconnected areas of
gray matter located deep below the
cerebral cortex, collectively known as
the basal ganglia.
Parts are smaller in children
with ADHD
•1. Right prefrontal cortex.
•2. Right cerebral volumes.
Thalamus
•Different thalamic sub-circuits
associated with differing ADHD
symptoms linked with the regulation
of motor and emotional responses.
Thalamic mode network
•The network tends to be active at rest
but tends to shut off during task
engagement - but not as effectively in
those with ADHD.
Neural circuitry
•Circuits develop differently or later
in ADHD.
•Especially in the prefrontal regions.
Neurochemicals are
implicated in ADHD
•1. Dopamine.
•2. Norepinephrine.
•Dopamine and norepinephrine are
the most implicated.
•3. Epinephrine.
•4. Serotonin.

Symptoms predict a greater likelihood of developing ADHD if
present for 1 year at the preschool level
• 1. Hyperactive impulsivity.
• 2. Oppositional behavior.
Symptoms in the preschool years indicate a greater likelihood of
developing ADHD symptoms in the third grade
• 1. Difficulties in resisting temptation.
• 2. Difficulties delaying gratification.
• 3. Difficulties inhibiting behavior during

Comorbidities
• Conduct disorder/oppositional defiant disorder
• (most common)
• Autism spectrum disorder
• 20-50%
• Tourette's syndrome/tics
• Developmental coordination disorder
• Substance misuse
• Reading disorders
• Epilepsy
• Anxiety can accompany ADHD as a symptom or
comorbid disorder.
• Anxiety can manifest as overactivity

Relationship
between mania
and ADHD
• A diagnosis of childhood BP sharply increases
the child's risk for previous or co-occurring
ADHD.
• But a diagnosis of ADHD does not appear to
indicate a risk for BP.
• Share many core features such as excessive
verbalisation, hyperactivity high levels of
distractibility addition,
• children with mania, irritability is more
common than euphoria.

AAP (2019) Treatment Recommendations for ADHD
First-line
Second line
Preschool children (4-5 years)
Behavior therapy
Methylphenidate
Methylphenidate, if no significant improvement and moderate-to-severe functional
impairment
Elementary school (6–11 years)
Behavior therapy or medication, preferably both.
Evidence
stimulants > atomoxetine > guanfacine ER > Clonidine ER
(Wolraich et al., 2019)

Summary, NICE Treatment Recommendations 2018 (NICE, 2018; Faltinsen et al., 2018)
Children over 5 years Discussion and ADHD-focused Support Medication
Support: Offer a minimum of 1 or 2
sessions of support, can be group based.
education on the causes and impact of ADHD
advice on parenting strategies liaison with school, parents, and carers
Discussion
Before starting treatment, discuss with the
carers
The benefits of a healthy lifestyle, including
exercise The benefits and harms of non-
pharmacological and pharmacological treatments
Their preferences and concerns How other
conditions affect treatment choices
Importance of treatment
adherence
Record the person's preferences and concerns
Ask if they wish a carer to join discussions
Reassure that they can revisit decisions
Medication
Children over 5
Methylphenidate Lisdexamfetamine, after 6weeks trial off the
methylphenidate

(c) Justpsychiatry 5/20/2022
Summary, NICE Treatment Recommendations 2018
First-line Second line
Children under 5
years
Discussion
Group parent-
training program
(ADHD-Focused)
Medication
(Only a specialist can
start)
Start medications only after seeking advice from ADHD specialist services

A 9-year-old child presented to you in the outpatient department, brought by his mother. The latter was concerned
about his deficient performance at school, saying his brother and sister are much more competent. On enquiry, she
revealed that the child seems absent-minded, repeatedly loses items, does not seem to listen when being talked to, is
fidgety and keeps running and bouncing ‘as if driven by a motor.’ His academic report revealed ‘below-average
performance’, and he scored 90 on the Weschler Intelligence Scale for Children. The rest of the assessment was
unremarkable.
What would be your recommendation?
a) Atomoxetine
b) Clonidine
c) Methylphenidate
d) Lisdexamfetamine
e) Psychosocial Interventions

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Differentials
• Conduct disorder/oppositional defiant disorder (most common)
• Anxiety disorders
• Mania
• Intellectual disability
• Epilepsy
• Hearing impairment
• Receptive language disorders

Prognosis
• About 50% of cases diagnosed in
childhood retain full diagnosis in
adolescence
• About 10-20 % of cases diagnosed in
childhood retain diagnosis in Adulthood
• Prognosis is poor when overactivity is
severe, associated with learning
difficulties and antisocial behaviour

Prognosis
• Adults with ADHD can experience more opportunities to ‘live with the disorder as
they no longer need to attend school with its associated institutional demands and
can choose career paths more suited to their work patterns and needs.
• Many adults with ADHD describe the poor motivation, inattention and poor
organisation ---Problems at work and in relationships.
• Comorbid mood disorders and substance misuse are common in Adulthood

Prognosis
• Unmedicated individuals appear to have higher rates of:
• Substance Abuse
• Antisocial PD,
• Other PD and psychiatric disorder,
• Academic failure,
• Unemployment,
• Accidents
(Barkley et al., 2001, Rasmussen & Gillberg, 2000, Biederman, 1998)

Prognosis
• Hyperactivity-impulsive symptoms tend to predict aggressive behaviors and
peer rejection.
• Inattention symptoms tend to predict academic problems and peer neglect.

Assessment
• Full developmental assessment
• Pregnancy, birth, developmental milestones, medical history, Family history
• Screening Tools, eg, Connors Rating Scale (parent, teacher and child version)
• Clinical interview with parents
• Clinical interview with the child
• School Information: School report forms or school visit
• MSE for comorbid psychiatric conditions
• Psychosocial assessment for needs of child and carers.

Speech and language assessment
If delay present.
Screen for comorbidities:
• Tourette’s syndrome,
• Autism,
• Conduct disorder

Investigations
Hearing Tests TFTs
Rule Out Hyperthyroidism
EEG
Episodic Changes.

Treatments
Biological Treatments
Psychosocial Interventions

Biological Treatments
Stimulant Medications:
• Methylphenidate( First-choice)
• Potential for abuse.
• Short-acting:
• Ritalin
• Long-acting:
• Equasym XL, Concetta XL, Ritalin LA

Methylphenidate
• Inhibits reuptake of dopamine and norepinephrine (block transporters)
• Increased dopaminergic/noradrenergic activity in the prefrontal cortex
• Prefrontal cortex---regulates attention and behaviour
• Difference from amphetamines: does not promote dopamine release from synaptic
vesicles.

BIOLOGICAL
1. Non-Stimulant Medication: Atomoxetine (
Strattera)—Nor-adrenaline reuptake
inhibitor with no potential for abuse.
2. Antipsychotics: Risperidone = severe co-
existing aggression and agitation in those
with intellectual disability
(c) Justpsychiatry 5/20/2022

Psychosocial
Interventions
1. Education of family
2. Parent training program based on
behavioural interventions
1. Managing disruptive child
behaviour at home.
2. Reducing parent-child
conflict.
3. Promoting prosocial and
self-regulating behaviours.

Psychosocial Interventions
Social Skills training
01
Support to carers
02
Classroom
Interventions ( Small
class, breaks, Seats
to the front-not close
by window)
03
Address any child
protection concerns
04

Frequently asked
questions
Regarding ADHD treatments

“Will taking a stimulant to
make my child more likely
to take street drugs?”
ADHD increases the risk of your child
developing substance abuse. It
seems from recent research that
your child’s risk may decrease with
the use of ADHD medication.

“What are the long term affects of ADHD
medications?”
Methylphenidate has been in use for over 50 years, so we know and monitor for most side effects. It is
believed that treating your child for ADHD is more beneficial than not. Risks of road traffic accidents,
substance misuse and criminality, seem to decrease with treated ADHD.

Does Ritalin help
people without ADHD?

• Stimulants do not increase IQ (Advokat et al. 2008)
• Students are taking unnecessary risks including the
potential for harmful side effects, which may cause
psychosis and sudden death.
• Potential for dependence.
• Do not offer as much help to people with greater
intellectual abilities.

GPA as a function of study habits in
ADHD and Non-ADHD undergraduates
(c) Justpsychiatry
5/20/2022
When you study for an exam do you:
Non-ADHD (n) ADHD (n)
Study well before the exam? 3.12 (56) 3.16 (22)
Study in the day or two before the
exam?
3.10 (86) 2.86 (64)
ns p < 0.05
Adapted from Advokat & Scheithauer, 2013

5/20/2022 (c) Justpsychiatry; data from Advokat & Scheithauer, 2013
3.12
3.16
3.1
2.86
2.7
2.75
2.8
2.85
2.9
2.95
3
3.05
3.1
3.15
3.2
Non-ADHD (n) ADHD (n)
When you study for an exam do you:
Study well before the exam? Study in the day or two before the exam?

GPA of ADHD students: the relationship between study
habits and medication.
5/20/2022 (c) Justpsychiatry Adapted from Advokat & Scheithauer, 2013
Study ahead of time? Take medication?
Yes (n) No (n)
Yes 3.15 (19) 3.19 (3)
No 2.88 (47) 2.84 (15)

GPA of ADHD students: the relationship between study habits and
medication.
2.6
2.7
2.8
2.9
3
3.1
3.2
3.3
Take medication No medication
Study ahead of time Not ahead of time

Thank you; this ends the slideshow.
https://psych.thinkific.com
(c) Justpsychiatry 5/20/2022 56

References
1. Advokat, C., & Scheithauer, M. (2013). Attention-deficit hyperactivity disorder (ADHD) stimulant medications as cognitive
enhancers. Frontiers in neuroscience, 7, 82-82. https://doi.org/10.3389/fnins.2013.00082
2. Excellence, T. N. I. f. H. a. C. (2018, September 13, 2019). Attention Deficit Hyperactivity Disorder: Diagnosis and Management:
NICE guideline [NG87]. The National Institute for Health and Care Excellence. Retrieved May 11 from
https://www.nice.org.uk/guidance/ng87
3. Faltinsen, E., Zwi, M., Castells, X., Gluud, C., Simonsen, E., & Storebø, O. J. (2018). Updated 2018 NICE guideline on
pharmacological treatments for people with ADHD: a critical look. https://ebm.bmj.com/content/early/2018/12/10/bmjebm-
2018-111110
4. Advokat, C. D., Guidry, D., & Martino, L. (2008, May-Jun). Licit and illicit use of medications for Attention-Deficit Hyperactivity
Disorder in undergraduate college students. Journal of American College Health, 56(6), 601-606.
https://doi.org/10.3200/jach.56.6.601-606
5. Biederman, J. (1998). Attention-deficit/hyperactivity disorder: a life-span perspective. J Clin Psychiatry, 59 Suppl 7, 4-16.
6. Barkley, R. A., Edwards, G., Laneri, M., Fletcher, K., & Metevia, L. (2001, Dec). The efficacy of problem-solving communication
training alone, behavior management training alone, and their combination for parent-adolescent conflict in teenagers with
ADHD and ODD. J Consult Clin Psychol, 69(6), 926-941.
7. Rasmussen, P., & Gillberg, C. (2000, Nov). Natural outcome of ADHD with developmental coordination disorder at age 22 years: a
controlled, longitudinal, community-based study. J Am Acad Child Adolesc Psychiatry, 39(11), 1424-1431.
https://doi.org/10.1097/00004583-200011000-00017
8. Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD practice guidelines (CAP-guidelines) [Internet]. 3rd. Toronto:
CADDRA; 2011. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity
Disorder in Children and Adolescents. Pediatrics. 2011;128(5):1007-1022. doi:10.1542/peds.2011-2654

List of Abbreviations
• ADHD attention-deficit/hyperactivity disorder
• ADHD-PI ADHD, predominantly an inattentive subtype
• ADHD-C ADHD, combined subtype
• KPK Khyber-Pakhtunkhwa
• PK Pakistan
• GPA grade point average
• PCT
• TFTs thyroid function tests
• EEG electroencephalography

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