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ADHD - Attention Deficit Hyperactivity Disorder

The document discusses Attention Deficit Hyperactivity Disorder (ADHD), detailing its etiology, clinical features, diagnosis, and management strategies. It highlights the prevalence, commonly recognized symptoms like inattention and impulsivity, and the importance of a multimodal approach to treatment that includes educational and behavioral interventions. Additionally, it reviews the diagnostic criteria from DSM-5 and ICD-10 and differentiates ADHD from other disorders with similar manifestations.

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Dr C. Naveen Kumar, 1st year PG ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• Introduction • Etiology • Clinical features & Diagnosis • Differential Diagnoses • Management – Pharmacological & Non-pharmacological • Prognosis Overview Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• ADHD is the most common neurobehavioral disorder of childhood. • It is characterized by developmentally inappropriate and impairing levels of gross motor over activity, inattention and impulsivity. • It can continue through adolescence and adulthood. Introduction Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• Pooled data from various studies indicate that the world wide prevalence is 5.29%. o 5-10% in school going children o 2-6% in adolescents o 2% in adults • More common in male gender (3-6 times) • Prevalence in India is comparable to that of other countries. Introduction contd. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
History 1798 Sir Alexander Crichton, Scottish physician “The incapacity of attending with a necessary degree of constancy to any one object” Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
History 1844 Heinrich Hoffmann, German physician “Fidgety Phil” – character in his illustrated children's stories, fits hyperkinetic type of ADHD Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
History 1902 Sir George Frederick Still, Father of British Pediatrics “defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease” Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
History 1908 Alfred Tredgold, British physician – Early brain damage (perinatal anoxia or birth defect) leading to subsequent behavioral problems or learning disorders. Post Encephalitic Behavior Disorder – following Influenza encephalitis epidemic 1932 Franz Kramer & Hans Pollnow, German physicians described “Hyperkinetic Disorder of infancy” 1930-1940 1960 Minimal Brain Damage – responsible for various behavioral problems in children Changed to Minimal Brain Dysfunction 1937 Charles Bradley – positive effect of stimulant medications in children with various behavior disorders Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
History 1968 DSM-II mentioned “Hyperkinetic Reaction of Childhood”, which diminishes by adolescence. 1980 DSM-III Attention Deficit Disorder: with and without hyperactivity 1987 DSM-III R Attention Deficit Hyperactivity Disorder 1994 DSM-IV ADHD was divided into 3 subtypes Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• ADHD is thought to result from complex interaction between multiple genetic and environmental factors. Genetic – Twin, sibling and family studies support strong genetic component in ADHD causation. • Concordance rate in monozygotic twins is 59- 92% and in dizygotic twins, it is 29-42%. • 50% chance to have the disease if one parent has ADHD, 20-25% chance if a first degree relative is affected. Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Genetic – Polygenic Inheritance. • DAT1 (Dopamine Transporter) gene • DRD4 (Dopamine 4 Receptor) gene • DBH (Dopamine β Hydroxylase) gene, DRD5 (Dopamine 5 Receptor) gene, COMT (Catechol- O-methyltransferase) gene, genes related to Androgen receptors play role. Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Attention is the behavioral and cognitive process of selectively concentrating on one aspect of the environment while ignoring other things. BOTTOM-UP PROCESSING or STIMULUS-DRIVEN ATTENTION or EXOGENOUS ATTENTION It is driven by the properties of the objects themselves. Ex: A sudden loud noise, can attract our attention in a pre-conscious, or non-volitional way. We attend to them whether we want to or not. Regulated by PARIETAL, TEMPORAL CORTEX & BRAIN STEM. TOP-DOWN PROCESSING or GOAL-DRIVEN ATTENTION or ENDOGENOUS ATTENTION or EXECUTIVE ATTENTION It is under the control of the person who is attending. Ex: If we come across a harmful object such as hot stove, our prior knowledge stored in memory makes sure that we don’t touch that. Mediated primarily by FRONTAL CORTEX AND BASAL GANGLIA Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
BOTTOM-UP PROCESSING or STIMULUS-DRIVEN ATTENTION or EXOGENOUS ATTENTION Regulated by PARIETAL, TEMPORAL CORTEX & BRAIN STEM. TOP-DOWN PROCESSING or GOAL-DRIVEN ATTENTION or ENDOGENOUS ATTENTION or EXECUTIVE ATTENTION Mediated primarily by FRONTAL CORTEX AND BASAL GANGLIA Both these processes are coordinated by pre-frontal cortex. There is dysregulation in-between them in ADHD. Due to increased exogenous attention, children with ADHD fail to sustain attention on one thing and get distracted easily by exogenous stimuli. Due to diminished top down processing, children with ADHD fail to execute organizational tasks, they don’t know consequences of their actions and are frequently prone for injuries & accidents. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Neuroanatomical MRI, PET & SPECT studies suggested decreased volume and activity in prefrontal areas, anterior cingulate, globus pallidus, caudate and thalamus in children with ADHD compared to controls. Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Neurotransmitters Catecholamine imbalance is suggested to be a cause for ADHD. This is supported by usefulness of various drugs that interfere with catecholamine metabolism, in ADHD. • Amphetamines bind to DAT (Dopamine Transporter) and prevent Dopamine re-uptake. • Tricyclic Antidepressants and Atomoxetine are Norepinephrine reuptake inhibitors. Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Pregnancy & Early Childhood Factors • Maternal cigarette smoking, alcohol consumption • Very low birth weight • Prematurity • Fetal hypoxia • Maternal stress during pregnancy Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Environmental Toxins & Dietary Factors • Pesticides • PCBs – Polychlorinated Biphenyl • Lead toxicity • Iron & Zinc deficiency • Poly Unsaturated Fatty Acid deficiency • Food additives • Food high in sugar content Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Psychosocial Factors • Poverty • Low parental education • Negative parenting • Deprivation • Family discordance • Bullying & peer victimization Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• Excessive and impairing level of activity, inattention and impulsiveness. • Particularly evident in situations that require child to be thoughtful and restrained. • Symptoms are present in two or more settings. (E.g. With family, in school & with friends etc.) • In early childhood, ADHD children have sleep problems and show clear hyperactivity. • Motor milestones are achieved normally or early, with child being described as starting to run as soon as he could walk. Clinical features Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• Fail to pay attention and get easily distracted. • Miss details, forget things. • Frequently switch from one activity to another. • Become bored with a task after only a few minutes. • Child may attend a test rapidly but answers only first few questions. • They are unable to wait to be called on in school and may respond before anyone else. • Have difficulty in organizing and completing a task. • Difficulty in learning something new. • Have trouble completing homework assignments,. • Often loose things (E.g.. Pencils, toys etc.) • Become easily confused. • Struggle to follow instructions. Clinical features - Inattention Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• Difficult to remain in their seats. Fidget and squirm (Squirm - To twist the body from side to side, as a result of discomfort) in their seats • Talk nonstop • Dash around, touching or playing with anything and everything in sight • Have trouble sitting still during dinner, school, and story time • Be constantly in motion • Have difficulty doing quiet tasks or activities. Clinical features - Hyperactivity Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Impulsiveness is a tendency to act in rush without forethought or concern about consequences. • Be very impatient. • Blurt out inappropriate comments. • Show their emotions without restraint, and act without regard for consequences. • Have difficulty waiting for things they want or waiting their turns in games. • Often interrupt conversations or others’ activities. • Running thoughtlessly across a busy street, being violent towards siblings and peers. Clinical features - Impulsivity Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• Become bored with interactive games with peers, and leave such games early before they are finished. • They find it difficult to delay gratification. • They show variable performance on tasks, which may negatively affect self-esteem. • They have difficulty with time management and have poor sense of time. • Even don't know when to come home when out playing with other children. Clinical features Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• As a result of their actions, they face difficulty in establishing and maintaining peer relationships. • By adolescence, hyperactivity is replaced by internal sense of restlessness & inattention is manifested as poorly organized approach to work. • ADHD adolescent is accident prone. • Poor concentration, inability to complete tasks, procrastination, occasional mood outbursts result. Procrastination: Practice of carrying out less urgent tasks, which are more pleasurable in preference to more urgent ones, which are less pleasurable and thus postponing them to deadline. Clinical features Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• The diagnosis of ADHD is based purely on symptoms. • Evaluation includes inputs from parents, teachers and other care givers. • ADHD has been defined both in the American Psychiatric Association Diagnostic and Statistical Manual (DSM- V) and the International Classification of Diseases (ICD-1O). • In ICD-10 it is named Hyperkinetic Disorder (HKD). Diagnosis Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
• Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), offers standard criteria for the classification of psychiatric disorders. • In DSM-V, ADHD is included under neurodevelopmental disorders. DSM-V Criteria Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
IMPULSIVITY Onset before 12 Years of age Symptoms should be present in 2 or more settings Interfere with social/ academic functioning Not better explained by another psychiatric disorder Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
A. A persistent pattern of inattention and/or hyperactivity- impulsivity that interferes with functioning or development. 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). DSM-V Criteria Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
At least 6 symptoms for <17 years age group. At least 5 symptoms for 17 years or more age group. For at least 6 months duration. 1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities 2. Often has difficulty sustaining attention in tasks or play activities 3. Often does not seem to listen when spoken to directly 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace A-1 Inattention Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
5. Often has difficulty organizing tasks and activities 6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort 7. Often loses things necessary for tasks or activities. 8. Is often easily distracted by extraneous stimuli 9. Is often forgetful in daily activities A-1 Inattention Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
At least 6 symptoms for <17 years age group. At least 5 symptoms for 17 years or more age group. For at least 6 months duration. 1. Often fidgets with or taps hands or feet or squirms in seat. 2. Often leaves seat in situations when remaining seated is expected 3. Often runs about or climbs in situations where it is inappropriate. 4. Often unable to play or engage in leisure activities quietly. 5. Is often “on the go,” acting as if “driven by a motor” 6. Often talks excessively. A-2 Hyperactivity & Impulsivity Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
7. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). 8. Often has difficulty waiting his or her turn (e.g., while waiting in line). 9. 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 permission) A-2 Hyperactivity & Impulsivity Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Combined : If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months. Predominantly inattentive : If Criterion A1 (inattention) is only met for the past 6 months. Predominantly hyperactive/impulsive : If Criterion A2 (hyperactivity- impulsivity) is only met for the past 6 months. 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. Subtypes Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Parent Rating Scales • Conner's Parent Rating Scale • Child Behavior Checklist • Yale Children's Inventory Home Situations Questionnaire Teacher Rating Scales • Conner's Teacher Rating Scale • Child Behavior Checklist-Teacher Form School Situations Questionnaire • ADHD Comprehensive Teacher Rating Scale (ACTReS) • Swanson, Nolan and Pelham (SNAP-IV) scale • Vanderbilt ADHD Scale • INCLEN – ADHD Diagnostic tool (Indian adaptation) Parent and Teacher Rating Scales to assess ADHD Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
INCLEN Diagnostic tool (International Clinical Epidemiology Network)  Based on DSM-IV TR  Rewording to make the criteria applicable to Indian scenario  SECTION-A : Whether the child fulfills the criteria or not.  SECTION-B : Whether pervasive functional impairment is present or not.  Diagnosis as No ADHD, ADHD, Other NDD or Indeterminate. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
DIFFERENTIAL DIAGNOSES INTELLECTUAL DEVELOPMENTAL DISORDER Children with moderate to severe MR have attention and activity levels that are appropriate for developmental age not chronological age. SENSE ORGAN DEFICITS Hearing loss in glue ear etc. condition may lead to inattention. INTERMITTENT EXPLOSIVE DISORDER Impulsive behavior common to both. Children with Intermittent Explosive Disorder show serious aggression to others, which is not seen in ADHD. SPECIFIC LEARNING DISORDER These children may show in attention due to inability to learn and frustration. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
DIFFERENTIAL DIAGNOSES OPPOSITIONAL DEFIANT DISORDER (ODD) A pattern of negative, hostile and defiant behavior. Symptoms include frequent loss of temper, arguing (especially with adults), refusal to obey rules, intentionally annoying others, blaming others. CONDUCT DISORDER (CD) A pattern of behavior that persistently violates the basic rights of others or society’s rules. Behaviors may include aggression toward people and animals, destruction of property, deceitfulness or theft, or serious rule violations. DRUGS Medications like Phenobarbitone, Lamotrigine, Clonazepam & Vigabatrin can cause hyperactivity that can mimic ADHD. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
DIFFERENTIAL DIAGNOSES AUTISM ADHD Both exhibit inattention, social dysfunction and difficult to manage behavior. Has no great desire to be social. Wants to be social. Feel sad, confused on isolation. Repetitive patterns of behavior are present. Absent. Difficulty in communication is present. There is no difficulty in communication. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
MANAGEMENT Multimodal approach • Education and information for parents & children • Family intervention • Behavioral management • School Interventions • Medication Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Education of parents & family interventions • Parents should be counselled that child is not exhibiting symptoms voluntarily & he/she can meet reasonable expectations if managed properly. • Formulate a regular daily routine and ensure that the child follows it. • Give short term simple tasks and on completion, praise the child. • Avoid over stimulation and excessive fatigue. Give time for relaxation. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Family interventions • Keep valuable, breakable and dangerous articles out of reach of the child. • Ensure quiet and peaceful bedtime. Avoid exciting T.V. programs, games during night. • Encourage peer relationships and teach social skills. • Give clear instructions and positively reinforce good behavior. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
School interventions • Child should be seated near to teachers desk. • Teachers should make frequent eye contact with child. • Permit the child to do something with hands while engaged in sustained listening. • Allow intermittent activities like cleaning blackboard, distributing papers etc. • Teach concepts, reduce memory burden. • Divide work into small chunks. • Reinforce positive behavior. • Give regular non-accusatory feedback to child regarding his/her attention control. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Medication STIMULANT MEDICATION NON-STIMULANT MEDICATION • Amphetamines: Dextroamphetamine Pemoline • Methylphenidates: Methylphenidate, Dexmethylphenidate • Atomoxetine • Tricyclic Anti-depressants: Imipramine, Norimipramine & Nortryptiline • α2-Adrenergic Agents: Clonidine, Guanfacine • Non-TCA anti depressant: Bupropion Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Stimulants • Not used for < 3years age group. • Beneficial effects: Enhanced concentration, reduced hyper arousal state, reduced impulsivity., improved school and homework performance. • Methylphenidate commonly used started at 5mg/day dose and gradually increased up to 60mg/day. • Adverse effects: headache, abdominal pain, jitteriness, anorexia, insomnia, growth failure (Drug holiday during vacation), substance abuse. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Atomoxetine • Norepinephrine Reuptake Inhibitor (NRI) • Reduces ADHD behaviors in children, adolescents, and adults. • Doesn't have abuse potential. TCAs • Imipramine, desipramine, and nortriptyline • Advere effects: Cholestatic jaundice, tachycardia, delirium, weight gain, constipation, skin rash, lowered seiizure threshold Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Bupropion • 3-6 mg/Kg/day • Adverse effects: Insomnia, irritability, seizure α2-Adrenergic Agents: • Clonidine at 3-10 mg/kg/day used as alternative or adjunctive to Methylphenidate. • Its sedative effect counters insomniac effect of Methylphenidate. • Useful for tics, impulsivity, aggression. Doesn’t improve inattention. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
PROGNOSIS • Course of ADHD is variable. • Remission usually occurs between 12-20 years of age, unlikely before that. • 40-60% continue to be symptomatic through adolescence, 20-40% through adult hood. • Most cases get better as they grow. Hyperactivity usually stops by teenage. Easy distractibility, mood swings, hot tempers & inability to complete tasks persist. • Those continue to have symptoms are vulnerable to antisocial behavior, substance abuse, mood disorders & learning disorders. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
References • Behavioural problems in children and adolescents – Jaydeep Choudhary • DSM – V • Kaplan Sadock Text Book of Psychiatry • Nelson Text Book of Pediatrics • Indian Journal of Practical Pediatrics • www.indianpediatrics.net Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
Thank You Dr Naveen Kumar Cheri S.V. Medical College, Tirupati

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ADHD - Attention Deficit Hyperactivity Disorder

  • 1.
    Dr C. NaveenKumar, 1st year PG ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 2.
    • Introduction • Etiology •Clinical features & Diagnosis • Differential Diagnoses • Management – Pharmacological & Non-pharmacological • Prognosis Overview Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 3.
    • ADHD isthe most common neurobehavioral disorder of childhood. • It is characterized by developmentally inappropriate and impairing levels of gross motor over activity, inattention and impulsivity. • It can continue through adolescence and adulthood. Introduction Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 4.
    • Pooled datafrom various studies indicate that the world wide prevalence is 5.29%. o 5-10% in school going children o 2-6% in adolescents o 2% in adults • More common in male gender (3-6 times) • Prevalence in India is comparable to that of other countries. Introduction contd. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 5.
    History 1798 Sir Alexander Crichton,Scottish physician “The incapacity of attending with a necessary degree of constancy to any one object” Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 6.
    History 1844 Heinrich Hoffmann, German physician “FidgetyPhil” – character in his illustrated children's stories, fits hyperkinetic type of ADHD Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 7.
    History 1902 Sir George FrederickStill, Father of British Pediatrics “defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease” Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 8.
    History 1908 Alfred Tredgold, Britishphysician – Early brain damage (perinatal anoxia or birth defect) leading to subsequent behavioral problems or learning disorders. Post Encephalitic Behavior Disorder – following Influenza encephalitis epidemic 1932 Franz Kramer & Hans Pollnow, German physicians described “Hyperkinetic Disorder of infancy” 1930-1940 1960 Minimal Brain Damage – responsible for various behavioral problems in children Changed to Minimal Brain Dysfunction 1937 Charles Bradley – positive effect of stimulant medications in children with various behavior disorders Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 9.
    History 1968 DSM-II mentioned “HyperkineticReaction of Childhood”, which diminishes by adolescence. 1980 DSM-III Attention Deficit Disorder: with and without hyperactivity 1987 DSM-III R Attention Deficit Hyperactivity Disorder 1994 DSM-IV ADHD was divided into 3 subtypes Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 10.
    • ADHD isthought to result from complex interaction between multiple genetic and environmental factors. Genetic – Twin, sibling and family studies support strong genetic component in ADHD causation. • Concordance rate in monozygotic twins is 59- 92% and in dizygotic twins, it is 29-42%. • 50% chance to have the disease if one parent has ADHD, 20-25% chance if a first degree relative is affected. Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 11.
    Genetic – PolygenicInheritance. • DAT1 (Dopamine Transporter) gene • DRD4 (Dopamine 4 Receptor) gene • DBH (Dopamine β Hydroxylase) gene, DRD5 (Dopamine 5 Receptor) gene, COMT (Catechol- O-methyltransferase) gene, genes related to Androgen receptors play role. Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 12.
    Attention is thebehavioral and cognitive process of selectively concentrating on one aspect of the environment while ignoring other things. BOTTOM-UP PROCESSING or STIMULUS-DRIVEN ATTENTION or EXOGENOUS ATTENTION It is driven by the properties of the objects themselves. Ex: A sudden loud noise, can attract our attention in a pre-conscious, or non-volitional way. We attend to them whether we want to or not. Regulated by PARIETAL, TEMPORAL CORTEX & BRAIN STEM. TOP-DOWN PROCESSING or GOAL-DRIVEN ATTENTION or ENDOGENOUS ATTENTION or EXECUTIVE ATTENTION It is under the control of the person who is attending. Ex: If we come across a harmful object such as hot stove, our prior knowledge stored in memory makes sure that we don’t touch that. Mediated primarily by FRONTAL CORTEX AND BASAL GANGLIA Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 13.
    BOTTOM-UP PROCESSING or STIMULUS-DRIVENATTENTION or EXOGENOUS ATTENTION Regulated by PARIETAL, TEMPORAL CORTEX & BRAIN STEM. TOP-DOWN PROCESSING or GOAL-DRIVEN ATTENTION or ENDOGENOUS ATTENTION or EXECUTIVE ATTENTION Mediated primarily by FRONTAL CORTEX AND BASAL GANGLIA Both these processes are coordinated by pre-frontal cortex. There is dysregulation in-between them in ADHD. Due to increased exogenous attention, children with ADHD fail to sustain attention on one thing and get distracted easily by exogenous stimuli. Due to diminished top down processing, children with ADHD fail to execute organizational tasks, they don’t know consequences of their actions and are frequently prone for injuries & accidents. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 14.
    Neuroanatomical MRI, PET &SPECT studies suggested decreased volume and activity in prefrontal areas, anterior cingulate, globus pallidus, caudate and thalamus in children with ADHD compared to controls. Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 15.
    Neurotransmitters Catecholamine imbalance issuggested to be a cause for ADHD. This is supported by usefulness of various drugs that interfere with catecholamine metabolism, in ADHD. • Amphetamines bind to DAT (Dopamine Transporter) and prevent Dopamine re-uptake. • Tricyclic Antidepressants and Atomoxetine are Norepinephrine reuptake inhibitors. Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 16.
    Pregnancy & EarlyChildhood Factors • Maternal cigarette smoking, alcohol consumption • Very low birth weight • Prematurity • Fetal hypoxia • Maternal stress during pregnancy Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 17.
    Environmental Toxins &Dietary Factors • Pesticides • PCBs – Polychlorinated Biphenyl • Lead toxicity • Iron & Zinc deficiency • Poly Unsaturated Fatty Acid deficiency • Food additives • Food high in sugar content Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 18.
    Psychosocial Factors • Poverty •Low parental education • Negative parenting • Deprivation • Family discordance • Bullying & peer victimization Etiology Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 19.
    • Excessive andimpairing level of activity, inattention and impulsiveness. • Particularly evident in situations that require child to be thoughtful and restrained. • Symptoms are present in two or more settings. (E.g. With family, in school & with friends etc.) • In early childhood, ADHD children have sleep problems and show clear hyperactivity. • Motor milestones are achieved normally or early, with child being described as starting to run as soon as he could walk. Clinical features Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 20.
    • Fail topay attention and get easily distracted. • Miss details, forget things. • Frequently switch from one activity to another. • Become bored with a task after only a few minutes. • Child may attend a test rapidly but answers only first few questions. • They are unable to wait to be called on in school and may respond before anyone else. • Have difficulty in organizing and completing a task. • Difficulty in learning something new. • Have trouble completing homework assignments,. • Often loose things (E.g.. Pencils, toys etc.) • Become easily confused. • Struggle to follow instructions. Clinical features - Inattention Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 21.
    • Difficult toremain in their seats. Fidget and squirm (Squirm - To twist the body from side to side, as a result of discomfort) in their seats • Talk nonstop • Dash around, touching or playing with anything and everything in sight • Have trouble sitting still during dinner, school, and story time • Be constantly in motion • Have difficulty doing quiet tasks or activities. Clinical features - Hyperactivity Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 22.
    Dr Naveen KumarCheri S.V. Medical College, Tirupati
  • 23.
    Impulsiveness is atendency to act in rush without forethought or concern about consequences. • Be very impatient. • Blurt out inappropriate comments. • Show their emotions without restraint, and act without regard for consequences. • Have difficulty waiting for things they want or waiting their turns in games. • Often interrupt conversations or others’ activities. • Running thoughtlessly across a busy street, being violent towards siblings and peers. Clinical features - Impulsivity Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 24.
    • Become boredwith interactive games with peers, and leave such games early before they are finished. • They find it difficult to delay gratification. • They show variable performance on tasks, which may negatively affect self-esteem. • They have difficulty with time management and have poor sense of time. • Even don't know when to come home when out playing with other children. Clinical features Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 25.
    • As aresult of their actions, they face difficulty in establishing and maintaining peer relationships. • By adolescence, hyperactivity is replaced by internal sense of restlessness & inattention is manifested as poorly organized approach to work. • ADHD adolescent is accident prone. • Poor concentration, inability to complete tasks, procrastination, occasional mood outbursts result. Procrastination: Practice of carrying out less urgent tasks, which are more pleasurable in preference to more urgent ones, which are less pleasurable and thus postponing them to deadline. Clinical features Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 26.
    • The diagnosisof ADHD is based purely on symptoms. • Evaluation includes inputs from parents, teachers and other care givers. • ADHD has been defined both in the American Psychiatric Association Diagnostic and Statistical Manual (DSM- V) and the International Classification of Diseases (ICD-1O). • In ICD-10 it is named Hyperkinetic Disorder (HKD). Diagnosis Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 27.
    • Diagnostic andStatistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), offers standard criteria for the classification of psychiatric disorders. • In DSM-V, ADHD is included under neurodevelopmental disorders. DSM-V Criteria Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 28.
    IMPULSIVITY Onset before 12 Years ofage Symptoms should be present in 2 or more settings Interfere with social/ academic functioning Not better explained by another psychiatric disorder Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 29.
    A. A persistentpattern of inattention and/or hyperactivity- impulsivity that interferes with functioning or development. 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). DSM-V Criteria Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 30.
    At least 6symptoms for <17 years age group. At least 5 symptoms for 17 years or more age group. For at least 6 months duration. 1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities 2. Often has difficulty sustaining attention in tasks or play activities 3. Often does not seem to listen when spoken to directly 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace A-1 Inattention Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 31.
    5. Often hasdifficulty organizing tasks and activities 6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort 7. Often loses things necessary for tasks or activities. 8. Is often easily distracted by extraneous stimuli 9. Is often forgetful in daily activities A-1 Inattention Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 32.
    At least 6symptoms for <17 years age group. At least 5 symptoms for 17 years or more age group. For at least 6 months duration. 1. Often fidgets with or taps hands or feet or squirms in seat. 2. Often leaves seat in situations when remaining seated is expected 3. Often runs about or climbs in situations where it is inappropriate. 4. Often unable to play or engage in leisure activities quietly. 5. Is often “on the go,” acting as if “driven by a motor” 6. Often talks excessively. A-2 Hyperactivity & Impulsivity Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 33.
    7. Often blurtsout an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). 8. Often has difficulty waiting his or her turn (e.g., while waiting in line). 9. 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 permission) A-2 Hyperactivity & Impulsivity Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 34.
    Combined : Ifboth Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months. Predominantly inattentive : If Criterion A1 (inattention) is only met for the past 6 months. Predominantly hyperactive/impulsive : If Criterion A2 (hyperactivity- impulsivity) is only met for the past 6 months. 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. Subtypes Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 35.
    Parent Rating Scales •Conner's Parent Rating Scale • Child Behavior Checklist • Yale Children's Inventory Home Situations Questionnaire Teacher Rating Scales • Conner's Teacher Rating Scale • Child Behavior Checklist-Teacher Form School Situations Questionnaire • ADHD Comprehensive Teacher Rating Scale (ACTReS) • Swanson, Nolan and Pelham (SNAP-IV) scale • Vanderbilt ADHD Scale • INCLEN – ADHD Diagnostic tool (Indian adaptation) Parent and Teacher Rating Scales to assess ADHD Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 36.
    INCLEN Diagnostic tool (InternationalClinical Epidemiology Network)  Based on DSM-IV TR  Rewording to make the criteria applicable to Indian scenario  SECTION-A : Whether the child fulfills the criteria or not.  SECTION-B : Whether pervasive functional impairment is present or not.  Diagnosis as No ADHD, ADHD, Other NDD or Indeterminate. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 37.
    DIFFERENTIAL DIAGNOSES INTELLECTUAL DEVELOPMENTAL DISORDER Children withmoderate to severe MR have attention and activity levels that are appropriate for developmental age not chronological age. SENSE ORGAN DEFICITS Hearing loss in glue ear etc. condition may lead to inattention. INTERMITTENT EXPLOSIVE DISORDER Impulsive behavior common to both. Children with Intermittent Explosive Disorder show serious aggression to others, which is not seen in ADHD. SPECIFIC LEARNING DISORDER These children may show in attention due to inability to learn and frustration. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 38.
    DIFFERENTIAL DIAGNOSES OPPOSITIONAL DEFIANT DISORDER (ODD) Apattern of negative, hostile and defiant behavior. Symptoms include frequent loss of temper, arguing (especially with adults), refusal to obey rules, intentionally annoying others, blaming others. CONDUCT DISORDER (CD) A pattern of behavior that persistently violates the basic rights of others or society’s rules. Behaviors may include aggression toward people and animals, destruction of property, deceitfulness or theft, or serious rule violations. DRUGS Medications like Phenobarbitone, Lamotrigine, Clonazepam & Vigabatrin can cause hyperactivity that can mimic ADHD. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 39.
    DIFFERENTIAL DIAGNOSES AUTISM ADHD Bothexhibit inattention, social dysfunction and difficult to manage behavior. Has no great desire to be social. Wants to be social. Feel sad, confused on isolation. Repetitive patterns of behavior are present. Absent. Difficulty in communication is present. There is no difficulty in communication. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 40.
    MANAGEMENT Multimodal approach • Educationand information for parents & children • Family intervention • Behavioral management • School Interventions • Medication Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 41.
    Education of parents& family interventions • Parents should be counselled that child is not exhibiting symptoms voluntarily & he/she can meet reasonable expectations if managed properly. • Formulate a regular daily routine and ensure that the child follows it. • Give short term simple tasks and on completion, praise the child. • Avoid over stimulation and excessive fatigue. Give time for relaxation. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 42.
    Family interventions • Keepvaluable, breakable and dangerous articles out of reach of the child. • Ensure quiet and peaceful bedtime. Avoid exciting T.V. programs, games during night. • Encourage peer relationships and teach social skills. • Give clear instructions and positively reinforce good behavior. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 43.
    School interventions • Childshould be seated near to teachers desk. • Teachers should make frequent eye contact with child. • Permit the child to do something with hands while engaged in sustained listening. • Allow intermittent activities like cleaning blackboard, distributing papers etc. • Teach concepts, reduce memory burden. • Divide work into small chunks. • Reinforce positive behavior. • Give regular non-accusatory feedback to child regarding his/her attention control. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 44.
    Medication STIMULANT MEDICATION NON-STIMULANT MEDICATION • Amphetamines: Dextroamphetamine Pemoline • Methylphenidates: Methylphenidate, Dexmethylphenidate •Atomoxetine • Tricyclic Anti-depressants: Imipramine, Norimipramine & Nortryptiline • α2-Adrenergic Agents: Clonidine, Guanfacine • Non-TCA anti depressant: Bupropion Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 45.
    Stimulants • Not usedfor < 3years age group. • Beneficial effects: Enhanced concentration, reduced hyper arousal state, reduced impulsivity., improved school and homework performance. • Methylphenidate commonly used started at 5mg/day dose and gradually increased up to 60mg/day. • Adverse effects: headache, abdominal pain, jitteriness, anorexia, insomnia, growth failure (Drug holiday during vacation), substance abuse. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 46.
    Atomoxetine • Norepinephrine ReuptakeInhibitor (NRI) • Reduces ADHD behaviors in children, adolescents, and adults. • Doesn't have abuse potential. TCAs • Imipramine, desipramine, and nortriptyline • Advere effects: Cholestatic jaundice, tachycardia, delirium, weight gain, constipation, skin rash, lowered seiizure threshold Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 47.
    Bupropion • 3-6 mg/Kg/day •Adverse effects: Insomnia, irritability, seizure α2-Adrenergic Agents: • Clonidine at 3-10 mg/kg/day used as alternative or adjunctive to Methylphenidate. • Its sedative effect counters insomniac effect of Methylphenidate. • Useful for tics, impulsivity, aggression. Doesn’t improve inattention. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 48.
    PROGNOSIS • Course ofADHD is variable. • Remission usually occurs between 12-20 years of age, unlikely before that. • 40-60% continue to be symptomatic through adolescence, 20-40% through adult hood. • Most cases get better as they grow. Hyperactivity usually stops by teenage. Easy distractibility, mood swings, hot tempers & inability to complete tasks persist. • Those continue to have symptoms are vulnerable to antisocial behavior, substance abuse, mood disorders & learning disorders. Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 49.
    References • Behavioural problemsin children and adolescents – Jaydeep Choudhary • DSM – V • Kaplan Sadock Text Book of Psychiatry • Nelson Text Book of Pediatrics • Indian Journal of Practical Pediatrics • www.indianpediatrics.net Dr Naveen Kumar Cheri S.V. Medical College, Tirupati
  • 50.
    Thank You Dr NaveenKumar Cheri S.V. Medical College, Tirupati