ADHD is a developmental disorder characterized by difficulties with attention span, impulse control, and activity level. It affects 3-6% of children and adolescents. The document discusses symptoms, types, prevalence, impact, pathophysiology, diagnosis, differential diagnosis, management, and conclusion of ADHD. Management includes pharmacotherapy, psychotherapy, family therapy, classroom accommodations, and nutrition.

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

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

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

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

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

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

7. Difficulty sustaining attention
(Meetings, Reading, Paperwork)
Paralyzing procrastination
Slow, inefficient
Poor time management
Disorganized
Difficulty sustaining attention
Doesn’t listen
No follow through
Can’t organize
Loses important items
Lifetime Course of ADHD
Lifetime Course of ADHD
Symptoms: Inattention Domain
Symptoms: Inattention Domain
Childhood Adult
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. Inefficiencies at work
Can’t sit through meetings
Can’t wait in line
Drives too fast
Selects very active job
Can’t tolerate frustration
Talks excessively
Makes inappropriate comments
Interrupts others
Squirming, fidgeting
Can’t stay seated
Can’t wait turn
Runs/ climbs excessively
Can’t play/ work quietly
On the go/ driven by motor
Talks excessively
Blurts out answers
Intrudes/ interrupts others
Lifetime Course of ADHD
Lifetime Course of ADHD
Hyperactivity/ Impulsivity Domain
Hyperactivity/ Impulsivity Domain
Childhood Adult
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
1,2,3
– ADHD affects 3-6% of children & adolescents,
ADHD affects 3-6% of children & adolescents,
with some estimates as high as 16.1%.
with some estimates as high as 16.1%.
– Boys 3 - 4 times more than girls.
Boys 3 - 4 times more than girls.
Prevalence of ADHD is underestimated
Prevalence of ADHD is underestimated4,5
4,5
– Comorbidities may mask diagnosis.
Comorbidities may mask diagnosis.
– Girls are under-recognized & undertreated.
Girls are under-recognized & undertreated.
– Difficult diagnosis in the adolescent.
Difficult diagnosis in the adolescent.
1. Goldman LS et al. JAMA. 1998;279:1100-1107; 2
US Department of Health and Human Services, 1999 3
Scott-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;
Prevalence of ADHD
Prevalence of ADHD

10. Low self-
esteem
Smoking and
substance abuse
Injuries Motor vehicle
accidents
Legal
problems
Occupational
difficulties
Childhood Adolescence Adulthood
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.
Impaired family and
peer relationships
Academic
limitations
Potential Impact of Untreated
ADHD Across the Lifespan

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

12.  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.
Pathophysiology of ADHD
(DA & NE Neurotransmission)

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

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

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

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

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

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

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

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

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

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

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

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

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