ADHD ,Autism is increasing in India,Psychological problems are increasing with great speed.If these children are not identified in early childhood most of the children can land up in adult personality disorders or psychiatric disorders

1. Approach to ADHD in children
Dr vijay warad
Sai speciality clinic,satara road
Inamdar and sahyadri hospitals,pune

2. What comes to your Mind ?

3. INTRODUCTION
ADHD is one of the most common childhood
Neurobehavioural disorders
First described by Dr. Heinrich Hoffman in 1845
“The Story of Fidgety Philip”
In 1902, Sir Geroge Still described the condition
First published report in 1937 of stimulant
medication in ADHD
ADHD often continues into Adolescence and
Adulthood

4. What Is ADHD?
ADHD, or attention deficit hyperactivity
disorder, is a Behavioral Condition
characterized by inattention, impulsiveness,
and/or hyperactivity.
Approximately 1-20% of Indian children
have ADHD
Source – Indian Academy of Pediatrics

5. Persistent pattern of inattention and / or
hyperactivity and impulsive behaviour
that is more severe than that expected
in children of that age and level of
development.
Definition

6. PREVALENCE
Prevalence of ADHD 3 -10% ( Rowland et al
2002)
Affects 5% of school children (1/ class room)
More common in boys 4 – 9:1 (Gender bias)
Recent revised estimate 2 – 4:1 (Safer & Malever
2000)

7. ASSOCIATED FEATURES
School failure
Poor planning, organization and task
performance
Speech and language problems
Poor motor co-ordination
Enuresis
Instability
High stimulus seeking
Low frustration tolerance

8. ASSOCIATED CO-MORBID CONDITION
Language and learning disability (10-15% have
ADD)
Tourette’s syndrome (70% have ADHD)
Oppositional Defiant Disorders (33% of ADHD)
Conduct Disorders (25 -50% of ADHD)
Major Depression (20% of ADHD)
Anxiety Disorders (25% of ADHD)

9. ADHD COMORBIDITY

10. Secondary Complications
of Rhinitis
Allergic inflammation does not necessarily limit itself to the nasal airway
 Asthma : up to 80% of asthma patients have accompaning AR,38% of AR have
asthma
 Chronic sinusitis
 Otitis media
 Hearing difficulties
 Facial changes
 Failure to thrive
 Behavioural disorders (hyperactivity)
 Increased Social & emotional issues affect learning & ability to integrate with
peers
 Uncontrolled AR & adverse effects of sedating medications affect cognitive
functions
 Pneumonias
 COPD

11. What Are the Symptoms of ADHD?
Hyperactivity
Impulsivity
Inattention

12. Child's functioning in social and
academic settings, Interfere…
Paying attention to tasks at home or school
Making careless errors
Being easily distracted
Not following through with tasks or
completing instructions
Bored, losing things, being forgetful, having
difficulty organizing tasks
Being fidgety, seated at one place
Talking excessively

13. How Do I Know if a Child Has
ADHD?
Many of the symptoms of ADHD are also
symptoms seen during normal childhood
and development
Exhibiting one or more of the symptoms
does not mean that a child has ADHD
NEVER JUMP TO CONCLUSION

14.  The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth
edition) Below is the Diagnostic Criteria for diagnosing Attention Deficit
(Hyperactivity) Disorder:
 A. Either (1) or (2)
 1) Six or more of the following symptoms of inattention have persisted
for at least six months to a degree that is maladaptive and inconsistent
with the developmental level:
 Inattention
 often fails to give close attention to details or makes careless mistakes in
schoolwork, work, or other activities
 often has difficulty sustaining attention in tasks or play activities
 often does not seem to listen when spoken to directly

15.  often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to oppositional
behaviour or failure of comprehension)
 often has difficulty organizing tasks and activities
 often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
 often loses things necessary for tasks or activities at school or at home
(e.g. toys, pencils, books, assignments)
 is often easily distracted by extraneous stimuli
 if often forgetful in daily activities

16.  2) Six or more of the following symptoms of hyperactivity-impulsivity
have persisted for at least 6 months to a degree that is maladaptive
and inconsistent with the developmental level:
 Hyperactivity
 often fidgets with hands or feet or squirms in seat
 often leaves seat in classroom or in other situations in which remaining
seated is expected
 often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective feelings
of restlessness)
 often has difficulty playing or engaging in leisure activities quietly
 often talks excessively
 is often 'on the go' or often acts as if 'driven by a motor'

17.  Impulsivity
often has difficulty awaiting turn in games or group situations
 often blurts out answers to questions before they have been completed
 often interrupts or intrudes on others, e.g. butts into other children's games
 B. Some hyperactivity - impulsive or inattentive symptoms that cause
 impairment were present before the age of 7 years.
 C. Some impairment from the symptoms is present in more than two or more
settings (e.g. at school or work or at home).
 D. There must be clear evidence of clinically significant impairment in social,
academic, or occupational functioning.
 E. The symptoms do not occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder, and are
not better accounted for by another mental disorder (e.g. Mood Disorder,
Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

18. Symptoms of Hyperactivity
in ADHD
The child often fidgets with hands or feet or
squirms in their seat
The child often leaves the seat in the
classroom or in other situations in which
remaining seated is expected
The child often talks excessively.

19. Symptoms of Impulsivity in ADHD
The child often blurts out answers before
the questions have been completed
The child often experiences difficulty
awaiting his or her turn
The child often interrupts or intrudes on
others

20. Symptoms of Inattention in ADHD
The child often fails to give attention to
details, or makes careless mistakes in
schoolwork, work, or other activities.

21. The child often has difficulty sustaining
attention in tasks or play activities.

22. LIFE TIME COMORBID DISORDERS
Shekim WO, et al Comprehensive Psychaitry 1990; 31(5):416-425
Biedermen J, et al. Am. J. Psychiatry 1993; 150(12): 1792-1798
PSUD: Psychoactive substance use disorder; MDD: Major
Depressive Disorder ; LD: Learning disability;
ASP: Antisocial personality

23. PRESENTING FEATURES
Look for features of dyslexia, dysgraphia
Cruelty towards people, animals
Destruction of property, stealing
Delinquent behavior
Argumentative, disobedient, defiant, Back answers, quick
to take offense

24. PRESENTING FEATURES
Excessive crying or worry
Preoccupation with death or suicides
Neglect of self environment, antisocial
Low self esteem
Substance abuse

25. DIFFERENTIAL DIAGNOSIS
Mental Retardation with Hyperactivity
Under stimulation for highly intelligent children
Hyperthyroidism
Lead poisoning
Seizures (Petit Mal, Non Convulsion Status)
Medication – AED’s, antihistaminic, decongestants etc.
Chronic illness, sleep disorders

26. COMPREHENSIVE MANAGEMENT
PROTOCOLS
Screening in pre-school and school children
Assessment to fit DSM IV Criteria
Evaluation for co-morbid conditions
Investigations when indicated
Pharmacological treatment
Psychological treatment
Lifestyle modification

27. TREATMENT PLAN
Psycho-education of parent, teacher, child
BT initially for mild to moderate ADHD
Psycho-stimulants strongly recommended for
moderate to severe ADHD
Combination of both is most beneficial
Constant follow up since it’s a chronic condition

28. Medicines
 Automoxetin: Axpeta (25 mg,50 mg)
Above 6 years preffered
 Methylphenidate:- Inspiral,Adwise 10 mg,20 mg

29. ALTERNATIVE THERAPIES
Omega-3 fatty acids
Hypnosis
EEG biofeedback
Yoga, meditation
Ginkgobiloba
Mega-Vitamin Therapy

30. OMEGA -3 FATTY ACIDS
3 Major Type ingested in food
ALA – Alpha Linolenic Acid
EPA – Eicosapentaenoic Acid
DHA – Docosahexaenoic Acid
Once ingested Body converts ALA to EPA & DHA

31. DIETARY SOURCES
ALA – in Flax seeds, Canola Oil, Walnuts
DHA – in Seafood, Tuna, Salmon
EPA – Whole Grains, Garlic, Olive Oil

32. MECHANISM OF ACTION
Blocks action of cytokines
Enhance Neurotrophic activity in Synapses
Forms an essential part in physicochemical properties of
cell membranes, oligodendrocytes and astrocytes
(Purdue Study, Durham Study, Richardson and Puri Study)

33. STUDY WITH OMEGA 3 FATTY ACID
Study on pre school children with LD and ADHD
showed significant improvement in cognitive &
behavioural functions after 12 weeks of O3 Fatty Acid
(Richardson + Puri Oxford Univ.)
Study of Pregnant ladies given O3 Fatty Acid
supplement --- Children followed upto 5-6 years age
significant different in learning capabilities and
academic performance (Meherban Singh)
Docosahexaenoic Acid for Reading, Cognition and
Behavior in Children Aged 7–9 Years: A Randomized,
Controlled Trial (The DOLAB Study)
Alexandra J. Richardson*, Jennifer R. Burton, Richard P. Sewell, Thees F.
Spreckelsen, Paul Montgomery
Centre for Evidence-Based Intervention, University of Oxford, Oxford, United
Kingdom

34. PROGNOSIS
About 60-80% of childhood ADHD continue into Adolescent
& adults.
They may out grow Impulsivity and Hyperactivity.
Inattention and Disorganization persist and may worsen.
Adults with H/o ADHD in childhood have higher rates of
antisocial, criminal behaviour, Injuries, accidents, teen
pregnancies
Employment and Marital difficulties.
May need treatment and follow up lifelong.

35. ADHD
Low self
esteem
Academic
limitations
Relationships
Smoking and
substance abuse
Injuries
Motor vehicle
accidents
Legal
difficulties
Occupational/
vocational
Symptoms of ADHD through the
life cycle

36. Treatment Option…
Very IMPORTANT…

37. COGNIUM SYP CLINICAL
TRIALS
Proven in a Comparative clinical trial with 60 ADHD
Childrens,for 16 weeks
-Conducted by Dr.Vwarad,MD(Paed)in Pune
-Conducted on 2 Group of 300 children each,Gr
A&Gr B
-group A with cognium syrup and Behavioral therapy
-Group B with Behavirol therapy alone
-Assesssed by VANDERBILT ASSESSMENT SCALE