Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders in children characterized by inattention, hyperactivity, and impulsivity. It is diagnosed based on symptoms that cause impairment in multiple settings according to the DSM-IV criteria. Treatment involves psychosocial interventions, behavior management training, and stimulant medication which effectively treat the core symptoms of ADHD.

1. Attention-Deficit / Hyperactivity Disorder (ADHD) Prof. Saad S Al Ani Senior Pediatric consultant Head of pediatric Department Khorfakkan Hospital Sharjah ,UAE [email_address]

2. Attention-deficit/hyperactivity disorder (ADHD) Is the Most common neurobehavioral disorder of childhood , One of the most prevalent chronic health conditions affecting school-aged children The most extensively studied mental disorder of childhood.

3. The Characteristic of ADHD ADHD Is characterized by: Inattention , including increased distractibility and difficulty sustaining attention Poor impulse control and decreased self-inhibitory capacity Motor overactivity and motor restlessness Fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV),

4. Types of ADHD Three types of ADHD are identified by DSM-IV : 1. Predominantly hyperactive-impulsive symptoms type 2. Predominantly inattentive symptoms type 3. Combined type Fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV),

5. Problems experienced by ADHD child ► Affected children commonly experience problems with : Academic underachievement Interpersonal relationships with family members and peers low self-esteem .

6. ADHD & associated disorders ► ADHD frequently co-occurs with other: Emotional Behavioral Language Learning disorders

7. Etiology ADHD is a heterogeneous condition for which no single cause has been identified. Evidence suggests that genetic and environmental factors play a significant role during fetal and postnatal development in the emergence of ADHD during early childhood.

8. Etiology (cont.) Both morphologic and functional brain differences have been identified, including - Moderate reduction in the size of : 1. Corpus callosum 2. Basal ganglia 3. Frontal lobes - Hypoperfusion of the frontal-striatal dopamine pathways.

9. Etiology (cont.) ADHD commonly occurs following : 1.Damage to the CNS (e.g., prematurity or traumatic brain injury) 2.Toxic exposure (e.g., fetal alcohol syndrome or lead poisoning), 3.Maldevelopment (e.g., mental retardation syndromes), 4. Sequelae of infectious processes affecting the CNS . ADHD also occurs in otherwise physically healthy children.

10. Etiology Twin and family studies suggest a strong genetic component to ADHD, and molecular genetic studies have identified abnormalities in : 1. Dopamine transporter gene 2. D4 receptor gene 3. Human thyroid receptor beta gene.

11. Epidemiology Prevalence to be between 3% and 5% among school-aged children (DSM-IV) Prevalence rate ranging from 4% to 12% among school-aged children ( Community samples ) . The condition is approximately 3 to 4 times more common in males (9.2%) than females (2.9%)

12. Epidemiology (cont.) Inattentive subtype is the most common in females . Environmental factors , such as psychosocial stressors, parenting difficulties, and classroom factors may exacerbate ADHD but do not cause the syndrome.

13. Epidemiology (cont.) Epidemiologic studies suggest that ADHD is underdiagnosed in the population at large, and children with the disorder are often undertreated with medications

14. Clinical Manifestations DSM-IV criteria were developed in field trials conducted mainly with children 5 to 12 yr of age . These criteria emphasize several factors .

15. DSM-IV criteria (cont.) Behaviors must : 1. Statistically abnormal for the child's age and developmental level 2. Begin before the age of 7 yr 3. Present for at least 6 mo .

16. DSM-IV criteria (cont.) Symptoms must : 1. Pervasive in nature (present in at least two or more settings) 2. Impair the child's ability to function normally. 3. Not be secondary to another disorder.

17. DSM-IV criteria (cont.) A. Either 1 or 2 1. Six (or more) of the symptoms of inattention have persisted for at least 6 mo to a degree that is maladaptive and inconsistent with development level 2. Six (or more) of the symptoms of hyperactivity-impulsivity have persisted for at least 6 mo to a degree that is maladaptive and inconsistent with developmental level:

18. DSM-IV criteria (cont.) B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 yr of age . C. Some impairment from the symptoms is present in 2 or more settings (e.g., at school [or work] or at home).

19. DSM-IV criteria (cont.) 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 personality disorder).

20. Inattention a. Often fails to give close attention to details or makes careless mistakes in school work, work, or other activities b. Often has difficulty sustaining attention in tasks or play activities c. Often does not seem to listen when spoken to directly

21. Inattention (cont.) d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) e. Often has difficulty organizing tasks and activities f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

22. Inattention (cont.) g. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) h. Is often easily distracted by extraneous stimuli i. Is often forgetful in daily activities

23. Hyperactivity a. Often fidgets with hands or feet or squirms in seat b. Often leaves seat in classroom or in other situations in which remaining seated is expected c. 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)

24. Hyperactivity (cont.) d. Often has difficulty playing or engaging in leisure activities quietly e. Is often "on the go" or often acts as if "driven by a motor" f. Often talks excessively

25. Impulsivity g. Often blurts out answers before questions have been completed h. Often has difficulty awaiting turn i. Often interrupts or intrudes on others (e.g., butts into conversations or games)

26. Clinical Manifestations (cont.) With increasing age, clinical manifestations may change from predominantly motor restlessness, aggressive, and disruptive behavior in preschool children to disorganized, distractible, and inattentive symptoms in older adolescents and adults.

27. Difficult to diagnose In preschool children , who normally tend to be active and restless. In children with cognitive disabilities , who often act in an immature fashion and whose intentions may be difficult to judge.

28. Diagnoses of ADHD Primarily on clinical grounds after a thorough evaluation whose components include : 1. Behavior rating scales 2. Clinical interview 3. Physical examination 4. Neuropsychologic evaluation .

29. BEHAVIOR RATING SCALES These scales are useful in establishing the magnitude and pervasiveness of the symptoms but are not sufficient alone to make a diagnosis of ADHD Several standardized behavior rating scales are widely available and perform well in discriminating between children with ADHD and controls (e.g., Conner's Rating Scale ; ADHD Index ;)

30. BEHAVIOR RATING SCALES (cont.) Other broad-band checklists , such as the Achenbach Child Behavior Checklist (CBCL) are useful in screening for co-occurring problems in areas other than ADHD (e.g., anxiety, depression, conduct problems, etc.). It is important to gather information from a variety of sources -typically parents, teachers, and, when appropriate, other caretakers-to determine pervasiveness of the symptoms.

31. CLINICAL INTERVIEW A major goal of the clinical interview is exploration of whether symptoms might be the result of other conditions that mimic ADHD. Review of the child's health, development, and social and family history should emphasize factors that might affect the development or integrity of the CNS, or reveal the presence of chronic illness, sensory impairments, or medication use that might affect the child's functioning.

32. CLINICAL INTERVIEW (cont.) Disruptive social factors , such as family discord, situational stresses, abuse, or neglect may result in hyperactive or anxious behaviors . Finally, a family history of first-degree relatives with ADHD, mood or anxiety disorders, learning disability, antisocial disorder, or alcohol or substance abuse may indicate increased risk for ADHD and/or co-morbid conditions.

33. PHYSICAL EXAMINATION (cont.) No medical screening or laboratory tests are specific to ADHD . Careful examination may reveal the presence of 1.chronic illnesses 2. sensory impairments 3. genetic/birth defect syndromes that may contribute to behavioral and learning difficulties.

34. PHYSICAL EXAMINATION (cont.) The presence of: 1. hypertension 2. motor tics 3. ataxia 4. thyroid disorder may be contraindications for use of stimulant medications to treat ADHD symptoms and should prompt further diagnostic evaluations. Fine motor coordination delays and other "soft signs" are common but are not sufficiently specific to contribute to a diagnosis of ADHD.

35. PHYSICAL EXAMINATION (cont.) It is important to note that behavior in a highly structured or novel setting may not reflect typical behavior at home or school. Reliance on observed behavior in a physician's office may result in incorrect diagnosis .

36. NEUROPSYCHOLOGIC EXAMINATION Standardized tests of general intelligence and educational achievement may indicate the presence of mental retardation or specific learning disabilities. Incompatibility between classroom expectations and the child's ability may result in inattentive or inappropriate behaviors.

37. NEUROPSYCHOLOGIC EXAMINATION (cont.) Tests of sustained attention-continuous performance tests can help corroborate a diagnosis of ADHD but are not adequate by themselves to confirm or deny the diagnosis.

38. Differential Diagnosis Chronic illnesses ► affect up to 20% of children in the United States ► may impair children's attention and school performance (e.g., migraine headaches, absence seizures, asthma and allergies, hematologic disorders, juvenile diabetes, childhood cancer, etc.), either because of the disease itself or medications used to treat or control the underlying illness (e.g., medications for asthma, steroids, anticonvulsants, antihistamines). Substance abuse ► in older children and adolescents, may result in declining school performance and inattentive behavior.

39. Differential Diagnosis Sleep disorders ► including those secondary to chronic upper airway obstruction from enlarged tonsils and adenoids, frequently result in behavioral and emotional symptoms. Conversely, behavioral and emotional disorders may cause disrupted sleep patterns. Depression and anxiety disorders ► may present many of the same symptoms as ADHD (e.g., inattention, restlessness, inability to focus and concentrate on work, poor organization, forgetfulness) and may be present as co-morbid conditions.

40. Differential Diagnosis (cont.) Obsessive-compulsive disorder may mimic ADHD, particularly when recurrent and persistent thoughts, impulses, or images are intrusive and interfere with normal daily activities. Adjustment disorders secondary to major life stresses (e.g., death of a close family member, parental divorce, family violence, parental substance abuse, a move, etc.) or parent-child relationship disorders involving conflicts over discipline, overt child abuse and/or neglect, or overprotection, may result in symptoms similar to ADHD.

41. Treatment. Include: 1.Psychosocial interventions 2. behavior management training 3. medication Which are effective in treating the various components of ADHD.

42. Treatment. (cont.) * The effectiveness of stimulant medication in treating core symptoms of ADHD * Psychosocial interventions and behavior management training were effective in treating many co-morbid disorders frequently seen in children with ADHD. National Institute of Mental Health Collaborative Multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA study)

43. PSYCHOSOCIAL INTERVENTIONS Goals should be set to : 1. Improve the child's relationships with parents, siblings. teachers, and peers 2. Decrease disruptive behaviors 3. Increase independence in completing homework 4. Improve self-esteem .

44. PSYCHOSOCIAL INTERVENTIONS (cont.) Behavior therapy should include a broad plan for modifying 1. The physical and social environment 2. the child's behaviors . For example, school and home settings may be adjusted to 1. Accommodate the child's learning style 2. Decrease distractions .

45. BEHAVIOR MANAGEMENT TRAINING Training may consist of 8-12 weekly individual or group sessions. Parents learn principles of behavior management with emphasis on consistency, while children work on improving peer relationships and self-esteem. Specific "target" behaviors are identified that impair the child's daily life functions (e.g., violating home or school rules, disruptive behavior, not completing homework assignments, etc.).

46. BEHAVIOR MANAGEMENT TRAINING Next, parents and teachers must implement specific techniques of providing rewards to the child for demonstrating the desired behavior ( positive reinforcement ) or consequences for failure to meet the goals ( negative reinforcement ). Family and individual psychotherapy may be necessary in complex situations or to address overt mental health conditions such as depression, anxiety, social withdrawal, school phobia, etc.

47. BEHAVIOR MANAGEMENT TRAINING Psychologists, school personnel, community mental health therapists, or primary care clinicians can provide behavior therapy; however, many clinicians prefer to refer families to community providers because behavior therapy is time-consuming and often requires specific training and skills. National organizations , such as CHADD (Children with Attention Deficit Disorders) and ADDA (Attention Deficit Disorders Association) may also provide valuable support to families and children.

48. MEDICATION Stimulants are the most effective psychotropic agents in treating ADHD Stimulants are effective in ameliorating core symptoms of: * Inattention * Impulsivity * Hyperactivity. In addition, improvements are seen in: * Noncompliant behaviors * Impulsive aggression * Social interactions with peers and family members * Academic productivity and accuracy. In contrast, stimulants are not likely to improve reading skills, academic achievement, or antisocial behaviors.

49. Main classes of stimulants The two main classes of stimulants are: 1. Methylphenidate and its derivatives (Ritalin, Concerta, Metadate CD, and Methylin) 2. Amphetamine and its derivatives (Dexedrine and Adderall). Both classes are available in * short * intermediate * long-acting forms . All stimulant forms are equally effective , but individual children may respond differently to one or another medication When the stimulants are used sequentially, approximately 80% of children will respond favorably to one of them with satisfactory relief of major symptoms of ADHD.

50. Stimulants; contraindications and adverse effects Stimulants have few contraindications and adverse effects are usually predictable and generally mild . Common short-term side effects include * Loss of appetite * Initial weight loss * Abdominal discomfort * Dysphoria * Difficulty sleeping. A slight increase in heart rate may also be seen Less often , tics may become evident in children who start stimulant medications. These adverse symptoms usually remit when 1. the dosage is lowered 2. an alternative stimulant preparation or another class of medication is used.

51. Stimulants; contraindications and adverse effects (cont.) long-term use of stimulants Does not result in addiction (i.e., there is no development of tolerance, craving, or withdrawal) and is unlikely to lead to abuse drugs . Much lower incidence of illicit substance and alcohol abuse than those who do not receive appropriate treatment. Do not result in aggressive or assaultive behavior, do not increase the risk of seizures, are not a cause of Tourette syndrome, and do not exacerbate anxiety disorders

52. Other Medications Other agents, such as tricyclic antidepressants (imipramine and desipramine) and buproprion (Wellbutrin) are considered second-line agents that have been shown to be effective in treating ADHD, particularly in the presence of co-morbid depression. Alpha-2 adrenergic blocker agents , such as clonidine (Catapres) and guanfacine (Tenex), are also effective and often used alone or in combination with stimulants.

53. Prognosis. In at least 80% of affected children, symptoms of ADHD persist into adolescence and adulthood. With increasing age: * Hyperactivity tends to decrease * inattention , impulsivity , disorganization , and relationship difficulties often persist and become more prominent.

54. Prognosis (cont.) If not properly identified and treated , affected individuals across the age span are at risk for a wide range of unfavorable health and psychosocial outcomes , including: * accidental injuries * educational underachievement * employment difficulties * risky sexual behavior * criminal activity. with a combination of medication and psychosocial and behavioral interventions, most children's symptoms are significantly ameliorated .

55. Summary ADHD Is characterized by: Inattention , Poor impulse control, Motor overactivity Three types of ADHD are identified 1. Predominantly hyperactive-impulsive symptoms type 2. Predominantly inattentive symptoms type 3. Combined type Genetic and environmental factors play a significant role during fetal and postnatal development in the emergence of ADHD during early childhood Prevalence rate ranging from 4% to 12% among school-aged children (Community samples ).

56. Summary (cont.) Inattentive subtype is the most common in females Other disorders are frequently present as co-morbid conditions : 1.Oppositional defiant disorder or conduct disorder (35%) 2.Depression and mood disorders (18%) 3.Anxiety disorder (25%) 4.Learning disorders (10-25%) Treatment Include : 1.Psychosocial interventions 2. behavior management training 3. medication Stimulants are the most effective psychotropic agents in treating ADHD

57. References American Academy of Child and Adolescent Psychiatry: Summary of the practice parameter for the use of stimulant medication in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry 2001;40:1352-5 American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder: Clinical practice guideline: Treatment of the school-aged child with Attention-Deficit/ Hyperactivity Disorder. Pediatrics 2001;108:1033-44. Pliszka SR, Greenhill LL, Crismon ML, et al: The Texas Children's Medication Algorithm Project: Report of the Texas consensus conference panel on medication treatment of childhood attention-deficit/hyperactivity disorder. Part II: Tactics. J Am Acad Child Adolesc Psychiatry 2000;39:920-7. Medline Similar articles Wolraich ML, Greenhill LL, Pelham W, et al: Randomized, controlled trial of OROS Methylphenidate once a day in children with Attention-Deficit/Hyperactivity Disorder. Pediatrics 2001;108:883-92. Medline Similar articles