ADHD is a neurodevelopmental disorder characterized by inattention and/or hyperactivity-impulsivity. It affects 5-8% of children and persists into adulthood in approximately 60% of cases. Boys are more likely to be affected than girls. ADHD is diagnosed based on symptoms interfering with functioning in multiple settings. While the exact causes are unknown, genetic factors and executive function deficits play a role. Treatment involves behavioral therapy and stimulant medications, with methylphenidate and dexmethylphenidate being first line medication options.

1. Attention Deficit Hyperactivity
Disorder
Dr. Adithi Mohan

2. ADHD is a Neuro - Psychiatric / Neuro - Biological condition characterized by persistent pattern of inattention, and/or
hyperactivity and impulsivity that negatively impacts directly on social, academic and occupational activities or functioning.
ADHD affects up to 5 to 8 percent of school-aged children, with 60 to 85 percent of those diagnosed as children continuing to meet
criteria for the disorder in adolescence, and up to 60 percent continuing to be symptomatic into adulthood.

3. Epidemiologic studies suggest that ADHD occurs in about 5 percent of youth including children and adolescents, and about
2.5 percent of adults.
• The rate of ADHD in parents and siblings of children with ADHD is 2 to 8 times greater than in the general population.
• Siblings of children with ADHD are also at higher risk than the general population for learning disorders and academic
difficulties.
• ADHD is more prevalent in boys than in girls, with the ratio ranging from 2 : 1 to as high as 9 : 1
• First-degree biological relatives are at high risk for developing ADHD as well as other psychiatric disorders, including
disruptive behavior disorders, anxiety disorders, and depressive disorders.

4. Prevalence rate of
ADHD among
different age groups
in male and female
2013 Survey
 Boys have more prevalence over girls
 9-10 years of age group shows
relatively higher prevalence.

5. Co-Morbidity in ADHD
Based on CBQ A and B score (Children’s Behavior and Questionnaire) done in 2013 ADHD Study survey.
Its is obtained from personal information questionnaire filled by parents of 72 children with ADHD

6. ADHD and Socio
Economic Status
More prevalence of ADHD is seen
in Lower socio - economic status
family.

7. Diagnostic Criteria
A. 6 or more of following symptoms that have persisted for at least 6 months to a degree that is inconsistent with developmental level and
negatively impacts on social, academic and occupational activity.
B. Several inattentive or hyperactive - impulsive symptoms present prior to age of 12 years.
C. Several inattentive or hyperactive - impulsive symptoms present in 2 or more settings.
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 other psychotic disorder and are not better explained by
another mental disorder.

8. In-attention :
• Often fails to give close attention to details or makes careless mistakes.
• Difficulty sustaining attention in a task or play activities.
• Does not seem to listen when spoken to directly.
• Does not follow through on instructions and fail to finish school work, chores or duties in work place.
• Has difficulty in organizing task and activity.
• Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort.
• Loses things necessary for task or activity.
• Often easily distracted by extraneous stimuli.
• Often forgetful in daily activities.

9. Hyperactivity and Impulsivity :
• Often fidgets with or taps hands or feet or squirms on seat.
• Leaves seats in situation when expected to remain seated.
• Runs about or climbs in situation where it is inappropriate.
• Unable to play or engage in leisure activities quietly.
• Is often “on the go” acting as if “driven by motor” (Restlessness).
• Often talk excessively.
• Blurts out and answer before a question has been completed.
• Difficulty waiting for his or her turn in a line.
• Interrupts or intrudes on others.

10. 1. Combined presentation : If criteria A1 (inattention) and criteria A2 (hyperactivity - impulsivity) are met for past 6
months.
2. Predominantly inattentive presentation : If criteria A1 (inattention) is met but criteria A2 (hyperactivity - impulsivity) is
not met for past 6 months.
3. Predominantly hyperactive or impulsive presentation : If criteria A2 (hyperactivity - impulsivity) is met but criteria A1
(inattention) is not met for past 6 months.
 Partial remission of ADHD : When full criteria were previously met, and/or
fewer than the full criteria have been met for past 6 months,
and the symptoms still result in impairment in social, academic or occupational functioning.

11. Prevalence of
ADHD
presentation (%)

12. Severity
Mild ADHD : Few or any symptoms in excess of those required to make the diagnosis are present and
symptoms result in no more than minor impairments.
Moderate ADHD : Symptoms or functional impairments between “mild” and “severe” are present.
Severe ADHD : Many symptoms in excess of those required to make the diagnosis, or several symptoms that
are particularly similar are present, or the symptoms result in marked impairment of social or occupational
functioning.

13. Clinical Features
ADHD can have its onset in infancy, although it is rarely recognized until a child is at least toddler age. More
commonly, infants with ADHD are active in the crib, sleep little, and cry a great deal.
In school, children with ADHD may attack a test rapidly, but may answer only the first two questions. They may
be unable to wait to be called on in school and may respond before everyone else.
At home, they cannot be put up for even a minute. Impulsiveness and an inability to delay gratification are
characteristic..

14. The most cited characteristics of children with ADHD, in order of frequency, are :
 Hyperactivity,
 Attention deficit (short attention span, distractibility, perseveration, failure to finish tasks, inattention, poor concentration),
 Impulsivity (action before thought, abrupt shifts in activity, lack of organization, jumping up in class),
 Memory and thinking deficits,
 Specific learning disabilities, and
 Speech and hearing deficits.
Associated features often include perceptual motor impairment, emotional lability, and developmental coordination disorder.

15. Course and Prognosis
The course of ADHD is variable. Symptoms have been shown to persist into adolescence in 60 to 85 percent of
cases, and into adult life in approximately 60 percent of cases. The remaining 40 percent of cases may remit at
puberty, or in early adulthood. In some cases, the hyperactivity may disappear, but the decreased attention span
and impulse-control problems persist. Overactivity is usually the First symptom to remit, and distractibility is the
last.
When remission occurs, it is usually between the ages of 12 and 20.
Most patients with the disorder, however, undergo partial remission and are vulnerable to antisocial behavior,
substance use disorders, and mood disorders. Learning problems often continue throughout life.

16. Examination and Investigations
A child being evaluated for ADHD should receive a comprehensive psychiatric and medical history. Prenatal, perinatal, and toddler
information should be included in the history. Complications of mother’s pregnancy should also be obtained.
Medical problems that may produce symptoms overlapping with ADHD include petit mal epilepsy, hearing and visual
impairments, thyroid abnormalities, and hypoglycemia. A thorough cardiac history should be taken, including an investigation of
the lifetime history of syncope, family history of sudden death, and a cardiac examination of the child. Although it is reasonable to
obtain an electrocardiography (ECG) study prior to treatment, if any cardiac risk factors are present, a cardiology consultation and
examination are warranted.
No specific laboratory measures are pathognomonic of ADHD.

17. Management
It involves of combination of psychological interventions and medications.
Psychological interventions :
 Psycho-education.
 Academic organization skills remediation.
 Parent training.
 Cognitive behavioral therapy.
 Social skills training.
 Behavioral therapy for parents with ADHD child.
 Behavioral interventions at school.

18. Pharmacotherapy
Pharmacologic treatment is considered the first line of treatment for ADHD.
 Stimulant Medications
 Non Stimulant medications

19. • CNS Stimulants are the 1st choice of agents.
• Stimulants are contraindicated in children,
adolescents and adults with cardiac conditions.
• Current strategies favor once a day sustained
release stimulant preparations for convenience.
• Common side effect on long term use without
drug holiday is growth suppression.
• Adverse effects : Head ache, Stomach Ache,
Nausea, Insomnia.
Methyphenidate (highly effective) are the first choice of drug, they are
dopamine agonist.
Dexmethyphenidate are the second choice of drugs.

20. • It is a potent nor-epinephrine uptake inhibitor. (inhibition of pre-synaptic
Nor-epinephrine transporter).
• Adverse effects of Strattera – increased suicidal thoughts and behavior.
• Tricyclic drugs are not recommended in treatment of ADHD due to potential
cardiac arrythmias.
• Non stimulant medications approved in the treatment of ADHD by FDA
(Food and Drug Administration) include Atomoxetine (Strattera).
• Anti psychotics are generally not chosen in the treatment of ADHD due to risk of tardive dyskinesia, withdrawal dyskinesia,
Neuroleptic malignant syndrome and weight gain.

21. Differential
Diagnosis Specific Learning disorder
Autism Spectrum disorder
Anxiety disorder
Depressive Disorder
Bipolar Disorder
Personality Disorder
Psychotic Disorder
Medication Induced Symptoms of ADHD