This document provides information on attention deficit hyperactivity disorder (ADHD), including its diagnostic criteria, epidemiology, etiology, clinical features, diagnosis, differential diagnosis, treatment, and prognosis. Some key points include: - ADHD is characterized by inattention, hyperactivity and impulsivity. It has predominantly inattentive, hyperactive/impulsive, or combined presentations. - Genetic and neurological factors are involved in its etiology. Stimulant medications like methylphenidate and amphetamines are commonly used treatments. - ADHD symptoms often emerge by age 3 and persist into adolescence or adulthood in about 50% of cases, though hyperactivity may decrease over time.

1. MARCH 2009
‫حسين‬ ‫محمد‬

2. ADHD
 a pattern of diminished sustained attention and higher
levels of impulsivity in a child or adolescent than expected
for someone of that age and developmental level.
 ADHD subtypes:
 inattentive,
 hyperactive/impulsive,
 or combined
 To diagnosis of ADHD in children older than 7 years
 To diagnose impairment from inattention and/or
hyperactivity-impulsivity must be observable in at least
two settings.

3. Epidemiology
 Incidence in the U.S. varied from 2 : 20 % of grade-school
children.
 In U.K. less than 1 %.
 male:female 2:1 to as much as 9 to 1.
 First-degree biological relatives are at high risk to develop ADHD
as well as to develop disruptive behavior disorders, anxiety
disorders, and depressive disorders.
 Siblings of children with ADHD are also at higher risk have
learning disorders
 The parents of children with ADHD show an increased incidence
of sociopathy, alcohol use disorders, and conversion disorder.
 Symptoms are often present by age 3 years, but the diagnosis is
generally not made until the child is in a structured school setting,
such as preschool or kindergarten, when teacher information is
available comparing the attention and impulsivity of the child in

4. Etiology
 involves complex interactions of neuroanatomical and
neurochemical systems
 based on twin and adoption family genetic studies,
dopamine transport gene studies, neuroimaging studies,
and neurotransmitter data.
 Most children with ADHD have no evidence of gross
structural damage in the CNS.

5. Etiology

6. Genetic Factors
 greater concordance in monozygotic than in dizygotic
twins.
 Siblings of hyperactive children have about twice the risk
of having the disorder as those in the general population.
 Biological parents with ADHD have a higher risk for than
adoptive parents.
 Children with ADHD are at higher risk of developing
conduct disorders, and alcohol use disorders and
antisocial personality disorder are more common in their
parents than in those in the general population

7. Developmental Factors
 September is the peak month for births of children with
ADHD.
 Prenatal exposure to winter infections during the first
trimester may contribute to the emergence of ADHD
symptoms in some susceptible children

8. Brain Damage
 It has been speculated that some children affected by
ADHD had subtle damage to the CNS and brain
development during their fetal and perinatal periods.
 The hypothesized brain damage may potentially be
associated with circulatory, toxic, metabolic, mechanical,
or physical insult to the brain during early infancy caused
by infection, inflammation, and trauma.
 Children with ADHD exhibit nonfocal (soft) neurological
signs at higher rates than those in the general population

9. Neurochemical Factors
 Many neurotransmitters have been associated with
ADHD symptoms.
 Animal studies have shown that the locus ceruleus plays
a major role in attention.
 The peripheral noradrenergic system may be of more
importance in ADHD. Thus, a dysfunction in peripheral
epinephrine, which causes the hormone to accumulate
peripherally, could potentially feed back to the central
system and “reset” the locus ceruleus to a lower level.

10. Neurophysiological Factors
 The human brain normally undergoes major growth
spurts at several ages: 3-10 months, 2-4 years, 6-8 years,
10-12 years, and 14-16 years.
 Some children have a maturational delay.
 Presence of a variety of nonspecific abnormal (EEG)
patterns that are disorganized and characteristic of
young children. In some cases, the EEG findings
normalize over time.
 CT head scans of children with ADHD show no
consistent findings.

11. Neurophysiological Factors….
 (PET) lower cerebral blood flow and metabolic rates in
the frontal lobe.
 One theory explains these findings by supposing that the
frontal lobes in children with ADHD are not adequately
performing their inhibitory mechanism on lower
structures, an effect leading to disinhibition

12. Psychosocial Factors
 Children in institutions are frequently overactive and have poor
attention spans.
 These signs result from prolonged emotional deprivation, and
disappear when deprivational factors are removed, such as
through adoption or placement in a foster home ‫المالجئ‬.
 anxiety-inducing factors contribute to the initiation of ADHD
 Predisposing factors:
 child's temperament
 genetic-familial factors
 demands of society to adhere to a routinized way of behaving and performing.
 Socioeconomic status does not seem to be a predisposing
factor.

13. types

14. Diagnosis
 The principal signs of inattention, impulsivity, and
hyperactivity are based on a detailed history of a child's
early developmental patterns along with direct
observation of the child.
 Hyperactivity may be more severe in some situations
(e.g., school) and less marked in others (e.g., one- on-
one interviews), and it may be less obvious in pleasant
structured activities (sports).

15.  short attention span and easy distractibility.
 In school, cannot follow instructions and often demand extra
attention from their teachers.
 At home, they often do not comply with their parents' requests.
 They act impulsively, show emotional lability, and are explosive
and irritable.
 Children who have hyperactivity as a predominant feature are
more likely to be referred for treatment than are children with
primarily symptoms of attention deficit.
 Disorders involving reading, arithmetic, language, and
coordination can occur in association with ADHD.
 School history and teachers' reports are important.
Diagnosis

16.  MSE:
 may show a secondarily depressed mood,
 A child may show great distractibility, perseveration,
 concrete thinking.
 visual-perceptual, auditory-perceptual, language, or cognition problems
may be present.
 A neurological examination:
 may reveal visual, motor, perceptual, or auditory impairments without
overt signs of visual or auditory acuity disorders.
 may have problems with motor coordination nonfocal neurological signs
(soft signs).
 EEG
 short absence spells.
Diagnosis

17. DSM-IV-TR Diagnostic Criteria for
ADHD

18. TYPES

19.  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
 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)
6 or more of the following symptoms have persisted
for at least 6 months to a degree that is maladaptive
and inconsistent with developmental level:

20.  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 (e.g., toys,
school assignments, pencils, books, or tools) is
 often easily distracted by extraneous stimuli
 is often forgetful in daily activities
6 or more of the following symptoms have persisted
for at least 6 months to a degree that is maladaptive
and inconsistent with developmental level:…….

21.  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.
 is often “on the go” or often acts as if “driven by a motor”.
6 or more of the following symptoms have persisted
for at least 6 months to a degree that is maladaptive
and inconsistent with developmental level:…….
Hyperactivit
y

22.  often blurts out answers before questions have been
completed.
 often has difficulty awaiting turn.
 often interrupts or intrudes on others (e.g., butts into
conversations or games)
6 or more of the following symptoms have persisted
for at least 6 months to a degree that is maladaptive
and inconsistent with developmental level:…….

24. Clinical Features
 onset in infancy, rarely recognized until a child is at least
toddler age.
 sensitive to stimuli & easily upset by noise, light,
temperature, and other environmental changes.
 active in the crib, sleep little, and cry a great deal.
 At times, the reverse occurs the children are placid,
sleep much of the time,
 appear to develop slowly in the first months of life.
 negative self-concept and reactive hostility

25. ….Clinical Features
In school:
 attack a test rapidly, but answer only the first two questions.
 respond before everyone else.
At home:
 cannot be put off for even a minute.
 often explosive or irritable.
 emotionally labile and easily set off to laughter or to tears; their
mood and performance are apt to be variable and
unpredictable.
 Impulsiveness and an inability to delay gratification are
characteristic.

26. The most cited characteristics
in order of frequency
 hyperactivity,
 perceptual motor impairment,
 emotional lability,
 general coordination deficit,
 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, speech and hearing
deficits,
 equivocal neurological signs and EEG
 Impulsivity:
 action before thought,
 abrupt shifts in activity,
 lack of organization,
 jumping up in class
 memory and thinking deficits
 specific learning disabilities, speech
and hearing deficits,
 equivocal neurological signs and
EEG irregularities.
 75% show behavioral symptoms of
aggression.

27. Pathology and Laboratory
Examination
 No specific laboratory measures are pathognomonic.
 PET may show decreased cerebral blood flow in the frontal
regions.
 Cognitive testing :
 continuous performance task,
in which a child is asked to press a button each time a particular
sequence of letters or numbers is flashed on a screen. Children with
poor attention make errors of omission—that is, they fail to press the
button, even when the sequence has flashed. Impulsivity is
manifested by errors of commission, in which children cannot resist
pushing the button, although the desired sequence has not yet
appeared on the screen.

28. Differential Diagnosis
 A temperamental constellation:
 high activity level and short attention span
 in the normal range of expectation for a child's age.
 Difficult to Differentiate from ADHD before the age of 3 years because of
the overlapping features of a normally immature nervous system and the
emerging.
 Anxiety:
 can accompany ADHD as a secondary feature,
 anxiety alone can be manifested by overactivity and easy distractibility.
 Mania:
 share many core features, such as excessive verbalization, motoric
hyperactivity, and high levels of distractibility.
 irritability seems to be more common than euphoria.
 conduct disorder
 Learning disorders

29. Course and Prognosis
 The course is variable.
 Symptoms persist into adolescence or adult life in 50 %.
 In the remaining 50 %, they may remit at puberty, or in early
adulthood.
 hyperactivity may disappear, but the decreased attention span and
impulse-control problems persist.
 ADHD does not usually remit during middle childhood.
 Persistence is predicted by a family history of the disorder, negative
life events, and co-morbidity with conduct symptoms, depression,
and anxiety disorders.
 Remission is unlikely before the age of 12 years.
 Most patients undergo partial remission and are vulnerable to
antisocial behavior, substance use disorders, and mood disorders.

30. Treatment
 Pharmacotherapy
 Stimulant Medications
 methylphenidate :Ritalin, Ritalin-SR, Concerta
 dextroamphetamine and amphetamine salt combinations
 Non-stimulant Medications
 Atomoxetine HCL
 Psychosocial Interventions

31.  dopamine agonists
 effective in up to 3/4of all children with ADHD
 common adverse effects:
 headaches,
 stomachaches,
 Nausea,
 insomnia.
 rebound effect
 methylphenidate can exacerbate the tic disorder.
 growth suppression.
Ritalin 5, 10, 15, 20 3 to 4 0.3–1 mg/kg t.i.d; up to 60 mg/d

32. Nonstimulant Medications: Atomoxetine
HCl
 norepinehprhine uptake inhibitor
 effective for inattention as well as impulsivity in children and in adults
with ADHD
 half-life is approximately 5 hours and it is usually administered twice
daily.
 metabolized by the cytochrome P450 (CYP) 2D6 hepatic enzyme
system.
 Drugs that inhibit CYP 2D6, including fluoxetine, paroxetine, and
quinidine, may lead to increased plasma levels of this medication.
 side effects:
 diminished appetite,
 abdominal discomfort,
 dizziness,
Strattera 10, 18, 25, 40 (0.5 to 1.8 mg/kg) 40 to 80 mg/d, may
use b.i.d.