A D H D PRESENTATION IN CHILDREN NEWER .pptx

Hyperactive Child

1. PRESENTER-Dr.Sri harsha MODERATOR-Dr.Nirmala

2. 1 INTRODUCTION 2 EPIDEMIOLOGY & ETIOLOGY 3 PATHOGENESIS 4 CLINICAL FEATURES 5 DIFFRENTIAL DIAGNOSIS 6 APPROACH TO DIAGNOSIS 7 8 NUT SHELL MANAGEMENT & PREVENTION

3. INTRODUCTION Attention-deficit hyperactivity disorder (ADHD) is Neurobehavioural disorder characterized by developmentally inappropriate motor hyperactivity, inattention and impulsiveness leading to impairment at home and school. Impairment in academic and social functioning along with skill deficits render such children to academic failures and social isolation leading to demoralization, poor self-esteem, delinquency and substance use.

4. TIMELINE OF EVOLUTION OF DIAGNOSIS 1960’s “Hyperkinetic reaction of childhood” enters the DSM-2(1968) 1990’s DSM-4(1994) evidence-based redefinition of ADHD criteria NIMH Conference to review state of ADHD diagnosis and treatment (1998). 1930’s Clinical use of “minimal brain damage” and then “ minimal brain dysfunction” 1980’s DSM-3(1980) “hyperkinetic syndrome changed to “attention deficit disorder with or without hyperactivity” in DSM-3-R(1987) 2000’s AAP Practice guidelines for primary care providers (2001) DSM-5 criteria (2013) 1902 George Still published in LANCET

5. EPIDEMIOLOGY Worldwide studies report prevalence of ADHD in children to be between 3% and 9%. ADHD affects both genders with male to female ratio of up to 10:1. Prevalence rates of ADHD in the Indian subcontinent vary from 5% to 15.5% with the male to female ratio ranging from 3 to 6.4:1 The Indian Council of Medical Research reported prevalence rate of hyperkinetic disorders to be 1.6% among children aged 4–16 years with higher rates in urban middle class (3.7%), than slum (1.2%) and rural areas (0.5%).

6. FAMOUS PERSONALITIES WITH ADHD

7. ETIOLOGY Environmental factors: -Maternal -External factors Genetic factors:

8. ETIOLOGY

9. ETIOLOGY Genetic’s: Family studies have found two- to eight-fold higher rates of ADHD in affected families in comparison to their healthy unaffected relatives. Twin studies have observed higher concordance rates in monozygotic compared to dizygotic twins. There is a strong genetic component to ADHD. Genetic studies have primarily implicated 2 candidate genes, the dopamine transporter gene (DAT1) and a particular form of the dopamine 4 receptor gene (DRD4), in the development of ADHD.

10. ETIOLOGY Genetic syndromes: Fragile X syndrome, tuberous sclerosis and Smith- Magenis syndrome, and Fetal alcohol syndrome. Psychosocial family stressors can also contribute to or exacerbate the symptoms of ADHD, including poverty, exposure to violence, and malnutrition.

11. PATHOGENESIS Neuropsychological Studies: An alteration in the corticostriatal circuitry has been implicated in ADHD. This circuit includes the dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC), the dorsal striatum (especially the caudate nucleus) and the thalamus, linking to the cerebellum. The DLPFC has role in response inhibition, working memory, planning and organizing behavior. The ACC apart from its role in cognition and motor control, govern the arousal/drive state. Dorsal striatum modulates responses and the cerebellum coordinates motor activities and attention.

12. PATHOGENESIS Neurochemistry of ADHD: Dopaminergic neural circuits are suggested to play a major role in altered reward processing mechanism endorsed by ADHD. Other factors implicating dopamine hypothesis are: drugs (like methylphenidate) utilized in managing ADHD act on dopaminergic synapses; linkage of various dopamine transporter and receptor genes to ADHD.

13. PATHOGENESIS Neurophysiological Studies : Few electroencephalograph (EEG) studies report increased slow wave activity (predominantly theta) in frontal region. whereas others have shown decreased delta and increased beta percent power over the left hemisphere, indicating both under-arousal and over-arousal in ADHD.

14. PATHOGENESIS Structural Neuroimaging: Decrease in overall total brain size is the most consistent finding being reported. Magnetic resonance imaging (MRI) studies report of decreased right prefrontal cortex volume, reversal or loss of asymmetry of caudate nucleus volume (usually right caudate nucleus is larger than the left), lack of age-related decrease in caudate volume (usually caudate nucleus volume decreases with age in males), smaller size of globus pallidus, and decreased volume of corpus callosum.

15. CLINICAL FEATURES The core symptoms of ADHD are hyperactivity , impulsivity and inattention . While teachers usually complain of creating nuisance in the classrooms and deterioration of academic performance, parents report a lack of interest in activities requiring sustained effort or child being constantly “out of control”. The symptoms suggestive of the disorder need to be present in two or more setting (at home, at school, during play, in social gatherings, etc.); present for at least 6 months; and must be severe enough to interfere with functioning in various settings.

16. CLINICAL FEATURES Symptoms of Hyperactivity: Excessive fidgetiness (e.g., tapping hands or feet, squirming in seat) • Difficulty remaining still when sitting is expected (e.g., at dinner, school, etc.) • Excessive talking, difficulty playing quietly • Run around a lot, always “on the go”.

17. CLINICAL FEATURES Symptoms of Impulsivity : Impatient, difficulty waiting turns, interrupt conversations or others’ activities Blurt out inappropriate statements/answers too quickly Express emotions without restraint Act without considering consequences.

18. CLINICAL FEATURES Symptoms of Inattention : Easily distractible, frequently switch from one task to another, forgetfulness in routine activities (e.g., homework, chores, etc.) Difficulty in focusing on organizing and completing an activity or learning something new in play, school, or home activities. Avoids tasks that require consistent mental effort. Gets easily bored, unless doing some enjoyable activity. Misses details, makes careless mistakes, often loses belongings (e.g., pencils, toys, books) Seems not to listen when spoken to Have difficulty in following instructions as quickly and accurately as others.

19. CLINICAL FEATURES The symptoms may secondarily dispose a child towards difficulty in forming friendships, peer rejection, poor self-esteem, and increased risk for depression and anxiety. The symptoms should also not be part of another psychotic disorder.

20. PRESENTATION IN ADHD Based on the types of symptoms, three kinds (presentations) of ADHD can occur: Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months. Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months. Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

21. DIFFRENTIAL DIAGNOSIS

22. DIFFRENTIAL DIAGNOSIS

23. DIAGNOSTIC CRITERIA DSM-5 Criteria for ADHD People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development: Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. Often has trouble holding attention on 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 (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted. Is often forgetful in daily activities.

24. DIAGNOSTIC CRITERIA 2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Is often "on the go" acting as if "driven by a motor". Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or games)

25. DIAGNOSTIC CRITERIA In addition, the following conditions must be met: Several inattentive or hyperactive-impulsive symptoms were present before age 12 years. Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities). There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning. The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, or a Personality Disorder).

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

27. APPROACH TO DIAGNOSIS Every child visiting the clinic should be assessed for ADHD. The evaluation comprises of medical, developmental, behavioral, educational and psychosocial perspectives. The assessment should include careful and detailed medical, social, and family history taking; clinical interviews and observation of the child with and without the parent; gathering information about functioning in child care center or school (from teachers) and at home (from parents/ caregivers); and assessment for coexisting emotional or behavioral disorders.

28. APPROACH TO DIAGNOSIS Medical Evaluation: An evaluation of child and family, dietary history and daily sleep pattern should be undertaken before initiating medications. The physical examination including a complete neurological examination should be undertaken. Regular monitoring of vital signs, height, weight and head circumference aids in assessment of medication effects.

29. APPROACH TO DIAGNOSIS Developmental and Behavioral Evaluation: A thorough assessment should be conducted regarding: Developmental history, particularly language milestones. Onset, duration, course, and degree of functional impact of ADHD symptoms. Behavior at home and school.

30. APPROACH TO DIAGNOSIS Open-ended questions or questionnaires may be utilized to acquire historical information regarding symptoms. Example of a questionare was developed by INCLEN international Delhi and was being followed in AIIMS

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37. CASE 1 A 9 year boy has been referred to a child Psychiatrist at the request of his school teacher, because of the difficulties he creates in class. His teacher complains that: He is so restless that the rest of the class is unable to concentrate He is hardly ever in his seat and roams around in the class Talks to other children while they are working He seems to have no control over his behavior which is unpredictable and can even be quite outrageous

38. His mother says that his behavior has been difficult since he was a toddler Even when he was around 4-years old he was unbearably restless, demanding and forgetful about his daily activities He required little sleep and awoke before anyone else When he was five, he had managed to unlock the door of the house and wander off into a busy Main Street Fortunately, he was rescued from the oncoming traffic by a passerby He was asked to leave a play school because of his difficulty in following instructions and paying attention in class 

39. Presently he avoids doing his home work. He has minimal interest in TV (only a few selected programs), and dislikes games or toys that require prolonged concentration or patience. At home he prefers to be outdoors. However, he is not popular with other children because he cannot await his turn and picks up fights easily. Whenever he plays with toys, his games are messy and destructive, and his mother cannot get him to keep his things away tidily.

40. What symptoms of ADHD does this boy have? List out his symptoms of inattention, hyperactivity & impulsivity separately?

41. Only inattention. His behavior typically demonstrates the characteristic inattention symptoms of ADHD (A1-a, b, d, e, f, i)

42. CASE 2

43. An 8 year old boy was brought to the OPD with complaints of pharyngitis Through the open door, the physician noted that the child was pushing others, running about and jumping from one bench to the other when he was waiting outside. His mother was having trouble trying to restrain him However, on entering the doctor's room, he was an alert, quiet child who however kept on getting distracted by noises outside

44. On inquiry, the parents said that the child has been like this since 6 years of age and frequently engages in dangerous activities like jumping from walls, running on the road and breaking household objects His teachers also frequently complain that his behavior disturbs others in the classroom during classes He often leaves the seat in class and when seated fidgets with hands or feet Nobody wants to sit next to him Even while playing in school he cannot remain engaged in one game for more than ten minutes While playing cricket near home he can not wait for his turn for batting.

45. She was concerned that, he has difficulty in concentrating in the class and got easily distracted She had been noticing these behaviours during past six months. She also felt that he talks too much and often made careless mistakes in his home work book His mother complained that he often lost pencils and note books in school However she said that he could organize his activities like preparing his school bag and keeping his toys in their place He could also get ready for school on his own including tying shoe laces and buttoning

46. He fulfills the following criteria A1-a,c,d,e,g,h (inattention) A2- a, b, c, d, e (Hyperactivity) and h (Impulsivity) These symptoms have been persisting for about one year and affecting his school performance. Onset of symptoms was around 6 years of age. Hence, a diagnosis of ADHD can be made.

47. APPROACH TO DIAGNOSIS Behavior rating scales: Scales are useful for acquiring structured information of behavior, estimating symptom severity, measure treatment response and may add to the validity of the diagnosis. However, none of the global rating scales can provide a definitive diagnosis. Narrow band scales focus on the core symptoms of ADHD and have a high sensitivity and specificity. They have parent, teacher and patient versions. These include Vanderbilt assessment scales: can be used in children more than or equal to 4 years Conners Comprehensive Behavior Rating Scales: validated in preschool children and ADHD Rating Scale IV : validated in preschool children. Broadband scales assess a broad variety of behavioral symptoms, e.g., Child Behavior Checklist. They can help to recognize comorbid conditions and make the differential diagnosis narrow.

48. APPROACH TO DIAGNOSIS Educational evaluation: Assessment of the functional impact of ADHD symptoms in academic setting should be conducted utilizing information regarding grades, absences, learning pattern, report cards, samples of schoolwork, etc. Details of parent-teacher meetings should also be sought.

49. APPROACH TO DIAGNOSIS Psychosocial evaluation It is prudent to assess the impact of symptoms on the psychosocial environment and vice versa which may provide an alternative explanation for the symptoms. Social responses at home and school—play activities, peer relationship, etc. Psychosocial stressors (death, divorce, or economical constrains in family).

50. APPROACH TO DIAGNOSIS Neuropsychological testing: It may be valuable in assessing coexisting conditions (like learning disabilities), excluding other disorders, planning interventions, and charting treatment progress. It can also help to identify specific problem areas in like reasoning, cognitive flexibility, planning and working memory.

51. APPROACH TO DIAGNOSIS Comorbid evaluation Multiple conditions may mimic or coexist with ADHD such as reported in Indian literature are developmental delays, temper-tantrums, enuresis, tics, parental discord and parental psychiatric illness. After the complete evaluation, a thorough discussion of the clinician with the parents is recommended regarding the child problematic behavior with its appropriate management measures. which may entail implementing a daily report card procedure prior to initiating a medication trial or other psychosocial intervention.

52. MANAGEMENT An effective treatment strategy includes pharmacological and psychosocial approach, intervening in the personal, social, educational and occupational spheres. Before initiating treatment, clinician should discuss the myths regarding ADHD. Regular follow-ups should be ensured to increase treatment adherence.

53. MANAGEMENT Pharmacological Intervention Pharmacological treatment relies on agents targeting dopamine and/or norepinephrine receptors. Stimulants imply the most extensively available first-line treatment option for ADHD. Stimulant medications should be used as supervised treatment in patients 6 years or older with no medical contraindications meeting the diagnostic criteria for ADHD. As being an activating drug, they should be given in daytime. The general rule of “ start low and go slow ” approach is followed during drug titration.

54. MANAGEMENT Other drugs approved by FDA having less abuse potential than stimulants are atomoxetine and extended release formulations of clonidine and guanfacine, which recently were approved as an adjunctive treatment to stimulant therapy for treating pediatric ADHD.

55. MANAGEMENT Psychosocial Intervention Psychosocial treatment is beneficial in cases where pharmacological treatment, despite its effectiveness, may lead to intolerable side effects. Psychosocial treatments include psychoeducation, parent training, academic organization skill teaching and remediation, behavior modification, social skills training and individual therapy. This modality is preferred in children with age less than 6 years, mild symptomatology, uncertain diagnosis and when preferred by parents. Behavioral parent training has been the most widespread and effective intervention being advised to preschool and school age children with oppositional and socially aggressive behavior.

56. MANAGEMENT Adolescents generally respond well to behavior techniques, academic interventions and family therapy. Though nonpharmacological treatment plays important role in management of ADHD, the effect is modest. The most favorable treatment in general is individually tailored psychosocial treatment plus pharmacotherapy.

57. OUTCOME With a family history of ADHD there are 50% increase chances of developing the disorder if either parent has ADHD or 35% chances if one of the siblings have ADHD. Symptom onset can occur at 3–4 years age, though only half the cases develop the disorder by 7 years of age and more than 90% develop by 12 years of age. With the child reaching 4 years of age, hyperactive and impulsive symptoms starts appearing which continue to increase over next 3–4 years peaking at 7–8 years of age with emergence of inattentive symptoms. Hyperactive symptoms start declining after 7–8 years of age with almost negligible symptoms (in form of restlessness or inability to settle down) by the adolescence. On the other hand, impulsive symptoms persist throughout life.

58. OUTCOME ADHD symptoms can persist up to adulthood in 60% of children. The prevalence rate of adult ADHD is 4%. It may manifest in form of drug and alcohol misuse and antisocial behavior. Despite their poor overall performance in comparison to non- ADHD counterparts, children with ADHD are capable of attaining high educational and vocational objectives. Many children have negligible emotional or behavioral problems by the time they reach mid-twenties.

59. PREVENTION Primary prevention includes promotion of maternal health during pregnancy, such as caution against use of alcohol and cigarette. Initiative should be taken to reduce environmental toxins like lead, mercury, and polychlorinated biphenyls. Though not accepted worldwide, an elimination diet has been proposed to lessen hyperactivity which targets artificial colorings, flavorings and preservatives. Free fatty acids have some role in reducing ADHD symptoms. Couples with family history should be counseled regarding the risk of genetic loading of ADHD.

60. PREVENTION Secondary prevention Includes early intervention of at risk children such as children with a family background of ADHD,premature children, low birthweight babies, mothers with intake of toxic substances during pregnancy and children with serious craniocerebral traumas. Making teacher and parents to work together to identify ADHD at early stage should be a priority. Behavior management may be put forth through techniques such as focusing attention, disciplinary classroom promulgation and anger management. Monitoring of academic performance via multiple measures such as class participation and homework completion should also be incorporated.

61. PREVENTION Tertiary prevention is applied actively in symptomatic children with provision of pharmacological management and individual based therapy.

62. NUT SHELL ADHD, a neuropsychologically heterogeneous condition, is among the most common disorders of childhood. It is highly prevalent worldwide with a long-term course and pervasive effects. Multiple factors may be responsible for its varied manifestations such as illness severity, family history of the disorder, shifting impairment between home and school setting, executive functioning deficits, comorbidity and developmental stage. Recent studies provide more insight into the genetic, environmental, and neurobiological causes of this disorder, thereby, further enhancing our understanding of pathophysiologic processes, which, in turn, will bring about novel prevention and intervention strategies.

63. NUT SHELL Promising pharmacotherapeutic options in form of stimulant as well as nonstimulant medications offers new options for managing ADHD. Utmost treatment outcome may be achieved using a multimodal management approach employing appropriate pharmacotherapy with psychosocial intervention. A pragmatic, multifaceted management based around the establishment of good working relationships with family and school should be incorporated. The disorder requires a long-term therapeutic alliance among clinician and the patient along with their families improving their quality of life.

64. REFFRENCES NELSON PIYUSH GUPTHA DEVELOPMENTAL-BEHAVIORAL PEDIATRICS

65. THANK YOU.....