ADHD - Attention Deficit Hyperactivity Disorder

ADHD - Attention Deficit Hyperactivity Disorder
ADHD is the most common neurobehavioral
disorder of childhood. It is characterized by developmentally inappropriate and impairing levels of gross motor over activity, inattention and
impulsivity. It can continue through adolescence and
adulthood.

1. DrC. Naveen Kumar,
1
st
year PG
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
(ADHD) Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

2. •Introduction
•Etiology
•Clinical features & Diagnosis
•Differential Diagnoses
•Management –Pharmacological &
Non-pharmacological
•Prognosis
Overview Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

3. •ADHD is the most common neurobehavioral
disorder of childhood.
•It is characterized by developmentally
inappropriate and impairing levels of gross
motor over activity, inattention and
impulsivity.
•It can continue through adolescence and
adulthood.
Introduction Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

4. •Pooled data from various studies indicate that
the world wide prevalence is 5.29%.
o5-10% in school going children
o2-6% in adolescents
o2% in adults
•More common in male gender (3-6 times)
•Prevalence in India is comparable to that of
other countries.
Introduction contd. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

5. History
1798
Sir Alexander Crichton, Scottish physician
“The incapacity of attending with a necessary degree
of constancy to any one object” Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

6. History
1844
Heinrich Hoffmann,
German physician
“Fidgety Phil” –
character in his
illustrated children's
stories, fits hyperkinetic
type of ADHD Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

7. History
1902
Sir George Frederick Still, Father of British Pediatrics
“defect of moral control as a morbid manifestation,
without general impairment of intellect and without
physical disease” Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

8. History
1908
Alfred Tredgold, British physician–Early brain damage
(perinatal anoxia or birth defect) leading to subsequent
behavioral problems or learning disorders.
Post Encephalitic Behavior Disorder–following
Influenza encephalitis epidemic
1932
Franz Kramer & Hans Pollnow, German physicians
described “Hyperkinetic Disorder of infancy”
1930-1940
1960
Minimal BrainDamage –responsible for various
behavioral problems in children
Changed to Minimal Brain Dysfunction
1937
Charles Bradley –positive effect of stimulant medications
in children with various behavior disorders Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

9. History
1968
DSM-IImentioned “Hyperkinetic Reaction of
Childhood”, which diminishes by adolescence.
1980
DSM-IIIAttention Deficit Disorder: with and
without hyperactivity
1987
DSM-III R AttentionDeficit Hyperactivity
Disorder
1994DSM-IVADHD was divided into 3 subtypes Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

10. •ADHD is thought to result from complex
interaction between multiple genetic and
environmental factors.
Genetic –Twin, sibling and family studies support
strong genetic component in ADHD causation.
•Concordance rate in monozygotic twins is 59-
92% and in dizygotic twins, it is 29-42%.
•50% chance to have the disease if one parent
has ADHD, 20-25% chance if a first degree
relative is affected.
Etiology Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

11. Genetic –Polygenic Inheritance.
•DAT1 (Dopamine Transporter) gene
•DRD4 (Dopamine 4 Receptor) gene
•DBH (Dopamine βHydroxylase) gene, DRD5
(Dopamine 5 Receptor) gene, COMT (Catechol-
O-methyltransferase) gene, genes related to
Androgen receptors play role.
Etiology Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

12. Attention is the behavioral and cognitive process of
selectively concentrating on one aspect of the
environment while ignoring other things.
BOTTOM-UP PROCESSING or
STIMULUS-DRIVEN ATTENTION
or
EXOGENOUS ATTENTION
It is driven by the properties of the
objects themselves.
Ex: A sudden loud noise, can attract
our attention in a pre-conscious, or
non-volitional way. We attend to
them whether we want to or not.
Regulated by PARIETAL,
TEMPORAL CORTEX & BRAIN
STEM.
TOP-DOWN PROCESSING or
GOAL-DRIVEN ATTENTIONor
ENDOGENOUS ATTENTION or
EXECUTIVE ATTENTION
It is under the control of the person
who is attending.
Ex: If we come across a harmful
object such as hot stove, our prior
knowledge stored in memory
makes sure that we don’t touch
that.
Mediated primarily by FRONTAL
CORTEX AND BASAL GANGLIA Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

13. BOTTOM-UP PROCESSING or
STIMULUS-DRIVEN ATTENTION
or
EXOGENOUS ATTENTION
Regulated by PARIETAL,
TEMPORAL CORTEX & BRAIN
STEM.
TOP-DOWN PROCESSING or
GOAL-DRIVEN ATTENTIONor
ENDOGENOUS ATTENTION or
EXECUTIVE ATTENTION
Mediated primarily by FRONTAL
CORTEX AND BASAL GANGLIA
Both these processes arecoordinated by pre-frontal cortex.
There is dysregulation in-between them in ADHD.
Due to increased exogenous
attention, children with ADHD
fail to sustain attention on one
thing and getdistracted easily by
exogenous stimuli.
Due to diminishedtop down
processing, children with ADHD
fail to execute organizational
tasks, they don’t know
consequences of their actions
and are frequently prone for
injuries & accidents. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

14. Neuroanatomical
MRI, PET & SPECT studies suggested decreased
volume and activity in prefrontal areas, anterior
cingulate, globuspallidus, caudate and thalamus in
children with ADHD compared to controls.
Etiology Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

15. Neurotransmitters
Catecholamine imbalance is suggested to be a
cause for ADHD.
This is supported by usefulness of various drugs
that interfere with catecholamine metabolism, in
ADHD.
•Amphetamines bind to DAT (Dopamine
Transporter) and prevent Dopamine re-uptake.
•Tricyclic Antidepressants and Atomoxetineare
Norepinephrine reuptake inhibitors.
Etiology Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

16. Pregnancy & Early Childhood Factors
•Maternal cigarette smoking, alcohol
consumption
•Very low birth weight
•Prematurity
•Fetal hypoxia
•Maternal stress during pregnancy
Etiology Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

17. Environmental Toxins &Dietary Factors
•Pesticides
•PCBs –Polychlorinated Biphenyl
•Lead toxicity
•Iron & Zinc deficiency
•Poly Unsaturated Fatty Acid deficiency
•Food additives
•Food high in sugar content
Etiology Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

18. Psychosocial Factors
•Poverty
•Low parental education
•Negative parenting
•Deprivation
•Family discordance
•Bullying & peer victimization
Etiology Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

19. •Excessive and impairing level of activity, inattention and
impulsiveness.
•Particularly evident in situations that require child to be
thoughtful and restrained.
•Symptoms are present in two or more settings. (E.g.
With family, in school & with friends etc.)
•In early childhood, ADHD children have sleep problems
and show clear hyperactivity.
•Motor milestones are achieved normally or early, with
child being described as starting to run as soon as he
could walk.
Clinical features Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

20. •Fail to pay attention and get easily distracted.
•Miss details, forget things.
•Frequently switch from one activity to another.
•Become bored with a task after only a few minutes.
•Child may attend a test rapidly but answers only first few
questions.
•They are unable to wait to be called on in school and may
respond before anyone else.
•Have difficulty in organizing and completing a task.
•Difficulty in learning something new.
•Have trouble completing homework assignments,.
•Often loose things (E.g.. Pencils, toys etc.)
•Become easily confused.
•Struggle to follow instructions.
Clinical features -Inattention Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

21. •Difficult to remain in their seats. Fidget and squirm
(Squirm -To twist the body from side to side, as a
result of discomfort) in their seats
•Talk nonstop
•Dash around, touching or playing with anything and
everything in sight
•Have trouble sitting still during dinner, school, and
story time
•Be constantly in motion
•Have difficulty doing quiet tasks or activities.
Clinical features -Hyperactivity Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

22. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

23. Impulsiveness is a tendency to act in rush without
forethought or concern about consequences.
•Be very impatient.
•Blurt out inappropriate comments.
•Show their emotions without restraint, and act without
regard for consequences.
•Have difficulty waiting for things they want or waiting
their turns in games.
•Often interrupt conversations or others’ activities.
•Running thoughtlessly across a busy street, being violent
towards siblings and peers.
Clinical features -Impulsivity Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

24. •Become bored with interactive games with peers,
and leave such games early before they are finished.
•They find it difficult to delay gratification.
•They show variable performance on tasks, which
may negatively affect self-esteem.
•They have difficulty with time management and have
poor sense of time.
•Even don't know when to come home when out playing
with other children.
Clinical features Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

25. •As a result of their actions, they face difficulty in establishing
and maintaining peer relationships.
•By adolescence, hyperactivity is replaced by internal sense of
restlessness & inattention is manifested as poorly organized
approach to work.
•ADHD adolescent is accident prone.
•Poor concentration, inability to complete tasks,
procrastination, occasional mood outbursts result.
Procrastination: Practice of carrying out less urgent tasks, which
are more pleasurable in preference to more urgent ones, which are
less pleasurable and thus postponing them to deadline.
Clinical features Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

26. •The diagnosis of ADHD is based purely on
symptoms.
•Evaluation includes inputs from parents, teachers
and other care givers.
•ADHD has been defined both in the American
Psychiatric Association Diagnostic and Statistical
Manual (DSM-V) and the International Classification
of Diseases (ICD-1O).
•In ICD-10 it is named Hyperkinetic Disorder (HKD).
Diagnosis Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

27. •Diagnostic and Statistical Manual of Mental
Disorders (DSM), published by the American
Psychiatric Association (APA), offers standard
criteria for the classification of psychiatric
disorders.
•In DSM-V, ADHD is included under
neurodevelopmental disorders.
DSM-V Criteria Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

28. IMPULSIVITY
Onset
before 12
Years of age
Symptoms
should be
present in 2 or
more settings
Interfere
with social/
academic
functioning
Not better
explained by
another
psychiatric
disorder Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

29. A.A persistent pattern of inattention and/or hyperactivity-
impulsivity that interferes with functioning or development.
B.Several inattentive or hyperactive-impulsive symptoms were
present prior to age 12 years.
C.Several inattentive or hyperactive-impulsive symptoms are
present in two or more settings (e.g., at home, school, or
work; with friends or relatives; in other activities).
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 another psychotic disorder and are not
better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality
disorder, substance intoxication or withdrawal).
DSM-V Criteria Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

30. At least 6 symptoms for <17 years age group.
At least 5 symptoms for 17 years or more age group.
For at least 6 months duration.
1.Often fails to give close attention to details or makes
careless mistakes in schoolwork, at work, or during other
activities
2. Often has difficulty sustaining attention in tasks or play
activities
3.Often does not seem to listen when spoken to directly
4.Often does not follow through on instructions and fails to
finish schoolwork, chores, or duties in the workplace
A-1 Inattention Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

31. 5. Often has difficulty organizing tasks and activities
6. Often avoids, dislikes, or is reluctant to engage in tasks that
require sustained
mental effort
7. Often loses things necessary for tasks or activities.
8. Is often easily distracted by extraneous stimuli
9. Is often forgetful in daily activities
A-1 Inattention Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

32. At least 6 symptoms for <17 years age group.
At least 5 symptoms for 17 years or more age group.
For at least 6 months duration.
1. Often fidgets with or taps hands or feet or squirms in seat.
2. Often leaves seat in situations when remaining seated is
expected
3. Often runs about or climbs in situations where it is
inappropriate.
4. Often unable to play or engage in leisure activities quietly.
5.Is often “on the go,” acting as if “driven by a motor”
6. Often talks excessively.
A-2 Hyperactivity & Impulsivity Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

33. 7. Often blurts out an answer before a question has been
completed (e.g., completes
people’s sentences; cannot wait for turn in conversation).
8. Often has difficulty waiting his or her turn (e.g., while
waiting in line).
9. Often interrupts or intrudes on others (e.g., butts into
conversations, games, or activities; may start using other
people’s things without asking or receiving permission)
A-2 Hyperactivity & Impulsivity Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

34. Combined : If both Criterion A1 (inattention) and Criterion
A2 (hyperactivity-impulsivity) are met for the past 6 months.
Predominantly inattentive : If Criterion A1 (inattention) is
only met for the past 6 months.
Predominantly hyperactive/impulsive : If Criterion A2
(hyperactivity-impulsivity) is only met for the past 6
months.
Partial remission: When full criteria were previously met,
fewer than the full criteria have been met for the past 6
months, and the symptoms still result in impairment in
social, academic, or occupational functioning.
Subtypes Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

35. Parent Rating Scales
•Conner's Parent Rating Scale
•Child Behavior Checklist
•Yale Children's Inventory Home Situations
Questionnaire
Teacher Rating Scales
•Conner's Teacher Rating Scale
•Child Behavior Checklist-Teacher Form School
Situations Questionnaire
•ADHD Comprehensive Teacher Rating Scale
(ACTReS)
•Swanson, Nolan and Pelham (SNAP-IV) scale
•Vanderbilt ADHD Scale
•INCLEN –ADHD Diagnostic tool (Indian adaptation)
Parent and Teacher Rating Scales to
assess ADHD Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

36. INCLEN Diagnostic tool
(International Clinical Epidemiology
Network)
Based on DSM-IV TR
Rewording to make the criteria applicable to
Indian scenario
SECTION-A :Whether the child fulfills the
criteria or not.
SECTION-B :Whether pervasive functional
impairment is present or not.
Diagnosis as No ADHD, ADHD, Other NDD or
Indeterminate. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

37. DIFFERENTIAL DIAGNOSES
INTELLECTUAL
DEVELOPMENTAL
DISORDER
Children with moderate to severe MR have
attention and activity levelsthat are appropriate for
developmental age not chronological age.
SENSE ORGAN
DEFICITS
Hearing loss in glue ear etc. condition may lead to
inattention.
INTERMITTENT
EXPLOSIVE
DISORDER
Impulsive behavior commonto both. Children with
Intermittent Explosive Disorder show serious
aggression to others, which is not seen in ADHD.
SPECIFIC
LEARNING
DISORDER
These children may show in attention due to
inability to learn and frustration. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

38. DIFFERENTIAL DIAGNOSES
OPPOSITIONAL
DEFIANT
DISORDER (ODD)
A pattern of negative, hostileand defiant behavior.
Symptoms include frequent loss of temper, arguing
(especially with adults), refusal to obey rules,
intentionally annoying others, blaming others.
CONDUCT
DISORDER (CD)
A pattern of behavior that persistently
violates the basic rights of others or society’s rules.
Behaviors may
include aggression toward people and animals,
destruction of property,
deceitfulness or theft, or serious rule violations.
DRUGS
Medications like Phenobarbitone, Lamotrigine,
Clonazepam & Vigabatrincan cause hyperactivity
that can mimic ADHD. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

39. DIFFERENTIAL DIAGNOSES
AUTISM ADHD
Both exhibit inattention, social dysfunction and difficult to
manage behavior.
Has no great desire to be
social.
Wantsto be social. Feel sad,
confused on isolation.
Repetitive patterns of behavior
are present.
Absent.
Difficulty in communication is
present.
There is no difficulty in
communication. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

40. MANAGEMENT
Multimodal approach
•Education and information for parents &
children
•Family intervention
•Behavioral management
•School Interventions
•Medication Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

41. Education of parents & family
interventions
•Parents should be counselled that child is not
exhibiting symptoms voluntarily & he/she can
meet reasonable expectations if managed
properly.
•Formulate a regular daily routine and ensure that
the child follows it.
•Give short term simple tasks and on completion,
praise the child.
•Avoid over stimulation and excessive fatigue.
Give time for relaxation. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

42. Family interventions
•Keep valuable, breakable and dangerous articles
out of reach of the child.
•Ensure quiet and peaceful bedtime. Avoid
exciting T.V. programs, games during night.
•Encourage peer relationships and teach social
skills.
•Give clear instructions and positively reinforce
good behavior. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

43. School interventions
•Child should be seated near to teachers desk.
•Teachers should make frequent eye contact with
child.
•Permit the child to do something with hands while
engaged in sustained listening.
•Allow intermittent activities like cleaning
blackboard, distributing papers etc.
•Teach concepts, reduce memory burden.
•Divide work into small chunks.
•Reinforce positive behavior.
•Give regular non-accusatory feedback to child
regarding his/her attention control. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

44. Medication
STIMULANT
MEDICATION
NON-STIMULANT
MEDICATION
•Amphetamines:
Dextroamphetamine
Pemoline
•Methylphenidates:
Methylphenidate,
Dexmethylphenidate
•Atomoxetine
•Tricyclic Anti-depressants:
Imipramine, Norimipramine
& Nortryptiline
•α2-Adrenergic Agents:
Clonidine,Guanfacine
•Non-TCA anti depressant:
Bupropion Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

45. Stimulants
•Not used for < 3years age group.
•Beneficial effects: Enhanced concentration, reduced
hyper arousal state, reduced impulsivity., improved
school and homework performance.
•Methylphenidate commonly used started at
5mg/day dose and gradually increased up to
60mg/day.
•Adverse effects: headache, abdominal pain,
jitteriness, anorexia, insomnia, growth failure (Drug
holiday during vacation), substance abuse. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

46. Atomoxetine
•Norepinephrine Reuptake Inhibitor (NRI)
•Reduces ADHD behaviors in children, adolescents,
and adults.
•Doesn't have abuse potential.
TCAs
•Imipramine, desipramine, and nortriptyline
•Advereeffects: Cholestaticjaundice, tachycardia,
delirium, weight gain, constipation, skin rash,
lowered seiizurethreshold Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

47. Bupropion
•3-6 mg/Kg/day
•Adverse effects: Insomnia, irritability, seizure
α2-Adrenergic Agents:
•Clonidine at 3-10 mg/kg/day used as alternative or
adjunctive to Methylphenidate.
•Its sedative effect counters insomniac effect of
Methylphenidate.
•Useful for tics, impulsivity, aggression. Doesn’t
improve inattention. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

48. PROGNOSIS
•Course of ADHD is variable.
•Remission usually occurs between 12-20 years of age,
unlikely before that.
•40-60% continue to be symptomatic through
adolescence, 20-40% through adult hood.
•Most cases get better as they grow. Hyperactivity usually
stops by teenage. Easy distractibility, mood swings, hot
tempers & inability to complete tasks persist.
•Those continue to have symptoms are vulnerable to
antisocial behavior, substance abuse, mood disorders &
learning disorders. Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

49. References
•Behaviouralproblems in children and adolescents –
JaydeepChoudhary
•DSM –V
•Kaplan SadockText Book of Psychiatry
•Nelson Text Book of Pediatrics
•Indian Journal of Practical Pediatrics
•www.indianpediatrics.net Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati

50. Thank You Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati