ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

Moderator: Dr. G. BezboruahProf. & HODDeptt. Of Pediatrics

Presenter : Dr. NishantP.G.TGMCH

INTRODUCTION :

¶ ADHD is the most common neurobehavioral disorder of childhood, among the most prevalent chronic health conditions affecting school-aged children, and the most extensively studied mental disorder of childhood.

¶ ADHD is characterized by inattention, including increased distractibility and difficulty sustaining attention; poor impulse control and decreased self-inhibitory capacity; and motor over activity and motor restlessness.

¶ Affected children commonly experience academic underachievement, problems with interpersonal relationships with

family members and peers.low self-esteem.

¶ ADHD often co-occurs with other emotional, behavioral, language, and learning disorders

EPIDEMIOLOGY:

Studies of the prevalence of ADHD across the globe have generally reported that 9% of school-age children are affected, although rates vary considerably by country.

The prevalence rate in adolescent samples is 2-6%.

HISTORY OF ADHD:

Mid-1800s: Minimal Brain DamageMid 1900s: Minimal Brain Dysfunction1960s: Hyperkinesia1980: Attention-Deficit Disorder

With or Without Hyperactivity

1987: Attention Deficit Hyperactivity Disorder1994 (DSM IV): ADHD

Primarily Inattentive Primarily Hyperactive Combined Type

Diagnosing ADHD: DSM-V Inattention: (A1)

Lacks attention to detail; makes careless mistakes.

has difficulty sustaining attentiondoesn’t seem to listen.fails to follow through/fails to

finish instructions or schoolwork.has difficulty organizing tasks.avoids tasks requiring mental

effort.often loses items necessary for

completing a task.easily distracted. is forgetful in daily activities.

Persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities

Diagnosing ADHD: DSM-VHyperactivity/

Impulsivity:(A2)Fidgets or squirms excessivelyleaves seat when inappropriateruns about/climbs extensively

when inappropriatehas difficulty playing quietlyoften “on the go” or “driven by a

motor”talks excessivelyblurts out answers before question

is finishedcannot await turninterrupts or intrudes on others

Persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities

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.

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. 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, personality disorder).

Diagnosing ADHD: DSM-V

Specify whether:• Combined presentation: If both Criterion A1

(inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months.

• Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.

• Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.

Diagnosing ADHD: DSM-V

Specify if:

• In 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.

Diagnosing ADHD: DSM-V

Specify current severity:

• Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or 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

NOTE: . For older adolescents and adults (age 17 and older), at least five symptoms of A1 or A2 are required.

Diagnosing ADHD: DSM-V

ETIOLOGY :• No single factor determines the expression of ADHD; • Mothers of children with ADHD are more likely to

experience birth complications, such as toxaemia, lengthy labour, and complicated delivery.

• Maternal smoking and alcohol use during pregnancy and prenatal or postnatal exposure to lead are commonly linked the development of ADHD.

• There is a strong genetic component to ADHD. [dopamine transporter gene (DAT1) and a particular form of the dopamine 4 receptor gene (DRD4)]. There are some other genes that might contribute to ADHD.

ETIOLOGY : (CONT.)

• Severe traumatic brain injury with subsequent onset of substantial symptoms of impulsivity and inattention are reported in some children.

• Structural or functional abnormalities have been identified in children with ADHD without pre-existing identifiable brain injury.

These include dysregulation of the frontal subcortical circuits, small cortical volumes in this region,

widespread small-volume reduction throughout the brain.

abnormalities of the cerebellum.• Psychosocial family stressors can also contribute to or

exacerbate the symptoms of ADHD.

Lower activity in brain regions associated with executive function

(particularly abnormalities in frontostriatal circuit):

Prefrontal cortexBasal gangliaCerebellum(vermis)

These areas of the brain are associated with executive function abilities:

Attention, spatial working memory, and short-term memory. Response inhibition and set shifting.

PATHOGENESIS

• Abnormal central dopaminergic and noradrenergic tone. ¶ Dopamine has been associated with approach and

pleasure-seeking behaviors.¶ Norepinephrine plays a role in emotional/

behavioral regulation.• Smaller brain volume in prefrontal cortex, caudate

nucleus, and vermis of the cerebellum. (a 5-10% reduction in these brain structures)

Cont.

A Possible Developmental Pathway for ADHD

From Mash & Wolfe, 2007

DIAGNOSIS :• A diagnosis of ADHD is made primarily in clinical

settings after a thorough evaluation, including – a careful history and clinical interview to rule in or

to identify other causes or contributing factors; – completion of behavior rating scales; – a physical examination;– any necessary or indicated laboratory tests.

• It is important to systematically gather and evaluate information from a variety of sources, including the child, parents, teachers, physicians, and when appropriate other caretakers.

Clinical Interview and History:

¶ history of the presenting problems, ¶ growth and development,¶ pregnancy complications, such as maternal illness

(eclampsia, diabetes), ¶ maternal smoking, alcohol, or illicit drug use. ¶ The perinatal period-- presence of labor problems, delivery

complications, prematurity, jaundice, and low birth weight. ¶ Disruptive social factors, such as family discord, situational

stress, and abuse or neglect. ¶ A family history of 1st-degree relatives with ADHD, mood or

anxiety disorders, learning disability, antisocial disorder, or alcohol or substance abuse (indicate an increased risk of ADHD and/or comorbid conditions)

Behavior Rating Scales: • Behavior rating scales are useful in establishing the

magnitude of the symptoms, but are not sufficient alone to make a diagnosis of ADHD.

• Many scales available– Conners Comprehensive Behavior Rating Scales

(Conners CBRS)-- 6 to 18 years for teacher forms and parent forms & 8 to 18 years for self-report forms

– Connors-EC for ages 2-6 yrs– Connors Comprehensive and ADHD Rating Scale IV for

ages 4-5 yrs – Connors-3 for ages 6-18 yrs – Academic Performance Rating Scale for grades 1-6

PHYSICAL EXAMINATION AND LABORATORY FINDINGS • To rule out physical disorders that can mimic the

symptoms of ADHD. • To identifies other physical problems that increase the

risk of serious adverse events when a stimulant medication used.

Exploration of cardiac status as well as monitoring of height and weight.

• identify any possible vision or hearing problems.• testing for elevated lead levels in children those who are

exposed to environmental factors that might put them at risk (substandard housing, old paint).

DIFFERENTIAL DIAGNOSIS • Chronic illnesses, such as migraine headaches, absence

seizures, asthma and allergies, hematologic disorders, diabetes, childhood cancer, can impair children's attention and school performance, either because of the disease itself or because of the medications used to treat or control the underlying illness (medications for asthma, steroids, anticonvulsants, antihistamines) .

• In older children and adolescents, substance abuse can result in declining school performance and inattentive behavior.

• Sleep disorders, including those secondary to chronic upper airway obstruction from enlarged tonsils and adenoids, often result in behavioral and emotional symptoms.

• Depression and anxiety disorders can cause many of the same symptoms as ADHD, but can also be comorbid conditions.

• Obsessive-compulsive disorder can 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 (death of a close family

member, parents’ divorce, family violence, parents’ substance abuse, a move)

– parent-child relationship disorders involving conflicts over discipline, overt child abuse and/or neglect, or overprotection.

Comorbid disorders:Prevalence of comorbid disorders for children with ADHD vs those without

Larson et al, 2007

TREATMENT : No treatments have been found to cure this disorder,

but many treatments exist results in the greatest degree of improvement in the symptoms of the disorder.

Psychosocial Treatments • The parents and child should be educated with regard

to the ways ADHD can affect learning, behavior, self-esteem, social skills, and family function.

• The clinician should set goals for the family to improve the child's interpersonal relationships, develop study skills, and decrease disruptive behaviors.

Behaviorally Oriented Treatments :

• The goal of such treatment is for the clinician to identify targeted behaviors that cause impairment in the child's life (disruptive behavior, difficulty in completing homework, failure to obey home or school rules)

• The clinician should guide the parents and teachers in implementing rules, consequences, and rewards to encourage desired behaviors.

• Behavioral interventions are only modestly successful at improving behavior, but they may be particularly useful for children with complex comorbidities and family stressors, when combined with medication.

Medications : The most widely used medications are the pre synaptic

dopaminergic agonists, commonly called psychostimulant medications

¶ Over the first 4 wk of treatment, the physician should increase the medication dose as tolerated (keeping side effects minimal to absent) to achieve maximum benefit.

¶ If this strategy does not yield satisfactory results, or if side effects prevent further dose adjustment in the presence of persisting symptoms, the clinician should use an alternative class of stimulants that was not used previously.

¶ If satisfactory treatment results are not obtained with the second stimulant, clinicians may choose to prescribe atomoxetine, a noradrenergic reuptake inhibitor. .

STIMULANTS:

Methylphenidate: • Available in immediate and sustained release.• Absorption: From the GI tract, slow and incomplete • Dose(Ritalin): 5mg (0.3mg/kg/dose) PO BID before

breakfast and lunch.– Increase by 5-10mg/day (0.2mg/kg/day) at weekly intervals.– Max = 60mg/day (2mg/kg/day).

• Once dose is determined, can switch to longer acting agent (Concerta ~20% IR and 80% ER, Metadate ~30% IR and 70% ER , Ritalin LA ~50% IR and 50% delayed 4hrs).

Amphetamines:

• Dextroamphetamine (single salt) - 5mg PO once or twice daily MAX: 40mg/day.

• Mixed amphetamine salts - – >6 years old 5mg PO once or twice daily;

MAX:40mg/day (5-6 yr start at start with 2.5 mg ), – 10mg PO(for SR product); MAX: 30mg/day.

• Lisdexamphetamine (prodrug) – – 6-8 years old: 20 mg PO-- MAX 70 mg/day.– >8 years old: 30mg PO --MAX: 70 mg/day.– May increase in increments of 10-20 mg/day at weekly

intervals till max dose until optimal response is obtain.

Dexmethylphenidate• D-threo-enantiomer of methylphenidate. • Better absorbed. • Initial Dose: 2.5mg PO BID OR 10mg PO (XR).Side effect of stimulant• Common: Anorexia, Sleep disturbance, Weight

loss, Nervousness/ Restlessness,Growth retardation Increased blood pressure.

• Severe: Tics, Arrhythmia, Psychosis, Sudden cardiac death, drug abuse potential.

NON-STIMULANTS• Usually second-line treatments

– If stimulants are poorly tolerated or ineffective– As monotherapy or adjunct to stimulants

Atomoxetine• MOA: selective nor epinephrine reuptake inhibitor.• Second-line treatment or alternative for patients with history of

drug abuse.• Dose: 0.5mg/kg, then titrate up every 3 days to 1.2mg/kg in

either 1 or 2 daily doses • Max = 1.4mg/kg or 100mg (whichever is less)• Side Effects:

– Common: weight loss, abdominal pain, appetite suppression, sleep disturbance

– Serious: rare but severe liver injury– suicidal ideation

• Clonidine and Guanfacine – MOA: alpha-2 adrenergic agonist.– Provides modest reduction in ADHD symptoms by reducing

impulsivity, hyperactivity and improving sleep. – Must taper slowly- risk for rebound hypertension.

• Desipramine – MOA: inhibit NE and serotonin.– SE: anticholinergic effects, lowers seizure threshold, CV effects.

• Bupropion– MOA: inhibits NE and DA.– Equivalent to methylphenidate.– SE: tics, lowers seizure threshold.

• Others-- Iron May augment effects of stimulant therapy in adolescent patients with low ferritin.

Follow up:– Every 1-3 weeks during initial titration.– Every 3-6 months thereafter.

• Assess treatment response through validated behavioral ADHD rating scales (Patients, parents and teachers)

• Monitor height and weight during stimulant therapy

Stopping Therapy• Consider stopping if patient is stable and doing

well. Stop for 1-4 weeks then reevaluate.

PROGNOSIS

• From 60-80% of children with ADHD continue to experience symptoms in adolescence, and up to 40-60% of adolescents exhibit ADHD symptoms into adulthood.

• In children with ADHD, a reduction in hyperactive behavior often occurs with age. Other symptoms become more prominent with age, such as inattention, impulsivity, and disorganization.

• A variety of risk factors can affect children with untreated ADHD as they become adults. These risk factors include engaging in risk-taking behaviors (sexual activity, delinquent behaviors, substance use), educational underachievement or employment difficulties, and relationship difficulties.

PREVENTION • Parent training can lead to significant improvements in

preschool children with ADHD symptoms, and parent training for preschool youth with ADHD can reduce oppositional behavior.

REFERENCES• NELSON TEXTBOOK OF PEDIATRICS, 20th EDITION.• KAPLAN & SADOCK'S COMPREHENSIVE TEXTBOOK OF

PSYCHIATRY, 9th EDITION.• MASH & WOLFE ABNORMAL CHILD PSYCHOLOGY,4th

EDITION• Journal of PEDIATRICS Volume 127, Number 3, March

2011

THANK YOU

Kevin T. Blake, Ph.D., P.L.C. All Rights Reserved www.drkevintblake.com 38

MTA Study• Medication Management Treatment Group did best.

50% decline in symptoms.• Medication with Behavioral Modification Group did

no better.• Behavior Modification Group did better than

placebo. • Community Treatment only had 25% decline in

symptoms.• Medication helps with social interaction. NIMH Research Treatment for Attention Deficit Hyperactivity Disorder (ADHD): The Multimodal

Treatment Study – Questions and Answers. From website: www.nimh.nih.gov/chilfhp/mt.aqu.cfm

Kevin T. Blake, Ph.D., P.L.C. All Rights Reserved www.drkevintblake.com 39

The MTA Study• Group 1: “Experimental Medication”

– Three medications used• Methyltphenidate (Ritalin)• D Amphetamine (Dexedrene)• Pemoline (Cylert)**

– If medication one did not work or there was a side effect, changed to the next medication and so on.

–Each month parent and child was seen by physician. Child checked for response to treatment and side effects. Each month questionnaires given to parents and teachers.

Kevin T. Blake, Ph.D., P.L.C. All Rights Reserved www.drkevintblake.com 40

The MTA Study• Group 2: Behavior Modification

– Parents taught how to use token economies at home and daily report cards, teachers taught how to teach AD/HD child, how to use token economies in the classroom, and daily report cards, AD/HD children were sent to special camp for AD/HD kids, parents and teachers given “800” number for consultation 24/7, continued on for 14 months!

Kevin T. Blake, Ph.D., P.L.C. All Rights Reserved www.drkevintblake.com 41

The MTA Study

• Group 3: “Experimental Medication Plus Behavior Modification Group”

Kevin T. Blake, Ph.D., P.L.C. All Rights Reserved www.drkevintblake.com 42

The MTA Study

• Group 4: “Community Services”– The parents are told their child has Combined

Type AD/HD and they are encouraged to go out to their community and get what services they want for their child…This was the “Control Group.”• Medication, aroma therapy, etc.

Behavioral Treatment Components• Psychoeducation about ADHD• Structure/routines• Clear rules/expectations• Attending/rewards• Planned ignoring• Effective commands• Time out/loss of privileges• Point/token systems• Daily school-home report card• Intensive summer treatment programs