ADHD

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ADHD DISRUPTIVE DISORDERS

• EHSAN U. SYED
• PSYCHIATRY
• AGA KHAN UNIVERSITY

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Heinrich Hoffmann (18091894).

• As early as 1846, the typical symptoms of ADHD
  were described by Heinrich Hoffmann, a physician
  who later founded the first mental hospital in
  Frankfurt. Interestingly, his description was
  published in a childrens book entitled
  "Struwwelpeter" which he had designed for his
  3-year-old son Carl Philipp. The symptomatology
  is impressively depicted in the colourfully
  illustrated story of "Zappel-Philipp" ("Fidgety
  Philip"), probably the first written mention of
  ADHD by a medical professional. This clearly
  shows that the diagnosis of ADHD is not an
  "invention" of modern times.

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Heinrich Hoffmann (18091894).
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Zappel Philipp
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Post encephalitic behavior disorder

• Encephalitis epidemic 1917 North America
• Surviving children with multiple impairments e.g.
  
• inattention,
• impulsivity,
• dysregulation of activity,
• social disruption and
• cognitive deficits

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Minimal Brain Damage

• Organic driveness (Kahn Cohen1934)
• Restlessness syndrome (Childers 1935)
• Minimal brain damage 1950s
• It was not until 1970s when ADHD/ADD cases were
  teased out of brain damaged children
• ADDH and ADD-H (with or without hyperactivity)
  1980s
• ADD becomes ADHD in DSMIII late 1980s

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DISRUPTIVE DISORDERS DSMIV TR

• ATTENTION DEFICIT HYPERACTIVITY DISORDER
• OPPOSITIONAL DEFIANT DISORDER
• CONDUCT DISORDER
• DISRUPTIVE DISORDER NOS

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ADHD

• Diagnosis Criteria for Attention Deficit
  Hyperactivity Disorder (DSM-IV)(A) Either (1) or
  (2)
• 1. Six (or more) of the following symptoms of in
  attention occur often and have persisted for at
  least 6 months.
• Inattention
• Fails to give close attention to details.
• Has difficulty sustaining attention in tasks or
  play activities.
• Does not seem to listen when spoken to directly.
• Does not follow through on instruction and fails
  to finish school work, chores or duties in the
  work place
• Has difficulty organizing tasks and activities.
  Avoids, dislikes or is reluctant to engage in
  task that requires sustained mental effort.
• Loses things necessary for task or activities.
• Is easily distracted by extraneous stimuli.
• Is forgetful in daily activities.

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ADHD

• 2.Six (or more) of the following symptoms of in
  hyperactivity / impulsivity occur often and have
  persisted for at least 6 months.
• Hyperactivity
• Fidget with hands or feet or squirms in seat.
• Leaves seat in classroom or in other situations
  in which remaining seated is expected.
• Runs about or climbs excessively in situations in
  which it is appropriate.
• Has difficulty playing or engaging in leisure
  activities quietly.
• Is on the go or acts as if driven by motors.
• Talks excessively.

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ADHD

• Impulsivity
• Blurts out answers before questions have been
  completed.
• Has difficulty a waiting turn.
• Interrupts or intrudes on other
• B) Some hyperactive impulsive or inattentive
  symptoms that caused impairment were present
  before age 7 years.
• C) Some impairment from the symptoms is present
  in two or more settings e.g. at school (or work)
  and at home
• D) There must be clear evidence of clinically
  significant impairment in social, academic or
  occupational areas.
• E) The symptoms do not occur exclusively during
  the course of a Pervasive Developmental
  Disorders, Schizophrenia, or others psychotic
  Disorder and are not being accounted for by
  another mental disorder.

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ADHD

• Types
• Attention Deficit Hyperactivity Disorder,
  combined type. If both criteria A1 and A2 are met
  for the past six months.
• Attention Deficit Hyperactivity Disorder,
  Predominantly Inattentive Type. If criteria A1 is
  met but criteria A2 is not met for the past six
  months.
• Attention Deficit Hyperactivity Disorder,
  Predominantly Hyperactivity Impulsive type if
  criteria A2 is met but criteria A1 is not met for
  the past six months.

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ADHD

• DSMIV ADHD 5 - 10
• ICD 10 HKD 1-2
• ADHDDAMP 6
• More common among boys
• 21 to 51
• Girls manifest inattentive subset more commonly
  under diagnosed
• Symptoms there by age 7
• Peak age of diagnosis 9

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ETIOLOGICAL FACTORS

• HETEROGENOUS
• NEUROCOGNITIVE
• GENETIC
• PSYCHOSOCIAL
• ENVIRONMENTAL
• COMPLEX INTERPLAY BETWEEN ALL THE FACTORS

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DOPAMINE

• Altered dopamine functioning in
  mesolimbic,mesocortical nigrostriatal pathways1
• Altered sensitivity to reinforcement and
  deficient extinction of previously reinforced
  behavior
• Deficient attention towards a target, poor
  planning and executive functioning
• Impaired modulation of motor behavior
• Deficient learning and memory
• 1 Barkley RA In Attention Deficit Hyperactivity
  Disorder Etiologies. The Guilford Press New York
  3rd Edition 2006

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Molecular genetic studies

• More than one gene is highly likely responsible
• Polymorphism(7 or more repeats) of DRD4 gene
  for D4 receptor, also implicated in novelty
  seeking behavior
• DAT 1 dopamine transporter gene
• DBH gene (dopamine beta hydroxylase contributes
  to conversion of dopamine to norepinephrine)
• Barkley RA In Attention Deficit Hyperactivity
  Disorder Etiologies. The Guilford Press New York
  3rd Edition 2006

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Environmental Social factors?

• Maternal smoking and alcohol use during pregnancy
• Excess TV in first 3 years correlation with
  ADHD symptoms at age 7 but cause effect
  relationship not established
• Overcritical and commanding mothering may be a
  consequence of ADHD symptoms in children rather
  than a cause!
• No currently available credible scientific theory
  of causation of ADHD by purely social means
• Barkley RA In Attention Deficit Hyperactivity
  Disorder Etiologies. The Guilford Press New York
  3rd Edition 2006

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Recent developments

• Neuroanatomic correlates
• Regions most commonly differentiating ADHD from
  Non ADHD controls in structural imaging
  techniques1
• total cerebral volume
• Caudate nucleus
• Splenium of corpus callosum
• cerebellum
• A group of 15 to 19 Adolescents with familial
  ADHD were found to have large right caudate and
  Inferior frontal gyrus2
• 1.Valera EM,Faraone SV,Murray KE,Seidman
  LJ,Metaanalysis of structural imaging findings in
  attention-deficit hyperactivity
  disorder.Biological Psychiatry 2006
• 2.Garret et al Neuroanatomical Abnormalities in
  Adolescents with Attention deficit hyperactivity
  disorder. Journal of American Academy of child
  and adolescent psychiatry 4711 November 2008

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OPPOSITIONAL DEFIANT DISORDER

• Often looses temper
• Often argues with adults
• Often actively defies or refuses to comply with
  adults rules
• Often deliberately annoys people
• Often blames others for his or her mistakes or
  misbehavior
• Often touchy or easily annoyed by others
• Often angry and resentful
• Often spiteful or vindictive

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CONDUCT DISORDER

• Aggression to people and animals
• Bullying, threatening, intimidating
• Initiating physical fights often using weapons
• Cruelty to people and animals
• Mugging, mobile snatching, armed robbery
• Sexual assaultiveness
• Destruction of property
• Fire setting with intent to destroy
• Destroying other peoples property with intent
• Deceitfulness or theft
• Breaking and entry
• Conning Forgery
• Shoplifting
• Serious violation of societal norms
• Staying out and running away from home
• Truancy

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MANAGEMENT OF ADHD

• PARENTAL TASKS
• UNDERSTAND THE CHILD DONT GET FRUSTRATED
• STRUCTURE HOME ENVIRONMENT ESTABLISH HEIRARCHY
• PREDICTABLE ROUTINES
• REDUCE OVERSTIMULATION
• REWARD COMLIANCE
• MINI TASKS BUT NO MULTI TASKING

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MANAGEMENT OF ADHD

• TEACHERS TASKS
• SMALL CLASSROOM SIZE
• TEAHCHERS ASSISTANTS
• SIT THEM IN FRONT
• SHORT TASKS WITH IMMEDIATE FEEDBACK
• ALLOW PHYSICAL ACTIVITY e.g. CLEAN THE
  WRITINGBOARD
• REWARD INCREASED ATTENTION SPAN
• PRAISE THE CHILD FOR CONTROLLING FIDGETINESS

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MANAGEMENT OF ADHD

• PHYSICIANS TASKS
• EVALUATE THE FAMILY SITUATION
• ASSESS THE PARENTS SPECIALY MOTHERS
• GET TEACHERS FEEDBACK
• HELP THEM SEE THIS AS A DISORDER
• HELP THEM STRUCTURE HOME ENVIRONMENT
• RULE OUT ANXIETY MENTAL RETARDATION AND LEARNING
  DISABLITY
• LOOK FOR COMORBIDS e.g.ENURESIS,FINE MOTOR DELAY
  ETC.
• RECRUIT OTHER PROFESSIONALS e.g. OCCUPATIONAL
  THERAPIST,PSYCHOLOGISTS

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MANAGEMENT OF ADHD

• STIMULANT MEDICATIONS
• METHYLPHENIDATE (RITALINR ) GOLD STANDARD
• DEXTROAMPHETAMINES
• OROS FORMUALTION (CONCERTAR )
• NON STIMULANTS
• ATOMOXETINE (STRETTERAR)
• RISPERIDONE (RISPERDALR AND OTHERS)
• TCAs

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MECHANISM OF ACTION

• STIMULANTS BLOCK THE DOPAMINE TRANSPORTER
• PREVENT RE ENTRY OF DOPAMINE IN THE PRESYNAPTIC
  NEURON
• INCREASED RESTING LEVEL OF EXTRACELLULAR DOPAMINE
• REDUCTION IN RELATIVE RISE IN DOPAMINE LEVEL
  TRIGGERD BY AN IMPULSE

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ADHD RATING SCALES
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RECOMMENDATIONS (AACAP)

• Psychopharmacological treatment alone is
  satisfactory if
• Robust response to medicine
• Normative functioning in academic, family and
  social domains
• Psychosocial treatment in conjunction with
  medications if
• Less than optimal response to medicines
• Presence of co morbid disorders
• Dysfunctional family
• Periodic assessment and follow-up patient to
  determine if
• Medication effective
• Dosage optimal
• Side effects monitoring
• Appropriate growth across percentiles
• Treatment should continue as long as symptoms
  remain present and cause impairment