ATTENTION DEFICIENT HYPERACTIVITY

DISORDERS

Dr. Rabia ramadan Gajum

consultant behavior & psychiatry
at children hospital
Tripoli Libya
 ADHD
►Most common Neurobehavioral disorder affecting children
characterized by :
- Inattentiveness
- Impulsiveness
- Hyperactivity
- Difficult concentration
- Restlessness
- Distractibility
- Excitability
► Hyperactivity significantly affect child's function at
- Home
- School
- Playground
- 40% of school children who has problem in school was ADHD.
- boys more frequent ( 2-8 times)
- 70% of symptoms persist to Adolescent
 Symptoms of ADHD
• Symptoms:
►May vary substantially between :
- Home & School
- Structured & not structured settings.
- Stimuli make high & low demands on the child's performance.
► Have trouble concentrating on activities that other children enjoy as:
- coloring
- pasting
- Doing puzzles
► May show sign of :
- free flight of ideas
- Difficulty Feeling satisfied
- Social immaturity
- Inconsistent performance
- Mood swings
► As get older :
- Excessive Fidgeting
- Restlessness ( Rather than gross motor activity)
 ► ADD-H
- function at slower cognitive speed.
- appear more confused.
- Apathetic
- Lethargic
- Increase social withdrawal
- more likely to suffer from ( anxiety or depression )
- Tend to be female
- Diagnosed in later grades of elementary school ( when
begin to fall behind academically.
- Disorganized
- Forgetful
- Often labeled lazy or under achieving.
 Types of ADD

1. hyperactive & impulsive.( ADHD)

2. Combined hyperactivity & inattentive( ADHD)

3. inattentive ( ADD-H)

( first tow groups → Indistinguishable → refer as ADHD.)

 ► Children with ADHD
- more noisy
- Aggressiveness
- Disruptive
- Messy
- Irresponsible
- Immature
- Less successful in establishing
relationship with peer
 ► Diagnostic criteria for ADHD
Diagnostic Criteria for Attention Deficit Hyperactivity Disorder •
1.Symptoms of inattention: •
*Lack of attention to details. •
*Difficulty sustaining attention for prolonged periods . •
*Not listening . •
*Difficulty following through or completing tasks . •
*Disorganization . •
*Avoidance of activities that require sustained attention . •
*Tendency to lose personal belongings. •
*Marked distractibility . •
* Forgetfulness. •
2.Symptoms of hyperactivity:
*Difficulty remaining in seat, or sitting quietly. •
*Developmentally excessive activity level . •
* Difficulty engaging in nonaction activities . •
*Talking excessively . •
3.Symptoms of impulsively: •
*Blurting out answers without raising hand or waiting for the end of the question . •
*Difficulty with turn – taking activities. •
*Frequent interruption or intrusion into others, conversations or activities. •
Presence of some symptoms before age 7 years. •
Significant functional impairment a5 a result of the symptoms. •
 ►Causes of ADHD
• 1.Inherited Disorders.
- Relatives has high risk of:
- ADHD
- Common bio psychiatric disorder
- School failure
- Learning disability
- 1 in 4 children → biological parent has same problem.
- Identical twin.
2. Abnormalities of Neurotransmitters in Frontal area.
- stimulant medication:
→ Increase activity in Frontal lobe.
→ High conc. Of Dopamine metabolic in CSF.
( Correlate to high degree of hyperactivity and good response to treatment)
 causes of ADHD cont.
3. Structural abnormalities of Brain
(No normal asymmetry of caudate in which Rt. > Lt)

4. Abnormal Frontal lobes

Decrease volume of Rostrum & rostral body of corpus collusion-MRI
5. Birth Injury :
- Fetal distress
- Difficult Labor
- Damage before birth
6. Drug & Alcohol Abuse during pregnancy
.
7. Environmental Toxins →
( Lead, artificial flavor, dyes, preservatives & food additives)
 ► D/D of Hyperactivity
•
-Age appropriate over activity.
- Emotional problem due to Divorce.
- Learning Disability
- Anxiety
- Conduct Disorder
- Oppositional defiant disorder
- Speech or Language Disability
- Tourettes syndrome
- Affection Disorder { Mania, Depression, Schizophrenia or Psychosis}.
- In adequate environment or parenting
- Mental Retardation
- In utero exposure to (Alcohol, cocaine, lead )
- Iatrogenic (Medication)
- Theophylline
- Barbiturats
- Steroids
- Irritating skin condition Enzyme
- Endocrine:
→ Hyperthyroidism
→ Pheochromocytomia
→ Hypoglycemia
-Chromosomal:
→ Down syndrome
→ Fragile X Syndrome
→ Klinfelter
→ Turner
 ► Diagnosis of ADHD
- Symptoms must present before age of 7 years.

- Impairment happen in two or more settings.

- No single, medical, Lab. or psychological diagnostic

test
 ► Diagnosis of ADHD cont.

1.Clinical:

done On basis of a picture that begins early in life, persist

overtime pervades different settings of the child's life. This
picture must impair function of child.
 ► Diagnosis of ADHD cont.

2. Interviews with caregiver:( parental interview)

► Full developmental history (to role out develop,learning & language disability)
- Child behavior at infancy:
Resistance to cuddling, high activity levels, sleep & feeding disturbance
Behavior at this time correlate with future ADHD
ask for Child behavior in various settings.
→ alone
→ plays (Leisure time activity)
→ shopping
Review behavior management techniques used by parent.
- is appropriate for age
- is overly punitive
- Indulgent
 ► Diagnosis of ADHD cont.

► Child academic performance:

- Learning disability is more in ADD-H
- Normal or superior intelligence
- Chronic under achievement
- at adolescent up to 1/3 failed at least one grade
► Peer relationships
► Family History : Hyperactivity or Learning Disability
 ► Diagnosis of ADHD cont.
3. Teacher Report :
- Ability to finish work
- stay on task
- respect others
- level of academic achievement
- General intelligence
4. Physical Examination
5. Role out coexisting condition
6. Rating Scales (Assess children's behavior at home and in
school)
 Rating scales

a. Conner's teacher rating scale.

b. ADD-H comprehensive rating scales
c. performance tests
 Rating scales Cont .

A. Conners teacher rating scale.

- rate children on several aspects.
- cannot provide diagnosis
 Rating scales Cont .
b.ADD-H comprehensive rating scales.
- rate children on several aspects of behavior.
- separate evaluation to 4 area of behavior
* attention
* hyperactivity
* social skills
* oppositionality
- Make initial diagnosis of ADHD.
- estimate symptom severity
- monitor child's response to treatment
- cannot provide diagnosis.
 Rating scales Cont .
c. performance tests:
- Assess ability to sustain & focus attention
- to refrain from responding impulsively:
a. matching familiar figures test
b. continuous performance test
- produce useful information
- result not infallible
 ► Diagnosis of ADHD cont

7. Physical Examination :
- Observe child behavior at office.
- only 20% of ADHD exhibit hyperactivity
- Done to role out visual and hearing problems { impaired attention and memory}.
- excludes physical illness
- to see medication effects
- to see major Neurological or Developmental problems
- dysmorphic features – syndromes
→ Fragile X syndrome
→ Fetal Alcohol syndrome
- major or vocal Tics → tourettes syndrome
- pick up soft neurological signs :
→ Fine motor coordination problems
→ Choriform
→ motor overflow movement
 ► Diagnosis of ADHD cont

8. EEG :
- may show abnormalities
- increase slow wave abnormality
- not definite (many has normal EEG)
- done only if has reason.
9. Psychological Testing :
- done by Psychologist or Educational consultant
- IQ (learning disability)
- Reading test appropriate to chronological age (reading disability)
 ► Diagnosis of ADHD cont

10. Psychiatric Evaluation:

- Severe and complex symptoms of (anxiety,depression,anger)

- to differentiate if the problem is causing or complicating the co-

existing symptom.

- significant family conflict.

- Need alternative medication.

 ►Treatment
•
- To improve child's function
1.- Behavioral therapies Modificate → Inattentiveness, impulsiveness & Hyperactivity }.
2.- School modification

3.- Trial of medication → Methylephenidate(Ritaline)

* maximize cognitive function
* improve social skills
* improve behavioral skills
* raising self- esteem
* keep side effect to minimum
4.- Education :
- Accurate information to be given to family and the child about ADHD, associated problems & the
treatment.
- parental support groups.

5.- Multi model therapy → Combination of :

- Education
- Medication
- Psychological treatment
- Appropriate classroom intervention
Thank you