ADHD

A. Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or

development, as characterized by:
Inattention Hyperactivity and impulsivity
(6\9) if 17Y or adult (5\9) for 6month
• fails to give close attention to details or makes careless mistakes • fidgets tap hands or feet or squirms in seat
• difficulty sustaining attention in tasks or play activities • leaves seat when remaining seated is expected
• does not seem to listen when spoken to directly • runs or climbs where it is inappropriate.
• does not follow through on instructions and fails to finish work • unable to play quietly
• unable to be still for extended time >> on the go acting
• has difficulty organizing tasks and activities • talks excessively
• avoids, dislikes to engage in tasks require sustained mental effort • blurts out an answer before a question has been completed
• loses things necessary for tasks or activities • difficulty waiting his or her turn
• easily distracted • interrupts others
• often forgetful in daily activities
B. symptoms were present prior to age 12 years.
C. symptoms are present in two or more settings
D. clear evidence that the symptoms interfere with social, academic, or occupational functioning.
E. not better explained by another mental disorder
Specify whether: ❖ in partial remission
❖ Combined presentation ❖ Mild
❖ Predominantly inattentive presentation (common in ♀) ❖ Moderate
❖ Predominantly hyperactive/impulsive presentation ❖ sever

Epidemiology: 5-8%- in adult 1-5%- ADHD in parent & sibling of children è ADHD is 2-8x greater than general population-
♂2-9: ♀1 in children, in adult ♂1: ♀1- 1st degree relative @↑ risk of other behavioral≠, anxiety, mood, learning, substance

Biomarker!! Neuro-transmitters (dopamine DRD4- norepinephrine) – prefrontal cortex.

Impairment in ADHD: parent stress>> family conflicts>> accident & injuries>> smoking, substance>> legal problems>>
poor peer’s relationships>> school failure>> psychiatric comorbidities.

Comorbidity: learning disorder- mood- anxiety- disruptive behaviors- substance- antisocial behavior.

ADHD rating scales Achenbach Child Behavior Checklist, Connors ADHD Rating Scale, Brown Scale
Attention tests Connors Continuous Performance Test, Test of Variable Attention
Achievement tests Wechsler Individual Achievement Test, Peabody Individual Achievement Test
IQ tests Wechsler Intelligence Scale for children 6-16, Wechsler preschool & Primary Scale for 21\2-7 YO
Neuroimaging If neurological hx. Or signs present.
NB. Rule out seizure (petit mal, or temporal lobe), hearing & visual impairment, & thyroid abnormality. Cardiac Hx.
Including Hx. Of syncope, family Hx. Of sudden death, ECG & physical examination

Formulation:
Predisposing factors Precipitating factors
- Inherited 75%, if parent has ADHD risk↑ >50% - Family stressors
- Prenatal toxic exposure including smoking - Severe early deprivation, abuse, maltreatment & neglect
- Maternal infection during pregnancy - Food additive, coloring & preservative
- Prematurity, low birth wt., traumatic brain injury - traumatic brain injury
- Food additive, coloring & preservative
- Severe early deprivation, abuse, maltreatment & neglect
Perpetuating factors Prognostic factors
- Family stressors - Combined & hyperactive types→ ↑conduct than inattentive
- Lack of family support - 60-85% syx. Persist into adolescent, 60% into adult
- Presence of comorbidities - 40% remit @ puberty- Hyperactivity may disappear but
- -ve. Self-image ↓attention & impulsivity persist
- Persistence predicted by: family hx. -ve. Life events, comorbid è
conduct, anxiety & depression.
 Management:
Social psychological
- Support therapy - Psychoeducation
- Academic organization skills - Parent teacher behavioral therapy
- Social skills training - Behavioral training for parents
- Evaluation & treatment of learning disorder - Behavioral therapy for coexisting disorder→ anxiety,
- Improve family situation depression & conduct disorder
- ↓ child aggression - Group therapy to↑ social skills & self-esteem in children who
have difficulty in group setting especially @ school

Pharmacological treatment: considered first line treatment for ADHD

Stimulants Non-stimulants
Methylphenidate block reuptake of dopamine & norepinephrine Atomoxetine (Strattera)
▪ Ritalin (0.3-1mg\kg) TID MAX 60mg daily- 1\2 life 3-4hours ¤ selective inhibition of presynaptic norepinephrine
preparation→ 5-10-15-20 ¤ 0.5-1.8mg\Kg- MAX 100mg daily
▪ Concerta preparation 18-36 → up to 54mg daily ¤ metabolized by P450-2D6 interact è Fluoxetine, Paroxetine
Amphetamine block & release dopamine & norepinephrine Quinine, MAOI, pressor drugs→↑ its level
▪ Dextroamphetamine ¤ Black box warning→↑ suicidal thought & behavior
▪ Dextroamphetamine& amphetamine salt combination
Bupropion → 3-6mg\KG – MAX 300mg daily preparation 75-100-
▪ lisdexamfetamine→ pro-drug of Dextroamphetamine
↓seizure threshold, dose dependent >400mg
Side-effects: headache- GI syx.- may exacerbate tics- growth Clonidine→ α2 agonist- monitor HR & BP- used if tic exacerbate
suppression→ drug holiday- insomnia→ diphenhydramine 25-75 with stimulants- preparation (0.1- 0.2- 0.3)
trazodone 25-50- or clonidine Guanfacine
NB. Contraindicated in pt. è cardiac problems

Other specified ADHD:

used in situations in which the clinician chooses to communicate the specific reason that the presentation does not
meet the criteria for ADHD → “with insufficient inattention symptoms”).
Unspecified ADHD:
Syx. Cause significant distress but not fully met the criteria. Used when the clinician chooses not to specify the reason that
the criteria are not met for ADHD, and includes presentations in which there is insufficient information to make a more
specific diagnosis.

NB. Leading figure for adult ADHD→ Paul Wender.