Attention deficit hyperactivity disorder

From childhood to adulthood

BY

Ghada Ahmed Abdel Gawad

Psychiatric consultant

Arab board ,
DPP (kings college ,UK )
MSc(Kasr el Aini)
HMD(sadat academy)
 Hyperactive-Impulsive Type

Even though each of these behaviors is normal in children at different ages to

a certain degree , in those with ADHD , the behaviors far exceed that which is
normal developmentally ( in frequency , level , and intensity ) .
 Symptoms of Hyperactivity

On the go or acts as if driven by a motor .

Leaves seat in classroom or in other situations in which remaining
seated is expected .
Cannot sit still ( jumping up and out of chair , falling out of chair ,
sitting on knees or standing by desk ) ..
 Runs about or climbs excessively in situation in which it is inappropriate

Seems to need something in hands . Finds/reaches for nearby objects to play

with and/or put in mouth .
Difficulty playing or engaging in leisure activities quietly .
Intrudes in other peoples space ; difficulty staying within own boundaries ---
self esteem.
Difficulty settling down or calming self .
 Symptoms of Impulsivity

Much difficulty in situation requiring to wait patiently .

Talks excessively .
Difficulty with raising hand and waiting to be called .
Interrupts or intrudes on others (conversations or games) .
Bursts out answers before questions have been completed .
Has difficulty waiting for his or her turn in games and activities .
Cannot keep hand /feet to him self .
 Cannot wait or delay gratification wants things now

Knows the rules and consequences ,but repeatedly makes the same errors

Cannot stop and think

Difficulty standing in line

Does not think or worry about consequences

Accident prone breaks things
 symptoms of Inattention :

Easily distracted by extraneous stimuli ( sights , sounds , movement , in the

environment ) .
Dose not seem to listen when spoken to directly .
Difficulty remembering and following directions .
Difficulty sustaining attention in tasks and play activities . Forgetful in daily
activities .
Dose not follow through on instructions and fails to finish schoolwork , chores ,
or duties in the workplace ( not due to oppositional behavior or failure to
understand instructions ) .
 Daydreams ( thoughts are elsewhere ) .
..
Dose not complete work , resulting in many incomplete
assignments .

. Avoids , Dislikes , or is reluctant to engage in tasks requiring sustained

mental effort ( such as schoolwork or homework ) .

Difficulty organizing tasks and activities (planning , scheduling , preparing).

 Gets bored easily .

Sluggish or Lethargic ( may fall asleep easily in class ) .

Fails to pay attention to details and makes many careless mistakes ( with
math computation , spelling , written mechanics-capitalization , punctuation ) .
Loses things necessary for tasks or activities ( toys , pencils , books , or
tools).
Difficulty organizing tasks and activities (planning , scheduling , preparing).
 preschool Primary school adolescence adulthood

inattentive Short play<3 Brief act ,>10, Persistence < peer Detail not
,not listening, forgetful <30 min completed,
incomplete distracted, lack details , forget appointment
activities poor planning ,lack of foresight
disorganized

overactive whirlwind Restless when calm fidgety Subjective sense of

expected restlessness

Impulsive Does not listen ,no Acting out Poor self control, Accidents
sense of danger interrupting risk taking Unwise decision
thoughtless rule
break Impatience
accidents. ( Rutter 2008 )
 risk Factors :
More serious accidents , hospitalizations and significantly higher
medical costs ( Centers for Disease Control and prevention 2003 )

More school failure and dropout .

Earlier experimentation and higher use of alcohol , tobacco ,

and drugs .
More trouble socially and emotionally .
More underachievement and underperformance at school/work
(Barkley , 2006 ) .
.

ADHD is a lifelong disorder .

Most children with ADHD ( up to 80 percent ) continue to have substantial

symptoms into adolescence ,

As 67 percent continue to exhibit symptoms into adulthood

( CHADD , 2003 ) .
Symptoms that may look like ADHD
:
Learning disabilities
Mood disorders
Oppositional defiant disorder
Conduct disorder
Anxiety
 Autism

Low intellectual ability

Severe emotional disturbance

Side effects of medications being taken

( for example anti-seizure medication , asthma
medication ) .
Does everyone with
Inattention has
ADHD?
 To date the causes of ADHD are not fully known or understood

Hereditary

This is the most likely common cause of ADHD based on

the evidence :

Heredity accounts for about 60 t0 90 percent of children

with ADHD according to leading researchers( Rutter 2008) .
 It is believed that genetic predisposition to the disorder
is inherited . children with ADHD will frequently have a
parent , sibling , grandparent or other close relative
with ADHD
 Prenatal , during birth , or
postnatal trauma/injury :
It has been found that trauma to the developing fetus during pregnancy or birth ,
which may cause brain injury or abnormal brain development can cause ADHD
. (Rutter 2008 ), trauma might include :
Fetal exposure to alcohol and/or cigarettes .
 Exposure to high levels of lead .
Complications during pregnancy and birth such as toxemia .

Brain injury from disease (like encephalitis) or trauma especially to

the frontal area.
Pathology and laboratory examination

PET(Positron emission tomography) SPECT (single

photon emission computed tomography)

decrease cerebral blood flow in the frontal

region(Rutter 2008)

fMRI reduced activity of the prefrontal

cortex
 Chemical Imbalance or Deficiency in
Neurotransmitters :

It is believed that those with ADHD have a deficiency ,

imbalance or inefficiency in brain called Neurotransmitters called the dopamine

and norepinephrine which are the main one thought to be involved in ADHD.

( Essential Psychopharmacology ) .
 Medication:
1- Psychstimulant :

Stimulant medication have been used since 1930

.In fact ,they are the most well researched of all
medication for children .
Stimulants have proven to be highly effective for 75
to90 % of children with ADHD. They are the most
prescribed medication.
 How do stimulant work ?

The neurotransmitter that are released more effectively when a

child takes stimulants are dopamine and , to a lesser extent nor
epinephrine .

As a result , the child is able to focus attention , regulate

activity level & impulsive behaviors
1-Methyphenidate(Ritalin ,Ritalin SR,
Concerta ) .
2-Dextroamphetamine

Methylphenidate are among the most

carefully studied drugs they are known to be
highly effective and safe .
Some of the stimulants come in short and long acting forms .The :
Start to work about short acting forms twenty minutes from the time taken.
Metabolize quickly and are effective for about 3-4 hours.
Regularly need an additional dosage at school.
May require a third dose in the evening .
The long acting formulas of the medication have delivery systems that
release the medication to give extended coverage throughout the day .
Concerta ( methylphenidate ) begin after ingestion and last for 10 to 12
hours .
 The long acting formulas :

10-12 hours
Sustained level throughout the day
minimize rebound phenomena
beneficial or who are embarrassed ,resistant or forgetful
about going to school for a midday dose .
 Take care of :

*growth suppression (holidays) , anorexia ----- use stimulant with meals .

*Insomnia ------------- earlier in day, discontinue afternoon dosing .
*dizziness ------- encourage fluid and monitor BP .
*exacerbate tic disorder .
*Dysphoria -------------- consider co morbid diagnosis-reduce the dose
consider adjunctive or alternative treatment e.g. lithium , antidepressant .
 Atomoxetine (Strattera)

Selective norepinephrine reuptake inhibitor .

It is similar in effect of methylphenidate
It has the advantage that include continuous coverage of symptoms
throughout the work/school and evening
This action increases the availability of norepinephrine which is
another brain chemical essential in regulating impulse control ,
organization and attention .
 Strattera is an oral capsule .
It work after 4 weeks so begin with stimulants for the
first 4 weeks .
begin with 0.5mg/kg/day-------7days----1.2mg/kg/day .
>70kg ---start with 40mg ---7days--80mg .
It has the advantage that include continuous coverage of
symptoms throughout the work/school and evening

 Psychosocial intervention

Children should be taught the purpose of medication and

have a chance to talk about their feelings.

Make it clear that medication are just help in you (you are
not crazy)
 Strategies include:
Telling the child what they are required to do ,using clear and
simple statements.

Breaking down multitask instructions into several single-task

statements.

Changing the child's classroom seat ,so that they are nearer to
the teacher and further away from the disruptive influence of
peers.
 Telling and reminding them when their turn will be

Making task interesting and choosing rewards that are valuable to

them

Using a structured day with a clear program

Using rewards that give the child responsibility and control

Setting clear rules and boundaries and ensuring that the child has
access to them for a reminder.
 Presenting learning in small chunks , with frequent time off

Establishing a positive and supportive atmosphere in which the

child is able to learn from their mistakes and successes.

Ensuring that children know what is unacceptable behavior and

also what the consequences will be if rules are broken

Supporting the family

Providing information about support group and books .

 Take home Message

ADHD is a lifelong disorder

High genetic element
Medications are not addictive &safe
For a better quality of life for the patient
&family
Thank you
For

your attention
 Post test

1.ADHD is a problem of insufficient

willpower

a.True
b.False
2.Male to female ratio of ADHD is :

a.1:1
b.2:1
C.4:1