Child and Adolescent Psychiatry Department,

“Carol Davila” University of Medicine and Pharmacy

ADHD
 Definitions and clasifications

- neurobiological deficit with genetic determinism that can also be strongly influenced by
education

- executive functions (organization, planning, working memory, selective attention,

flexibility) are impaired due to dopaminergic and noradrenergic dysfunctions in the areas
of the limbic system (cerebral amygdala, anterior cingulate, hippocampus, striatum)

- the hyperactive child has an inability to focus attention, difficulty controlling attention,
behavioral and cognitive impulsivity, as well as inappropriate restlessness and impatience.
DSM 5 ICD 10
ADHD and Disruptive Behavior Disorders Hiperkinetic disorders F.90

 ADHD - Disturbance of activity and attention F90.0

 Predominantly inattentive presentation - Hyperkinetic conduct disorder F90.1
 Predominantly hyperactive/impulsive - Other hyperkinetic disorders F90.8
presentation - Hyperkinetic disorder, unspecified F90.9
 Combined presentation
 Inattention:


Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or
misses details, work is inaccurate)

Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or
lengthy reading)

Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction)

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but
quickly loses focus and is easily sidetracked)

Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings
in order; messy, disorganized work; has poor time management; fails to meet deadlines)

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older
adolescents and adults, preparing reports, completing forms, reviewing lengthy papers)

Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, papenwork, eyeglasses,
mobile telephones)

Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts)

Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills,
keeping appointments)
 Impulsivity


Often blurts out an answer before a question has been completed (e.g., completes
people’s sentences; cannot wait for turn in conversation)

Often has difficulty waiting his or her turn (e.g., while waiting in line)

Often interrupts or intrudes on others (e.g., butts into conversations, games, or
activities; may start using other people’s things without asking or receiving
permission; for adolescents and adults, may intrude into or take over what others
are doing
 Historical retrospective of the term ADHD
Year The name

1902 (Still) Morbid Defect of Moral Dyscontrol

1906 (French Psychomotor instability (Instabilité Psychomotrice)

classification)
1941/1947 (Strauss) Minimal Brain Damage Syndrome

1962 (Clements and Minimal Brain Dysfunction

Peters)
1968 (DSM II) Hyperkinetic Reaction Disorder

1980 (DSM III) Attention Deficit Disorder with or without Hyperactivity

1987 (DSM III-R) Attention Deficit/Hyperactivity Disorder

1994 (DSM IV) Attention Deficit/Hyperactivity Disorder

2000 (DSM IV-TR) Attention Deficit/Hyperactivity Disorder

7
 Epidemiology


About 11% of children aged 4-7 years were diagnosed with ADHD (2011)

The percentage of children diagnosed with ADHD is increasing:
- 7.8% in 2003
- 9.5% in 2007
- 11.0% in 2011

ADHD is more common in boys (13.2%) than in girls (5.6%)

More severe forms begin under 7 years
Centers for Disease Control
 Family factors BASIC
SYMPTOM
Genetic factors S
NEURO
BIOLOGICA
L
Peri- and Socioeconomic SUBSTRATE ASSOCIATE
Postnatal factors factors D
DEFICITS

PHARMACOLOGICAL SKILLS
CBT TRAININ
TREATMEN
The etiological model of ADHD and the G
T
possibilities of therapeutic intervention
Brain areas involved in ADHD

Sensory rgans and limbic system:

parietal lobe: Attention, Emotional significance
Perception and location prefrontal cortex (PFC):
Postponement, analysis and judgment
PFCseems to be most involved in ADHD.

Hippocampus:
Association; Corpus callosum:
Memory and Complex
recognition integration

locus coeruleus and nucleus acumbens and striatum:

reticular activating system Retransmission and interruption
Activation and alert

Amygdala:
Motivation, anger,
anxiety
11
 The role of prefrontal cortex (PFC) in ADHD

 ADHD involves PFC dysfunction:

 Right CPF is lower in ADHD patients

 In the PFC the following are modulated by NA and DA: CPF

- Working memory
- Cognition

 PFC executive functions

- Planning
- Organization
- Response initiation or delay
PFC dysfunction EF deficit Symptomatology
12

1. Castellanos et al , 1996; 2. Faraone et al, 1998; 3. Barkley , 1997.

 Neurotransmitters involved in ADHD

Posterior system Right

Anterior system
Mediated by NE frontal Mediated by DA and NE
lobe

Posterior
Shifting attention to DA ¨ Data analysis
parietal lobe
new stimuli DLPFC
¨ Response
Focus attention on NE preparation
new stimuli

Pliszka SR, et al. J Am Acad Child Adolesc Psychiatry 1996;35:264-72.

 Neurotransmitters involved in ADHD


The DA and NE system is dysfunctional
 DA low, NE increased

 Low NE
 Dopaminergic model of the alternation between hypofunction (in PFC - cognitive
deficits) and hyperfunction (in the striatal system - impulsivity, hyperactivity)


DA - the key neurotransmitter in learning regulation - hypofunction

Barkley, 2000; Voeller, 2004

 Genetics and ADHD

 Highly heritable disorder: 60-80%

- Twin and family studies:
- 50 -60% of children with ADHD have parents with ADHD
(at least one)
- 40-50% of children with ADHD have siblings with ADHD
- 80% of monozygotic twins have ADHD

 Heredity has been shown to be polygenic

15
. Cumings et al, 1996; Cumings, 2000; Yudofsky and Hales, 2002, Barkley 2000
 Risk factors


Prenatal exposure to:
- Alcohol (fetal alcohol syndrome): 2-4% have ADHD
- Tobacco
- Organic solvents, Gasoline, Pesticides, Pb, Hg
- The fetus is vulnerable even to low-level exposures
- The direct connection with ADHD is speculative


Low birth weight(< 2500g)
 16% ADHD risk
 Especially in boys - children without cerebral palsy, with normal IQ but with soft neurological
signs and behavioral disorders

Koger, Schettler&Wiss, 2005; Lezak, 2004

The impactul of untreated childhood ADHD on development

Conduct disorders Professional failures

School difficulties Low self-esteem
Social interaction difficulties Interpersonal problems
Low self-esteem Substance abuse
Legal issues, smoking, Violence / accidents
Hyperactivity aggression

Preschooler Adolescent Adult

School-aged Student

Academic failure
Conduct disorders Social interaction difficulties
School difficulties Low self-esteem
Social interaction difficulties Substance abuse
Low self-esteem Violence / accidents
Barkley, 2004
The multidisciplinary approach


Medical

Psihotherapeutic

Educational

= Interventional technique of maximum effectiveness in ADHD

 The ABC Model :

Our behavior is determined by antecedents and maintained by
consequences

A B C
A = antecedent
B = behaviour
C = consequence
 Behavioural intervention strategies:


The use of a daily, weekly or monthly calendar

Performing a more difficult task before an easier one

Fragmentation of complex tasks into smaller, simpler ones

The use of intermediate objectives instead deadlines

Control of environmental stimuli to minimize distractors

Adapting the tasks and the learning moment to the optimal learning style and
lifestyle
Wolraich, 2005

Request the support of a supervisor
 RULES MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
I wake up at 8 o'clock

I wash my teeth

I dress myself

I eat at the table

I rest for 1 hour when I

return from school

I do my homework with
a 10-min break for each
30 min of work (2 hrs)

Spare time

I take a shower and put

on my pyjama
I go to sleep at 10 o'clock
2
2
 Child and Adolescent Psychiatry Department,
“Carol Davila” University of Medicine and Pharmacy

Oppositional defiant disorder

 Caracteristici clinice

Copilul prezintă dintotdeauna sau de la 3-4 ani:


crize de mânie, uneori cu spasm al hohotului de plâns, care apare destul de frecvent;

un temperament „mai iute” care „se înfurie uşor”, „care se ceartă mereu”;

incapacitatea de a respecta regulile, un copil care „se opune tot timpul”, „un încăpăţânat de mic”, „care
face numai ce vrea el”;

pare tot timpul nemulţumit şi „pus pe harţă”, îi învinovăţeşte pe ceilalţi pentru greşelile lui;

nu prea este acceptat la joacă de ceilalţi copii pentru că „le strică jocul” sau „nu respectă regulile jocului”,
„face numai cum vrea el”, „sare iute la bătaie”, „este certăreţ”, „le strică jucăriile”;

uneori sunt anxioşi, temători în faţa evenimentelor noi; nu sunt prietenoşi, îşi fac cu greutate prieteni dat
fiind felul lor de a fi;
 Clinical features

The child has always presented or begins to manifest the following features at ages 3-4:

Temper tantrums, sometimes (frequently enough) accompanied by crying spasms

A "quicker" temperament that "gets furious", "always quarrels";

Inability to abide by the rules, a child who "opposes all the time", "a stubborn little one", "who only does
what he wants";

Seems unhappy (unsatisfied) most of the times, always ready to start a fight

pare tot timpul nemulţumit şi „pus pe harţă”, îi învinovăţeşte pe ceilalţi pentru greşelile lui;

nu prea este acceptat la joacă de ceilalţi copii pentru că „le strică jocul” sau „nu respectă regulile jocului”,
„face numai cum vrea el”, „sare iute la bătaie”, „este certăreţ”, „le strică jucăriile”;

uneori sunt anxioşi, temători în faţa evenimentelor noi; nu sunt prietenoşi, îşi fac cu greutate prieteni dat
fiind felul lor de a fi;
 Clinical features

When they get older, they start to feel the resentment of others and thus, the hostile behaviour
worsens: "they begin to act badly on purpose", "to hit others or to destroy their notebooks or
bags"

They feel that they are not loved and thus they seem to "get even worse";

They want to be noticed by educators and teachers and they end up “telling on other children",
which further attracts the disapproval of others

Prepubescent children and adolescents begin to challenge the authority of their parents and the
rules of their families, increasing their anger and rejection, which exacerbates the child's
opposition
 "Physiological oppositional crisis"
 The period between 2-5 years – the “no", “I don’t want to“, “because that’s what I want” period
 The child learns "that it represents an individuality invested with his own will, different and opposed to
the will of others”
 The child is not defiant, nor does he manifest ill will towards the adult,
 Oppositional behaviour “puts a strain on the child, generating other feelings of guilt, but especially the
anxious fear of losing the affection and love of those close to him”;
 The feeling of guilt makes the child insecure, capricious, inconsistent and not infrequently even more
obstructive, the opposition itself generating oppositionˮ
 The persistence of this behavior over the age of 6 years, with its aggravation, at the beginning of the
first school year must raise question marks and the suspicion of the onset of ODD;
 Child and Adolescent Psychiatry Department,
“Carol Davila” University of Medicine and Pharmacy

Conduct disorder
 ADHD

Oppositional defiant disorder

Conduct disorder

Juvenile delinquency
 Clinical features

 Unusually frequent or severe temper tantrums;

 Often argues with adults;
 Often actively defies or refuses adults’ requests or rules;
 Often, apparently deliberately, does things that annoy other people;
 Often blames others for one’s own mistakes or misbehaviour;
 Often touchy or easily annoyed by others;
 Often angry or resentful;
 Often spiteful or vindictive;
 Frequent and marked lying;
 Excessive fighting with other children, with frequent initiation of fights (no including fights with siblings)
 Uses a weapon that can cause serious physical harm to others (bat, brick, broken bottle, knife, gun);
 Often stays out after dark without permission (beginning before 13 years of age);
 Clinical features
 Physical cruelty to other people;
 Physical cruelty to animals;
 Deliberate destruction of others’ property;
 Deliberate fire-setting with a risk of intention of causing serious damage;
 Stealing without confrontation with the victim (shoplifting);
 Frequent truancy from school beginning before 13 years of age;
 Running away from home (at least 2 times or once during the night time);
 Aggression towards the victim, while stealing (armed robbery);
 Forcing another person into sexual activity against their wishes;
 Often gets into fights with others(deliberate infliction of pain or hurt including persistent intimidation,
tormenting, or molestation);
 Breaks into someone else’s house, building or car;
 ICD 10

 Conduct disorder confined to the family context;

 Unsocialized conduct disorder;
 Socialized conduct disorder;
 Child and Adolescent Psychiatry Department,
“Carol Davila” University of Medicine and Pharmacy

Depressive disorder in children and

adolescents
 Depression in toddlers and preschoolers

 apathy, refusal to eat, refusing to play

 crying, screaming, easily irritable

 they cling to the mother, only want to be carried, then they can have moments of rejection

 failure in reaching the recommended weight for age

 sleep disorders

 enuresis, encopresis

 destructive playing

 they look unpleased, unhappy, rarely smiling

 Patient interviews reveal affective neglect, inadequate care, abuse

 Depression in school-aged children

 It starts with psychosomatic symptoms (headache, abdominal pain) or vegetative disorders accompanied by
anxiety up to the paroxysmal form with panic attacks

 Decrease in attention focus

 There can be a decrease in school performance and school refusal may occur

 They do not use the term sad / depressed but they state that they are "hopeless", "bored" or "no longer like
what they were doing before“

 Inability to deal with frustrating situations - withdraws into a corner, cries helplessly, or becomes violent
(screaming, crying or hitting)

 Suicide attempts are very rare at this age, but if asked, they say they "want to die"
 Depression in adolescents

 the symptomatology becomes similar to that of the adult

 the differentiation between symptom depression and depressive illness is made up of the persistence of the
disorder, its intensity and whether it affects the social functionality
 Treatment of child and adolescent depression

- The first line of intervention is the psychotherapeutic one - cognitive- behavioral therapy is
the intervention validated with results in the case of children and adolescents

- Family counseling in adopting a supportive attitude

- In major depressive episodes the first line of psychopharmacological intervention is

represented by SSRIs (selective serotonin reuptake inhibitors)

- In cases of anxiety-depressive comorbidity, the use of benzodiazepines for the anxiolytic

effect is also recommended
 Reactive attachment disorder (RAD)
 Inadequate social interactions in a developmentally appropriate way Institutionalized children

 Starts before the age of 5 and is associated with pathological care

Neglected children, raised in
unfavorable environments

Inhibited RAD
Disinhibited RAD
- Inhibited response to social interactions
- Hypervigilant - Non-discriminatory in attachment relationships
- Avoidance, aggression, fear In relationship with - Superficial social relations, the child doesn’t worry
the caregiver if the care giver changes
- No interest in friendships - This superficiality in the relationship helps them
seem“resourceful”
- May have hyperactivity, low tolerance for
frustration, aggressive behavior