ATTENTIO

N-
DEFICIT/
HYPERACT
IVITY
DISORDER
Prepared by meron
tadesse
May, 17-2022
Outline
• Historically background
• Introduction
• Epidemiology
• Etiology
• diagnosis
• Differential diagnosis
• Course and prognosis
• Treatment
Historically background
• Heinrich Hoffman (1809-1894) Germen physician a famous story book
creator .
• 1847- ‘let me see if Philip can be a little gentlemen :let me see if he is able
to sit still for once at a table ‘the story of fidgety Philipp’
• Hoffman illustrated a family conflict at a dinner caused by the fidgety
behavior of the son in his falling over together with food on the table-
these can be interpreted as an early case of ADHD
• He describe the inattention and hyperactivity in Philipp, parents become
very angry –show the distress in the family .
Defect of moral control (sir George Frederic Still ,1868-1941)-
considered to be the scientific starting point of the history
ADHD
Psychiatrist and pediatrician
decide to have names –at that
time focus was only on ;
“ impaired moral control “
And set a criteria which used to
determine whether u lack moral
control –these mini diagnosis of
origin for what would become
ADHD
The time of influenza pandemic-correlation between early brain damage
caused by birth defect and subsequent behavioral disorder ‘post
encephalitis behavioral disorder’
The first treatment of hyperactivity –report of positive effect of
stimulant in children with various behavior disorder
In monkey with frontal lobe ablation-behavioral change
Introduction
• ADHD -is a neuropsychiatric condition .
• A pattern of diminished sustained attention, and increased impulsivity
or hyperactivity.
• Clear evidence to support a biological basis for ADHD
- Dopamine continues to be a focus
- PFC has been implicated b/c of its high utilization of dopamine.
reciprocal connection with other brain region .
CONT..
• Largely genetic, with a heritability of approximately 75%.
• Symptoms are the product of complex interactions of neuroanatomical
and neurochemical systems evidenced by.
- twin and adoption family genetic studies
- dopamine transport gene studies
- neuroimaging studies
• Most children with ADHD have no evidence of gross structural damage
in the CNS
• several contributory factors for ADHD suggested.
 Epidemiology
ADHD affects
5 - 8 % of school-aged children,
60- 85 % of those continuing to meet the criteria for the disorder in
adolescence
60 % continuing to be symptomatic into adulthood.
• Significant impairment in academic functioning as well as in social and
interpersonal situations.
• Frequently associated with comorbid disorders including learning, anxiety
mood disorders, and disruptive behavior disorders.
CONT..
• The rate of ADHD in parents and siblings of children with ADHD is 2 - 8
X > general population.
• boys than in girls, 2:1 to as high as 9:1.
• First-degree biological relatives are at high risk for developing ADHD
• Siblings of children with ADHD are also at higher risk than the general
population for learning disorders and academic difficulties.
• Symptoms often present by age 3 years.
Etiology

Neurochemical Factors –
dopamine ,NE

Neuroanatomical

Developmental Factors.

Psychosocial Factors
Neuroanatomical Aspects- PFC, anterior cingulated, globus pallidus, caudate,
thalamus, and cerebellum. Another theory postulates that the frontal lobes in children
with ADHD do not adequately inhibit lower brain

Psychosocial factor. Severe chronic abuse, maltreatment, and neglect are

associated with certain behavioral symptoms that overlap with ADHD including poor
attention and poor impulse control. Predisposing factors may include the child’s
temperament and genetic–familial factors

Developmental factor. Prematurity, maternal infection during pregnancy

Perinatal insult to the brain during early infancy caused by infection, trauma.
CONT..
• Elicited on the basis of a detailed history of a child’s early dev’t patterns
along with direct observation of the child, especially in situations that
require sustained attention.
• The diagnosis of ADHD requires persistent, impairing symptoms of either
hyperactivity/impulsivity or inattention in at least two different settings.
• Rating scale - Vanderbilt ADHD rating scale (assist in the diagnosis)
- Conners Abbreviated symptom question
Clinical Features
• Distinguishing features
Short attention span and high levels of distractibility for chronological
age and developmental level
In school, children with ADHD often exhibit difficulties following
instructions and require increased individualized attention from
teachers. At home, frequently have difficulty complying with their
parents’ directions and may need to be asked multiple times to
complete relatively simple tasks
Typically act impulsively, are emotionally labile, explosive, lack focus,
and are irritable
CONT..
• Onset in infancy, are active in the crib, sleep little, and cry a great deal.
• Rarely recognized until a child is at least toddler age.
• Children for whom hyperactivity is a predominant feature are more
likely to be referred
• Often susceptible to accidents.
• Combined or predominantly hyperactive-impulsive symptoms, are
more apt to have a stable diagnosis over time and to exhibit comorbid
conduct disorder than those children with inattentive ADHD.
CONT..
• Global developmental assessment must be considered to rule out
other sources of inattention.
• School history and teachers’ reports are critical
• In addition to intellectual limitations, poor performance in school may
result from maturational problems, social rejection, mood disorders,
anxiety, or poor self-esteem due to learning disorders. Assessment of
social relationships with siblings, peers, and adults, and engagement
in free and structured activities may yield valuable diagnostic clues to
the presence of ADHD.
 MSE
The child with ADHD
• who is aware of his /her impairment may reflect a depressed mood
• Exhibit distractibility and perseveration/language-based learning disorders.
• A neurological examination may reveal visual, motor, perceptual, or auditory
discriminatory immaturity or impairments without overt signs of visual or
auditory disorders.
• Children with ADHD often have problems with motor coordination and
difficulty copying age-appropriate figures, rapid alternating movements.
Differential Diagnosis
• Normal
• Anxiety - can accompany ADHD as a symptom or comorbid disorder.
• Mania and ADHD share many core features, such as excessive
verbalization, motoric hyperactivity, and high levels of distractibility.
In addition, in children with mania, irritability seems to be more
common than euphoria.
• Although mania and ADHD can coexist, children with BPI disorder
exhibit more waxing and waning of symptoms than those with ADHD.
CONT..

• Frequently ODD/ conduct disorder and ADHD may coexist, and when
that occurs, both disorders are diagnosed.
• Specific learning disorders of various kinds must also be distinguished
from ADHD.
Course and Prognosis
• The course of ADHD is variable
- 60 - 85 % persist into adolescence
- 60 % of cases adult life
- 40 % of cases may remit at puberty, or in early adulthood.
- Does not usually remit during middle childhood.
• When remission occurs, it is usually b/n the ages of 12 and 20
• Persistence is predicted by a family history of the disorder, negative
life events, and comorbidity with conduct, depression, and anxiety
disorders.
CONT..
• Most patients with the disorder, however, undergo partial remission and
are vulnerable to antisocial behavior, substance use disorders, and mood
disorders. Learning problems often continue throughout life
• In some cases, the hyperactivity may disappear, but the decreased
attention span and impulse control problems persist.
• Overactivity is usually the first symptom to remit, and distractibility is the
last.
• Overall, the outcome of ADHD in childhood seems to be related to the
degree of persistent comorbid psychopathology, especially conduct
disorder, social disability, and chaotic family factors.
 Psychosocial Interventions

CNS STIMULANT-
Methylphenidate,
Treatment amphetamine

psychop Nonstimulant
harmac -Atomoxetine ( NE uptake
inhibitor)
ology -A-agonists (clonidine
guanfacine)
Antidepressants(bupropion,
TCA-Imipramine Antipsychotics
–in refractory cases
TREATMENT OF CNS STIMULANT SIDE EFFECTS.

• CNS stimulants are generally well tolerated.

• once a day dosing is preferable for convenience and to minimize
rebound side effects.
• Long-term tolerability of once-daily mixed amphetamine salts has
shown mild side effects, most commonly decreased appetite,
insomnia, and headache.
Monitoring
• Stimulant medications have adrenergic effects and cause moderate
increases in blood pressure and weight.
• Monitoring starts with the initiation of medication, height, weight,
blood pressure, and pulse checked on a and have a physical
• Because school performance is most markedly affected, special
attention and effort should be given to establishing and maintaining a
close collaborative working relationship with a child’s school
personnel.
CONT..
• No evidence indicates that medications directly improve any existing
impairments in learning, although, when the attention deficits
diminish, children can learn more effectively medication can improve
self-esteem when children are no longer constantly disapproval for
their behavior.
• Children treated with medications should be taught the purpose of
the medication and given the opportunity to describe any side effects
that they may be experiencing.
Psychosocial Interventions
• Include psychoeducation, Academic organization skills remediation,
parent training, behavior modification in the classroom and at home,
CBT, and social skills training.
• When children are helped to structure their environment, their
anxiety diminishes.
• Treatment of coexisting learning or additional psychiatric disorders is
important.
• It is beneficial for parents and teachers to work together to develop a
concrete set of expectations for the child and a system of rewards for
the child when the expectations are met.
CONT..
• Goal of therapy is to help parents of children with ADHD recognize and
promote the notion that, although the child may not “voluntarily” exhibit
symptoms of ADHD, he or she is still capable of being responsible for
meeting reasonable expectations.
• Parents should also be helped to recognize that, despite their child’s
difficulties, every child faces the normal tasks of maturation, including
significant building of self-esteem when he or she develops a sense of
mastery. Therefore, children with ADHD do not benefit from being exempted
from the requirements, expectations which is applicable to other children.
• Parental training is an integral part of the psychotherapeutic interventions
for ADHD
References
• Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry
Eleventh Edition
• KAPLAN SADOCK’S COMPRENSIVE textbook of psychiatry
• Stahl's essential psychopharmacology fifth edition