Attention Deficit Hyperactivity

Disorder
(ADHD)

Dr. Wajantha Kotalawala

MBBS (Colombo), MD (Psychiatry), MRCPsych (UK)

Consultant Child & Adolescent Psychiatrist

• No other childhood disorder is as
controversial as is ADHD.
(Barry Schneider, Child psychopathology)
 International Statistical
Classification of Diseases
10th revision 1996
• Hyperkinetic disorder
Diagnostic and Statistical Manual
of Mental Disorders, 5th Edition
2013
• Attention Deficit Hyperactivity Disorder
(ADHD)
 ICD 11
• Attention Deficit Hyperactivity Disorder
(ADHD)
mcq – ? Child tends to be vigilant
• Fidgeting - make small movements,
especially of the hands and feet, through
nervousness or impatience.

• Squirming - twist the body from side to side,

especially as a result of nervousness or
discomfort.
Vigilant

keeping careful watch for possible danger or difficulties.

Hyper vigilant ??
 Early warning signs
• In infancy
Difficult to settle babies
Excessive crying
Poor sleep
Restlessness and fidgety
 Preschool period

Signs of inattention

• i.e. not able to continue a game or play more than

10-15 minutes.

Signs of hyperactivity

• Child may run around completely out of control

jumping from heights
 Preschool period
• Signs of impulsivity i.e. trouble with social
interactions and skills

• Child may lose interest in playing a game or

watching a TV show

• may run around completely out of control

 At school
• Fails to give close attention.
• Makes careless mistakes
• Often becoming easily distracted by irrelevant
sights and sounds
• Rarely following instructions carefully and
completely losing or forgetting things like toys, or
pencils, books, and tools needed for a task
               
• Often skipping from one uncompleted activity to
another
Development and course of ADHD

• Excessive motor activity is usually observed by

parents when the child is a toddler.

• However, since normative behaviours are highly

variable before age of 4, symptoms are difficult to
distinguish from normal behaviour.

• Most often, ADHD is identified during primary

school years.
Development and course of ADHD
• Main manifestation during pre-school age is
hyperactivity.

• During primary school, inattention becomes more

prominent.

• During early adolescent period, ADHD becomes

relatively stable in terms of symptoms.

• In most children with ADHD hyperactivity becomes

less after adolescence but inattentions and
impulsivity usually persist
 Comorbid disorders of ADHD
• Oppositional defiant disorder (ODD) is a main comorbidity of
ADHD as approximately 50% of the children with combined type
have it.

• Conduct disorder is present in about 25 % of children.

• Specific leaning disorder can also commonly co-occur with ADHD.

• Major depressive disorder and anxiety disorders are more often than
in general population but occur only in a minority of children with
ADHD
 Functional consequences
What will happen if not treated?
• associated with reduced academic attainment

• would lead to poorer occupational

performance in adulthood.

• Academic difficulties are mostly associated

with increased symptoms of inattention.
 Functional consequences
What will happen if not treated?
• There is also a higher probability of interpersonal
conflicts during adulthood.

• at a higher risk of developing conduct disorder in

adolescence and anti-social personality disorder in
adulthood.

• more vulnerable to develop substance use disorders.

 ADHD-like behavior
• A sudden change in the child’s life
• Undetected seizures, such as in petit mal or
temporal lobe seizures
• A middle ear infection that causes intermittent
hearing problems, Vision problems
• Medical disorders that may affect brain
functioning
• Underachievement caused by learning disability
• Anxiety or depression.
 Epidemiology
• One of the most common behaviour disorders with a childhood
onset.

• 3–7% of school age children are affected.

• 5% in most cultures.

• commoner in boys than in girls, with a ratio of approximately 4: 1 in

children.

• Girls are more likely than boys to present primarily with symptoms of
inattention.
 Aetiology of ADHD

• Both environmental and genetic factors

 Risk factors
• Family history of ADHD
• Family history of specific learning disability
• Eclampsia
• Mothers who abused drug and alcohol during the
pregnancy
• prolonged labour
• Prematurity / post maturity
• Very low birth weight.
• Child with birth trauma, Complications during
early days of life
 Risk factors
• history of abuse in childhood

• multiple foster placements

• exposure to neurotoxins such as lead

• infections such as encephalitis

Neurobiology
 Neurobiology
• Dysfunction of,
1. Dopamine
2. Noradrenaline

• In,
Prefrontal cortex
 Management
• In mild to moderate cases, education and
behaviour therapy are considered as first line
treatment.

• When non pharmacological management is

unsuccessful or inappropriate, medication is
indicated.

• In severe cases pharmacological treatment can be

used as first-line therapy.
 Management
• When a drug is indicated, methylphenidate is
usually the first choice.

• It is a stimulant of central nervous system. It

has a large evidence base.

• Dexamphetamine and Atomoxetine are first

line alternatives.
 Pharmacotherapy
• stimulants

• non-stimulants
 Stimulants

• Methylphenidate (Ritalin)
• Dexmethilphenidate
• Dextroamphetamine
• Methamphetamine
• Lisdexamphetamine

• short-acting, long-acting and sustained-

release.
Dosing of Methylphenidate (MPH)
• Short acting MPH
• Action for 4 hrs

• Eg. 20 kg child in grade 3

• can start 5 mg mane…later increased 5 mg

mane and vesper….
• Later 10 mg mane ..5 mg vesper etc..
• Maximum 1.7 mg/ kg / day
 Long-acting and Sustained-release.

• 8 hrs

• 12 hrs

• Not available in Sri Lanka.

 Side effects of MPH
• Insomnia
• loss of appetite / nausea/ vomiting
• Headache (transient) / dizziness
• Irritability
• Agitation
• Nervousness / Anxiety symptoms
• Tremor
• weight loss
 Side effects of MPH
• exacerbate tics
• may reduce final adult height.

• Palpitations / increased hear rate

• Increased blood pressure

• risk for abuse or diversion.

• ? Alopecia
 Monitoring stimulant
• Physical examination
• Blood pressure
• Pulse
• Weight
• Height
 Mechanism of Action of
MPH
• dopamine reuptake inhibitor
• blocking the dopamine transporter and
norepinephrine transporter,

• leading to increased concentrations of

dopamine and norepinephrine within
the synaptic cleft.
Non-stimulant medications
• Atomoxetine
• Clonidine
• Guanfacine
 Atomoxetine
• A selective noradrenaline reuptake inhibitor (SNRI)
( so no dopaminergic side effects eg. tics and anxiety)

• Atomoxetine can reduce anxiety symptoms in adults and

children and is an option for the treatment of ADHD with
comorbid anxiety disorders.

• It is also preferable for patients with a history of substance

misuse (or if there are other household members who use
drugs because of the risk of diversion).

• Compared to stimulants, atomoxetine has a slower onset of

action but can be taken once daily.
 Atomoxetine
• Starting dose is 0.5mg/kg/day that can be increased
up to 1.2mg/kg/day.

• The most frequent adverse events are transitory

gastrointestinal symptoms, reduced appetite, sleep
problems, increased heart rate and blood pressure.

• Severe but very rare side effects include

hepatotoxicity, with increase in hepatic enzymes,
bilirubin and jaundice and Increased suicidal
thoughts.
 Clonidine & Guanfacine
• alpha-2 agonists with demonstrated efficacy in the treatment of
ADHD.

• Guanfacine is more selective than clonidine causing fewer adverse

effects such as somnolence.

• These medications can also be used for patients with comorbid tic
disorders or Tourette’s syndrome, in which its efficacy seems to be
higher.

• There are now long-acting formulations for both clonidine and

guanfacine available.
 Modafinil
• A non-stimulant medication used for the treatment
of narcolepsy that has been tested for ADHD.

• Modafinil activates glutamatergic circuits while

inhibiting GABA.

• its efficacy has been demonstrated in randomized

clinical trials.
 Tricyclic antidepressants
• such as imipramine, have also been shown to reduce
ADHD symptoms.

• Nevertheless tricyclic antidepressants are associated

with significant side effects, are less effective than
stimulant

• medications and should be used only after failure to

respond to two or three stimulants and atomoxetine.
 Bupropion
• is considered a third line treatment for ADHD.

• it can be tried in case of failure of stimulants,

atomoxetine and alpha-2 agonists.

• Bupropion lowers seizure threshold in a dose

dependent fashion.
 Anti - psychotics
• No evidence to use for ADHD symptoms

• But risperidone may be helpful in reducing

severe aggression and agitation especially
with learning disability.
Non – pharmacological treatment
Education Child
Family
School

Behavioural treatment

Psychological treatment
 Education of the parents
Make them aware of the nature of the disorder.

Relieve them from the guilt they have about the child.

To reduce misconceptions about the condition and the

treatment.

To motivate parents into the treatment plan.

To improve the compliance.

Eliminating artificial colouring and additives from the diet
is not recommended as a generally applicable treatment
for ADHD.
How to deal with the hyperactive
behavior
Providing activities for the child which absorbs energy
such as running, jumping, climbing.

Identifying potentially dangerous objects and distancing it

from the child.

Identifying potentially dangerous activities of the child

and preventing it or stopping it as far as possible.
 The behaviour modification
techniques
Organizing a schedule for the child such as time for
studying, sleep, play and meals.

Predict the activity before it is being happening.

Laying down rules and adhering to it consistently by all

the members of the family.

Rewarding the child immediately after positive behavior.

 The behaviour modification
techniques
Disregarding negative behavior by immediately
removing privileges.

Appropriate methods of giving instructions to the child

such as the instruction being given should be short in
clear voice, looking directly at the child and repeating
whenever possible.

Providing advices about good and bad conduct and

how to build up relationships.
 Incorporating the support of the
class teacher
Discuss clinical state of the child and the management
plan.
To have clear rules and regulations.
Be consistent with the response when they are breeched
by the child.
To have an organized schedule for the child.
To have a rewarding system organized to encourage the
positive behavior such as charting stars.
 About the steps that can be taken to improve the
attentiveness to school work

Having the child sits in front.

Having two clam children sit either side of the child.
Having look at the face and eyes of the child frequently
when teaching.
Immediately rewarding the child for positive response by
praising, patting or smiling.
Providing simple tasks with the aim of increasing the
duration of the task in each successive completion, which
is facilitated by immediate rewarding.
 Social skills training

Target a range of areas including:

 social skills with peers
 problem solving
 self-control
 listening skills
 skills to deal with feelings.
skills to express feelings

Use active learning strategies and give rewards for achieving

key elements of learning
THE END