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注意力不足過動症

注意力不足過動症. Attention-deficit/hyperactivity disorder. Diagnostic criteria of DSM-V. A. characterized by (1) and/or (2)

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注意力不足過動症

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  1. 注意力不足過動症 Attention-deficit/hyperactivity disorder

  2. Diagnostic criteria of DSM-V • A. characterized by (1) and/or (2) • 1. inattention: >= 6 of the following 9 s/s for more than 6 months that is inconsistent with developmental level and negatively impacts directly on social and academic/occupational activities • a. often fails to give close attention to details or makes careless mistakes in schoolwork or other activities • b. has difficulty sustaining attention in tasks or play activities • c. does not seem to listen when spoken to directly • d. does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace

  3. Diagnostic criteria of DSM-V • 1. inattention • e. had difficulty organizing tasks and • activities • f. often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort • g. often loses things necessary for tasks or activities • h. easily distracted by extraneous stimuli • i. Forgetful in daily activities

  4. Diagnostic criteria of DSM-V • 2. hyperactivity and impulsivity: >= 6 s/s have persisted for at last 6 months that is inconsistent with developmental level and negatively impacts directly on social and academic/occupational activities • a. often fidgets with or taps hands or feet or squirms in seat • b. often leaves seat in situations when remaining seated is expected • c. often runs about or climbs in situations where it is inappropriate • d. often unable to play or engage in leisure activities quietly • e. often on the go, acting as if driven by a motor

  5. Diagnostic criteria of DSM-V • 2. hyperactivity and impulsivity • f. often talks excessively • g. often blurts out an answer before a question had been completed • h. often had difficulty waiting his or her turn • i. Often interrupts or intrudes on others

  6. Diagnostic criteria of DSM-V • B. Symptoms were present prior to age 12 years • C. Symptoms were present in 2 or more settings (eg. Home, school, with friends, in activities) • D. Symptoms interfere with or reduce the quality of social , academic or occupational functioning. • E. Exclude schizophrenia or other mental disorder (eg. Mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdraw)

  7. Epidemiology • Incidence: 2-20% of grade-school children in USA; 3-7% pre-pubertal elementary school children • Boy>girl (2-9 : 1) • Parents show a increased incidence of hyperkinesis, sociopathy, alcohol use or conversion disorder • Siblings are at higher risk to have learning disorder and academic difficulty • 1st degree relatives are at high risk to develop ADHD, disruptive behavior disorders, anxiety disorders, and depressive disorders.

  8. Etiology • Genetic factors • Developmental factors: winter infection during the 1st trimester • Brain damage: ADHD exhibit soft neurological signs at higher rates • Neuro-chemical factors: noradrenergic system of the central system( locus ceruleus) and peripheral sympathetic system

  9. Etiology • Neurophysiological factors • 1. EEG: increased beta band percentages • decreased delta band percentage • 2. CT scan: no consistent finding • 3. PET: lower cerebral blood flow & metabolic rates in the frontal lobe area

  10. Etiology • Psychosocial factors: emotional deprivation stressful psychic events disruption of family equilibrium anxiety-inducing factors

  11. Pathology and Lab. examination • EEG &PET: decreased cerebral blood flow in the frontal regions • Continuous performance task (CPT): errors of omission (poor attention) errors of commission (impulsivity)

  12. Differential diagnosis • Anxiety disorder • mania • Conduct disorder • Learning disorder

  13. Course and prognosis • Symptoms persist into adolescence or adult life: 50% • Overactivity is usually the 1st symptom to remit and distractibility is the last • Remission is usually between ages of 12-20 • Most patients undergo partial remission, are vulnerable to antisocial behavior, substance use disorder & mood disorders. Learning problems often continue throughout life.

  14. Course and prognosis • ADHD adults: diminished hyperactivity remain impulsive and accident-prone lower in educational attainments at risk for developing conduct disorder & substance-related disorder Social difficulties

  15. Pharmacologic Treatment • 1. CNS stimulants: The 1st choice • Two most commonly used agents in USA: • (1) Dextroamphetamine: >= 3 years old • (2) Methylphenidate: >= 6 years old

  16. Stimulant medications • Dopamine agonist • Effective in up to ¾ children • Common side effect: headache, stomache, nausea, insomnia, rebound effect • MPH can exacerbate tic disorder, cause growth suppression (make up at drug free period) • 75% children exhibited sig. improvement in school performance

  17. Stimulant medications • MTS(MPH transdermal system): 0.45-1.8mg/h • Onset: one hour • good for children who have difficulty swallowing pills • patches releasing MPH continually • Side effect: as oral form MPH

  18. pharmacologic treatment • 2. Non-stimulant medications • Atomoxetine (strattera): • selective inhibition of presynatic norepinephrine transporter • Maximal plasma levels: 1-2 hours • Half-life: 5 hours • For children>=6 years old

  19. Atomoxetine (strattera): • Common side effects: • Dimmished appetite • Abd. Discomfort • Dizziness • Irritability • Increase BP & HR

  20. Atomoxetine (strattera): • Metabolized by cytochrome P450 (CYP) 2D6 hepatic enzyme system • Increase plasma concentration of Atomoxetine: 1. poor metabolizers 2. drugs inhibit CYP 2D6 (eg. fluxetine, paroxetine, quinidine)

  21. Other drugs for ADHD • Bupropion (Wellbutrin) • Clonidine: ADHD with tic disorders • Tricycline drugs: arrhythmia side effect • Antipsychotic: for refractory hyperactivity in children and adolescents. Watch out side effect • Modafinil (Provigil): CNS stimulant

  22. Monitoring pharmacological treatment • Workup before starting use of stimulant medications • Physical examination: annually • Pulse: quarterly • Weight: quarterly • Height: quarterly

  23. Psychosocial interventions • Social skill groups • Training for parents • Behavioral interventions at school & at home. • Manage coexisting learning disorder or additional psychiatric disorders

  24. ADHD in adults • Utah criteria for adult ADHD • I. retrospective childhood ADHD diagnosis ( by parent interview or reported by pt) • II. 5 additional symptoms: inattentiveness, hyperactivity, mood lability, irritability and hot temper, impaired stress tolerance, disorganization, impulsivity • III. Exclusions: severe depression, psychosis, severe personality disorder

  25. treatment • Fist line choice: CNS stimulant • Positive response: increased attention span, decreased impulsiveness, improved mood

  26. Questions • 1. What is the incidence of ADHD of prepubertal elementary school children? a. 1% b. 3-7% c. 20% d.50% • 2. What is the current hypothesis that ADHD is transmitted? a. infection b. drug induced c. genetic d. unknown • 3. What are the core symptoms of ADHD? • a. inattention b. mood c. substance abuse d. insomnia • 4. What is the first choice of agents for ADHD children and adults? a. haldol b. halcion c. NSAID d.CNS stimulant • 5. What is the percentage of ADHD symptoms persisting into adolescence or adult life? a. 10% b. 20% c. 30% d. 40-50%

  27. Answers • 1. 3-7% • 2. genetic • 3. inattention • 4. CNS stimulant • 5. 40-50%

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