ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

1. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER Dr. Vivek Agarwal Professor Department of Psychiatry

2. INTRODUCTION • ADHD is one of the most common childhood psychiatric disorder • Core symptoms include • Inattention • Hyperactivity • impulsivity

3. EPIDEMIOLOGY • Affects 5-12% of children worldwide • The male to female ratio is about 2:1 in epidemiological samples, in contrast to 3-5:1 and even up to 9:1 in clinic samples • Onset before 7 years of age

4. ADHD Master Y , 9 years old male child was referred to us by school. His teacher complaints that he is restless and noisy. He often leaves his seat and disturb other children while they are working. He makes a lot of mistakes in the class work. Often leaves the work incomplete. He often fails to note down the home work. He often fails to bring books of the subjects as per time table. He often looses things like pen, notebooks etc. His mother said that his is very naughty and difficult to manage at home also.

5. Clinical features Inattention (a)often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities. Eg. Not reading instructions right in tests, leaving questions blank by accident, forgetting to do problems on both sides of a handout. (b) often has difficulty sustaining attention in tasks or play activities Eg. Difficulty concentrating in one task for long and shifting to alternate task

6. (c) often does not seem to listen when spoken to directly eg. Child finds it hard to remember what the parents or teachers say (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions). eg: Child forgets to do home work. Child finds it difficult to remember what instructions he /she gets. (e) often has difficulty organizing tasks and activities. Eg. The child has a messy room and his / her bag is never arranged .

7. (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) eg. Child dislikes doing homework and tries to find a way to get out of doing it. (g) often loses things necessary for tasks or activities e.g. toys, school assignments, pencils, books, or tools (h) is often easily distracted by extraneous stimuli e.g. Child is easily distracted by external stimuli and hence fails to pay attention to tasks. (i) is often forgetful in daily activities e.g. Child tends to forget small things in day to day activities like forgetting something after keeping it in a particular place.

8. Hyperactivity • Often Fidgets with hand or feet, squirms in seat • Often leaves seat in situation where remaining seated is expected. • Often runs about or climbs in situations where it is inappropriate

9. Unable to play or engage in leisure activities quietly. • Often on the go or as if driven by motor. • Often talks excessively

10. Impulsivity • Often blurts out answer. • Has difficulty waiting his turn. • Interrupts or intrude on others. In conversation, games, activities

11. Symptoms should be present across the situations • Should be impairing. Academic, peer group, family

12. ASSESSMENT (Contd.) • Developmental and family history might give a clue to a possible other disorder which might be mimicking ADHD • Detailed physical examination to rule out physical problems like cardiac, thyroid etc that might have a bearing on diagnosis and treatment • Mental status examination to look for other co-morbid psychiatric disorders or evidences of inattention, hyperactivity and impulsivity to support the diagnosis

13. ASSESSMENT (Contd.) • INVESTIGATIONS • Diagnosis is mainly clinical but investigations may be carried out if history is suggestive of physical problems • IQ assessment may be done to correctly estimate the mental age of the child as the excess or normal behavior will be based on the mental age of the child

14. CO-MORBIDITIES • Co-morbidity can cause some diagnostic challenges because the co-morbid disorders can mask ADHD • High rate of co-morbid psychiatric disorders (1,2,3) • oppositional-defiant disorder (up-to 50%) • Conduct disorder (15%) • anxiety disorders (25-30%) • learning disorder (20-25%) • Increased risk for development of mood disorders and substance use disorders in adolescence and adulthood

15. As many as 60% of the childhood cases continue to have some symptoms as adults although symptoms decrease (hyperactivity-impulsivity more than inattention) but impairment remains

16. DIFFERENTIAL DIAGNOSIS • PSYCHIATRIC • Autism/ PDD • Mental Retardation • Mood disorders specially mania • Anxiety disorders PHYSICAL • Severe head injury • Hyperthyroidism • petit mal epilepsy • Sensory- mild hearing and/or vision losses • Drug induced- drug side effects (e.g. Phenobarbital, bronchodilators)

17. Etiology • Genetic- risk 2-8 times in sibling • Reduce Gray matter volume, Reduce white matter volume • Involvement of prefrontal cortex important for executive functions and inhibitory control of lower centres like striatum

18. TREATMENT • Behavioral treatment • FDA-approved sympathomimetic agents (stimulants and atomoxetine) and other drugs • In acute and medium-length studies medication generally outperforms behavioral treatment for symptom suppression • However, combination treatments generally have a better outcome than either alone and are recommended • Treatment of co-morbidities

19. TREATMENT (Contd.) • Psycho-education of family members • ADHD has many symptoms, and not every patient with ADHD has all of them. • Three main symptoms are inattention, hyperactivity, and impulsivity • Other symptoms are frequent and often disabling, though not important for the diagnosis • Symptoms are just excess amounts of normal behavior

20. TREATMENT (Contd.) • Symptoms are not the patient's fault, but the patient can improve with help • ADHD lasts a long time, perhaps a lifetime, although it tends to get better with age • Important not to give up or neglect treatment • Treatment helps prevent secondary problems • Many different treatments are available

21. PHARMACOLOGICAL TREATMENT • For mild ADHD only behavioural treatment is recommended • For moderate to severe ADHD combined treatment should be used. • Medication will improve only core symptoms of ADHD but such children also require help in many areas like social skill, academics, day to day activities etc. • Behavioural treatments like behavioural parent training and social skill training have been found effective.

22. Methylphenidate has the most robust evidence of effectiveness in ADHD.(Paykina, 2008) • MPH has significant benefit in 65%-75% of ADHD • Largest and most rapid effect on ADHD, response starts in 30-90 min of administration. • Medically safer than most psychoactive drugs

23. Atomoxetine, a nor-epinephrine reuptake inhibitor, is useful specially in ADHD children with anxiety disorders, tic disorders, substance abuse, enuresis or intolerable side effects of MPH • other medicines like clonidine, modafinil, bupropion, antipsychotics are also used as second line medications

24. Oppositional Defiant Disorder (ODD) • Characterised by the disobedience or defiance to authority figure like parents, teachers. • 2-16% prevalence starting around 4 yr • Mostly childhood onset • More common in boys

25. An 8 year old male child was brought by the parents with complaint of frequent anger outbursts on minor issues for 1 year. The boy would frequently loose temper on his parents and would show his aggression by destroying household items. He would repeatedly fights with his younger siblings on minor issues. Father said that his son often deliberately annoyed his mother and also other children in the neighborhood. He often argues with elders in the family and would not obey them. He was being labeled as a “problem child” by his teachers.

26. Clinical faetures • Argues a lot • Looses temper easily, angry and resentful • Defy adult request • Blame others for their mistakes • Deliberately annoy others • Demanding and obstinate • Throw temper tantrums

27. May present only in home setting or outside also • Symptoms cause impairment in academics, peer relationships and family

28. Conduct Disorder • Prevalence 2-10% • More common in boys • Onset primarily in adolescence • Characterised by the aggression and violation of rights of others

29. Clinical faetures Aggression to people and animals • Bullies, intimidate others • Initiates physical fights • Use of weapon with intention to harm • Cruel to animals • Forced sexual activity

30. Destruction of property • Fire setting • Damaging others property Theft • Broken in to some ones home, shop, car • Non aggressive stealing • Lies to obtain favour

31. Violation of rules • Stays out at night • Run away from home • Truancy

32. Aetiology • Temperament • Low IQ and poor social cognition • Family problems- harsh parenting, lax parenting, marital disharmony • Childhood trauma- abuse • Violence in neighbourhood- slums • Peer influence

33. Treatment • Treatment requires multimodal approach targeting simultaneously child and the family. • Parent management includes- consistent parenting, less harsh discipline, monitoring of child and positive feed back. • For child- social skill training, problem solving and anger management strategies.

34. Pharmacotherapy improves impulsive aggression associated with DBDs. Lithium, mood stabilizers, typical antipsychotics, and atypical antipsychotics have been used. • Atypical antipsychotics specially risperidone, aripiprazole and olanzapine has the best evidence based data.