2. Attention-Deficit Hyperactivity
Disorder, Early Detection
Prof. Hani Hamed Dessoki, M.D.PsychiatryProf. Hani Hamed Dessoki, M.D.Psychiatry
Prof. PsychiatryProf. Psychiatry
Chairman of Psychiatry DepartmentChairman of Psychiatry Department
Beni Suef UniversityBeni Suef University
APA memberAPA member

3. DisclosureDisclosure
• NO relevant financial relationships with aNO relevant financial relationships with a
commercial interest.commercial interest.

4. Outline of Presentation
I. History of ADHD
II. Diagnosis and Associative Features
III. Statistics
IV. Etiology
A. Environmental Theories
B. Biogenic Theories
V. Prognosis and Impact
VI. Treatment

5. Attention Deficit Hyperactivity
Disorder (ADHD(
ADHD is a pervasive, heterogeneous
behavioural syndrome characterised by
the core symptoms of inattention,
hyperactivity and impulsivity.

6. ADHD: Historical Development of the Concept
1902: George Still identified impulse control difficulties in some children
1950s: Medical model explanations predominated: “minimal brain damage”,
and “educationally subnormal” labels were used
1970s: Psychological/Familial/Environmental models gained ground:
individual and family coping strategies were emphasised
1980s: In the USA, “Attention Deficit Disorder” had been added to DSMIII
1990s: Concept of “Attention Deficit” and ADHD gained ground in the U.K.
In the U.S., DSMIV added “hyperactivity” to the main diagnosis and
ADD became one of the sub-categories.

7. Disruptive Behavior Disorders
• ADHD: Attention Deficit Hyperactive
Disorder
• ODD: Oppositional Defiant Disorder
• CD: Conduct Disorder

8. Diagnosing ADHD
• Clinical examinations and questionnaires are important because of the
many controversial diagnosis of ADHD (Jackson & Farrugia, 1997(
• Medical and family history
– physical examination
– interviews with parents, the child, and child’s teacher
– behavior rating scales by parents and teacher
– observation of the child
– psychological tests (IQ, social and emotional adjustment, and
indication of learning disabilities(
• DSM-IV (1994( allows for adult diagnosis as long as the associative
characteristics are met...

9. Attention-Deficit
Hyperactivity Disorder
(ADHD( – DSM IV definition
Attention-Deficit Hyperactivity Disorder (ADHD)
is a neurobiological condition that characterized
by developmentally inappropriate level of
inattention (concentration, distractibility)
hyperactivity and impulsiveness that can occur
in various combinations across school, home,
and social settings.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Washington, DC, American Psychiatric Association, 2000.

10. Myth #1
• Psychiatric disorders do not occur in
children.

11. Myth #2
• ADHD is nothing more than applying a
diagnostic label to normal childhood
behavior.

12. Myth #3
• If ADHD really existed, wouldn’t it be
obvious?

13. “The medicines used to treat
ADHD are dangerous and
addictive”
Myth #4

14. Attention-Deficit/Hyperactivity
Disorder

15. Statistics
• Effects 3-5% of all school-aged children
• Most commonly diagnosed behavioral disorder in children
• 9-18% of school-aged children with mental retardation meet criteria for
ADHD (comorbidity is high in ADHD( (Epstein et al, 1986(
• Males to female ratio ranges from 4:1 to 9:1 depending on the setting (clinic
or general population( (DSM-IV, 1994(

16. Statistics
• Occurs in all cultures, with prevalent findings in Western cultures (due to
diagnostic methods( (DSM-IV(
• Mood and Anxiety, Learning, Substance-related, and Antisocial Personality
Disorders are more prevalent in family members of those with ADHD (high
rate of comorbidity( (DSM-IV(
• 9.5 million adults are suffering from ADHD (Quinn, 1997(

17. Why the Explosion in ADHD?
- Possible Explanations
1. We are better at finding and helping
children and adults who really do have
ADHD.
2.There are more children now who actually
have ADHD

18. Why the Explosion in ADHD?
- Possible Explanations
3.We have loosened the definition so more
kids are being diagnosed and treated.
4.We are actually diagnosing and treating
many children who don’t have ADHD, even
by a loosened definition.

19. AetiologyAetiology

20. Aetiology
• Heritability is the strongest factor in
development of ADHD
• Risk factors account for only a small portion of
variance
• Pregnancy variables: young maternal age,
maternal use of tobacco and alcohol, toxaemia,
post-maturity and extended labour
• Medical factors: fragile X syndrome, G6PD
deficiency, phenylketonuria, brain trauma, lead
poisoning, malnutrition

21. Main Neurotransmitters in ADHD
• Dopamine
• Noradrenaline
To regulate the inhibitory influences in
the frontal-cortical processing of
information

23. Dopamine
- enhances signals
- improves:
. attention,
. focus vigilance,
. acquisition,
. on-task behaviour and cognition

24. Noradrenaline
• dampen « noise »
• decrease distractibility and shifting
• improve executive operations
• increase behavioural, cognitive,
motoric inhibition

25. Associate symptoms with brain regions and
circuits that regulate them
HyperactiveHyperactive
symptomssymptoms
ImpulsiveImpulsive
symptomssymptoms
PrefrontalPrefrontal
motormotor
cortexcortex
OrbitalOrbital
frontalfrontal
cortexcortex
SelectiveSelective
attentionattention
SustainedSustained
attentionattention
problemproblem
solvingsolving
DorsalDorsal
ACCACC
DLPFCDLPFC
Stahl , 2008

26. Match neurotransmitters with circuits
DorsalDorsal
ACCACC
DLPFCDLPFC
HAHA
NENE DADA
AChACh
Selective attentionSelective attention Sustained attentionSustained attention
problem solvingproblem solving
•Little attention to detailLittle attention to detail
•Careless mistakesCareless mistakes
•Does not listenDoes not listen
•Loses thingsLoses things
•DistractedDistracted
•forgetfulforgetful
•Sustaining attentionSustaining attention
•follow through/finishfollow through/finish
•OrganizingOrganizing
•Avoids sustainedAvoids sustained
mental effortmental effortStahl , 2008

27. Aetiology
• ADHD symptoms and a diagnosis of ADHD may
themselves create interpersonal problems and
produce additional symptoms in the child
• Some children sensitive to
colourings/preservatives – not sugar per se

28. - Neurophysiological Factors:
Studies using PET have found lower cerebral blood flow
and metabolic rates in the frontal lobe areas of
children with ADHD than controls, pointing towards
frontal-striatal dysfunction.
- Psychosocial Factors:
Stressful psychic events, disruption of family
equilibrium and other anxiety provoking factors
contribute to the initiation or perpetuation of ADHD.
Etiology of ADHD

29. Symptoms and Early Detection

30. Inattention symptoms
• Fails to give close attention; careless mistakes
• Difficulty sustaining attention in tasks or play activities = requires
frequent redirection
• Does not seem to listen when spoken to directly
• Does not follow through on instructions; fails to finish task (not
oppositional or failure to understand
• Difficulty organizing tasks = homework poorly organized
• Dislikes sustained mental effort = schoolwork; homework
• Loses possessions
• Easily distracted
• Forgetful

31. Hyperactivity
• Fidgets
• Leaves seat when expected to sit
• Runs or climbs excessively
• Difficulty in playing quietly
• Often "on the go" or acts as if "driven by a motor"
• Often talks excessively
Perceived « immature »
Accidents/injuries prone

32. Impulsivity
• blurts out answers before questions
completed
• difficulty waiting turn
• interrupts or intrudes on others
Impatient
Rushing into things
Risk taking; Taking dares

33. DSM IV Criteria
A:
• 6 / 9 inattention
&/or
• 6 / 9 hyperactivity & impulsivity
= 6 months; maladaptive & inconsistent with development level
B: symptoms before age of 7
C: impairment in 2 settings
D: clinically significant – social/academic
E: not better explained by something else

34. A) Six or more of the following symptoms of inattention have been present for
at least 6 months to a point that is disruptive and inappropriate for
developmental level:
Inattention (CALL FOR FRED)
1) Often does not give close attention to details or makes Careless
mistakes in schoolwork, work, or other activities.
2) Often has trouble keeping Attention on tasks or play Activities.
3) Often does not seem to Listen when spoken to directly.
4) Often does not Follow instructions and Fails to finish schoolwork,
chores, or duties in the workplace (not due to oppositional behavior
or failure to understand instructions).
5) Often has trouble Organizing activities.
6) Often avoids, dislikes, or doesn’t want to do things that take a lot of
mental effort for a long period of time (such as schoolwork or
homework). Reluctant
7) Often Loses things needed for tasks and activities
(e.g. toys, school assignments, pencils, books, or tools).
8) Is often easily Distracted.
9) Is often Forgetful in daily activities.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Washington, DC, American Psychiatric Association, 2000.
Attention-Deficit/Hyperactivity Disorder
--Diagnostic Criteria

35. B) Six or more of the following symptoms of hyperactivity-impulsivity have
been present for at least 6 months to an extent that is disruptive and
inappropriate for developmental level:
Hyperactivity (RUNS FASTT)
1) Often fidgets with hands or feet or squirms in seat.
2) Often gets up from seat when remaining in seat is expected.
3) Often runs about or climbs when and where it is not appropriate
(adolescents or adults may feel very restless).
4) Often has trouble playing or enjoying leisure activities quietly.
5) Is often "on the go" or often acts as if "driven by a motor".
6) Often talks excessively.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Washington, DC, American Psychiatric Association, 2000.
Attention-Deficit/Hyperactivity Disorder
--Diagnostic Criteria

36. Impulsivity
7) Often blurts out answers before questions have been
finished.
8) Often has trouble waiting one’s turn.
9) Often interrupts or intrudes on others (e.g., butts into
conversations or games).
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Washington, DC, American Psychiatric Association, 2000.
Attention-Deficit/Hyperactivity Disorder
--Diagnostic Criteria

37. Based on these criteria, three types of ADHD are identified:
1) ADHD, Combined Type: if both criteria 1A and 1B are met for
the past 6 months.
2) ADHD, Predominantly Inattentive Type: if criterion 1A is met
but criterion 1B is not met for the past six months.
3) ADHD, Predominantly Hyperactive-Impulsive Type: if
Criterion 1B is met but Criterion 1A is not met for the past six
months.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Washington, DC, American Psychiatric Association, 2000.
Attention-Deficit/Hyperactivity Disorder
--Diagnostic Criteria

38. Depending upon which symptoms predominate
DSM-IV-TR
recognized three subtypes of ADHD.
 Combined subtype - 50% to 75%
 Inattentive subtype - 20% to 30%
 Hyperactive impulsive subtype - <15% cases
Subtypes of ADHD

39. 1.Infancy:
- More active, sleep less and cry much.
- Difficult to recognize until child achieves toddler age.
2.Preschool
- Motor restlessness, insatiable curiosity, vigorous and
destructive play ,demanding of parental attention
- Excessive temper tantrums.
- Decrease and/or restless sleep.
- Delays in motor and language development.
Clinical Features

40. Video

41. 3.School age Children:
- Easily distracted.
- Difficulty in waiting for a turn.
- At home cannot be put off for even a minute.
- Often irritable.
- Emotionally labile – easily set off to laughter and tears.
- Mood and performance is variable and unpredictable.
- Impulsive- unable to delay gratification.
- Accident prone.
- Negative self concept and reactive hostility.
- 75% children show behavioral symptoms of aggression
and defiance.
- School difficulties both learning and behavioral coexist.
Clinical Features (cont…)

42. Scope of problem: school and
adolescence
• At least 10% of children under 18 years of age are or have
been affected by psychiatric disorders (12% of boys, 8% of
girls) - including ADHD, ASD, TS, CD, (and psychosis,
eating disorder, depression, and anxiety disorders)
• Another 10% or more are affected by various kinds of
psychosocial problems (including drug abuse), some of
which may be triggered by or interacting with ESSENCE
• About 5% are affected by “dyslexia”
• 1-2% are affected by LD
• Overlap/”Comorbidity”/Co-existence substantial
• When looking back: vast majority had symptoms <5 years

43. 4.Adolescents:
- Excessive motor activity.
- Discipline problems, family conflicts.
- Anger and emotional liability.
- Difficulty with authority.
- Significant lags in academic performance.
- Poor peer relationship.
- Poor self esteem.
- Speedy accidents.
- Delinquent children.
Clinical Features (cont…)

44. 5.Adults:
- Difficulty with concentration and performing
sedentary tasks.
- Disorganization.
- Forgetfulness.
- Failure to plan.
- Depending on others to maintain order.
- Trouble both getting started and ending tasks.
- Changing plans and jobs in midstream.
- Restlessness , impulsivity.
- Absent mindedness.
- Anti social acts.
Clinical Features (cont…)

45. Significance of InattentionSignificance of Inattention
for cognitive processesfor cognitive processes
Chhabildas, Pennington, Willcutt, J Abnorm Child Psychol, 2001Chhabildas, Pennington, Willcutt, J Abnorm Child Psychol, 2001
• Inattention symptom cluster is theInattention symptom cluster is the
strongest predictor of neuropsychologicalstrongest predictor of neuropsychological
impairmentsimpairments
– vigilance, processing speed, inhibitionvigilance, processing speed, inhibition
• Hyperactivity/impulsivityHyperactivity/impulsivity notnot associatedassociated
with neuropsychological impairmentswith neuropsychological impairments

46. Expert Rev Neurother , 2011
• Early detection and intervention may
prevent or ameliorate the development of
the disorder and reduce its long-term
impact.

47. DD
• Age appropriate behaviors in active
children,
• Intelligent children in under stimulating
environments eg classrooms,
• MR
• Psychiatric: ODD,CD, Anxiety disorders,
substance use disorders, PTSD, Mood
dis, PDD, LD
• Psychosocial: abuse/ neglect; poor
nutrition, chaotic family, bullied at school,
violent neighborhood
• Medical: Thyroid, heavy metal poisoning,
medications: sedating or activating

48. As many as one-third of
children diagnosed with
ADHD also have a co-
existing condition

50. Comorbid DSM-IV Disorders
• Oppositional Defiant Disorder (40-70%)
ADHD contributes to and likely causes ODD.
• Conduct Disorder (20-56%)
• Delinquent/Antisocial Activities (18-30%)
Psychopathy – rates unknown but 20% of CD.
• Anxiety Disorders (10-40%; referral bias!)
Related to poor emotion regulation than to fear.
• Major Depression (0-45%; 27% by age 20)
Likely genetic linkage to ADHD.
• Bipolar Disorder (0-27%; likely 6-10% max.)
Not documented in any follow-up studies to date.

51. Comorbidity
O.C.D.
O.D.D.
C.D.
‘Dyslexia’
Tics/
Tourettes
Anxiety/
Depression
Speech &
Language
‘Dyspraxia’
Substance
Abuse
A.D.H.D. Bipolar
Disorder
Asperger’s
Syndrome
Sleep
Disorders

52. Oppositional Defiant Disorder
(ODD)
A pattern of negativistic, hostile and defiant behavior
lasting at least six months, during which four or
more of the following are present:
• Often loses temper.
• Often argues with adults.
• Often actively defies or refuses to follow adults rules.
• Often deliberately annoys people.
• Often blames others for his/her mistakes.
• Often is touchy / easily annoyed by others.
• Often is resentful.
• Often is spiteful / vindictive.
The disturbance in behavior causes significant impairment in social,
academic or occupational functioning.

53. Conduct Disorder
Repetitive and persistent pattern of behavior in
which the basic rights of others or major age
appropriate norms or rules of society are
violated.
• Aggression to people or animals.
• Destruction of property.
• Deceitfulness or theft.
• Serious violation of rules.

54. “Hyperactivity and
impulsivity are
among the most
important personality
or individual
difference factors that
predict later
delinquency.”
Farrington 1996

55. Prognosis
• 50% continue to suffer from clinically
significant symptoms
• Increased risk for substance use disorders
particularly if CD
• Low self esteem and poor social skills

56. Essential Concepts
• ADHD is a clinical diagnosis based on:
– Careful history taking
– Clinical examination
– Information from several sources & multiple settings (school, home& community)
• Hyperactivity does not need to be present during the mental state
exam to diagnose ADHD
• Concomitant learning disabilities & comorbid psychiatric disorders should
be evaluated
• Morbidity & disability often persist into adult life
• Children with ADHD have a higher injury rates, increased rate for CD
(1/3), criminal behavior, substance abuse, coordination deficits & other
psychiatric disorder (over 50%)
• There is increased risk for physical punishment, stress within the family
and economic cost to schools and criminal justice

57. ADHD Guideline Recommendations
1. The primary care clinician should initiate an
evaluation for ADHD for any child who
presents with academic or behavioral
problems and symptoms of inattention,
hyperactivity, or impulsivity. B/strong
recommendation
American Academy of Pediatrics

58. ADHD Guideline Recommendations
2. To make a diagnosis of ADHD, the primary
care clinician should determine that Diagnostic
and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) criteria have been met
(including documentation of impairment in
more than 1 major setting) with information
obtained primarily from parents/guardians,
teachers, and other school and mental health
clinicians involved in the child’s care. The
primary care clinician should also rule out any
alternative cause. B/strong recommendation
American Academy of Pediatrics

59. ADHD Guideline Recommendations
3. Evaluation of a child for ADHD should include
assessment for coexisting conditions, including
emotional, developmental, and physical.
B/strong recommendation

60. ADHD Guideline Recommendations
4. The primary care clinician should establish a
treatment program that recognizes ADHD as a
chronic condition and a child with ADHD as a
child/adolescent with special health care needs
who needs a medical home. B/strong
recommendation

61. Evaluation
 Identify core symptoms.
 Assess impairment.
 Identify possible underlying or alternative
causes.
 Identify co-occurring (co-morbid) conditions.

62. Assessment
• History – parents or caregivers,
− as well as a classroom teacher or other
school professional
• Interview of child
• Parent and teacher ratings of ADHD-related
behaviours
• Investigations - No clinical examination or lab tests
are accepted as either “rule in” or “rule out.”
Recommend vision & hearing tested

63. Overlap and issues
• Is ODD not a comorbidity but an index of
severity in ADHD?
• Are learning problems a result of non-assortative
mating in parents?
• Are DCD problems an index of a link with ASD?
• Is ASD a very common comorbidity signalling
some shared genes?
• Are ASD and ADHD in some cases on the same
spectrum?

64. Impact
Emotional
• Low self esteem
• Impaired self-regulation
• Relationship difficulties
Cognitive
• Organizing; planning and time management
• Learning delay
• Short term memory problems; lack of focus
• Language/speech
Physical
• Fine & gross motor skill delay
Behaviour
• Impaired self-regulation

65. ManagementManagement

66. Psychological
Psychiatric Educational
Other
individually
determined
strategies
MedicalDietary
Coaching
Behavioural &
parent training
programmes
Multidisciplinary
Management of
ADHD
Substance
abuse

67. Non-Pharmacological
Management
Diet
• Elimination diets – difficult
• Omega 3 – at least 1000mg/day for a month
Academic skills training: focus on following
directions, becoming organized, using time
effectively, checking work, taking notes

68. Non-Pharmacological Management
Behavioural therapy
- Does not reduce symptoms
– May improve social skills and compliance
– Does not lead to maintenance of gains or
improvement over time after the therapy is
completed
Social skills group
- Uses modelling, practice, feedback and
contingent reinforcement to address the social
deficits common in children with ADHD
- Useful for the secondary effects of ADHD,
such as low self-esteem, but not helpful for
core symptoms of ADHD

71. MEDICATIONS FOR ADHD
Stimulant Medications
–Methylphenidate (Ritalin, Ritalin
LA, Concerta)
–Dexamphetamine
Non-stimulant
Atomoxetine (Strattera)
Other
Clonidine (Catapres)
Risperidone (Risperdal)

72. MEDICATIONS FOR ADHD
Tricyclic Antidepressants
–Desipramine ;Imipramine (Tofranil)
Other Antidepressants
–Bupropion (Zyban); Fluoxetine
(Prozac)

73. Stimulants Specific Effects
• Improved sustained attention
• Reduced distractibility
• Improved short-term memory
• Reduced impulsivity
• Reduced motor activity
• Decreased excessive talking
• Reduced bossiness and aggression
with peers

74. Non-Stimulants
 Atomoxetine is a highly specific norepinephrine
reuptake inhibitor.
 Extended release guanfacine and clonidine are
alpha 2 adrenergic agents.

75. ADHD Guideline Recommendations
5. Recommendations for treatment of children
and youth with ADHD vary depending on the
patient’s age:

76. Preschool-aged Children
(4–5 Years of Age(
A. Prescribe evidence-based parent- and/or
teacher-administered behavior therapy as the
first line of treatment. A/strong
recommendation
and
May prescribe methylphenidate if the behavior
interventions do not provide significant
improvement and there is moderate-to-severe
continuing disturbance in the child’s function.
B/recommendation

77. Elementary School-aged Children
(6–11 Years of Age(
B. Prescribe FDA-approved medications for
ADHD. A/strong recommendation
and/or
Evidence-based parent- and/or teacher-
administered behavior therapy as treatment for
ADHD.
Preferably both. B/recommendation

78. Adolescents (12–18 Years of Age(
C. Prescribe FDA-approved medications for
ADHD with the assent of the adolescent.
A/strong recommendation
and
May prescribe behavior therapy as treatment for
ADHD. C/recommendation
Preferably both.

79. ADHD Guideline Recommendations
6. The primary care clinician should titrate doses
of medication for ADHD to achieve maximum
benefit with minimum adverse effects. B/strong
recommendation

80.  How ADHD affects children or adolescents and their families.
 Potential benefits associated with nonpharmacologic interventions
such as parental behavior therapy programs.
 Potential benefits and adverse effects associated with
psychostimulants and nonstimulants.
 Patient preferences regarding diagnosis and treatment options,
including pharmacologic and nonpharmacologic interventions.
 How they can access information on ADHD about diagnosis and
treatment, educational programs, public benefits, and other issues.
What To Discuss With Your Patients
and Their Caregivers
Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available at
www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.

81. Summary
 Children from preschool age through
adolescent age can be diagnosed and treated
for ADHD.
 Both medications (stimulants, selective
norepinephrine reuptake inhibitors and alpha
adreneric agents) and behavior therapy are
effective and safe treatments for ADHD.
 Effective treatments require appropriate
titration and ongoing monitoring to remain
effective.

82. Effective Treatment of ADHD
Multidisciplin
e:
– Medical
– Psychological
– Educational
– Rehabilitation
The Team :
1.Consultant Child and Adolescent Psychiatrist
2.Clinical Psychologists
3.Occupational Therapists
4.Speech Therapists
5. Parents & Family
6. School officials