lecture

1. Attention deficit hyperactive
disorder
By :Nancy Mohammed Alaa
Assistant lecturer of pediatrics
Assiut university

2. 1-definition,why it is increasing
2-epidemiology
3-causes
4-pathogenesis
5-subtypes
6-presentation
7-diagnosis, its criteria
8- associated comorbidity
9-differential diagnosis
10-management
11-prevention
12-prognosis

3. 1-definition
• ADHD is characterized by inattention, including
increased distractibility and difficulty sustaining
attention; poor impulse control and decreased
self-inhibitory capacity; and motor over activity
and motor restlessness

4. why it is increasing
1-We are better at finding and helping children and adults
who really do have ADHD.
.
2.We have loosened the definition so more kids are being
diagnosed and treated
.
3.We are actually diagnosing and treating many children
who don’t have ADHD, even by a loosened definition.

5. • 2-epidemiology
 Most commonly diagnosed behavioral disorder of
childhood
• Studies of the prevalence of ADHD across the globe
have generally reported that 9% of school-age
children are affected,
.
• Rates may be higher if symptoms (inattention,
impulsivity, hyperactivity) are considered in the
absence of functional impairment.
• The prevalence rate in adolescent samples is 2-6%.

6.  Males: Females = 2 – 9:1
 Virtually all neurodevelopmental disorders are
more common in boys prior to age 10 years; by
adulthood, we get closer to 1:1 ratios
• Family studies:
• (1) sibling risk increases 2-5x;
• (2) 3-5x increased likelihood that parent is affected
•
• More in lower socioeconomic

7. 3-causes
 A child’s vulnerability rests on the interaction
of:
 genetic factors
 Maternal factors
 Environmental factors
 Family factors
 Infection
 Dietary factors

8. • A-Genetic studies
• A Family History of hyperactivity, conduct disorder,
mood disorders, anxiety disorders and learning
disabilities increases
• 20-32% Of parents ,siblings of children diagnosed
with ADHD also show this disorder
• at least 2 candidate genes, the dopamine
transporter gene (DAT1) and a particular form of the
dopamine 4 receptor gene (DRD4),.

10. B-Maternal factors
• 1-Mothers of children with ADHD are more likely to experience
birth complications, such as toxemia, lengthy labor, and
complicated delivery.
• 2-Maternal drug use, smoking and alcohol use during
pregnancy, lead or mercury exposure (prenatal or postnatal)

11. • C-enviromental factor
 Lead poisoning
 Carbon Monoxide
 Pesticides
 Effect on the early embryologic neuro-developmental system

12.  D -Family factors
 Single parent households
 Multiple moves
 Child abuse
 Low parental intelligence
 Family problems
 Psychosocial family stressors can also contribute to or
exacerbate the symptoms of ADHD, including poverty, exposure
to violence, and under- or malnutrition

13.  E -Infection
 CNS infection with herpes simples was found to be
associated with ADHD

14. G-Dietary factors
• Nuitritional deficiency (zinc ,magnesium, fatty acid)
• Food colorings and preservatives have inconsistently been
associated with hyperactivity in previously hyperactive children

15. 4-pathogenesis
• 1-area affected by ADHD ,fuction of this area
• 2-,role of neurotransmitters
• 3-executive function
• 4-disorder in ADHD

16. area of brain affected , its fuction,
The Prefrontal Cortex
is responsible for planning, initiating, and realising actions as
well as correcting errors, avoiding distractions, and being flexible
when things change.
The Basal Ganglia
is responsible for impulse control. It coordinates information
coming from other regions of the brain to prevent automatic
responses to stimuli, such as loud noises.
The Corpus Callosum
is responsible for communication between the two brain
hemispheres to ensure coordinated, complementary work.
The Anterior Cingulate
is responsible for management of emotions
These areas communicate through two neurotransmitters
called dopamine and noradrenaline.

20. An executive function
is “a neuropsychological concept referring to the
cognitive processes required to plan and direct
activities, including task initiation and follow through,
working memory, sustained attention, performance
monitoring, inhibition of impulses, and goal-directed
persistence

21. • Disorder in ADHD
• MRI studies indicate that a loss of normal
asymmetry in the brain, in addition to smaller
brain volumes of specific structures, such as the
prefrontal cortex and basal ganglia, is seen in the
brains of children with ADHD.
.

23. 4-subtypes

25. Combined Type:
 Clinical levels of both inattention and
hyperactivity/impulsivity
 Most common subtype
 more common in males
Predominantly Inattentive Subtype
 Clinical levels of inattention only
 Often not identified until middle school
 more common in females

26. Predominantly Hyperactive/Impulsive
Subtype:
 Clinical levels of hyperactivity/impulsivity
only
 more common in males
 More common among very young children
prior to school entry

27. presentation
Clinical manifestations of ADHD may change with age
in preschool children
The symptoms may vary from motor restlessness and
aggressive and disruptive behavior, which are common
ADHD is often difficult to diagnose in preschoolers because
distractibility and inattention are may be considered
developmental norms during this period
in older adolescents and adults
to disorganized, distractible, and inattentive symptoms, which
are more typical.

28. Symptom Evolution
Time
Inattention
Hyperactivity
Impulsivity

30. Diagnosis
A diagnosis of ADHD is made primarily in clinical
settings after a thorough evaluation, including a
1-careful history
2- clinical interview to rule in or to identify other
causes or contributing factors;
3-completion of behavior rating scales by different
observers from at least 2 settings (e.g., teacher and
parent);
4- a physical examination;
5-laboratory tests

31. Clinical Interview and History
Must be in group setting
1-. During the interview, the clinician should gather information pertaining
to the history of the presenting problems, the child’s overall health and
development, and the social and family history.
2-The interview should emphasize factors that might affect the
development or integrity of the centra nervous system or reveal chronic
illness, sensory impairments, or medication use that might affect the
child’s functioning
.
3- Disruptive social factors, such as family discord, situational stress,
and abuse or neglect, can result in hyperactive or anxious behaviors.
4- A family history of 1st-degree relatives with ADHD, mood or anxiety
disorders, learning disability, antisocial disorder, or alcohol or substance
abuse might indicate an increased risk of ADHD and/or comorbid
conditions.

32. Behavior Rating Scales
1-Behavior rating scales are useful in establishing the
magnitude of the symptoms, but are not sufficient alone to
make a diagnosis of ADHD.
2-There are a variety of well-established behavior
rating scales that have obtained good results in discriminating
between children with ADHD and control subjects.
3-These measures include,
,

33. Physical Examination
1-. The presence of hypertension, ataxia, or a thyroid disorder should prompt
further diagnostic evaluation.
2- Impaired fine motor movement and poor coordination and other subtle
neurologic Motor signs (difficulties with finger tapping, alternating movements,
fingerto-nose, skipping, tracing a maze, cutting paper) are common,
but they are not sufficiently specific to contribute to a diagnosis of ADHD
.
3-The clinician should also identify any possible vision or hearing problems.
4-Behavior in the structured laboratory setting might not reflect the child’s
typical behavior in the home or school environment. Therefore, reliance on
observed behavior in a physician’s office can result in an incorrect diagnosis.
.

34. Laboratory Findings
No laboratory investigations for the diagnosis of ADHD
No role for EEG or CT in diagnosis
The clinician should consider testing for elevated lead levels in children who
present with some or all of the diagnostic criteria, if these children are exposed to
environmental factors that might put them at risk (substandard housing, old paint,

35. diagnostic criteria according to diagnostic and
Statistical Manual of Mental Disorders,
5th edition (DSM-V) criteriaDSM-5 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder
A . A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes
with functioning or development more than 6 months
B . Several inattentive or hyperactive-impulsive symptoms were present prior to
age 12 years.
C . Several inattentive or hyperactive-impulsive symptoms are present in two or
more settings (e.g., at home, school, or work; with friends or relatives; in other
activities).
D . There is clear evidence that the symptoms interfere with, or reduce the quality
of, social, academic, or occupational functioning
.
E . The symptoms do not occur exclusively during the course of schizophrenia or
another psychotic disorder and are not better explained by another mental
disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality
disorder, substance intoxication or withdrawal).
:

36. 1. Inattention
• Six (or more) of the following symptoms have persisted and
For older adolescents and adults (age 17 and older), at least
five symptoms are required.
• 1. Often fails to give close attention to details or makes
careless mistakes in schoolwork, at work
• 2. Often has difficulty sustaining attention in tasks or play
activities
• 3. Often does not seem to listen when spoken to directly (

37. 4. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace
5. Often has difficulty organizing tasks and activities
.
6. Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (e.g., schoolwork or homework;
7. Often loses things necessary for tasks or activities
.
8. Is often easily distracted by extraneous stimuli (for older adolescents and
adults, may include unrelated thoughts).
9. Is often forgetful in daily activities (e.g., doing chores, running errands; for
older adolescents and adults, returning calls, paying bills, keeping
appointments).

38. • 2. Hyperactivity and impulsivity:
Six (or more) of the following symptoms have
persisted.and for older adolescents and adults (age 17
and older), at least five symptoms are required.
1. Often fidgets with or taps hands or feet or squirms in seat.
2. Often leaves seat in situations when remaining seated is
expected
3. Often runs about or climbs in situations where it is inappropriate.
4. Often unable to play or engage in leisure activities quietly.

39. 5. Is often “on the go,” acting as if “driven by a motor”
6. Often talks excessively.
7. Often blurts out an answer before a question has been
completed
8. Often has difficulty waiting his or her turn (e.g., while waiting
in line)
.
9. Often interrupts or intrudes on others without asking or
receiving permission; for adolescents and adults, may intrude
into or take over what others are doing).

40. associated comorbidity
1-oppositional defiant disorder (ODD) 50-70%
2-Learning disability 46%
3-conduct disrder 27%
4-autism 25%
5-anxiety 18%
6-depression 14%
7-speech problems 12%
8-tic tourette 10%

41. • 5-differential diagnosis may be inattentive if
A-PSYCHOSOCIAL FACTORS
Response to physical or sexual abuse
Response to parental psychopathology
Response to inappropriate classroom setting
B-Adverse effects of medications
C-Effects of abused substances
D-Sensory deficits (hearing and vision)

42. E -Chronic illnesses
(migraine headaches, hematologic disorders, diabetes, childhood
cancer)
F -Sleep disorders,
including those secondary to chronic upper airway obstruction from
enlarged tonsils and adenoids
• G -Depression and anxiety disorders may cause many of the
same symptoms as ADHD
• H--Adjustment disorders
• (death of a close family member, parents’ divorce, family
violence,

43. Management
1-Behavioral Therapy
2-medication
3-nuitrition
– Individual Educational Plan (IEP)

44. American Academy of Child & Adolescent
Psychiatry (AACAP):
 1-Treatment “may consist of pharmacological and/or
behavior therapy”
 2-but that “pharmacological intervention for ADHD is
more effective than a behavioral treatment alone”
 3-and that “behavioral intervention alone might be
recommended as an initial treatment if the patient’s
ADHD symptoms are mild with minimal impairment to
try to solve problems…or parents reject medication”

45. A-Parents can help their child who has
ADHD by doing the following:
 Use rewards and incentives more than punishments
 Know what your child’s responsibilities are in school
 Provide close supervision for homework
 Help your child stay organized
 Monitor the child’s performance and let doctors know
 Find the things your child does well and encourage them

46.  Learn as much about ADHD as you can
 Allow time for movement
 Environment with fewer distractions during tests

47.  B-Teachers can provide accommodations in
the classroom
 —
 Preferential seating
 Shorter assignments
 Closer supervision
 Clearer instructions
 Help in getting on assignments

48. 2-medication
Treatment trial:
– Risk of adverse effects is significant
– Not necessarily “diagnostic” even if effective
– At least 2 – 3 medications should be attempted before patient
deemed non-responder
They are
1-psychostimulant
2-ATOMOXETINE
3-TRICYCLIC ANTIDEPRESSANT
4-α-AGONISTS
5-Antipsychotics(Aripiprezon-risperidon)
6- Other Antidepressants
– Bupropion (Zyban); Fluoxetine (Prozac

50. A-Pychostimulatants:
1-types
A-Methylphenidate
 Immediate-release(Ritalin,5,10,20mg tab)
 Extended-release(Concerta, 18,27,36, and 54 mg cap)
B--Dexmethylphenidate
 (Focalin ,2.5,5, and 10 mg tab)
c-Dextroamphetamine:
 Short-acting( Dexedrine, 5,10, and 15 mg tab)
 Intermediate-acting( Dexedrine Spansule,5,10, and 20 mg tab)
d-MIXED AMPHETAMINE SALTS:
 Intermediate-acting (Adderall ,5,10, and 20 mg tab)
 Extended-release( Adderall XR ,5,10,15,20,25, and 30 mg cap)

51. 2-mechanism of action
Reuptake inhibition of NE & DA
Cause increased release of presynaptic NE/DA
3-indication
History of favorable response to stimulants
Those who require “drug holidays”
Obese/overweight patients.
Augmenting Strattera

53. 4-effects
Improved sustained attention
Reduced distractibility
Improved short-term memory
Reduced impulsivity
Reduced motor activity
Decreased excessive talking

54. – 5-how to use
– Effective during school and homework-time
– May use Monday to Friday or 7 days /week
– Weekend use if significant behavioural comorbidity or
needed for weekend activity:
– Use does not predispose to subsequent substance
abuse – ‘protective’

55. 6-side effects
Insomnia
Decreased Appetite (in 50-60%) =>Weight Loss
Headaches
Stomach aches (20-40%)
Mood lability
Tics (<5%) and Tourette’s (Very Rare) - possible
exacerbation or uncovering of tics
(Increases in Heart Rate and Blood Pressure

56. • 7-contraindications
 HTN,
 symptomatic cardiovascular disease,
 glaucoma,
 hyperthyroidism,
 tics/Tourette’s (relative),,
 psychosis (relative)

57. How to manage tic disorder
 Up to 65% of children initiating Rx with MPH
may develop a transient tic
 Motor, or Vocal
 Stimulants may cause or “unmask” tics
 Treatment: Alteration in stimulant dose,
discontinuation of stimulant, change of stimulant
to α-2 agonists, antipsychotics,

58. • 8-Response
• :25% of patients have an optimal response on a low (<0.5
mg/kg/day for methylphenidate,<0.25 mg/kg/day for
amphetamines),
25% on medium(0.5-1.0 mg/kg/day for methylphenidate,
0.25-0.5 mg/kg/day for amphetamines),
or high (1.0-1.5 mg/day for methylphenidate, 0.5-0.75
mg/kg/day for amphetamine) daily dosage;
another 25% will be unresponsive or will have side effects,
making that drug particularly unpalatable for the family.

59. Over the first 4 wk of treatment, the physician should
increase the medication dose as tolerated (keeping side
effects minimal to absent) to achieve maximum benefit.
If this strategy does not yield satisfactory results, or if
side effects prevent further dose adjustment in the
presence of persisting symptoms, the clinician should use
an alternative class of stimulants that was not used
previously.
If satisfactory treatment results are not obtained with
the second stimulant, clinicians may choose to prescribe
atomoxetine, a noradrenergic reuptake inhibitor that is
superior to placebo in the treatment of ADHD in children,
adolescents, and adults and that has been approved by
the FDA for this indication

60. B-ATOMOXETINE:
1-types
Extended-release (Strattera attensera,atomoxetine
, 10,18,25,40, and 60 mg cap)
 2-mechanism of action
Norepinephrine reuptake inhibitor; acts at presynaptic neuron;
primary mechanism

62. 3-indication
History of adverse effect to stimulants
Comorbid anxiety, depression, tics, enuresis or Tourette’s
Concern about insomnia
24-hour duration of action with once-daily dosing

63. 4-side effects
Abdominal pain
Anorexia
constipation
dry mouth
5-contraindication
;1-pheochromocytoma
2-cardiovascular
3-cerebrovascular disease

64.  Routine Treatment with Stimulants and
Atomoxetine
Prior to treatment
Height, weight, Blood Pressure & Heart Rate
Cardiac Exam
Family history of sudden cardiac death and/or personal or family history of syncope,
chest pain, shortness of breath, or exercise intolerance warrants an ECG and pediatric
cardiology referral for an echo
During Treatment
1-At least annual height & weight (compare to published norms); if height for age
decreases by > 1 standard deviation while on stimulants, refer to a pediatric
endocrinologist (re: possible growth hormone deficiency or hypothyroidism)
2-Repeat blood pressure and heart rate at least twice annually and anytime prior and
subsequent to a dosage increase

65. C-α-AGONISTS
1-types
Guanfacine
Clonidine
2-mechaniosm of action
Stimulation of the post-synaptic alpha-2A receptors is thought to strengthen working
memory, reduce susceptibility to distraction, improve attention regulation, improve
behavioral inhibition, and enhance impulse control
3- indication
originally developed as an antihypertensive agent, is also FDA approved
for the treatment of ADHD, although it appears to be less successful
for hyperactivity and more likely to assist with impulsivity.
It can also treat motor and vocal tics, and so may be a reasonable choice in a child
with a comorbid tic disorder.

66. 4-contraindication
Heart block..
Slow heart rate.
Low blood pressure.
Heart failure -.
5-side effects
drowsiness, dizziness;
dry mouth, loss of appetite;
constipation;
dry eyes, contact lens discomfort; or.
sleep problems (insomnia), nightmare

67. D-Antidepressant therapy
1-types
Tricyclic antidepressants, (imipramine)
,
2-mechaniosm of action
Most of the TCAs inhibit the reuptake of norepinephrine, though not dopamine,
3- indication
1-associated with depression
.
.

68. 4-side effects
• :
• Constipation
• Dry mouth
• Blurred vision
• Drowsiness
• Low blood pressure
• Weight gain
• Tremor
• Sweating
• Tricyclic antidepressants also have the potential to
cause serious heart conduction defects

69. 5-Antipsychotics
(A--risperidon)
• 1-MECHANISM OF ACTION.
• Risperidone works by blocking the receptors in the brain that
dopamine acts on.
• This prevents the excessive activity of dopamine and helps to
control schizophreni
• 2- indication
• Associated with depression,ODD

70. • SIDE EFFECTS
• ]
• Neuroleptic malignant syndrome
• Tardive dyskinesia
• Metabolic Changes
• Hyperprolactinemia

71. B-Aripiprazole
• 1-mechaniosm of action
• , as a partial agonist at the dopamine D2 and
serotonin 5HT1A receptors
• 2-side effects
• extrapyramidal syndrome, hyperprolactinemia,
weight gain, metabolic disorders, and sedation)
which are common problems with other
antipsychotic drugs.

72. SUMMARY DRUGS

74. Nutrition
–
1-Nutrition – food Sensitivities and elimination diets
2-Nutritional Supplements
– Omega-3 Fatty Acids
– Zinc
– Magnesium
– Multivitamins

75. prevention
• Avoid
1-birth complications, such as toxemia, lengthy labor, and complicated
delivery.
2- Maternal drug use, smoking and alcohol use during pregnancy, lead
or mercury exposure (prenatal or postnatal
3-Psychosocial family stressors
 4-Food colorings and preservatives
 Protective factors:
 1-Positive family environment
 2-Good nutritional habit ;Zinc, calcium,lead
 3-Early treatment

76. 7-prognosis
1--From 60-80% of children with ADHD continue to experience symptoms in
adolescence, and up to 60% of adolescents exhibit ADHD symptoms into
adulthood.
2-In children with ADHD, a reduction in hyperactive behavior often occurs with
age.
3-Other symptoms associated with ADHD can become more prominent with age,
such as inattention, impulsivity, and disorganization,
4-A variety of risk factors can affect children with untreated ADHD as they become
adults. These risk factors include
A -engaging in risk-taking behaviors (sexual activity, delinquent behaviors, substance
use),
B -educational underachievement or employment difficulties,
C -and relationship difficulties.
5-With proper treatment, the risks associated with the disorder can be significantly
reduced.

77. references
• 1-American Psychiatric Association. 2013
• 2-nelson 2016
• 3-swaiman pediatric neurology 2018