Chapter – 27ATTENTION DEFICIT HYPERACTIVITY DISORDER

Introduction• prevalence : 5-12% of school-aged children; M:F= 4:1, although girls may be under-diagnosed• girls tend to have inattentive/distractible symptoms; boys have impulsive and hyperactive symptoms

Etiology• genetic- dopamine candidate genes, catecholamine/neuroanatomical hypothesis• cognitive- development disability, inhibitory control and other errors of executive function • arousal- alterations in the sensory system filters

Diagnosis• differential: learning disorders, hearing/visual defects, thyroid, atopic conditions, congenital problems (fetal alcohol syndrome, Fragile X), lead poisoning, history of head injury, traumatic life events (abuse)• diagnosis (3 subtypes):

Combined Type- 6 or more symptoms of inattention and 6 or more symptoms of hyperactivity-impulsivity

Predominantly Inattentive Type- 6 or more symptoms of inattention

Predominantly Hyperactive-Impulsive Type- 6 or more symptoms of hyperactivity impulsivity

symptoms persist for > 6months

onset before age 7 symptoms present in at least two settings (i.e. home, school, work)

interferes with academic, family, and social functioning

doesnot occur exclusively during the course of another psychiatric disorder

Inattention Hyperactivity Impulsivity

Careless mistakes Fidgets, squirms in seats 8lurts out answer before questions completed

Cannot sustain attention in tasks or play

Leaves seat when expected to remain seated

Difficult awaiting turn

Doesnot listen when spoken to directly

Runs and claims excessively Interrupts/intrudes on others

Fails to complete tasks Cannot play quietly

Disorganized On the “go”, driven by a motor

Avoids, dislikes tasks that require sustain mental effort

Tasks excessively

Loses things necessary for tasks or activitiesDistractible

Forgetful

Features• average onset 3 yrs old• identification upon school entry• rule out development delay, genetic syndromes, encephalopathies or toxins (alcohol, lead)• risk of substance abuse, particularly cannabis and cocain, depression, anxiety, academic failure, poor social skills, risk of comorbid CD and/or ODD, risk of adult ASPD• associated with family history of ADEID, diffucult temperamental characteristics

Treatment• non-pharmacological: parent management, anger control strategies, positive reinforcement, social skills training, individual/ family therapy, resource room, tutors, classroom intervention, exercise routines, extracurricular activities

• pharmcological standard treatment: stimulants (methylphenidate- Ritalin, Concerta [long acting]; Biphentin; dextroamphetamine; mixed amphine salts- Adderall; lisdexamphetamine- Vyvanse), SNRI (atomoxetine- Strattera)

for comorbid symptoms: antidepressants, antipsychotics

Vit B6: 6-12 months Prognosis• 65% continue into adulthood; secondary personality disorders and compensatory anxiety disorders are identifiable• 70-80% continue into adolescene, but hyperactive symptoms usually abate.

The End