lecture 22 attention-deficit or hyperactivity disorder (adhd)

8/12/2019 Lecture 22 Attention-Deficit or Hyperactivity Disorder (ADHD)

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ADHD

- Chronic neurobehavioral disorders that can

interfere with an individuals ability to inhibit

behavior (impulsivity), function efficiently ingoal-oriented activities (inattention), or

regulate the activity level (hyperactivity) in

developmentally appropriate ways

Three basic form of ADHD

- Attention

- Hyperactive

- Combine (most frequent)

Miller KJ, Castellanos FX. AD/HDs. Ped in Rev 1998; 19 (11)


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ADHD significant functional problems

-school difficulties- academic underachievement

- troublesome interpersonal relationships with

family members and peers

- low esteem

Untreated childhood ADHD

More likely to experience conduct disorder,substance abuse, antisocial behavior and

injuries later in life

EARLY RECOGNITION, ASSESSMENT & MANAGEMENT


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Prevalence rates vary substantially (changing

diagnostic criteria overtime; variations depend ondifferent settings sample estimation

- Varying from 4% to 12%- Males 9.2% (5.8%-13.6%)

- Female 2.9% (1.9%-4.5%)

- School samples 6.9% (5.5%-8.5%)

- Community samples 10.3% (8.2%-12.7%)

- Indriyani, dkk (2007) RSUP Sanglah (2005-2006)

( 3 yo -


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The causes of ADHD are unknown

GENETIC FACTORS

DEVELOPMENTAL FACTORS

NEUROCHEMICAL FACTORS

NEUROPHYSIOLOGICAL FACTORS

PSYCHOSOCIAL FACTORS

Anonym. Attention-Deficit Disorders. In: Kaplan & Sadocks.

Synopsis of Psychiatry. Ninth Ed. USA: Lippincott; 2003


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Precise neural & pathophysiologic of ADHD remainsunknown

Frontostriatal regions, rich in noradrenergic,

adrenergic and dopaminergic neurotransmitters are

consistently implicatedDysregulation of inhibitory frontocortical activity

(predominantly noradrenergic) on striatal structures

(predominantly dopaminergic)

Imaging studies reveal structural differencesassosiated with ADHD in the caudates, globus

pallidus, right frontal lobe. Anterior-inferior peribasal

gangglia, bilateral retrocallosal, posterior parietal-

occipital regions and the cerebellum


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ACTION (monitoring self regulation)

ACTIVATION(organizing; prioritizing; activating to work)

FOCUS(focusing; shifting focus; sustaining focus)

EFFORT(sustaining effort; regulating alertness;

processing speeds)

EMOTION(managing frustration; modulating emotion)

MEMORY (using working memory; assessing & recall)

FRONTAL EXECUTIVE FUNCTION


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SKALA RATING GURU VERSI INDONESIA (Dwijo Saputro)

Tidak samasekali

Sekali-kali

CukupSering

Hampirselalu

Aktivitas berlebihan

Impulsif

Mengganggu anaklain

Gagal menyelesaikan

tugas, selang

perhatian pendek

Menggerakkananggota tubuh terus

menerus

Perhatian mudah

teralih


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..SKALA RATING GURU VERSI INDONESIA (Dwijo Saputro)

Tidak sama

sekali

Sekali-

kali

Cukup

Sering

Hampir

selalu

Permintaan harus

segera dituruti

Sering menangis

Suasana hati berubahdengan cepat

Ledakan kekerasan

eksplosif

Tidak sana sekali : 0

Sekali-kali : 1

Cukup sering : 2

Hampir selalu : 3

12


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SKALA PENGUKURAN ADHD (CONNERS PARENT RATING SCALES)

Tidak

sama

sekali(0)

Sekali

-kali

(1)

Cukup

sering

(2)

Hampir

selalu

(3)

1 Tidak kenal lelah atau aktivitas

berlebihan

2 Mudah menjadi gembira, impulsif

3 Mengganggu anak-anak lain

4 Gagal menyelsaikan pekerjaan

yang telah dimulainya, selang

waktu perhatiannya pendek

5 Menggerakkan anggota

badan/kepala secara terus

menerus

6 Perhatiannya mudah teralihkan


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Tidak

sama

sekali

(0)

Sekali

-kali

(1)

Cukup

sering

(2)

Hampir

selalu

(3)

7 Permintaannya harus segera

dipenuhi, mudah menjadi frustasi

8 Sering dan mudah menangis

9 Suasana hatinya berubah dengan

cepat dan drastis

10 Ledakan kekesalan tingkah laku

eksplosif dan tak terduga

15


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SYMPTOM CHECKLIST ADHD (Karen J Miller)

Never Some-

times

Often Very

often

SCALE A

1 Fails to play close attention to

details or makes careless mistaken

in schoolwork, chores, or other

tasks

2 Has difficulty sustaining attentionto tasks, chores, or activities

3 Does not seem to listen when

spoken to directly

4 Does not follow through on

instructions and fails to finishschoolwork, chores, or duties (not

due to oppositional behavior or

failure to understand directions)

5 Has difficulty organizing tasks and

activities


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Never Some-

times

Often Very

often

6 Avoids, dislikes, or is reluctant to

engage in tasks that require

sustained mental effort (such asschoolwork)

7 Loses things necessary for tasks or

activities (eg. Toys, school

assignments, pencils, books, or

tools)8 Is distracted by unimportant stimuli

9 Is forgetful in daily acvtivities

SCALE B

10 Fidgets with hands or feet orsquirms in seat

11 Leaves seat in classroom or in

other situations when expected to

remain seated


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Never Some-

times

Often Very

often

SCALE B

12 Runs about or climbs excessivelyin situations where it is

inappropriate (in adolescence, may

be limited to restlessness)

13 Has difficulty playing or engaging

quietly in leisure activities

14 Is on the go or often acts as if

driven by a motor

15 Talks excessively

16 Blurts out answers before the

questions have been completed

17 Has difficulty awaiting turn

18 Interrupts or intrudes on others (eg.

butts into others conversations or

games)


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Never Some-

times

Often Very

often

SCALE C

19 Is uncooperative or defiant orargues with adults

20 Has difficulty getting along with

other children

21 Is often angry, irritable, or easily

upset

22 Has excessive anxiety, worry, or

fearfulness

23 Seems sad, moody, depressed, or

discouraged

24 Has problems with academicprogress (skill level or learning)

25 Has problem with academic

performance (productivity or

accuracy)


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SCALE A (Inattention) and

SCALE B (Hyperactivity-impulsivity)

At least six of the nine criteria from one or both sets

should be excessive in frequency (often/very often)

SCALE C

Screening questions that address commonly

associated problems with compliance,

socialization, emotional control, anxiety, mood,learning, and academic performance


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DSM -IV-TR (Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition, Text Revision)

A.Either 1 or 2

- Inattention: six (or more) of the following symptoms

of inattention have persisted for at least 6 months to adegree that is maladaptive and inconsistent with

developmental level:

a. Often fails to give close attention to details or

makes careless mistakes in schoolwork, work, orother activities

b. Often has difficulty sustaining attention in tasks or

play activities


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c. Often does not seem to listen when spoken to directly

d. Often does not follow through with instructions and

does not finish schoolwork, chores, or duties in the

workplace (not due to oppositional behavior or

failure to understand instructions)

e. Often has difficulty organizing tasks and activities

f. Often avoids, dislikes, or is reluctant to engage in tasks

that requires sustained mental effort (such as

schoolwork or home work)

g. Often loses things necessary for tasks or activities (eg.

toys, school assignments, pencils, books or tools)

h. Is often easily distracted by extraneous stimuli

i. Is often forgetful in daily activities

..Inattention


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- Hyperactivity/Impulsivity: Six (or more)of the following

symptoms of hyperactivity and impulsivity havepersisted for at least 6 months to a degree that is

maladaptive and inconsistent with developmental level:

Hyperactivity

a. Often fidgets with hands or feet or squirms in seatb. Often leaves seat in classroom or in other

situations in which remaining seated is expected

c. Often runs about or climbs excessively in situation

in which this behavior inappropriate(in adolescents or adults may be limited to

subjective feelings of restlessness)


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d. Often has difficulty playing or engaging in leisure

activities quietly

e. Is often on the go or often acts as if driven by a motor

f. Often talks excessively

Impulsivity:

g. Often blurts out answers before questions have been

completed

h. Often has difficulty awaiting turns

i. Often interrupts or intrudes on others (eg. Butts into

conversations or games)

.Hyperactivity/Impulsivity


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B. Some hyperactive-impulsive or inattentive symptoms

that caused impairment were present before age 7 years

C.Some impairment from the symptoms is present in twoor more setting(eg. at school (or work) and at home)

D. There must be clear evidence of clinically significant

impairment in social, academic, or occupational

functioningE. The symptoms do not occur exclusively during the

course of Pervasive Developmental Disorders,

Schizoprenia or other Psychotic Disorder and are not

better accounted for by another mental disorder (eg.

Mood Disorder, Anxiety Disorder, Dissociative Disorder,

or a Personality Disorder)


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The DSM-IV-TR notes that the designation of not

otherwise specified (NOS) may be used for

disorders with prominent symptoms of inattentionor hyperactivity-impulsivity that do not meet ADHD

criteria


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SUBTYPE OF ADHD

1. INATTENTIVE TYPE (ADHD/I)

meeting at least 6 of 9 inattention behaviors

2. HYPERACTIVE-IMPULSIVE TYPE (ADHD/HI)

meeting at least 6 of 9 hyperactive-impulsive

behaviors

3. COMBINED TYPE (ADHD/C)

meeting at least 6 of 9 behaviors in both the

inattention and hyperactive-impulsive list


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Anxiety disorder

Conduct disorder

Eating disorder

Learning disorder

Mood disorder

Oppositional Defiant Disorder

Pervasive Developmental Disorder

Sleep disorder


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dr. IGA Endah Ardjana, SpKJ (K)


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BEHAVIORAL- Presentation of educational material for the

patient, parents and school personnel

- Behavior-modification techniques (daily

report card)- Educational Interventions and

Accommodations for Patients with Learning

Disabilities (preferential seat placement,

more intensive accommodation)- Social skill training (improve interactions

with peers)


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- Individual counseling ( to alleviate secondary

symptoms such as low self-esteem, oppositional defiant

behavior and conduct disorder ; to control their own

behavior)

PHARMACEUTICAL / MEDICATION

When impulsive behavior places the child at

physical or psychological risk (table)

STIMULANT MEDICATIONS


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Medication Initial

dose

Range (R) & Common dose

(CD)

Available tablets/

Spansules

Methylphenidate (Ritalin,

generic)

2.5-5 mg R: 0.1-0.8 mg/kg/dose PO qdto 5 times/d

CD: 0.3-0.5 mg/kg/dose PO

tid/qid

5-,10- and 20 mgscored tablets

Methylphenid

ate slowrelease

(Ritalin SR,

generic SR)

Convert

fromregular

R: 0.2-1.4 mg/kg/dose PO

qd/tidCD: 0.6-1 mg/kg/dose PO

qd/bid

20 mg spansules

do not cut, crush,or chew

Methylphenid

ate

prolonged

release

(Concerta,

Metadate CD)

Convert

from

regular or

use 18 mg

R: 0.3-2 mg/kg PO qd

CD: 0.8-1.6 mg/kg PO qd

18- and 36 mg

tablets

Do not cut, crush,

or chew



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Medication Initial

dose

Range (R) & Common dose

(CD)

Available tablets/

Spansules

Dextroamphetamine

(Dexedrine,

Dextrostat)

2.5-5 mg R: 0.1-0.7 mg/kg/dose POqd/qid


qd/tid

Dexedrine 5 mgscored tablets

Dextrostat 5-, 10-

and 15-mg scored

tablets

Dextroamphetamine

spansules

(Dexedrine

CR)

5 mg R: 0.1-0.75 mg/kg/dose POqd/bid

CD 0.3-0.6 mg/kg/dose PO

qd/bid

5-, 10- and 15-mgspansules

Do not cut, crush,

or chew

Dextroamphe

tamine and

amphetamine

4-salt

combination

2.5-5 mg R: 0.1-0.7 mg/kg/dose PO

qd/qid


tid/qid

5-, 7.5-,10-,12.5-,

15-,20-, and 30-

mg scored tablets

EFFECTS OF STIMULANTS


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EFFECTS OF STIMULANTS

Cognitive - Increased attention to assigned task

- Decreased response to irrelevant stimuli

- Improved speed and accuracy of performance

- Improved short-term memory

- Improved short-term academic performance

Motor - Reduced activity level (often normalizes)

- Decreased off-task motor behavior

- Decreased excessive talking or noise- Increased independent play and work

- Improved fine motor control/handwriting

Social - Decreased anger and aggression

- Decreased emotional and behavioral intensity- Increased sensitivity to reinforcement

- Increased compliance with adult requests

- Decreased negative interactions with peers

- Improved mother-child & family interaction

- Improved teacher-student relations


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SIDE EFFECTS OF STIMULANTS

Common side

effect

- Appetite suppression, Weight loss, Delay in

sleep onset, Abdominal discomfort, Headache,Dizziness, Minor increases in pulse & blood

pressure, Behavioral rebound

Infrequent side

effect

- Withdrawal hyperactivity (rebound),

Agitation/jitteriness, Moodiness/sadness,Social withdrawal, Tics/dyskinesias, Weight

loss/reduced growth velocity, Liver toxicity

(pemoline only)

Overmedication

/Toxic effect

- Irritability / weepiness (at peak), Over focusing,

Dazed appearance, Fatigue, Psychosis

Miller KJ, Castellanos FX. ADHD. Ped in Rev 1998; 19 (11)


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Outcome is significantly affected by persistence ofAD/HD symptoms, comorbid condition andpsychosocial factors

30%-70% of children continue to be symptomatic asadults

Adults who have AD/HDs achieve lower academiclevels, socioeconomic status, less vocational stability,

increased marital problemsMedication continues to be effective for adults, butresponse rate may be lower

Initial treatment of Children with Activity/Attention Problem


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NO

ADHD OR HYPERKINETIC DISORDER DIAGNOSED

PSYCHOEDUCATION, ADVICE, SUPPORT TO

CHILD, FAMILY AND TEACHER

PSYCHOSOCIAL

INTERVENTION

PARENT TRAINING

YES

STIMULANT MEDICATION GOOD

RESPONSE

CHILDREN UNDER 6 YEARS?

SIGNIFICANT IMPAIRMENT

PERSISTS

SPECIALIST REVIEW,IDENTIFICATION OF

STRESSORS AND/OR

ASSOCIATED

PROBLEMS, CONSIDER

MEDICATION

SIGNIFICANT

IMPAIRMENT EXISTS

TRY SECOND STIMULANT

YES

REVIEW, ADD BEHAVIOURTHERAPY,TREAT CO-

MORBIDITY,TRY SECOND LINE

DRUGS, E.G NORADRENERGIC

SIGNIFICANT IMPAIRMENT

PERSISTS

SIGNIFICANT

IMPAIRMENT PERSISTS

PROBLEM AT

SCHOOL?

SCHOOL LIAISON AND

ADVICE TO CHILD

PROBLEM AT HOME ?

PARENT TRAINING

AND

ADVICE TO CHILD

NO

PERVASIVE,SEVERE

DISABILITY

MAINTAIN TREATMENT

REVIEW AND IF

NECESSARY

TREAT

COEXISTENT PROBLEM

GOOD

RESPONS

E


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Primary symptom include inattention and/or

hyperactivity/impulsivityClear interference with developmentally appropriate

social, academic, or occupational functioning

Precise neural and pathophysiologic substrate of ADHD

remain unknown

Frontostriatal regions, rich in noreepinephrine,

epinephrine and dopamine neurotransmitters, are

consistently implicatedEarly recognition, assessment and management of

ADHD can redirect educational and psychosocial

development


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lecture 22 attention-deficit or hyperactivity disorder (adhd)

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