Docstoc

ADHD by Dr. Ehsan Syed

Document Sample
ADHD by Dr. Ehsan Syed Powered By Docstoc
					   ADHD
&DISRUPTIVE
 DISORDERS
   EHSAN U. SYED
    PSYCHIATRY
AGA KHAN UNIVERSITY
Heinrich Hoffmann (1809–1894).
• As early as 1846, the typical symptoms of ADHD
  were described by Heinrich Hoffmann, a physician
  who later founded the first mental hospital in
  Frankfurt. Interestingly, his description was
  published in a children’s book entitled
  "Struwwelpeter" which he had designed for his
  3-year-old son Carl Philipp. The symptomatology
  is impressively depicted in the colourfully
  illustrated story of "Zappel-Philipp" ("Fidgety
  Philip"), probably the first written mention of
  ADHD by a medical professional. This clearly
  shows that the diagnosis of ADHD is not an
  "invention" of modern times.
Heinrich Hoffmann (1809–1894).
Zappel Philipp
 Post encephalitic behavior
         disorder
• Encephalitis epidemic 1917 North
  America
• Surviving children with multiple
  impairments e.g.
      –   inattention,
      –   impulsivity,
      –   dysregulation of activity,
      –   social disruption and
      –   cognitive deficits
    Minimal Brain Damage
• Organic driveness (Kahn & Cohen1934)
• Restlessness syndrome (Childers 1935)
• Minimal brain damage 1950s
• It was not until 1970s when ADHD/ADD
  cases were teased out of brain damaged
  children
• ADD+H and ADD-H (with or without
  hyperactivity) 1980s
• ADD becomes ADHD in DSMIII late 1980s
 DISRUPTIVE DISORDERS
       DSMIV TR

• ATTENTION DEFICIT HYPERACTIVITY
  DISORDER
• OPPOSITIONAL – DEFIANT
  DISORDER
• CONDUCT DISORDER
• DISRUPTIVE DISORDER NOS
                          ADHD
 Diagnosis Criteria for Attention Deficit Hyperactivity
     Disorder (DSM-IV)(A) Either (1) or (2)
1. Six (or more) of the following symptoms of in attention occur
     often and have persisted for at least 6 months.
Inattention
•    Fails to give close attention to details.
•    Has difficulty sustaining attention in tasks or play activities.
•    Does not seem to listen when spoken to directly.
•    Does not follow through on instruction and fails to finish
     school work, chores or duties in the work place
•    Has difficulty organizing tasks and activities. Avoids, dislikes
     or is reluctant to engage in task that requires sustained
     mental effort.
•    Loses things necessary for task or activities.
•    Is easily distracted by extraneous stimuli.
•    Is forgetful in daily activities.
                    ADHD

2.Six (or more) of the following symptoms of in
    hyperactivity / impulsivity occur often and have
    persisted for at least 6 months.
Hyperactivity
•   Fidget with hands or feet or squirms in seat.
•   Leaves seat in classroom or in other situations
    in which remaining seated is expected.
•   Runs about or climbs excessively in situations in
    which it is appropriate.
•   Has difficulty playing or engaging in leisure
    activities quietly.
•   Is “on the go” or acts as if “driven by motors”.
•   Talks excessively.
                     ADHD
Impulsivity
• Blurts out answers before questions have been
  completed.
• Has difficulty a waiting turn.
• Interrupts or intrudes on other
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 two or
   more settings e.g. at school (or work) and at home
D) There must be clear evidence of clinically significant
   impairment in social, academic or occupational areas.
E) The symptoms do not occur exclusively during the course
   of a Pervasive Developmental Disorders, Schizophrenia, or
   others psychotic Disorder and are not being accounted for
   by another mental disorder.
                ADHD
 Types
• Attention Deficit Hyperactivity Disorder,
  combined type. If both criteria A1 and
  A2 are met for the past six months.
• Attention Deficit Hyperactivity Disorder,
  Predominantly Inattentive Type. If
  criteria A1 is met but criteria A2 is not
  met for the past six months.
• Attention Deficit Hyperactivity Disorder,
  Predominantly Hyperactivity Impulsive
  type: if criteria A2 is met but criteria A1
  is not met for the past six months.
                  ADHD
• DSMIV ADHD 5% - 10%
• ICD 10 HKD 1-2%
• ADHD+DAMP 6%
• More common among boys
        » 2:1 to 5:1
• Girls manifest inattentive subset
  more commonly – under diagnosed
• Symptoms there by age 7
        » Peak age of diagnosis 9
ETIOLOGICAL FACTORS
    HETEROGENOUS
   – NEUROCOGNITIVE
   – GENETIC
   – PSYCHOSOCIAL
   – ENVIRONMENTAL
COMPLEX INTERPLAY BETWEEN ALL
         THE FACTORS
                DOPAMINE
• Altered dopamine functioning in
  mesolimbic,mesocortical &
  nigrostriatal pathways1
        » Altered sensitivity to reinforcement and
          deficient extinction of previously reinforced
          behavior
        » Deficient attention towards a target, poor
          planning and executive functioning
        » Impaired modulation of motor behavior
        » Deficient learning and memory
        1 Barkley RA In Attention Deficit Hyperactivity Disorder :Etiologies. The Guilford
           Press New York 3rd Edition 2006
  Molecular genetic studies
• More than one gene is highly likely
  responsible
• Polymorphism(7 or more repeats) of DRD4
  – gene for D4 receptor, also implicated in
  novelty seeking behavior
• DAT 1 dopamine transporter gene
• DBH gene (dopamine beta hydroxylase
  contributes to conversion of dopamine to
  norepinephrine)
          Barkley RA In Attention Deficit Hyperactivity Disorder :Etiologies. The Guilford Press New York
             3rd Edition 2006
    Environmental &Social
           factors?
• Maternal smoking and alcohol use during
  pregnancy
• Excess TV in first 3 years – correlation
  with ADHD symptoms at age 7 but cause
  effect relationship not established
• Overcritical and commanding mothering
  may be a consequence of ADHD
  symptoms in children rather than a cause!
• No currently available credible scientific
  theory of causation of ADHD by purely
  social means
          Barkley RA In Attention Deficit Hyperactivity Disorder :Etiologies. The Guilford Press New York
             3rd Edition 2006
     Recent developments
• Neuroanatomic correlates
         – Regions most commonly differentiating ADHD from Non
           ADHD controls in structural imaging techniques1:
             » total cerebral volume
             » Caudate nucleus
             » Splenium of corpus callosum
             » cerebellum
         – A group of 15 to 19 Adolescents with familial ADHD
           were found to have large right caudate and Inferior
           frontal gyrus2
    1.Valera EM,Faraone SV,Murray KE,Seidman LJ,Metaanalysis of structural imaging findings
       in attention-deficit hyperactivity disorder.Biological Psychiatry 2006
    2.Garret et al Neuroanatomical Abnormalities in Adolescents with Attention deficit
       hyperactivity disorder. Journal of American Academy of child and adolescent psychiatry
       47:11 November 2008
         OPPOSITIONAL DEFIANT
              DISORDER
• Often looses temper

• Often argues with adults

• Often actively defies or refuses to comply with adult’s rules

• Often deliberately annoys people

• Often blames others for his or her mistakes or misbehavior

• Often touchy or easily annoyed by others

• Often angry and resentful

• Often spiteful or vindictive
       CONDUCT DISORDER
• Aggression to people and animals
              »   Bullying, threatening, intimidating
              »   Initiating physical fights often using weapons
              »   Cruelty to people and animals
              »   Mugging, mobile snatching, armed robbery
              »   Sexual assaultiveness
• Destruction of property
              » Fire setting with intent to destroy
              » Destroying other people’s property with intent
• Deceitfulness or theft
              » Breaking and entry
              » Conning & Forgery
              » Shoplifting

• Serious violation of societal norms
              » Staying out and running away from home
              » Truancy
  MANAGEMENT OF ADHD
• PARENTAL TASKS
       » UNDERSTAND THE CHILD – DON’T GET
         FRUSTRATED
       » STRUCTURE HOME ENVIRONMENT –
         ESTABLISH HEIRARCHY
       » PREDICTABLE ROUTINES
       » REDUCE OVERSTIMULATION
       » REWARD COMLIANCE
       » MINI TASKS BUT NO MULTI TASKING
  MANAGEMENT OF ADHD
• TEACHERS TASKS
       » SMALL CLASSROOM SIZE
       » TEAHCHER’S ASSISTANTS
       » SIT THEM IN FRONT
       » SHORT TASKS WITH IMMEDIATE FEEDBACK
       » ALLOW PHYSICAL ACTIVITY e.g. CLEAN THE
         WRITINGBOARD
       » REWARD INCREASED ATTENTION SPAN
       » PRAISE THE CHILD FOR CONTROLLING
         FIDGETINESS
  MANAGEMENT OF ADHD
• PHYSICIAN’S TASKS
       » EVALUATE THE FAMILY SITUATION
       » ASSESS THE PARENTS SPECIALY MOTHERS
       » GET TEACHERS FEEDBACK
       » HELP THEM SEE THIS AS A DISORDER
       » HELP THEM STRUCTURE HOME ENVIRONMENT
       » RULE OUT ANXIETY MENTAL RETARDATION
         AND LEARNING DISABLITY
       » LOOK FOR COMORBIDS e.g.ENURESIS,FINE
         MOTOR DELAY ETC.
       » RECRUIT OTHER PROFESSIONALS e.g.
         OCCUPATIONAL THERAPIST,PSYCHOLOGISTS
MANAGEMENT OF ADHD
   STIMULANT MEDICATIONS
   » METHYLPHENIDATE (RITALINR ) GOLD STANDARD
   » DEXTROAMPHETAMINES
   » OROS FORMUALTION (CONCERTAR )


   NON STIMULANTS
   » ATOMOXETINE (STRETTERAR)
   » RISPERIDONE (RISPERDALR AND OTHERS)
   » TCAs
   MECHANISM OF ACTION
• STIMULANTS BLOCK THE DOPAMINE TRANSPORTER


• PREVENT RE ENTRY OF DOPAMINE IN THE PRESYNAPTIC
  NEURON


• INCREASED RESTING LEVEL OF EXTRACELLULAR
  DOPAMINE


• REDUCTION IN RELATIVE RISE IN DOPAMINE LEVEL
  TRIGGERD BY AN IMPULSE
        ADHD RATING SCALES
Academic Performance rating   19 item- assesses academic performance in grade 1 to 6
scale

ADHD Rating scale IV          18 item scale based on DSMIV




Child Behavior Check List     118 item wide range of disorders –parent and teacher
(CBCL)                        version.


Conner's Rating scales        Multi informant- short and long version-




IOWA Conner’s                 10 item – can be used in clinical monitoring- used to
                              separate from ODD.
          RECOMMENDATIONS
              (AACAP)
•   Psychopharmacological treatment alone is satisfactory if:
                   » Robust response to medicine
                   » Normative functioning in academic, family and social
                     domains
•   Psychosocial treatment in conjunction with medications if:
                   » Less than optimal response to medicines
                   » Presence of co morbid disorders
                   » Dysfunctional family
•   Periodic assessment and follow-up patient to determine if:
                   » Medication effective
                   » Dosage optimal
                   » Side effects monitoring
                   » Appropriate growth across percentiles
• Treatment should continue as long as symptoms
  remain present and cause impairment

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:2
posted:9/14/2011
language:English
pages:26