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FOCUS...Whats that?

BY : Andrew Joseph

You Know this..?


An 8 year old boy is brought to the pediatrician for a routine check.
His mother says he is always running around, doesnt listen, and
keeps his room a mess. She hopes he will grow out of it soon. Upon
further questioning you discover that the boy's school teacher
reports that he answers questions impulsively and out of turn, and
that he cannot sit at his desk for a very long time without fidgeting.
He also frequently forgets to bring his homework. Symptoms have
been going on for a year with decreased academic performance
over the last 6 months.

What does this boy and Adam Levine have in common?

ADHD
A PERSISTENT PATTERN OF INATTENTION AND/OR HYPERACTIVITY AND
IMPULSIVITY THAT INTERFERES WITH FUNCTIONING OR DEVELOPMENT, AS
CHARACTERIZED BY (1) AND/OR (2)

ADHD
Inattention

6 or more symptoms of
inattention have
persisted for at least 6
months to a degree that
is inconsistent with
developmental level and
that negatively impacts
directly on social media
and
academic/occupational
activities

Hyperactivity-impulsivity

6 or more symptoms of
hyperactivity-impulsivity
have persisted for at
least 6 months to a
degree that is
inconsistent with
developmental level and
negatively impacts
directly on social and
academic/occupational
activities

ADHD: Epidemiology

The prevalence of ADHD is about 5% in young and school-age


children and 2.5% in adults.

More common in boys than in girls 3:1

Often diagnosed in elementary school and is relatively stable


throughout adolescence

Some children have bad outcomes and may develop antisocial


behaviors, some meeting the criteria for conduct disorder

ADHD: Etiology and Pathophys.

UNCERTAIN

However it does seem to run in families and is highly heritable.

Because dopamine mediated the reward system in the brain and


treatments for ADHD work through dopamine, genes related to
dopamine have been receiving special attention.

RISK FACTORS:

MATERNAL SMOKING

SUBSTANCE ABUSE

MALNUTRITION

EXPOSURE TO TOXINS AND VIRAL INFECTIONS

The possible role of such factor is consistent with higher prevalence of


ADHD in boys due to increased vulnerability during pre and perinatal
periods.

ADHD: ETIOLOGY AND PATHOPHY.

Brain imaging studies using MRI have shown that the prefrontal
cortex, cortex, basal ganglia, and cerebellum either reduced in
size or have abnormalities in asymmetry in children with ADHD.

These findings correlate well with neuropsychological data


showing that people with ADHD have difficulties in response
inhibition, executive functions mediated through the pre-frontal
cortex, or timing functions mediated through the cerebellum.

Functional imaging studies have shown hypoperfusion in


prefrontal and basal ganglia regions that may be reversible with
stimulant treatment.

ADHD: Differential Diagnosis

Clinician must be aware that a child with ADHD may have comorbid
disorders common in childhood such as:

Seizure disorders

Conduct disorder

ODD

Learning disorders

Childhood bipolar disorder or depression may present with similar or


overlapping symptoms.
In some cases, ADHD symptoms may be appear to be a normal response
to an abusive home environment.
Neuroendocrine abnormalities such as thyroid disorder also need to be
ruled out.

ADHD: Clinical Management

Methylphenidate (10-60 mg/day) is usually the first line


treatment, followed by dextroamphetamine (5-40 mg/ day)

If neither of these succeeds, atomoxetine (strattera), an alpha 2


agonist (e.g, clonidine, guanfacine), imipramine, or bupropion
may be used.

Psychotherapy