Attention Deficit

Hyperactivity Disorder
INTRODUCTION
 Background
Attention deficit hyperactivity disorder (ADHD) is a
developmental condition of inattention and distractibility, with or
without accompanying hyperactivity.
In the past, various terms were used to describe this condition,
including hyperactive syndrome and, from the Diagnostic and
Statistical Manual of Mental Disorders, Third Edition (DSM-III),
"minimal brain dysfunction."
In the revised DSM-III, this condition was renamed ADHD.
In the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV-TR), adults or children must have had an
onset of symptoms before age 7 years that caused significant
social or academic impairment.
More recently, attention has focused on adult forms of ADHD,
which probably have been underdiagnosed.
 Pathophysiology
The pathology of ADHD is not clear.
Findings indicating that psychostimulants (which
facilitate dopamine release) and noradrenergic
tricyclics treat this condition have led to
speculation that certain brain areas related to
attention are deficient in neural transmission.
The neurotransmitters dopamine and
norepinephrine have been associated with ADHD.
 The underlying brain regions predominantly
thought to be involved are frontal and prefrontal;
the parietal lobe and cerebellum may also be
involved.
In one functional MRI study, children with ADHD
who performed response-inhibition tasks were
reported to have differing activation in frontal-
striatal areas compared to healthy controls.
Adults with ADHD also have been reported to
have deficits in anterior cingulate activation while
performing similar tasks
 Frequency

In the US: Incidence in school-age

children is estimated to be 3-7%.

Internationally: the worldwide

prevalence of ADHD is between 8%
and 12%.
 Mortality/Morbidity

No clear correlation with mortality

exists in ADHD.

exact morbidity has not been

established
 Sex
In children, ADHD is 3-5 times more
common in boys than in girls.
Some studies report an incidence ratio of
as high as 5:1.
The predominantly inattentive type of
ADHD is found more commonly in girls
than in boys.
In adults, the sex ratio is closer to even.
 Age
ADHD is a developmental disorder that requires an onset of
symptoms before age 7 years.
After childhood, symptoms may persist into adolescence
and adulthood, or they may ameliorate or disappear.
The percentages in each group are not well established, but
at least an estimated 15-20% of children with ADHD
maintain the full diagnosis into adulthood.
As many as 65% of these children will have ADHD or some
residual symptoms of ADHD as adults.
The prevalence rate in adults has been estimated at 2-7%.
CLINICAL
 History
The 3 types of attention-
deficit/hyperactivity disorder (ADHD)
are:
(1) predominantly hyperactive,
(2) predominantly inattentive, and
(3) combined.

The DSM-IV-TR criteria are as follows:

 Inattention - Must include at least 6 of
the following symptoms of inattention that
must have persisted for at least 6 months
to a degree that is maladaptive and
inconsistent with developmental level:
Often fails to give close attention to details or
makes careless mistakes in schoolwork, work,
or other activities
Often has difficulty sustaining attention in
tasks or play activities
Often does not seem to listen to what is being
said
 Often does not follow through on instructions
and fails to finish schoolwork, chores, or duties
in the workplace (not due to oppositional
behavior or failure to understand instructions)
Often has difficulties organizing tasks and
activities
Often avoids or strongly dislikes tasks (such as
schoolwork or homework) that require
sustained mental effort
Often loses things necessary for tasks or
activities (school assignments, pencils, books,
tools, or toys)
Often is easily distracted by extraneous
stimuli
 Hyperactivity/impulsivity - Must include at
least 4 of the following symptoms of
hyperactivity-impulsivity that must have
persisted for at least 6 months to a
degree that is maladaptive and
inconsistent with developmental level:
Hyperactivity evidenced by fidgeting with
hands or feet, squirming in seat
Hyperactivity evidenced by leaving seat in
classroom or in other situations in which
remaining seated is expected
 Hyperactivity evidenced by running about or climbing
excessively in situations where this behavior is
inappropriate (in adolescents or adults, this may be
limited to subjective feelings of restlessness)
Hyperactivity evidenced by difficulty playing or engaging
in leisure activities quietly
Impulsivity evidenced by blurting out answers to
questions before the questions have been completed
Impulsivity evidenced by showing difficulty waiting in
lines or awaiting turn in games or group situations
 Onset is no later than age 7 years.
Symptoms must be present in 2 or more
situations, such as school, work, or home.
The disturbance causes clinically significant
distress or impairment in social, academic, or
occupational functioning.
Disorder does not occur exclusively during the
course of a pervasive developmental disorder,
schizophrenia, or other psychotic disorder and is
not better accounted for by mood, anxiety,
dissociative, or personality disorder.
 Numeric codes indicating type based on criteria (adapted
from DSM-IV-TR) are as follows:
314.00 ADHD: Predominantly inattentive type if inattention
criterion is met for the past 6 months, but
hyperactivity/impulsivity criterion is not met
314.01 ADHD: Predominantly hyperactive/impulsive type if
hyperactivity/impulsivity criterion is met for the past 6
months, but inattention criterion is not met
314.01 ADHD: Combined type if both inattention and
hyperactivity/impulsivity criteria are met for past 6 months
(Note that this code is the same as that used for the
predominantly hyperactive type.)
314.9 ADHD not otherwise specified (NOS): Other disorders
with prominent symptoms of attention-deficit or
hyperactivity-impulsivity that do not meet DSM-IV-TR criteria
 Physical
No physical findings have been well correlated
with ADHD.
Mental Status Examination may note the
following:
Appearance: Most often, appointments are difficult to
structure and maintain due to hyperactivity and
distractibility. Children with ADHD may present as
fidgety, impulsive, and unable to sit still, or they may
actively run around the office. Adults with ADHD may
be distractible, fidgety, and forgetful.
 Affect/mood: Affect usually is appropriate and may be
elevated, but it should not be euphoric. Mood usually is
euthymic, except for periods of low self-esteem and
decreased (dysthymic) mood. Mood and affect are not
primarily affected by ADHD, although irritability may
frequently be associated with ADHD.
Speech/thought processes: Speech is of normal rate but
may be louder due to impulsivity. Thought processes are
goal-directed but may reflect difficulties staying on a
topic or task. Evidence of racing thoughts or pressured
speech should not be present. These symptoms are more
consistent with a manic state (bipolar disorder).
 Thought content/suicide: Content should be
normal, with no evidence of suicidal/homicidal
or psychotic symptoms.
Cognition: Concentration and storage into
recent memory are affected. Patients with
ADHD may have difficulty with calculation
tasks and recent memory tasks. Orientation,
remote memory, or abstraction should not be
affected.
 Causes
Genetics
Parents and siblings of children with ADHD are 2-8 times more likely
to develop ADHD than the general population, suggesting that ADHD is
a highly familial disease.
Concordance of ADHD in monozygotic twins is greater than in dizygotic
twins, suggesting some contribution of genetics. Studies estimate the
mean heritability of ADHD to be 76%, indicating that ADHD is one of
the most heritable psychiatric disorders.
The involved genes or chromosomes are not definitively known.
Vulnerability to ADHD may be due to many genes of small effect. For
example, several genes that code for dopamine receptors or serotonin
products, including DRD4, DRD5, DAT, DBH, 5-HTT, and 5-HTR1B,
have been moderately associated with ADHD.
 Environment
Hypotheses exist that include in utero
exposures to toxic substances, food additives
or colorings, or allergic causes. However, diet,
especially sugar, is not a cause of ADHD.
How much of a role family environment has in
the pathogenesis of ADHD is unclear, but it
certainly may exacerbate symptoms.
WORKUP
 Lab Studies
The diagnosis of attention-deficit/hyperactivity disorder
(ADHD) is based on clinical evaluation. No laboratory-based
medical tests are available to confirm the diagnosis.
Basic laboratory studies that may help confirm diagnosis
and aid in treatment are as follows:
Serum CBC count with differential
Electrolyte levels
Liver function tests (before beginning stimulant therapy)
Thyroid function tests
 Imaging Studies
Brain imaging, such as functional MRI
or single photon emission computed
tomography (SPECT) scans have been
useful for research
But no clinical indication exists for
these procedures because the
diagnosis is clinical.
 Other Tests
Psychological testing
The Conners Parent-Teacher Rating Scale is a questionnaire
that can be given to both the parents and the child's teachers.
Barkley Home Situations Questionnaire may be useful.
The Wender Utah Rating Scale may be helpful in diagnosing
ADHD in adults.
The Continuous Performance Tests (CPTs) are computer-based
tasks that often are used to test attention and may be used in
conjunction with clinical information to make a diagnosis. A
currently popular example is the Test of Variable Attention
(TOVA). While these tests can be supportive of the diagnosis
in a full clinical evaluation, they have low sensitivity and
specificity and should not be the sole basis for diagnosis.
Vision and hearing should be checked.
TREATMENT
 Medical Care
Recent data suggest that carefully crafted
stimulant therapy is more effective than
behavioral therapy or regular community care
(medication management by pediatricians).
For related areas of functioning, such as social
skills and academic performance, medications
combined with behavioral treatments may be
indicated.
Pharmacotherapy includes the following:
Stimulants (methylphenidate,
dextroamphetamine)
 These are first-line therapy and probably the most
effective treatment.
All stimulants have similar efficacy but differ by dosing,
duration of action, and adverse effect profiles in
individual patients. Care should be made to start at the
lowest dose and titrate up for clinical efficacy or to
intolerance.
Targeted symptoms include impulsivity, distractibility,
poor task adherence, hyperactivity, and lack of
attention.
Some stimulants come in sustained-release preparations,
which may decrease the number of total daily doses.
Otherwise, dosing should be spaced every 4-6 hours.
 Care should be taken to not dose too close to bedtime
because stimulants may cause significant insomnia.
Other common adverse effects include appetite
suppression and weight loss, headaches, and mood
effects (depression, irritability).
Stimulants may exacerbate tics in children with
underlying tic disorders.
Whether growth might be affected while a child is
taking stimulants remains unclear. Drug holidays (during
summer or on weekends) may or may not be
recommended to allow periods of normal growth. The
decision is based on the child's growth rate chart and
behavior and cognition off medication.
 Atomoxetine (Strattera) has become a
second-line and, in some cases, first-line
treatment in children and adults with
attention-deficit/hyperactivity disorder
(ADHD) because of its efficacy and
classification as a nonstimulant.
Recent data suggest that bupropion or
venlafaxine may be effective. Dosages are
similar to those used to treat depression.
 Tricyclic antidepressants (imipramine,
desipramine, nortriptyline) have been
found effective in numerous studies in
children with ADHD; however, because of
potential adverse effects, they are rarely
used for this purpose.
Clonidine and guanfacine have been used
with mixed reports of efficacy.
 Modafinil (Provigil) has recent placebo-
controlled data supporting its efficacy in
children with ADHD. This medication may
currently be used as a third- or fourth-
line treatment.
Magnesium pemoline (Cylert) had been
used in the 1990s, but concerns of rare,
potentially fatal hepatotoxicity have made
it a rarely used medication.
 Behavioral psychotherapy often is effective when
used in combination with an effective medication
regimen.
Working with parents and schools to ensure
environments conducive to focus and attention is
necessary.
Behavioral therapy or modification programs can help
diminish uncertain expectations and increase
organization.
For adults with ADHD, working to establish ways of
decreasing distractions and improving organizational
skills may be helpful.
 Diet
For decades, speculation and folklore have
suggested that foods containing
preservatives or food coloring or foods
high in simple sugars may exacerbate
ADHD.
Many controlled studies have examined
this question.
To date, no adequate data set has
confirmed the speculation.
FOLLOW-UP
 Further Outpatient
Care
Regular follow-up is needed long-term for
patients with attention-
deficit/hyperactivity disorder (ADHD).
Like diabetes or hypertension, ADHD is
not an illness for which one can hand the
patient a prescription for pills and assume
recovery is automatic with the medication.
 Prognosis
Childhood ADHD may confer a higher risk of
diagnosis with conduct disorders and substance
abuse into adolescence and adulthood. These may
be primary coexisting disorders or disorders
secondary to untreated or undertreated ADHD.
Most children with ADHD have relatively good
psychiatric outcomes once they reach adulthood.
At least 15-20% continue to have full ADHD as
adults, and as many as 65% may continue to have
problematic symptoms of ADHD that interfere
with full realization of academic or work potential.
 Patient Education
The educational requirements of these patients
and their family members are high.
Family members include parents and siblings of
children, spouses and children of adults, and
grown children of elderly patients.
Encouragement of medication use, education on
time structuring and behavioral control, social
skill training, and frequent cognitive redirecting is
needed.
 Medical/Legal Pitfalls
If the medications used are schedule-II
controlled substances (d-amphetamine,
methylphenidate), patients should transport the
drugs or travel with them in their original
pharmacy bottle.
The event of a stimulant-abusing individual
presenting with a complaint of attention-
deficit/hyperactivity disorder (ADHD) in order to
get substances to abuse is surprisingly rare. It
does occur, however, so remain alert for the
possibility.
 Special Concerns
ADHD can be comorbid with the following conditions:
Other developmental learning disorders
Conduct disorder or oppositional defiant disorder
Bipolar disorder
Tourette syndrome
Pervasive developmental disorder
Mental retardation
When evaluating a patient with any of these disorders, special care
should also be made to evaluate for ADHD thoroughly. ADHD, like
bipolar disorder, is readily treatable.
ADHD is a heterogeneic disorder that carries significant
comorbidity. Symptoms consistent with ADHD can present as
other disorders, or these signs and symptoms could be a precursor
in childhood to later disorders such as bipolar disorder or
schizophrenia

TERIMAKASIH