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Attention-Deficit/Hyperactivity Disorder

Suryadi Susanto
Pediatric Department
Krida Wacana Christian University
ADHD

The most common neurobehavioral disorder of childhood

Among the most prevalent chronic health conditions affecting


school-aged children

The most extensively studied mental disorder of childhood


ADHD
Characteristics:

Inattention, including increased distractibility and difficulty


sustaining attention

Poor impulse control and decreased self-inhibitory


capacity

Motor overactivity and motor restlessness


DSM-IV DIAGNOSTIC CRITERIA FOR ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER
A . Either 1 or 2
1. Six (or more) of the following symptoms of inattention have persisted for
6 mo to a degree that is maladaptive and inconsistent with development
level:
Inattention
a. Often fails to give close attention to details or makes careless mistakes
in schoolwork, work, or other activities
b. Often has difficulty sustaining attention in tasks or play activities
c. Often does not seem to listen when spoken to directly
d. 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)
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
g. Often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books, tools)
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
2. Six (or more) of the following symptoms of hyperactivity-impulsivity have
persisted for 6 mo to a degree that is maladaptive and inconsistent with
developmental level:
Hyperactivity
a. Often fidgets with hands or feet or squirms in seat
b. Often leaves seat in classroom or in other situations in which
remaining seated is expected
c. Often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective
feelings of restlessness)
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 turn
i. Often interrupts or intrudes on others (e.g., butts into conversations
or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment
were present before 7 yr of age
C. Some impairment from the symptoms is present in 2 or more settings (e.g., at
school [or work] or at home)
D. There must be clear evidence of clinically significant impairment in social,
academic, or occupational functioning
E. Symptoms do not occur exclusively during the course of a pervasive developmental
disorder, schizophrenia, or other psychotic disorder, and are not better accounted
for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative
disorder, personality disorder)

CODE BASED ON TYPE


314.01 Attention-deficit/hyperactivity disorder, combined type: if both criteria
A1 and A2 are met for the past 6 mo
314.00 Attention-deficit/hyperactivity disorder, predominantly inattentive type:
if criterion A1 is met but criterion A2 is not met for the past 6 mo
314.01 Attention-deficit/hyperactivity disorder, predominantly hyperactive-
impulsive type: if criterion A2 is met but criterion A1 is not met for the
past 6 mo
DIFFERENTIAL DIAGNOSIS OF ATTENTION-
DEFICIT/HYPERACTIVITY DISORDER
PSYCHOSOCIAL FACTORS MEDICAL AND NEUROLOGIC CONDITIONS
Response to physical or sexual abuse Thyroid disorders (including general
Response to inappropriate parenting resistance to thyroid hormone)
practices Heavy metal poisoning (including lead
Response to parental psychopathology Adverse effects of medications
Response to acculturation Effects of abused substances
Response to inappropriate classroom Sensory deficits (hearing and vision)
setting Auditory and visual processing disorders
DIAGNOSES ASSOCIATED WITH ADHD Neurodegenerative disorder
BEHAVIORS Post-traumatic head injury
Post-encephalitic disorder
Fragile X syndrome
Fetal alcohol syndrome
Pervasive developmental disorders
Obsessive-compulsive disorder
Tourette's syndrome
Attachment disorder with mixed emotions
and conduct
Etiology
Risk Factors and Association
multifactorial
birth complications
maternal drug use
maternal smoking and alcohol use
food colorings and preservatives
abnormal brain structures/functions
psychological stressors
Genetic Studies
dopamine transporter gene (DAT1)
dopamine 4 receptor gene (DRD4

Additional genes (might contribute):


DOCK2
associated with a pericentric inversion 46N inv(3)(p14:q21)
involved in cytokine regulation,
a sodium-hydrogen exchange gene
DRD5, SLC6A3, DBH, SNAP25, SLC6A4, and HTR1B.
Epidemiology

5-10% of school-aged children are affected

2-6% in adolescent

2% of adults
Pathogenesis
MRI studies
loss of normal asymmetry in the brain
smaller brain volumes of specific structures

Functional MRI findings


low blood flow to the striatum
deficits functional striatum, prefrontal regions, parietal
lobe, and temporal lobe
dopamine hypothesis
Clinical Manifestations
Age 5-12yo

The behavior must be developmentally inappropriate

Must begin before age 7yo

Must be present for at least 6 mo,

Must be present in 2 or more settings

Must not be secondary to another disorder.


DSM-IV: 3 subtypes of ADHD.

1st subtype: attention-deficit/hyperactivity disorder,


predominantly inattentive type
often includes cognitive impairment
more common in females

Attention-deficit/hyperactivity disorder, predominantly


hyperactive-impulsive type

Attention deficit/hyperactivity disorder, combined type


more common in males
Symptoms
Motor restlessness

Aggressive and disruptive behavior

Disorganized

Distractible

Inattentive symptoms
Diagnosis and Differential Diagnosis

Made primarily in clinical settings

Completion of behavior rating scales

A physical examination

Any necessary or indicated laboratory tests


Treatment

Psychosocial Treatments

Behaviorally Oriented Treatments

Medications
Cardiac evaluation of children and adolescents receiving or being
considered for stimulant medications.
Prognosis
Persistent ADHD throughout the life span.

60-80% of children with ADHD continue to experience symptoms in


adolescence

40-60% of adolescents exhibit ADHD symptoms into adulthood

Reduction in hyperactive behavior often occurs with age

Other symptoms associated with ADHD can become more


prominent with age
Untreated ADHD

Engaging in risk-taking behaviors (sexual activity,


delinquent behaviors, substance use)

Educational underachievement or employment difficulties

Relationship difficulties
Prevention

Parent training

Earlier detection, diagnosis, and treatment and prevention of


long-term adverse effects