Attention-Deficit/

Hyperactivity Disorder


Hicham Baba - Med3

Psychiatry Clerkship
 ADHD: Definition

 Most common
neurobehavioral disorder
in children
 It is characterized by:
1. Inattention
2. Hyperactivity
 Inappropriate excessive
motor activity
3. Impulsiveness
 Hasty, without forethought
Harmful to self

 Subtypes
 Predominantly inattentive
 Predominantly hyperactive/impulsive
 Combined type
 Epidemiology
 Prevalence:

 5-9% of school-age children
 2-6% of adolescents
 2.5% of adults
 2:1 male-female ratio.
 Females present with ADD
 Several symptoms present before age 12
 Symptoms occur in at least 2 settings

 The incidence of ADHD appears increased in children with

neurologic disorders such as epilepsies, neurofibromatosis,
tuberous sclerosis.
 Relevance

Children often have a bad
experience with:
 School
 Academic problems
 Relationship issues
 Family
 Self-esteem
 Future likelihood of conduct and antisocial disorders
 Risk Factors

 Maternal drug use
 Alcohol use
 Lead and mercury exposure
 Birth complications, such as
toxemia, lengthy labor, and
complicated delivery.
 Very low birth weight
 Etiology

 There is a very strong genetic component to ADHD.
 Genetics: DAT1 and DRD4 dopamine genes
 Structural:
 atrophied prefrontal cortex and basal ganglia (~10%)
 low blood flow to the striatum
 These areas are rich in dopamine

 20% of children with severe traumatic brain injury are

reported to have subsequent onset of substantial symptoms
of impulsivity and inattention.
Symptoms

 Symptoms >6
predominantly inattentive <-> combined <-> predominantly hyperactive/impulsive


 Diagnosis of ADHD

 Careful history and clinical interview
 Completion of behavior rating scales by different observers
from at least 2 settings (teacher and parent);
 A physical examination; and any necessary or indicated
laboratory tests which arise from conditions suspected based on
history and/or physical examination
 No specific test to diagnose
 FDA has approved the Neuropsychiatric EEG-Based
Assessment Aide (NEBA) system, which may identify an
abnormal theta : beta wave ratio associated with ADHD.
Behavior Rating Scales

 Differential Diagnosis

 Absence seizures  Disruptive mood
 Migraine dysregulation
 Asthma and allergies,  Depression and bipolar
 Hematologic disorders  Autism
 Diabetes, cancer  Tourette
 Substance abuse  Specific learning
 Sleep disorders  Intellectual disability
 Restless leg syndrome  Personality (borderline,
 Oppositional defiant narcissistic…)
 Intermittent explosive  OCD
 Adjustment
 Associated Disorders

 Of children with ADHD:
 15-25% have learning disabilities,
 30-35% have developmental language disorders,
 15-20% have diagnosed mood disorders,
 20-25% have coexisting anxiety disorders.

 Children with ADHD can also have co-occurring diagnoses

of sleep disorders, memory impairment, and decreased motor
skills.
ADHD and adulthood

 TREATMENT

Age Therapy
4-5 years Behavioral mainly
6-11 years Behavioral + Pharma
12-18 years Pharma mainly
 TREATMENT

1- Behavioral Therapy
Initial therapy when:
 Symptoms are mild with minimal impairment
 Diagnosis is not certain, or disagreement parent/teacher
 Parents reject medication treatment
Outcomes:
 Improve behavior, control and self-esteem
 Most effective when given by parents (w/ doctor support)
 TREATMENT

2- Pharmacological Therapy
Stimulants
 Dextroamphetamine (DEX)
 Methylphenidate (Ritaline) (don’t use <6yo)
 Mixed salts amphetamine,

Most common side effects of stimulants is weight loss and decreased appetite

Non-stimulants
 Atomoxetine (co-substance/anxiety/tics)
 Alpha-2 agonists (clonidine, guanfacine)
ADHD - Summary


 References

 DSM V
 Kaplan and Saddock
 Uworld
 Google.images.com
 Dr. Tahan’s lecture during Med2