Attention Deficit Disorder

ATTENTION AND HYPERACTIVITY

(ADHD)

Dr. Luis Rodriguez

Child Psychiatrist
Attention Deficit Hyperactivity Disorder (ADHD)
Definition
Neurobiological condition that can manifest throughout life.
Persistent and inappropriate pattern of inattention and/or hyperactivity-
impulsivity.
Symptoms present for more than 6 months.
It appears before the age of 7.
It generates dysfunction in school, work, social, and/or family performance.
It is presented in two or more places (e.g.: at school, at home, at work)
etc.)
Adapted from the American Psychiatric Association, DSM-IV TR, 2000.
ADHD is a Universal Disorder1
1Faraone S, Sergeant J, Gilberg C, Biederman J. World Psychiatry. June 2003; 2:2
Over-diagnosis?
Over-treatment?
jMore children are being referred, identified, and treated,
but
jADHD was immensely underdiagnosed and undertreated
in previous decades
jThere is no evidence that it is being over-
overdiagnosed or overmedicated (American Medical
Association / American Academy of Pediatrics
Less than 50% of children with ADHD in the communities
estudiadas, fueron identificados y tratados± esto es un adelanto,
but children's mental health services still have a lot of work to do
to reach the rest of the children.
The medication rate in the USA is 2-3%, while the
disorder exists in 5-8% of children ± many are not
receiving medication.
ADHD:
Causes
Current causal theory of ADHD
jADHD is a disorder of the Central Nervous System.
jMulticausal.
jThere is a genetic predisposition.
j Decrease in the availability of
Neurotransmitters (substances that facilitate the
neuron to neuron communication
j Specifically in norepinephrine and dopamine
Brain areas involved and their functions
SENSORY ORGANS AND
PARIETAL LOBE
Perception and localization
LIMBIC SYSTEM
Motivation and emotion
PREFRONTAL CORTEX
Executive function, analyzes, plans
Time management, control impulses
Judgment and critical thinking
HIPPOCAMPUS
Association,
recognition
Nucleus Accumbens and Striatum
Broadcast and interruption
LOCUS CERULEUS, SARA
Attention
State of alert
ADHD in Children
j IT IS NOT CAUSED BY:
Foods/Diets (sugar)
Poor care of children
Excessive television or video games
Hormones
ADHD:
EPIDEMIOLOGY
ADHD: Prevalence in Children
jPrevalence: 3%-7% of all school-aged children.
j More common in males:
4 men : 1 woman
Girls present to a greater extent
frequency of the subtype of inattention
j It is presented in all nations.
ethnic groups and social classes.
j60% show symptoms when they reach adulthood.
Goldman et al. JAMA. 1998; 279: 1100-1107. Barkley RA. Attention-deficit hyperactivity disorder. In: Mash
EJ, Barkley RA, eds. Child Psychopathology. 1996: 63-112.
TDAH:SINTOMASY
CLINICAL MANIFESTATIONS
ADHD Clinical Subtypes
Predominantly
Inattentive
20 - 30%
50 - 75%
Combined
<15%
Predominantly
Hyperactive
impulsive
Adapted from the American Psychiatric Association, DSM-IV TR, 2000.
DSM-IV Diagnostic Criteria
A. 1 or 2
1. Six (or more) symptoms of inattention for at least 6 months, not related to
level of development
a. Does not pay enough attention to details, or makes mistakes
due to
carelessness in schoolwork, work, or others.
Difficulty maintaining attention in tasks or recreational activities.
c. Seems not to listen when spoken to directly.
d. Does not follow instructions, does not complete school tasks, assignments
or
obligations at work.
Difficulties in organizing tasks and activities.
She dislikes or is reluctant to tasks that require mental effort.
prolonged.
He/She misplaces essential items for tasks or activities.
He gets easily distracted by irrelevant activities.
Neglect in daily activities.
DSM-IV Diagnostic Criteria (cont.)
2. Six (or more) symptoms of hyperactivity/impulsivity for at least 6 months,
not related to the level of development
a. Often moves hands, feet, or squirm in the seat.
b. He/she gets up from his/her seat in class or in other situations
where not
it is appropriate.
He/she runs or jumps excessively when it is inappropriate.
d. Difficulties in playing or engaging in recreational activities.
It is often in motion or acts as if it has an engine.
He/She often talks too much.
g. It rushes answers before they have been completed
the questions.
Difficulties in making an appointment.
Interrupts and interferes in the activities of others.
DSM-IV Diagnostic Criteria (cont.)
[Link] síntomas de hiperactividad-impulsividad o

attendance present before 7 years.

The symptoms occur in 2 or more environments.
Significant deterioration of academic activity,
social or labor
The symptoms are not due to other diseases.
mental conditions such as autism, schizophrenia, or others.
ADHD in preschool age (3-5 years)
jMotor hyperactivity (³always in
march with the engine on.
jAggressiveness (hits others).
jVery vigorous and even destructive game,
break objects.
j³Daring´² can take risks or
to risk others.
jInsatiable curiosity.
jDoes not obey.
jDemanding, discussing, noisy.
jInterrupts others.
jTantrums and tantrums.
DuPaul GJ, et al. J Am Acad Child Adolesc Psychiatry 2001;40:508-15.
ADHD: in school age (6 to 11 years)
jLow academic performance.
jEasily distracted.
jDifficulty organizing tasks,
with errors, incomplete, or loses them.
jFrequent warnings.
jNo waiting turns in games
jFrecuentemente fuera de su asiento.
jDifficulty in relationships with peers.
jPerceived as 'immature'
jHe refuses to help at home
jProne to accidents
jLow self-esteem.
j Aggressive.
jRespond before they finish
to ask.
jInterrupts and meddles
Greenhill LL. J Clin Psychiatry 1998;59 Suppl 7:31-41.
ADHD:
Evolution
ADHD in Adolescence
jInternal feeling of restlessness.
jLow self-esteem.
jDifficulty in relationships with peers.
j Unmodifiable behaviors with rewards or
punishments.
jEngages in risky activities (sexual,
substance abuse etc).
j Negligent or careless with their own safety
(accidents).
jSpecific learning disabilities.
jDifficulty organizing schoolwork and
poor results.
Greenhill LL. J Clin Psychiatry 1998; 59 Suppl 7: 31-41.
ADHD:

CONSEQUENCES AND
IMPLICATIONS
Consequences of ADHD in parents and family members
jIncreased stress in parents and relatives:
Concern and anxiety
Frustration and anger
j Low Self-Esteem in Parents and Family Members:
Self-blame and depression,
Social isolation and often self-imposed
jMajor Job Loss
jMajor marital disagreements
jGreater abuse of drugs and alcohol
Murphy KR, et al. Am J Orthopsychiatry 1996; 66: 93-102.
Academic Performance of children and

adolescents with ADHD

46.3%
50
40
29.3%
30
20
10.6%
10
0
They Are Expelled
They repeat at
less than 1 year
They do not complete the
secondary
Barkley RA. In Murphy KR, et al. 1998:197.
Risk of injuries in untreated children with ADHD
ADHD
Control
60

p<.001
Á p = .05

40
20
0
Á

Trauma in
or riding a bicycle The head
Multiple
injuries
Admitted to ICU
Injuries as a Pedestrian
DiScala C, et al. Pediatrics 1998; 102:1415-1421.
Traffic violations and accidents in adults with

ADHD that have never received treatment

*p=.004
p=.07
p=.01
90
Á
ADHD n=25
80
Control n=23
70

60
50
40
30
20
10
0
*

Á
Violations of Excess of
traffic speed
Drive
Suspension of Accidents
drunk
license
Caused by
The driver
Barkley RA, et al. Pediatrics 1996; 98: 1089-1095.
Without Borders:
Finding the keys
An International Survey of 930 Parents
Sponsored by:
Impact of ADHD on the Child
Results of the International Study
Disagree
Agreed
Limit academic
Worried that ADHD puts in
risk the academic success of the child
10
10
success
87
Worried that ADHD puts at risk
Limit career success
85
the success of the university career
The boy has been excluded from activities
social issues due to ADHD symptoms
Excluded from social
activities
36
58
39
The boy causes problems with others in the
Neighbourhood trouble
neighborhood
52
-100 -80
-60
-40
-20
0
20
40
60
80
100
Impact of ADHD on the family
Results of the International Study
disagree
Agree
Parents often stressed and worried
about your child's ADHD
Parent Stress
7
88
60
50
46
Our family activities
Disrupt family activities
they are altered
29
38
41
Our marriage has been negatively
affected
Marriage affected
Finding babysitters has been difficult
Babysitters
It's difficult to go places with my son.
Go places
43
46
-100 -80 -60
-40
-20
0
20
40
60
80
100
Conclusions of Existing Research1
In children
j25-70% have learning difficulties

j90% have poor academic performance

j50±70% have poor relationships with their peers

j25-45% develop antisocial behaviors

jGreater parental and family stress

1.
Barkley R A. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 1998, Guildford Publications, New York
SUMMARY
1. ADHD is a condition caused by the imbalance of
norepinephrine and dopamine in the CNS.
It has a hereditary pattern.
The prevalence is between 3% and 7% of school-aged children.
There are three subtypes: predominantly inattentive,
predominantly hyperactive and combined type.
5. The symptoms are present 24 hours a day and in 60%.
of cases continues into adulthood.
SUMMARY
6. It creates serious difficulties for functioning in school,
work, family and social environment.
Those people who do not undergo treatment risk not
desarrollar su potencial intelectual, a sufrir lesiones severas,
traffic accidents and other consequences.
ADHD treatments
ADHD treatment
Current treatment strategies for ADHD
j
include:
Pharmacological treatment
Stimulants
No stimulants
Psychoeducation for parents and teachers
Psychotherapeutic Treatment
Pharmacological and behavioral therapy is usually employed.
Unproven treatments for ADHD
j

Diet management.
jMegavitamins, antioxidants and/or minerals.
jSensory Integration Training.
j Chiropractic Manipulation of the Skull.
j Biofeedback.
Wolraich ML, et al. Clinical Pediatrics 1997; 36(9): 497-504.
What medications can and cannot do
to do
What medications can
to do
What medications cannot
to do
Decrease the level of activity
Calm down for a longer time.
Teach good behavior.
Teaching to reflect.
Teaching social skills.
Allow to concentrate for longer.
Make more precise work.
Improve attention.
Teach past school supplies.
Teach to determine what it should be
concentrate.
Decrease impulsivity.
Better comply with the rules.
Think before acting.
Teaching to manage feelings.
Make the child happy.
Be less aggressive.
Motivate the child.
Managing frustration.
Solve learning problems.
Conclusions:
jADHD is a neurobiological disorder related to chemistry and
anatomy of the brain.
jThe symptoms of inattention and/or hyperactivity-impulsivity are more
frequent and severe than in other children.
jThe child suffers from it 24 hours a day.
jSymptoms do not disappear with age in most cases.
jThe treatment must be multidisciplinary. Work with a doctor, psychologist,
teaching staff and the parents.
jIts goal is to improve academic, family, and social performance.
work-related.
Thank you