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attentiondeficiethyperkineticdisorder.pdf
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- 2. INTRODUCTION • Attention deficithyperactivity disorder (ADHD) is defined as a pattern of inattentive and hyperactive impulsive behavior inconsistent with developmental level which interferes with functioning in social, educational or work setting. • Chronic disorder which can cause impairment into adolescence and adulthood. • Core symptoms - selective inattention, sustained attention , hyperactive symptoms and impulsive symptoms.
- 5. PSYCHOPATHOLOGY • Selective attention- loop of dorsal anterior cingulate cortex (dACC) projecting to the striatal complex then the thalamus and then back to dACC. • Sustained attention - cortico striato thalamo cortical loop that involves the dorsolateral prefrontal cortex.
- 8. • Impulsivity - corticostriato thalamo cortical loop that involves the orbitofrontal cortex. • Impulsive - talking excessively, blurting things out, not waiting one’s turn and interrupting.
- 9. • Motor activity- cortico striato thalamo cortical loop from the prefrontal motor cortex to the putamen to the thalamus and back to the prefrontal motor cortex. • Hyperactivity - fidgeting, leaving one’s seat, running, being constantly at the go and having trouble playing quietly.
- 10. ETIOLOGY ● Highly heritablecondition (upto 75%). Identified about 25-45 genes based on genome-wide scans. DAT1 and DRD4 genes are commonly implicated. ● 2 to 8 times increased risk in siblings and parents of ADHD. ● Prematurity is an important factor. Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbidity. ● Imaging studies have detected differences in the neural structure. ● Brain maturation appears delayed and structural and functional connectivity are affected. ● Dopaminergic pathways are implicated. ● Underlying hypothesis - yet to be developed.
- 11. • Traditionally, achildhood disorder but this perspective is rapidly changing with ADHD now being seen also as a major psychiatric disorder of adults. • Classic form of ADHD - Onset by 7 years. • Synapses rapidly increase in prefrontal cortex by age six and upto half of them are rapidly eliminated by adolescence. • Timing of onset of ADHD suggests that formation of synapses and importantly the selection of synapses for removal in prefrontal cortex during childhood may contribute to the onset and lifelong pathophysiology. • Those who are able to compensate for these prefrontal abnormalities by new synapse formation may be the ones who ‘’grew out of their ADHD’’ and this may explain why prevalence of ADHD in adults is only half that in children and adolescents.
- 12. GENETICS OF ADHD •THYROID RECEPTOR B GENE • DOPAMINE TYPE D2 RECEPTOR GENE • DOPAMINE TRANSPORTER GENE • DOPAMINE 4 RECEPTOR GENE
- 13. KEY NEUROTRANSMITTERS INADHD AND THEIR AMINO ACID PRECURSOR • Dopamine regulates attention, impulse control and pleasure-seeking. • Norepinephrine plays a major role in attention and emotional/behavioral regulation.
- 14. PREVALENCE OF ADHD Prevalenceof ADHD - 5% in Children and 2.5% in adults (APA 2013) INDIAN DATA: Prevalence of ADHD among primary school children was found to be 11.32%. Prevalence was found to be higher among the males, prevalence was found to be highest between the age group of 9 and 10 years. (Venkata et al, IJP 2013)
- 15. CLINICAL FEATURES • Mostcited characteristics of children with ADHD in order of frequency - hyperactivity, attention deficit, impulsivity, memory and thinking deficits, specific learning disabilities, speech and hearing deficits. • Associated features - perceptual motor impairment, emotional lability and developmental coordination disorder. • Significant percent - aggression and defiance. • Overactivity usually the first symptom to remit while distractibility is the last. • Hyperactivity - inappropriate excessive motor activity - restlessness, fidgeting and appearing to be driven by a motor. • Behavior first noticed when the child is a toddler but can be normative before age 4.
- 16. ● Level ofgross motor activity usually decreases with age however the inner sense of restlessness may continue into young adult life. ● Hyperactivity decreases when child is engaged in an activity they find particularly engrossing such as playing video games. ● Impulsivity - actions without forethought about consequences and may be associated with desire for immediate rewards or to avoid delay. ● Impulsivity - seen when the child engages in dangerous activities, yells out in class or interrupts or intrudes on others during games or conversations. ● Impulsive behavior might result in trouble with parents, teachers or other children including verbal or physical fights. ● Symptoms of impulsivity can persist into adulthood even after hyperactive symptoms have diminished.
- 17. • Inattention -difficulty sustaining focus, trouble maintaining organization and being easily distracted by extraneous stimuli. • Symptoms of inattention become prominent in elementary school when the child is approximately 8 to 9 years old and symptoms can be lifelong. • Sluggish Cognitive Tempo (SCT) is a type of attentional difficulty associated with the inattentive subtype of ADHD. • SCT describes a constellation of symptoms - daydreaming, staring, tendency towards confusion, mental fogging, sleepiness, apathy and physical hypoactivity. • Growing evidence suggesting that SCT is a condition distinct from ADHD, however SCT is currently not considered a separate disorder or diagnostic subtype.
- 18. ASSOCIATED FACTORS • Difficultywith time management and do not develop an internal sense of pace in planning tasks. • Poor sense of time leads to problems in estimating the actual difficulty of waiting in line, planning how much time a task requires or even knowing when to come home when playing with other children. • Problems in emotion regulation, resulting in temper outbursts, mood lability and reactivity. • Moods can change dramatically with no obvious connection with what is going on in the environment. • Social skills are often significantly impaired. • Face peer rejection because of their overreactivity in social situations, which has been shown to be a reliable long term negative predictor of development particularly in adolescence. • Approximately 60 percent of children with ADHD continue to be impaired in adult life.
- 19. Diagnostic Criteria: Comparative ICD-10CRITERIA DSM-5 CRITERIA Simultaneous hyperactivity, impulsivity and inattentiveness Symptoms can now occur by age 12 rather than by age 6 Symptoms prior to 6 years of age and of long duration. New descriptions were added to show what symptoms might look like at older ages Diagnosis of HKD may also be made in adult life using the same criteria, however, attention and activity must be judged with reference to developmentally appropriate norms. For adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children 19
- 20. COMORBIDITIES - 65to 70% have one or more
- 22. EEG CHANGES INADHD • Slow wave activity • Increased theta in frontal and prefrontal region • Increased alpha and beta in posterior regions
- 23. Diagnosis • Detailed medicalhistory including family history and developmental history • Rating scales should not be used independently, but can be particularly helpful in establishing the presence of core ADHD symptoms in more than one setting. • ADHD-specific scales have been found to have greater than 90 percent sensitivity and specificity if used in the correct population. • Commonly used rating scales: • Conners Rating Scales for parents (CPRS-R) and teachers (CTRSR), Adolescent Self-Report Scale, • Vanderbilt ADHD Diagnostic Parent and Teacher Scales • Swanson, Nolan and Pelham (SNAPIV) • Brown ADD Rating Scales for Children, Adolescents, and Adults
- 24. MANAGEMENT ● Pharmacologic treatmentis considered the first line. ● Central nervous system stimulants are the first choice of agents. Shown to have the greatest efficacy with generally mild tolerable side effects. ● Stimulants are contraindicated in children, adolescents, and adults with known cardiac risks and abnormalities. ● Two group of stimulant medication that have achieved F.D.A approval are amphetamines and methylphenidates.
- 25. Methylphenidate • Works byincreasing norepinephrine and dopamine action action by blocking their reuptake. • Enhancement in dorsolateral prefrontal cortex improves attention, concentration, executive function and wakefulness. • In medically healthy youth, excellent safety records are documented for short and sustained-release preparations. • Newer preparations - methylin, a chewable form of methylphenidate; daytrana, a methylphenidate patch; and dexmethylphenidate, the denantiomer (Focalin), and its longer acting form Focalin XR. • Onset of action – 30 minutes • Can take several weeks to attain maximum benefit. • Usual dose range – 2.5 to 10 mg twice per day. • Has habit abuse potential. • Should be carefully tapered.
- 26. Side Effects ● CNS– insomnia, headache, nervousness , irritability, tremors, dizziness, exacerbation of tics, rare is neuroleptic malignant syndrome. ● GI - anorexia, nausea, abdominal pain, weight loss ● CVS - palpitation, tachycardia, hypertension, sudden death in patients with pre existing cardiac structural abnormalities.
- 27. AMPHETAMINES ● Amphetamine ismanufactured as immediate release formulation. ● Work by increasing norepinephrine and dopamine action by blocking their reuptake and facilitating their release. ● Enhancement in dorsolateral prefrontal cortex improves attention, concentration, executive function and wakefulness. ● Dosing – in ADHD for ages 6 years and older, initially 5 mg per day can increase by 5 mg each week, generally first dose is given on waking. ● Dose range – 5 to 40 mg per day. ● High habit forming potential ● Careful supervision is required during withdrawal from abusive use since severe depression may occur. ● Amphetamine works in patient not responding to other stimulants.
- 28. Vyvanse • Vyvanse (lisdexamfetaminedimesylate) is a pro-drug of dextroamphetamine, which requires metabolism by R.B.C and intestinal metabolism in order to reach its active form. • Approved by FDA for children 6 years and older. • Inactive until it is metabolized, is a less likely agent to have risks of abuse or overdose. • Side effects and efficacy similar to the other forms of amphetamines. • Less abuse potential as used intravenously or intanasaly has similar effects to oral administration.
- 29. • Current strategiesfavor once a day sustained-release stimulant preparations for their convenience and diminished rebound side effects. • Advantages of the sustained-release preparations for children are that one dose in the morning will sustain the effects all day. • Child is no longer required to interrupt his or her school day. • Physiological advantage is that the medication is sustained at an approximately even level in the body throughout the day so that periods of rebound and irritability are avoided.
- 30. • Methylphenidate preparationshave been shown to be highly effective in up to three fourths of children, with relatively few adverse effects. • Concerta, the 10- to 12-hour extended-release OROS (osmotic controlled-release extended delivery system) form of methylphenidate, is administered once daily in the morning and is effective during school hours as well as after school during the afternoon and early evening. • Shorter forms of methylphenidate and Concerta have similar common adverse effects including headaches, stomach aches, nausea and insomnia. • Some children experience a rebound effect, in which they become mildly irritable and appear to be slightly hyperactive for a brief period when the medication wears off.
- 31. • During periodsof use, methylphenidate is associated with slightly decreased rates of growth, and if used over many years continuously without any drug holidays growth suppression of about several centimeters has been noted. • When given “drug holidays” on weekends or summers, children tend to eat more and also make up the growth. • Amphetamine and Methylphenidate both share the ability to reduce gross motor over activity, increased sustained attention on tasks and reduce impulsive response on laboratory measures. • Some individuals respond preferably to MPH while others respond to amphetamines. • Majority of evidence indicates that MPH and amphetamine are equally efficacious.
- 32. NONSTIMULANT MEDICATIONS • Usedfor non responders or those who experience moderate to severe adverse events. • Considered first line in individuals whose parents have a personal objection to stimulants or the child has comorbid anxiety symptoms or severe stimulant side effects. • Atomoxetine and clonidine are the FDA approved non stimulant medications.
- 33. Atomoxetine • Atomoxetine HCl(Strattera) is a norepinephrine uptake inhibitor approved by the FDA for children age 6 years and older. • Mechanism of action is not well understood, but it is believed to involve selective inhibition of presynaptic norepinephrine transporter. • Absorbed by the gastrointestinal tract, and maximal plasma levels are reached in 1 to 2 hours after ingestion. • Shown to be effective for inattention as well as impulsivity. • Half-life is approximately 5 hours and it is usually administered twice daily. • Most common side effects - diminished appetite, abdominal discomfort, dizziness, and irritability. • In some cases, increases in blood pressure and heart rate have been reported.
- 34. ALPHA-ADRENERGIC AGONISTS • Clonidineand guanfacine should be tried in suboptimal response to psychostimulants, or in whom they cannot be tried. Can be used along with stimulants. • Newer controlled-release formulations are better. • Selective alpha (2A) adrenoceptor agonist, guanfacine extended-release is a once a day formulation that significantly improves the symptoms of inattention and hyperactivity-impulsivity in a dose range of 1-4 mg/day.
- 35. Management of AdverseEffects of Medication
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- 37. Dietary Advice • Minorityof children might benefit from free fatty acid supplementation. • Restriction of artificial food colourants (red and yellow) can also help a minority of children. • Some parents who suspect their children’s behaviour is affected by the food they eat have observed improvement after elimination of certain foods after following a strict elimination diet.
- 38. PSYCHOEDUCATION • Information regardingcore symptoms, diagnostic criteria, etiology and empirically supported treatments (of ADHD, ODD, or CD) • What is and why the parent training • Parent child coercive interaction cycle • Antecedent-Behavior-Consequence (ABC) model
- 39. Parent child coerciveinteraction cycle
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- 41. POINT SYSTEM ORTOKEN ECONOMY • Child earns token, points, or privileges for positive behavior at home and then that can be cashed in for rewards or valued activities – Target behavior should be clearly observable and specific – Points should be assigned weighted by importance or difficulty level – Set point costs for each reward based on the total points that the child can earn in any given day or week – Use reward list (star chart)
- 42. Behavior Modification • Behaviormodification has been successfully applied to the classroom with a meta analysis of 70 studies showing an effect size of 0.6 SD compared to an attention control condition. • In contrast, CBT has not shown to be effective. • ADHD is a chronic condition for which ongoing long term monitoring and treatment is required to optimize functioning.
- 43. SENSORY INTEGRATION THERAPY -Based on A. Jean Ayres' theory of sensory integration “Sensory diets”
- 46. THE ALERT PROGRAM •Mary Sue Williams and Sherry Shellenberger • Self regulation • How does your engine run? • Too fast? : squeezing balls, dimming lights and listening to relaxing music • Too slow? : fast music, tickling, dancing, bright lights
- 47. BRAIN GYM • PAULE. DENNISON • Improve communication between right and left side of the brain • Pseudoscience
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- 49. TRICKS FOR PARENTS •Proximity control: increase supervision of the child • Utilize checklists and to-do lists • Use cue devices such as verbal reminders, alarm clocks, and post-its • Give child scripts for problem situations and practice regularly • Break tasks down into small steps • Give breaks to child during tasks as needed • Use social stories that teach emotional control • Make tasks interesting for students • Give child something fun to do when task is completed • Provide attention and praise when student is remaining on task • Create a visual cue to prompt child to get started, such as a note on their desk • Walk through the first part of the task to help child get started • Have child tell you when they will begin the task and cue them when the time arrives • Plan a schedule for the child
- 50. SIKSTROM AND SODERLUND’S MODERATEBRAIN AROUSAL THEORY - Moderate noise is beneficial for cognitive performance whereas both excessive and insufficient noise is detrimental. - MBA model suggests that the amount of noise required for optimal cognitive performance is modulated by levels of dopamine.
- 51. CLASSROOM SETUP • SeatADHD student away from distractions, preferably front and center • Seat student near a good role model • Increase distance between desks to decrease distractions • Create a cool-down area • Play quiet music • Create a stage for announcements in the classroom
- 52. Multimodal Treatment Studyof Children with ADHD • The National Institute of Mental Health supported Multimodal Treatment Study of Children with ADHD that involved RCT trials based on four different treatment strategies: 1. medication management 2. behavior therapy 3. combination 4. community care • The combination treatment had significantly better outcomes that any other treatment modality.
- 53. Adult ADHD • Longitudinalfollow up has shown that 60 percent of children with ADHD have persistent impairment from symptoms into adulthood. • Residual signs of the disorder include impulsivity and attention deficit (difficulty in organizing and completing work, inability to concentrate , increased distractibility and sudden decision making without thought of the consequences). • Many people have a secondary depressive disorder with low self esteem related to their impaired performance which affects both occupational and social functioning. ▪ Children initially diagnosed with ADHD combined (inattention and hyperactivity-impulsivity) type exhibit fewer impulsive hyperactive symptoms as they get older and by the time they are adults will meet criteria for ADHD inattentive type. ▪ Treatment in adult ADHD is similar to that used in children and adolescents with ADHD. In adults only long acting stimulants are FDA approved.
- 54. REFERENCES ● Venkata JA,Panicker AS. Prevalence of attention deficit hyperactivity disorder in primary school children . Indian J Psychiatry 2013;55:338-42 ● Stahl’s essential psychopharmacology ● Kaplan and sadock’s comprehensive textbook of psychiatry. ● Synopsis of psychiatry eleventh edition.