Attention Deficit Hyperactivity Disorder ADHD In children

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Attention Deficit Hyperactivity Disorder (ADHD)
In children

• Dr. Samir Khalil
• Consultant in Pediatric Neurology
• Dept. of Pediatrics Makassed Hosp. Jerusalem
• Clinical Assistant Professor
• Medical School, Al-Quds University
• September 2001

2
References

• Diagnosis and evaluation of the child with
  Attention-Deficit-Hyperactivity Disorder.
• Clinical Practice Guidelines
• American Academy of Pediatrics / Committee on
  Quality Improvement, Sub-committee on Attention
• Deficit / Hyperactivity Disorder.
• 5 May 2000
• Treatment of the School-Aged child with
  Attention-Deficit-Hyperactivity Disorder.
• Clinical Practice Guidelines
• American Academy of Pediatrics / Committee on
  Quality Improvement, Sub-committee on Attention
• Deficit / Hyperactivity Disorder.
• 4 October 2001
• Evidence Based Management Of Attention-Deficit-Hyp
  eractivity Disorder.
• Evidence Based Pediatrics
• BMJ Vol. 24 November 2001
• Randomized, Controlled Trial of OROS
  Methylphenidate Once a Day in Children with
• Attention-Deficit / Hyperactivity Disorder.
• Pediatrics Vol. 108 No.

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ADHD

Definition
Developmentally inappropriate degree of
3 core symptoms See criteria chart
in the school or home setting
(American Psychiatric Association)
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ADHA
Introduction

• The most common neurological behavior disorder of
  
• childhood.
• 
  

• Hyperkinesia
• Hyperkinetic syndrome
• Minimal Brain Dysfunction
• (MBD)
• Attention Deficit Syndrome
• with Hyperactivity ADSH,

Many concepts were used to describe this same
disorder
Finally under ADHD
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Etiology
Attention subsumes a series of control mechanisms
through which the CNS regulate behavior and
learning
Unknown cause
Attention deficit shows various patterns of
impairment of these control mechanisms
Resulting symptoms affect Learning, behavior and
social interaction.
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Etiology
Hypothesis

• Genetic Hypothesis
• Factors affecting brain development during
  prenatal early
• postnatal.
• Environmental factors
• Social disadvantages (Large family size over
  crowding)
• Catecholamine hypothesis (Dopamine deficiency)
• Experimental studies
• Abnormal dopamine turnover in CNS low dopamine
• concentration in CSF.
• Norepinephrine Serotonin hypothesis
• Stimulants increase the release of such neuro
  transmitters.

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Epidemiology
Incidence
One of the most common chronic conditions of
childhood
10 using DSM IV 4-12 among school aged
group

• Male
• Hyperactive type

Female inattentive type (academic under
achievement)
Male / female 31
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Diagnostic Criteriasee chart
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Diagnosis
DSM-IV criteria

• Target children from 6 to 12 yr. of age.
• Obtain information in more than one sitting
• Home
• Community
• School ()
• Search for coexisting conditions that may make
  the diagnosis more difficult (and so complicate
  treatment planning).

Diagnostic Statistical Manual of Mental Health
Disorders, 4th Edition Criteria
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ADHD 3
sub types

• Combined Type
• If both criteria A1 and A2 are met for the past 6
  months.
• Inattentive Type
• If criterion A1 is met but criterion A2 is not
  met for the past 6 months.
• Hyperactive, Impulsive Type
• If criterion A2 is met but criterion A1 is not
  met for the past 6 months.

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Diagnosis Exclusions /
DSM-IV criteria

• Mental Retardation.
• Pervasive developmental disorder.
• Moderate to sever sensory deficit
  (visual hearing impairment).
• Chronic disorder associated with medication that
  may effect behavior.

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ADHD
Laboratory Findings

• CBC.
• Growth parameters.
• EEG
  (R/O absence
  epilepsy)
• CT scan and MRI
  (non useful diagnostic value)
• Hearing assessment
• Visual assessment

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ADHD Psychological
Testing

• Test of intelligence
• Educational achievement (WRAT), ( PIAT).
• Tests of sustained attention (eg. continuous
  performance tests )
• Behavior rating scales.

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ADHD AAP Diagnostic Recommendations 1
(May 2000)

• In a child 6 to 12 years old who presents
• with inattention, hyperactivity, impulsivity,
• academic underachievement, or behavior
• problems, primary care clinicians should
• initiate an evaluation for ADHD.

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ADHD AAP Diagnostic Recommendations 2
(May 2000)

• The diagnosis of ADHD requires that a child
• meet DSM-IV criteria

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ADHD AAP Diagnostic Recommendations 3
(May 2000)

• The assessment of ADHD requires evidence
• directly obtained from parents or caregivers
• regarding the core symptoms of ADHD in
• various settings, the age of onset, duration
• of symptoms, and degree of functional
• impairment.

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ADHD AAP Diagnostic Recommendations 4/b
(May 2000)

• The assessment of ADHD requires evidence
• directly obtained from the class room teacher
• (or other school professional) regarding the
• core symptoms of ADHD, the duration of
• symptoms, the degree of functional
• impairment, and coexisting conditions.

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ADHD AAP Diagnostic Recommendations 4/b
(May 2000)

• A physician should review any reports from
• a school-based multidisciplinary evaluation
• where they exist, which will include
• assessments from the teacher or other
• school-based professional.

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ADHD AAP Diagnostic Recommendations 5
(May 2000)

• Evaluation of the child with ADHD should
• include assessment for coexisting conditions.

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ADHD
Special Information

• Activity should be thought of, not only in terms
  of
• actual movement, but also in terms of variations
  in
• responding to touch, pressure, sound, light, and
• other sensations.
• For the infant and young child, activity and
  attention
• are related to the interactions between the child
  and
• Caregiver (teacher), eg, when sharing attention
  and
• playing together.

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ADHD
Special Information

• Activity and impulsivity often normally increase
• when the child is tired or hungry and decrease
  when
• sources of fatigue or hunger are addressed.
• Activity normally may increase in new situations
  or
• when the child may be anxious. Familiarity then
• reduces activity.

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ADHD
Special Information

• Both activity and impulsivity must be judged in
  the
• context of the caregivers expectations and the
  level
• of stress experienced by the caregiver.
• When expectations are unreasonable, the stress
• level is high.
• When the parent has an emotional disorder
• (especially depression), they may exaggerate the
• childs level of activity/impulsivity.

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ADHD
Special Information

• Activity level is a variable of temperament.
• The activity level of some children is on the
  high
• end of normal from birth and continues to be high
• throughout their development.

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ADHD Differential Diagnosis Developmental
Variations of Impulsive/Hyperactive Behaviors

• High levels of hyperactive/impulsive behavior do
• not indicate a problem or disorder if the
  behavior
• does not impair function.
• In early childhood the child runs in circles,
  doesnt
• stop to rest, may bang into objects or people,
  and
• asks questions constantly.

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ADHD Differential Diagnosis Developmental
Variations of Impulsive/Hyperactive Behaviors

• In middle childhood the child plays active games
• for long periods. The child may occasionally do
• things impulsively, particularly when excited.
• In Adolescence, the adolescent engages in active
• social activities (eg, dancing) for long periods,
  may
• engage in risky behaviors with peers.

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ADHD Differential
Diagnosis

• Absence seizure
• Sensorial deficit (audition)
• Lead toxicity (irritability).
• Medical condition (thyroid dysfunctions)
• Medicine ( Phenobarbital, Theophylin)
• Other psychiatric disorder

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ADHD
Management
Golden Rule

• The initiation of treatment requires the accurate
  establishment of the diagnosis of
• ADHD

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ADHD Management Plan
Basics

• Identification of target outcomes
• To agree on at least 3-6 key target and desired
  changes.
• The goals should be realistic, attainable and
  measurable).
• Development of a comprehensive treatment plan.
• Assessment of response to treatment plan.

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ADHD Primary goals of
treatment

• Maximize function.
• Improve inter-relationships with parents,
  sib-lings, teachers, and peers
• Reduce mechanisms of ADHD.
• Improve ability to follow order.
• Decrease emotion over activity.
• Decrease disruptive behaviors

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ADHD Primary goals of
treatment

• Improve academic performance, particularly in
  volume of work, efficiency, completion, and
  accuracy.
• Increase independence in self-care or home-work.
• Improve self-esteem.
• Enhance safety in the community, such as in
  crossing streets or riding bicycles.

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ADHD Treatment
methods

• Treatment management (medications alone).
• Behavior management alone.
• Combined management (medications behavior).

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ADHD Questions faced during elaboration
of management plan and follow up

• Is response to treatment (stimulant medication
  and/or behavior reinforcement) plan adequate ?
• Is the child taking his medication? (Adherence to
  the plan)
• If only on medication, is it needed to reinforce
  with behavior therapy ?
• Have all stimulant medications been tried ?

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ADHD Questions faced during elaboration
of management plan and follow up

• Is it justified to consider another stimulant
  medication ?
• Is it justified to consider second-line
  medications after all stimulants have been tried
  ?
• The educational system plays an important role in
  the treatment and monitoring of children with
  ADHD.

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ADHD AAP Management Recommendations 1
(Oct 2001)
Clinical Practice Guideline

• Primary care clinicians should
• establish a management program
• that recognizes ADHD as a chronic
• condition.

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ADHD AAP Management Recommendations 2
(Oct 2001)
Clinical Practice Guideline

• The treating clinician, parents, and
• the child, in collaboration with
• school personnel, should specify
• appropriate target out-comes to
• guide management.

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ADHD AAP Management Recommendations 3/A
(Oct 2001)
Clinical Practice Guideline

• The clinician should recommend
• stimulant medication (strength of
• evidence good) and/or behavior
• therapy (strength of evidence fair),
• as appropriate, to improve target
• outcomes in children with ADHD.

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ADHD AAP Management Recommendations 3/B
(Oct 2001)
Clinical Practice Guideline

• For children on stimulants, if one
• stimulant does not work at the
• highest feasible dose, the clinician
• should recommend another.

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ADHD AAP Management Recommendations 4
(Oct 2001)
Clinical Practice Guideline

• When the selected management for a
• child with ADHD has not met target
• outcomes, clinicians should evaluate
• the original diagnosis, use of all
• appropriate treatments, adherence to
• the treatment plan, and presence of
• coexisting conditions.

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ADHD AAP Management Recommendations 5
(Oct 2001)
Clinical Practice Guideline

• The clinician should periodically
• provide a systematic follow-up for the
• child with ADHD. Monitoring should be
• directed to target outcomes and
• adverse effects by obtaining specific
• information from parents, teachers,
• and the child.

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Prognosis

• Symptoms of ADHD abated over times.
• But persists in
• 22-85 of adolescents (AAP 60-80?)
• 4-50 of Adults.
• 
  ......................continued to meet criteria
  for its Diagnosis.
• Children in highest group of attention
  difficulties should the highest proposition of
  school failure (60) by age 18.

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Drug therapy

• 1st Line treatment
• Methylphenidate
• Dextroamphetamine
• 2nd Line treatment
• Tricyclic Antidepressants
• Bupropion
• Hypotensive (clonidine,

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• Stimulants are highly effective in the management
  of core symptoms of ADHD (inattention,
  impulsivity and hyperactivity) and in improving
  social and class room behavior. Also it improves
  the childs ability to follow rules and decreases
  emotional over-reactivity, thereby leading to
  improved relationships with peers and parents
• Short-term efficacy of stimulant medications in
  reducing core symptoms is evident. Long-time
  effect is unclear.
• The effect on intelligence and achievement test
  are modest.

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• Individual children, may respond to one of the
  stimulants but not to another.
• No significant difference in outcome between
  short-, intermediate- or long-acting forms.
• Recommended stimulants require no serologic,
  hematologic, or electrocardiogram monitoring.
• Not weight dependent. The best dose of medication
  is the one that leads to optimal effects with
  minimal side effects
• Start with a low dose and titrate upward (marked
  individual variability in the dose-response
  relationship).
• The first dose that a childs symptoms respond to
  may not be the best dose to improve function.
  Clinicians should continue to use higher doses to
  achieve better responses.

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• Reduce the dose when a higher dose produces side
  effects or no further improvement.
• The dosing schedules vary depending on target
  outcomes. For example, if there is a need for
  relief of symptoms only during school, a 5-day
  schedule may be sufficient. By contrast, a need
  for relief of symptoms at home and school
  suggests a 7-day schedule.
• Generally considered safe medications with few
  contraindications to their use.
• Side effects occur early in treatment and tend to
  be mild and short-lived.
• No Dose-related growth delays.

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The most common side effects are

• Decreased appetite,
• Stomachache
• Headache,
• Delayed sleep onset,
• Jitteriness,
• Social withdrawal.
• Motor tics in 15 to 30 of children. Most of
  which are transient. Half of children with
  Tourette syndrome have ADHD. Is not an absolute
  contraindication to the use of stimulant
  medications
• Psychotic reactions, mood disturbances, or
  hallucinations.

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• Most of these symptoms can be successfully
  managed through adjustments in the dosage or
  schedule of medication.
• Contraindications to stimulants
• Seizure disorders,
• A history of seizure disorder, or
• Abnormal EEGs.
• However, no increase in seizure frequency or
  severity when it is added to appropriate
  anticonvulsant medications.

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Tricyclic antidepressants and Bupropion

• Positive effects on ADHD symptoms.
• VS. methylphenidate either no differences in
  response or slightly better results with
  stimulant use.
• Select after the failure of 2 or 3 stimulants.
• Desipramine use has been associated, in rare
  cases, with sudden death.

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Clonidine

• one of the anti-hypertensive drugs occasionally
  used in the treatment of ADHD
• Effect sizes lower than those for stimulants.
• In children with ADHD and coexisting conditions,
  especially sleep disturbances.

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Behavior Therapy

• Represents a broad set of specific interventions
  that have a common goal of modifying the physical
  and social environment to alter or change
  behavior.
• Usually is implemented by training parents and
  teachers in specific techniques of improving
  behavior
• Behavior therapy then involves providing rewards
  for demonstrating the desired behavior (eg,
  positive reinforcement) or
• Consequences for failure to meet the goals (eg,
  punishment).
• Repetitive application of the rewards and
  consequences gradually shapes behavior Although
  behavior therapy
• Along with behavior therapy, most clinicians,
  parents, and schools address a variety of changes
  in the childs home and school environment
  (environmental modifications).