Attention Deficit

ATTENTION DEFICITHYPERACTIVITY DISORDER

Jose David Gamez Godoy, M.D.

ADHD

• Most common neurobehavioral disorder of childhood

• Inattention, including increased distractibility and difficulty sustaining attention

• Poor impulse control and decreased self inhibitory capacity

• Motor over activity and motor restlessness

American Psychiatric Association’s Diagnostic and Statistical Manual (DMS-IV)

ETIOLOGY• Birth complications• Maternal drug use• Maternal smoking and alcohol• Genetic component• Exposure to toxins• High sensitivity to food colorings and additives

Eigenmann PA, Haenggeli CA: Food colorings, preservatives and hyperactivity. Lancet 370:2007

• Abnormal brain structures• Severe traumatic brain injury• Psychosocial family stressors• Family history approximately 80%• Maternal stress

Grizenko et al, Relation of maternal strees during pregnancy to symptom severity and response to treatment in children with ADHD, Rev Psychiatr Neurosci 2008

EPIDEMIOLOGY

• Prevalence 2-18% school aged children• 2-6% adolescents• 4.4 million children aged 4-17 years• 11% boys and 4.4% girls• 4:1 hyperactive and 2:1 inattentive• 56.3% treated with medication• Health care costs $3.3 billion annually• Comorbid psychiatric diagnoses

CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003

EPIDEMIOLOGY

Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health, 2003

CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003

EPIDEMIOLOGY

Percent of Youth 4-17 ever diagnosed and currently medicated for Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health, 2003

CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003

PATHOGENESIS

• Smaller brain volumes, prefrontal cortex and basal ganglia (5-10%)

• Increased gray matter in the posterior temporal and inferior parietal cortices

• Atypical frontal-striatal function• Increase in dopamine transporter density

PATHOGENESIS

Ellison-Wright et al, Structural brain change in Attention Deficit Hyperactivity Disorder identified by meta-analysis, BMC Psychiatry. 2008

PATHOGENESIS

Volkow et al, Depressed Dopamine Activity in Caudate and Preliminary Evidence of Limbic Involvement in Adults With Attention-Deficit/Hyperactivity Disorder, Arch Gen Psychiatry. 2007

CLINICAL MANIFESTATIONS

• Inattention• Hyperactivity• Impulsivity• Developmentally inappropriate• Before 7 years of age• At least 6 months• 2 or more settings• Impairment in social, academic or occupational

functioning• Not be secondary to another disorder

HYPERACTIVITY

• Difficulty remaining seated• Difficulty playing quietly• Frequent restlessness• Always “on the go”• Peak 7-8 years of age

IMPULSIVITY

• Difficulty waiting turns• Blurting out answers too quickly• Disruptive classroom behavior• Interrupting other’s activities• Peer rejection• Unintentional injury• Greater risk of engaging in drug use• Impulse buying

INATTENTION

• Forgetfulness• Easily distracted• Losing or misplacing things• Disorganization• Academic underachievement• Poor follow-through with assignments or tasks• Poor concentration• Poor attention to detail

SUBTYPES

• Inattentive• Hyperactive-impulsive• Combined

DIAGNOSIS

• Clinical interview and history• School assessment• Behavioral rating scales• Physical examination and laboratory findings

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

• Dimensional• Psychosocial• Medical• Coexisting conditions• Diagnoses with associated ADHD behaviors• Neurologic

TREATMENT GOALS

• improvements in relationships with parents, siblings, teachers, and peers

• decreased disruptive behaviors• improved academic performance• increased independence in self-care or

homework• improved self-esteem• enhanced safety in the community

TREATMENT

• Behavioral/psychologic interventionsa. Daily scheduleb. Distractions to a minimumc. Specific places for toys, schoolwork and clothesd. Small goalse. Rewarding positive behaviorf. Checklistsg. Limiting choicesh. Activities in which the child can be successful

TREATMENT

• Medicationsa) Psychostimulant (70%)b) Amphetaminec) Atomoxetined) Antidepressantse) Investigational

Generic name Brand name

Methylphenidate Immediate Ritalin, Methylin

Extended Metadate ER, Methylin ER, Ritalin LA, Concerta

Dexmethylphenidate Immediate Focalin

Extended Focalin XR

Dextroamphetamine Short acting Dexedrine, DextroStat

Intermediate acting Dexedrine Spansule

Mixed Amphetamine salts Intermediate acting Adderall

Extended release Adderall XR

Atomoxetine Extended release Strattera

Tricyclic antidepressants Bupropion Wellbutrin

Imipramine Tofranil

Desimipramine Norpramin

Nortriptyline Aventyl, Pamelor

Alpha Agonist Clonidine

TREATMENT

• Common side effects:a. Anorexia (80%)b. Sleep disturbances (3-85%)c. Weight loss (10-15%)• Cardiovascular• Psychiatric (psychosis, mania)• Tics• Diversion and misuse

TREATMENT

• Alternative therapiesa. Vision trainingb. Dietsc. Megavitaminsd. Herbal supplementse. Mineral supplementsf. EEG biofeedbackg. Kinesiology

PROGNOSIS

PROGNOSIS

• 60-80% symptoms in adolescence• 40-60% symptoms in adulthood• Increased risk for antisocial personality disorder

(12-23% vs 2-3%)• Risk taking behaviors (substance use, injuries,

driving)• Educational underachievement• Employment difficulties• Relationship difficulties

REFERENCES• Nelson textbook of pediatrics (18th edition)• CDC Mental Health in the United States, 2003• Up to Date: Evaluation and diagnosis of attention deficit hyperactivity

disorder in children, Dec 2007• Up to Date: Overview of the treatment and prognosis of attention deficit

hyperactivity disorder in children and adolescents, Jun 2008• Up to Date: Pharmacotherapy for attention deficit hyperactivity disorder in

children and adolescents, Jun 2008• Clinical Pediatric Guideline: Diagnosis and Evaluation of the child with ADHD,

Pediatrics 2000• Treatment of Attention-Deficit/Hyperactivity Disorder: Overview of the

Evidence, Pediatrics 2005• Clinical Practice Guideline: Treatment of the School-Aged Child With

Attention-Deficit/Hyperactivity Disorder, Pediatrics 2001