ADHD

9th dec. 2015 Dr. Sami Adil

•ADHD is a neuropsychiatric condition starting since childhood characterized by diminished sustained attention, and increased impulsivity or hyperactivity. ADHD significantly affects academic functioning, as well as social and interpersonal functioning.•Dopamine and prefrontal cortex

Epidemiology

• Affects 5% of school-aged children and 50% continue to have symptoms as adults (2.5% of adults). More in males than in females.

Aetiology

Largely genetic. Heritability of 75%. 2-8 times increased risk in first degree relatives. Normal CNS structure. Dysfunction in the prefrontal cortex and dopamine has been theorized.

Dx. & Clinical featuresThe patient should have 6 symptoms from a list of 18 signs and symptoms. We would not mention all those 18 list. Usually the diagnosis should be made cautiously. There is a risk of overdiagnosis.

For diagnosis to be made these symptoms must be present for at least 6 months, onset be before age 12 years plus evidence of impairment in 2 settings

DSM 5 specifiers: 1. Combined presentation, 2. Predominantly hyperactive/impulsive,

and 3. Predominantly inattentive.

Differential diagnosis1.Petit mal epilepsy2.Hearing and visual impairment3.Thyroid abnormalities4.Hypoglycemia5.Normal child, especially before

the age of 3 years. 6.Bipolar7.Conduct disorder8.Learning disability9.Specific learning disorders

Course and prognosis

•Fifty percent of patients have remission between the ages of 12 and 20. The other 50% continue to have symptoms as adults. They are more predisposed to antisocial behavior, substance use disorders, and mood disorders.

Treatment •Pharmacotherapy is the 1st line. CNS stimulants are 1st choice, but CI in cardiac problems. •methyphenidate and dextroamphetamine (both are dopamine agonists). •Vyvanse is a pro-drug of dextroamphetamine that is FDA approved for children 6 years and older.

•Nonstimulant medication approved by the FDA for ADHD is atomoxetine ( a norepinephrine uptake inhibitor). •Other drugs: alpha-agonists like clonidine and quanfacine are both FDA approved for children above 6 years of age.

Notes on drugs:• Amphetamines exacerbate motor tics, can also cause growth suppression (to decrease the risk of growth suppression we give “drug holidays” on weekends or summers).• Atomoxetine can cause disturbance in blood pressure, and live functions hence we should check for this. • Psychosocial interventions include psychoeducation for child and parents, structuring the environment, and CBT. Children with ADHD do not benefit from exemption from normal requirements and expectations.

•  • Reference:• Synopsis of Psychiatry 11th Edition (2015) Kaplan and

Sadock