Attention Deficit

Hyperactivity Disorder

DR. AMI SHAH

RESIDENT
DEPARTMENT OF PSYCHIATRY
KJSMC
 Contents
• Introduction
• Myths
• Aetiology
• Diagnosis of the disorder
• Differential Diagnosis and comorbidities
• Treatment
 Introduction
• Also called as attention deficit disorder

• Affect 3-5 % of school age population

• Boys out number girls-3:1

 Myths
• All kids with ADD/ADHD are hyperactive.

• Kids with ADD/ADHD can never pay attention.

• Kids with ADD/ADHD could behave better if they

wanted to.

• Kids will eventually grow out of ADD/ADHD.

• Medication is the only treatment option for

ADD/ADHD.
Fact
 Aetiology
1. Genetics-
If u have a…. Your risk for having
ADHD is..
Parent with ADHD More than 50%

Brother or sister with ADHD 41%

Child with ADHD 21%

Identical twin with ADHD 80%

 Aetiology…
2. Neuroanatomy-Decreased cerebellar
volume.
 Aetiology……
3. Neurotransmitters –

 Dopamine System-very important

 Noradrenergic System
 Serotonin system-weak association
 Aetiology…
4.Environmental factors :

 High exposure to lead, heavy metals

 Nutritional deficiency-zinc, iron, omega 3 fatty acid
 Maternal smoking
 Pregnancy and delivery complications
Diagnosis
 Based on DSM 4 criteria
Criteria A----Inattention Criteria B-----Hyperactivity-Impulsivity

Fails to give close attention to details Hyperactivity

Difficulty sustaining attention in tasks -often fidgets with hands or feet or squirms in
seat
Does not seem to listen when spoken to
-often leaves seat in classroom or in other
directly situations in which remaining seated is expected
Often does not follow through on -often runs about or climbs excessively
instructions and fails to finish -often has difficulty playing or engaging in
schoolwork, chores, or duties in the leisure activities
workplace -often is “on the go” or as if “driven by a motor”
Often has difficulty organizing tasks -talks excessively
and activities Impulsivity
Often loses things necessary for tasks -often blurts out answers before questions are
or activities completed
Is often easily distracted -has difficulty awaiting turn
-interrupts or intrudes on others
Often forgetful in daily activities
 Diagnostic criteria
A: Six or more of the previously noted symptoms
persisting for 6 months or longer qualifies for a
diagnosis of ADHD in either the inattentive category or
hyperactivity-impulsive category.

If both inattentive and hyperactive-impulsive symptoms

are present then a combined type diagnosis is given.

B: One of the symptoms needs to have been present

before the age of 7.
 Diagnostic criteria..

C: Some impairment from the symptoms is present in

two or more settings, such as school or home.

D: There must be clear and significant evidence of a

social, academic, or occupational impairment

E: The symptoms are not better accounted for by

another mental disorder
 Changes in DSM5
 Symptoms are as same as DSM4

 For adult ADHD diagnosis only 5 symptoms are

required

 In DSM 5 ADHD symptoms should be present prior to

the age of 12 years

 DSM 5 no exclusion criteria for autism since

symptoms of both co exist
 Diagnosis

Based on these criteria-3 types of ADHD are identified

1. COMBINED TYPE-if criteria for both A and B are

present for 6 months

2. PREDOMINANTLY INATTENTIVE TYPE: if criterion A

is met but criterion B is not met for the past six months.

3. PREDOMINANTLY HYPERACTIVE-IMPULSIVE TYPE: if

criterion B is met but Criterion A is not met for the past
six months.
 Differential Diagnosis
1. Organic disorders-
Seizure disorder
Thyroid abnormality
Learning Disability
Frontal lobe –abscess/neoplasm
Substance abuse
Lead intoxication
2. Functional disorders-
Oppositional Disorder & Conduct Disorder (frequently comorbid)
Mood & Anxiety Disorder
Personality disorder
Family disruption, neglect, abuse
3. R/o age appropriate over activity
 Clinical Assessment
Extensive history

F/h of psychiatric disorders

Antisocial behaviour, substance use and internalizing
disorders
Complete pre natal, perinatal and post natal
development
History of accident, head trauma , eye and ear
infection
School related assessment regarding behaviour
Social functioning-both from teacher and parents
Treatment
 Stimulants

Methylphenidate & Dextro amphetamine

MOA
Increase NE and DA actions
Improves attention, concentration, executive function

Dosage
MPH - 2 mg/kg/day (5-40mg/day, max 60 mg/day)
Divided doses for IR tablets
OD morning dose for ER tablets
 Non stimulant medication

Atomoxetine HCL

MOA
Norepinephrine reuptake inhibitor
Well absorbed.
Minimally affected by food.
Maximum plasma conc-1-2 hours after ingestion.

Dosage-0.5-1.2mg/kg per day in children

 Other medications
TCAs
Imipramine, Nortryptiline, Amitryptiline
Lower dosages are required compared to depression

Bupropion
Non TCA anti depressants
Less effective than TCA or stimulants
75 mg twice a day

Clonidine and Guanfacine (alpha adrenergic antagonists)

Decrease impulsivity and hyperactivity
Start at 0.025mg
Psychosocial Treatment of ADHD

 Psychoeducation of parent and child

 Academic Organizational Skills and Remediation
 Parent training in Behavior therapy
 Family therapy

Note: Studies found combined medical and behavior

treatment best followed by medication treatment
alone.
 CASE discussion
8 year old male presented with complaints of
difficulty staying attentive in class since one year,
looking out of window frequently during class. Parents
complained he was misplacing items, forgetting things
in school and needed to be reminded to do things
frequently. School teachers complained he would be
changing seats frequently, bunking classes, blurting
out answers during class and have incomplete books
and would frequently be punished due to his behavior
interfering with his performance in school and this
started affecting his relationship with his peers.
 D ER
OR
D I S
U CT
N D
CO
 Definition
 Conduct disorder is a psychiatric syndrome occurring in childhood
and adolescence

 Characterized by a longstanding pattern of violations of rules and

antisocial behavior.

 Strikes children between the ages of 9 and 17 years.

 It is more common in boys

 Diagnosed only when the conduct is more serious than the ordinary
mischief and pranks of children and if the behaviors occur
repeatedly such that the child's life is negatively impacted by
them.
 Epidemiology
• Approximately 9 percent of boys and 2 percent of girls under
the age of 18 years have the disorder.

• The disorder is more common among boys than among girls and
the ratio ranges from 4 to 1 to 12 to 1.

• Conduct disorder is more common in children of parents with

antisocial personality and alcohol dependence than it is in the
general population.

• The prevalence of conduct disorder and antisocial behavior is

significantly related to socioeconomic factors.
 Etiology
A variety of bio-psychosocial factors contribute to development:

Parental Factors

•Parental attitudes and faulty child-rearing practices

•Chaotic home conditions and strife between the parents
•Child abuse and negligence
•Sociopathy, alcoholism and substance abuse in parents
•Serious psychopathology, including psychoses parents
•Psychodynamic hypotheses- Children with conduct disorder
unconsciously act out their parents antisocial wishes.
•Poor fit between, on the one hand, a child’s temperament and emotional
needs and on the other hand, parental attitudes and child-rearing
practices.
 Etiology…
Sociocultural Factors

•Socioeconomically deprived children are forced to resort to socially

unacceptable means to reach goals. Often these children adhere to the
values of their own subculture.

Psychological Factors

•Children brought up in negligent conditions become angry, disruptive,

demanding, develop the poor frustration tolerance

•Basis for developing both an ego-ideal and a conscience is lacking as role

models are poor and frequently changing.

•Little motivation to follow societal norms and are relatively remorseless.

 Etiology…
Neurobiological Factors

• Neurobiological factors in conduct disorder have been little

studied. However, ADHD research yields some important findings
and conduct disorder and ADHD often coexist.
•ADHD, central nervous system (CNS) dysfunction or damage and
early extremes of temperament can predispose a child to conduct
disorder.
 Clinical features
Typical behaviors of a child with Conduct D/o include

• Refusal to obey parents or other authority figures

• Truancy
• Tendency to use drugs at a very early age
• Lack of empathy for others
• Spiteful and vengeful behavior
• Being aggressive to animals
• Being aggressive to people, including bullying and physical or sexual
abuse
• Tendency to hang out in gangs
• Keenness to start physical fights
• Using weapons in physical fights
• Lying
 Diagnostic criteria
A. A repetitive and persistent pattern of behavior in which the basic
rights of others or major age-appropriate societal norms or rules are
violated, as manifested by the presence of three (or more) of the
following criteria in the past 12 months, with at least one criterion present
in the past 6 months:

Aggression to people and animals:

(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery)
(7) has forced someone into sexual activity
 Diagnostic criteria…
Destruction of property

(8)has deliberately engaged in fire setting with the intention of causing serious damage

(9) has deliberately destroyed others' property (other than by fire setting)

Deceitfulness or theft

(10) has broken into someone else's house, building, or car

(11) often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)

(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without
breaking and entering; forgery)
 Diagnostic criteria…
Serious violations of rules

(13) often stays out at night despite parental prohibitions, beginning before
age 13 years

(14) has run away from home overnight at least twice while living in parental or
parental surrogate home (or once without returning for a lengthy period)

(15) is often truant from school, beginning before age 13 years

B. The disturbance in behavior causes clinically significant impairment in

social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for
Antisocial Personality Disorder.
 Treatment
Treatment is difficult.
•Most common: placement in a corrective institution.
•Behavioral, educational & psychotherapeutic measures are employed for
changing the behavior.

Non pharmacological interventions include:

•Behavior therapy
•Cognitive behavioral therapy (CBT)
•Anger management
•Stress management
•Social skills training
•Special education program
•Parent management training
•Integrated approach by family, teachers
 Treatment…
Pharmacological interventions

Drug treatment may be indicated:

•in the presence of epilepsy (anticonvulsants),

•hyperactivity (stimulant medication),
•impulse control disorder &
•episodic aggressive behavior (lithium, carbamazepine)
•psychotic symptoms (antipsychotics).
PERVASIVE DEVELOPMENTAL
DISORDERS…
 Introduction
 AKA Autism Spectrum Disorders(ASDs)

 Impairment in development; reciprocal communication skills, social

interaction skills, or presence of stereotyped behavior, interests and
activities

 Evident in first years of life

 Associated with some degree of Mental Retardation

 Range from a severe form called Autistic Disorder, through Pervasive

Development Disorder Not Otherwise Specified), to a milder form,
Asperger’s Disorder

 Includes Rett’s and Childhood Disintegrative Disorder

AUTISM
 Autism
INTRODUCTION

•Also known as spectrum disorder

•is a lifelong disability.

•is classified as a developmental disability.

•occurs mostly in males. The ratio is about4:1.

•typically manifests around the ages of 18 months to 3 years.

•is characterized by severe problems in 3 main areas: communication,

behavior and social skills.
 Clinical features: Autism
CLINICAL FEATURES

A)COMMUNICATION SKILLS

•Difficulties in using and understanding both verbal and non-verbal

language.
•Failure to initiate or sustain conversational interchange.
•Abnormalities in the pitch, stress, rate, rhythm, and intonation of
speech.
•Poor receptive and expressive skills.
•May echo words (echolalic speech).
•May use screaming, crying, tantrums, aggression, or self-abuse as ways
to communicate.
•Repeating words or phrases in place of normal, responsive language.
 Clinical features: Autism
B) BEHAVIOUR SKILLS

•Poor receptive and expressive skills.

•May echo words (echolalic speech).
•May use screaming, crying, tantrums, aggression, or self-abuse as
ways to communicate.
•Repeating words or phrases in place of normal, responsive language.
•Laughing, crying, or showing distress for reasons not apparent to
others.
•Unreasonable insistence on following routines in precise detail.
 Clinical features: Autism
C) SOCIAL SKILLS

•Lack of awareness of the existence or feelings of others.

•Severe impairment in the ability to relate to others.
•Aloof and distant from others.
•Appears not to listen when spoken to.
•Fails to produce appropriate facial expressions to specific occasions.
•Avoids eye contact.
•Difficulty with changes in environment and routine.
•Does not seek opportunities to interact with others.
•Unwillingness and/or inability to engage in cooperative play.
 Management of Autism
NON PHARMACOLOGICAL INTERVENTIONS

Educational practices should focus on the following:

•Communication skills
•Behavior
•Functional academics
•Self-help skills
•Gross and fine motor skills
•Social and leisure skills
•Vocational and independence
•Structure, routine and organization

Occupational therapy helps improve independent function and teaches

basic skills (e.g., buttoning a shirt, bathing)
 Management: Autism…
NON PHARMACOLOGICAL INTERVENTIONS..

Physical therapy involves using exercise and other physical measures (e.g.,
massage, heat) to help patients control body movements.

Play therapy is a type of behavior modification that is used to improve

emotional development, which in turn, improves social skills and learning.

Social stories can also be used to improve undeveloped social skills.

Speech therapy may be used to help patients gain the ability to speak.

Picture exchange communication systems (PECS) enable autistic patients

to communicate using pictures that represent ideas, activities, or items.
 Management: Autism…
OTHER NON PHARMACOLOGICAL INTERVENTIONS

• Reduce self destructive behaviors.

• Physically stop the child from harming himself.
• Give verbal or physical reinforcement.
• Foster appropriate use of language.
• Provide positive reinforcement when the child indicates his needs
correctly.
• Encourage development of self esteem.
• Encourage self care.
• Encourage acceptance of minor environmental changes.
• Provide emotional support to the parents.
• Refer them to the Autism Society.
 Management: Autism
PHARMACOLOGICAL INTERVENTIONS

Antipsychotic medications

Clozapine, risperidone olanzapine and quetiapine may decrease hyperactivity,

behavioral problems, withdrawal, and aggression in autistic patients.

Stimulants

Methylphenidate, amphetamine and dextroamphetamine may also be

prescribed for autism. These drugs may increase focus and decrease
impulsivity and hyperactivity in high-functioning patients. Prolonged use of
stimulants may lead to drug dependence.
ASPERGER’S DISORDER
 Asperger’s syndrome
INTRODUCTION

•Identified in the 1940’s by Hans Asperger

•An autism spectrum disorder that effects language and communication
skills
•Affects boys more often than girls
•Usually diagnosed between the ages of 5 and 9
 Clinical features: Asperger’s
• Qualitative impairment in social interaction

• Restricted repetitive and stereotyped patterns of behavior, interests, and

activities.

• The disturbance causes clinically significant impairment in social, occupational,

or other important areas of functioning

• There is no clinically significant delay in language (e.g., single words by age 2

years, communicative phrases used by age 3 years).

• There is no clinically significant delay in cognitive development, self help

skills, adaptive behavior, and curiosity about the environment in childhood.

• Criteria are not met for another specific pervasive developmental Disorder or
Schizophrenia.
 Asperger’s versus Autism
ASPERGER’S SYNDROME AUTISM

•Symptoms often masked •Symptoms evident by 30

until 5 years of age. months of age.
•Display social desire, but •Show less social interest/
often unsuccessful. initiative.
•Language development
•Delayed/deviant language
advanced, but deviant.
•IQ’s generally reflect ⇑ development.
VIQ’s than PIQ’s •IQ’s generally reflect ⇑
PIQ than VIQ
•Poor gross motor skills. •Good gross motor skills.
•Often enter into
•Rarely enter into
relationships and have
children. relationships or
have
children.
 Management: Asperger’s
Multi-modal approach

NON PHARMACOLOGICAL INTERVENTIONS

• Cognitive & Behavioral Therapy
• Social & Communication skills training
• Psycho-education for parents and teachers

PHARMACOTHERAPY FOR CO-MORBID CONDITIONS

•To treat depression:
Fluoxetine
•To treat obsessive-compulsive behavior (OCD):
Clomipramine
•To treat inattentiveness or hyperactivity:
Methylphenidate
Dextroamphetamine
RETT’S DISORDER
 Rett’s disorder
INTRODUCTION

•Progressive neurodevelopment disorder

•Common cause of profound mental impairment in girls

•Babies with Rett syndrome develops normally until the age of 6 to 18

months until their development regresses

•They lose the purposeful use of their hands and are disabled for life with
reduced muscle tone and seizures and lose of communication skills
 Diagnosis & Clinical features:
Rett’s d/o
CLINICAL FEATURES

• A. All of the following:

(1) apparently normal prenatal and perinatal development
(2)apparently normal psychomotor development through the first 5 months
after birth
(3) normal head circumference at birth

• B. Onset of all of the following after the period of normal development:

(1) deceleration of head growth between ages 5 and 48 months
(2) loss of previously acquired purposeful hand skills between ages 5 and 30
months with the subsequent development of stereotyped hand movements
(e.g., hand-wringing or hand washing)
(3) loss of social engagement early in the course (although often social
interaction develops later)
(4) appearance of poorly coordinated gait or trunk movements
(5) severely impaired expressive and receptive language development with severe
psychomotor retardation
 Rett’s D/O versus Autism
RETT’S DISORDER
AUTISM

• Mostly females
• Deterioration in developmental •Mostly males
milestones, head circumference, •Abnormalities present from
overall growth birth
•Stereotypic hand movements
• Loss of purposeful hand
not always present
movements •Little to no loss in gross
• Stereotypic hand movements motor function
(hand-wringing, hand washing, •Aberrant language, but not
hand-to-mouth) complete loss
• Poor coordination, ataxia, apraxia •No respiratory irregularity
• Loss of verbalization •Seizures rare; if occur,
• Respiratory irregularity develop in adolescence
•Normal CSF nerve growth
• Early seizures factor
• Low CSF nerve growth factor
 Treatment: Rett’s d/o
NON PHARMACOLOGICAL TREATMENT

• Increasing the patient's communication skills, especially with

augmentative communication strategies
• Parental counseling
• Modifying social medications
• Sleep aids
• occupational therapy may improve purposeful use of the hands
• Physical and speech therapy
– use of braces or casts can help children who have scoliosis.
– physical therapy can also help maintain walking skills, balance and
flexibility
 Treatment: Rett’s d/o
PHARMACOLOGICAL INTERVENTIONS

•Selective serotonin reuptake inhibitors (SSRIs)

•Anti-psychotics (for self-harming behaviors)
•Beta-blockers rarely for long QT syndrome
• Nutritional support: Some children with Rett syndrome may need a
high-fat, high-calorie diet. Others may need to be fed through a tube
placed in the nose (nasogastric tube) or directly in the stomach
(gastrostomy).
CHILDHOOD DISINTEGRATIVE
DISORDER
 CDD
INRODUCTION:

 Childhood disintegrative disorder (CDD) is a rare condition

 unknown cause
 affects children (boys)
 most often around ages 3-4, but may range from ages 2-10.

 For diagnosis: After at least 2 years of normal postnatal development,

significant losses manifest in the following domains:
1. Expressive or receptive language
2. Social or adaptive behavior
3. Bladder or bowel control
4. Play
5. Motor skills
 Clinical features: CDD
CLINICAL FEATURES

–Loss of social skills

–Loss of bowel and bladder control
–Loss of expressive or receptive language
–Loss of motor skills
–Lack of play
–Failure to develop peer relationships
–Impairment in nonverbal behaviors
–Delay or lack of spoken language
–Inability to start or sustain a conversation
 Management: CDD
NON PHARMACOLOGICAL INTERVENTIONS
–Language therapy
• Improve social interaction and communication with peers
• Develop language skills
• Using pictures to help communicate needs

–Physical therapy
• Improve movement, posture, balance

–Occupational therapy
• Adjusts environment to the child’s needs

- Develop a highly structured and individualized program with a routine

- Aims to develop areas of difficulty & builds on child’s strengths and
interests
 Management: CDD
PHARMACOTHERAPY

– Anti-psychotics are used to treat behavior problems

• Typical: haloperidol, thioridazine, fluphenazine, chlorpromazine
• Atypical: risperidone, olanzapine, ziprasidone

– Anticonvulsants help treat seizures

• Carbamazepine, lamotrigine, topiramate, valproic acid

– Monitor effects closely to determine benefit

– Inform parents of potential side effects

 PDD NOS
KEY POINTS
Pervasive developmental disorder (NOS):

•A ‘sub-threshold’ condition in which some –but not all – features of autism

or another explicitly identified Pervasive Developmental Disorders are
identified
•also been referred to as:
“atypical personality development”
“atypical PDD”
“atypical autism”
•four times more likely to affect boys
•no known cause
•R/o a specific Pervasive Developmental Disorder, Schizophrenia,
Schizotypical Personality Disorder,Avoidant Personality Disorder
•Treatment includes positive behavioural support, special education and
use of medication where required along with counseling.
THANK YOU!