Attention Deficit
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Transcript of 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