considered to be one of three "disruptive behavior" disorders, along with Conduct Disorder and Oppositional Defiant Disorder
symptoms present in childhood and in more than one setting
characterized by a variety of symptoms which comprise two groups:
Differentiation of Hyperactive vs. Inattentive Types:
Hyperactivity/Impulse
fidgets
often leaves seat
runs about
difficult being quiet
blurts out words
difficulty waiting
often on the go
Inattentive
fails to give close attention to detail
difficulty sustaining attention
does not follow through
easily distracted
difficulty organizing
Etiology
family history Þ biological (genetic)
neuroimaging Þ hypometabolism (no tests available for diagnosis)
Epidemiology
disruptive behavior is the #1 reason a child is brought to a pediatrician offic
just because a child displays disruptive behavior does not mean that he/she has a Disruptive disorder
5% of children suffer from ADHD, 3 times as many boys than girls
ADHD persists through adolescence and into adulthood; original belief that ADHD "remits" during adolescence is probably due to the fact that the symptoms change across the life cycle Þ an adult is more sedentary than a child
scientific evidence that many children with ADHD are not diagnosed despite the public perception of its over diagnosis
if they are not diagnosed they are not treated
serious disorder that may lead to significant difficulties that persists into adulthood such as Ý rates of antisocial and substance abuse and possibly mood disorders during adulthood
Diagnosis of ADHD
It is a Clinical Diagnosis
based on careful physician interview; no specific tests available
must cause an impairment or dysfunction; chronic disorder
Differential Diagnosis/Assessment
symptoms of ADHD may be present in a variety of medical or psychiatric conditions (lead toxicity, mood disorders, psychotic disorders, substance abuse, and other disruptive behavior disorders, non-syndromal disorders)
Clinical Evaluation
family history (runs in families)
longitudinal history
Co-Morbidity Associated with ADHD
50-80% of patients with ADHD have a co-morbid disorder
disruptive behavioral disorders (30-50% of patients), Mood or Anxiety disorder, Substance Abuse, Learning disorder, PDD
Impact of ADHD
serious disorder that may lead to significant difficulties that persists into adulthood
impact on education, emotion, social interactions, family and peers (pts often become the class clown or daredevil)
increased rates of antisocial and substance abuse and possibly mood disorders during adulthood
Treatment
- multimodal treatment plan
Pharmacotherapy
: most beneficial
Stimulants
Þ stimulate underactive areas of the brain
Pros: long term efficacy, no long-term side effects
Cons: 30% failure rate
Side effects: anorexia, weight loss, stomach pain, insomnia, tics (induces tics only in susceptible people)
does not stunt growth and abuse is not common
Examples
:
Methylphenidate (Ritalin) - most common drug (short acting)
Pemoline (Cylert) - severe hepatotoxicity
O-Amphetamine
Adderall (longer acting and more potent than Ritalin)
Medication Monitoring: CBD, lead level, BP and pulse
Antidepressants
tricyclics
MAO inhibitors
Þ Ý Dopamine, serotonin
Buproprion
Þ very effective but can cause irritability and insomnia
Fluoxetine ( blocks benzodiazepam receptor) - only reported as successful once but still in use (Certraline and Paroxetin are other similar drugs)
Venlafaxine
a
2 Agonists
Clonidine and Guanfacine
Antipsychotics
: not recommended, considered only treatment of last resort
Psychosocial
- school based, family, peer, individuality
Psychotherapy
- can lead to significant improvements especially in the mildly effected
school intervention, individual treatment, rehabilitation model, multisegmental perspective