Attention Deficit Hyperactivity Disorder in Children

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Tutor Group 3:

Attention Deficit Hyperactivity Disorder

Abdullatiff Sami AL-RashedBlock 3.4College of Medicine, King Faisal University Al-Ahsa, Saudi Arabia

+Objectives

- The case

- Introduction

- In terms of Differential Diagnosis, which somatic causes of ADHD-like symptoms should be considered/ruled out?

- How is ADHD diagnosed ?

- Which treatment options are available for ADHD (pharmalogical & non pharmalogical)

The Case

+Introduction

- Attention deficit hyperactivity disorder (ADHD) is a disorder that manifests in childhood with symptoms of hyperactivity, impulsivity, and/or inattention.

- The symptoms affect cognitive, academic, behavioral, emotional, and social functioning.

IN TERMS OF DIFFERENTIAL DIAGNOSIS, WHICH SOMATIC

CAUSES OF ADHD-LIKE SYMPTOMS SHOULD BE CONSIDERED/RULED

OUT?

+ ADHD Differential Diagnosis

DDx

Hearing or vision

impairment

Lead poisonin

g

Hyperthyroidism

Heart Faliure

Hearing and vision screen

Measurement of blood lead level

Laboratory studies

Medical history; echocardiograph

+ ADHD Differential Diagnosis

DDx

Substance abuse

Undernutrition

Seizure disorder

Medication side

effects

History; toxicology screening

Assessment of growth parameters

History; electroencephalography if clinically indicated

History

HOW IS ADHD DIAGNOSED ?

+ADHD Diagnosis

- The American Psychiatric Association has defined consensus criteria for the diagnosis of attention deficit disorder (ADHD), which are published in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)

+ADHD Diagnosis

- For children <17 years, the DSM-5 diagnosis of ADHD requires:

≥6 symptoms of hyperactivity

and impulsivity

≥6 symptoms of inattentionOR

+ Hyperactivity and Impulsivity Symptoms

Excessive fidgetiness (eg, tapping the hands or feet, squirming in seat)

Difficulty remaining seated when sitting is required

Feelings of restlessness (in adolescents)

Blurting out answers too quickly

Difficulty playing quietly

Interruption or intrusion of others

+ Inattention Symptoms

Failure to provide close attention to detail

Seems not to listen, even when directly addressed

Difficulty maintaining attention in play, school, or home activities

Forgetfulness in routine activities

Easily distracted by irrelevant stimuli

Difficulty organizing tasks, activities, and belongings

+ADHD Diagnosis

- The symptoms of hyperactivity/impulsivity or inattention must:

1- Occur often.

2- Be present in more than one setting (eg, school and home).

3- Persist for at least six months.

4- Be present before the age of 12 years.

5- Impair function in academic, social, or occupational activities.

6- Be excessive for the developmental level of the child.

7- In addition, other physical, situational, or mental health conditions that could account for the symptoms must be excluded.

WHICH TREATMENT OPTIONS ARE AVAILABLE FOR ADHD (PHARMALOGICAL & NON

PHARMALOGICAL)

Behavioral Therapy

Pharmalogical therapy

Combination Therapy

TREATMENT MODALITIES

+Behavioral Therapy

- Behavioral interventions include modifications in the physical and social environment that are designed to change behavior using rewards and nonpunitive consequences.

+Behavioral Therapy

- Behavior therapy and environmental changes that can be used by parents or teachers to shape the behavior of children with ADHD include:

1- Maintaining a daily schedule.

2- Providing specific and logical places for the child to keep his schoolwork, toys, and clothes.

3- Rewarding positive behavior (eg, with a “token economy”).

4- Using charts and checklists to help the child stay "on task”.

5- Limiting choices.

6- Finding activities in which the child can be successful (eg, hobbies, sports).

+Pharmalogical Therapy

Several different types of medications may be used to treat ADHD:

1- Stimulants are the best-known and most widely used treatments. Between 70-80 % of children with ADHD respond positively to these medications.

Dextroamphetamine, Methylphenidate.

+Pharmalogical Therapy

2- Nonstimulants were approved for treating ADHD in 2003. This medication seems to have fewer side effects than stimulants.

Alpha2-adrenergic Agonists, (SNRIs), Antidepressants

+Combination Therapy

- Combination therapy uses both behavioral/psychologic interventions and medications.

- Combination therapy may be beneficial for school-aged children and adolescents who have a suboptimal response to pharmacotherapy or in preschool children who do not respond to behavioral interventions

+Treatment Choice

- The treatment strategies for children with ADHD vary according to age:

1- For preschool children (age 4 through 5 years) who meet the diagnostic criteria for ADHD, we recommend behavior therapy rather than medication as the initial therapy.

+Treatment Choice

2- For most school-aged children and adolescents (≥6 years of age) who meet the diagnostic criteria for ADHD and specific criteria for medication, we suggest initial treatment with stimulant medication combined with behavioral therapy, to improve core symptoms and target outcomes.

+References

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