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Definition According to the fourth edition of the American Psychiatric Association's (APA) DSM (DSM-IV), ADHD is a behavioral and neurocognitive condition.

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Presentation on theme: "Definition According to the fourth edition of the American Psychiatric Association's (APA) DSM (DSM-IV), ADHD is a behavioral and neurocognitive condition."— Presentation transcript:

1 Definition According to the fourth edition of the American Psychiatric Association's (APA) DSM (DSM-IV), ADHD is a behavioral and neurocognitive condition characterized by developmentally inappropriate and impairing levels of gross motor overactivity, inattention, and impulsivity. There are five main diagnostic criteria: (1) an onset before age 7 years; (2) duration greater than 6 months; (3) an 18-item symptom list of which 6 of 9 inattention or 6 of 9 hyperactive/impulsive symptoms have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level; (4) some impairment in two or more settings; and (5) symptoms that do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder, such as depression.

2 ADHD is diagnosed by history taken from the parent and at least one other adult, such as a teacher or coach. As with many psychiatric disorders, there is no simple objective test, such as a blood test, that can aid in making the diagnosis.

3 Etiology Although the etiology of ADHD yet has to be determined, there is a growing consensus that the condition involves functional and anatomical dysfunction in the brain's frontal cortex and basal ganglia segments of the cortico-basal ganglia-thalamo-cortical circuitry. These areas support the regulation of attentional resources, the programming of complex motor behaviors, and the learning of responses to reinforcement. Theories involving these areas have been examined in series involving neurobiological studies of healthy humans, humans with ADHD, and animal models. Reviews by Castellanos and Swanson have delineated ADHD's complexity, its theoretical diversity, and the many questions yet to be resolved. The symptoms of ADHD are multidimensional, suggesting the interaction of neuroanatomical and neurochemical systems. The current evidence for the neurobiological factors suggests that genetics and neurochemistry play key roles.

4 First-degree relatives of children with ADHD have a 20 to 25 percent risk for ADHD, compared with 4 to 5 percent for relatives of controls. If a parent has ADHD, 50 percent of his or her offspring are likely to have that condition

5 Thyroid Receptor B Gene
Early molecular genetic studies showed that mutation of the thyroid receptor B gene, which causes resistance to thyroid hormone, was associated with high rates (61 percent) of hyperactivity and impulsivity (but not inattention) in affected children and adults. However, only 1 of 2,500 patients with ADHD had this thyroid abnormality, which generally was very rare. Thus, this gene could not be a major cause of ADHD.

6 Dopamine Type D2 Receptor Gene
Dopamine Transporter Gene Dopamine 4 Receptor Gene

7 Neuroanatomical Aspects
Mirsky and Castellanos described neuroanatomical correlations for the superior and temporal cortices with the focusing of attention; external parietal and corpus striatal regions with motor executive function; the hippocampus with the encoding of memory traces; the prefrontal cortex with the act of shifting from one salient stimulus to another; and brainstem areas such as reticular thalamic nuclei with the sustaining of attention

8 Hechtman's review of magnetic resonance imaging (MRI), positron emission tomography (PET), single emission computed tomography (SPECT), and functional MRI studies suggested decreased volume and activity in prefrontal areas, anterior cingulate, globus pallidus, caudate, thalamus, hippocampus, and cerebellum in children with ADHD. These findings are supported by morphological studies of Castellanos and colleagues

9 Neurotransmitters in ADHD
Certain brain areas have been associated with specific neurotransmitters—for example, the caudate nucleus and corpus striatum with dopamine and the median raphe with serotonin. Even so, neuroanatomical studies of neurotransmitters have proven to be very complex because these neuroanatomical regions of interest receive projections from multiple nuclei and neurotransmitter pathways, confounding theories that posit dysfunction in a single neurotransmitter system as the etiology of ADHD. However, for clarity, each neurotransmitter system is discussed separately in what follows.

10 Dopamine System Noradrenergic System Serotonergic System

11 Environmental Factors
High lead exposure and maternal smoking have been associated with higher rates of diagnosis of ADHD. However, it has been difficult for investigators working with children affected by adversity to determine whether their ADHD symptoms reflect a response to negative parenting, a harsh environment, a genetically influenced biological problem, or some interaction among these factors. Only with further multifaceted prospective research, such as the Centers for Disease Control and Prevention/National Institutes of Health National Children's Study in the United States, will there be a clearer, more comprehensive understanding of the possible etiology, natural history, and treatment of ADHD.

12 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder According to the Text Revision of the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders Either (1) or (2): six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention

13 often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities often has difficulty sustaining attention in tasks or play activities often does not seem to listen when spoken to directly often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) often has difficulty organizing tasks and activities often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) is often easily distracted by extraneous stimuli is often forgetful in daily activities

14 six (or more) of the following symptoms of hyperactivity impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity

15 often fidgets with hands or feet or squirms in seat
often leaves seat in classroom or in other situations in which remaining seated is expected often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) often has difficulty playing or engaging in leisure activities quietly is often “on the go” or often acts as if “driven by a motor” often talks excessively

16 Impulsivity often blurts out answers before questions have been completed often has difficulty awaiting turn often interrupts or intrudes on others (e.g., butts into conversations or games)

17 Some hyperactive impulsive or inattentive symptoms that caused impairment were present before age 7 years. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

18 Associated Factors Children with ADHD might have areas of impairment that are not listed under the DSM-IV symptom criteria covered exactly by the 18 symptom exemplars of hyperactivity, impulsivity, or inattention

19 Behavioral Children with ADHD often lack persistence. They become bored with interactive games with peers, and leave such games early before they are finished. They find it difficult to delay gratification. They show variable performance on tasks, which may negatively affect self-esteem

20 Cognitive Children and adolescents with ADHD often show difficulty with time management and do not develop an internal sense of pace in planning tasks. This poor sense of time leads to problems in estimating the actual difficulty of waiting in line, planning how much time a task requires, or even knowing when to come home when out playing with other children

21 Deficit of Behavioral Inhibition and Executive Functioning
Lack of behavioral inhibition has been postulated to lead to impairments in motivation, arousal, ability to delay gratification, working memory, and self-regulation of affect. Dysfunction in these areas is said to impair executive functioning, interfering with goal-directed behavior. However, executive functioning problems occur in other psychiatric disorders of childhood, such as depression, and are not specific to ADHD. Neuropsychological tests often used by clinicians tap into but do not totally explain a child's or adolescent's executive functioning. Recent data show that academic functioning is more strongly affected by an impulsive need to get through tests quickly, a deficit closely linked to poor behavioral inhibition rather than poor executive functioning.

22 Poor inhibitory control has been postulated to lead to impairments in
motivation, arousal, delay of gratification, working memory, and self-regulation of affect. This has been assessed in the laboratory using Stop Signal Tasks and the Go-No Go test. Other deficits include greater intraindividual variability of reaction time, cerebellar associated deficits in motor timing, inability to delay response to reward, and possible alternations in synchronization in the cingulate-precuneus default mode network

23 Dysfunction in these areas is said to impair executive functioning, interfering with
goal-directed behavior . However, executive functioning problems occur in other psychiatric disorders of childhood, such as depression, and are not specific to ADHD. On any given measure of executive function, less than half of children with ADHD have been found to be impaired. Although findings of executive function deficits can appear in the results of testing children with ADHD, the lack of such deficits does not rule out the disorder. Some neuropsychologists use the Behavior Rating Inventory of Executive Function (BRIEF) as part of their evaluation battery, but this measure has not been used in a prospective manner to assess the effect of stimulant medications

24 Emotional ADHD is often associated with dysregulation of affect, resulting in temper outbursts, mood lability, and reactivity. Moods can change dramatically with no obvious connection with what's going on in the environment. The reaction of others and the consequences of an action are often poorly understood by the individual with ADHD, who has moved on to something else and does not understand what the fuss is about.

25 Social Individuals with ADHD may have problems accurately interpreting nonverbal social cues and thus react inappropriately. This is associated with reports from peers, who report these individuals to be intrusive, bossy, and insensitive to the needs of others. There is trouble cooperating with other children and following rules in games. Children with ADHD often have strong reactions, overreacting to situations that can be predictably triggered by others, leading to teasing and ridicule. Their tendency to respond to frustration in social situations can lead to verbal or physical aggression, a strong stimulus for peer rejection, which has been shown to be a reliable long-term negative predictor of development, particularly in adolescence

26 Course and Prognosis Parents often notice very high levels of gross motor activity when the child with ADHD is a toddler, just when the child has learned to walk independent of the parent's help. However, the energy, oppositionality, and curiosity of toddlers can be confused with the excessive, almost random motion of older children with ADHD, so that one must be cautious when applying the ADHD diagnosis to a preschooler. Usually, the ADHD diagnosis is first applied in primary school, during grades 1 to 6, when adjustment to the sedentary learning style is compromised.

27 The motor and attentional symptoms and impairment create a consistent picture through early adolescence, when often the external overactivity lessens but the internal restlessness does not. Whereas the school-age child is mostly at risk for academic failure and peer rejection, the adolescent with ADHD who is untreated has other risks in excess of peers with no mental disorder, including a threefold increase in substance use and abuse, trouble with the law, and an increased rate of automobile accidents when the teenager begins to drive. Approximately 60 percent of those who develop childhood ADHD continue to be impaired well into adult life, with prevalence estimates suggesting that 4 percent of adults may suffer from ADHD. These individuals may show instability in job status and relationships, even if the numbers of ADHD symptoms do not meet the threshold required for the childhood diagnosis.

28 شیوع 3-7% سن شروع4و5و6 جنس پسرها6به 1از نظر هوشی غذا عواقب اختلال سلوک –اختلال یادگیری-وسواس-تیک-افسردگی-اختلال دوقطبی-مصرف مواد-اختلال هماهنگی حرکتی-اختلال اضطراب

29 زمان دارو عوارض دارو تا کی به مصرف ادامه می دهیم

30 توقع خود را کم کنید هرزمان به یک مشکل رفتاری توجه کنید دستورات ساده تشویق بهتر از تنبیه مدیریت زمان ورزش ارتباط با معلمان محیط ارام

31 Treatment Stimulants Amphetamines and methylphenidates are two groups of stimulant medication that have received U.S. Food and Drug Administration (FDA) approval for the treatment of youth with ADHD. They are marketed in both immediate release (IR) and long-acting preparations and can be purchased as either generic or branded versions. Since 2000, multiple stimulants have been marketed with FDA approval for ADHD treatment, including long-duration mixed salts of amphetamine, dexmethylphenidate, osmotic-release methylphenidate, the prodrug lisdexamfetamine, and beaded methylphenidate. All of these products include either amphetamine or methylphenidate as the active ingredient. These chemicals structurally resemble the catecholamine neurotransmitters dopamine (DA) and norepinephrine (NE). All can be described as psychostimulants, which refers to their ability to increase central nervous system activity in brain regions (Table ).

32 Nonstimulant Medication in the Treatment of Children with ADHD
Atomoxetine HCl

33

34 Tricyclic Antidepressants
α-Adrenergic Agents Bupropion

35 Psychosocial Treatment of Children with ADHD

36 Multimodal Treatment (MTA Study)


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