Chapter – 27 ATTENTION DEFICIT HYPERACTIVITY DISORDER

Introduction prevalence : 5-12% of school-aged children; M:F= 4:1, although girls may be under-diagnosed girls tend to have inattentive/distractible symptoms; boys have impulsive and hyperactive symptoms Etiology genetic- dopamine candidate genes, catecholamine/neuroanatomical hypothesis cognitive- development disability, inhibitory control and other errors of executive function arousal- alterations in the sensory system filters

Diagnosis differential: learning disorders, hearing/visual defects, thyroid, atopic conditions, congenital problems (fetal alcohol syndrome, Fragile X), lead poisoning, history of head injury, traumatic life events (abuse) diagnosis (3 subtypes):  Combined Type- 6 or more symptoms of inattention and 6 or more symptoms of hyperactivity-impulsivity  Predominantly Inattentive Type- 6 or more symptoms of inattention  Predominantly Hyperactive-Impulsive Type- 6 or more symptoms of hyperactivity impulsivity  symptoms persist for > 6months

 onset before age 7  symptoms present in at least two settings (i.e. home, school, work)  interferes with academic, family, and social functioning  doesnot occur exclusively during the course of another psychiatric disorder

InattentionHyperactivityImpulsivity Careless mistakesFidgets, squirms in seats8lurts out answer before questions completed Cannot sustain attention in tasks or play Leaves seat when expected to remain seated Difficult awaiting turn Doesnot listen when spoken to directly Runs and claims excessivelyInterrupts/intrudes on others Fails to complete tasksCannot play quietly DisorganizedOn the “go”, driven by a motor Avoids, dislikes tasks that require sustain mental effort Tasks excessively Loses things necessary for tasks or activities Distractible Forgetful

Features average onset 3 yrs old identification upon school entry rule out development delay, genetic syndromes, encephalopathies or toxins (alcohol, lead) risk of substance abuse, particularly cannabis and cocain, depression, anxiety, academic failure, poor social skills, risk of comorbid CD and/or ODD, risk of adult ASPD associated with family history of ADEID, diffucult temperamental characteristics Treatment non-pharmacological: parent management, anger control strategies, positive reinforcement, social skills training, individual/ family therapy, resource room, tutors, classroom intervention, exercise routines, extracurricular activities

pharmcological  standard treatment: stimulants (methylphenidate- Ritalin, Concerta [long acting]; Biphentin; dextroamphetamine; mixed amphine salts- Adderall; lisdexamphetamine- Vyvanse), SNRI (atomoxetine- Strattera)  for comorbid symptoms: antidepressants, antipsychotics  Vit B6: 6-12 months Prognosis 65% continue into adulthood; secondary personality disorders and compensatory anxiety disorders are identifiable 70-80% continue into adolescene, but hyperactive symptoms usually abate.

The End