Attention Deficit Hyperactivity
Disorder.
Sok Sedhaboth. MD., Psychiatrist
I. Definition:
Children with ADHD have a short attention
span; difficulties with inhibitory control,
manifested by behavioral an cognitive
impulsivity; and inappropriate restlessness.
II. History:
Similar syndromes have been described since
the late 1800’s. Many different names for
these syndromes have been used, including
minimal brain dysfunction, hyperkinetic
syndrome of childhood, and attention deficit
disorder.
III. Prevalence:
Figures vary greatly. Most studies done in the USA
show prevalence between 2-8%.
IV. Etiology:
Exact cause is not known. There is likely an
underlying CNS dysfunction, but its nature has not
been determined. Frontal lobe abnormalities may be
involved. Most children with ADHD do not show
evidence of gross structure damage. Many studies
have documented the important of genetic
transmission of ADHD.ADHD is more common in
siblings and parents of children with ADHD.
Other contributing factors for ADHD include
prenatal toxic exposure (Fetal Alcohol Syndrome
often presents with many symptoms of ADHD),
prematurity, and prenatal mechanical insult to the
fetal nervous system.
Psychosocial factors, such as prolonged emotional
deprivation may contribute.
V. Diagnostic Criteria for ADHD:
A. Either
1) Six or more symptoms of inattention, for at least six
months, maladaptive and inconsistent with
developmental level.
Or
2) Six or more symptoms of hyperactivity-
impulsivity, maladaptive and inconsistent with
developmental level.
B. Some symptoms of inattention or hyperactive-
impulsivity that caused impairment were present
before age 7 years.
C. Impairment is present in at least two or more
locations (e.g., at school (or work) and at home).
D. Clear evidence of impairment in social, academic,
or occupational functioning
E. Symptoms are not better accounted for by another
mental disorder.
Types:
ADHD, combined type
ADHD, predominantly inattentive Type
ADHD, predominantly Hyperactive-Impulsive Type
VI. Clinical Features
Onset is often in infancy. These children may have
been very active and cranky.
Inappropriate or excessive activity unrelated to the
task at hand. This may be very annoying to others.
This may not be visible during the first visit to the
physician.
Poor sustained attention in school; these children may
rapidly begin a task, but not be able to complete it.
This may lead to poor
schoolwork. Not paying attention at games may
lead to poor popularity with peers.Difficulties
inhibiting impulses in social behavior and on
cognitive tasks. They may blurt out answers to
questions, may interrupt others and may engage in
dangerous activities. Difficulty in getting along
with others. School Underachievement Poor self
esteem secondary to the above.Others, coexisting
externalizing behavior disorders.
(Opposition defiant disorder or Conduct disorder
occur in 40% of ADHD children), specific learning
disorders, anxiety disorders, and depression.
Treatment
Must be multimodal.
1) Parent training-Parents should be taught the
principle of behavioral management. They should
be assisted in development a behavioral treatment
program. Positive reinforcement should target both
academic and social activities. Parents should
assist with providing structure for school (i.e. help
child organize his school supplies, set a routine or
doing homework, make sure pt. remembers to take
assignments to the school). Consistency and
predictability are very important.
2) Social skills training-group therapy may be
effective.
3) Individual Therapy-In order to help patient to
understand his disorder and to help him deal with low
self-esteem which may be a result of his disorder.
4) Assist teachers in devising strategies to help
patient.
Seating arrangements
Consistent routines
Start with short assignments
Focus on success
Teacher can help provide feedback as to efficacy
of medication.
5) Pharmacotherapy
Stimulants (dextroamphetamine,
methylphenidate)-May help control symptoms of
inattention, as well as hyperactivity. Action is
usually within 45 minutes and least several hours.
Must be given 2-3 times/day.
Tricyclic Antidepressants-Imiprimine, desiprimine
and nortryptaline have been used to treat this
disorder with some success. However, sudden death
has been reported in several children taking
desiprimine and in one child taking imipramine.
Therefore, antidepressant use requires very close
monitoring in children, including ECG. Clonidine
Center-acting alpha adrenergic agonist used in adults
for treatment of hypertension.
Clonidine may help with symptoms of hyperactivity,
but usually not with symptoms of inattention. May
start with 0.05 mg bid and increase to up to
35mcg/kg/day. Clonidine takes up one month for full
effect. When clonidine is stopped, it must be done
slowly in order to avoid hypertensive crisis.
