Attention Deficit Hyperactivity Disorder

1. Attention Deficit Hyperactivity Disorder Dr TG Magagula 13 August 2012

2. Behavioral disorder: noise-making, motor driven

3. Diagnosis • 6 or more symptoms of inattention: • careless mistakes, can’t sustain attention, doesn’t listen, can’t organize tasks, avoids schoolwork, loses things, easily distracted, forgetful. • 6 or more symptoms of hyperactivity- impulsivity: • Fidgeting or squirming, leaves seat, runs or climbs excessively, cannot play quietly, on the go, talks excessively, blurts out answers, cannot await turn, often interrupts.

4. Diagnosis • Some symptoms have been present before age 7. • Symptoms present in at least 2 settings. • Impairment of academic and / or social functioning. • Not due to another Axis 1 disorder. • Code subtype: -combined type for 6/12; predominantly: inattentive for past 6/12 or hyperactive-impulsive for past 6/12 • Adults/adolescents: in partial remission

5. Clinical Features • ADHD may have its onset in infancy although it is usually only diagnosed when the child is a toddler. • They have difficulty in waiting for anything and often start a task in a rush, but they have difficulty in finishing it. • Their mood is often irritable.

6. Clinical Features • Concomitant (co-morbid) emotional- behavioral difficulties are common. • About 75% of children show aggressive and defiant behavior fairly often. • School difficulties (emotional and scholastic) are common.

7. Etiology • No single factor is known to cause ADHD: • Genetic factors: • Greater concordance in monozygotic twins. • Siblings have twice the risk to develop ADHD. • Biological parents have higher risk for ADHD. • Developmental factors: • More soft neurological deficits • Brain insults: prematurity, toxins: smoking and drinking first trimester

8. Co-morbidity/differential diagnoses • Temperament & visual-motor-perceptual impairments in ADHD • Anxiety/depressive disorders • Mania bipolar I disorder wax & wane • Conduct disorder; ODD • Learning disorders, epilepsy • Mental retardation • (check family history)

9. Course and Prognosis • The course of ADHD is very variable. • Symptoms may continue into adulthood. • Symptoms may fully remit. • Hyperactivity may disappear while attention problems persist. • Persistence is predicted by: • Family history, negative life events, punitive, harsh parenting, co morbidity.

10. Treatment: • Bio psychosocial (MDT) • Comprehensive treatment program indicated • Not all children need meds • Decision to use meds based on thorough assessment of severity, impact and developmental appropriateness of symptoms • Stimulants: Methylphenidate Ritalin • Non-stimulants include: Atomoxetine- Strattera, Modafinil-Provigil

11. Cognitive-behavioral approach: • Train skills: self-instruction, -evaluation,-monitoring, anger management, social behavior. Problem solving skills • Evaluation and treatment of co morbid psychiatric disorders; child and parent(s) • Inform child about purpose of meds • Talk about “I am crazy” • Family therapy

12. Social intervention • Social skills groups. • Training, assessment and treatment of parents. • Expectations and behavioral programs. • Parents and teachers work together to structure environment with set of expectations and rewards. • Behavioral interventions at home & school (star chart)

14. Conclusion • Concerns: Inappropriate dx -/under dx of ADHD & prescription of ADHD medication. • “Best researched disorder in medicine” • Multiple agents and therapies are necessary to treat ADHD and co-morbidity; prevent disability.