ATTENTION DEFICIT/ HYPERACTIVITY DISORDER Georgina M.

Gozo-Oliver, MD, FPPA, FCAPPI AUF School of Medicine Department of Neurology & Psychiatry DEFINITION Consists of a consistent pattern of inattention &/or hyperactivity, and impulsive behavior that is more severe than expected in children of that age and level of development; Some symptoms must be present before 7 years old; Many are not diagnosed until they are 7 years old or older when their behavior causes problems in school & other places. SYMPTOMS OF INATTENTION Fails to give close attention to details Makes careless mistakes Difficulty in sustaining attention in tasks & play Does not seem to listen when spoken to directly Does not follow through on instructions & fails tofinish work ( not because he does not want to orhe can not understand) Difficulty organizing tasks & activities Easily distracted by extraneous stimuli Forgetful in daily activities SYMPTOMS OF HYPERACTIVITY Fidgets & squirms in seat Leaves seat in situations in which remaining seated is expected Runs about or climbs excessively in inappropriate situations Difficulty in doing activities quietly on the go, driven by a motor SYMPTOMS OF IMPULSIVITY Blurts out answers before questions have been completed Has difficulty awaiting turn Interrupts or intrudes on others EPIDEMIOLOGY 2-20% of grade school children (US); 1% reported in GB 3-7% of prepubertal elementary school children More prevalent in boys than in girls (2:1 9:1) Parents of kids with ADHD show increased incidence of hyperkinesis, sociopathy, alcohol use disorders, & conversion disorders. Symptoms are often present by age 3 years ETIOLOGY Cause are unknown No evidence of gross structural damage in the CNS; Lack of neurophysiological or neurochemical basis currently; Suggested Contributory Factors: Prenatal toxic exposures Prematurity Prenatal mechanical insult to the fetal NS Food additives, colorings, preservatives, sugar No scientific evidence has been established. Genetic factors Greater concordance in monozygotic twins than in dizygotic twins Siblings have 2X the risk of having ADHD than the general population Biological parents have a higher risk of ADHD than adoptive parents Developmental factors Prenatal exposure to winter infections during the first trimester Brain damage caused by circulatory, toxic, metabolic, or mechanical insult during early infancy Nonfocal (soft) neurological signs occurs at higher rates in ADHD vs general population Neurochemical factors No clear-cut evidence implicates a single neurotransmitter in the development of ADHD Many NTs may be involved in the process Animal studies implicate the Locus Ceruleus, consisting mainly of noradrenergic neurons, playing a major role in attention. Stimulant medications that help control ADHD symptoms affect both dopamine & norepinephrine

Neurophysiological factors Maturational delay in the sequence of brain development which appear to normalize at about age 5 years old; Frontal lobes in children with ADHD are not adequately performing their inhibitory mechanism on lower structures leading to disinhibition Psychosocial factors Prolonged emotional deprivation Stressful psychic events Disruption of family equilibrium Other anxiety-inducing factors DIAGNOSIS Six or more symptoms of inattention Six or more symptoms of hyperactivity-impulsivity Some symptoms have caused impairment before age 7 years Impairment is present in 2 or more settings Clear evidence of clinically significant impairment in social, academic, or occupational functioning Rule out PDD, schizophrenia, or other psychotic Disorders PATHOLOGY & LABOATORY EXAMINATIONS No specific laboratory measures are pathognomonic for ADHD Continuous performance task shows errors of omission (inattention) & commission (impulsivity) Nonspecific abnormal results in hyperactive children: Disorganized, immature EEG PET shows decreased cerebral blood flow in the frontal Regions COURSE & PROGNOSIS Variable course Hyperactivity may disappear but decreased attention span & impulsivity may persist; Symptoms may remit in puberty; Symptoms may persist into adolescence & adulthood; Overactivity is the first symptom to disappear; distractibility the last. TREATMENT PHARMACOTHERAPY CNS stimulants Reduce overactivity, distractibility, impulsivity, explosiveness, & irritability AACAP Practice Parameters: Physical examination Blood pressure Pulse Weight Height Methylphenidate (Ritalin, Ritalin-SR, Concerta, Metadate ER, Metadate CD) Dexmethylphenidate (Focalin) Dextroamphetamine (Dexedrine, Dexedrine spansule) Dextroamphetamine & amphetamine salts (Adderall, Adderall XR) Non-stimulant medications Bupropion (Wellbutrin) Venlafaxine (Effexor) Alpha-adrenergic agonists (Clonidine, Guanfacine) Atomoxetine (Strattera) PSYCHOSOCIAL INTERVENTIONS Social skills groups Refining social skills (waiting, listening); increasing self-esteem by instilling a sense of success Training for parents of children with ADHD Behavioral interventions in school & at home Evaluation & treatment of co-existing learning disorders or additional psychiatric disorders