“Mental

disorders World Health Organization,

Geneva, 2001
affect one in
four.”
Attention –deficit hyperactivity disorder (ADHD)
Dr. Saqib Siddique,
Assistant Professor of Psychiatry,
MBBS (KMC), DCP (IRE),
FCPS (PAK),
Certified Cognitive Therapist (KMU).
© Justpsychiatry
Scenario 1

“Musa is constantly forgetting things. His

homework is rarely finished, and his parents
describe homework time as “a nightmare.”

Children with ADHD frequently have difficulty

paying attention top tasks at hands.
Scenario 2

“Osman can hardly stay in his seat during class

and gets up as soon as the bell rings. During
lunchtime, he grabs other students’ food and
frequently cuts in line”

Sitting still, or in one place, for a long period of

time is torture for many kids with ADHD.
 Dear Psychiatrist,
Thank you for seeing the above 8-year-old boy with
behavioural difficulties. Parents report that he cannot

Referral sit still and that he runs all the time. He has been
having difficulty in school also and almost daily receives
a note in his journal. He has an older sibling with ADHD,
please assess him for same.
Kind regards, GP
Terms

ADHD and ADD >> DSM 5,

• The American Psychiatric
Association.
• Hyperkinetic Disorder >> ICD 10
• World Health Organization.
Definition

• Attention deficit hyperactivity disorder (ADHD) is a behavioral disorder that

presents with symptoms such as inattentiveness, hyperactivity and
impulsiveness.
• Second most common psychiatric disorder of Childhood.
Subtypes

• Predominantly Inattentive
• Hyperactive/Impulsive
• Combined Presentation
ADHD Diagnostic
Criteria in DSM 5
Inattention

• Makes careless mistakes

• Difficulty sustaining attention
• Does not seem to listen when spoken to directly
• Fails to follow tasks and instructions
• Exhibits poor organization
• Avoids tasks requiring mental effort
• Loses things necessary for tasks/activities
• Easily distracted
• Seems forgetful in daily activities
Hyperactivity/Impulsivity

• Fidgets with or taps hands or feet, turns in seat

• Leaves seat in situations when remaining seated is expected
• Experiences feelings of restlessness
• Has difficulty engaging in quiet, leisurely activities
• Is “on-the-go” or acts as if “driven by a motor”
• Talks excessively
• Blurts out answers
• Has difficulty waiting their turn
• Interrupts or intrudes on others
 Other Criteria

9 symptoms in Onset before persisting for 6 Pervasive Inappropriate Impaired Not better
each category. 12 year of age. months. across for functioning. explained by
situations developmental any other
(Home, Class, age. diagnosis.
Clinic)
6 required to make
the diagnosis.
Epidemiology

Prevalence: 3%

Male to Female ratio: 3:1

Socioeconomic association None

Age of Onset

Most diagnosed in 6-to-12-year-old.

Age of onset before 12 per DSM-5
Age of onset before 7 per ICD-10
Etiology
 Etiology

Maternal Smoking
Prematurity, Low birth weight
Early Psychosocial adversity (children
raised in extreme deprivation
Toxins such as Pesticides
Comorbidities

• Conduct Disorder/Oppositional Defiant Disorder (most common)

• Autism Spectrum Disorder---20-50%
• Tourette's Syndrome/Tics
• Developmental Coordination Disorder
• Substance misuse
• Reading Disorders
• Epilepsy
Differentials

• Conduct Disorder/Oppositional Defiant

Disorder (most common)
• Anxiety Disorders
• Mania
• Intellectual Disability
• Epilepsy
• Hearing Impairment
• Receptive Language Disorders
Prognosis

• About 50% of cases diagnosed in childhood retain full

diagnosis in adolescence
• About 10-20 % cases diagnosed in childhood retain
diagnosis in Adulthood
• Prognosis is poor when overactivity is severe,
associated with learning difficulties and antisocial
behavior
Prognosis

• Adults with ADHD can experience more opportunities to

‘live with’ the disorder as they no longer need to attend
school with its associated institutional demands and can
choose career paths more suited to their work patterns and
needs.
• Many adults with ADHD describe poor motivation,
inattention and poor organization---Problems at work and
relationships.
• Comorbid mood disorders and substance misuse are
common in Adulthood
 Unmedicated individuals
Prognosis appear to have higher rates
of:
• Substance Abuse
• Antisocial PD,
• Other PD and psychiatric
disorder,
• Academic failure,
• Unemployment,
• Accidents

Reference:
Barkley 2001, Rasmussen & Gillberg 2000, Biederman et al 1998
 • Full developmental assessment: Pregnancy,
birth, developmental milestones, medical
history, Family history
• Screening Tools/Scales: Connors Rating
Scale( Parent, Teacher and Child version)
• Clinical Interview with parents
Assessment • Clinical Interview with Child
• School Information: School report forms or
School visit
• MSE for comorbid Psychiatric conditions
• Psychosocial assessment for needs of child
and carers.
Speech and Language assessment.
if delay present.
Screen for comorbidities:
• Tourette’s Syndrome,
• Autism,
• Conduct Disorder
Investigations

HEARING TESTS TFTS EEG

RULE OUT HYPERTHYROIDISM EPISODIC CHANGES.
Biological Treatments
Psychosocial Interventions

Treatments
Biological
Treatments
Stimulant Medications:
• Methylphenidate( First-Choice)
• Potential for abuse.
• Short-acting:
• Ritalin
• Long-acting:
• Equasym XL, Concerta XL, Ritalin LA
Methylphenidate
• Inhibits reuptake of Dopamine and Norepinephrine (block transporters_
• Increased Dopaminergic/Noradrenergic activity in prefrontal Cortex
• Prefrontal Cortex---regulates attention and behavior
• Difference from Amphetamines: Does not promote dopamine release from
synaptic vesicles.
BIOLOGIC 2) Non-Stimulant Medications :
AL Atomoxetine ( Straterra)—Nor-
adrenaline reuptake inhibitor with
no potential for abuse.

3) Antipsychotics : Risperidone =
severe co-existing aggression and
agitation in those intellectual
disability
Psychosoci
al 1. Education of family
2. Parent training program based on
Intervention behavioral interventions

s
 Social Skills training

Psychosocial Support to carers

Classroom Interventions ( Small class,
Interventions breaks, Seats to the front-not close by
window)
Address any child protection concerns
Frequent questions
asked by parents
Regarding ADHD treatments
 “Will taking a stimulant make my child more likely to
take street drugs?”

ADHD increases the risk of your child

developing substance abuse. It seems from
recent research that your child’s risk may
decrease with use of ADHD medication
“What are the long term effects of
ADHD medications?”

Methylphenidate has been in use for over 50 years, so we are aware and monitor for most side effects. It is
believed that treating your child for ADHD is more beneficial than not. Risks of road traffic accidents, substance
misuse and criminality seem to decrease with treated ADHD.
Does Ritalin help
people without
ADHD?
• Stimulants do not increase IQ (Advokat et al. 2008)
• Students are taking unnecessary risks including the potential
for harmful side effects, which may cause psychosis sudden
death.
• Potential for dependence.
• Do not offer as much help to people with greater intellectual
abilities.
 Dr. Saqib Siddique,
Assistant Professor of Psychiatry,
MBBS (KMC), DCP (IRE),
FCPS (PAK),
Certified Cognitive Therapist (KMU).

Last updated: 12/13/2020

 This document is only for your personal use.

Last updated: 12/13/2020 © Justpsychiatry