ADHD

Mohammad Jamal Holdar, MD, FRCP(C)

Assistant Professor
Child and Adolescent Psychiatrist
 Objectives

u By the end of the lecture, students will be familiar with:

u Diagnosticcriteriaof ADHD
u Possible etiology of ADHD
u Treatment of ADHD
DSM-5 Diagnostic Criteria
u Onset before the age of 12
u Symptoms in two or more settings (e.g. home, school, work, with
friends and relatives, social functions)
u Affect functioning (e.g. social, academic, occupational)
u Doesn’t occur exclusively during the course of schizophrenia ond
not better explained by another mental disorder.
 Inattentive symptoms (at least 6)
1. Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or during other activities (e.g., overlooks or misses details,
work is inaccurate).
2. Often has difficulty sustaining attention in tasks or play activities (e.g., has
difficulty remaining focused during lectures, conversations, or lengthy reading).
3. Often does not seem to listen when spoken to directly (e.g., mind seems
elsewhere, even in the absence of any obvious distraction).
4. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is
easily sidetracked).
5. Often has difficulty organizing tasks and activities (e.g., difficulty managing
sequential tasks; difficulty keeping materials and belongings in order; messy,
disorganized work; has poor time management; fails to meet deadlines).
Inattentive symptoms (cont.)
6. Often avoids, dislikes, or is reluctant to engage in tasks
that require sustained mental effort (e.g., schoolwork or
homework; for older adolescents and adults, preparing
reports, completing forms, reviewing lengthy papers).
7. Often loses things necessary for tasks or activities (e.g.,
school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile telephones).
8. Is often easily distracted by extraneous stimuli (for older
adolescents and adults, may include unrelated thoughts).
9. Is often forgetful in daily activities (e.g., doing chores,
running errands; for older adolescents and adults, returning
calls, paying bills, keeping appointments).
Hyperactivity and impulsivity (at least 6)
1. Often fidgets with or taps hands or feet or squirms in seat.
2. Often leaves seat in situations when remaining seated is expected
(e.g., leaves his or her place in the classroom, in the office or other
workplace, or in other situations that require remaining in place).
3. Often runs about or climbs in situations where it is inappropriate. (Note:
In adolescents or adults, may be limited to feeling restless.)
4. Often unable to play or engage in leisure activities quietly.
5. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to
be or uncomfortable being still for extended time, as in restaurants,
meetings; may be experienced by others as being restless or difficult
to keep up with).
Hyperactivity and impulsivity (cont.)
6. Often talks excessively.
7. Often blurts out an answer before a question has been
completed (e.g., completes people’s sentences;
cannot wait for turn in conversation).
8. Often has difficulty waiting his or her turn (e.g., while
waiting in line).
9. Often interrupts or intrudes on others (e.g., butts into
conversations, games, or activities; may start using other
people’s things without asking or receiving permission;
for adolescents and adults, may intrude into or take
over what others are doing).
 Presentations of ADHD

ü Combined Presentation (most common).

ü Predominantly Inattentive Presentation.
ü Predominantly Hyperactive/Impulsive Presentation.
 Etiology

u Genetic Factors: monozygotic > dizygotic twins. Increased risk for

siblings of an ADHD child.
u Neurochemical Factors: main neurotransmitters implicated are
dopamine and norepinephrine (as evidenced by stimulants being
quite effective in managing ADHD symptoms)
u Developmental Factors: premature birth and maternal infections
during pregnancy.
u Psychosocial: Severe chronic abuse, maltreatment, and neglect are
associated with poor attention and impulse control.
Shaw et al.
2007
 Treatment

uPharmacotherapy:
u Stimulants (first line): Methylphenidate- (e.g. Ritlain and Concerta) and
Amphetamine- (e.g. Vyvanse) based medications.
u MPH: Dopamine and Norepinephrine reuptake inhibitors.
u AMPH: Stimulate release of dopamine, to a lesser extent norepinephrine
u Advantages: highly efficacious in ADHD, rapid onset of action and rapid resolution
of side effects (within the same day)
u Side effects: anorexia, insomnia, headache, aggression, anxiety, increase HR/BP,
tics.
 Treatment (cont.)

u Non-stimulant medications:
1. Atomoxetine (norepinephrine reuptake inhibitor): longer titration period and
needs to wait weeks to months for full response. Less efficacious than stimulants.

u Adverse effects: sedation, dizziness, dry mouth, suicidal ideations, mood

symptoms such as irritability and dysphoria, rare risk of sever liver injury.
 Treatment (cont.)

2. Alpha 2 agonists (e.g. Guanfacine): helpful in ADHD cases

associated with aggression.

u Adverse effects: hypotension, somnolence, sedation, fatigue, headache.

u Blood pressure has to be monitored especially during titration.
 Treatment (cont.)

u Psychosocial interventions:
u Psychoeducation
u Structured day (kids with ADHD function poorly without aclear structure. e.g. “6
AM you eat your breakfast; after school you do your homework”….etc. Better if it
is on chart.
u Reward system to promote positive behavior (token economy)
u Ensure you get the attention of the child by direct eye contact while talking to him
u School accommodation: in the front of the class; close to the teacher; taking tests in
aspace away from any noise to avoid distraction.
References

u DSM 5
u Kaplan and Sadock's Comprehensive Textbook of Psychiatry (10th
ed)
u Attention-deficit/hyperactivity disorder is characterized by a delay
in cortical maturation; Shaw et al. (PNAS 2007)