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Child and Adolescent Psychiatry Department, "Carol Davila" University of Medicine and Pharmacy
Child and Adolescent Psychiatry Department, "Carol Davila" University of Medicine and Pharmacy
Child and Adolescent Psychiatry Department, "Carol Davila" University of Medicine and Pharmacy
ADHD
Definitions and clasifications
- neurobiological deficit with genetic determinism that can also be strongly influenced by
education
- the hyperactive child has an inability to focus attention, difficulty controlling attention,
behavioral and cognitive impulsivity, as well as inappropriate restlessness and impatience.
DSM 5 ICD 10
ADHD and Disruptive Behavior Disorders Hiperkinetic disorders F.90
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)
Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or
lengthy reading)
Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction)
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)
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)
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)
Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, papenwork, eyeglasses,
mobile telephones)
Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts)
Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills,
keeping appointments)
Impulsivity
Often blurts out an answer before a question has been completed (e.g., completes
people’s sentences; cannot wait for turn in conversation)
Often has difficulty waiting his or her turn (e.g., while waiting in line)
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
Historical retrospective of the term ADHD
Year The name
About 11% of children aged 4-7 years were diagnosed with ADHD (2011)
The percentage of children diagnosed with ADHD is increasing:
- 7.8% in 2003
- 9.5% in 2007
- 11.0% in 2011
ADHD is more common in boys (13.2%) than in girls (5.6%)
More severe forms begin under 7 years
Centers for Disease Control
Family factors BASIC
SYMPTOM
Genetic factors S
NEURO
BIOLOGICA
L
Peri- and Socioeconomic SUBSTRATE ASSOCIATE
Postnatal factors factors D
DEFICITS
PHARMACOLOGICAL SKILLS
CBT TRAININ
TREATMEN
The etiological model of ADHD and the G
T
possibilities of therapeutic intervention
Brain areas involved in ADHD
Hippocampus:
Association; Corpus callosum:
Memory and Complex
recognition integration
Amygdala:
Motivation, anger,
anxiety
11
The role of prefrontal cortex (PFC) in ADHD
Posterior
Shifting attention to DA ¨ Data analysis
parietal lobe
new stimuli DLPFC
¨ Response
Focus attention on NE preparation
new stimuli
The DA and NE system is dysfunctional
DA low, NE increased
Low NE
Dopaminergic model of the alternation between hypofunction (in PFC - cognitive
deficits) and hyperfunction (in the striatal system - impulsivity, hyperactivity)
DA - the key neurotransmitter in learning regulation - hypofunction
15
. Cumings et al, 1996; Cumings, 2000; Yudofsky and Hales, 2002, Barkley 2000
Risk factors
Prenatal exposure to:
- Alcohol (fetal alcohol syndrome): 2-4% have ADHD
- Tobacco
- Organic solvents, Gasoline, Pesticides, Pb, Hg
- The fetus is vulnerable even to low-level exposures
- The direct connection with ADHD is speculative
Low birth weight(< 2500g)
16% ADHD risk
Especially in boys - children without cerebral palsy, with normal IQ but with soft neurological
signs and behavioral disorders
Academic failure
Conduct disorders Social interaction difficulties
School difficulties Low self-esteem
Social interaction difficulties Substance abuse
Low self-esteem Violence / accidents
Barkley, 2004
The multidisciplinary approach
Medical
Psihotherapeutic
Educational
A B C
A = antecedent
B = behaviour
C = consequence
Behavioural intervention strategies:
The use of a daily, weekly or monthly calendar
Performing a more difficult task before an easier one
Fragmentation of complex tasks into smaller, simpler ones
The use of intermediate objectives instead deadlines
Control of environmental stimuli to minimize distractors
Adapting the tasks and the learning moment to the optimal learning style and
lifestyle
Wolraich, 2005
Request the support of a supervisor
RULES MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
I wake up at 8 o'clock
I wash my teeth
I dress myself
I do my homework with
a 10-min break for each
30 min of work (2 hrs)
Spare time
The child has always presented or begins to manifest the following features at ages 3-4:
Temper tantrums, sometimes (frequently enough) accompanied by crying spasms
A "quicker" temperament that "gets furious", "always quarrels";
Inability to abide by the rules, a child who "opposes all the time", "a stubborn little one", "who only does
what he wants";
Seems unhappy (unsatisfied) most of the times, always ready to start a fight
pare tot timpul nemulţumit şi „pus pe harţă”, îi învinovăţeşte pe ceilalţi pentru greşelile lui;
nu prea este acceptat la joacă de ceilalţi copii pentru că „le strică jocul” sau „nu respectă regulile jocului”,
„face numai cum vrea el”, „sare iute la bătaie”, „este certăreţ”, „le strică jucăriile”;
uneori sunt anxioşi, temători în faţa evenimentelor noi; nu sunt prietenoşi, îşi fac cu greutate prieteni dat
fiind felul lor de a fi;
Clinical features
When they get older, they start to feel the resentment of others and thus, the hostile behaviour
worsens: "they begin to act badly on purpose", "to hit others or to destroy their notebooks or
bags"
They feel that they are not loved and thus they seem to "get even worse";
They want to be noticed by educators and teachers and they end up “telling on other children",
which further attracts the disapproval of others
Prepubescent children and adolescents begin to challenge the authority of their parents and the
rules of their families, increasing their anger and rejection, which exacerbates the child's
opposition
"Physiological oppositional crisis"
The period between 2-5 years – the “no", “I don’t want to“, “because that’s what I want” period
The child learns "that it represents an individuality invested with his own will, different and opposed to
the will of others”
The child is not defiant, nor does he manifest ill will towards the adult,
Oppositional behaviour “puts a strain on the child, generating other feelings of guilt, but especially the
anxious fear of losing the affection and love of those close to him”;
The feeling of guilt makes the child insecure, capricious, inconsistent and not infrequently even more
obstructive, the opposition itself generating oppositionˮ
The persistence of this behavior over the age of 6 years, with its aggravation, at the beginning of the
first school year must raise question marks and the suspicion of the onset of ODD;
Child and Adolescent Psychiatry Department,
“Carol Davila” University of Medicine and Pharmacy
Conduct disorder
ADHD
Conduct disorder
Juvenile delinquency
Clinical features
they cling to the mother, only want to be carried, then they can have moments of rejection
sleep disorders
enuresis, encopresis
destructive playing
It starts with psychosomatic symptoms (headache, abdominal pain) or vegetative disorders accompanied by
anxiety up to the paroxysmal form with panic attacks
There can be a decrease in school performance and school refusal may occur
They do not use the term sad / depressed but they state that they are "hopeless", "bored" or "no longer like
what they were doing before“
Inability to deal with frustrating situations - withdraws into a corner, cries helplessly, or becomes violent
(screaming, crying or hitting)
Suicide attempts are very rare at this age, but if asked, they say they "want to die"
Depression in adolescents
the differentiation between symptom depression and depressive illness is made up of the persistence of the
disorder, its intensity and whether it affects the social functionality
Treatment of child and adolescent depression
- The first line of intervention is the psychotherapeutic one - cognitive- behavioral therapy is
the intervention validated with results in the case of children and adolescents
Inhibited RAD
Disinhibited RAD
- Inhibited response to social interactions
- Hypervigilant - Non-discriminatory in attachment relationships
- Avoidance, aggression, fear In relationship with - Superficial social relations, the child doesn’t worry
the caregiver if the care giver changes
- No interest in friendships - This superficiality in the relationship helps them
seem“resourceful”
- May have hyperactivity, low tolerance for
frustration, aggressive behavior