ADHD Across the Lifespan

1
ADHD Across the Lifespan

• Recognition, reality resolution

Somnath Banerjee Associate specialist community
paediatrics
2
Definition

• Age inappropiate inattention with/without
  hyperactivity impulsivity, beginning in the
  first 7 yrs of life, for more than 6 mo, persist
  in more than one situation not associated with
  PDD, other mental health disorders e.g. anxiety,
  depression or other psychiatric problems.

3

• A developmental disorder resulting from
  immaturity of brain inhibitory system.
• Maladaptive inconsistent with age-appropriate
  behaviour.
• Significant impairment in social academic
  functioning.
• First reported by Prof G Still in 1902

4
Shifts in Conceptualising ADHD

• 1930s - 50s Minimal Brain damage.
• 1950s - 60s Minimal Brain Dysfunction.
• 1966 68 Hyperkinetic reaction of
  childhood.(ICD-8 DSM-II)
• 1980 - Attention Deficit Disorder (DSM-III)
• 1987 - ADHD ( only combined dx) DSM-IIIR
• 1992 - ICD-10 HKD
• 1994 DSM-IV AD/HD 3 types

5
Prevalence

• 3-5 in school age children. (DSM-IV)
• UK- N.I.C.E. estimated 5 of school age
• ( 345,000 in England 21,000 in Wales)!
• AACAP 10 boys, 5 girls in schools.
• Boys girls 3-4 1.
• Persists in 50-60 into adolescents adults
  (profile may change)

6
Pathophysiology
7
Causes

• Altered brain function MRI,SPECT,PET- small
  frontal lobe basal ganglia, less dopamine
  activity.
• Hereditary genetic rather than environmental /
  polygenic inheritance.
• Maternal smoking, drug misuse and exposure to
  toxins
• Not due to psychol stress, disturbed family.

8
Evidence supporting genetic basis

• ADHD is more common in biological relatives.
• Higher rate of ADHD in related parents children
  compared to adopted children.
• Greater incidence in identical twins than
  non-identical twins.

9
Subtypes of ADHD (DSM-IV)

• Based on core symptoms of IN, HP and IMP,
  two broad categories
• Combined type with inattention
  hyperactivity/impulsive
• Predominantly inattentive
• Predominantly hyperactive/impulsive

10
(No Transcript)
11
Clinical features

• Hyperactivity- excess of movements, restlessness,
  fidgety, faster tempo of behaviour. Noted in
  preschool children
• Reported by parents
• Inattention brief activities, changes
  activities frequently, do not persist with tasks
  long enough to profit from them or to get them
  right. Reported by teachers.

12
Clinical features continued

• Impulsivity dislike waiting, act erratically.
• Noted in secondary school. Reported by
  teachers, self.

13
Assessment

• Detailed history since birth.
• Physical examination.
• Development.
• Standardised rating scales.
• Diagnosis criteria of ICD-10 or DSM-IV.
• Co-morbid conditions.

14
Input needed to make a diagnosis

• Teacher gtgtgtgtgt Diagnosis ltltltltlt Parent
• child

15
Screening and Diagnosis
16
Diagnosis

• IN 9 HP 6 IMP 3.
• DSM-IV Combined IN gt 6 HP/IMP gt 6
• InattentiveIN gt 6 HP/IMP lt 5
• HP/IMP INlt 5 HP/IMP gt 6
• ICD-10 IN- gt6 HP- gt3 IMP - gt1.

17
(No Transcript)
18
Co-morbidity

• Oppositional defiant disorder (ODD).
• Conduct disorder.
• Learning disability.
• Tourettes syndrome.
• Anxiety / depression disorder, OCD.
• Dyslexia, DCD, DAMP.
• PDD, SLI.

19
Complications

• Substance misuse smoking, drinking drugs
• Nicotine extremely common
• 8 yrs ADHD 14 yrs non ADHD
• 15 ADHD 8 non ADHD
• 65 of ADHD children are symptomatic in adulthood
  (AACAP).

20
Population study 162 children
19
Dyslexia
22
26
7
23
Dyspraxia
10
8
ADHD
40 / 48 ADHD co morbid
21
Criminal Behaviour School Exclusion Substance
Abuse Teenage Pregnancy Conduct
Disorder Complex learning Disabilities Lack of
motivation
Challenging Behaviour ODD
Disruptive Behaviour Poor social Skills Learning
delay
ADHD only
Low self esteem
Key Stage
2
3
4
1
Age
6
10
14 to 16
22
ADHD 50 - Have ODD / CD 80 100 ODD / CD
have associated ADHD before puberty. 25 ODD
have CD 80 CD already ODD
7 years 17 years
ADHD
CD
23
Differential Diagnosis

• Physical illness, disability, drugs hyper.
• Hearing loss, dev delay inattention
• S.E of medications e.g. AED
• Sleeplessness anxiety, ODD

24
Management

• 3 primary modalities are
• Educational modifications extra help, modified
  IEP.
• Behaviour modifying strategies.
• Medications.

25
Behaviour modifying educational approach

• Clinical behavioural mx strategies
• Family therapy
• Social skill training
• Individual therapy- art, psycho, play, music
• Support groups and link families
• Parenting skill training

26
(No Transcript)
27
Medications

• Psycho stimulants. 2 drugs licensed in UK are
  MPH DEX. MPH is a derivative of
  amphetamine.Release inhibit reuptake of DA -gt
  RAS stimulation -gtmaintain attention arousal.
• gt 6 yrs-MPH ( Ritalin, Equasym) IR-5 mg, 10 mg,
  20 mg, SR-20 mg, Sustain (continuous)
  release-18,36 mg.
• gt 3 yrs-DEX (Dexedrine) 5 mg.

28
(No Transcript)
29
Use side effects

• Both drugs 2-3 times daily. MPH max 60 mg, DEX
  max 30 mg / day.
• MPH more commonly used gt DEX
• 3 common side effects are
• Reduction in appetite (wt loss)
• Insomnia
• Headache, abdo pain, tearfulness in first few
  days.

30
Medication (cont)

• Other drugs-Clonidine,Imipramine, Risperidone.
• Newer drug- Atomoxetine.
• Experimental - Diet, biofeedback

31
Key Messages

• ADHD is a common behavioural condition with clear
  diagnosis criteria.
• ADHD co-exists with other cond. in one third of
  children.
• A strong evidence of role of stimulants/-
  behavioural therapy.
• Early recognition tr. may result in less
  antisocial behaviour, criminality substance
  abuse in later life.

32
Some useful websites

• www.nice.org.uk
• www.addiss.co.uk
• www.adders.org
• www.mentalhealth.com
• ? Contact me
• snbanerjee_at_doctors.org.uk

33
Thank You