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ATTENTION DEFICIT
HYPERACTIVITY DISORDER
Dr Tsui Kwing Wan
Senior Medical Officer
Department of Paediatrics and Adolescent Medicine
Alice Ho Miu Ling Nethersole Hospital!
Objectives
1. Define the scope ADHD in school age
children
2. Is ADHD a real disorder ()?
3. Medical management of ADHD
4. Helping students in ADHD in school, from
perspectives of a Paediatrician
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ADHD!
(DSM-III-R)!
Minimal brain
dysfunction!
1900
1955
MPH!
1960
DSM-V!
Update criteria!
1980
1987
Attention deficit
disorder +/hyperactivity!
DSM-III!
1994
2000
2013
DSM-IVTR!
DSM-IV!
Update criteria!
EPIDEMIOLOGY
ADHD is among one of the most common neurobehavioural
problem in children
Prevalence:
"
"
"
Hong Kong:
"
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Pervasiveness!
Two or more settings!
ADHD!
Impairment!
Onset!
Before 7 years of age!
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"
"
"
"
"
"
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EXCLUSIONS
1. Pervasive Developmental Disorder (not
present in new DSM V diagnostic criteria)
2. Schizophrenia, or other Psychotic Disorder
3. Other mental disorders, e.g., Mood
Disorder, Anxiety Disorder, Dissociative
Disorder, or a Personality Disorder
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CO-MORBIDITIES OF ADHD
Up to 2/3 of children with ADHD has comorbidities
1.Oppositional defiant
disorder
6.Depressive disorder
7.Conduct disorder
8.Learning disabilities
9.social and
communication
problems
4.Anxiety disorder
10.Substance abuse
5.Sleep disturbance
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GxE
Manifestation of ADHD is a result of
interaction between genetic and
environmental influences.
Genetic factors predispose an individual to
adverse prenatal and later life circumstances;
contribute more to the development of
behavioural symptoms in a context of high
environmental adversity. (Hicks et al. 2009)!
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Brains in ADHD
Involved areas including frontal and parietal
cortexes, basal ganglia, cerebellum,
hippocampus and corpus callosum.
Longitudinal studies showed developmental
delay of cortical thickness in ADHD
fMRI study showed decreased connectivity in
a fronto-striato-parieto-cerebellar network;
which was normalised by methylphenidate.!
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FUNCTIONAL MRI
Placebo!
Methylphenidate!
BJ Casey, et al. New potential leads in the biology and treatment of attention
deficit-hyperactivity disorder. Current Opinion in Neurology 2007;20:119- 124
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NEUROCOGNITIVE MODEL
Dual pathway model of ADHD
Links inattention and deficits in executive
functions to impairments in prefrontalstriatal circuits; whereas
Hyperactivity to dysfunctions of reward
response and motivation, related to frontallimbic system.!
EXECUTIVE FUNCTIONS
Involve
"
"
"
"
Emotional control
"
Planning / Prioritizing
"
Organisation
"
Task initiation
"
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Retained in grade!
42%!
100%!
68%!
Enrolled in College!
78%!
21%!
23%!
55%!
26%!
10%!
22%!
Control!
15%!
Ever arrested*!
ADHD!
1%!
Ever convicted*!
0%!
34%!
14%!
10%!
20%!
30%!
40%!
50%!
60%!
70%!
80%!
90%!
100%!
FRAMEWORK OF EVALUATION
Full clinical and psychosocial assessment
"
"
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Investigations
Questionnaires
CBCL, SDQ, SWAN and Conners rating scale
Judicious use of questionnaires
not diagnostic , serves as screening tools
Blood tests are not needed most of time
EEG for suspected epilepsy, e.g. absence
seizure
Ab
i
lit
When to treat
y!
s!
d
an
em
Drugs!
Behavioral Intervention!
ity
Abil
Age!
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"
Treatment groups
"
Medication management
"
"
"
"
Medication group 56 %
"
Behavior group 34 %
"
Community group 25 %
"
"
Quality of intervention
"
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ADHD Medications
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ADHD Medications
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"
Non-stimulant - Atomoxetine
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Duration of action
CHOICE OF DRUGS
First line: Rilatin / Ritalin LA
Second line: Rilatin LA, Concerta,
atomoxetine (good for child with anxiety and
tics)
Drug Holiday not advisable for short
holiday or at weekend
Cost concern
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RITALIN
Short acting methylphenidate
Rapid absorption, onset of action ~ 30
minutes
Last ~ 4 hours, needs to be taken 2 to 3
times a day (morning, lunch and after
school)
May be Used in conjunction with
intermediate / long acting drug
Compliance problems, in particular at lunch
hour!
RITALIN LA
Intermediate acting, last 8 hours
Each capsule contains half immediaterelease beads and half as enteric-coated,
delayed-release beads
Onset of action similar to Ritalin
Less peak and trough fluctuation
May need pm dose of short short acting
methylphenidate after school
Only 20 mg capsule available in HK
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CONCERTA
Long acting methylphenidate
Onset ~ 30 minutes (coated with
immediate release methylphenidate)
Last up to 12 hours after single dose
Advantages: decrease stigma and
improved compliance; less drug level
frustration
Disadvantages: Cost; if side effects
emerge, they may extend later into
the day!
Usually mild and most patients can tolerate after short period
of time.
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Story of a driver
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Management overview
Structured setting!
Academic support!
Organization skill!
Social skill !
Choice of drugs!
Monitor response and
side eects !
Educational
support!
Psychosocial
intervention /
Behavioral
therapy!
Medication
Management!
Family
support!
Positive reinforcement!
Rewards!
Limit setting and
consequence!
Organization skill!
Social skills !
Parents education!
Parenting skills!
Structured environment
!
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Psychosocial interventions
Inconsistent performance
child knows how to perform but not consistent in
outcome
environmental adaptation and accommodation
Lack of skills
child does not yet possess the skills
provide direct instruction and increase opportunities!
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School accommodation
Modified seating arrangement, sitting closer to teacher
and away from sources of distractions (windows, doors
and other children with attention problems);
Better to work in smaller groups
Provide attention cue by the teachers, e.g. good eye
contact
Check school diary for completeness (providing a buddy)
Reduce workloads
Provide an Extended time for tests
Allow to take tests / examinations in a quiet room
Provide buddy!
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School-Family-Hospital as partners
1.Mutual sharing of knowledge
2.Maintain good communications, e.g. parents as
bridge, questionnaires and direct contact
3.Drug supervision in school
4.Streamline the interventional programs provided
in different settings (school, home and hospital)
to minimize duplication
5.
Conclusions
1.ADHD is a real neurodevelopmental problems with
strong neurobiological base.
2.It is a chronic disability and leads to long term
adverse consequence if untreated.
3.Medication and psychosocial interventions have
been proven effective.
4.School is an ideal setting to support children to deal
with their academic and social difficulties.
5.Treatment goal: change repeated failures to
frequent successes, no matter how trivial they are.
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THANK YOU
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