dr.

IGA Endah Ardjana, SpKJ (K)

 ADHD - Chronic neurobehavioral disorders that can interfere with an individuals ability to inhibit behavior (impulsivity), function efficiently in goal-oriented activities (inattention), or regulate the activity level (hyperactivity) in developmentally appropriate ways
Miller KJ, Castellanos FX. AD/HDs. Ped in Rev 1998; 19 (11)

Three basic form of ADHD - Attention - Hyperactive - Combine (most frequent)

 ADHD significant functional problems

- school difficulties

- academic underachievement - troublesome interpersonal relationships with family members and peers - low esteem Untreated childhood ADHD More likely to experience conduct disorder, substance abuse, antisocial behavior and injuries later in life EARLY RECOGNITION, ASSESSMENT & MANAGEMENT

 Prevalence rates vary substantially (changing diagnostic criteria overtime; variations depend on different settings sample estimation

- Varying from 4% to 12% - Males 9.2% (5.8%-13.6%) - Female 2.9% (1.9%-4.5%) - School samples 6.9% (5.5%-8.5%) - Community samples 10.3% (8.2%-12.7%)
AAP. Clinical Practice Guideline ADHD. Pediatrics 2000; 105 (5)

- Indriyani, dkk (2007) RSUP Sanglah (2005-2006) ( 3 yo - <7 yo) 45.9%

 The causes of ADHD are unknown

GENETIC FACTORS DEVELOPMENTAL FACTORS

NEUROCHEMICAL FACTORS
NEUROPHYSIOLOGICAL FACTORS PSYCHOSOCIAL FACTORS

Anonym. Attention-Deficit Disorders. In: Kaplan & Sadocks. Synopsis of Psychiatry. Ninth Ed. USA: Lippincott; 2003

 Precise neural & pathophysiologic of ADHD remains unknown Frontostriatal regions, rich in noradrenergic, adrenergic and dopaminergic neurotransmitters are consistently implicated Dysregulation of inhibitory frontocortical activity (predominantly noradrenergic) on striatal structures (predominantly dopaminergic) Imaging studies reveal structural differences assosiated with ADHD in the caudates, globus pallidus, right frontal lobe. Anterior-inferior peribasal gangglia, bilateral retrocallosal, posterior parietaloccipital regions and the cerebellum

FRONTAL EXECUTIVE FUNCTION

ACTION (monitoring self regulation)

ACTIVATION (organizing; prioritizing; activating to work) FOCUS (focusing; shifting focus; sustaining focus)

EFFORT (sustaining effort; regulating alertness;

processing speeds) EMOTION (managing frustration; modulating emotion) MEMORY (using working memory; assessing & recall)

SKALA RATING GURU VERSI INDONESIA (Dwijo Saputro)

Tidak sama sekali Aktivitas berlebihan Impulsif Mengganggu anak lain Gagal menyelesaikan tugas, selang perhatian pendek Menggerakkan anggota tubuh terus menerus Perhatian mudah teralih Sekalikali Cukup Sering Hampir selalu

..SKALA RATING GURU VERSI INDONESIA (Dwijo Saputro)

Tidak sama sekali Permintaan harus segera dituruti Sering menangis Suasana hati berubah dengan cepat

Sekalikali

Cukup Sering

Hampir selalu

Ledakan kekerasan eksplosif Tidak sana sekali : 0 Sekali-kali :1 Cukup sering :2 Hampir selalu :3

12

SKALA PENGUKURAN ADHD (CONNERS PARENT RATING SCALES)

Tidak Sekali sama -kali sekali (1) (0) Cukup sering (2) Hampir selalu (3)

1 2
3 4

Tidak kenal lelah atau aktivitas berlebihan Mudah menjadi gembira, impulsif
Mengganggu anak-anak lain Gagal menyelsaikan pekerjaan yang telah dimulainya, selang waktu perhatiannya pendek Menggerakkan anggota badan/kepala secara terus menerus

Perhatiannya mudah teralihkan

Tidak Sekali sama -kali sekali (1) (0) 7 8 9 10 Permintaannya harus segera dipenuhi, mudah menjadi frustasi Sering dan mudah menangis Suasana hatinya berubah dengan cepat dan drastis Ledakan kekesalan tingkah laku eksplosif dan tak terduga

Cukup sering (2)

Hampir selalu (3)

15

SYMPTOM CHECKLIST ADHD (Karen J Miller)

Never SCALE A Some- Often times Very often

Fails to play close attention to details or makes careless mistaken in schoolwork, chores, or other tasks
Has difficulty sustaining attention to tasks, chores, or activities Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork, chores, or duties (not due to oppositional behavior or failure to understand directions) Has difficulty organizing tasks and activities

2 3 4

Never 6 Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork) Loses things necessary for tasks or activities (eg. Toys, school assignments, pencils, books, or tools) Is distracted by unimportant stimuli Is forgetful in daily acvtivities SCALE B 10 11 Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations when expected to remain seated

Some- Often times

Very often

8 9

Never SCALE B 12 Runs about or climbs excessively in situations where it is inappropriate (in adolescence, may be limited to restlessness) Has difficulty playing or engaging quietly in leisure activities Is on the go or often acts as if driven by a motor Talks excessively Blurts out answers before the questions have been completed Has difficulty awaiting turn

Some- Often times

Very often

13 14 15 16 17

18

Interrupts or intrudes on others (eg. butts into others conversations or games)

Never SCALE C 19 20 21 Is uncooperative or defiant or argues with adults Has difficulty getting along with other children Is often angry, irritable, or easily upset

Some- Often times

Very often

22
23 24 25

Has excessive anxiety, worry, or fearfulness

Seems sad, moody, depressed, or discouraged Has problems with academic progress (skill level or learning) Has problem with academic performance (productivity or accuracy)

SCALE A (Inattention) and SCALE B (Hyperactivity-impulsivity) At least six of the nine criteria from one or both sets should be excessive in frequency (often/very often)

SCALE C
Screening questions that address commonly associated problems with compliance, socialization, emotional control, anxiety, mood, learning, and academic performance

DSM -IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) A. Either 1 or 2 - Inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities b. Often has difficulty sustaining attention in tasks or play activities

..Inattention
c. Often does not seem to listen when spoken to directly d. Often does not follow through with instructions and does not finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) e. Often has difficulty organizing tasks and activities f. Often avoids, dislikes, or is reluctant to engage in tasks that requires sustained mental effort (such as schoolwork or home work) g. Often loses things necessary for tasks or activities (eg. toys, school assignments, pencils, books or tools) h. Is often easily distracted by extraneous stimuli i. Is often forgetful in daily activities

- Hyperactivity/Impulsivity: Six (or more) of the following symptoms of hyperactivity and impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity a. Often fidgets with hands or feet or squirms in seat b. Often leaves seat in classroom or in other situations in which remaining seated is expected c. Often runs about or climbs excessively in situation in which this behavior inappropriate (in adolescents or adults may be limited to subjective feelings of restlessness)

.Hyperactivity/Impulsivity d. Often has difficulty playing or engaging in leisure activities quietly e. Is often on the go or often acts as if driven by a motor f. Often talks excessively
Impulsivity: g. Often blurts out answers before questions have been completed h. Often has difficulty awaiting turns i. Often interrupts or intrudes on others (eg. Butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years C. Some impairment from the symptoms is present in two or more setting (eg. at school (or work) and at home) D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning E. The symptoms do not occur exclusively during the course of Pervasive Developmental Disorders, Schizoprenia or other Psychotic Disorder and are not better accounted for by another mental disorder (eg. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)

The DSM-IV-TR notes that the designation of not

otherwise specified (NOS) may be used for disorders with prominent symptoms of inattention

or hyperactivity-impulsivity that do not meet ADHD

criteria

SUBTYPE OF ADHD

1. INATTENTIVE TYPE (ADHD/I)

meeting at least 6 of 9 inattention behaviors 2. HYPERACTIVE-IMPULSIVE TYPE (ADHD/HI)

meeting at least 6 of 9 hyperactive-impulsive

behaviors 3. COMBINED TYPE (ADHD/C) meeting at least 6 of 9 behaviors in both the inattention and hyperactive-impulsive list

 Anxiety disorder

Conduct disorder
Eating disorder Learning disorder Mood disorder Oppositional Defiant Disorder Pervasive Developmental Disorder Sleep disorder

dr. IGA Endah Ardjana, SpKJ (K)

 BEHAVIORAL - Presentation of educational material for the patient, parents and school personnel - Behavior-modification techniques (daily report card) - Educational Interventions and Accommodations for Patients with Learning Disabilities (preferential seat placement, more intensive accommodation) - Social skill training (improve interactions with peers)

- Individual counseling ( to alleviate secondary symptoms such as low self-esteem, oppositional defiant behavior and conduct disorder ; to control their own behavior) PHARMACEUTICAL / MEDICATION When impulsive behavior places the child at physical or psychological risk (table)

STIMULANT MEDICATIONS
Medication Initial dose Range (R) & Common dose (CD) R: 0.1-0.8 mg/kg/dose PO qd to 5 times/d CD: 0.3-0.5 mg/kg/dose PO tid/qid R: 0.2-1.4 mg/kg/dose PO qd/tid CD: 0.6-1 mg/kg/dose PO qd/bid R: 0.3-2 mg/kg PO qd CD: 0.8-1.6 mg/kg PO qd Available tablets/ Spansules 5-,10- and 20 mg scored tablets

Methylphenid 2.5-5 mg ate (Ritalin, generic) Methylphenid Convert ate slow from release regular (Ritalin SR, generic SR) Methylphenid ate prolonged release (Concerta, Metadate CD) Convert from regular or use 18 mg

20 mg spansules do not cut, crush, or chew

18- and 36 mg tablets Do not cut, crush, or chew

STIMULANT MEDICATIONS
Medication Initial dose Range (R) & Common dose (CD) Available tablets/ Spansules

Dextroamphe 2.5-5 mg tamine (Dexedrine, Dextrostat)

Dextroamphe 5 mg tamine spansules (Dexedrine CR)

R: 0.1-0.7 mg/kg/dose PO qd/qid CD: 0.3-0.5 mg/kg/dose PO qd/tid

R: 0.1-0.75 mg/kg/dose PO qd/bid CD 0.3-0.6 mg/kg/dose PO qd/bid

Dexedrine 5 mg scored tablets Dextrostat 5-, 10and 15-mg scored tablets

5-, 10- and 15-mg spansules Do not cut, crush, or chew

Dextroamphe 2.5-5 mg tamine and amphetamine 4-salt combination

R: 0.1-0.7 mg/kg/dose PO qd/qid CD: 0.3-0.5 mg/kg/dose PO tid/qid

5-, 7.5-,10-,12.5-, 15-,20-, and 30mg scored tablets

EFFECTS OF STIMULANTS Cognitive - Increased attention to assigned task - Decreased response to irrelevant stimuli - Improved speed and accuracy of performance - Improved short-term memory - Improved short-term academic performance Motor - Reduced activity level (often normalizes) - Decreased off-task motor behavior - Decreased excessive talking or noise - Increased independent play and work - Improved fine motor control/handwriting - Decreased anger and aggression - Decreased emotional and behavioral intensity - Increased sensitivity to reinforcement - Increased compliance with adult requests - Decreased negative interactions with peers - Improved mother-child & family interaction - Improved teacher-student relations

Social

SIDE EFFECTS OF STIMULANTS Common side effect - Appetite suppression, Weight loss, Delay in sleep onset, Abdominal discomfort, Headache, Dizziness, Minor increases in pulse & blood pressure, Behavioral rebound - Withdrawal hyperactivity (rebound), Agitation/jitteriness, Moodiness/sadness, Social withdrawal, Tics/dyskinesias, Weight loss/reduced growth velocity, Liver toxicity (pemoline only)

Infrequent side effect

Overmedication - Irritability / weepiness (at peak), Over focusing, /Toxic effect Dazed appearance, Fatigue, Psychosis
Miller KJ, Castellanos FX. ADHD. Ped in Rev 1998; 19 (11)

 Outcome is significantly affected by persistence of AD/HD symptoms, comorbid condition and psychosocial factors 30%-70% of children continue to be symptomatic as adults

Adults who have AD/HDs achieve lower academic levels, socioeconomic status, less vocational stability, increased marital problems Medication continues to be effective for adults, but response rate may be lower

Initial treatment of Children with Activity/Attention Problem

ADHD OR HYPERKINETIC DISORDER DIAGNOSED PSYCHOEDUCATION, ADVICE, SUPPORT TO CHILD, FAMILY AND TEACHER

NO

CHILDREN UNDER 6 YEARS?

YES

PERVASIVE,SEVERE DISABILITY

YES

STIMULANT MEDICATION

GOOD RESPONSE

PSYCHOSOCIAL INTERVENTION PARENT TRAINING

NO

SIGNIFICANT IMPAIRMENT PERSISTS

PROBLEM AT HOME ?
PARENT TRAINING AND ADVICE TO CHILD

TRY SECOND STIMULANT

SIGNIFICANT IMPAIRMENT PERSISTS

SIGNIFICANT IMPAIRMENT EXISTS

PROBLEM AT SCHOOL? SCHOOL LIAISON AND ADVICE TO CHILD GOOD RESPONS E SIGNIFICANT IMPAIRMENT PERSISTS

REVIEW, ADD BEHAVIOUR THERAPY,TREAT COMORBIDITY,TRY SECOND LINE DRUGS, E.G NORADRENERGIC

SPECIALIST REVIEW, IDENTIFICATION OF STRESSORS AND/OR ASSOCIATED PROBLEMS, CONSIDER MEDICATION

MAINTAIN TREATMENT
REVIEW AND IF NECESSARY TREAT COEXISTENT PROBLEM

 Primary symptom include inattention and/or hyperactivity/impulsivity Clear interference with developmentally appropriate social, academic, or occupational functioning Precise neural and pathophysiologic substrate of ADHD remain unknown Frontostriatal regions, rich in noreepinephrine, epinephrine and dopamine neurotransmitters, are consistently implicated Early recognition, assessment and management of ADHD can redirect educational and psychosocial development