EXTERNALIZING DISORDERS

Chapter D.1

Attention
Deficit
Hyperactivity
Disorder
Tais S Moriyama,
Aline C M Cho, Rachel E
Verin, Joaquín Fuentes &
Guilherme Polanczyk

Adapted by Henrikje Klasen & Julie Chilton

The “IACAPAP Textbook of Child and Adolescent Mental Health” is available at the
IACAPAP website http://iacapap.org/iacapap-textbook-of-child-and-adolescent-
mental-health

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• Differentiate and diagnose
– Mild or marked ADHD
– Other related mental/physical health problems
• Treat or manage through:
– Psycho-education
– Basic psycho-social interventions
– Pharmacotherapy
• Know when to refer patient to a specialist
• Inattention, hyperactivity and
impulsivity
• Two Diagnoses:
– ADHD (DSM)
– Hyperkinetic Disorder (ICD)
• Affects 3-5% of children
• Abnormal neuro-psychological
functioning and neurobiological
correlates
Tree climbing
(Vauvau, 2009)
1800’s Heinrich Hoffman
“Impulsive Insanity”
&
“Defective Inhibition”

Der Struwwelpeter, an illustrated book

portraying children misbehaving
(“Impulsive Insanity/Defective
Inhibition”) by Heinrich Hoffman (1854).
• 1902 Lancet article
• 1920’s “minimal brain damage”
• 1930’s “hyperkinetische
Erkrankung”
• 1960’s “minimal brain
dysfunction”
• 1937 Benzedrine discovered
• Hyperkinetic Syndrome of
Childhood” in ICD-9
• 1980 inattention recognized
• DSM-III Attention-Deficit Disorder
with or without Hyperactivity
• Relevance in your country?
• Tell us about your cases
• Do local people recognize ADHD?
• Is ADHD more of a problem in high income countries (HIC)?
• Are there any other points to discuss?
Ahmed and Peter are both 7 years old and both have ADHD,
combined type… listen to their story

• Ahmed lives in a small village in Africa. He goes to school in

the mornings and plays or herds his father’s goats
afterwards.
• Peter lives in a medium size town in Western Europe. He
goes to school until 3 pm then usually plays football with his
friends.
How does ADHD impact their lives?
 Listen to Ahmed and Peter’s experience at school...

What will happen to Peter and Ahmed’s education

after they have been expelled from
2nd year primary school?
Listen what happens when Ahmed and Peter get
impulsive…

Children with ADHD are accident prone.

How will the broken leg impact on the lives of
Peter and Ahmed? How long will it take to get
help? What if an operation is needed?
Listen what happens, if Ahmed and Peter fail to pay
attention and become forgetful…

Children with ADHD are forgetful.

How does the loss of something expensive impact on the
lives of Peter and Ahmed? Will they be punished? How?
Will it affect the family as a whole?
ADHD:
• Is common
• Can be serious
• Can persist
• Is stigmatizing
• Is treatable
• Core symptoms
– Inattention, hyperactivity, impulsivity
– Present in more than one context
– Leading to functional impairment
• Subtypes https://www.youtube.co
m/watch?v=GR1IZJXc6d8
– In DSM: combined, predominantly &feature=related

hyperactive, predominantly inattentive

– In ICD: Hyperkinetic disorder
 ADHD
Epidemiology
• Prevalence
– 6% for children
– 3% for adolescents
• Male>Female
• ADHD (DSM definition) > HKS (ICD definition)
 ADHD
Differences According to Age
• Pre-school: play < 3mins, not listening, no sense of danger

• Primary school: activities < 10 mins, forgetful, distracted,

restless, intrusive, disruptive

• Adolescence: attention< 30 mins, no focus/planning,

fidgety, reckless

• Adult: incomplete details, restless, forgetful, impatient,

accidents
 ADHD
Course
• Some chronic
• Unclear persistence (Faraone 2006)
– 15% full persistence
– 40-60% partial remission
• Severe cases more persistent
 ADHD
Associations with Durability of Symptoms
• Lower academic achievement
• Marital problems and dissatisfaction
• Divorce
• Difficulties dealing with offspring
• Lower job performance
• Unemployment
• Employment below potential
• Traffic accidents
• Other psychiatric disorders
 ADHD
Etiology & Risk Factors
• Strong genetic component (76%)
• Perinatal factors – some evidence
• Neurobiological deficits – growing evidence
• Deprivation and family factors – important for
course and outcome
• Discuss:
– popular explanations in your cultural context?
 ADHD
Neurobiology

• Frontal-striatal
dysfunction
– mediated by GABA
– modulated by
catecholamines

• Catecholaminergic
dysregulation

• Delay in cortical
maturation
• Defiant, aggressive antisocial behaviors
• Problems with social relationships
• IQ tends to be lower than in the general
population
• Specific learning problems
• Co-ordination problems
• Specific developmental delay
• Poor emotional self-regulation
• Inattention
• Hyperactivity
• Impulsivity
• Pervasive symptoms
• Duration/age of onset
• Impairment or distress

*Diagnosis exclusively made on clinical grounds

• Information from at least two contexts
– Teachers are key
• Medical and psychiatric assessment
• Assess co-morbidity
• No additional tests necessary
• Situational hyperactivity
• Behavioral disorders (ODD/CD)
• Emotional disorders
• Tics, chorea or other dyskinesias
• Misuse of substances
• Autism Spectrum Disorder
• Intellectual Disability
*Frequent Comorbidity*
• Parental mental health issues
• Severe marital discord or recent divorce
• Domestic violence
• Child abuse or neglect
• Severe bullying or exclusion by peers
• Severe deprivation or poverty
• SNAP IV: http://www.adhd.net/snap-iv-form.pdf
• SDQ : http://www.sdqinfo.org
• SWAN: http://www.adhd.net/SWAN_SCALE.pdf
• Many other proprietary (not free) scales
 ADHD
Review of Assessment Algorithm
• Does the child have problems
with inattention and over-
activity?
Consider ADHD if the answer to
• Are symptoms persistent, both is ‘yes’
severe and causing
impairment in the child’s
functioning?
Explore ways to address
environmental stressor
• Explore the impact of as part of management
environmental stressors (e.g.,
plan
family)
Manage or refer
• Rule out medical or other
conditions 28
• Individually tailored
• Reduce symptoms
• Improve educational outcomes
• Reduce family and school-based problems
 ADHD

What works?

Evidence Based Treatments:

• Best evidence for stimulant medication
• Behaviour treatments also effective in mild to
moderate cases
• Psycho-education for parents and school

30
• Behavior therapy
– Individual, not always generalize
– Parent management training: particularly useful in younger
children and for associated behavior problems
– School based: child in front of class, short tasks etc.

• Generally effective, but smaller effect size than

medication

• First line treatment in younger children or milder

cases
Methylphenidate or Amphetamines
– Efficacy and safety well established
– ES 0.8-1.1; clinical response in 70%
– Dose: titrate for optimum response
– Short/long acting (sustained release) available
– NOT on WHO list of essential medicines

• Common side effects: nausea, weight loss, insomnia,

agitation
• More serious side effects: tics, psychotic symptoms,
raised blood pressure, growth retardation
• Atomoxetine
• Clonidine
– Start dose 0.1mg at bedtime
– Add a.m. dose after 3-7 days, then midday dose after 3-7 days
– Increments by 0.05-0.1mg, max. 0.4mg
• Imipramine
– 2-3 times/day; 1-4mg/kg/day
– 30-50% response rate in 10 studies
– ECG recommended prior to treatment (cardiotoxicity)
*Non-stimulants: less effective, more side effects, try only
when stimulants not available, not tolerated or not appropriate*
• Acupuncture
• Meditation
• Homeopathy
• Physical exercise
• Chiropractic care
• St. John’s wort
• Music therapy Hypericum perforatum
“St. John’s Wort”

• Bach flower remedies

• Elimination diets
• If no response and severe impairment after
pharmacological treatment combined with
behavioral approaches
– Re-evaluate diagnosis and co-morbidity
– Check for undetected social adversity or abuse
• If still no response after 6 months consult with
specialist
• AACAP ADHD Resource Center
http://www.aacap.org/AACAP/Families_and_Youth/Resource
Centers/ADHD_Resource_Center/Home.aspx

• NICE Guideline, Tools,

and Resources
http://www.nice.org.uk/guidance/cg72/resources