Dr TG Magagula13 August 2012

Behavioral disorder: noise-making, motor driven

Diagnosis6 or more symptoms of inattention:

careless mistakes, can’t sustain attention, doesn’t listen, can’t organize tasks, avoids schoolwork, loses things, easily distracted, forgetful.

6 or more symptoms of hyperactivity- impulsivity:Fidgeting or squirming, leaves seat, runs or

climbs excessively, cannot play quietly, on the go, talks excessively, blurts out answers, cannot await turn, often interrupts.

DiagnosisSome symptoms have been present before

age 7.Symptoms present in at least 2 settings.Impairment of academic and / or social

functioning.Not due to another Axis 1 disorder.Code subtype: -combined type for 6/12;

predominantly: inattentive for past 6/12 or hyperactive-impulsive for past 6/12

Adults/adolescents: in partial remission

Clinical FeaturesADHD may have its onset in infancy although

it is usually only diagnosed when the child is a toddler.

They have difficulty in waiting for anything and often start a task in a rush, but they have difficulty in finishing it.

Their mood is often irritable.

Clinical Features Concomitant (co-morbid) emotional-

behavioral difficulties are common.About 75% of children show aggressive and

defiant behavior fairly often.School difficulties (emotional and scholastic)

are common.

EtiologyNo single factor is known to cause ADHD:Genetic factors:

Greater concordance in monozygotic twins.Siblings have twice the risk to develop ADHD.Biological parents have higher risk for ADHD.

Developmental factors:More soft neurological deficits Brain insults: prematurity, toxins: smoking and

drinking first trimester

Co-morbidity/differential diagnosesTemperament & visual-motor-perceptual

impairments in ADHDAnxiety/depressive disordersMania bipolar I disorder wax & waneConduct disorder; ODDLearning disorders, epilepsyMental retardation(check family history)

Course and PrognosisThe course of ADHD is very variable.

Symptoms may continue into adulthood.Symptoms may fully remit.Hyperactivity may disappear while attention

problems persist.Persistence is predicted by:

Family history, negative life events, punitive, harsh parenting, co morbidity.

Treatment: Bio psychosocial (MDT)Comprehensive treatment program indicatedNot all children need medsDecision to use meds based on thorough

assessment of severity, impact and developmental appropriateness of symptoms

Stimulants: Methylphenidate RitalinNon-stimulants include: Atomoxetine-

Strattera, Modafinil-Provigil

Cognitive-behavioral approach:

Train skills: self-instruction, -evaluation,-monitoring, anger management, social behavior. Problem solving skills

Evaluation and treatment of co morbid psychiatric disorders; child and parent(s)

Inform child about purpose of medsTalk about “I am crazy” Family therapy

Social interventionSocial skills groups.Training, assessment and treatment of parents.

Expectations and behavioral programs.Parents and teachers work together to structure

environment with set of expectations and rewards.

Behavioral interventions at home & school (star chart)

ConclusionConcerns:

Inappropriate dx -/under dx of ADHD & prescription of ADHD medication.

“Best researched disorder in medicine”Multiple agents and therapies are

necessary to treat ADHD and co-morbidity; prevent disability.