GEORGE STILL-1902

Defect in moral character

 One of the most common neurobiological childhood
psychiatric condition
 Symptoms of hyperactivity, impulsivity, and/or inattention
 Global prevalnce in childhood 4-17 years is 7.2% (meta-
analysis of 175 studies,thomas et al,2015)
 Prevalance in adulthood is 4.4% (Kessler et al,2005)
 It is a chronic condition and persists into adolescence and
young adulthood in 60-80% of patients diagnosed (AACAP-
2007)
 The rate of lifetime childhood diagnosis of ADHD was 7.8% where as
4.3% had ever been treated with medication for the disorder. –CDC
(2005)(AACAP-2007)- 11% (parent reported survey 4-17 yr – NSCH :AAP
2011)
 Prevalance increases with age
 Prevalence of ADHD is increased in children with neurological disorder
like epilepsies, neurofibromatosis, tuberous sclerosis
 Male to Female is 4:1 for hyperactive type, 3:1 for combined type and
2:1 for inattentive type
 In community inattentive type more prevalent ( 1.5 * combined type)
 Age- as age advances inattentive type more common
 INDIAN PREVALANCE – 11% in school going ( Coimbatore study 2013)
 Imbalance between dopaminergic and noradrenergic regulation mediate the
core symptoms of ADHD – these NT increase inhibitory influences of frontal
cortical activity on subcortical structures
 ALL 3 components:
 Biological
 H/o birth complications-toxemia, lengthy labour, complicated delivery
 Maternal drug use- smoking and alcohol during pregnancy
 Lead and mercury exposure
 Food colouring and preservatives
 Abnormal brain structures-anatomical and functional
 Severe traumatic brain injury
 Dysregulation of frontal subcortical circuits (functional MRI) esp frontal
lobe with caudate putamen and globus pallidus
 Small cortical volumes in this region and small volume reduction
throughout brain
 Abnormalities of cerebellum, esp midline / vermian elements
 Genetic component- parents and siblings of a child with ADHD have a 2-8 *
increased risk for ADHD, identical twin- > 50 % chance
 DAT 1- Dopamine transporter gene
 DRD4- Dopamine 4 receptor gene
 DRD 5
 DOCK 2- associated with pericentric inversion 46 inv(3)(p14:q21) involved in
cytokine regulation
 Na-H exchange gene
 Serotonergic genes (5HTT, HTR1B)
 Synaptosomal-associated protein (SNAP)
 Markers at chromosome 4,5,6,8,11,16 and 17
 Psychosocial
◦ Family stressor – poverty, exposure to violence, under or malnutrition, chronic
family conflict, decreased family cohesion
 A persistent pattern inattention and/or hyperactivity impulsivity
that interferes with functioning or development
◦ 1. Inattention- >= 6 symptoms out of 9 < 17 yr for min 6 mths inconsistent
with development and that negatively impacts social, academic/ occupational
activities
Fails to give attention to details or careless mistakes
Difficulty sustaining attention in tasks or play activities
Often does not seem to listen to when spoken to directly
Often does not seem to follow instructions and fails to finish work
Often has difficulty in organinzing tasks and activities
Often dislikes, avoids tasks requiring mental effort
Often looses things
Often easily distracted by extraneous stimuli
Is often forgetful in daily activites
2. Hyperactivity/impulsivity- Persisted > 6 mths and inconsistent with
developmental level and interfering with social, academic/occupational
functioning
 Often fidgets with or taps hands and feet or squirms in seat
 Often leaves seat in situations where seating is expected
 Often runs about or climbs in situations where inappropriate
 Often unable to play or engage in leisure activities quietly
 “On the go” or “driven by motor like”
 Often talks excessively
 Often blurts out answer before question completed
 Often difficulty waiting turn
 Often interrupts or intrudes on others

The symptoms are not sole manifestation of oppositional behaviour, defiance,

hostility, or failure to understand tasks or instructions.
 3. Several of these inattentive/Hyperactive-impulsive symptoms were present
<12 years
 4. Present in >= 2 settings
 5. Clear evidence that symptoms interfere with social, academic and or
occupational functioning
Specifiers – whether:
Combined
Predominantly Inattentive
Predominantly Hyperactive
Specifiers- whether
Mild, Moderate or Severe
Minimum age of diagnosis is 4 years (2011AAP guidelines)
 Cognitive impairments- deficits in attention, memory,
organization, time management, judgment, lack of impulse
control
 Activity limitations and academics-difficulties in learning and
applying knowledge, problems with carrying out single or
multiple tasks, studying, self managing behaviour
 Interpersonal relations(emtional and behavioural)-impairment
in family relationships, peer relation , self esteem and
perception
 social functioning-Impacts establishment of community,
social and civic life.
Surviellance
 Address parent’s concerns at every well visit
 Monitor milestones in developmental and behavioural
domains
 Identify patients with risk factors
Screening
 Identify children at risk
 Order further tests and detailed evaluation
 Monitor for medical and mental health concerns
 Oppositional defiant disorder 54-84%
 Conduct disorder-1/3 rd cases-significant proportion of ODD develop
CD
 Anxiety disorder- 33% (2ndary to ADHD or independent d/o)
 Depressive disorder- 0-33% (ADHD C/I)
 Mania -16%
 Learning or language disorder- 20%-60% (more in ADHD C/I)
 Substance abuse- adolescents with new onset ADHD esp prone (always
treat before tt of ADHD with med) 15-19% including smoking

Presence of coexisting conditions can change outcome prediction and

influence treatment
Co-morbidity presentations in adults repIaces ODD by CD and mood d/o
increases
AACAP 2007
 Medical, developmental ,educational and psychosocial evaluation
 Confirm presence, persistence, pervasiveness, and functional complications
of core symptoms and identify co-existing emotional, behavioural, and
medical d/o, exclude other explanations of core symptoms

 History- Parent and patient

◦ Antenatal and birth history
◦ Developmental history
◦ H/o chronic illness
◦ H/o acute illness- CNS infections, head injury
◦ Drug h/o
◦ Sensory impairments
◦ Psychosocial h/o – family stressors, CAN
◦ Family h/o ADHD or mental ailments/ substance abuse, LD, antisocial behaviours
◦ H/o functioning in school/daycare
◦ H/o coexisting emotional, behavioural d/o
◦ H/o sleep disturbance and appetite (esp for Pharmacotherapy)
◦ Cardiac h/o in family and child ( for DRUGS)
 Examination
◦ Wt/Ht/HC/Vital signs
◦ Associated dysmorphism and neurocut markers
◦ Neurological examination with vision and hearing
◦ Subtle neurological motor signs and coordination and fine motor movements
◦ Observation of child’s behaviour

 Developmental and behavioural evaluation

◦ Details of behaviour change –onset, course, duration, functional impact
◦ School concerns and absence
◦ Observation of parent –child interaction

Discuss safety and Injury prevention at each visit as these children at increased
risk
 ADHD specific scales
◦ National Initiative for Children’s Healthcare Quality (NICHQ) ADHD toolkit
includes VANDERBILT RATING SCALE for school age children
(6-12 yrs)
◦ Conner’s comprehensive behaviour rating scale and ADHD rating scale IV (in
preschool age also)
◦ ACTeRS rating scale (kindergarden to eighth grade)
◦ Attention Deficit Disorder scale 4 th ed ( 4-18 yrs)
◦ Brown Reporting Scale ( 3yr-adult)
◦ SNAP- Swanson ,Nolan, Pelham Checklist
 Broadband scales (mainly for co-existing conditions)
◦ CBCL
◦ BASC-Behaviour assessment scale for children
◦ Long Conner’s-3
 Children with learning, language, visual-motor, or auditory
processing d/o difficult to differentiate from ADHD.
(Neuropsychological testing helps clarify diagnosis)

 Identify specific problems areas that may occur in ADHD and

◦ Abstract reasoning
◦ Mental flexibility
◦ Planning Executive function
◦ Working memory
These and direct assessment of attention and behaviour disturbances
helps in planning environmental and behavioural interventions and
track progress of treatment
 Completion of ADHD specific rating scale
 A narrative summary of classroom behaviour and
interventions, learning patterns, and functional impairments
 Copies of report cards and samples of schoolwork
 Review of school based evaluations if done

Teacher providing data should have a contact period of 4-6

months
 US FDA approved this for assesment of children with ADHD 6-
17 yrs
 Current evidence insufficient to support qEEG for diagnosis of
ADHD ( Neuropsychiatric EEG-Based Assesment Aide :NEBA)

EEG profile used –Theta to Beta ratio abnormality

 Depending on D/D kept or clinical features
◦ Speech and language evaluation
◦ Occuppational therapy (motor coordination disorders)
◦ Mental health evaluation (mood d/o, anxiety, ODD,CD, OCD, PTSD, ADJ
d/o)
◦ Blood pb levels
◦ Thyroid hormone levels
◦ Genetic testing ( fragile X)
◦ Overnight polysomnography for children with symptoms s/o risk
factors for obstructive sleep apnea syndrome or restless leg syndrome
◦ Neurological consultation or EEG
 In Europe diagnosis of Hyperkinetic d/o is defined by ICD-10
criteria
◦ 3 (out of 5) symptoms of hyperactivity
◦ 6 (out of 8) of Inattention
◦ 1(out of 4) symptom of impulsivity

Present in more than 1 setting

Divided into with/without CD
 From preschool/daycare/child care program
 If no preschool or child care program:
◦ Child enrolled in qualified preschool program and then info from there
(Head start, Public prekindergarden programs, Early Childhood Special
Education services)
◦ Parent enrolled in parent training program with the child being directly
observed
 Information from 2 teachers / adults (1 may be parent) with
whom child spends time and interacts (coach/guide)
 Developmental variations- gifted child /ID
 Neurodev d/o-may co-exist or mimic ADHD
◦ Learning disabilities
◦ Language or communication d/o
◦ ASD
◦ Neurodevelopmental syndromes like (fragile X, Fetal alcohol,
Kleinfelters)
◦ Seizure d/o
◦ Sequelae of CNS infection or trauma
◦ Metabolic d/o (ALD/MPS type III)
◦ Motor coordination d/o
 Ask child to write a sentence
 Ask child to tell you about a movie or video seen recently
 Ask child to read a paragraph
 Ask child to copy a geometric figure or do a draw a person
test
 Ask child to repeat a series of random numbers in both
forward and reversed manner
 Ask child a multiple –step task to complete in order given
 Emotional and Behavioural d/o –(co-occur /mimic)
 Anxiety and mood d/o
 ODD
 CD
 OCD
 PTSD
 ADJ D/O

 Psychosocial and Environmental factors

◦ Usually affect beh in one setting
◦ Parent-child temparment mismatch or personality mismatch and
parental health condition—Affects reporting-use multiple respondents
 Medical conditions
◦ Thyroid
◦ Sensory impaiments
◦ Pb poisoning
◦ Sleep d/o
◦ PLMD
◦ Medication effects/substance abuse
◦ Chronic illnesses like asthma, allergies, childhood cancers, diabetes,
migrain, hematological d/o
 Initiate evaluation of ADHD for any child between 4-18 yr
with academic or behaviour problems and symptoms of
Inattention,Hy, or Imp( Level A Ev)
 To make diagnosis take DSM criteria including documentation
of impairment in >= 2 settings after ruling out other causes
 Always evaluate for co-morbidities (Level B)
 Recognize it as a chronic health illness and consider these
children as children with special needs
 Education to the family (including the child and the caregivers)
 Setting specific goals for home and classroom setting to guide
management and monitoring
 Psychosocial treatment (Behavioural Management 8-12 sessions)
 Accomodations in the home and classroom
 Medications
 Treat co-morbidities
 If target not met review the selected intervention, review diagnosis,
look for co-morbidities, adherence to treatment plan
 Monitor medication for adequacy of dose and S/E
 Preschoolers (4-5 years)
◦ Parent/teacher administered behaviour therapy
◦ Methylphenidate- If behaviour therapy does not provide significant
improvent and moderate to severe continuing disturbances in child’s
function
 School going (6-11)
◦ Medications and/or Behaviour therapy
 Adolescents (12-18)
◦ Medications with the assent of the adolescent and may prescribe
behavioural therapy
 In preschoolers medication considered if
◦ Moderate to severe dysfunction
◦ Symptoms have persisted for 9 months
◦ Symptoms in >=2 settings
◦ Dysfunction not responded adequately to behavioural therapy
◦ Consider factors like
 Developmental impairment
 Safety risks
 Consequences for school and social impairment
Doses s/be smaller and in less incremental doses as rate of metabolizing
stimulant medications is slower
In adolescents before beginning treatment rule out substance abuse
 Identify targeted behaviours causing impairments in child’s
life
 Parents taught to implement rules, consequences, rewards to
encourage desired behaviour
 Esp useful in children with complex co-morbidities and family
stressor
 Behaviour Modification techniques and social learning theory
◦ Role modelling appropriate beh, attitudes, and emotional reactions of
others
◦ Consistent and positive parent-child interaction
◦ Cut down on negative interaction
◦ Parent training for
 Providing appropriate consequences for their child’s beh
 More empathetic to child’s point of view
 Help children improve their abilities to manage their own behaviour
 Teach self control rather than punishment
 Positive Behaviours to be reinforced by praise and Negative behaviours to
be extinguished by ignoring
 Punishment only for intolerable or dangerous behaviour
 Understand student’s strengths and needs
 Preferred seating
 Modified work assignments
 Provide written direction or steps
 Give minimum no of directions or steps at a time
 Deconstructing tasks
 Organization tips
 Tests modification- location and time
 Daily behavioural report card
 How to
◦ Deliver and follow through on clear commands
◦ Shape behaviours in gradual increments
◦ Use daily contingency charts
◦ Institute procedures like “time out, token economy, response cost”

 Daily behaviour report cards

◦ For target behaviours
◦ So parents can provide positive reinforcement or consequences at
home
 Stimulants
◦ Treatment of choice in school going
◦ Are available in short and long acting forms
◦ No tolerance is developed
◦ Titrate dose to achieve the best response (not mg/kg) with min S/E
◦ Behavioural effects seen in 30-45 min effect lasts 4-6 hrs in short acting
◦ Disruptive behaviours -affected rapidly increased attention -upto 1.5 hrs

◦ DOSE: Low- 0.5mg/kg/day , Medium- 0.5-1 mg/kg/day, high- 1-1.5 mg/kg/day

◦ Over 1st 4 weeks dose increased to max tolerated (keeping SE min or absent)
◦ 65-75% patients respond to stimulants (AACAP)

◦ Preschoolers can be used but doses titrated more carefully and lower mean doses
may be effective (0.7+- 0.4 mg/kg/day) PATS study
◦
 Drug 3 stages titration, maintenance, termination
 Started in low dose and increased every 3-7 days till
symptoms improve by 40-50% or there are S/E
 Frequency depends on type of ADHD and domain of function
in which improvement is desired
 If no response or intolerable s/e then change drug within
same class
 If NA then other class , when switching from stimulant to
atomoxetine – cont stimulant for 1st few weeks and add
atomoxetine (for atomoxetine to start working)
 Not vice versa
 METHYLPHENIDATE

SHORT ACTING ADWIZE METEDATE

3-6 hrs INSPIRAL RITALIN 5,10,20 mg

INTERMEDIATE ACTING
INSPIRAL SR
6-8 hrs 10,20 ,30mg

LONG ACTING 18,27,36,54

CONCERTA
10-12 hrs mg
 Starting dose ≤ 25 kg - 2.5 mg, >25 kg 5mg ,
Methylphenidate increment of 2.5 AND 5 every 3-7 days
Max 35, 60 mg respectively

Methylphenidate XR 20% immediate release and 80% sustained

Concerta release over 10-12 hrs with increase of 9-18
mg /dose every 3-7 days

Tab must be swallowed whole

Max < 13 yr 54 > 13 yr 72mg
 SIDE EFFECTS S/E usually at start of tt and managed by alteration in
dose, timing, or use of alternate stimulant
medications or adjunct therapy to treat s/e eg
melatonin or antihistamine for insomnia
Stomachache(GI
symptoms)
Headache C/I- glucoma , previous Not C/I in tics and do
Decreased Apetite sensitivity, not lower seizure thresh
Insomnia Cases of drug abuse, pt on hold
Jitteriness MAO inhibitors , Active
Tics Psychotic pts
Growth (ht)
Mood lability Before starting always be sure of any cardiac h/o
in pt or family , seizure h/o, FH of sudden death –
if so evaluation by cardiologist
Monitor Ht, Wt, BP, HR regularly
Rare S/E of toxic psychotic symptoms
before and while on tt
specifically involving visual and tactile
hallucinations of insects, symptoms of
aggression and suicidality
 NON STIMULANTS
Doses : 0.3 mg/kg/day
When stimulants ineffective or cause sig S/E or Titrated over 1-3 weeks
exacerbation of co-existing d/o to a max of 1.2-1.8
mg/kg/day BD
ADHD and co-morbidity treatment by single drug preferably (max-
100mg)
ATOMOXETINE (strattera) 10,18,25,40,60 mg

Age : >= 6 yr
Mode of action: NE Reuptake inhibitor and blocks Rare S/E of toxic psychotic
the presynaptic NE transporter in prefrontal cortex symptoms specifically
involving visual and tactile
S/E – GI (decreases apetite), lesser tics, less effects hallucinations of insects,
on sleep, more fatigue and nausea and sedation symptoms of aggression
,headache some reports of liver toxicity
Some increase in suicide ideation but no actual
suicide Greatest effect at 6 weeks
comorbid anxiety,tics, or substance abuse-1st line
 If pt fails to respond to above for adequate time-review
diagnosis
 Consider comorbidities which may be the primary cause of
adhd
 Consider Behavioural therapy if not tried earlier
 Then 2nd line agents
 TCAs BUPROPION

Imipramine, Desipramine (most dangerous) Antidepressant with

Nortryptiline noradrenergic and dopaminergic
ECG must, plasma levels properties
MOA: Inhibit NE reuptake
ADHD with Depression
C/I in ongoing Sz
Desipramine : ADHD with Tics or Tourette
d/o

S/E: Cardiac S/E: need for cardiac monitoring,

monitoring of plasma levels, possible ass with
sudden death
 CLONIDINE (catapres)AND GUANFACINE (Intuniv)

Presynaptic , central acting alpha 2 adrenergic For comorbid aggression or tics

agonists As an adjuct therapy to treat tics and
Affect NE discharge rates in locus ceruleus which stimulant induced insomnia
indirectly affect dopamine

Clonidine- counter insomnia by stimulants, and Guanfacine-ADHD (mainly impulsivity), Tics , and
ADHD with Aggression aggression 1,2,3 mg tab
1 mg/day incr by 1 mg max 4 mg
3-10ug/kg/day bid or qid (0.1 mg
increment of 0.1 mg max of .4 mg)
 If patient has been symptom free for at least 1 year then
think of tapering
 Signs of remission
◦ Lack of adj of dose despite growth
◦ Lack of deterioration when dose missed
◦ New found abilities to concentrate during drug holidays
 low stress time s/as holidays good time for withdrawing
 1. Group I- Initial small improvement followed by gradual
improvement over time
 2. Group II- Large initial improvement who maintained
improvement over 36 months- may not require medication on
fu
 3. Group III- Showed initial improvement but then
deteriorated (higher aggression and lower IQs at baseline)
 Related to disease severity, type of symptoms, co-existing
conditions, family situations, treatment, intelligence
 Adults with a childhood h/o ADHD (untreated) have higher
than expected rates of antisocial and criminal
behaviour,injuries and accidents, employment and marital
difficulties, health problems and more likely to have teen
pregnancy
 60-80% of childhood ADHD persists into adolescence and 60%
of adolescence persist into adults
 Hyperactivity usually decreases with age while impulsivity and
inattention persists