1. ATTENTION DEFICITHYPERACTIVITY DISORDER Jose David Gamez Godoy, M.D.

2. ADHD Most common neurobehavioral disorder of childhood Inattention, including increased distractibility and difficulty sustaining attention Poor impulse control and decreased self inhibitory capacity Motor over activity and motor restlessness American Psychiatric Association’s Diagnostic and Statistical Manual (DMS-IV)

4. ETIOLOGY Birth complications Maternal drug use Maternal smoking and alcohol Genetic component Exposure to toxins High sensitivity to food colorings and additives Eigenmann PA, Haenggeli CA: Food colorings, preservatives and hyperactivity. Lancet 370:2007 Abnormal brain structures Severe traumatic brain injury Psychosocial family stressors Family history approximately 80% Maternal stress Grizenko et al, Relation of maternal strees during pregnancy to symptom severity and response to treatment in children with ADHD, Rev PsychiatrNeurosci 2008

5. EPIDEMIOLOGY Prevalence 2-18% school aged children 2-6% adolescents 4.4 million children aged 4-17 years 11% boys and 4.4% girls 4:1 hyperactive and 2:1 inattentive 56.3% treated with medication Health care costs $3.3 billion annually Comorbid psychiatric diagnoses CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003

6. EPIDEMIOLOGY Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health, 2003 CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003

7. EPIDEMIOLOGY Percent of Youth 4-17 ever diagnosed and currently medicated for Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health, 2003 CDC Mental Heatlh in the United States: Prevalence of Diagnosis and Medication treatment for ADHD, 2003

8. PATHOGENESIS Smaller brain volumes, prefrontal cortex and basal ganglia (5-10%) Increased gray matter in the posterior temporal and inferior parietal cortices Atypical frontal-striatal function Increase in dopamine transporter density

9. PATHOGENESIS Ellison-Wright et al, Structural brain change in Attention Deficit Hyperactivity Disorder identified by meta-analysis, BMC Psychiatry. 2008

10. PATHOGENESIS Volkow et al, Depressed Dopamine Activity in Caudate and Preliminary Evidence of Limbic Involvement in Adults With Attention-Deficit/Hyperactivity Disorder, Arch Gen Psychiatry. 2007

11. CLINICAL MANIFESTATIONS Inattention Hyperactivity Impulsivity Developmentally inappropriate Before 7 years of age At least 6 months 2 or more settings Impairment in social, academic or occupational functioning Not be secondary to another disorder

12. HYPERACTIVITY Difficulty remaining seated Difficulty playing quietly Frequent restlessness Always “on the go” Peak 7-8 years of age

13. IMPULSIVITY Difficulty waiting turns Blurting out answers too quickly Disruptive classroom behavior Interrupting other’s activities Peer rejection Unintentional injury Greater risk of engaging in drug use Impulse buying

14. INATTENTION Forgetfulness Easily distracted Losing or misplacing things Disorganization Academic underachievement Poor follow-through with assignments or tasks Poor concentration Poor attention to detail

15. SUBTYPES Inattentive Hyperactive-impulsive Combined

16. DIAGNOSIS Clinical interview and history School assessment Behavioral rating scales Physical examination and laboratory findings

17. DIAGNOSIS

19. DIFFERENTIAL DIAGNOSIS Dimensional Psychosocial Medical Coexisting conditions Diagnoses with associated ADHD behaviors Neurologic

20. TREATMENT GOALS improvements in relationships with parents, siblings, teachers, and peers decreased disruptive behaviors improved academic performance increased independence in self-care or homework improved self-esteem enhanced safety in the community

21. TREATMENT Behavioral/psychologic interventions Daily schedule Distractions to a minimum Specific places for toys, schoolwork and clothes Small goals Rewarding positive behavior Checklists Limiting choices Activities in which the child can be successful

22. TREATMENT Medications Psychostimulant (70%) Amphetamine Atomoxetine Antidepressants Investigational

24. TREATMENT Common side effects: Anorexia (80%) Sleep disturbances (3-85%) Weight loss (10-15%) Cardiovascular Psychiatric (psychosis, mania) Tics Diversion and misuse

25. TREATMENT Alternative therapies Vision training Diets Megavitamins Herbal supplements Mineral supplements EEG biofeedback Kinesiology

26. PROGNOSIS

27. PROGNOSIS 60-80% symptoms in adolescence 40-60% symptoms in adulthood Increased risk for antisocial personality disorder (12-23% vs 2-3%) Risk taking behaviors (substance use, injuries, driving) Educational underachievement Employment difficulties Relationship difficulties

28. REFERENCES Nelson textbook of pediatrics (18th edition) CDC Mental Health in the United States, 2003 Up to Date: Evaluation and diagnosis of attention deficit hyperactivity disorder in children, Dec 2007 Up to Date: Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents, Jun 2008 Up to Date: Pharmacotherapy for attention deficit hyperactivity disorder in children and adolescents, Jun 2008 Clinical Pediatric Guideline: Diagnosis and Evaluation of the child with ADHD, Pediatrics 2000 Treatment of Attention-Deficit/Hyperactivity Disorder: Overview of the Evidence, Pediatrics 2005 Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder, Pediatrics 2001