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EXTERNALIZING DISORDERSChapter D 1HyperactivityTais S Moriyama Aline C M Cho Rachel E Verin .Joaqu n Fuentes Guilherme PolanczykCompanion PowerPointPresentationAdapted by Henrikje Klasen Julie Chilton. The IACAPAP Textbook of Child and Adolescent Mental Health is available at theIACAPAP website http iacapap org iacapap textb... mental healthPlease note that this book and its companion powerpoint are Free and no registration is required to read or download it. This is an open access publication under the Creative Commons Attribution Non commercial License According to this use distribution and reproduction in anymedium are allowed without prior permission provided the original work isproperly cited and the use is non commercial Learning Objectives. 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 specialistGeneral Considerations Inattention hyperactivity and.impulsivity Two Diagnoses ADHD DSM Hyperkinetic Disorder ICD Affects 3 5 of children. Abnormal neuro psychologicalfunctioning and neurobiologicalcorrelatesTree climbing Vauvau 2009 .Historical Note1800 s Heinrich Hoffman Impulsive Insanity Defective Inhibition Der Struwwelpeter an illustrated book.portraying children misbehaving Impulsive Insanity DefectiveInhibition by Heinrich Hoffman 1854 Historical Note 1902 Lancet article. 1920 s minimal brain damage 1930 s hyperkinetischeErkrankung 1960 s minimal braindysfunction . 1937 Benzedrine discovered Hyperkinetic Syndrome ofChildhood in ICD 9 1980 inattention recognized DSM III Attention Deficit.Disorder with or withoutHyperactivityIn Your World 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 Impact of ADHD in LAMIC vs HICAhmed 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 inthe mornings and plays or herds his father s goatsafterwards Peter lives in a medium size town in Western Europe He.goes to school until 3 pm then usually plays football with hisHow does ADHD impact their lives Impact of ADHD EducationListen to Ahmed and Peter s experience at school What will happen to Peter and Ahmed s education.after they have been expelled from2nd year primary school Impact of ADHD Impulsivity DistractibilityListen what happens when Ahmed and Peter getimpulsive .Children with ADHD are accident prone How will the broken leg impact on the lives ofPeter and Ahmed How long will it take to gethelp What if an operation is needed Impact of ADHD Inattention Forgetfulness.Listen what happens if Ahmed and Peter fail to payattention and become forgetful Children with ADHD are forgetful How does the loss of something expensive impact on thelives of Peter and Ahmed Will they be punished How .Will it affect the family as a whole Why Do You Need to Know Is common Can be serious Can persist. Is stigmatizing Is treatableThe Basics Core symptoms Inattention hyperactivity impulsivity. Present in more than one context Leading to functional impairment Subtypes https www youtube com watch v GR1IZJXc6d8 In DSM combined predominantly feature related.hyperactive predominantly inattentive In ICD Hyperkinetic disorderEpidemiology Prevalence 6 for children. 3 for adolescents Male Female ADHD DSM definition HKS ICD definition 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 . Some chronic Unclear persistence Faraone 2006 15 full persistence 40 60 partial remission Severe cases more persistent.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.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 Neurobiology Frontal striatal.dysfunction mediated by GABA modulated bycatecholamines Catecholaminergic.dysregulation Delay in corticalmaturationAssociated Features Defiant aggressive antisocial behaviors. Problems with social relationships IQ tends to be lower than in the generalpopulation Specific learning problems Co ordination problems. Specific developmental delay Poor emotional self regulationComorbid Disorders in BrazilianCommunity SamplesClinical Presentation Diagnosis. Inattention Hyperactivity Impulsivity Pervasive symptoms Duration age of onset. Impairment or distress Diagnosis exclusively made on clinical groundsClinical Assessment Information from at least two contexts Teachers are key. Medical and psychiatric assessment Assess co morbidity No additional tests necessaryNeuropsychological TestingDifferential Diagnosis. Situational hyperactivity Behavioral disorders ODD CD Emotional disorders Tics chorea or other dyskinesias Misuse of substances. Autism Spectrum Disorder Intellectual Disability Frequent Comorbidity Further Differential Considerations 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.Rating Scales SNAP IV http www adhd net snap iv form... SDQ http www sdqinfo org SWAN http www adhd net SWAN SCALE p... Many other proprietary not free scales.Review of Assessment Algorithm Does the child have problemswith inattention and over Are symptoms persistent Consider ADHD if the answer toboth is yes .severe and causing impairmentin the child s functioning Explore ways to address Explore the impact of environmental stressorenvironmental stressors e g as part of management.family plan Rule out medical or other Manage or referconditionsAims of Treatment Individually tailored. Reduce symptoms Improve educational outcomes Reduce family and school based problemsWhat works Evidence Based Treatments . Best evidence for stimulant medication Behaviour treatments also effective in mild tomoderate cases Psycho education for parents and schoolPsychosocial Treatments. Behavior therapy Individual not always generalize Parent management training particularly useful in younger childrenand 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 milderStimulant MedicationMethylphenidate 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 . More serious side effects tics psychotic symptoms raised blood pressure growth retardationStimulant MedicationNon Sti mulant Medicati on 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 onlywhen stimulants not available not tolerated or not appropriate .Interventi ons without Much Evidence Acupuncture Meditation Homeopathy Physical exercise. Chiropractic care St John s wort Music therapy Hypericum perforatum St John s Wort Bach flower remedies. Elimination dietsSummar y of Recommendati ons for Treatmentdi cati on When to Refer If no response and severe impairment after.pharmacological treatment combined withbehavioral approaches Re evaluate diagnosis and co morbidity Check for undetected social adversity or abuse If still no response after 6 months consult with.specialistdi cati on Further Resources AACAP ADHD Resource Centerhttp www aacap org AACAP Famil... .Centers ADHD Resource Center H... NICE Guideline Tools and Resourceshttp www nice org uk guidance ... di cati on .Thank You ADHD has long been described in the medical literature. Heinrich Hoffmann (1809-1894), a German psychiatrist, was the first to describe children whose behavior was marked by impulsivity and hyperactivity. He named this behavioral problem â€œimpulsive insanityâ€ or â€œdefective inhibitionâ€.