Dr TG Magagula 13 August 2012

Behavioral disorder: noise-making, motor driven

Diagnosis 6 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.

Diagnosis Some 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 Features ADHD 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.

Etiology No 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 diagnoses Temperament & visual-motor-perceptual impairments in ADHD Anxiety/depressive disorders Mania bipolar I disorder wax & wane Conduct disorder; ODD Learning disorders, epilepsy Mental retardation (check family history)

Course and Prognosis The 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 indicated Not all children need meds Decision to use meds based on thorough assessment of severity, impact and developmental appropriateness of symptoms Stimulants: Methylphenidate Ritalin Non-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 meds Talk about “I am crazy” Family therapy

Social intervention Social 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)

Conclusion Concerns: 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.