1. NURLIYANA BINTI DZULKARNAIN

2.  Based on DSM-1V-TR criteria,defined as developmentally inappropriate poor attention span or age-inappropriate features of hyperactivity and impulsivity or both  At least for 6 months, occur before 7 years old  Cause impairment in academic or social functioning  Considered a childhood disorder

3.  The DSM-IV, or Diagnostic and Statistical Manual of Mental Disorders, 2000 edition, defines three types of ADHD:DSM-IV 1) An inattentive typeinattentive 2) A hyperactive/impulsive typehyperactiveimpulsive 3) A combined type

4. Inattentive type (ADHD-I)  Procrastination Procrastination  Indecision, difficulty recalling and organizing details required for a task  Poor time management, losing track of time  Avoiding tasks or jobs that require sustained attention  Difficulty initiating tasks  Difficulty completing and following through on tasks  Difficulty multitaskingmultitasking  Difficulty shifting attention from one task to another

5. Hyperactive/Impulsive-type (ADHD-H)  Chooses highly active, stimulating jobs  Avoids situations with low physical activity or sedentary work  May choose to work long hours or two jobs  Seeks constant activity  Easily bored  Impatient  Intolerant to frustration, easily irritated  Impulsive, snap decisions and irresponsible behaviors  Loses temper easily, angers quickly

6.  DSM-IV-TR criteria were developed for children and adolescents-cannot always applied to adults-alteration to criteria to fit adult symptoms  Symptoms stated in criteria not appropriate in adults-rely on observations to childhood activities  Under report the severity of symptoms  Impairment also include social and leisure activities,parenting,and intimate relationships

7.  Establishing whether the symptoms were also present in childhood, even if not previously recognized  Combination of a careful history of symptoms up to early childhood, including corroborating evidence from family members, previous report cards, etc. along with a neuropsychiatric evaluationneuropsychiatric  Also screening tests,ruling out depression,substance abuse,anxiety,hyperthyroidism

8.  Structural differences(neuroimaging methods)  Significant reductions in Total cortical grey matter,prefontal and anterior cingulate volumes and right putamen/globus pallidus grey matter  Thinning of cerebral cortex in networks that mediate attention and executive fx  Right hemisphere involving the inferior parietal lobule,dorsolateral prefontal anterior cingulate cortices

9.  Neurochemistry Near infrared spectroscopy  Increases oxygenated Hb in ventrolateral prefontal cortex,indicating reduced activation of this area in task related actvts  marked in working memory  Higher N-acetyl-aspartate/creatine ratios in the prefrontal corticosubcotical region and left centrum semiovale.

10.  Neurochemistry Positron emission tomography (PET)  Involvement of dopamine transporter  Lower dopamine D2/D3 receptor activity in caudate,hippocampus and amygdala Magnetic Resonance Imaging (MRI)  Reduced activation of the ventral prefontal cortex,anterior cingulate cortex and striatum

11.  Professional and economic impact -More likely to change jobs -Work productivity is lower  concentration difficulties,disorganization and reduced ability to cope with large workload  Social problems -Lack of friendships & poor relationship with parents -Relationship difficulties -Problems adjusting after marriage -Parenting-more likely to have lack of parental discipline,-ve parent child interactions

12.  Comorbidities -Mood disorders and anxiety disorders occur with greater frequency in adults with ADHD -Bipolar disorder -Substance abuse disorder  Sleep and activity disturbances -Difficulty in falling asleep and numerous waking throughout the night  daytime fatigue -Driving accidents-attributed to impulsivity,inattention,loss of concentration and fatigue

13.  Current guidelines by AACAP,CADDRA and BAP-combination therapy recommended:- Psychoeducation, An initial trial medication with titration to an individual effective dose, Assesment of residual symptoms Long term community follow-up  NICE Guidelines Methylphenidate is first line drug If ineffective or unacceptable-Atomoxetine or Dexamfetamine

14.  First line-Pharmacotherapy -1 st choice-Methylphenidate(psychostimulant)  Mechanism-Reuptake inhibition of monoamine transporters  increases levels of dopamine and norepinephrine in the brain  Available as immediate release (IR),extended release (ER),OROS MPH -2 nd choice  Atomoxetine(non psychostimulant) -inhibit norepinephrine transporter

15.  Pharmacotheraphy-Concerns  Methylphenidate -Abuse-esp short acting prescriptions  risk of being injected or snorted -Risk of adverse cardiovascular events-MI and hypertension -Amphethamine-better side effect profile,better tolerated  Atomoxetine(non-stimulant medications) -Rare-increase potential for liver damage and suicidal ideation

16.  Psychosocial treatment  As adjunctive treatment  CBT(15 weeks) -Motivational interviewing and practice -Repetition and review of skills such as organizing and planning,reducing distractibility,problem solving,adaptive thinking in times of stress.  Dialectic behavioural therapy(3 months) -Sessions discussing mindfullness,emotion regulation and impulse control -Also undertake daily exercises and reading educational materials regarding ADHD.