ATTENTION DEFICIT HYPERACTIVITY DISORDER IN CHILD

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) IN CHILD

It is defined as hyperactivity, impulsiveness and inattentiveness inappropriate for age. Boys suffer thrice compared to girls.

Classification

Class 1: Hyperactivity, impulsiveness and inattentiveness (most common)

Class 2: Hyperactivity and impulsiveness only

Class 3: Mainly inattentiveness (uncommon)

Etiology

The cause is not precisely known though brain damage, prematurity, low birth weight, and psychosocial and genetic factors have been blamed. An interaction between biologic (genetic endowment) and psychosocial factors appears to be the cause. Of course, clinical expression is influenced by child’s environments. Problems of attention and learning difficulties may well be secondary to frustration.

Diagnosis

It is mainly clinical. At least 6 symptoms of hyperactivity-impulsiveness or inattentiveness are required. Lead toxicity, IDA, thyroid disorder, CAN, substance abuse (Phenobarbital, vigabatrin), mild mental retardation, mood and anxiety disorder, schizophrenia, learning disability, etc should be excluded. Only role of investigations is to rule out other disorders.

Diagnostic criteria in ADHD

Inattention

At least six of the following criteria for a minimal of six months:

1. Often fails to give close attention to details or makes careless mistakes in school work or other activities.
2. Often has difficulty in sustaining attention in talks or play activity.
3. Often doesn’t seem to listen where spoken to directly
4. Often doesn’t follow through instructions and fails to finish schoolwork, chores, duties in workplace (not due to oppositional behavior or failure to understand instructions).
5. Often has difficulty in organizing tasks and activities.
6. Often avoids, dislike, or is reluctant to engage in tasks that require sustained mental effort(such as school work or homework)
7. Often loses things necessary for talks or activities, e.g. toys, school assignments, pencils, books, tools, etc.
8. Often easily distracted by extraneous stimuli
9. Often forgetful in daily activities.

Hyperactivity/ Impulsivity

At least six of the following criteria for a minimal of six months:

1. Often fidgets with hands or squirms in seat
2. Often leaves seat in the classroom or other situations in which remaining seated is expected.
3. Often runs about or climbs excessively in situations in which it is inappropriate
4. Often has difficulty in playing or in engaging in leisure activities.
5. Often “on the go” or acts as if “driven by a motor”.
6. Often talks excessively
7. Impulsivity
8. Often blurts out answers before questions have been completed
9. Often has difficulty awaiting turn
10. Often interrupts or intrudes on others, e.g. bursts into conversations or games.

Management

Tutoring

Management aims at tutoring the child to acceptable behavior and at his training with patience and understanding through behavioral and psychosocial therapy aimed at the child, the parents and the school. The program must involve close coordination among parents, teachers and psychologists.

Pharmacotherapy

Stimulant drugs such as methylphenidate (Rit, alin), dextroamphetamine, magnesium pemoline, and tricyclic antidepressants( imipramine, desipramine), alpha adrenergic agonists (clonidine) and phenothiazines (diphenhydramine, thioridazine) are efficacious and are strongly recommended.

Nonstimulant drug, atomoxetine, has been recommended as a preferred drug for

1. Adolescent ADHD  and
2. ADHD with comorbidities and contraindications to stimulants

It acts by increasing norepinephrine and dopamine levels, especially in the prefrontal cortex.

Prognosis

Prognosis is favorable, many children doing well in adulthood if they are properly employed. The presence of aggression in childhood is a predictive symptom of adult psychopathy in the form of sociopathy, hysteria and alcoholism.