lecture 22 attention-deficit or hyperactivity disorder (adhd)
TRANSCRIPT
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ADHD
- Chronic neurobehavioral disorders that can
interfere with an individuals ability to inhibit
behavior (impulsivity), function efficiently ingoal-oriented activities (inattention), or
regulate the activity level (hyperactivity) in
developmentally appropriate ways
Three basic form of ADHD
- Attention
- Hyperactive
- Combine (most frequent)
Miller KJ, Castellanos FX. AD/HDs. Ped in Rev 1998; 19 (11)
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ADHD significant functional problems
-school difficulties- academic underachievement
- troublesome interpersonal relationships with
family members and peers
- low esteem
Untreated childhood ADHD
More likely to experience conduct disorder,substance abuse, antisocial behavior and
injuries later in life
EARLY RECOGNITION, ASSESSMENT & MANAGEMENT
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Prevalence rates vary substantially (changing
diagnostic criteria overtime; variations depend ondifferent settings sample estimation
- Varying from 4% to 12%- Males 9.2% (5.8%-13.6%)
- Female 2.9% (1.9%-4.5%)
- School samples 6.9% (5.5%-8.5%)
- Community samples 10.3% (8.2%-12.7%)
- Indriyani, dkk (2007) RSUP Sanglah (2005-2006)
( 3 yo -
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The causes of ADHD are unknown
GENETIC FACTORS
DEVELOPMENTAL FACTORS
NEUROCHEMICAL FACTORS
NEUROPHYSIOLOGICAL FACTORS
PSYCHOSOCIAL FACTORS
Anonym. Attention-Deficit Disorders. In: Kaplan & Sadocks.
Synopsis of Psychiatry. Ninth Ed. USA: Lippincott; 2003
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Precise neural & pathophysiologic of ADHD remainsunknown
Frontostriatal regions, rich in noradrenergic,
adrenergic and dopaminergic neurotransmitters are
consistently implicatedDysregulation of inhibitory frontocortical activity
(predominantly noradrenergic) on striatal structures
(predominantly dopaminergic)
Imaging studies reveal structural differencesassosiated with ADHD in the caudates, globus
pallidus, right frontal lobe. Anterior-inferior peribasal
gangglia, bilateral retrocallosal, posterior parietal-
occipital regions and the cerebellum
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ACTION (monitoring self regulation)
ACTIVATION(organizing; prioritizing; activating to work)
FOCUS(focusing; shifting focus; sustaining focus)
EFFORT(sustaining effort; regulating alertness;
processing speeds)
EMOTION(managing frustration; modulating emotion)
MEMORY (using working memory; assessing & recall)
FRONTAL EXECUTIVE FUNCTION
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SKALA RATING GURU VERSI INDONESIA (Dwijo Saputro)
Tidak samasekali
Sekali-kali
CukupSering
Hampirselalu
Aktivitas berlebihan
Impulsif
Mengganggu anaklain
Gagal menyelesaikan
tugas, selang
perhatian pendek
Menggerakkananggota tubuh terus
menerus
Perhatian mudah
teralih
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..SKALA RATING GURU VERSI INDONESIA (Dwijo Saputro)
Tidak sama
sekali
Sekali-
kali
Cukup
Sering
Hampir
selalu
Permintaan harus
segera dituruti
Sering menangis
Suasana hati berubahdengan cepat
Ledakan kekerasan
eksplosif
Tidak sana sekali : 0
Sekali-kali : 1
Cukup sering : 2
Hampir selalu : 3
12
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SKALA PENGUKURAN ADHD (CONNERS PARENT RATING SCALES)
Tidak
sama
sekali(0)
Sekali
-kali
(1)
Cukup
sering
(2)
Hampir
selalu
(3)
1 Tidak kenal lelah atau aktivitas
berlebihan
2 Mudah menjadi gembira, impulsif
3 Mengganggu anak-anak lain
4 Gagal menyelsaikan pekerjaan
yang telah dimulainya, selang
waktu perhatiannya pendek
5 Menggerakkan anggota
badan/kepala secara terus
menerus
6 Perhatiannya mudah teralihkan
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Tidak
sama
sekali
(0)
Sekali
-kali
(1)
Cukup
sering
(2)
Hampir
selalu
(3)
7 Permintaannya harus segera
dipenuhi, mudah menjadi frustasi
8 Sering dan mudah menangis
9 Suasana hatinya berubah dengan
cepat dan drastis
10 Ledakan kekesalan tingkah laku
eksplosif dan tak terduga
15
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SYMPTOM CHECKLIST ADHD (Karen J Miller)
Never Some-
times
Often Very
often
SCALE A
1 Fails to play close attention to
details or makes careless mistaken
in schoolwork, chores, or other
tasks
2 Has difficulty sustaining attentionto tasks, chores, or activities
3 Does not seem to listen when
spoken to directly
4 Does not follow through on
instructions and fails to finishschoolwork, chores, or duties (not
due to oppositional behavior or
failure to understand directions)
5 Has difficulty organizing tasks and
activities
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Never Some-
times
Often Very
often
6 Avoids, dislikes, or is reluctant to
engage in tasks that require
sustained mental effort (such asschoolwork)
7 Loses things necessary for tasks or
activities (eg. Toys, school
assignments, pencils, books, or
tools)8 Is distracted by unimportant stimuli
9 Is forgetful in daily acvtivities
SCALE B
10 Fidgets with hands or feet orsquirms in seat
11 Leaves seat in classroom or in
other situations when expected to
remain seated
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Never Some-
times
Often Very
often
SCALE B
12 Runs about or climbs excessivelyin situations where it is
inappropriate (in adolescence, may
be limited to restlessness)
13 Has difficulty playing or engaging
quietly in leisure activities
14 Is on the go or often acts as if
driven by a motor
15 Talks excessively
16 Blurts out answers before the
questions have been completed
17 Has difficulty awaiting turn
18 Interrupts or intrudes on others (eg.
butts into others conversations or
games)
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Never Some-
times
Often Very
often
SCALE C
19 Is uncooperative or defiant orargues with adults
20 Has difficulty getting along with
other children
21 Is often angry, irritable, or easily
upset
22 Has excessive anxiety, worry, or
fearfulness
23 Seems sad, moody, depressed, or
discouraged
24 Has problems with academicprogress (skill level or learning)
25 Has problem with academic
performance (productivity or
accuracy)
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SCALE A (Inattention) and
SCALE B (Hyperactivity-impulsivity)
At least six of the nine criteria from one or both sets
should be excessive in frequency (often/very often)
SCALE C
Screening questions that address commonly
associated problems with compliance,
socialization, emotional control, anxiety, mood,learning, and academic performance
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DSM -IV-TR (Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision)
A.Either 1 or 2
- Inattention: six (or more) of the following symptoms
of inattention have persisted for at least 6 months to adegree that is maladaptive and inconsistent with
developmental level:
a. Often fails to give close attention to details or
makes careless mistakes in schoolwork, work, orother activities
b. Often has difficulty sustaining attention in tasks or
play activities
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c. Often does not seem to listen when spoken to directly
d. Often does not follow through with instructions and
does not finish schoolwork, chores, or duties in the
workplace (not due to oppositional behavior or
failure to understand instructions)
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks
that requires sustained mental effort (such as
schoolwork or home work)
g. Often loses things necessary for tasks or activities (eg.
toys, school assignments, pencils, books or tools)
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
..Inattention
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- Hyperactivity/Impulsivity: Six (or more)of the following
symptoms of hyperactivity and impulsivity havepersisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:
Hyperactivity
a. Often fidgets with hands or feet or squirms in seatb. Often leaves seat in classroom or in other
situations in which remaining seated is expected
c. Often runs about or climbs excessively in situation
in which this behavior inappropriate(in adolescents or adults may be limited to
subjective feelings of restlessness)
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d. Often has difficulty playing or engaging in leisure
activities quietly
e. Is often on the go or often acts as if driven by a motor
f. Often talks excessively
Impulsivity:
g. Often blurts out answers before questions have been
completed
h. Often has difficulty awaiting turns
i. Often interrupts or intrudes on others (eg. Butts into
conversations or games)
.Hyperactivity/Impulsivity
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B. Some hyperactive-impulsive or inattentive symptoms
that caused impairment were present before age 7 years
C.Some impairment from the symptoms is present in twoor more setting(eg. at school (or work) and at home)
D. There must be clear evidence of clinically significant
impairment in social, academic, or occupational
functioningE. The symptoms do not occur exclusively during the
course of Pervasive Developmental Disorders,
Schizoprenia or other Psychotic Disorder and are not
better accounted for by another mental disorder (eg.
Mood Disorder, Anxiety Disorder, Dissociative Disorder,
or a Personality Disorder)
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The DSM-IV-TR notes that the designation of not
otherwise specified (NOS) may be used for
disorders with prominent symptoms of inattentionor hyperactivity-impulsivity that do not meet ADHD
criteria
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SUBTYPE OF ADHD
1. INATTENTIVE TYPE (ADHD/I)
meeting at least 6 of 9 inattention behaviors
2. HYPERACTIVE-IMPULSIVE TYPE (ADHD/HI)
meeting at least 6 of 9 hyperactive-impulsive
behaviors
3. COMBINED TYPE (ADHD/C)
meeting at least 6 of 9 behaviors in both the
inattention and hyperactive-impulsive list
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Anxiety disorder
Conduct disorder
Eating disorder
Learning disorder
Mood disorder
Oppositional Defiant Disorder
Pervasive Developmental Disorder
Sleep disorder
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dr. IGA Endah Ardjana, SpKJ (K)
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BEHAVIORAL- Presentation of educational material for the
patient, parents and school personnel
- Behavior-modification techniques (daily
report card)- Educational Interventions and
Accommodations for Patients with Learning
Disabilities (preferential seat placement,
more intensive accommodation)- Social skill training (improve interactions
with peers)
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- Individual counseling ( to alleviate secondary
symptoms such as low self-esteem, oppositional defiant
behavior and conduct disorder ; to control their own
behavior)
PHARMACEUTICAL / MEDICATION
When impulsive behavior places the child at
physical or psychological risk (table)
STIMULANT MEDICATIONS
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STIMULANT MEDICATIONS
Medication Initial
dose
Range (R) & Common dose
(CD)
Available tablets/
Spansules
Methylphenidate (Ritalin,
generic)
2.5-5 mg R: 0.1-0.8 mg/kg/dose PO qdto 5 times/d
CD: 0.3-0.5 mg/kg/dose PO
tid/qid
5-,10- and 20 mgscored tablets
Methylphenid
ate slowrelease
(Ritalin SR,
generic SR)
Convert
fromregular
R: 0.2-1.4 mg/kg/dose PO
qd/tidCD: 0.6-1 mg/kg/dose PO
qd/bid
20 mg spansules
do not cut, crush,or chew
Methylphenid
ate
prolonged
release
(Concerta,
Metadate CD)
Convert
from
regular or
use 18 mg
R: 0.3-2 mg/kg PO qd
CD: 0.8-1.6 mg/kg PO qd
18- and 36 mg
tablets
Do not cut, crush,
or chew
STIMULANT MEDICATIONS
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STIMULANT MEDICATIONS
Medication Initial
dose
Range (R) & Common dose
(CD)
Available tablets/
Spansules
Dextroamphetamine
(Dexedrine,
Dextrostat)
2.5-5 mg R: 0.1-0.7 mg/kg/dose POqd/qid
CD: 0.3-0.5 mg/kg/dose PO
qd/tid
Dexedrine 5 mgscored tablets
Dextrostat 5-, 10-
and 15-mg scored
tablets
Dextroamphetamine
spansules
(Dexedrine
CR)
5 mg R: 0.1-0.75 mg/kg/dose POqd/bid
CD 0.3-0.6 mg/kg/dose PO
qd/bid
5-, 10- and 15-mgspansules
Do not cut, crush,
or chew
Dextroamphe
tamine and
amphetamine
4-salt
combination
2.5-5 mg R: 0.1-0.7 mg/kg/dose PO
qd/qid
CD: 0.3-0.5 mg/kg/dose PO
tid/qid
5-, 7.5-,10-,12.5-,
15-,20-, and 30-
mg scored tablets
EFFECTS OF STIMULANTS
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EFFECTS OF STIMULANTS
Cognitive - Increased attention to assigned task
- Decreased response to irrelevant stimuli
- Improved speed and accuracy of performance
- Improved short-term memory
- Improved short-term academic performance
Motor - Reduced activity level (often normalizes)
- Decreased off-task motor behavior
- Decreased excessive talking or noise- Increased independent play and work
- Improved fine motor control/handwriting
Social - Decreased anger and aggression
- Decreased emotional and behavioral intensity- Increased sensitivity to reinforcement
- Increased compliance with adult requests
- Decreased negative interactions with peers
- Improved mother-child & family interaction
- Improved teacher-student relations
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SIDE EFFECTS OF STIMULANTS
Common side
effect
- Appetite suppression, Weight loss, Delay in
sleep onset, Abdominal discomfort, Headache,Dizziness, Minor increases in pulse & blood
pressure, Behavioral rebound
Infrequent side
effect
- Withdrawal hyperactivity (rebound),
Agitation/jitteriness, Moodiness/sadness,Social withdrawal, Tics/dyskinesias, Weight
loss/reduced growth velocity, Liver toxicity
(pemoline only)
Overmedication
/Toxic effect
- Irritability / weepiness (at peak), Over focusing,
Dazed appearance, Fatigue, Psychosis
Miller KJ, Castellanos FX. ADHD. Ped in Rev 1998; 19 (11)
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Outcome is significantly affected by persistence ofAD/HD symptoms, comorbid condition andpsychosocial factors
30%-70% of children continue to be symptomatic asadults
Adults who have AD/HDs achieve lower academiclevels, socioeconomic status, less vocational stability,
increased marital problemsMedication continues to be effective for adults, butresponse rate may be lower
Initial treatment of Children with Activity/Attention Problem
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NO
ADHD OR HYPERKINETIC DISORDER DIAGNOSED
PSYCHOEDUCATION, ADVICE, SUPPORT TO
CHILD, FAMILY AND TEACHER
PSYCHOSOCIAL
INTERVENTION
PARENT TRAINING
YES
STIMULANT MEDICATION GOOD
RESPONSE
CHILDREN UNDER 6 YEARS?
SIGNIFICANT IMPAIRMENT
PERSISTS
SPECIALIST REVIEW,IDENTIFICATION OF
STRESSORS AND/OR
ASSOCIATED
PROBLEMS, CONSIDER
MEDICATION
SIGNIFICANT
IMPAIRMENT EXISTS
TRY SECOND STIMULANT
YES
REVIEW, ADD BEHAVIOURTHERAPY,TREAT CO-
MORBIDITY,TRY SECOND LINE
DRUGS, E.G NORADRENERGIC
SIGNIFICANT IMPAIRMENT
PERSISTS
SIGNIFICANT
IMPAIRMENT PERSISTS
PROBLEM AT
SCHOOL?
SCHOOL LIAISON AND
ADVICE TO CHILD
PROBLEM AT HOME ?
PARENT TRAINING
AND
ADVICE TO CHILD
NO
PERVASIVE,SEVERE
DISABILITY
MAINTAIN TREATMENT
REVIEW AND IF
NECESSARY
TREAT
COEXISTENT PROBLEM
GOOD
RESPONS
E
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Primary symptom include inattention and/or
hyperactivity/impulsivityClear interference with developmentally appropriate
social, academic, or occupational functioning
Precise neural and pathophysiologic substrate of ADHD
remain unknown
Frontostriatal regions, rich in noreepinephrine,
epinephrine and dopamine neurotransmitters, are
consistently implicatedEarly recognition, assessment and management of
ADHD can redirect educational and psychosocial
development
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