Definition

• According to the fourth edition of the American Psychiatric Association's (APA) DSM (DSM-IV), ADHD is a behavioral and neurocognitive condition characterized by developmentally inappropriate and impairing levels of gross motor overactivity, inattention, and impulsivity. There are five main diagnostic criteria: (1) an onset before age 7 years; (2) duration greater than 6 months; (3) an 18-item symptom list of which 6 of 9 inattention or 6 of 9 hyperactive/impulsive symptoms have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level; (4) some impairment in two or more settings; and (5) symptoms that do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder, such as depression.

• ADHD is diagnosed by history taken from the parent and at least one other adult, such as a teacher or coach. As with many psychiatric disorders, there is no simple objective test, such as a blood test, that can aid in making the diagnosis.

Etiology

• Although the etiology of ADHD yet has to be determined, there is a growing consensus that the condition involves functional and anatomical dysfunction in the brain's frontal cortex and basal ganglia segments of the cortico-basal ganglia-thalamo-cortical circuitry. These areas support the regulation of attentional resources, the programming of complex motor behaviors, and the learning of responses to reinforcement. Theories involving these areas have been examined in series involving neurobiological studies of healthy humans, humans with ADHD, and animal models. Reviews by Castellanos and Swanson have delineated ADHD's complexity, its theoretical diversity, and the many questions yet to be resolved. The symptoms of ADHD are multidimensional, suggesting the interaction of neuroanatomical and neurochemical systems. The current evidence for the neurobiological factors suggests that genetics and neurochemistry play key roles.

• First-degree relatives of children with ADHD have a 20 to 25 percent risk for ADHD, compared with 4 to 5 percent for relatives of controls. If a parent has ADHD, 50 percent of his or her offspring are likely to have that condition

Thyroid Receptor B Gene

• Thyroid Receptor B Gene• Early molecular genetic studies showed that

mutation of the thyroid receptor B gene, which causes resistance to thyroid hormone, was associated with high rates (61 percent) of hyperactivity and impulsivity (but not inattention) in affected children and adults. However, only 1 of 2,500 patients with ADHD had this thyroid abnormality, which generally was very rare. Thus, this gene could not be a major cause of ADHD.

• Dopamine Type D2 Receptor Gene

• Dopamine Transporter Gene• Dopamine 4 Receptor Gene

Neuroanatomical Aspects• Mirsky and Castellanos described neuroanatomical

correlations for the• superior and temporal cortices with the focusing of

attention; • external parietal and corpus striatal regions with

motor executive function; • the hippocampus with the encoding of memory traces;• the prefrontal cortex with the act of shifting from one

salient stimulus to another;• and brainstem areas such as reticular thalamic nuclei

with the sustaining of attention

• Hechtman's review of magnetic resonance imaging (MRI), positron emission tomography (PET), single emission computed tomography (SPECT), and functional MRI studies suggested decreased volume and activity in prefrontal areas, anterior cingulate, globus pallidus, caudate, thalamus, hippocampus, and cerebellum in children with ADHD. These findings are supported by morphological studies of Castellanos and colleagues

• Neurotransmitters in ADHD• Certain brain areas have been associated with specific

neurotransmitters—for example, the caudate nucleus and corpus striatum with dopamine and

• the median raphe with serotonin. Even so, neuroanatomical studies of neurotransmitters have proven to be very complex because these neuroanatomical regions of interest receive projections from multiple nuclei and neurotransmitter pathways, confounding theories that posit dysfunction in a single neurotransmitter system as the etiology of ADHD. However, for clarity, each neurotransmitter system is discussed separately in what follows.

• Dopamine System• Noradrenergic System• Serotonergic System

• Environmental Factors• High lead exposure• and maternal smoking • have been associated with higher rates of diagnosis of ADHD.

However, it has been difficult for investigators working with children affected by adversity to determine whether their ADHD symptoms reflect a response to

• negative parenting, a harsh environment, a genetically influenced biological problem, or some interaction among these factors. Only with further multifaceted prospective research, such as the Centers for Disease Control and Prevention/National Institutes of Health National Children's Study in the United States, will there be a clearer, more comprehensive understanding of the possible etiology, natural history, and treatment of ADHD.

• Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder According to the Text Revision of the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders

• Either (1) or (2):

– six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:Inattention

• often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

• often has difficulty sustaining attention in tasks or play activities • often does not seem to listen when spoken to directly • often does not follow through on instructions and fails to finish

schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

• often has difficulty organizing tasks and activities • often avoids, dislikes, or is reluctant to engage in tasks that

require sustained mental effort (such as schoolwork or homework) • often loses things necessary for tasks or activities (e.g., toys,

school assignments, pencils, books, or tools) • is often easily distracted by extraneous stimuli • is often forgetful in daily activities

• six (or more) of the following symptoms of hyperactivity impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:Hyperactivity

• often fidgets with hands or feet or squirms in seat • often leaves seat in classroom or in other situations in

which remaining seated is expected • often runs about or climbs excessively in situations in

which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

• often has difficulty playing or engaging in leisure activities quietly

• is often “on the go” or often acts as if “driven by a motor”

• often talks excessively

• Impulsivity • often blurts out answers before questions have been

completed • often has difficulty awaiting turn • often interrupts or intrudes on others (e.g., butts into

conversations or games)

• Some hyperactive impulsive or inattentive symptoms that caused impairment were present before age 7 years.

• Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

• There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

• The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

• Associated Factors• Children with ADHD might have areas of

impairment that are not listed under the DSM-IV symptom criteria covered exactly by the 18 symptom exemplars of hyperactivity, impulsivity, or inattention

• Behavioral• Children with ADHD often • lack persistence. • They become bored with interactive games with

peers, and leave such games early before they are finished. They find it

• difficult to delay gratification. • They show variable performance on tasks, which

may negatively affect self-esteem

• Cognitive• Children and adolescents with ADHD often show

difficulty with time management and do not develop an internal sense of pace in planning tasks.

• This poor sense of time leads to problems in estimating the actual

• difficulty of waiting in line, • planning how much time a task requires, • or even knowing when to come home when out

playing with other children

Deficit of Behavioral Inhibition and Executive Functioning

• Lack of behavioral inhibition has been postulated to lead to impairments in

• motivation, arousal, ability to delay gratification, working memory, and self-regulation of affect.

• Dysfunction in these areas is said to impair executive functioning, interfering with goal-directed behavior.

• However, executive functioning problems occur in other psychiatric disorders of childhood, such as depression, and are not specific to ADHD. Neuropsychological tests often used by clinicians tap into but do not totally explain a child's or adolescent's executive functioning.

• Recent data show that academic functioning is more strongly affected by an impulsive need to get through tests quickly, a deficit closely linked to poor behavioral inhibition rather than poor executive functioning.

• Poor inhibitory control has been postulated to lead to impairments in

• motivation, arousal, delay of gratification, working memory, and self-regulation of affect.

• This has been assessed in the laboratory using Stop Signal Tasks and the Go-No Go test. Other deficits include greater intraindividual variability of reaction time, cerebellar associated deficits in motor timing, inability to delay response to reward, and possible alternations in synchronization in the cingulate-precuneus default mode network

• Dysfunction in these areas is said to impair executive functioning, interfering with

• goal-directed behavior• . However, executive functioning problems occur in other

psychiatric disorders of childhood, such as depression, and are not specific to ADHD. On any given measure of executive function, less than half of children with ADHD have been found to be impaired. Although findings of executive function deficits can appear in the results of testing children with ADHD, the lack of such deficits does not rule out the disorder. Some neuropsychologists use the Behavior Rating Inventory of Executive Function (BRIEF) as part of their evaluation battery, but this measure has not been used in a prospective manner to assess the effect of stimulant medications

• Emotional• ADHD is often associated with dysregulation of

affect, resulting in temper outbursts, mood lability, and reactivity. Moods can change dramatically with no obvious connection with what's going on in the environment.

• The reaction of others and the consequences of an action are often poorly understood by the individual with ADHD, who has moved on to something else and does not understand what the fuss is about.

• Social• Individuals with ADHD may have problems accurately interpreting

nonverbal social cues and thus react inappropriately.• This is associated with reports from peers, who report these

individuals to be intrusive, bossy, and insensitive to the needs of others. There is trouble cooperating with other children and following rules in games. Children with ADHD often have strong reactions, overreacting to situations that can be predictably triggered by others, leading to teasing and ridicule. Their tendency to respond to frustration in social situations can lead to verbal or physical aggression, a strong stimulus for peer rejection, which has been shown to be a reliable long-term negative predictor of development, particularly in adolescence

• Course and Prognosis• Parents often notice very high levels of gross motor

activity when the child with ADHD is a toddler, just when the child has learned to walk independent of the parent's help. However, the energy, oppositionality, and curiosity of toddlers can be confused with the excessive, almost random motion of older children with ADHD, so that one must be cautious when applying the ADHD diagnosis to a preschooler. Usually, the ADHD diagnosis is first applied in primary school, during grades 1 to 6, when adjustment to the sedentary learning style is compromised.

• The motor and attentional symptoms and impairment create a consistent picture through early adolescence, when often the external overactivity lessens but the internal restlessness does not.

• Whereas the school-age child is mostly at risk for • academic failure and peer rejection, the adolescent with ADHD who is

untreated has other risks in excess of peers with no mental disorder, including a threefold increase in substance use and abuse, trouble with the law, and an increased rate of automobile accidents when the teenager begins to drive.

• Approximately 60 percent of those who develop childhood ADHD continue to be impaired well into adult life, with prevalence estimates suggesting that 4 percent of adults may suffer from ADHD. These individuals may show instability in job status and relationships, even if the numbers of ADHD symptoms do not meet the threshold required for the childhood diagnosis.

• 7-3شیوع %• شروع 6و5و4سن

• پسرها هوشی 1به 6جنس نظر از• غذا

• - یادگیری – اختالل سلوک اختالل عواقب- - - دوقطبی- اختالل افسردگی تیک وسواس

- هماهنگی اختالل مواد مصرف

• اضطراب- اختالل حرکتی

• دارو زمان• دارو عوارض

• دهیم می ادامه مصرف به کی تا

• کنید کم را خود توقع• کنید توجه رفتاری مشکل یک به هرزمان

• ساده دستورات• تنبیه از بهتر تشویق

• زمان مدیریت• ورزش

• معلمان با ارتباط• ارام محیط

• Treatment• Stimulants• Amphetamines and methylphenidates are two groups of stimulant

medication that have received U.S. Food and Drug Administration (FDA) approval for the treatment of youth with ADHD. They are marketed in both immediate release (IR) and long-acting preparations and can be purchased as either generic or branded versions. Since 2000, multiple stimulants have been marketed with FDA approval for ADHD treatment, including long-duration mixed salts of amphetamine, dexmethylphenidate, osmotic-release methylphenidate, the prodrug lisdexamfetamine, and beaded methylphenidate. All of these products include either amphetamine or methylphenidate as the active ingredient. These chemicals structurally resemble the catecholamine neurotransmitters dopamine (DA) and norepinephrine (NE). All can be described as psychostimulants, which refers to their ability to increase central nervous system activity in brain regions (Table 42.1-2).

• Nonstimulant Medication in the Treatment of Children with ADHD

• Atomoxetine HCl

• Tricyclic Antidepressants• α-Adrenergic Agents• Bupropion

• Psychosocial Treatment of Children with ADHD

• Multimodal Treatment (MTA Study)