July 13, 2012

AUTISM
AND ADHD
Dr. Eusebio
OUTLINE
I. Autistic Spectrum Disorder
II. Autism

Prevalence

Etiology

Diagnosis

Early Signs

Comprehensive evaluation

DSM IV Criteria

Laboratory

Accompanying problems

Management
III. ADHD

Introduction

Prevalence

Causes

Signs and symptoms

Developmental Trend

Co-morbidities

Diagnosis

DSM IV

Treatment
o
Standard treatment
o
Medications
o
Non traditional treatment

Burden of ADHD

A catch-all term when referring to the spectrum of autism

disorders

Under the pervasive developmental disorders (PDD) spectrum which

also includes Aspergers, childhood disintegrative, Retts and PDD not
otherwise specified (NOS) disorders
o
All share the inability to attain expected social and
communication, emotional, cognitive and adaptive abilities
Can be understood as disturbances of brain development with genetic
underpinnings.

AUTISTIC SPECTRUM DISORDER

THE EVOLVING NOMENCLATURE OF AUTISM
1943 Kanners autism
1944 Aspergers syndrome
1988 Autistic Disorder/Pervasive Developmental Disorder
(DSM-III DSM-III R)
1994 Autistic Disorder/PDD (DSM IV; ICD 10)
1995 Autistic Spectrum Disorders

He wandered about smiling, making stereotyped movements with

his fingers. He shook his head from side to side, whispering or
humming the same 3 note tune. He spun anything he could seize
upon to spin (Kanner 1943).

AUTISM
A complex developmental disability that typically appears
during the first three years of life
The result of neurological disorder that affects the functioning
of the brain
TRIADS OF IMPAIRMENTS
o Impaired social relatedness
o Impaired communication and play
o Presence of stereotypic and/or ritualistic activities
A lifetime disability
Results from a brain dysfunction but the exact etiology is
unknown

PDD (Pervasive Developmental Disorder) and ASD (Autistic Spectrum

Disorder) are one in the same. We use PDD is less stigmatizing.
Other subgroub Non-Autistic PDDs:

Aspergers Syndrome - is still an ASD but with normal

language development, however it is still peculiar

PDD NOS

Fragile X Syndrome

Retts syndrome

Chhildhood Disintegrative Disorder

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Early and appropriate intervention have a positive impact on

overall outcome
THE CONCEPT OF DEVELOPMENTAL DISORDERS
Autism is a developmental disorder, a condition a child is
believed to be born with, or born with a potential for
developing
This concept should be emphasized to parents. It has nothing to
do with pregnancy, poor child rearing, or anything in the
environment.

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PREVALENCE
The US Center for Disease Control has declared autism as the
fastest growing serious developmental disability
Autism rate doubles every 2 years:
o 1990: 1 out of 10,000
2007: 1 out of 150
A new CDC report:
o One in every 110 American children
o One in every 70 boys
4:1 ratio of boys to girls
Represent a 57% increase from 2002 to 2006
An astonishing 600% rise in the past 20 years

Researches on Vaccinations:
o The final report from IOM, Immunization Safety Review:
Vaccines and Autism, released in May 2004, stated that
the committee did not find a link.
Until 1999, DPT, Hib, and Hep B contained thimerosal as a
preservative
Today, with the exception of some flu vaccines, none of the
vaccines to protect preschool aged children against 12
infectious diseases contain thimerosal as a preservative.
The MMR vaccine does not and never did contain thimerosal.
Varicella, (IPV) and PCV have also never contained thimerosal.

No scientifically substantiated association between

administration of the MMR vaccine and development of AD.

Parents must be well educated that vaccines has nothing to do

with autism
This false belief came about because MMR is being given at
15months of age and the signs of autism are manifested at
18months.
Thimerosal was taken off from vaccines since 1990

the

Autism Epidemicor not?

Huge rise in prevalence rate

Globally affected
Raising figures
Environmental?
Result of unidentified risk
factors

Change in diagnostic
criteria
Improved detection
Rise in awareness
Better record keeping
More media attention

The work epidemic must be used with caution. We must avoid unnecessary
panic and be mindful that labels can be misleading.

ETIOLOGY
Exact cause still is unknown
ASDs are biologically based neurodevelopmental disorders that
are highly heritable
GENETICS
Involve multiple genes; demonstrate great phenotypic variation
A rare mutation involving the deletion or duplication of 25
genes on chromosome 16 over 1% of autism cases in the US
(Autism Update, Harvard Magazine, May-June 2011)
Estimates of recurrence risks: 5-6% (range: 2-8%) when there is
an older sibling with an ASD and even higher when there are
already 2 children with ASDs in the family. (Dr. Eusebio said
that the risk is 6-10%)
AUTISM AND VACCINES

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BIOLOGIC BASIS
Major brain structures implicated in autism: cerebellum,
cerebral cortex, limbic system, corpus callosum, basal ganglia,
and brainstem
Neurotransmitters: serotonin, dopamine, and epinephrine
Strong belief of Neurobiological alterations but cannot be
exactly pinpoint.
An interesting study was done wherein a Neuroscientist took
the head circumferences of infants diagnosed and suspected of
having Autism. He find out that there is an increase in the head
circumference of these children. His theory: this is because of
abnormal brain development or growth disregulation.

(Nelsons)

Head circumference in AD normal or slightly small than normal at

birth until 2 months of age

Afterwards, show an abnormally rapid increase in head circumference

from 6-14 month of age

Increased brain volume in 2-4 years olds

o
Increased volume of cerebellum, cerebrum and amygdala
o
Marked abnormal growth in the frontal, temporal, cerebellar and
limbic regions of the brain

Followed by abnormally slow or arrested growth

o
Areas of underdeveloped and abnormally circuitry in parts of
brains

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Most affected areas for higher-order cognitive, language,

emotional and social functions

DIAGNOSIS

Two-stage process:
o Developmental screening during well child check ups
o Comprehensive evaluation by a multidisciplinary team
Diagnosis is mainly clinical; must explain to parents that autism is
not diagnosed with newborn screening

AUTISM SCREENING
The AAP (American Academy of Pediatric) announced an
ambitious program to promote routine screening of all infants
for (ASDs) as part of 18-month and 24-month well-baby
examinations

M-CHAT (Modified Checklist for Autism in Toddlers)

Screening tool formulated in the UK
23 item questionnaire used for ages 18-42 months
Can be used by pediatrician or family physician
Most commonly used checklist
Most discriminative feature
Question 7 the most discriminative; it appeared in all three
CHAT instruments as screening toddlers for autism
Does your child ever use his/her index finger to point, to
indicate interest in something?
A normal child, if still cannot speak, would use gestures to
express interest in something; to reach for a toy the child would
point at it. But an autistic child will pull your hand and point it
at the object LEAD PONITING.
Autistic children do not know how to communicate even in
nonverbal manner very characteristic of autism.
EARLY SIGNS OF AUTISM
No babbling, pointing or meaningful gestures by 12 months
No words by 16 months
No 2-word combination by 24 months

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No response to name calling

Loss of language or social skills at any time

Dr. Eusebio grouped the early signs according to the triad of

impairments:
o Impaired social relatedness
Strongest clue: Fleeting Eye Contact (Minimal Eye Contact)
when interacting with the autistic children, their eyes are
wandering in space.
If the parents that would claim that their child looks at
them, with this qualify the question How long does your
child look at you?
Is he able to look at you until youre done with what
youre saying?
Selective response/Selective hearing (example: patient
wont respond to mothers voice but turns to the sound of
TV or cellphone ringing
Autistic child would not play with other children and stay in
one corner busy with self.
There are some autistic children that would touch other
children, but look at the quality of the social interaction of
the child.
o Impaired communication and play
Language delay
Language development Deviance parents would report
that child can say mama and dada at 1yr but would
disappear or child can say alphabet and count but does not
call mama and dada Language regression
There are who can talk but excessive jargoning
Echolalia
High functioning autistic child talks but with British Accent.
Even autistic child from payatas or smoky mountain still
speaks in English! They can talk on and on.
Repetitive Play (video of child stacking blocks)
o Presence of stereotypic and/or ritualistic activities
(Example: a child that loves a certain route going to school,
if the school bus goes through other route, the child will
throw an uncontrollable temper tantrum)
Usually awake at night (3am)

DEGREE OF AUTISM
Mild High functioning autistic can go to regular school,
pursue a career, and some can marry
Moderate to Severely retarded

RED FLAGS
Odd/idiosyncratic behavior (i.e. hand flapping, finger flicking,
constant spinning)
Regression in overall behavior play, social skills,
communication
Emotional ability, out of control tantrums
Odd/idiosyncratic behavior (i.e. hand flapping, finger flicking,
constant spinning)

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Regression in overall behavior play, social

communication
Emotional ability, out of control tantrums
Poor motor coordination
Fixate on objects (ie. Ceiling fans/bright lights of party)
Resists changes to specific routines/rituals
Self-injurious behavior
No fear of danger/pain
Dislikes to cuddle/be hugged
Unanimated facial expression or monotone voice
Extreme under/over activity

Diminished responses to pain (Nelson)

Lack of startle responses to sudden loud noises (nelson)

skills,

CLINICAL SIGNS ACCORDING TO NELSON

SOCIAL SKILLS

Impaired ability to engage in reciprocal social interactions

o
abnormal eye contact
o
failure to orient to name
o
failure to use gestures to point or show
o
lack of interactive play
o
failure to smile
o
lack of sharing
o
lack of interest in other children

impairment in joint attention

deficits in empathy

deficits in understanding what another person might be thinking a

lack of theory of mind
VERBAL ABILITIES

range from being nonverbal to having some speech

speech have an odd prosody or intonation

characterized by echolalia, pronoun reversal, nonsense rhyming

PLAY SKILLS

little symbolic play

ritualistic rigidity

preoccupation with parts of objects

prefer solitary play

restrictive or repetitive interests or behaviors

ritualistic behavior
o
often need to maintain a consistent, predictable environment

tantrum-like rages can accompany disruptions of routine

INTELLECTUAL FUNCTIONING

can vary from mental retardation to superior intellectual functioning in

select areas

some show typical development in certain skills and show areas of

strengths in specific areas

COMPREHENSIVE EVALUATION
Diagnosed by the clinical examination (Nelson)
DSM-IV criteria

Autism Diagnostic Interview Revised (ADI-R) and Autism Diagnostic

Observation Schedule (ADOS) gold standard diagnostic tools (Nelson)

Assorted checklist (eg. CARS, ADDS, M-CHAT, PDDST)

o

Failure to meet age-expected language or social milestones are

important red flags for PDD (Nelson)

Cognitive testing
o

Establish overall cognitive function and eligibility for services

(Nelson)

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Adaptive skills testing

o

A.

Vineland Adaptive Behavior Scale (VABS) is essential to establish

priorities for treatment planning (Nelson)

DSM IV CRITERIA
When an individual displays 6 or more of 12 symptoms listed
across three (3) major areas:
o Social
o Communication
o Behavior

DSM-IV-TR DIAGNOSTIC CRITERIA FOR

AUTISTIC DISORDER
A total of six or more items from (1), (2) and (3) with at least
two from (1) and one each from (2) and (3)
1. Evaluative impairment in social interaction as manifested
by at least two of the ff:
a. Marked impairment in the use of multiple nonverbal
behaviors such as eye-toeye gaze, facial expression,
body posture and gesture to regulate social
interaction
b. Failure to develop peer relationships appropriate to
developmental level
c. Lack of spontaneous seeking to share enjoyment,
interests and achievements with others (eg. Lack of
showing, bringing or pointing out objects of interests
to other people)
d. Lack of social or emotional reciprocity (Note: in the
description, it gives one of the ff. as examples: not
actively participating in simple social play/games,
prefers solitary activites or involving other activites
only as tools or mechanical aids)
2. Qualitative impairments in communication as manifested
by at least one of the following:
a. Delay in, or total lack of, the development of spoken
language (not accompanied by an attempt to
compensate through alternative modes of
communication such as gesture or mime)
b. In individuals with adequate speech, marked
impairment in the ability to initiate or sustain a
conversation with others
c. Stereotyped and repetitive use of language or
idiosyncratic language
d. Lack of varied, spontaneous make-believe play or
social imitative play appropriate to developmental
level

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3.

B.

C.

Restricted repetitive and stereotyped patterns of behavior,

interests, and activities, as manifested by at least one of
the following:
a. Encompassing preoccupation with one or more
stereotyped and restricted patterns of interest that is
abnormal either in intensity or focus
b. Apparently inflexible adherence to specific,
nonfunctional routines or rituals
c. Stereotyped and repetitive motor manners (e.g. hand
or finger flapping or twisting, or complex whole-body
movements)
d. Persistent preoccupation with parts of objects
Delays or abnormal functioning in at least one of the following
areas, with onset prior to age 3 years: (1) social interaction, (2)
language as used in social communication, or 93) symbolic or
imaginative play
The disturbance is not better accounted for by Retts Disorder
or Childhood Disintegrative Disorder.

SPECIALIST/MULTIDISCIPLINARY TEAM
Developmental pediatrician
Pediatric neurologist
Child psychiatrist
Child psychologist
Speech pathologist
Occupational therapist
SPED teacher
Geneticist
Parent support groups

LABORATORY/DIAGNOSTICS
BAER hearing test
EEG some have seizures
Neurological imaging
Metabolism screening (thyroid, lead)
Chromosomal studies to rule out Fragile X syndrome
Critical Elements of the Evaluation (Nelson)

Detailed developmental history

o
Review of communicative and motor milestones
Medical history
o
Discussion of possible seizures, sensory deficits or other medical
conditions
Family history
o
Presence of other developmental disorders
Review of current and past psychotropic medications
o
Review of medication dosages and behavioral response, along
with adverse effects

PROBLEMS THAT MAY ACCOMPANY (ASD)

Sensory problems
Hypersensitivity to certain sounds, textures, tastes and smells
Sounds like vacuum cleaner, ringing of telephone, sudden
storm, waves lapping the shoreline will cause these children to
cover their ears and scream

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Mental Retardation
Many children with ASD have some degree of mental
impairment
Seizures

Prevalence: 11-39%
HigHer prevalence if 42% with co-morbid mental retardation
and motor deficits
Onset of epilepsy in ASDs has two peaks: before 5 years of age
and adolescent
PATHOLOGY (Nelson)
Head circumference in AD normal or slightly small than normal at
birth until 2 months of age
Afterwards, show an abnormally rapid increase in head circumference
from 6-14 month of age
Increased brain volume in 2-4 years olds
o
Increased volume of cerebellum, cerebrum and amygdale
o
Marked abnormal growth in the frontal, temporal, cerebellar and
limbic regions of the brain
Followed by abnormally slow or arrested growth
o
Areas of underdeveloped and abnormally circuitry in parts of
brains
o
Most affected areas for higher-order cognitive, language,
emotional and social functions

MANAGEMENT

Primary goals of treatment are to maximize the childs ultimate

functional independence and quality of life
o
Minimizing the core features of the disorder
o
Facilitating development and learning
o
Promoting socialization
o
Reducing maladaptive behaviors
o
Educating and supporting families

Treatment is primarily non medical

TREATMENT APPROACHES
Applied Behavioral Analysis (ABA)
DIR Method (Floortime)
Miller method
Relationship Development Intervention
Son-Rise
TEACCH Program

Discrete Trial Training (DTT)

Speech and language therapy

Augmentative communication
Picture exchange communication
Sign language
Sensory Integration Therapy
Occupation Therapy
Physical therapy

CLINICAL THERAPIES

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Occupational therapy is done first. If the child (70-80%) is looking at

you and is responding at you, thats the time you add speech
therapy. And if the child is ready for school, must assess if the child is
to go to a special school or regular school.

Biomedical Treatment

Tomatis Method

COMPLEMENTARY THERAPY (BIOLOGICAL)

Immunoregulatory interventions
o Dietary restriction of food allergens
o Administration of immunoglobulin or antiviral agents
Detoxification therapies
o chelation
Gastrointestinal treatment
o Digestive enzymes
o Antifungal agents
o Probiotics
o yeast-free diet, gluten/casein-free diet
o Vancomycin
Dietary supplements
o Vit. A, B6, B12, C, magnesium, folic acid, folinic acid,
dimethylglycine and trimethylglycine, inositol, fatty acids,
omega-3, various minerals and others
Hyperbaric therapy

Hyperbaric Oxygen
Neurofeedback
Floor time (DIR)
Social skills

Current Treatment Options

Early and Intensive Behavioral
Intervention (EIBI)
Treatment and Education of
Autism
and
Related
Communication
Handicapped
Children (TEACCH)
Risperidone (Risperdal)

Therapy is still the best known management and not these niological
treatment methods.

Insufficient published evidence;

need for treatment evaluation
studies, not for food selective
children
Not supported by any published
research studies at present
Lack
of
well
controlled
experimentations
Needs more empirical research
Looks promising, relatively new
but needs more research
A well structured group seems
very beneficial

US Surgeon General has

recommended this a s effective
treatment
National research council has
recommended this as plausible
intervention
with
positive
program evaluation date
Can be used as a treatment
approach for problem behavior
only after a function based
approach was ineffective

Family Support

Respite

Support groups and web sites

Psychological services

Seminar and conference services

List Services
Autism Society of the Philippines it is hard for parents to accept, as
if they have a child who is terminally ill. It is normal that parents
undergo the normal process of acceptance. If a parent cannot
accept, just lay your cards and explain the developmental problems
in intellect and language of the child that need to be corrected.
If it improved, good then. If not, that is Autism. Because some grow
normal but still have signs of autism like eye fleeting.

PROGNOSIS
Most persons with PDD remain within the spectrum as adults
o
Continue to experience problems with independent living,
employment, social relationships, and mental health
Better prognosis is associated with higher intelligence, functional
speech and less-bizarre symptoms and behavior.

Pharmacotherapy

Pharmacological intervention targets associated comorbid conditions

and problematic behaviors
1. SSRIs mood and anxiety symptoms and compulsive-like
behaviors
2. Typical antipsychotics (Haloperidol) reducing stereotypy and
facilitating learning
3. Atypical neuroleptics for symptoms of agitation, irritability,
aggression, self-injury and severe temper outbursts
4. Stimulants (in moderate doses) children with hyperactivity and
impusivity
5. -adrenergic agonists reduce hyperarousal symptoms including
hyperactivity, irritability, impusivity, and repetitive behavior

CURRENT LEVEL OF EVIDENCE

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ATTENTION DEFICIT HYPERACTIVITY DISORDER

INTRODUCTION

Most common neurobehavioral disorder of childhood affecting schoolaged children

ADHD is a childhood onset neurobehavioral disorder which is

characterized by inattention, impulsivity, and hyperactivity.

ADHD is heterogeneous behavioral DO with multiple possible

etiologies:
o Neurobiological factors
o Genetic origins (mean heritability is higher than
Schizophrenia)
o CNS insults
o Environmental factors (poor nutrition or exposure to Lead)

ADHD Historic Timeline

HERITABILITY OF ADHD
Mean heritability of ADHD is 0.75
There is a strong genetic component to ADHD
o
2 candidate genes: dopamine transporter gene (DAT1) and
dopamine 4 receptor gene (DRD4)

NEUROBIOLOGY OF ADHD
PET scan shows decreased cerebral metabolism in brain area
controlling attention

1930: minimal brain damage

1968: hyperkinetic reaction of childhood (DSM-II)
1994: ADHD
2010: DSM-V
ADD (Attention Deficit Disorder) and ADHD are one and the same

PREVALENCE
Accounts for 30-40% of referrals
More common in boys than girls (5:1)
Estimated prevalence of children with ADHD is about 2-12%
(5.2%)
Can persist in adulthood:
o 8.10% of children have ADHD
o 9.6% of adolescents have ADHD
o 4.4 % of adults have ADHD
o Up to 65% of children with ADHD continue to experience
the DO into adulthood
Often underdiagnosed in children and adolescent

WHAT CAUSES ADHD?

Prevailing misconceptions such as:

o Kulang sa Pansin
o Temporary and will be outgrown
o Young, boy typical
o Laziness
o Diet: high in sugar intake
o Allergy
o Poor parenting, poor home life
o Poor teaching style in school
Hyperactivity can be normal for 2-4 years of age because this is the
run about stage but if this activity is impairing the childs functioning
then it is abnormal.

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It is believed that there is a diminished blood flow to the frontal lobe,

which is the center of executive function, attention, and
concentration.
Nuerobiochemical Imbalance: Lack of Norepinephrine and
Dopamine. That is why medication plays a very important role in
management.
ENVIRONMENTAL CONTRIBUTION

Maternal drug use

Maternal smoking
Alcohol use during pregnancy
Prenatal or postnatal exposure to lead
Food colorings and preservatives have inconsistently been associated
with hyperactivity in previously hyperactive children
Psychosocial family stressors

Prenatal or perinatal insults (premature asphyxiated, stormy

course of neotatal)
Maternal depression

INTERPLAY OF ETIOLOGIC FACTORS

Exact etiology is unknown but it is believed that it is of
Neurobiological problem and environmental factors play an
important role.

SIGNS AND SYMPTOMS

Characterized by (CORE SYMPTOMS):
o Inattention
o Impulsivity

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o Hyperactivity
Other symptoms:
o Non compliance
o Impulse aggression
o Social interaction
o Academic efficiency
o Academic accuracy
o Irritable
o Problems with sleep
EARLY INDICATORS
Diagnosis not made until 4years of age but early signs can be
seen
Before I was born, mom said I love to do cartwheels in her
belly
In infancy, may be characterized by unpredictable behavior,
shrill crying, irritability and overactivity
May show only brief periods of quiet sleep

Clinical manifestations may change with age

o
Preschool children motor restlessness and, aggressive and
disruptive behavior
o
Older adolescents and adults disorganized, distractible, and
inattentive symptoms

Squirms and fidgets

Cannot stay seated
Runs or climbs excessively
Cannot play or work quietly
Is on the go or driven by a motor
Talks excessively
Pushing, hitting other children thinking that it is still part of play
Impatient

SYMPTOMS OF IMPULSIVITY
Blurts out answers
Cannot wait for his turn
Intrudes, interrupts others

SYMPTOMS OF INATTENTION
Carelessness
Difficulty sustaining attention in activity
Does not listen
Does not follow through with tasks
Is disorganized
Avoids/dislikes tasks requiring sustained mental effort
Loses important items
Easily distracted
Forgetful in daily activities

SYMPTOMS OF HYPERACTIVITY

o
o

COMPARING BOYS AND GIRLS

BOYS
GIRLS
Frequency of Referral
more
Less
Symptom recognition
Earlier
Later
ADHD type
Combined (5:1)
Pred. Inattentive (2:1)
Signs
Externalizing:
Internalizing:
aggression,
Underachievement,
overreactivity
daydreaming
Females are diagnosed late because they manifest inattention than
the usual hyperactivity
ADHD DEVELOPMENTAL TREND BY AGE

As the child grows to adult, the hyperactivity and impulsivity would

decrease and what would remain is the Inattention.They usually
are impatient, restless, and disorganized.

ADHD CLINICAL SUBTYPES

More common in females

ADHD, predominantly hyperactive-impulsive type

More common in males

ADHD, combined type

ADHD: CO-MORBIDITY
Its presence is more the rule rather than the exception
Only ~30% will have pure ADHD
In those with co-morbidities:
o >80% have one co-morbidity
o 60% have at least 2 co-morbidities
Co-morbidities persist and more obvious when the patient
grows into an adult.
Most common co-morbidity is ODD (Oppositional Defiant
Disorder)

3 subtypes: (Nelson)
o
ADHD, predominantly inattentive type

Often includes cognitive impairment

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Useful in establishing the magnitude and pervasiveness of the

symptoms
Not sufficient alone to make a diagnosis of ADHD

1.
2.
3.
4.
5.

ADHD Diagnostic Rating Scale

Conner Rating Scales (parent and teacher)
ADHD Index
Swanson, Nolan and Pelham Checklist
ADD-H: Comprehensive Teacher Rating Scale

DIAGNOSIS OF ADHD

History
o
o
o

History of the presenting problems

The childs overall health and development
Social and family history

o
o

Maternal and birth history

Good family history (genetic) you can see if one of
parents have ADHD mother talking a lot or father
fidgeting
Interviews (parents, teachers and patient)
o Determine functional impairment at home and in
school/job setting
o Behavioral rating scale should be answered by both
parents and teachers because one of the criteria of
diagnosis is that this condition should be happening in two
settings
Rating scales to corroborate clinical symptoms
PE, VS, physical explanations for DO, secondary conditions,
drug contraindictation
DSM-IV TR criteria, ICD-10 criteria
Make assessment for co-morbid conditions
Interview should emphasize factors that might affect the development
or integrity of the CNS or reveal chronic illness, sensory impairments, or
medication use that might affect the childs functioning (Nelson)

Conners is the most commonly used

Physical Examination and Laboratory Findings

No laboratory tests available

Presence of HPN, ataxia or thyroid DO should prompt further diagnostic

evaluation

Impaired fine motor movement and poor coordination and other soft
signs are common
o
finger tapping
o
alternating movements
o
finger-to-nose
o
skipping
o
tracing a maze
o
cutting paper

DSM-IV CRITERIA

States that the behavior must be:

o
developmentally inappropriate
o
must begin before age 7 years
o
must be present for at least 6 months
o
must be present in 2 or more settings
o
must not be secondary to another disorder

Persistent pattern of inattention and/or hyperactivity or

impulsitivity
o No. of symptoms (6 or more)
o Duration of symptoms (> 6 mos)
o Onset (before 7 y/o)
o Setting (2 or more settings)
o Severity (developmentally inappropriate)
o Impact (significant impairment in social, academic and
occupational functioning)
o
Exclusion (other medical disorders)

Behavior Rating Scales

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STANDARD ADHD TREATMENT

EDUCATION
Understanding the DO
o Medical cause
o Not due to parenting
Environmental restructuring
o Classroom changes
o ADHD-friendly modification in family, work, leisure
activities
o Structure, list, delegating
Parent support groups: www.chadd.org or www.add.org
Educate parents that this condition is inborn and that poor
parenting is not the cause of the problem, how to handle the
child
PSYCHOSOCIAL INTERVENTION
Parent education
o Reinforce positive behavior and correct negative behavior
o Establish and maintain house rules
Academic Skill Training
o Focus on time management, study skill and following
directions

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Behavioral management in the time frame of 8-12 sessions

o Stress-conflict resolution
ADHD children does not have to be placed in special schools because
actually these children are very smart with normal IQ unless in cases
with concomitant intellectual disbilities
MEDICATION

o
o
o

Social Skill Training

o Target specific behaviors (e.g. playground aggression)

Remains as one of the most successful treatment for child with

ADHD
As effective as standard therapy treatment. Dr. Eusebio have
patients in the province with no therapy but on medication and
they are doing alright.
Medications increases the neurotransmitter in the synapses

Noradrenergic Reuptake Inhibitor (SECOND LINE)

Alternative Medications (Not Approved by FDA)

Psychostimulant (FIRST LINE)

Atomoxetine (Strattera)

Giving psychostimulant to somebody who Is already hyperactive, it is

postulated that in ADHD the stimulatory portion of the brain is the
only one activated and the inhibitory center is dormant or asleep.
The psychostimulants will work on the inhibitory center to correct
the imbalance.

MEDICATIONS APPROVED BY FDA

Social stigma
Diversion and abuse potential (DEA Schedule II drugs)
Prescribing Inconvenience

Amphetamine preparation
o Addreall
o Dexedrine
Methylphenidate preparation (best)
o Ritalin
o MPH Oros (Concerta)
o Transdermal delivery system (patch)

Antidepressants
o Bupropion
o Imipramine
o Nortriptyline
Alpha-2 Adrenergic Agents/Antihypertensives
o Clonidine (used prior to Methylphenidate but will only cure
the impulsivity and not the hyperactivity)
o Guanfacine
Arousal Agents
o Modafinil
Non-Traditional Therapies for ADHD
Dietary management
Bio/Neurofeedback Therapy
Tomatis Method
All are controversial and alternative treatments!!!
BURDEN OF ADHD

Psychostimulants found to improve core symptoms of ADHD

(inattention, impulsivity and hyperactivity). It also improve other
symptoms such as noncompliance, impulsive aggression, social
interactions, academic efficiency, academic accuracy and family
dynamics
Limitations to Psychostimulants

Tolerability issues
o Insomnia, irritability, headache, appetite suppression
o Parent/patient perception of mood and personality
change on medication
o Adverse effect on height and weight
o In other countries used as diet pills that is why it is
regulated

Co-morbid conditions (tics, anxiety) aggrevated

Controlled substance concerns

Ardales, Austria, Avancea|Azucenas

Impacts on all aspects of life

Childhood: Impair peer relationship, academic limitation,
socioemotional problem
Other children do not involve ADHD child because they are too
aggressive
Academic limitations because as more and more academic skills
need to learn the lack of attention impairs the receptivity to
learning, careless mistakes and not review test exams

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Adolescents: at risk of getting into risk taking behaviors like

alcohol and drug abuse, motor and vehicular accidents
Adults: moving from one job to another, or relationship from
one to another.

Adult Outcome of Children with ADHD

Adults who function fairly well: 30%
Adults who continue to have significant problems with
concentration, impulsivity and social interaction: 50-60%

Adults who have psychiatric or antisocial problems or both: 1015%

ADHD is not yet curable but certainly is manageable!

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Ardales, Austria, Avancea|Azucenas

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