家有過動兒

What is Attention-Deficit/ Hyperactivity

Disorder (ADHD)?

core symptoms

Inattention Hyperactivity/Impulsivity

2

Inattention

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

Often has trouble holding attention on 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 (e.g., loses focus, side-tracked).

Often has trouble organizing tasks and activities.

Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

Is often easily distracted

Is often forgetful in daily activities

≧6 symptoms of inattention for children 16y/o, ≦or 5 symptoms for adolescents > 17y/o and adults;≧symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level

Hyperactivity/Impulsivity

Often fidgets with or taps hands or feet, or squirms in seat.

Often leaves seat in situations when remaining seated is expected.

Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

Often unable to play or take part in leisure activities quietly.

Is often "on the go" acting as if "driven by a motor".

Often talks excessively.

Often blurts out an answer before a question has been completed.

Often has trouble waiting his/her turn.

Often interrupts or intrudes on others (e.g., butts into conversations or games)

≧ 6 symptoms for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level

DSM-5 Criteria People with ADHD show a persistent pattern of inattention and/or

hyperactivity-impulsivity that interferes with functioning or developmentSymptoms of Inattention

Symptoms of Hyperactivity and Impulsivity

In addition, the following conditions must be met:• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.• Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).

• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.• The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Series10%

5%

10%

15%

2003 2007 2011

2.3%

9.5%

11.0%

Prevalence

國小 9.9% 1993

小一小二 6.3% 2003

7-12y/o 8.4% 2002

1070 國一生 2005

7.5%

Gender

1/51/11

Psychiatric Disorder?

ADHD is one of the most common

neurodevelopemental disorders of childhood.

USA CDC website

The age of attaining peak cortical thickness in children with ADHD compared with typically developing children.

Shaw P et al. PNAS 2007;104:19649-19654

Delay cortical maturation

Toward Systems Neuroscience of ADHD: A Meta-Analysis of 55 fMRI Studies (Am J Psychiatry 2012; 169:1038–1055)

Hypoactivation in ADHD relativeto comparison subjects was observedmostly in systems involved in executivefunction (frontoparietal network) and attention(ventral attentional network).

長大會好嗎？

J Psychiatr Res. 2011

ADHD: 110 人Control 105 人

78%Persistence

Impaired function

Remitted but treated

Genetic component?

共病症

Disruptive behavior disorder

Mood disorders Anxiety disorders

tics and Tourette Syndrome Learning Disabilities

Substance abuse

Tics, Tourette syndrome

7% 過動症兒童有 TICS 或妥瑞症

60% 妥瑞症兒童有過動症

50%有學習障礙

Mood Disorder

10-30% 小孩47% 成人

憂鬱

躁症 , 雙極症20% of individual with ADHD

Anxiety Disorder

Up to 30% 小孩25-40% 成人

對 Ritalin 治療反應較不好(30% VS 70-80%)

Disruptive Behavior Disorder

40%Conduct Disorder

25% 兒童

40-50% 青少年

20-25% 成人

Oppositional Defiant Disorder

Substance abuse

%

ControlPersistent

Management

Behavioral therapy

Medication

Headache, abd painDecreased appetite, sleep disorder

Parent

PeerTeacher

579 ADHD combined type(7-10y/o) Follow-up 14 mo Arch Gen Psy 1999

Hyperactive-impulsive symptoms

Parent-Child ArguingSocial skills

Internalizing symptoms

Combined therapy

Improvements in academic performance

Reductions in conduct problems

Higher levels of parental satisfaction

Lower doses of stimulant medication

Superior for treating children of low socioeconomic status

Superior for treating children with coexisting anxiety

What can the physician do ?

AAP 2011 clinical practice guideline

1

4-18 y/oAcademic orBehavioralProblem

Initiate ADHD evaluation

Inattention,Hyperactivity,

Impulsivity+

SNAP IV

http://otk.idv.tw/snap/

兒童注意力量表

2To make a diagnosis of ADHD,

Meet DSM- V criteria

Obtain report from parents, guardian, teachers, and other school and mental health clinicians

Any alternative cause

Preschoolaged Children (4 –5 Years Old)

challenges in determining the presence of key symptoms

AdolescentsTry to obtain (with agreement from the adolescent) information from

at least 2 teachers as well as information from other sources such as coaches, school guidance counselors, or leaders of community activities in which the adolescent participates

Establish the younger manifestations of the condition that were missed

Consider strongly substance use, depression, and anxiety as alternative or co-occurring diagnoses.

Assess for other conditions that might coexist with ADHD, including

Emotional or behavioral condition

(eg, anxiety, depressive, oppositional defiant, and conduct disorders),

Developmental conditions(eg, learning and language disorders or other

neurodevelopmental disorders)

Physical conditions(eg, tics, sleep apnea)

3

Recognize ADHD as a

chronic condition

4

5Treatment vary depending on the patient’s age.

Preschoolaged children (4–5 y/o)

Elementary school-aged children

(6–11 y/o)

Adolescents(12–18 y/o)

Medication

Behavior therapy

Medication

Medication

Behavior therapy

Behavior therapy

每 13 個小孩有 1 個過動行為治療和藥物相輔相成