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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 development
Symptoms 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).
0%
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
1/5
1/11
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 relative
to comparison subjects was observed
mostly in systems involved in executive
function (frontoparietal network) and attention
(ventral attentional network).
長大會好嗎?
J Psychiatr Res. 2011
Predictors of Persistent ADHD: An 11-year Follow-up Study
Joseph Biedermana,*, Carter R. Pettya, Allison Clarkea, Alexandra Lomedicoa, and
Stephen V. Faraoneb
a Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School
b Departments of Psychiatry and Neuroscience & Physiology, SUNY Upstate Medical University
Abstract
Objective—Despite the existence of several follow-up studies of children with ADHD followed
up into adulthood, there is limited information on whether patterns of persistence and remission in
ADHD can be predicted over the long-term. The main aim of this study was to evaluate predictors
of persistence of ADHD in a large sample of boys with and without ADHD followed
prospectively for 11 years into young adulthood.
Method—Subjects were Caucasian, non-Hispanic boys with (N=110) and without (N=105)
ADHD who were 6 to 17 years old at the baseline assessment (mean age 11 years) and 15 to 31
years old at the follow-up assessment (mean age 22 years). Subjects were comprehensively and
blindly assessed with structured diagnostic interviews and assessments of cognitive, social, school,
and family functioning.
Results—At the 11-year follow-up, 78% of children with ADHD continued to have a full (35%)
or a partial persistence (subsyndromal (22%), impaired functioning (15%), or remitted but treated
(6%)). Predictors of persistence were severe impairment of ADHD, psychiatric comorbidity, and
exposure to maternal psychopathology at baseline.
Conclusions—These findings prospectively confirm that persistence of ADHD over the long
term is predictable from psychosocial adversity and psychiatric comorbidity ascertained 11 years
earlier.
Keywords
ADHD; persistence; predictors; longitudinal; young adult
Corresponding Author: Joseph Biederman, M.D. Massachusetts General Hospital, Pediatric Psychopharmacology Unit, 55 Fruit
Street, YAW 6A-6900, Boston, MA 02114; phone: 617-726-1731; fax: 617-724-3742; jbiederman@partners.org.
Conflicts of interest: Dr. Joseph Biederman is currently receiving research support from the following sources: Alza, AstraZeneca,
Bristol Myers Squibb, Eli Lilly and Co., Janssen Pharmaceuticals Inc., McNeil, Merck, Organon, Otsuka, Shire, NIMH, and NICHD.
In 2009, Dr. Joseph Biederman received a speaker’s fee from the following sources: Fundacion Areces, Medice Pharmaceuticals, and
the Spanish Child Psychiatry Association. In previous years, Dr. Joseph Biederman received research support, consultation fees, or
speaker’s fees for/from the following additional sources: Abbott, AstraZeneca, Celltech, Cephalon, Eli Lilly and Co., Esai, Forest,
Glaxo, Gliatech, Janssen, McNeil, NARSAD, NIDA, New River, Novartis, Noven, Neurosearch, Pfizer, Pharmacia, The Prechter
Foundation, Shire, The Stanley Foundation, UCB Pharma, Inc. and Wyeth.
-PAAuthorManuscriptNIH-PAAuthorManuscriptNIH-PAAuthorManuscrip
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
%
Control
Persistent
Management
Behavioral therapy
Medication
Headache, abd pain
Decreased appetite,
sleep disorder
Parent
Peer
Teacher
579 ADHD combined type(7-10y/o) Follow-up 14 mo
Arch Gen Psy 1999
Hyperactive-impulsive
symptoms
Parent-Child Arguing
Social 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
4-18 y/o
Academic or
Behavioral
Problem
Initiate ADHD evaluation
Inattention,
Hyperactivity,
Impulsivity
+
SNAP IV
http://otk.idv.tw/snap/
兒童注意力量表
To 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
Adolescents
Try 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)
Recognize ADHD as a
chronic condition
Treatment 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

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adHD powerpoint

  • 2. What is Attention- Deficit/ Hyperactivity Disorder (ADHD)?
  • 4. 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
  • 5. 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
  • 6. DSM-5 Criteria People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development Symptoms 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).
  • 8. 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%
  • 11. ADHD is one of the most common neurodevelopemental disorders of childhood. USA CDC website
  • 12. 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
  • 13. Toward Systems Neuroscience of ADHD: A Meta- Analysis of 55 fMRI Studies (Am J Psychiatry 2012; 169:1038–1055)
  • 14. Hypoactivation in ADHD relative to comparison subjects was observed mostly in systems involved in executive function (frontoparietal network) and attention (ventral attentional network).
  • 16. J Psychiatr Res. 2011 Predictors of Persistent ADHD: An 11-year Follow-up Study Joseph Biedermana,*, Carter R. Pettya, Allison Clarkea, Alexandra Lomedicoa, and Stephen V. Faraoneb a Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School b Departments of Psychiatry and Neuroscience & Physiology, SUNY Upstate Medical University Abstract Objective—Despite the existence of several follow-up studies of children with ADHD followed up into adulthood, there is limited information on whether patterns of persistence and remission in ADHD can be predicted over the long-term. The main aim of this study was to evaluate predictors of persistence of ADHD in a large sample of boys with and without ADHD followed prospectively for 11 years into young adulthood. Method—Subjects were Caucasian, non-Hispanic boys with (N=110) and without (N=105) ADHD who were 6 to 17 years old at the baseline assessment (mean age 11 years) and 15 to 31 years old at the follow-up assessment (mean age 22 years). Subjects were comprehensively and blindly assessed with structured diagnostic interviews and assessments of cognitive, social, school, and family functioning. Results—At the 11-year follow-up, 78% of children with ADHD continued to have a full (35%) or a partial persistence (subsyndromal (22%), impaired functioning (15%), or remitted but treated (6%)). Predictors of persistence were severe impairment of ADHD, psychiatric comorbidity, and exposure to maternal psychopathology at baseline. Conclusions—These findings prospectively confirm that persistence of ADHD over the long term is predictable from psychosocial adversity and psychiatric comorbidity ascertained 11 years earlier. Keywords ADHD; persistence; predictors; longitudinal; young adult Corresponding Author: Joseph Biederman, M.D. Massachusetts General Hospital, Pediatric Psychopharmacology Unit, 55 Fruit Street, YAW 6A-6900, Boston, MA 02114; phone: 617-726-1731; fax: 617-724-3742; jbiederman@partners.org. Conflicts of interest: Dr. Joseph Biederman is currently receiving research support from the following sources: Alza, AstraZeneca, Bristol Myers Squibb, Eli Lilly and Co., Janssen Pharmaceuticals Inc., McNeil, Merck, Organon, Otsuka, Shire, NIMH, and NICHD. In 2009, Dr. Joseph Biederman received a speaker’s fee from the following sources: Fundacion Areces, Medice Pharmaceuticals, and the Spanish Child Psychiatry Association. In previous years, Dr. Joseph Biederman received research support, consultation fees, or speaker’s fees for/from the following additional sources: Abbott, AstraZeneca, Celltech, Cephalon, Eli Lilly and Co., Esai, Forest, Glaxo, Gliatech, Janssen, McNeil, NARSAD, NIDA, New River, Novartis, Noven, Neurosearch, Pfizer, Pharmacia, The Prechter Foundation, Shire, The Stanley Foundation, UCB Pharma, Inc. and Wyeth. -PAAuthorManuscriptNIH-PAAuthorManuscriptNIH-PAAuthorManuscrip ADHD: 110人 Control 105人 78% Persistence Impaired function Remitted but treated
  • 18.
  • 20. Disruptive behavior disorder Mood disorders Anxiety disorders tics and Tourette Syndrome Learning Disabilities Substance abuse
  • 21. 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
  • 23. Mood Disorder 10-30% 小孩 47% 成人 憂鬱 躁症, 雙極症 20% of individual with ADHD
  • 24. Anxiety Disorder Up to 30% 小孩 25-40% 成人 對Ritalin治療反應較不好 (30% VS 70-80%)
  • 25. Disruptive Behavior Disorder 40% Conduct Disorder 25%兒童 40-50% 青少年 20-25% 成人 Oppositional Defiant Disorder
  • 29. Headache, abd pain Decreased appetite, sleep disorder
  • 31. 579 ADHD combined type(7-10y/o) Follow-up 14 mo Arch Gen Psy 1999 Hyperactive-impulsive symptoms Parent-Child Arguing Social skills Internalizing symptoms
  • 32. 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
  • 33. What can the physician do ? AAP 2011 clinical practice guideline
  • 34.
  • 35. 4-18 y/o Academic or Behavioral Problem Initiate ADHD evaluation Inattention, Hyperactivity, Impulsivity +
  • 37. To 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
  • 38. Preschoolaged Children (4 –5 Years Old) challenges in determining the presence of key symptoms
  • 39. Adolescents Try 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.
  • 40. 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)
  • 41. Recognize ADHD as a chronic condition
  • 42. Treatment 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

Editor's Notes

  1. 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
  2. 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)
  3. The age of attaining peak cortical thickness in children with ADHD compared with typically developing children. (A) dorsal view of the cortical regions where peak thickness was attained at each age (shown, ages 7–12) in ADHD (Upper) and typically developing controls (Lower). The darker colors indicate regions where a quadratic model was not appropriate (and thus a peak age could not be calculated), or the peak age was estimated to lie outside the age range covered. Both groups showed a similar sequence of the regions that attained peak thickness, but the ADHD group showed considerable delay in reaching this developmental marker. (B) Right lateral view of the cortical regions where peak thickness was attained at each age (shown, ages 7–13) in ADHD (Upper) and typically developing controls (Lower). Again, the delay in ADHD group in attaining peak cortical thickness is apparent.
  4. 39 children, 16 for adult Children: hyperactivation was observed in the right angular gyrus, middle occipital gyrus, posterior cingulate cortex, and midcingulate cortex
  5. 6-17Y/O
  6. The most careful studies suggest that between 10-30 percent of children with ADHD, and 47 percent of adults with ADHD, also have depression The antidepressant desipramine (Norpramin) has improved both ADHD and ADHD and depression Researchers have also found that stimulants (such as Ritalin) can be combined safely with antidepressants such as fluoxetine (Prozac) Newer antidepressants such as bupropion (Wellbutrin) and venlafaxine (Effexor )
  7. 如之前建議:改白底、減少文字、用更簡單的顏色,橘色要小心囉,如果有這兩種狀況,就要進入紅色,開始評估是否有 ADHD,而紅色與你的小圖放大鏡是一樣的顏色。
  8. the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) criteria have been met (including documentation of impairment in more than 1 major setting), and information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause.
  9. challenges in determining the presence of key symptoms Physicians may recommend that 1. parents complete a parent-training program before confirming an ADHD diagnosis for preschool-aged children and 2. consider placement in a qualified preschool program if they have not done so already. the use of validated DSM-IV– based ADHD rating scales
  10. clinicians need to try 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 it is important to establish the younger manifestations of the condition that were missed and to strongly consider substance use, depression, and anxiety as alternative or co-occurring diagnoses. Adolescents with ADHD, especially when untreated, are at greater risk of substance abuse.