Dr. Dipayan Sarkar
D.P.M (MGIMS)

Psychiatric and psychological issues are very important aspect for wellbeing of a child as well as overall growth of the society . The occurrence of signs and symptoms starts even when the baby is in womb .  There are  restricted scope for available diagnostic measures .The genetic studies for psychiatric illnesses are available only in few institutes and very much cost effective .  Even  if genetic evidence  is found in the foetus or new born, clear cut diagnosis can’t be made as most of the psychiatric illnesses originate from socio environmental background . It has been seen that  even delay in tooth eruption or head holding or delay in speech  initiation ultimately becomes responsible for preponderance to mental ailments  .
In these circumstances,  the only  available scope remains in the hand of clinicians or any other person examining the subject .The major stake holders in these cases are the parents, teachers, psychologists etc. and of course treating doctors. A number of  psychiatric illnesses are encountered by paediatricians and psychiatrists during infancy, childhood and adolescent period  . Disease can vary from simple mild mental retardation and learning difficulties to major illness like bipolar illness and schizophrenia. All these cases need to be addressed by the therapist for proper outcome of the patient in future life .  Ignorance of any of  such illness definitely hampers the subject in one way or other  .

So the main role of primary care physicians, family doctors or paediatricians are management, counselling or referral to the psychiatric speciality  . In the context of stigma about the different mental ailments,  disclosure of the same to the patient’s relative is a challenging job. It is readily observed that pointing out of   abnormal behaviour  to the caregivers or parents is helpful rather than direct forceful referral to the psychiatric speciality . For example, if a paediatrician notices symptom of hyperactivity in ADHD and reduced social reciprocity in autism spectrum disorder and ask caregiver for probability of mental illness then they become more observant to the symptoms and  if in another session another paediatrician repeats the same then they become aware about the illness and readily accept the the proposal of referral to psychiatric speciality .   In this article special attention has been brought  to ADHD .
Attention Deficit/Hyperactivity Disorder (ADHD) :
ADHD is characterised by a pattern of diminished sustained attention and higher levels of impulsivity in a child or adolescent than expected for someone of that age and developmental level . It is a heterogeneous  disorder of unknown etiology  . At least 30 % of children with ADHD may suffer from learning disability .

Epidemiology:

Reports on the incidence of ADHD in the United States have varied from 2 to 20 percent of grade-school children with male to female ration ranging from 2:1  to 9:1  .In the Indian context, in one study prevalence of ADHD among primary school children was found to be 11.32% with sex ratio of 2:1. The prevalence was more in lower socio-economic group. The prevalence was highest in the age group of 9 and 10 years.

Etiology:

Even though etiology is not clear, there are some evidence based factor those are discussed below:-

General Factors:

As siblings of hyperactive children have about twice the risk of having the disorder as those in the general population proves genetic contribution of ADHD.

Developmental Factors:

Reports in the literature state that September is the peak month for birth of children with or without co-morbid learning disorder. The important is that prenatal exposure to winter infection during the first trimester may contribute to the emergence of ADHD symptoms in some susceptible children.

Brain Damage:

Factors like damage to the CNS and brain development during their foetal and perinatal periods and exposure of brain tissue to circulatory, toxic, metabolic, mechanical , or physical assault to the brain tissue during early infancy  caused by infection, inflammation and trauma can be risk factors for ADHD.

Neurochemical factors:

Studies show that locus ceruleous , consisting of mainly  noradrenergic  neurons, play a major role in attention. Peripheral noradrenergic  system may be more important in ADHD. As per neurotransmitter  hypotheses both adrenergic and dopaminergic  system are involved. Stimulants (like methylphenidate) increase catecholamine concentration  promoting their release and blocking their uptake . Overall , no clear cut evidence implicates single neurotransmitter in causation of ADHD.

Neurophysiological factors:

The human brain normally undergoes  major growth spurts at several ages: 3 to 10 months, 2 to 4 yrs. 6 to 8 yrs. 10 to 12 yrs. and 14-16 yrs. Some children have a  maturational delay in the sequence  and manifest  symptoms of ADHD. There are non specific  EEG changes in most of the ADHD patients. CT Scan does not show any consistent findings. Rather studies using positron emission tomography (PET) have found lower cerebral blood flow and metabolic ratio in the frontal lobe areas of children with ADHD than in controls  .

Psychosocial Factors:

Prolonged emotional deprivation, stressful life events disruption of family equilibrium and anxiety inducing events can contribute to initiation or perpetration of ADHD.

Diagnosis:

The principal signs of inattention, impulsivity and hyperactivity are based on a detailed history of a child’s early developmental patterns along with direct observation of the child, especially in situations that require sustained attention.  For diagnosis of ADHD at least two settings are required like home and nursery/school/kindergarten and this is the reason for which diagnosis is not usually made before age of 6 years.  

As per DSM-IV-TR Diagnostic criteria at least 6 (or more) of the following core symptoms (either inattention or hyperactivity ) should persist for at least 6 months. Some of the symptoms must be present before 7 years of age .

Inattention:

1. Often fails to give close attention/careless mistakes in school work/other activities.
2. Difficulty in sustaining attention in task or play activities.
3. Often does not follow through on instructions.
4. Often does not seem to listen when spoken to directly.
5. Often has difficulty in organizing task and activities.
6. Often avoids task that require sustained mental afford.
7. Often loses things (e.g. toys, school assignments, pencils, tool, books).
8. Easily distracted by external stimuli.
9. Often forgetful in daily activities,

Hyperactivity:

1. Often fidgets with hands or feet or squirms in seat.
2. Often leaves seat in class rooms.
3. Often runs about or climbs excessively in situation which is inappropriate.
4. Often has difficulty playing or engaging in leisure activities quietly.
5. Always “On the go” motion.
6. Often talk excessively.
7. Often blurts out answers before the question is completed.
8. Often has difficulty awaiting turn.
9. Often interrupt others.

Often other disorders like learning disorder autistic disorder, conduct disorder etc. may occur along with ADHD which should be addressed separately.

 Symptoms have been shown to persist into  adolescence or adult life in about 50 % of cases .   In the remaining 50 % they may remit at puberty or in early adulthood.

Management:

It is divided in to pharmacological and non-pharmacological treatment. Pharmacological treatment is considered first line treatment for ADHD.

Stimulant Medication (Methylphenidate and amphetamine) are usually first line agents.  Methylphenidate has been shown to be highly effective in up to three quarter of all children with ADHD, with relatively few adverse effects.  The drug’s most common adverse effects include headache, stomach-ache, nausea and insomnia. The dose range of methylphenidate is 0.3-1mg/kg t.i.d; up to 60mg/day. Short acting/plain methylphenidate works for 3-4 hours and sustained release (SR) preparations works for 8hours. The drug is started from lower dose like 2.5-5mg/day and up-titration is done as per clinical response. The drug is not given during evening or night for sleep disturbance. In some cases methylphenidate can exacerbate the tic disorder. For this reason patients with tics are treated with non-stimulant medicines. Recently transdermal delivery system has  developed for methylphenidate.

Other drugs in this group are dextroamphetamine , amphetamine, dexmethylphenidate (d-enantiomer) used for ADHD.

The US Food and Drug Administration (FDA) approved the use of dextroamphetamine in children 3 years of age and older and methylphenidate in children 6 years of age and older .

Non-Stimulant Medication:

Atomoxetine is a norepinephrine uptake inhibitor approved for the treatment of ADHD for children aged 6 yrs. above. It is given at dose range of 0.5 to 1.8mg/kg, 40-80mg/day and may be used in b.i.d. dose. It is metabolized by cytochrome 2D6 hepatic enzyme system. A recent study of a combination of Atomoxetine with fluoxetine showed improvement in associated symptom of anxiety and depression.

There are other drugs like bupropion (3-6mg/kg) 150 to 300mg/day  effective for some children.

Venlafaxine 25 to 150 mg/day in b.i.d. dosing has been used in clinical practice for children and adolescents in ADHD with depression or anxiety features.

Clonidine is a alpha-adrenergic agonist drug used at 3 to 10 microgram/kg/day divided t.i.d.; 0.1mg t.i.d. Guanfacine (0.5 to 1mg/day) is another drug used for ADHD.

 During treatment, drug induced insomnia is managed  by diphenhydramine (25 to 75mg), low dose of trazodone (25 to 50mg) or addition of an alpha-adrenergic agent, such as guanfacine.

Before onset of stimulant medication proper physical examination, blood pressure, pulse, weight, height has to be checked and periodically monitored. 

Psychosocial intervention:

Medication alone is often not sufficient to satisfy the comprehensive therapeutic needs of children with ADHD and multimodal regimen is needed.  Social skill group, training of parents, behavioural interventions at school and at home are efficacious in management. Evaluation and treatment of co-existing learning disorders additional psychiatric disorders is important.   Positive reward technique is often helpful in encouraging socially expected behaviour. Unwanted behaviour should be ignored rather than punishing the patients. Group therapy aimed at both refining social skills and increasing self –esteem and a sense of success.

References :

1. American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105(5):1158 –1170
2. American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Committee on Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attentiondeficit/hyperactivity disorder. Pediatrics. 2001;108(4):1033–1044
3. Egger HL, Kondo D, Angold A. The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity disorder. Infant Young Child. 2006;19(2):109 –122
4. Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics. 2005;115(6):1734 –1746
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000
6. American Psychiatric Association. Diagnostic criteria for attention deficit/hyperactivity disorder. Available at: www.dsm5.org/ ProposedRevision/Pages/proposedrevision. aspx?rid383. Accessed September 30, 2011
7. Lahey BB, Pelham WE, Stein MA, et al. Validity of DSM-IV attention-deficit/hyperactivity disorder for younger children [published correction appears in J Am Acad Child Adolesc Psychiatry. 1999;38(2):222]. J Am Acad Child Adolesc Psychiatry. 1998;37(7):695–702
8. Symptom of treatments of psychiatric disorders edited by Glen O. Gabbard Sarad  D.Atkinson.
9. Kaplan & Sadock’s Synopsis of Psychiatry (behavioural sciences/ clinical psychiatry) .