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Kevin Lukito



Dr. Hexanto Muhartomo, Sp.S, M.Kes


– Attention Deficit Hyperactive Disorder (ADHD) is a chronic condition which

affects millions of children and often stays until adulthood.
– ADHD is combination of several problems such as difficulty to stay focus,
hyperactivity and impulsive behaviour.
– The principle characteristics of ADHD are innatention, hyperactivity and
– Children with ADHD have low self-esteem, problematic relationships and
receive low score at school.
– These symptoms must be there for at least 6 months and occur before the age
of 7.

– 2,2% for hyperactive and impulsive type

– 5,3% for combined hyperactive-impulsive and inattention type
– 15,3% for inattention type
– Boys > Girls in a ratio 2:1
– ADHD is usually found in first born child who is a boy

– The cause of this disorder is unknown

– Most children do not show any major structural injury in the central nervous
– Some disorders are assumed to have a relation with
other disorders which affect brain function such as:
– Learning disability
– Toxin exposure in prenatal period, prematurity and prenatal
mechanical injury in the fetus nervous system.
– Hyperactive behaviour
– Food additives and sugar are assumed as the cause for hyperactive
Predisposing Factors

– Genetic factor
– Mutation of neurotransmitter coding gene and Dopamine receptor (D2 and D4) in
chromosome 11p
– Monozygote twins > dizygote twins
– Siblings of child with ADHD have 5-7 times higher risk
– Children with ADHD parents have 50% probability
– Brain injury
– It is assumed that children with ADHD have a history of minor brain injury in the fetus and
prenatal period.
– Brain injury might be caused by toxin, metabolic, mechanical, stress and physical defect in
the brain which are caused by infection, inflammation and trauma
– Neurochemical factor
– Dysfunction in adrenergic and dopaminergic system
– Anatomic structure
– PET (Positron Emission Tomography) found decrease in serebral circulation and speed
of metabolism in frontal lobe of children with ADHD.
– Brain imaging found meaningful brain volume decrease in prefrontal cortex, right
caudal nucelus, right globus pallidus and vermis (part of cerebellum).
– The function of these parts of the brain is to regulate a person’s attention function.

– There are several theories involved in the pathophysiology of ADHD.

– Based on research:
– Decrease in brain volume, especially in the frontal lobe.
– Catecholamine is the main neurotransmitter for the function of frontal lobe.
Catecholamine are controlled by dopaminergic and noradrenergic transmission.
– Low Dopamine and Norepinephrine level makes it hard to focus.

– Based on DSM IV from American Phsychiatric Association (APA):

– Inattention type ADHD
– In this disorder someone will not be able to stay focused for a long time, his/her attention is
easily distracted.
– Hyperactive-impulsive type ADHD
– Impulsivity can be motor or verbal impulsivity. Motor impulsivity means the child always
move from one activity to another activity. Verbal impulsivity can be seen as a behaviour in
which the child makes a decision too soon before getting enough information.
– Combination type ADHD
– This type of disorder is the combination of inattention and hyperactive-impulsive disorder.
Clinical Manifestation

– Hyperactivity
– Motoric disorder
– Emotional lability
– Coordination deficit
– Attention problem
– Impulsivity
– Memory problem
– Learning disability
– Talking and listening problem
Diagnostic Criteria based on
– Either one (1) or (2):
1. Inattention  6 (or more) inattention symptomps stays for at least 6 months until maladaptive stage and
inconsistent with development stage:
– Often fails to give attention to details or make a careless mistake in school work, work or other activity.
– Often has difficulty in staying focus for work or game activity.
– Often look like the child is not listening while people are talking.
– Often not follow instruction and fail to finish school work, work or obligation at work (not because the child doesn’t
understand the instruction)
– Often has difficulty in arranging work and activities.
– Often avoid, hate or don’t want to be involved in activity that requires long mental work.
– Often avoid things that are needed for work or activity.
– Often easily distacted by outside stimulants.
– Often forget things in daily activity.
– Hyperactivity-impulsiveness  6 (or more) inattention symptomps stays for at
least 6 months until maladaptive stage and inconsistent with development
– Hyperactivity
– Often anxious with hands and feet or squirming at the seat.
– Often leave his/her seat in the class or other situation where the child needs to remain
– Often run around or climb excessively in inappropriate situation.
– Often has difficulty in playing or involved in free time activity.
– Often talk excessively.
– Impulsivity
– Often answers without thinking even before the question is finished.
– Often has difficulty in queue-ing or disturbing other people.
– Often interrupts or disturbing other people.
– Some hyperactive-impulsive or inattention symptoms have been there before the
age of 7.
– Some disorders caused by symptoms are there in 2 or more situations (ex: at school,
work and home)
– Definite proof of disorders must be there in social function, academic or work.
– The symptoms are not caused by other mental problems and are not defined better
by other mental disorder.
Supporting Examination

– Laboratorium test
– For substance abuse
– Radiology test
– Found decrease in circulation of frontal lobe.
– Other test
– Child Behaviour Check List atau Behavior Assessment System for Children  to find
other disorder in a child.
– Learning disability evaluation (intelligence {IQ} vs achievement)
Differential Diagnosis

– Neurologic disorder
– Tourette syndrome
– Hearing problem
– Psychiatric disorder
– Adaptation disorder
– Mental retardation
– Behaviour problem

– Pharmacotherapy
– Stimulants:
– Methylphenidate  age ≥ 6 y.o
– Dexamphetamine  age ≥ 3 y.o

– Atomoxetine
– Tricycline Antidepressants (TCAs)
– Imipramine, amitriptyline and clomipramine

– Other drugs
– Clonidine
– Behavioural therapy
– Focused on identifying behaviour problems and trying to change the behaviour to
desired result.

– There are no definite way to prevent ADHD, but there are ways to prevent the
problems that might cause or be caused by ADHD.
– Avoid toxins
– Protect child from pollutants and toxins
– Always consistent
– Arrange routine schedule with the child
– Avoid multitasking when talking with the child
– Work together with teacher and guardian to identify the problems as early as
Usually stays if family
history (+), negative
events in life,
Persistent (40-50%) comorbidity with
behaviour symptoms,
depression and anxiety


Total remission
Remission (50%)

Partial remission
ADHD Impact in Child’s Development
Behaviour problem Academic difficulty Job failure
Bad socialization Interpersonal relationship problem
Self image problem
Trauma or injury risk
Law breaking


Trauma or injury risk

Pre-school School Teenager College Adult

Behaviour problem Academic failure

Academic failure Job difficulty

Problematic relationship Self image problem

Self image problem Substance / drug abuse

Trauma or injury risk

– Attention Deficit Hyperactivity Disorder (ADHD) shows hyperactive, impulsive

and inattention behaviour. Main clinical manifestation of ADHD is inattention,
impulsivity and excessive activity that happens in > 1 environtment, under the
age of 7 and stays in a long time.
– The cause of ADHD is still unknown. There are a lot of factors that might be the
cause of ADHD such as genetic factor, brain development in pregnancy,
environtment, etc.
– Therapy of ADHD involves comprehensive approach with drugs and
psychosocial therapy like behaviour, cognitive behaviour and social skills