F90 hyperkinetic disorders. The main differences from ordinary children

Level prevalence, depending on ethnic and socio-cultural conditions, ranges from 1 to 6% of children in the prepubertal period; boys predominate (4-9:1). Patients make up 40 - 70% of the inpatient and 30 - 50% of the out-of-hospital contingent served by child psychiatrists. 17% of patients are adopted, which is significantly higher than the corresponding level not only in the population, but also among child psychiatric patients in general.

The reasons

Hyperkinetic disorder is unlikely to owe its appearance to any single cerebral mechanism. The latter, however, have not been sufficiently studied, therefore, for the time being, it continues to be determined mainly by behavioral criteria that overlap the multidimensionality of etiopathogenesis. Although the applied research methods do not reveal pronounced structural organic changes in the CNS in patients, it is assumed that damage to the brain tissue at the subclinical level due to neurocirculatory, neuroendocrine, intoxication and mechanical effects in the pre- and perinatal period, as well as infections and injuries in the early childhood. In children with cortical damage to the right hemisphere, hyperactivity occurs in 93% of cases. Certain hazards in the prenatal period are the most significant in the etiology of hyperactivity. Among intoxications, the most dangerous is exposure to lead (the main household source is the lead components of paints used to cover residential premises). From medicines there is a relationship with benzodiazepines, barbiturates and carbamazepine. The percentage of nonspecific deviations on the EEG is slightly increased, CT data and the IQ profile are usually within the normal range. Signs of cognitive deficits are diverse and non-specific compared to those associated with impaired school skills, social behavior, and mental retardation.

Increased concordance of hyperkinetic disorder in twins and siblings, increased hereditary burden of hyperkinesis (especially in girls) suggests the involvement of genetic mechanisms in the etiology of the disease. Increased hereditary burden of alcoholism, affective psychoses, hysterical and dissocial personality disorder, and in the biological parents of patients to a significantly greater extent than in the adoptive ones. It is possible to identify groups of patients with a predominant burden of a certain type mental pathology in the genus. No specific gene has been found and transmission is likely polygenic with possible involvement of psychosocial factors.

The detected neurochemical abnormalities are contradictory and do not allow us to formulate an independent hypothesis of etiopathogenesis. The cause of hyperkinetic disorder may be delays in the main stages of brain development, compensating for puberty. Predisposing factors may include prolonged emotional deprivation, malnutrition, and episodes of psychosocial stress. Hyperactivity and attention disorders are detected in 60% of severely malnourished children in the first year of life.

Clinical picture

The complexity of the clinical assessment of the condition is determined by the fact that in a conversation a sick child often denies the presence of symptoms and does not complain. Basic data can be obtained from the stories of parents and teachers, as well as direct observation of the behavior of the child in a natural situation. Signs of the disorder, at least to a moderate degree, should be detected in at least two of the three areas of observation (home environment, school, medical institution), since pervasive behavioral abnormalities are observed only in more severe cases.

Hyperkinetic disorder can begin at a very early age (mothers usually talk about excessive fetal mobility during pregnancy). AT infancy patients sleep little and find excessive sensitivity to any sensory stimuli. In mild cases, signs of hyperactivity may be a simple exaggeration of normal childhood activity. They also depend on age - the younger the child, the more his motor skills are spontaneous and the less it is determined by the environment. Motility disorders are characterized not only by hyperactivity, but also by an inability to modulate activity in accordance with social expectations (for example, to be less mobile in the classroom and more mobile, precise, and collected on the playing field). Motor activity is increased even during sleep. Attention disorders are manifested not only in its quantitative decrease (the classic version - the child "does not listen" to what adults say to him, avoiding eye contact), but also in the inability to control it, switch it depending on the requirements of the situation.

The core feature of impulsivity is the inability to establish causal relationships, as a result of which the child is not able to foresee the consequences of his actions. Discipline violations, unlike cases of social behavior disorder, are usually unintentional. Patients are deprived of normal caution and reckless in dangerous situations. Aggression is one of the aspects of manifestation of impulsivity, it is observed in 75% of patients. Vigorous exploration of the new environment in which the patient enters, immediately begins to climb somewhere and rudely handle objects, may look aggressive. The dynamics of impulsivity parallels the level of emotional and sensory stimulation, the state of hunger and fatigue. Symptoms may be more noticeable in a noisy classroom than in a quiet clinical setting. Explosive irritability at the slightest provocation is combined with pronounced lability of affect, rapid transitions from laughter to tears. Girls tend to have more low level hyperactivity, but greater severity of anxiety, mood swings, impaired thinking and speech.

Flow diseases in adolescence most of all draws attention to learning difficulties. Motor hyperactivity most often normalizes in adolescence or earlier, while impulsivity lingers longer, persisting into adulthood in about a quarter of patients. The latter compensates for violations of attention. The onset of improvement is unlikely before 12 years of age. In adolescence, compared with the population, patients have lower levels of social skills and self-esteem, higher alcohol and drug use, more suicide attempts, somatizing disorders and conflicts with the law. All of this may be a complication rather than an inherent feature of the disorder.

In 25% of adult patients, a dissocial personality disorder is determined, thus, as you move into adolescence, the relative proportion of the component of dissocial behavior in the structure of the syndrome increases. However, long-term follow-up observations do not reveal significant differences in this respect compared with control groups of healthy people.

Overall, the hyperkinetic syndrome is a good example of how a biologically based disorder can be modified by psychosocial influences and how genetic and neurological factors that dominate early development are overridden by environmental factors over time.

Diagnosis

It should be taken into account that distinct disorders of attention and motor skills should be presented for a sufficiently long time, in a variety of situations and without a causal relationship with other diseases (autism, affective syndromes).

To be diagnosed with hyperkinetic disorder, the condition must meet the following criteria.

1) Attention disorders. For at least six months, at least six signs of this group must be observed in severity incompatible with the normal stage of development of the child. Children:

• unable to complete a school or other assignment without errors caused by inattention to detail,
• often unable to complete the work or play they are doing,
• often do not listen to what they are told,
• usually fail to follow the clarifications required to complete school or other assignments (but not because of oppositional behavior or failure to understand instructions),
• often unable to properly organize their work,
• avoid unloved work that requires perseverance, perseverance,
• often lose items that are important for completing some tasks ( writing instruments, books, toys, tools),
• usually distracted by external stimuli,
• often forgetful in daily activities.

2) Hyperactivity. For at least six months, at least three of the signs of this group are noted in severity that does not correspond to this stage of development of the child. Children:

• often swing their arms and legs or roll around in their seats,
• leaving their seat in the classroom or other situations where perseverance is expected,
• running around or climbing somewhere in inappropriate situations,
• often noisy in games or incapable of quiet pastime,
• demonstrate a persistent pattern of excessive physical activity, uncontrolled by the social context or prohibitions.

3) Impulsiveness. For at least six months, at least one of the signs of this group is observed in severity that does not correspond to this stage of the child's development. Children:

• often jump out with an answer without listening to the question,
• often cannot wait their turn in games or group situations,
• often interrupting or disturbing others (for example, interfering in a conversation or game),
• often overly verbose, not responding adequately to social constraints.

4) The beginning of the disorder under the age of 7 years;
5) severity of symptoms: objective information about hyperkinetic behavior must be obtained from more than one area of ​​constant observation (for example, not only at home, but also in a school or clinic), because Parents' stories about behavior at school may be unreliable;
6) symptoms cause distinct disturbances social, educational or industrial functioning;
7) the condition does not meet the criteria general disorders development (F84), affective episode (F3) or anxiety disorder(F41).

To be diagnosed with F90.0 activity and attention disorder, the condition must meet the general criteria for F90 hyperkinetic disorder but not the criteria for F91 social behavior disorder. To be diagnosed with F90.1 hyperkinetic conduct disorder, the condition must meet both the general criteria for hyperkinetic disorder and the criteria for social behavior disorder.

Differential Diagnosis. Before the age of 3 years, hyperkinetic disorder can be difficult to distinguish from normal manifestations of active temperament, so the diagnosis is usually made later. Hyperactivity and increased distractibility as features of anxiety episodes, in contrast to hyperkinetic disorder, are delineated in time. Under the influence of social stress, patients with hyperkinesis may exhibit secondary depressive manifestations that are distinguishable from true depression due to the absence of motor inhibition and social isolation.

Particular care must be taken to distinguish the disorder from psychotic states, since the psychotic symptoms in cases of psychosis are aggravated by the use of psychostimulants, which are beneficial in cases of true hyperkinetic disorder. High degrees of attention deficit can create an outward impression of being preoccupied with psychotic experiences. The level of activity and impulsivity in the disorder under consideration is more constant in comparison with the less predictable behavior of patients with psychoses. Suspicion of psychosis should increase if the course does not match that expected in hyperkinetic disorder (progressive improvement).

Decreased attention and hyperactivity may accompany visual and hearing impairments, neurological diseases (Sydenham's chorea), skin pathology (eczema). Hyperkinesis is characteristic of patients with Tourette's syndrome, more than half of them are characterized by motor inhibition.

Treatment

In mild cases of the disorder, it may be sufficient to optimize the external conditions of the child's stay, his stay in a small school group, preferably with self-service in the classroom, thoughtful seating of children. Here much is determined by the teacher, who can adequately structure the observation of the child and give him enough individual attention. Parents should explain that permissiveness and exemption from responsibility are not good for the child. They should also be taught to create a system of rewards and punishments that is predictable for him, methods of more precise reinforcement of desirable and inhibition of undesirable behavior. The child's room should be painted in soothing colors, furnished with simple and durable furniture. Limit the number of friends who come and use toys at the same time, avoid large crowds, and encourage games and activities that require patience and the use of fine motor skills.

In more serious cases, drug therapy is necessary. It should be preceded by individual development of motivation for it. The child should not associate it with one of the means of self-control, against which he constantly protests. He must understand that the drugs are “on his side” and will help him better cope with his unloved activities, study.

Most effective drug methylphenidate (Ritalin) has proven itself, causing improvement in approximately 75% of patients in both childhood and adolescence. Positive changes can be observed within half an hour after the first dose, a stable effect for 10 days. The initial dose of 5 mg in the morning is increased by 5 mg every 3 days in the morning and afternoon, the average daily dose, depending on the effect, is 10-60 mg. The drug of prolonged (8 hours) action is convenient when the patient does not want to take it at school, but is somewhat less effective, probably due to an increase in pharmacodynamic tolerance. The latter in any case makes itself felt after continuous use for a year, which raises the question of switching to another stimulant drug. Ritalin can contribute to the manifestation of masked Tourette's syndrome, so a history of tics and a hereditary burden of this disease are a contraindication for its use.

Dextroamphetamine (Dexedrine) has an effect within 6 hours, it is recommended to take it in a daily dose of 5-40 mg. Stimulants are characterized by the effect of "rollback", some increase in behavioral symptoms and possible appearance ticks after end time pharmacological effect received dose. Tricyclic antidepressants (melipramine 0.3 - 2 mg/kg per day, desipramine), whose action lasts more than 24 hours, are deprived of this effect. Indications for the use of antidepressants are the excessive effect of "rollback" and side effects of stimulants, suspicion of addiction to them, the desirability of taking the drug once a day, comorbidity with depressive syndrome and high hereditary burden of affective pathology. The potential cardiotoxic effect of melipramine limits its use to the age of at least 6 years.

The next drug of choice is pemoline (Cilert), a dopamine agonist that is pharmacodynamically active for 12 hours, making it possible to take once a day. Stable improvement is observed at a daily dose of more than 50 mg, the maximum daily dose is about 100 mg. A possible complication of pemoline can be a hepatotoxic effect, provoking choreoathetoid movements and motor tics.

In the absence of an effect observed in 20% of cases, the unwillingness of parents to allow medication, side effects stimulants in the form of insomnia, headaches, delayed growth and weight gain, drugs of choice may be clonidine (under pressure control), carbamazepine ( possible complication is leukopenia), bupropion.

MAO inhibitors have shown good efficacy in the treatment of hyperactivity, but their use is limited due to the inability to rely on patients to adhere to a tyramine-free diet and the corresponding risk of hypertensive reactions.

Low dose antipsychotics (chlorpromazine 10–50 mg daily in 4 divided doses) may be an option, but they non-specific effect, Moreover, side effects make them unsuitable for long-term use. Benzodiazepines and barbiturates should be avoided as they increase psychomotor agitation. To a lesser extent, this effect is characteristic of chloral hydrate and diphenhydramine (Benadryl), so these drugs can be used to induce nocturnal sleep.

When conducting drug therapy Desirable is daily telephone communication with school staff, periodic discontinuation of medication to decide whether it is necessary to continue.

Behavioral therapy programs for hyperactivity are more effective than placebo, especially in correcting aggressive behavior, but no more effective than psychopharmacotherapy. They are more expensive because require a lot of time for the participation of therapists and teachers, so their use as an alternative to psychostimulants is possible only if the latter cannot be used.

Cognitive psychotherapy techniques are able to reduce attention deficit, but are also inferior in effectiveness medicines. Their main tasks are the development of inner speech, the ability to formulate instructions for themselves and see their mistakes, and not look at them. In general, additional pedagogical assistance is useful, although its effect does not extend beyond the learning situation. The effectiveness of various dietary strategies in the treatment of hyperactivity has not yet been convincingly demonstrated.

Psychopharmacological agents do not always provide an increase in school performance (even with a decrease in attention deficit), but they can eliminate dissocial behavior and improve the quality of relationships with others. They create the prerequisites for increased social adjustment, but do not in themselves determine whether it will occur. When used in isolation, they are ineffective in relation to more complex integrative aspects of mental functioning and development, therefore, the most effective is multimodal therapy, including psychopharmacological, psychopedagogical and psychotherapeutic approaches. Its implementation, however, is somewhat limited by the low motivation of patients and relative inaccessibility.

But at the age of two or three years, the child's activity may increase and he will already cause trouble for parents, educators and teachers. Children with this behavior need a different approach in communication and treatment than with a calm child:

Make more time for communication;
- do not deprive attention;
- teach discipline and calmness;
- to make reasoned remarks.

If the efforts of parents in pacifying the activity of the child do not give results, and the child becomes less and less controllable with age, then it is imperative to contact a specialist. Perhaps the child suffers from a neuropsychiatric disorder - attention deficit hyperactivity disorder (ADHD). If the research method confirms the presence of a disease in a child, then medication may be prescribed.

Typically, symptoms of ADHD appear around the age of three or four years, when there are difficulties in the child's behavior and concentration in kindergarten, or learning difficulties in school. Studies have shown that ADHD occurs in 3-7 percent of children.

Children with ADHD 3 to 6 years old

The main differences from ordinary children

Primary school children with ADHD

The behavior of children with the syndrome is determined by:

Violation of school discipline (the child talks and laughs in class, interferes with the teacher to conduct a lesson, can walk around the classroom during a lesson, behaves badly at a break, sticks to children);
- restlessness and inattention (unable to concentrate on mastering the material, it is difficult to complete tasks independently, makes many mistakes in reading and writing - he studies poorly);
- loss of interest in learning;
- excessive emotionality (due to irritability and temper, it is difficult for a child to make friends with other children, becomes the initiator of fights and quarrels).

Children with the syndrome may be different ages, but they are united by one thing - provocative behavior: restless, tease often swear and offend other children. Games with them often end in a fight. In the future, with the maturation of such children, the problems of their stay in society grow, and their behavior is aggravated.

Hyperactive children in the future may have different consequences of the manifestation of the disease:
- appearance bad habits(alcoholism, drug addiction);
- unprotected and promiscuous sex (infectious diseases);
- unstable mental state;
- criminal violations.

How to identify ADHD?

To identify hyperactivity, you need to evaluate:

The degree of the child's fussiness (sitting still or spinning);
- how restless;
- sits quietly and obediently or gets up without permission.
To detect a violation of attention, they reveal:
- perseverance of the baby;
- whether he is distracted by third-party objects and irritants;
- how many mistakes were made while completing the task;
- did the job completely.

The criterion for detecting impulsivity is whether the child can answer the question after listening to it to the end, so as not to interrupt and shout out the answer in advance without a queue.

How to treat ADHD?

One of the main methods of treating the syndrome is pharmacotherapy, only in cases where the medication and the previously listed methods have not yielded results. Pharmacotherapy is prescribed purely individually, taking into account all the features of the child's disease.

For the treatment of hyperactivity syndrome, nootropic drugs (hopantenic acid) are usually prescribed. They provide:
- sedative effect, resulting in reduced motor activity;
- stimulating effect on mental work, memory and attention.

Levocarnitine is also prescribed, which helps to cope with nervous tension and excessive excitability, stimulates the normal functioning of organs.

Hyperkinetic disorders

Manifestations of hyperkinetic disorder

Scientists have repeatedly tried to identify a reliable and more accurate cause of the syndrome in children. But to date, their research has not yielded the desired result.

Factors that influence the development of hyperkinetic disorders in children

3. psychosocial (intra-family conflicts, the influence of society from the outside);
4. external stimuli (pollution environment, industrial areas containing harmful trace elements, exhaust gases and harmful emissions);
5. food (lack of vitamins, micro and macro elements, deficiency of magnesium, zinc, iron and iodine);
6. prenatal (difficult pregnancy, violations during gestation, medication, alcohol and drugs during pregnancy, prolonged labor, complications after childbirth).

As noted earlier, hopantenic acid or levocarnitine is prescribed to treat this type of disorder. Research has been carried out to identify more effective drug in the treatment of hyperkinetic disorder.

Children taking hopantenic acid showed positive changes in the manifestation of the disease. While the majority of children taking placebo, the reaction to the changes for the better was not seen.

Another study showed that a small proportion of children who were treated with levocarnitine had positive results.

It can be seen that the results of the studies are ambiguous. This indicates a variety of reasons that cause hyperkinetic disorders in children. Thus, the body of children reacts differently to the above drugs.

Most parents face problems in raising children because of their disobedience and activity. But it is necessary to clearly distinguish between the established norm of activity of children and their pampering, and the disease - a hyperkinetic disorder that requires the intervention of a doctor and medical treatment.

Illustration of Katkov | Dreamstime.com is copyrighted

This group of disorders is characterized by an early onset; a combination of overly active, poorly modulated behavior with pronounced inattention and lack of perseverance in completing any tasks. Behavioral features are manifested in any situations and are constant in the time interval.

Etiology / pathogenesis

Hyperkinetic disorders usually occur in the first 5 years of life. Their main features are the lack of perseverance in cognitive activity, the tendency to move from one task to another without completing any of them; excessive but unproductive activity. These characteristics persist through school age and even into adulthood. Hyperkinetic children are often reckless, impulsive, prone to getting into difficult situations due to rash actions. Relationships with peers and adults are broken, without a sense of distance.
Secondary complications include dissocial behavior and reduced self-esteem. There are often accompanying difficulties in mastering school skills (secondary dyslexia, dyspraxia, dyscalculia and other school problems).

Diagnosis

Most difficult to differentiate from behavioral disorders. However, if most of the criteria for hyperkinetic disorder are present, then the diagnosis should be made. When there are signs of severe general hyperactivity and conduct disorders, the diagnosis is hyperkinetic conduct disorder (F90.1).
The phenomena of hyperactivity and inattention may be symptoms of anxiety or depressive disorders(F40 - F43, F93), mood disorders (F30-F39). These disorders are diagnosed when they are diagnostic criteria. Dual diagnosis is possible when there are separate symptoms of hyperkinetic disorder and, for example, mood disorders.
The presence of an acute onset of hyperkinetic disorder at school age may be a manifestation of a reactive (psychogenic or organic) disorder, manic state, schizophrenia, neurological disease.

Symptoms

The main signs are attention disorders and hyperactivity, which manifest themselves in various situations - at home, in children's and medical institutions. Frequent change and interruption of any activity is characteristic, without attempts to complete it. Such children are overly impatient, restless. They can jump up during any work, talk excessively and make noise, fidget... Comparison of the behavior of such children with other children of this age group is diagnostically significant.
Related clinical characteristics: disinhibition in social interaction, recklessness in dangerous situations, thoughtless violation of social rules, interruption of classes, rash and incorrect answers to questions. Learning disorders and motor clumsiness are quite common. They should be coded under (F80-89) and should not be part of the disorder.
Most clearly, the clinic of the disorder manifests itself at school age. In adults, hyperkinetic disorder can manifest itself in dissocial personality disorder, substance abuse or other condition with impaired social behavior.

Treatment

Outpatient treatment - with mild manifestations of hyperkinetic disorders. If it is impossible to relieve symptoms on an outpatient basis, with protracted course and persistent school maladaptation - treatment in a hospital.

Forecast

In most forms of emotional disorders, the prognosis is favorable.

What is Hyperkinetic Disorders

This group of disorders is characterized by an early onset; a combination of overly active, poorly modulated behavior with pronounced inattention and lack of perseverance in completing any tasks. Behavioral features are manifested in any situations and are constant in the time interval.

Hyperkinetic disorders usually occur in the first 5 years of life. Their main features are the lack of perseverance in cognitive activity, the tendency to move from one task to another without completing any of them; excessive but unproductive activity. These characteristics persist through school age and even into adulthood. Hyperkinetic children are often reckless, impulsive, prone to getting into difficult situations due to rash actions. Relationships with peers and adults are broken, without a sense of distance.

Secondary complications include dissocial behavior and reduced self-esteem. There are often accompanying difficulties in mastering school skills (secondary dyslexia, dyspraxia, dyscalculia and other school problems).

Prevalence

Hyperkinetic disorders are several times more common in boys than girls (3:1). In elementary school, the disorder occurs in 4-12% of children.

Symptoms of Hyperkinetic Disorders

The main signs are attention disorders and hyperactivity, which manifest themselves in various situations - at home, in children's and medical institutions. Frequent change and interruption of any activity is characteristic, without attempts to complete it. Such children are overly impatient, restless. They can jump up during any work, talk excessively and make noise, fidget... Comparison of the behavior of such children with other children of this age group is diagnostically significant.

Associated clinical characteristics: disinhibition in social interaction, recklessness in dangerous situations, thoughtless violation of social rules, interruption of classes, thoughtless and incorrect answers to questions. Learning disorders and motor clumsiness are quite common. They should be coded under (F80-89) and should not be part of the disorder.

Most clearly, the clinic of the disorder manifests itself at school age. In adults, hyperkinetic disorder may manifest as dissocial personality disorder, substance abuse, or another condition with impaired social behavior.

Diagnosis of Hyperkinetic Disorders

Most difficult to differentiate from behavioral disorders. However, if most of the criteria for hyperkinetic disorder are present, then the diagnosis should be made. When there are signs of severe general hyperactivity and conduct disorders, the diagnosis is hyperkinetic conduct disorder (F90.1).

The phenomena of hyperactivity and inattention may be symptoms of anxiety or depressive disorders (F40 - F43, F93), mood disorders (F30-F39). The diagnosis of these disorders is based on their diagnostic criteria. Dual diagnosis is possible when there are separate symptoms of hyperkinetic disorder and, for example, mood disorders.

The presence of an acute onset of a hyperkinetic disorder at school age may be a manifestation of a reactive (psychogenic or organic) disorder, a manic state, schizophrenia, or a neurological disease.

Which Doctors Should You See If You Have Hyperkinetic Disorders

Psychiatrist

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