(syndrome of hyperactivity and inattention)

Acronym for Awareness Deficit Hyperactivity Disorder.

Attention deficiency with hyperactivity disorder. The prevalence varies according to the diagnostic criteria but could be 5-10 % of children. Boys are more often affected than girls. 

The cause is unknown but there appears to be a genetic predisposition:

-        increased levels of dopaminergic receptors D2 and D3 in the corpus striatum

-        dysfunctional transport of dopamine

-        polymorphism of the NR2A and NR2B subunits of NMDA receptors

-        dysfunctional connectivity between the corpus striatum and the prefrontal cortex and between the prefrontal cortex and the basal ganglia (the size of some of those structures and the total size of the brain are decreased)

 

and environmental factors could play a role. A retrospective epidemiological study has shown a doubled risk (HR 1.95 in multivariate analysis) if the child has received more than two general anesthesia before the age of 2 years.

Diagnosis is based on a multi-disciplinary assessment and is supported by various scores. The signs must be present for at least 6 months, and before the age of 7 years; moreover the child should not present any other mental disorder or behavior disorder. 
The three signs are:

- hyperactivity: disruption and excessive activity level

- inattention: difficulty concentrating

- impulsive behavior

There are 3 subtypes:

- inattention-dominant

- hyperactive-impulsive dominant

- combined with the the hyperkinetic syndrome, the most severe form.

The treatment aims at facilitating the relational life of the child (home, school), and to decrease the risk of learning and relational problems.

Treatment ideally involves behavioural therapy (with parents) and temporary medical treatment of

-         methylphenidate (Ritalin ®): inhibits the recapture of dopamine and norepinephrine; increases the concentration of dopamine at the level of the D1 and Dé  receptors of the corpus striatum; low doses (0.3 to 0.5 mg/kg/d) are especially active on attention disorders while higher doses (0.5 to 1.0 mg/kg/d) act on hyperactivity and impulsivity. The dose is titrated according to the effect (5 to 60 mg/d); doses should be diminished slowly under medical supervision because the treatment can mask depression

-         or atomoxetine: an inhibitor of the norepinephrine reuptake at the level of the prefrontal cortex; metabolized by CYP2D6 (pharmacogenetic differences ); risk moderate liver toxicity; 0.8 to 1.6 mg/kg/d in one dosis

-         or guanfacine: α2 agonist; risk of hypotension and prolongation of the QT; risk of hypertension when the drug is stopped; metabolism by CYP3A 4 and 5: very sensitive to induction or inhibition of these cytochromes.

-        or pycnogenol: food supplement based on extract from maritime pine bark (Pinus Pinaster) which contains water-soluble polyphenols

-         or dextroamphetamine: blocks the synaptic reuptake of dopamine and norepinephrine. rarely used in Europe

-         or tricyclic antidepressants: in case of associated anxiety disorders or depression 

-                  or bupropion: selective inhibitor of neuronal reuptake of catecholamines; rarely used

-         or clonidine: rarely used.

Children on methylphenidate or amphetamines have a higher sympathetic tone: heart rate and systolic and diastolic blood pressure are slightly higher at rest than the average for their age.

Natural evolution: symptoms generally improve with age but the learning difficulties may lead to an economic-social disadvantage. However, the prognosis is less favourable if co-morbidities (disturbance, oppositional behaviour) are present because they result in an increased risk of mental disorders, addiction or criminal behaviour in the young adult.

 Anesthetic implications: 

-         enhanced risk for behavioral disorders during the pre-operative period and anesthetic induction 

-         significant increase in postoperative risk of behaviour disorders: pain scores are identical to those of the normal population, but these children take 1-2 more days to resume their normal activities   

-         possibility of interactions: 1) increase of the cardiovascular effects of methylphenidate in case of administration of ephedrine and tramadol; 2) risk of convulsions in case of administration of tramadol or pethidine. (3) increase in the MAC in case of treatment with methylphenidate or dexamphetamines, but the doses of propofol seem identical.

-        the chronic use of amphetamines can cause a depletion of endogenous catecholamines stocks and therefore an increased risk of hypotension during anesthesia: in this case, it is preferable to use a catecholamine with a direct effect to treat the hypotensive episode (adrenaline or noradrenaline)

References : 

-        SIGN. Management of attention deficiency and hyperkinetic disorders in children and young people. A national clinical guideline. 
October 2009. www.sign.ac.uk 

-         Sprung J, Flick RP, Katusic SK, Colligan RC, Barbaresi WJ et al. 
Attention deficiency/ hyperactivity disorder after early exposure to procedures requiring general anesthesia. 
Mayo Clin Proc 2012; 87: 120-9.

-        CBIP. 
Prise en charge du syndrome d’hyperactivité et de manque d’attention (ADHD) chez l’enfant. 
Folia Pharmacotherapeutica 2002;29:55-9. 

-         Biederman J, Faraone SV. 
Attention-deficiency hyperactivity disorder. 
Lancet 2005;366:237-48. 

-         Forsyth I, Bergesio R, Chambers NA. 
Attention-deficiency hyperactivity disorder and anesthesia. 
Pediatr Anesth 2006; 16: 371-3.

-         Tait AR, Voepel-Lewis T, Burke C, Doherty T. 
Anesthesia induction, emergence, and postoperative behaviors in children with attention-deficiency/hyperactivity disorders. 
Pediatr Anesth 2010; 20: 323-9.

-         Perruchoud C, Chollet-Rivier M. 
Cardiac arrest during induction of anaesthesia in a child on long-term amphetamine therapy (letter). 
Br J Anaesth  2008; 100: 421-2.

-        Kelly AS, Rudser KD, Dengel DR, Kaufman C, reiff MI et al. 
Cardiac autonomic dysfunction and arterial stiffness among children and adolescents with Attention deficiency Hypereactivity Disorder treated with stimulants. 
J Pediatr 2014; 165: 755-9.

-        Kitt E, Friderici J, Kleppel R, Canarie M. 
Procedural sedation for MRI in children with ADHD. 
Pediatr Anesth 2015; 25: 1026-32

-        Rosander S, Nause-Osthoff R, Voepel-Lewis T, Tait AR. 
A comparison of the postoperative experience in children with and without attention-deficit hyperactivity disorder (ADHD). 
Pediatr Anesth 2015; 25: 1020-5

-         Cartabuke RS, Tobias JD, Rice J, Tumin D. 
Hemodynamic profile and behavioral characteristics during induction of anesthesia in pediatric patients with attention deficit hyperactivity disorder. 
Pediatr Anesth 2017; 27:417-424

-        Zimmer L, Fourneret P.
Tout ce que vous devez connaître sur le méthyphénidate (sans oser le demander).
Arch Pédiatr 2018 ; 25 : 229-35.

-        Xu L, Hu Y, Huang L, Liu Y, Wang B, Xie L, Hu Z.
The association between attention deficit hyperactivity disorder and general anaesthesia: a narrative review.
Anaesthesia 2019; 74: 57-63

Updated March 2023