Lesson 5 ADHD Updated PDF

Lesson 5 Prepared by: Ms. Ma. April F. Arcilla What is ADHD? Attention Deficit Hyperactivity Disorder – Is a common, lifelong, neurodevelopmental disorder that affects a persons ability to focus attention, regulate activity levels and control their impulses. What is ADHD? – ADHD is the mo...

Lesson 5 Prepared by: Ms. Ma. April F. Arcilla What is ADHD? Attention Deficit Hyperactivity Disorder – Is a common, lifelong, neurodevelopmental disorder that affects a persons ability to focus attention, regulate activity levels and control their impulses. What is ADHD? – ADHD is the most common neurobehavioral disorder of childhood, among the most prevalent chronic health conditions affecting school-aged children, and the most extensively studied mental disorder of childhood. Three subtypes: 1) ADHD combined type 2) ADHD predominantly inattentive type 3) ADHD predominantly hyperactive-impulsive type.  History – 1902 Lancet article – 1920’s “minimal brain damage” – 1930’s “hyperkinetische Erkrankung” – 1960’s “minimal brain dysfunction” – 1937 Benzedrine discovered – Hyperkinetic Syndrome of Childhood” in ICD-9 – 1980 inattention recognized – DSM-III Attention-Deficit Disorder with or without Hyperactivity – Mid-1800s: Minimal Brain – 1987: Attention Deficit Damage Hyperactivity Disorder – Mid 1900s: Minimal Brain – 1994 (DSM IV): ADHD Dysfunction – Primarily Inattentive – 1960s: Hyperkinesia – Primarily Hyperactive – 1980: Attention-Deficit – Combined Type Disorder – With or Without Hyperactivity  Inattention Overactivity Impulsivity Fails to give close attention to detail Unable to sit still for as long as peers Difficulties taking turns, may interrupt Easily distracted by external stimuli Often up and out of seat Can not wait in a line Easily off task - changes Runs and climbs when inappropriate Talkative from one thing to another Makes careless mistakes Fidgety with hands and feet Unable to engage in play quietly Has difficulties listening when spoken Is often ‘on the go’ Premature or thoughtless actions to Inability to follow instructions Restless and shifting excess of movement Unable to complete tasks Difficulties with organisational skills Avoids tasks that require mental effort Often loses items required Forgetful in daily activities Disorganised – 3-9% of the elementary school population – more often in males than females, with the sex ratio being about 3:1 to 9:1 – most common disorders of childhood accounting for a large number of referrals to pediatricians, family physicians and child mental health professionals v Pre-school: play < 3mins, not listening, no sense of danger v Primary school: activities < 10 mins, forgetful, distracted, restless, intrusive, disruptive v Adolescence: attention < 30 mins, no focus/planning, fidgety, reckless v Adult: incomplete details, restless, forgetful, impatient, accidents  Symptoms of ADHD are associated with having lower levels of the brain chemicals dopamine and noradrenaline in the brain. Dopamine carries signals between nerves in the brain and is linked to movement, sleep, mood, attention, and learning, motivation, reward and cognition, Certain parts of the brain may be less active or smaller in children with ADHD.  Noradrenaline is linked to memory, alertness and learning T h e s e c h e m i ca l s p ro m o te s fe e l i n g s o f e n j o y m e nt a n d reinforcement to motivate performance. When we are deficient, it makes learning very difficult. That feeling of accomplishment when we learn something new simply isn’t there – Lower academic – Unemployment achievement – Employment below potential – Marital problems and – Traffic accidents dissatisfaction – Other psychiatric disorders – Divorce – Difficulties dealing with offspring – Lower job performance ADHD Risk Factors vStrong genetic component (76%) vPerinatal factors – some evidence vNeurobiological deficits – growing evidence vDeprivation and family factors – important for course and outcome ADHD Risk Factors – Maternal cigarette use – Toxemia – Maternal alcohol use – Meconium staining – Unusually long or short – Minor physical labor anomalies – Forceps delivery Neurobiology v Frontal-striatal dysfunction v mediated by GABA v modulated by catecholamines v Catecholaminergic dysregulation v Delay in cortical maturation  Diagnosing ADHD: DSM-V A.1 Inattention - Persisted for at least 6 – has difficulty organizing tasks. months to a degree that is inconsistent with – avoids tasks requiring mental effort. developmental level and that negatively impacts directly on social and – o f t e n l o s e s i t e m s n e c e s s a r y fo r academic/occupational activities completing a task. – Lacks attention to detail; makes careless – easily distracted. mistakes. – is forgetful in daily activities. – has difficulty sustaining attention – doesn’t seem to listen. – fails to follow through/fails to finish instructions or schoolwork.  Diagnosing ADHD: DSM-V A.2 Hyperactive/Impulsivity - Persisted – has difficulty playing quietly for at least 6 months to a degree that is – often “on the go” or “driven by a inconsistent with developmental level motor” and that negatively impacts directly on s o c i a l a n d a ca d e m i c /o c c u p at i o n a l – talks excessively activities – blurts out answers before question is – Fidgets or squirms excessively finished  cannot await turn – leaves seat when inappropriate  runs – interrupts or intrudes on others a b o u t /c l i m b s ex t e n s i v e l y w h e n inappropriate  Diagnosing ADHD: DSM-V B. Several inattentive or hyperactive- E. Symptoms do not occur exclusively impulsive symptoms were present prior during the course of a pervasive to age 12 years. developmental disorder, schizophrenia, C. Several inattentive or hyperactive- or other psychotic disorder, and are not impulsive symptoms are present in two or better accounted for by another mental more settings. disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, D. There must be clear evidence of personality disorder) clinically significant impairment in social, academic, or occupational functioning.  Diagnosing ADHD: DSM-V Specify whether: – Predominantly hyperactive/impulsive – Combined presentation: If both presentation: If Criterion A2 Criterion A1 (inattention) and Criterion (hyperactivity-impulsivity) is met and A2 (hyperactivityimpulsivity) are met Criterion A1 (inattention) is not met for the past 6 months. for the past 6 months. – Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.  Diagnosing ADHD: DSM-V Specify if: – Moderate: Symptoms or functional – In partial remission: When full criteria impairment between “mild” and were previously met, fewer than the full “severe” are present. criteria have been met for the past 6 – Severe: Many symptoms in excess of months, and the symptoms still result in those required to make the diagnosis, impairment in social, academic, or or several symptoms that are occupational functioning. particularly severe, are present, or the Specify current severity: symptoms result in marked impairment in social or occupational functioning – Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. – Situational hyperactivity – Behavioral disorders (ODD/CD) – Emotional disorders – Tics, chorea or other dyskinesias – Misuse of substances – Autism Spectrum Disorder – Intellectual Disability *Frequent Comorbidity* – No single factor determines the expression of ADHD; – Mothers of children with ADHD are more likely to experience birth complications, such as toxaemia, lengthy labour, and complicated delivery. – Maternal smoking and alcohol use during pregnancy and prenatal or postnatal exposure to lead are commonly linked the development of ADHD. – There is a strong genetic component to ADHD. [dopamine transporter gene (DAT1) and a particular form of the dopamine 4 receptor gene (DRD4)]. There are some other genes that might contribute to ADHD. – Severe traumatic brain injury with subsequent onset of substantial symptoms of impulsivity and inattention are reported in some children. – Structural or functional abnormalities have been identified in children with ADHD without pre-existing identifiable brain injury. These include dysregulation of the frontal subcortical circuits, small cortical volumes in this region, widespread small-volume reduction throughout the brain. abnormalities of the cerebellum. – Psychosocial family stressors can also contribute to or exacerbate the symptoms of ADHD – A diagnosis of ADHD is made primarily in clinical settings after a thorough evaluation, including – a careful history and clinical interview to rule in or to identify other causes or contributing factors; – completion of behavior rating scales; – a physical examination; – any necessary or indicated laboratory tests. – It is important to systematically gather and evaluate information from a variety of sources, including the child, parents, teachers, physicians, and when appropriate other caretakers  Review of Assessment Algorithm – Does the child have problems with inattention and over- activity? – Are symptoms persistent, severe Consider ADHD if the answer to and causing impairment in the both is ‘yes’ child’s functioning? – Explore the impact of Explore ways to address environmental stressors (e.g., environmental stressor family) as part of management plan – Rule out medical or other conditions Manage or refer – Behavior rating scales are useful in establishing the magnitude of the symptoms, but are not sufficient alone to make a diagnosis of ADHD. – Many scales available – Conners Comprehensive Behavior Rating Scales (Conners CBRS) – 6 to 18 years for teacher forms and parent forms & 8 to 18 years for self-report forms – Connors-EC for ages 2-6 yrs – Connors Comprehensive and ADHD Rating Scale IV for age – 4-5 yrs – Connors-3 for ages 6-18 yrs – Academic Performance Rating Scale for grades 1-6 – history of the presenting problems, – growth and development, – pregnancy complications, such as maternal illness (eclampsia, diabetes), – maternal smoking, alcohol, or illicit drug use. – The perinatal period-- presence of labor problems, delivery complications, prematurity, jaundice, and low birth weight. – Disruptive social factors, such as family discord, situational stress, and abuse or neglect. – A family history of 1st-degree relatives with ADHD, mood or anxiety disorders, learning disability, antisocial disorder, or alcohol or substance abuse (indicate an increased risk of ADHD and/or comorbid conditions) Aims of Treatment Individually tailored Reduce symptoms Improve educational outcomes Reduce family and school-based problems Psychosocial Treatments – The parents and child should be educated with regard to the ways ADHD can affect learning, behavior, self-esteem, social skills, and family function. – The clinician should set goals for the family to improve the child's interpersonal relationships, develop study skills, and decrease disruptive behaviors. Behavior therapy – Parent management training: particularly useful in younger children and for associated behavior problems – School based: child in front of class, short tasks etc. – Generally effective, but smaller effect size than medication – First line treatment in younger children or milder cases Behaviorally Oriented Treatments: – The goal of such treatment is for the clinician to identify targeted behaviors that cause impairment in the child's life (disruptive behavior, difficulty in completing homework, failure to obey home or school rules) – The clinician should guide the parents and teachers in implementing rules, consequences, and rewards to encourage desired behaviors. – Behavioral interventions are only modestly successful at improving behavior, but they may be particularly useful for children with complex comorbidities and family stressors, when combined with medication. – Special Education Services for existing learning problems – Classroom accommodations – Classroom behavior modification programs – The most widely used medications are the pre synaptic dopaminergic agonists, commonly called psychostimulant medications – Over the first 4 wk of treatment, the physician should increase the medication dose as tolerated (keeping side effects minimal to absent) to achieve maximum benefit. – If this strategy does not yield satisfactory results, or if side effects prevent further dose adjustment in the presence of persisting symptoms, the clinician should use an alternative class of stimulants that was not used previously. – If satisfactory treatment results are not obtained with the second stimulant, clinicians may choose to prescribe atomoxetine, a noradrenergic reuptake inhibitor. – Methylphenidate or Amphetamines – Efficacy and safety well established – ES 0.8-1.1; clinical response in 70% – Dose: titrate for optimum response – Short/long acting (sustained release) available – NOT on WHO list of essential medicines – Common side effects: nausea, weight loss, insomnia, agitation – More serious side effects: tics, psychotic symptoms, raised blood pressure, growth retardation – Can be reactive rather than proactive – Needs time, ability to focus on individual – Communication and positive relationships between family and school – Parents can be overwhelmed by process of diagnosis and assessment as well as receiving regular (negative) feedback from school – When the right fit is found, a school that can adapt around the child’s needs to keep them in the classroom, experiences become much more positive Classroom Setup Assignments – Sit away from distractions – Allow extra time –front and centre of – Break long assignments classroom into smaller parts, shorten – Utilise positive role models work periods – Increase distance between – Pairing written instructions desks with oral instructions Distractibility Behaviour – Provide peer assistance in note – Ignore minor inappropriate behaviours taking and ask student questions to – Increase immediacy of rewards and encourage participation consequences – Involve student in lesson preparation – Acknowledge correct answers only when hand is raised and student is called upon – Cuing student to stay on task with private signal – Send daily /weekly progress reports home – Scheduling 5 minute period to check – Set up achievable behaviour contract work prior to handing in Organization /Planning Moods / Socialization – Recommend binders / dividers and – Set up social behaviour goals with student colour coded folders and implement reward program – Provide assignment book and supervise – Encourage cooperative learning tasks writing down of assignments – Assign special responsibilities to student in – Allow student to keeps sets of books / presence of peer group resources at home – Compliment positive behaviour and work – Allow student to run errands or stand at give opportunity for leadership roles times – Frequent acknowledgment of appropriate behaviours – Provide short breaks – Encourage student to walk away from angering situations Helpful Daily Techniques Communication can be helped by: – Get their attention – Eye contact – Non-verbal cues – Facial Expression – Give advanced notice to transitions – Give two choices – An indirect approach often succeeds – Frequent praise v Try to use facial expressions and gestures when speaking to your child; this emphasises what you are saying and gives your child clues to what you mean. v This also increases your child’s understanding of non - verbal communication by linking words with gestures and faces. Also try to keep your voice lively to hold your child’s attention.  Avoid asking too many questions at once. This can be quite overwhelming for a young person, and can feel like they may be being tested. Asking questions one by one, that challenge them to think rather than need an immediate answer, can be less overwhelming. Repeating questions or instructions can also be helpful but make sure you wait for the answer.  Give your young person time to respond. It can take longer for some young people to turn their thoughts into a response when communicating. Giving them more time can relieve pressure to respond so quickly and allow them time to think. Make sure you maintain eye contact and their attention while awaiting a reply.  Use simple repetitive language Use the young person’s own words Model the right way to communicate  Games and songs can be good ways of improving attention and learning- think about your young person’s learning style  Rewarding good behaviour and ignoring unwanted behaviour when safe to do so Find the good and PRAISE! – ‘Reasonable consequences ensuring the child understands what he has done. – Avoid sending to a bedroom for all misdemeanors. – Avoid threatening things you will not follow through with – When the child is calm, use this time to explain how together you can help change behaviours – The behaviour is what you want to change not the child – Consistency amongst all adults involved – Problem solving - if the child has got into trouble it is often helpful to give them ‘what could you have done’ scenarios Thank you for listening!