Transcript Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity
Disorder (ADHD)
Inattention,
Overactivity
and Impulsivity
Programme for ADHD training day
 9:15 Introductions and Ice Breaker
 Name
 School
 Your most memorable impulsive act in the last 2 weeks!









9:30 -10:00
10:00 -10:45
10:45 - 11:15
11:15 - 12:30
12:30 - 1:30
1:30 – 3:00
3:00- 3:15
3:15-4.00
4:00-4:15
Fact or Fiction around ADHD a short quiz
Introduction to recognising ADHD type behaviours
Coffee
Identifying ADHD symptoms in the classroom
Lunch
Management in the classroom
Tea
How to make a referral to CAMHS and the use of medication
Plenary and finish
Is this a new disorder imported
from America ?
No. In 1902 at the Royal College of
Physicians in London, British Physician
Frederic Still described a group of children
as being ‘deficit in moral control’.
These children were characterized by a
deficit in sustained attention, neurological
abnormalities (twitching), restlessness,
fidgetiness, aggression and
destructiveness.
Core Symptoms of ADHD
Hyperactivity.
Inattention.
Impulsivity.
These behaviours must be exhibited to a degree
which is appreciably inappropriate for the child’s
developmental age and secondly are observed
as impeding the child’s capacity to regulate their
behaviour in a developmentally appropriate way.
Hyperactivity
 Often fidgets with hands and feet
 Often leaves seat when it is expected to remain seated
 Often runs about or climbs excessively in inappropriate
situations
 Difficulty in engaging in activities quietly.
 Could be described as always on the go as if driven by a
motor
 Often talks excessively
 The quality of the overactivity is disorganized,
haphazard, contextually inappropriate.
Inattention:Difficulty in Sustaining
Concentration due to being highly distractible
Learning skills
Every area of development is affected in terms of
staying on task long enough to take on board and
register what needs to be learnt
 Poor at filtering distractions, attending to work tasks
attention to detail, careless mistakes
 Short term memory processing problems, does not
follow through with tasks,
 Difficulty in sustaining mental effort to a task within their
capability and often fails to complete
 Can seem oblivious and is often day dreaming
 Poor organization of self, tasks and activities
Inattention: difficulty in sustaining
attention, highly distractible
 Social skills difficulties with:
 learning the subtle non-verbal communication skills
so important in maintaining relationships, poor
language skills.
 poor social skills either want to dominate or get
bored with games, peers find them difficult to get on
with and can lead to very low self esteem.
Impulsivity: Acting without thinking of the
possible consequences of their actions
The Dare Devil
 No sense of fear, ADHD children crave attention and
acceptance and can be spurred on to dangerous
acts for peer approval.
Safety
 A real issue for parents as they have to become
hypervigilant in order to prevent their children from
having accidents. Teaching ADHD children road
safety is difficult, as this behaviour requires a
complex sequence of behaviours, which need to be
learnt, understood and acted upon.
Impulsivity: Acting without thinking of the
possible consequences of their actions
 Social Isolation
 constantly interrupting the class activity, butting in,
saying the wrong things without thinking, hitting
other children because they have the urge to, this
causes disasters on the social scene for a child
desperate to make friends.
 These actions are often interpreted as oppositional
and anti-social traits and so the self fulfilling
prophecy begins to take shape.
Diagnosis: ADHD or HK
 1992 Hyperkinetic Disorder in ICD-10 World Health
Organization
 hyperactivity, inattention, impulsivity
 1994 Attention Deficit /Hyperactivity Disorder in
DSM-IV 3 types
i) Predominately Hyperactive-Impulsive type
ii) Predominately Inattentive Type
iii) Combined type
Prevalence
In the US between 5-10% DSM IV
In the UK between 2-5% ICD-10
Gender
Male to Female ratio = 4 to 1
Defining Comorbidity
ADHD is highly comorbid
Comorbidity is defined as two different
diagnoses present in an individual patient
It is important to recognise comorbid
disorders
Comorbidities may require treatment
independent from and different to therapy
for ADHD
To have ADHD alone is rare
Conduct Disorder
Dyslexia
Oppositional
Defiant Disorder
2 to 5 times
Substance Misuse
Dyspraxia
35-45%
33-50%
25-40%
Dysgraphia
increase
6%
Dyscalculia
A.D.H.D.
Bipolar Depression
25%
Anxiety
Depression
Autistic Spectrum
Disorder
20-40%
50-60%
Obsessive
Compulsive
Disorder
Sleep Disorders
Speech &
Language
Disorders
Tourette’s
ADHD: A familial disorder
 Genetic studies have demonstrated that ADHD
impairments are highly familial
 Hereditability cannot account for all ADHD, psychosocial adversity significantly influences the
expression of ADHD symptoms. The additive effect
of multiple stressors e.g. socioeconomic class,
parental psychopathology, foster placement had a
significant impact upon the level of impairment.
Developmental Impact of ADHD
Behavioural
disturbance
Pre-school
Academic problems
Poor with social interactions
Self-esteem issues
Legal issues, smoking
and injury
School-age
Behavioural disturbance
Academic difficulties
Difficulty with social
interactions
Self-esteem issues
Adolescent
Occupational failure
Self-esteem issues
Relationship problems
Injury/accidents
College-age
Adult
Academic failure
Occupational difficulties
Self-esteem issues
Substance abuse
Injury/accidents
The long term outlook
 Criminal activity
 Run away from home (31 vs 16%)
 Breaking and entering (20 vs 8%)
 Fist fighting (74 vs 53%)
 Carrying a weapon (39 vs 11%)
 Fire setting (16 vs 5%)
 Sexual activity
 Age of first intercourse (15.4 vs 16.5)
 Number of sexual partners (18.5 vs 6.5)
 Pregnancies (38 vs 4)
 Drug and substance abuse
 ADHD is not a predictor and in fact when medicated this group has a
lower incidence.
 ADHD plus conduct disorder- 50%+ will abuse
Part 2
Referral
Diagnosis
Medication
Referral, Diagnosis and Medication
How schools can make a referral?
What an ADHD assessment consists of?
Why medication can be useful in the
management of ADHD?
How to make a referral?
Schools can make referrals with the
permission of the parents using the:
The School information form
How a diagnosis is made at the ADHD
Clinic?
 The ADHD Clinic Assessment Protocol.
Information before Appointment.
School information form
The Developmental Questionnaire, (if child under 5 yrs a schedule
of growing skills)
Child’s medical history.
Family Developmental History Form history.
Conners’ Rating Scales, home and school.
Other agencies involved.
Physical examination.
Cognitive assessment.
Other significant conditions and co-morbid conditions
Treatment of ADHD
Medication.
Behavioural Modification.
Family Support.
Brain function in relation to ADHD
 There is no single brain structure for modulating
attention. It is a distributed process subserved
by many brain structures and neural networks,
which need to work together.
 There are a cluster of cognitive functions that
work together called the ‘executive function’. It
is this that connects, organizes, prioritizes and
integrates the whole system.
Brown’s Model of Executive Functions Impaired
by ADHD
Executive Function
Activation
Focus
Effort
Regulating
Organizing
Prioritizing &
Sustaining &
Activating to
Shifting
work
Focus
Alertness
Sustaining
Effort &
Processing Speed
Emotion
Memory
Managing
Utilizing
Frustration &
Working Memory
Modulating
& Accessing
Emotions
Recall
Executive function
Action
Monitoring
& Self-Regulation
of Action
Underlying mechanisms
It is proposed that there is a failure to varying degrees in the
transmission, processing, prioritizing and integration of information
around the neural network of the brain. This would effect for
example:
 Working memory; the ability to hold a small amount of information
in mind whilst carrying out further activities.
 Cognitive flexibility; refers to the ability to shift from one concept to
another or change a course of action or thought depending on the
demands of the new situation.
 Response Inhibition and State regulation;ADHD children appear
poor at inhibiting their responses in fast and slow rates of
presentation but not in medium conditions.
Neural Pathways and Stimulant
Medication
The brains structure is a complex system of
neural networks.
The frequency-modulated nerve impulses that
pass along these networks are the language of
brain function.
Neuro-transmitters provide chemical bridges
between the neurons.
Neural Pathways and Stimulant
Medication
Dopamine acts as a bridge across which the
electrical impulse can cross from one side of the
synaptic space to the dopamine receptors
located on the neural tissue of the next nerve.
Stimulant medications appear to work by
keeping the message carrying dopamine in the
synaptic space longer. The longer the dopamine
is in the space the stronger the circuit on which
the impulse is carried and the better the chance
of connecting.
Neurochemical Pathophysiology
of ADHD
Nerve Impulse
Excess dopamine taken up
to be reused again
Neurotransmitter
Dopamine
Transporter
Synapse
Synapse
Receptors
Receptors
The treatment of ADHD by Stimulant
medication
Methylphenidate (Ritalin) Dexamphetamine
(Dexadrine) belong to a group of drugs known
as psychomotor stimulants. These drugs bring
about change in the dopaminergic systems.
Methylphenidate primarily blocks the reuptake
of dopamine in the synaptic space. This allows
activation of the neural pathway to continue
longer than if the dopamine was not available.
Medications used in ADHD
 Stimulant
Methylphenidate
Short acting: Ritalin, (10mg 20mg) Equasym (5mg 10mg)
Long acting: Concerta XL (18mg 36mg) Equasym XL, (20mg)
Amphetamine Dextroamphetamine
Amphetamine - Short acting: Dexedrine (5mg 10mg)
Atomoxatine Straterra
Anti-depressants
Tricyclics: Imparime
SSRI’s
:
Citalopram
There are side effects to stimulant
medication











Insomnia
Appetite loss
Headaches
Stomach pain
Nausea
Vomiting
Dizziness
Increased blood pressure
Palpitations
Drowsy
Skin reactions









Tearfullness
Irritable
Increased aggression
Becoming withdrawn
Unusually happy
Anxiety/nervousness
Depression
Psychosis (abnormal thinking)
Tourettes (Tics)
Medication Management: the highs and the
lows
The highs: Use of stimulant medication can have a dramatic effect on
ameliorating the core symptoms of inattention, hyperactivity and
impulsivity. Children appear to listen more, comply with requests and
commands, be less forgetful, their quality of school work improves, they
are less irritating and frustrating to others.
The lows:
rebound
7am
8
9
10
11
12
1
2
3
4
5
6
7
The CONCERTA® XL Formulation
Laser-Drilled
Hole
MPH
Compartment
#1
MPH
Overcoat
MPH
Compartment
#2
Tablet
Shell
Push
Compartment