ADHD

1. ADHD Dr S.L Seape By Dr S.L Seape

2. Phil, stop acting like a worm The table is no place to squirm This speaks father to his son Severely says, not in fun Mother frowns and looks around although she doesn’t make a sound But Phillip will not advice he’ll have his way at any price He turns and turns, he wriggles & jiggles here and there on the chair Phil, these twists I can not bear.

3. ADHD – NO SMALL MATTER 32 – 40 % 70 – 80 % Underachieve Teen Pregnancy School drop out Depression Drug, alcohol and tobacco abuse. Speed and Motor Vehicle Accidents. Endanger their lives 40 % 20 – 30 % Also Associated with

4. ADHD – NO NEW MATTER Sir Alex Crichton 1763-1856-a Scottish physician. In 1798 described Disease of Attention “the incapacity of attending with a necessary degree of constancy to any object” “it becomes evident at a very early period of life and has a very bad effect, but it seldom is to so great a degree as to totally impede all instruction and what is fortunate is, it generally diminishes with age”.

5. ADHD – NO NEW MATTER Dr. Heinrich Hoffman 1809-1894 German physician - Wrote poems for kids - Protagonist was Fidgety Phillip See the naughty restless child growing still more rude and wild till his chair falls over quite Phillip screams with all his might catches at the cloth but then That makes matters worse again. Down upon the ground they fall glasses, plates, knives, forks and all. How mamma did fret and frown when she saw them tumbling down.

6. ADHD – NO NEW MATTER 1902- Sir George F Still British paediatrician Describe what is now ADHD “serious problems with sustained attention and self-regulation, showed little inhibitory volition excessively emotional or passionate could not learn from the consequences of their actions though their intellect was normal and defiant and resistant to disciple.”

7. DIAGNOSIS Who Should Diagnose • Child and adolescent psychiatrist • Neuro developmental paediatricians • Paediatric neurologist • GP & paediatricians with special interest in ADHD Associated myths • ADHD is a made-up diagnosis • Due to bad parenting • Can be diagnosed by EEG • M > F • Sole treatment is medication

8. THREE CLUSTERS OF SYMPTOMS First cluster- Inattention i. abnormally short concentration span ii. frequent resistance to sustained mental effort especially with boring repetitive tasks iii. Easy distractibility iv. marked forgetfulness v. tendency to loose things vi. difficulty organizing tasks, with poor planning vii. not listening properly to instruction viii. A tendency to rush work, giving poor attention to detail and making frequent careless mistakes ix. Often not completing tasks

9. THREE CLUSTERS OF SYMPTOMS Second Cluster :Hyperactivity i. constantly on the go ii. runs about or climbs excessively iii. restless, unable to stay seated iv. fidgets excessively excessively talking vi. plays loudly

10. THREE CLUSTERS OF SYMPTOMS Third Cluster: Impulsivity i. Often interrupts or intrudes on others ii. Can not wait his/her turn iii. Blurts out answers

11. DIAGNOSTIC PROCESS TO INCLUDE 1 2 Must interview child, especially re-subjective distress Collect info from as many sources as possible Observing child at work and play Use of scales – Connors Assessment Copeland Checklist 3 4 5

12. CONNORS ASSESSMENT CHILD’S NAME: …………………………… SCHOOL: …………………………… GRADE: …………………………… TEACHER’S/PARENTS NAME ……………………………

13. COPELAND CHECKLIST Name of child: ____________________________________________________________ Completed by: ___________________________________________________________ • Directions: Place a checkmark (✔ ) by each item below, including the degree to Which the behavior is characteristic of you child/ student.

14. CONFOUNDING VARIABLES 1. Temperament 1. Classroom 2. Social function 3. Distress and demoralization 2. Reification • Mood • Sensitivity • Distractibility • Activity level • Falsely calling something and entity when it is not • Areas of Impairment • Very important in early school where foundation skills are learned • Impaired secondary to hyperactivity and impulsivity

15. CONTRIBUTING CAUSES AND RISK FACTORS Heritability Neuroscience – 2 most important neuro transmitters are norpinephrenine, NE and dopamine DA Dopamine receptor transport DRT 7 repeat allele Most kids with 7R are ADHD

16. CONTRIBUTING CAUSES AND RISK FACTORS Environmental factors Prenatal – Smoking in pregnancy. - Alcohol consumption in pregnancy. -Maternal stress. Perinatal -prematurity with birth complications. -decrease blood flow to brain. Medical causes-epilepsy, encephalitis, HIV other congenital and genetic conditions.

17. ATTACHMENT -Close emotional bonds of affection which develop between baby and primary care giver. -Not bonding –bonding from mother to baby and instantaneous. -Attachment is in the baby and develops overtime. -Attachment has time period – should have been happening by 18/12. -Secure attachment needs consistency of primary care giver and caregiver to be in tune with child’s needs, i.e attention, affection and stimulation. -Important for child to feel valued sees others as good. -Offers protection in later life situations. -Offers capacity for steady relations.

18. Expressed emotion -Emotional milieu of the home Interaction of nurture & nature Orchids and dandelions Genetic volume - methylation

19. DIFFERENTIAL DIAGNOSIS • Great Smoky Mountain Study. • 57% of prescribed did not meet criteria. • 4% of unaffected got medication. • 72% of those meeting criteria were not getting medication.

20. 1. Anxiety often overlooked for ADHD 2. Depression 3. Bipolar Mood Disorder Shared symptoms irritability, hyperactive, poor impulse control, distractibility 4. Learning Disorder 5. Problems of executive function -Planning -Prioritizing - Delayed gratification 6. Medical Reductionism

21. COMORBIDITY – Very Common • RAD – • Reactive Attachment Disorder • Excessive exposure to severe conditions • They remain restless, fidgety and impulsive for ever • 2. Adjustment Disorder • After exposure to trauma, for about 3 months, have symptoms which include inattention, restless • should not continue for greater than 6, if the trauma stops

22. OTHER IMPORTANT FEATURES • Poverty • not many referrals from poorer communities • Race & ethnicity • Less numbers picked up in poorer areas • Gender Differences • Old notion was that male is greater than female, but actually similar • girls less hyperactive • Girls have different comorbidity- ↑ mood & anxiety

23. PREVENTION • Primary prevention 1. Education re-dangers in pregnancy 2. Attachment 3. Most important-good antenatal classes • Mothers and fathers to attend • Parenting skills • Stresses in pregnancy • Mother going back to work • Identifying post natal depression • Issues of outsourcing helpers 4. Turn off the TV -nil before 2 yrs. – no more than 2 hours/day thereafter • no direct contact with humans • decreased attachment • No stimulation at most important time in development • No waiting so impulsivity & poor self control of ADHD

24. PREVENTION Secondary Prevention 1. Parental training American National Institute of mental health study. 2. Exercise and cognitive stimulation.

25. PREVENTION Dietary strategies No scientific studies 1. Restrictions diet 2. Food colorants& artificial foods 3. Fish oils –omega 3 4. Many others –no sugar

26. PREVENTION Medication • Must be well considered • correct diagnosis Medication • 1937 Charles Bradley, USA paediatrician. Benzedrine an ampheltamine (Treating headache, kids improve behavior and academic performance) • Arithmetic pills  • 1944 Leandro Panizzon-Chemist • Synthesized methylphenidate for low BP for wife-Marguerite, • Nickname was Rita!!, so the drug became Ritaline

27. PREVENTION • 1954-Ritalin registered by Ciba Geigy (for chronic fatigue, Mild depression, narcolepsy) • Ritalin • 1963-Ritonic registered for children by Ciba Geigy • Methylphenidate and vitamins hormones for children  • 1963-first trails of Ritalin for hyperkinetic reaction-unequivocal results

28. STIMULANTS • Block Dopamine Transporter Protein therefore 1.Methylphrenidate • Ritalin • Concerta Ritalin effective 4-6 hrs. Ritalin LA effective 6-8 hrs Concerta effective 10hrs. • Favorable side effects profile • Not addictive • Non sedating • Improve attention, improve behaviour Reduce restlessness, forgetfulness • Improve ability to relate socially • Improve confidence & self esteem

29. NON STIMULANTS Similar to stimulants, improve executive function i. Atomoxetine • Strattera • Work 24 hrs • Important in anxiety ii. Antidepressants • Imipramine, amytryptiline, venlafaxine • Long acting • Can use in under 6 yrs. • Important in anxiety • Important in comorbidity iii. Antihypertensive • Clonidine • Controls impulsivity • Helps with sleep • Mostly used in combination with stimulants

30. SIDE EFFECTS • Stimulants • Headache, abdominal discomfort & decreased appetite • Stunting of growth, discontinued if serious, greater than 1cm/yr of expectation • Weight loss • Careful in epilepsy • Sudden death – lower than reported • Emotional – sullen, zombie, depressed • Suicidal thinking - Minor and no reported completed suicide • Rebound effects – tearful as medication wears off / in afternooncounter with eating a snack

31. SIDE EFFECTS Anti Depressants -Sedating -Dry mouth -Constipation -Increased heart rate -Blurred vision -Urinary retention NB - Fatal in overdose Atomoxetine -Headaches -GI symptoms & heartburn -Sedating Cloridine -Sedating, confusion, light headedness and headaches

32. PRESCRIBING • Prepare child • Time to effect • Full effect • Side effects • Duration of treatment • Engage adjunct treatment & skills • e.g. • OT - gross motor, fine motor, visual spatial sensory processing • Psychologist – IQ assessment • Remedial teacher - asindicated • Speech and language therapist - linguisticability, auditory perceptual disorder • Social worker - family disruption, family help

33. ADULT ADHD • All children grow • Many missed in childhood Consider if one is disorganized • Always late • Overwhelmed, can not remain calm • Disorganized • Forgetful

34. FOUR SYMPTOM CLUSTERS IN ADULTS • Sustained attention • Inhibiting behavior and emotional regulation • Resisting distraction • Regulating level of activity

35. COMMON SYMPTOMS IN ADULTS 1. Inattention • Concentration and focus • Easily disrupted by irrelevant sights and sounds • Can’t complete tasks • Overlook details • Poor listening skills • Move from activity to the next • Zoning out • Become bored • Hyper focus

36. COMMON SYMPTOMS IN ADULTS 2. Inhibiting behavior • Can’t inhibit behavior, comments, responses, act without thinking of consequences, • Interrupts others • Addictive tendencies • Act recklessly and spontaneously without regard • Can’t delay gratification • Irresponsible behavior e.g fast reckless driving, promiscuous sex, gambling and drug taking 

37. COMMON SYMPTOMS IN ADULTS 3. Resisting Distraction • Disorganized& forgetful • Chaotic life • Can not sift important information • Can not prioritize • Can not keep up with tasks and responsibilities • Loses things • Underestimates time • Chronically late • Forget appointments, meetings and commitments

38. COMMON SYMPTOMS IN ADULTS 4. Hyperactivity & Restlessness • not like children • have increased energy, fidgety, on the go • often feeling of inner restlessness and agitation • risk taking • easily bored • racing thoughts • craving excitement

39. COMMON SYMPTOMS IN ADULTS 5. Emotional difficulties • Can’t manage feelings • Poor frustration management • Irritable with mood swings • Can’t stay motivated • Short, explosive temper • Insecure

40. Effects in Adults Physical & Mental • Compulsive eater • Substance abuse • Anxiety • Depression • Poor self-care Work & financial • Career difficulties & underachievement • Can’t keep a job, not meeting deadlines • Can’t follow cooperative rules • Unpaid bills, lost paperwork and impulsive spending

41. Effects in Adults Relationships • They are a strain – work, home, family • Often fed up • Embarrassment, frustration, disappointment, loss of confidence But, can be: • Very creative • Passionate • Lots of energy • Out of the box thinking • Original ideas

42. Strategies for Adults i. Psycho education ii. Psychological techniques iii. Medication iv. Identify co-existing conditions v. lifestyle change • regular exercise, sleep hygiene, avoidance of substances, routines, balanced diet • time management vi work on relationship

43. We are not like the rest,Yet we desire to do our best.Not meaning to disappoint or anger,We want you to love and accept her,Right where she is at,But not because of obedience, no, not that.My brain chemistry is very different,My Dopamine non-existent.Please, it’s not our fault,and it often sends us into a downward catapult.Is there a Monster under his bed?No, but there is one is his head,Telling him he is stupid and bad,and that he is nothing but a Discipline case to his Dad.We want to BE like everyone else,Honest, it’s true. -GingerSnaap

44. Thank You!