ADHD Community Paediatric perspective

1. ADHD Community Paediatric perspective Marguerite Dalton March 2012

2. DSM IV • I. Either A or B: • A - Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level:

3. Inattention • Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. • Often has trouble keeping attention on tasks or play activities. • Often does not seem to listen when spoken to directly. • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). • Often has trouble organizing activities. • Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). • Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). • Is often easily distracted. • Is often forgetful in daily activities.

4. Hyperactivity – Impulsivity • B . Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

5. Symptoms Hyperactivity • Often fidgets with hands or feet or squirms in seat when sitting still is expected. • Often gets up from seat when remaining in seat is expected. • Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). • Often has trouble playing or doing leisure activities quietly. • Is often "on the go" or often acts as if "driven by a motor". • Often talks excessively. Impulsivity • Often blurts out answers before questions have been finished. • Often has trouble waiting one's turn. • Often interrupts or intrudes on others (e.g., butts into conversations or games).

6. DSM IV criteria cont. • II. Some symptoms that cause impairment were present before age 7 years. • III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). • IV. There must be clear evidence of clinically significant impairment in social, school, or work functioning.

7. DSM IV cont. • V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

8. DSM IV cont. • Based on these criteria, three types of ADHD are identified: • IA. ADHD, Combined Type: if both criteria IA and IB are met for the past 6 months • IB. ADHD, Predominantly Inattentive Type: if criterion IA is met but criterion IB is not met for the past six months  • IC. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion IB is met but Criterion IA is not met for the past six months.

9. Common Scenarios

10. Joshua Joshua is 3 - he has just started kindy he won’t sit still for mat time He is always on the go He won’t share toys He only wants to play outside He climbs all over the furniture He won’t settle to sleep for afternoon nap Is this ADHD?

11. Callum • Callum is aged 8 • Behind peers with school work • Doesn’t have many friends • Interrupts teacher in class • Disruptive in classroom • Never finishes work • Can’t sit still • Is this ADHD?

12. Others? • Teenagers • Adults

13. Behaviour in context Developmental Environmental ( different settings) Expectations Genetic Medical issues ( diet / allergy/ medication etc.)

14. Information • School / kindy report • Past history • Social history • Family history • General health • Developmental history • What has been tried before

15. Screening • PEDS – available from healthed • SDQ – www.sdqinfo.org

17. Strengths and Difficulties Questionnaire P or T For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please give your answers on the basis of the child's behaviour over the last six months or this school year. Child's name .............................................................................................. Male/Female Date of birth........................................................... Considerate of other people's feelings □ □ □ Restless, overactive, cannot stay still for long □ □ □ Often complains of headaches, stomach-aches or sickness □ □ □ Shares readily with other children, for example toys, treats, pencils □ □ □ Often loses temper □ □ □ Rather solitary, prefers to play alone □ □ □ Generally well behaved, usually does what adults request □ □ □ Many worries or often seems worried □ □ □ Helpful if someone is hurt, upset or feeling ill □ □ □ Constantly fidgeting or squirming □ □ □ Has at least one good friend □ □ □ Often fights with other children or bullies them □ □ □ Often unhappy, depressed or tearful □ □ □ Generally liked by other children □ □ □ Easily distracted, concentration wanders □ □ □ Nervous or clingy in new situations, easily loses confidence □ □ □ Kind to younger children □ □ □ Often lies or cheats □ □ □ Picked on or bullied by other children □ □ □ Often volunteers to help others (parents, teachers, other children) □ □ □ Thinks things out before acting □ □ □ Steals from home, school or elsewhere □ □ □ Gets along better with adults than with other children □ □ □ Many fears, easily scared □ □ □ Good attention span, sees work through to the end □ □ □ Signature ........................................................................... Thank you very much for your help Parent / Teacher / Other (Please specify): Date ...........................................................................

18. Diagnosis • History • Conners Rating Scales-Revised (CRS-R): C. Keith Conners,PhD psychcorp.pearsonassessments.com

19. Management • Family support and education • Behavioural • Educational • Support groups • Medication

20. Family Context • Parenting tips – including routines, sleep, diet etc. • Parenting courses – local , Plunket, Incredible years, Triple P positive parenting, Mellow parenting….

21. School • SENCO • RTLB • Specific programmes such as PMP

22. Medication 1 • Methyphenidate – • Different preparations • Different formulations – IR, SR , sustained release, LA

23. Medication 2 • Clonidine • Dexamphetamine • Atomoxetine

24. Follow up • Monitoring for side effects - b.p., weight loss ( appetite suppression) , growth , sleep issues, tics, mood disturbance • 3 monthly • Jointly with specialists • ?trial off • ?adulthood/ transition

25. Co-morbidities / associations • Dyslexia/ dyspraxia • ASD • Trisomy 21 • ID • Prematurity

26. Asperger’s syndrome Real or not? Dr. Marguerite Dalton March 2012

27. ASD / Asperger’s syndrome Spectrum of disorders ? Disorder for life?

28. Historical • Kanner 1943 – “early infantile autism” • Hans Asperger- Austrian Psychiatrist- 1944 “autistic psychopathy” – now termed Asperger’s syndrome- similarities – argument still continues as to whether they are separate entities

29. Differences

30. Motor development • Autistic ( Kanner) – good fine motor but poor gross motor • Asperger – poor gross and fine motor – diagnostic?

31. Speech • Autistic – delayed or non-verbal • Asperger’s - may appear normal initially – “talk like little adults”

32. Age of presentation • Autistic – early childhood / infancy • Asperger’s – early/late childhood

33. Severity of impairment • Autistic - more severe • Asperger’s - less severe

34. Intelligence • Initial descriptions suggest Autistic lower but not necessarily accepted now.

35. Similarities

36. Restricted or fixed interests • Repetitive or stereotype behaviour • Repetitive speech or echolalia • Hypo or hyper sensitivity to sensory input • Problems with social – emotional reciprocity • Problems with non-verbal communication • Problems developing and maintaining relationships appropriate to normal developmental level

37. DSM • IV – Autism and Aspergers separate categories • V - under same category as general consensus is that they are ends of the same spectrum , similar symptomatology , varying in severity.

38. Does it matter? • Labelling - what is in a name? • Funding • Coding • Research

39. Associations • Learning difficulties • Epilepsy • Sleep disturbance • Gut problems • Fragile X • Prematurity • Trisomy 21 • Tuberous Sclerosis

40. Life long diagnosis? • Personality or condition?

41. Genetics • Will this be the answer?