adhd at ipn cme 2010

8/6/2019 adhd at IPN CME 2010

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The Child

Pediatrician

Pediatric

Neurologist

Pediatric

Psychiatrist

Pediatric Orthopedic

Surgeon

Occupational

Therapist

Child Psychologist

and Counselor

Physical

Therapist

Speech

Therapist

Remedial

Educator


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Attention Deficit/HyperactiveAttention Deficit/Hyperactive

DisorderDisorder


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CasesCases

Diagnosis, Not TreatedDiagnosis, Not Treated

Diagnosis, Intermittent therapyDiagnosis, Intermittent therapy

Diagnosis, only Pharmac TherapyDiagnosis, only Pharmac TherapyDiagnosis, No parental/familial SupportDiagnosis, No parental/familial Support

Diagnosis, No Support from SchoolDiagnosis, No Support from School


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AttentionAttention

ConcentrationConcentration

ThoughtThoughtAwarenessAwarenessAbsorptionAbsorption


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DeficitDeficit

ShortageShortage

DiscrepancyDiscrepancyInsufficiencyInsufficiencyScarcityScarcityDearthDearth


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HyperHyper -- activityactivity

OverexcitedOverexcitedJumpyJumpy

TwitchyTwitchyEdgyEdgy

JitteryJitteryAgitatedAgitatedHecticHectic

FrenziedFrenzied

ActionActionMovementMovement

MotionMotionBustleBustle

CommotionCommotion


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DisorderDisorder

Pathological Medical condition/Pathological Medical condition/Ailment/ SyndromeAilment/ Syndrome

Chaos, DisarrayChaos, DisarrayConfusion, Mess, MuddleConfusion, Mess, MuddleTurmoil, Mayhem, BedlamTurmoil, Mayhem, Bedlam

UnrestUnrestAnarchyAnarchy


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AD/HD: A Syndrome/ ConditionAD/HD: A Syndrome/ Condition

in which the common thread ofin which the common thread of InattentionInattention

HyperactivityHyperactivity ImpulsivityImpulsivity

Runs throughRuns through all aspects of a childs lifeall aspects of a childs life

Manifests atManifests at home, school, playhome, school, playDisrupts neurodevelopmental processes,likeDisrupts neurodevelopmental processes,likeSocial Behaviour, Relationships and LearningSocial Behaviour, Relationships and Learning


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Lasts for more than 6 monthsLasts for more than 6 monthsOnset before 7 years of ageOnset before 7 years of age


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Commonest neuroCommonest neuro--behaviouralbehaviouraldisorder of childhood onset: 6disorder of childhood onset: 6 99

% of population% of populationBoys > GirlsBoys > Girls

Persist into adulthood in 60Persist into adulthood in 60--80%80%casescases


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No etiology likely to be found as aNo etiology likely to be found as asingular cause of ADHDsingular cause of ADHD

No Tests that can diagnose coreNo Tests that can diagnose coresymptoms, but only those thatsymptoms, but only those that

rate/evaluate their manifestationsrate/evaluate their manifestations


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Coexisting ConditionsCoexisting Conditions

Disruptive Behavioral Disorders:Disruptive Behavioral Disorders:Oppositional Defiant DisorderOppositional Defiant Disorder

Conduct DisorderConduct Disorder> Substance Abuse/ Anti Social> Substance Abuse/ Anti SocialBehaviorBehavior

Anxiety disordersAnxiety disordersDepressive DisordersDepressive DisordersLearning DisabilitiesLearning Disabilities

WORSENSPROGNOSIS AND OUTCOMEWORSENSPROGNOSIS AND OUTCOME


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Associated conditions to beAssociated conditions to be

consideredconsideredTuberous sclerosisTuberous sclerosisNeurofibromatosisNeurofibromatosisTourette syndromeTourette syndrome

Primary MicrocephalyPrimary MicrocephalyClosed head injuryClosed head injury

Autistic spectrum disordersAutistic spectrum disorders


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DiagnosisDiagnosis


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Physical examinationPhysical examinationVision, Hearing, NeurologicalVision, Hearing, NeurologicalIllness, Allergy, MalnutritionIllness, Allergy, MalnutritionAge and level of intelligenceAge and level of intelligence

SocioSocio--EconomicEconomic--Cultural issuesCultural issuesParenting PatternsParenting PatternsP

sychologists assessment and ratingP

sychologists assessment and rating

DiagnosisDiagnosis


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Diagnosis:Diagnosis: DSM IVDSM IV

Functional impairmentFunctional impairment necessary fornecessary forDiagnosis:Diagnosis:

Academics and school functioningAcademics and school functioningFamily relationshipsFamily relationshipsPeer relationshipsPeer relationships

Self esteem and self perceptionSelf esteem and self perceptionAccidental injuriesAccidental injuriesOverall Adaptive functioningOverall Adaptive functioning


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ManagementManagement


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MTA StudyMTA Study

579 children with AD/HD579 children with AD/HD

aged 7 to 10 yearsaged 7 to 10 years

Randomly assigned to receive one of fourRandomly assigned to receive one of fourtreatments:treatments:

medicationmedication management;management;

intensiveintensive behavioralbehavioral treatment;treatment;

combinedcombined medication management andmedication management andbehavioral treatment; orbehavioral treatment; or

standardstandard community carecommunity care..

"TheMultimodal Treatment Study ofChildren with Attention Deficit"TheMultimodal Treatment Study ofChildren with Attention Deficit

Hyperactivity Disorder," also known as theM

TA study, NIM

HHyperactivity Disorder," also known as theM

TA study, NIM

H


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Results:Results:

All 4 groups showed sizable reductions inAll 4 groups showed sizable reductions in

symptoms over time, with significantsymptoms over time, with significant

differences among them in degrees ofdifferences among them in degrees of

change.change.


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Children in theChildren in the combined treatmentcombined treatment andand

medicationmanagementmedicationmanagement groups showedgroups showed

signficantly greater improvement thansignficantly greater improvement than

those giventhose given intensive behavioral treatmentintensive behavioral treatment

alonealone andand community carecommunity care..


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CombinedCombined vsvs MedicalMedical

Children who receivedChildren who received combinedcombinedtreatmentstreatments orormedication managementmedication managementalonealone did not differ significantly on anydid not differ significantly on anydirect comparisons, but in severaldirect comparisons, but in severalinstances,instances, combined treatmentcombined treatment provedprovedsuperior tosuperior to intensive behavioral treatmentintensive behavioral treatmentalone and/oralone and/orcommunity carecommunity care whilewhilemedication management alone did not.medication management alone did not.


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Combined therapy:Combined therapy:

Improvements in other areasImprovements in other areas

including less anxiety,including less anxiety,

better academic performance, andbetter academic performance, and improved parentimproved parent--child relations and socialchild relations and social

skills.skills.

ADHD plus CoADHD plus Co--morbid conditions such asmorbid conditions such as

conduct disorder or anxietyconduct disorder or anxiety


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Key MessageKey Message

ADHD is a component of most developmentalADHD is a component of most developmental

problemsproblems

Children with ADHD, with or without other coChildren with ADHD, with or without other co--

morbid conditions, have difficulty in visual motormorbid conditions, have difficulty in visual motorintegration and handwritingintegration and handwriting

ADHD as hyperactivity/ impulsivity/ inattention /ADHD as hyperactivity/ impulsivity/ inattention /

features or all 3, but not as an exclusivefeatures or all 3, but not as an exclusive

disorder, needs intervention as a primary stepdisorder, needs intervention as a primary step

for further developmental interventionfor further developmental intervention


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Intervention hasIntervention has 22 AspectsAspects ::

PHARMACOLOGICALPHARMACOLOGICAL

NONNON--PHARMACOLOGICALPHARMACOLOGICAL (BEST)(BEST)

Promoting appropriatePromoting appropriate BehaviorBehavior

EducationalEducational accommodationsaccommodationsSupportSupport services for children andservices for children and

parentsparents

TrainingTraining


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StimulantsStimulants

Effect :Effect : focus attention (increase onfocus attention (increase on--task behavior)task behavior)

curb impulsivity and restrain hyperactivitycurb impulsivity and restrain hyperactivity

At School:At School:Decrease interrupting and fidgetingDecrease interrupting and fidgeting

At Home:At Home:Improve parentImprove parent--child interaction and compliancechild interaction and compliance

MethylphenidateMethylphenidate:: duration of clinical action is 3 to 4 hrsduration of clinical action is 3 to 4 hrs

Dosage: 5 mg three time dailyDosage: 5 mg three time daily

Not to be given below 6 yearsNot to be given below 6 years


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AtomoxetineAtomoxetine

Non stimulant, nor epinephrine reuptakeNon stimulant, nor epinephrine reuptake

inhibitor; blocks the presynaptic norepinephrineinhibitor; blocks the presynaptic norepinephrine

transporter in the prefrontal cortextransporter in the prefrontal cortex

Beyond 6 yrsBeyond 6 yrs

Dosage:Dosage: 0.5 mg/kg/day0.5 mg/kg/day once or twice daily.once or twice daily.

increased toincreased to 1.2 mg/kg/day1.2 mg/kg/day in 2 weeks.in 2 weeks.

peak efficacy: over 2 to 6 weeks.peak efficacy: over 2 to 6 weeks.Effects more gradual than those with stimulantEffects more gradual than those with stimulant

medications.medications.


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Efficacy:Efficacy:

Similar to stimulantsSimilar to stimulants

Efficacy forEfficacy forADHD plus coADHD plus co--occurringoccurring

diso

rdersdiso

rders anxiety, tics, and depression.anxiety, tics, and depression.

normal growth in height and weightnormal growth in height and weight

no abuse liability and is available OTC

no abuse liability and is available OTC


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AA combinationcombinationof stimulants and nonof stimulants and non

stimulants might be very helpful instimulants might be very helpful in

refractory cases of ADHD.refractory cases of ADHD.


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DietDiet

OmegaOmega--3 fatty acids3 fatty acids,, zinczinc andand

magnesiummagnesium may have benefits withmay have benefits with

regards to ADHD symptoms, but noregards to ADHD symptoms, but noconclusive evidence exists to supportconclusive evidence exists to support

the same.the same.


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Intervention may haveIntervention may have 22 AspectsAspects ::

PHARMACOLOGICALPHARMACOLOGICAL

NONNON--PHARMACOLOGICALPHARMACOLOGICAL (BEST)(BEST)

Promoting appropriatePromoting appropriate BehaviorBehavior

EducationalEducational accommodationsaccommodationsSupportSupport services for children andservices for children and

parentsparents

TrainingTraining


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I. Educational AccomodationsI. Educational Accomodations

Classroom

Environment

Classroom

Environment

Curriculum DesigningCurriculum Designing


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FOCUS

CHILD

CLASS ROOM


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INTEGRATES

..

CHILD

DEVELOPMENT

perceptions of the individuals in the childs environment

shape the content of what is taught, learned, and valued


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Classroom ManagementClassroom Management

Stable instructional regimenStable instructional regimen

Schedule matching physiological needsSchedule matching physiological needs

Monitoring students attention behaviours

Monitoring students attention behavioursAssistance cardsAssistance cards Please help mePlease help me

Please continue workingPlease continue workingStudy BuddyStudy Buddy


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Classroom ManagementClassroom Management

Do not useDo not use sarcasmsarcasmDo not keep away from othersDo not keep away from others unlessunless

necessarynecessaryWork inWork in groupsgroups of different numbersof different numbersMake sureMake sure cuescues given are discreetgiven are discreet

Train floatingTrain floating peer tutorspeer tutorsTeachTeach Time ManagementTime Management


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Curriculum InstructionCurriculum Instruction

Appropriate levelsAppropriate levels

Differential learning stylesDifferential learning styles

Study skills & organizational skillsStudy skills & organizational skillsFlow chartsFlow charts -- during teachingduring teaching

-- during evaluationsduring evaluations

Think AloudThink AloudWritten notesWritten notes


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Curriculum InstructionCurriculum Instruction

Lesson MenuLesson Menu -- Work AccommodationsWork Accommodations

To Do ListTo Do List

Wide range of T L AidsWide range of T L Aids

Divide large assignments into smallerDivide large assignments into smaller

unitsunits

Be clearBe clear

Realistic expectationsRealistic expectations -- Sure SuccessSure Success


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II. PromotingII. PromotingAppropriateAppropriate BehaviorsBehaviors

External ControlsExternal Controls

SelfManagementSelfManagement


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Token ReinforcementToken Reinforcement

Social ReinforcementSocial Reinforcement

Response CostResponse Cost

Time OutTime Out


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Prepare aPrepare a Game PlanGame PlanAvoid mixed messagesAvoid mixed messages

Be consistentBe consistentNo reprimand for their deficitsNo reprimand for their deficitsInclude the child in the patternInclude the child in the pattern

Frequent remindersFrequent remindersFlexibilityFlexibility


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LAADLAAD

LListenisten

AAcknowledgecknowledgeAAgreegree

DDeferefer


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MetaMeta--Cognitive StrategyCognitive Strategy

AA--AwareAware

RR-- ReRe--do/ readdo/ read

CC-- ContinueContinue


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SelfManagement.SelfManagement.

SelfSelfCueingCueing

SelfSelfMonitoringMonitoring

SelfSelfPraisePraise


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III. Support ServicesIII. Support Services

The key notes..The key notes..

FFind outind outAAdaptdapt

CCollaborateollaborateEEmpowermpower


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IV TrainingIV Training

Heterogeneous groupHeterogeneous groupOne size will not fit allOne size will not fit all

No sure fire method!


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Time to pause..Time to pause..

All behavior = context x purposeAll behavior = context x purpose

Mismatch between classroom environmentMismatch between classroom environment

and students needsand students needs

Empower Ourselves!Empower Ourselves!


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ManagementManagement

Psychological management shouldPsychological management should

be the first movebe the first moveP

ositive interactions between parents and childP

ositive interactions between parents and childIncentive schemes,home point systems,star charts,materialIncentive schemes,home point systems,star charts,materialawardsawardsStructured ignoring in the form of time out etcStructured ignoring in the form of time out etc


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OUTCOMESOUTCOMES

ADHD ~ IndisciplineADHD ~ Indiscipline

ADHC ~ Scholastic BackwardnessADHC ~ Scholastic Backwardness

ADHD ~ Difficult ChildADHD ~ Difficult Child


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DiscipliningDisciplining vsvs CommunicationCommunication

DiscipliningDiscipliningConsistencyConsistency

ImmediacyImmediacy

ReasonabilityReasonability

CommunicationCommunication

ClarityClarity FocusFocus

One to OneOne to One


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SummarySummary

Corporal punishmentCorporal punishment

rather than teaching a child to avoid certainrather than teaching a child to avoid certainbehaviorsbehaviors

teaches the child to avoid and fear certainteaches the child to avoid and fear certain

PEOPLE.PEOPLE.


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The negative valence of the punishmentThe negative valence of the punishment

is never associated with the act foris never associated with the act for

which it was delivered,which it was delivered,

but becomes associated, rather,but becomes associated, rather,

with the person delivering thewith the person delivering the

punishment.punishment.


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This ensures aThis ensures a total breakdown of alltotal breakdown of allfurther communication,further communication, and perhapsand perhapsrepetition of the defiant behavior,repetition of the defiant behavior,

A N D . . . .A N D . . . .


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Look for the causes of theLook for the causes of the

behavior; dont penalize the onebehavior; dont penalize the one

whos behaving that way.whos behaving that way.

Look for the writer of the script;Look for the writer of the script;

dont penalize the actors.dont penalize the actors.


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Arrest the driverArrest the driver --

Dont smash the car.Dont smash the car.

LeAVe Us kIDs AlOnE !LeAVe Us kIDs AlOnE !


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Feedback, Please!Feedback, Please!

[email protected] Horizons Child Development Centre,New Horizons Child Development Centre,

GoregaonEast, Mumbai 400 063.GoregaonEast, Mumbai 400 063.

T: 98200 26503, 657 11 586T: 98200 26503, 657 11 586


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Thank You!Thank You!


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Thank You!Thank You!


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Wat is ADDWat is ADD

ManaementManaement

DianosisDianosis At homeAt home

In scoolIn scool

In te clinicIn te clinic

Pitfalls in DianosisPitfalls in Dianosis

Multifactorial model of managementMultifactorial model of management

Manaement in clinicManaement in clinic

At omeAt ome

At scoo;lAt scoo;l

Medical manaementMedical manaementSocialManaementSocialManaement

Attitude of parents, rteacers oter LDsAttitude of parents, rteacers oter LDs

Failure of managgement: Kids/Parents/Teachers..doctors?Failure of managgement: Kids/Parents/Teachers..doctors?

adhd at ipn cme 2010

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