WHAT IS ADHD?WHAT IS ADHD?

Alicia PorterAlicia Porter

CASE HISTORYCASE HISTORY

Jimmy prematurely born, crying at night, far Jimmy prematurely born, crying at night, far more active, climbing, ignorant of danger, more active, climbing, ignorant of danger, needs constant supervision, difficult, needs constant supervision, difficult, fightingfighting

Ignores formality of class or teachers social Ignores formality of class or teachers social requests, pleased to get negative attention, requests, pleased to get negative attention, silly noise making, motor driven, academic silly noise making, motor driven, academic failure, class clown failure, class clown

German book 1863, Describes German book 1863, Describes ADHDADHD

Phil stop acting like a wormPhil stop acting like a wormThe table is no place to squirmThe table is no place to squirm……But Phillip will not take adviceBut Phillip will not take adviceHeHe’’ll have his way at any pricell have his way at any priceHe wriggles and jigglesHe wriggles and jigglesHere and there on the chairHere and there on the chairPhil these twists I cannot bearPhil these twists I cannot bear

SOME FACTSSOME FACTS

ADHD is one of the most common ADHD is one of the most common childhood conditionschildhood conditionsAffects 3Affects 3--5% of school age children5% of school age childrenDiagnosed 4 times more often in boys than Diagnosed 4 times more often in boys than girlsgirlsADHD runs in families. There is evidence ADHD runs in families. There is evidence that the principal cause is geneticthat the principal cause is geneticADHD often coexists with other behavioral ADHD often coexists with other behavioral disorders, learning or language disorders, disorders, learning or language disorders, and anxiety disordersand anxiety disorders

ADHD is a syndrome of inattention, ADHD is a syndrome of inattention, hyperactivity and impulsivity. hyperactivity and impulsivity. To meet criteria for the diagnosis of To meet criteria for the diagnosis of ADHD the problems need toADHD the problems need to

Be more severe than expected in Be more severe than expected in children of that age and level of children of that age and level of developmentdevelopmentBe present before age 7Be present before age 7--( although ( although many children are not diagnosed until many children are not diagnosed until they are older than 7 when their they are older than 7 when their behaviors cause problems in school and behaviors cause problems in school and other places)other places)Be present for at least 6 monthsBe present for at least 6 monthsBe present in 2 or more settingsBe present in 2 or more settingsBe genuinely disruptive to the childBe genuinely disruptive to the child’’s s everyday performance and wellbeing everyday performance and wellbeing

What causes ADHD?What causes ADHD?

The cause is unknown.The cause is unknown.Contributing factorsContributing factors-- prenatal toxic prenatal toxic exposure, prematurity, prenatal mechanical exposure, prematurity, prenatal mechanical insult to the fetal nervous system.insult to the fetal nervous system.Food additives, colourings, preservatives Food additives, colourings, preservatives and sugar have been proposed as causes and sugar have been proposed as causes but no scientific evidence to support this.but no scientific evidence to support this.Genetic FactorsGenetic FactorsDevelopmental FactorsDevelopmental FactorsNeurochemical FactorsNeurochemical FactorsNeurophysiological FactorsNeurophysiological FactorsPsychosocial FactorsPsychosocial Factors

Symptom criteria for ADHDSymptom criteria for ADHD

InattentionInattentionDoes not pay attention to detailsDoes not pay attention to detailsHas difficulty sustaining attention at schoolHas difficulty sustaining attention at schoolDoes not seem to listen when spoken toDoes not seem to listen when spoken toDoes not follow through on instructions or Does not follow through on instructions or finish tasksfinish tasksHas difficulty organising tasks and activitiesHas difficulty organising tasks and activitiesAvoids, dislikes or is reluctant to engage in Avoids, dislikes or is reluctant to engage in tasks that require sustained mental efforttasks that require sustained mental effortOften loses thingsOften loses thingsIs easily distractedIs easily distractedIs forgetfulIs forgetful

HyperactivityHyperactivity

Often fidgets with hands or feet or squirmsOften fidgets with hands or feet or squirms

Often leaves seat in classroom or Often leaves seat in classroom or elsewhereelsewhere

Has difficulty playing quietlyHas difficulty playing quietly

Often on the go, acting as if driven by a Often on the go, acting as if driven by a motormotor

Often talks excessivelyOften talks excessively

Often runs about and climbs excessivelyOften runs about and climbs excessively

ImpulsivityImpulsivity

Often blurts out answers before questions Often blurts out answers before questions are completedare completed

Often has difficulty awaiting his/her turnOften has difficulty awaiting his/her turn

Often interrupts or intrudes on others.Often interrupts or intrudes on others.

DiagnosisDiagnosis

There must be evidence of clinically significant There must be evidence of clinically significant impairment in social and academic functioningimpairment in social and academic functioning

Identifying ADHD should include bothIdentifying ADHD should include both--::A high severity or frequency of symptomsA high severity or frequency of symptomsInterference by these symptoms in the Interference by these symptoms in the functioning of the child at home, at school, functioning of the child at home, at school, with friends, or elsewherewith friends, or elsewhere

The diagnosis requires that the childThe diagnosis requires that the child’’s behavior is s behavior is inappropriate for his/her ageinappropriate for his/her ageParental checklists and accounts from teachers are Parental checklists and accounts from teachers are valuable to confirm the diagnosisvaluable to confirm the diagnosis

DiagnosisDiagnosis

A Full Assessment includes:A Full Assessment includes:Interview with parents or primary Interview with parents or primary caregivercaregiver

Interview with childInterview with child

Contact with school or preschoolContact with school or preschool

Physical examination including a vision Physical examination including a vision and hearing checkand hearing check

No specific laboratory tests are specific No specific laboratory tests are specific for ADHD. CT scan and EEG are not for ADHD. CT scan and EEG are not routinely done in ADHD unless routinely done in ADHD unless specifically indicated.specifically indicated.

CoCo--morbid conditionsmorbid conditions

Conduct DisorderConduct Disorder-- 2020--40% of ADHD children 40% of ADHD children develop conduct disorder.develop conduct disorder.Learning DisordersLearning Disorders-- 2020--30% of ADHD children 30% of ADHD children also have a specific learning problem.also have a specific learning problem.Oppositional Defiant DisorderOppositional Defiant Disorder--1/31/3--1/2 of all 1/2 of all children with ADHD have ODD. These children are children with ADHD have ODD. These children are defiant, stubborn, nondefiant, stubborn, non--compliant, argue with adults compliant, argue with adults and refuse to obey.and refuse to obey.Anxiety and DepressionAnxiety and Depression-- May also be present in a May also be present in a child with ADHD. Low self esteem and insecurity child with ADHD. Low self esteem and insecurity develops as a result of failure at school and develops as a result of failure at school and interpersonal relationships.interpersonal relationships.Tourettes SyndromeTourettes Syndrome--Small proportion of children Small proportion of children will have this neurological disorder characterised by will have this neurological disorder characterised by nervous tics and repetitive mannerisms.nervous tics and repetitive mannerisms.

TreatmentTreatment

1.1. PharmacotherapyPharmacotherapy2.2. Psychosocial Psychosocial

InterventionIntervention3.3. EducationEducation4.4. DietDiet

PharmacotherapyPharmacotherapy

Medication may provide symptomatic relief Medication may provide symptomatic relief of the symptoms of inattention, of the symptoms of inattention, hyperactivity, impulsivity.hyperactivity, impulsivity.

They do not cure ADHDThey do not cure ADHD

Medication options available in SA for Medication options available in SA for ADHD areADHD are

METHYLPHENIDATE METHYLPHENIDATE (Ritalin)(Ritalin)ATOMOXETINE (Stratera)ATOMOXETINE (Stratera)

METHYLPHENIDATEMETHYLPHENIDATE

Most common medication prescribed for Most common medication prescribed for ADHDADHD

Different preparations availableDifferent preparations available

Immediate releaseImmediate release-- takes effect 20takes effect 20--30mins after administration and lasts for 30mins after administration and lasts for approx 3approx 3--4 hrs and is usually taken 24 hrs and is usually taken 2--3 times 3 times a daya day

Long actingLong acting--lasts 6lasts 6--8 hours8 hours

Extended releaseExtended release-- Once daily dosing and Once daily dosing and lasts 12 hrslasts 12 hrs

Common Side EffectsCommon Side Effects

Stomach acheStomach ache

Appetite loss Appetite loss

Increased anxietyIncreased anxiety

Mild irritabilityMild irritability-- ‘‘rebound effectrebound effect’’

HeadacheHeadache

InsomniaInsomnia

Growth may be affectedGrowth may be affected

AtomoxetineAtomoxetine

1/3 of children with ADHD will not respond 1/3 of children with ADHD will not respond to methylphenidate or have intolerable side to methylphenidate or have intolerable side effects.effects.

Atomoxetine is an alternative.Atomoxetine is an alternative.

Maximum effect after 4weeks although Maximum effect after 4weeks although some effect after 1 week.some effect after 1 week.

Safe and well tolerated and the incidence Safe and well tolerated and the incidence of adverse effects is lowof adverse effects is low

Common Side EffectsCommon Side Effects

GIT upsetGIT upset-- abdominal pain, nausea etc.abdominal pain, nausea etc.

Decreased appetiteDecreased appetite

SomnolenceSomnolence

DizzinessDizziness

HeadachesHeadaches

Pruritis and other dermatological sidePruritis and other dermatological side--effectseffects

Monitoring of Methylphenidate Monitoring of Methylphenidate and and

AtomoxetineAtomoxetine

Baseline workBaseline work--up and followup and follow--upupPhysical examinationPhysical examinationBlood pressureBlood pressurePulsePulseWeightWeightHeightHeight

Other OptionsOther Options

Buproprion (Wellbutrin)Buproprion (Wellbutrin)

Venlafaxine (Effexor)Venlafaxine (Effexor)

Clonidine (Catapress)Clonidine (Catapress)

SSRISSRI’’s, antis, anti--psychotics and mood psychotics and mood stabilisers can be used in combination with stabilisers can be used in combination with stimulants and other to address co morbid stimulants and other to address co morbid conditionsconditions

Psychosocial TreatmentsPsychosocial Treatments

Medication alone is not enoughMedication alone is not enough

Evaluation and treatment of co morbid Evaluation and treatment of co morbid conditionsconditions

Psycho education of child and parentsPsycho education of child and parents

Inform child about the purpose of Inform child about the purpose of medicationmedication

Psychosocial TreatmentsPsychosocial Treatments

Social skills groupsSocial skills groups

Parent trainingParent training

Behavior management trainingBehavior management training

SchoolSchool--based performance or behavior based performance or behavior programmesprogrammes

Duration of TreatmentDuration of Treatment

Length of treatment is not fixed in advanceLength of treatment is not fixed in advance

May need to be continued for several yearsMay need to be continued for several years

A common mistake is to stop treatment A common mistake is to stop treatment prematurelyprematurely

Medication should be stopped periodically Medication should be stopped periodically to see how the child gets on without it.to see how the child gets on without it.

ConclusionConclusion

Medication is the most effective Medication is the most effective treatment for ADHDtreatment for ADHD

Where medication is used, it Where medication is used, it should be combined with should be combined with structured advice, support and structured advice, support and behavioral programmesbehavioral programmes