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What is ADHD? ADHD is now considered a neurodevelopmental disorder (DSM 5) rather than a behavior disorder (DSM IV) and affects both children and adults.
- Individuals with ADHD have difficulties with maintaining attention, executive function (or the brain's ability to begin an activity, organize itself and manage tasks) and impulsivity. **- Can also have hyperactivity but not always.
- It is described as a "persistent" or on** -going pattern of inattention and/or hyperactivityimpulsivity that gets in the way of daily life or typical development. - ADHD is found in all social classes and cultures around the world.
Types of ADHD?
- Inattentive Type: Easily distracted and bored, trouble completing tasks. More common in girls. No longer referred to as ADD. 20-30% of children with ADHD do NOT present with significant hyperactivity. - Hyperactive -Impulsive Type: Difficulty sitting still, always on the go, impatient, blurt things out. More common in boys. **- Combination type
- Symptoms can change over time.**
How does ADHD present in kids?
- These kids are often labelled as "trouble makers" or classroom disruptors. **- Often don't follow directions so presents as defiance
- Due to impulsivity, they get called out in class.
- Have trouble switching focus from something they like** to the next - Also have trouble making and keeping friends - Can focus during new settings, 1:1 interactions or during activities they like.
How does this effect executive functioning?
**- Adaptable thinking: Can be rigid thinkers, panic when rules/ routines change
- Planning: Have difficulty prioritizing tasks and following directions
- Organization: Have trouble organizing their thoughts
- Time Management: Have trouble completing tasks on time, submit things before the** deadline **- Working Memory: Forget what they just heard or read
- Self Control: Become too emotional and fixate on things, respond impulsively**
Causes?
- Genetics: Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. - Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several
**- "I'm not smart. I'm a failure. I don't belong"
- Girls with ADHD are significantly more likely to** experience major depression, anxiety and eating disorders. - Girls with combined -type ADHD have significantly higher rates of attempted suicide and self harm (Hinshaw, 2012)
How is it diagnosed? No single test can diagnose a child as having ADHD.
- Instead, a specialized mental health clinician needs to gather information about the child, and his or her behavior and environment. - A family may want to first talk with the child's pediatrician of GP initially but prior to medications should ensure they are seen by Specialized Mental Health Clinician.
Diagnosing ADHD?
- The mental health clinician may be a psychiatric nurse, a psychologist, a social worker or psychiatrist. **- The school will also be consulted also to gather collateral information.
- Consider getting teachers, coaches, and parents to complete ADHD rating scales.
- Children tend to under report symptoms so can't rely on self report.**
- Consider normal development i.e. It is developmentally appropriate for toddlers to be impulsive, get distracted, restless and display an abundance of energy. **- Misdiagnosis is a problem (if child is bipolar, stimulants can trigger a manic episode).
- Trauma in early childhood can look exactly like ADHD.**
Parts of the diagnosis? Clinical Interview Teacher Report ADHD Symptoms checklist Impairment Rating Scale Physical Exam
DSM-5 criteria?
Rule out medical causes?
**- First check if the child has:
- undetected seizures that could be associated** with other medical conditions - a middle ear infection that is causing hearing problems **- any undetected hearing or vision problems
- any medical problems that affect thinking and** behavior - any learning disabilities
- Health Canada has not approved ADHD medications for children under the age of six years old. An ADHD medication treatment trial for a child five years old or younger is "off-label" use and should be initiated or monitored by a specialist. - For elementary school aged children (6 -11 years of age): First line treatment = FDA approved medication for ADHD and /or behavioral interventions including Collaborative Problem Solving, preferably both. - For adolescents (12 -18 years of age): First line treatment = FDA approved medication for ADHD with the consent of the adolescent - May prescribe behavior therapy in addition to medication
Non pharmacological treatment?
- Increase the structure in the child's environment (schedules & routines are important). **- Encourage parents to teach organizational skills (check lists).
- Parents to give one direction at a time as these kids can't multi** -task initially. - Parents need to learn to be less reactive and more pro -active (e.g. giving them warnings before switching tasks). **- Use alarms to help them keep track of time.
- Ensure a regular sleep schedule
- Positive praise helps with low self esteem. Look for things they are doing** well. **- Behavior management with focus on positive reinforcement.
- Practice mindfulness, yoga, and coordinated physical activity.**
- Use visual aids, planners, timers, etc.
Parent education?
**- ADHD is a neurobiological condition with a strong genetic etiology
- It is NOT associated with lower intelligence levels.
- It is NOT caused by bad parenting.
- 65% of children not now outgrow ADHD and it will continue into adulthood.** Hyperactivity does decline with age. **- Stimulant medication is not addictive or related to future addiction.
- Stimulants may exacerbate tics but they don't cause them. -** It is safe to stop stimulants abruptly.
Exercise treatment?
- Betsy Hoza, PhD, professor of psychology at the University of Vermont conducted a study and found significant improvements in cognitive functioning with as little as 30 min a day of moderate to vigorous exercise. - Exercise is not recommended as a substitute for evidence -based treatments such as stimulants, but as an additional part of the treatment plan. - Be aware that many competitive sports may lead to increased stress so consider what activities best suite your child's personality.
Dr ross green?
- According to Dr. Ross Greene, working with
Two main classes of stimulants: Methylphenidate based and Amphetamine based
80% chance the child will see improvement in symptoms with stimulants
At therapeutic doses, these drugs also do not sedate or tranquilize children and do not increase the risk of addiction.
Example of stimulants?
**- Adderall (Short or long acting (XR) amphetamine)
- Concerta (long acting methylphenidate)
- Dexedrine (short or long acting amphetamine)
- Daytrana (extended release skin patch:** methylphenidate based) - Quillivant XR (extended release liquid formulation
- methylphenidate based) **- Ritalin (methylphenidate)
- Vyvanse (long acting amphetamine)**
Side effects of stimulents? Decreased appetite (weight loss) & sleep problems. We give these medications after meals.
A consistent sleep routine that includes relaxing elements like warm milk, soft music, or quiet activities in dim light, may also help. Some children also report mild stomach aches, nausea or headaches. Most side effects are minor and dose dependant. Growth issues: Known to cause stunted growth particularly in boys but taking 'drug holidays' reduces this effect.
Some children develop sudden, repetitive movements or sounds called tics. Changing the medication dosage may make tics go away. Some children also may have a personality change, such as appearing "flat" or "zombie-like" Rebound Effect: Children have an adverse reaction of aggression and irritability when the short acting stimulants wear off.
Non stimulent medication?
- Guanfacine & Clonidine (Alpha Adrenergic Agonists) originally used to lower BP but often used as adjunctive therapy with stimulants. Considered as second or third line compared to stimulants or for those with Tourette's. - Atomoxetine (Strattera) also approved by FDA for tx of ADHD. Norepinephrine Re-uptake inhibitor. Also has side effects (abd pain, sleeplessness)
inabilities to self-regulate lie at the root of many challenges faced by individuals with ADHD. He explains that individuals with ADHD may be unable to delay responses, thus acting impulsively and without adequate consideration of future consequences―beneficial or negative. o 4 Executive Functions o 1. Working Memory- remember past experiences and use these experiences to plan for the future. o 2. Internalized Speech- Children with ADHD have difficulty organizing and directing their behavior, following rules, and obeying others' instructions. Surroundings largely dictate actions o 3. Emotion Regulation o 4- Creative Problem Solving
Prevalence rate of ADHD for Children and adults - ANSWER - Prevalence rate for Children and Adolescents is 8.5% (Muthen & Muthen, 2000).
- Among adults, the prevalence of ADHD is 4-5% ( Barkley & Mash, 2014).
- Prevalence was highest in SA (11.8%) and Africa (8.5%) and lowest in the Middle East (2.4%).
- Use of stimulant medications is 2x higher or more in the United States.
- Male preponderance in Childhood: 2:1 or higher, ratio drops to 1.6:1 by adulthood (Barkley & Mash, 2014).
- Show comparable levels of impairment in academic and social functioning, but girls with the disorder may have greater intellectual deficits (Gaub & Carlson, 1997).
- Girls with ADHD show patterns of impairment in executive functioning and cognitive control similar to their male counterparts (Barkley & Mash, 2014).
- Increased risk for Bulimia, anxiety, depression among girls and woman with ADHD than among males with the disorder.
- Males with ADHD are more likely to engage in antisocial acts, engage in substance use, and risky driving.
Sleep Problems associated with ADHD - ANSWER o Sleep related involuntary movements o Teeth grinding
o Sleep talking o Restless sleep o Parasomnias o Sleep walking o Night wakings o Sleep terrors o Dyssomnias o Bedtime resistance o Sleep-onset difficulties o Trouble with waking in the morning o All three can exacerbate daytime inattention and overactivity in children
Impact on Motor Coordination, Academic Functioning, Social Problems - ANSWER o 60% of Children with ADHD may have poor motor coordination or developmental coordination disorder. o Exhibit sluggish gross motor movements and some difficulties in fine motor coordination o Underproductivity o Score lower on standardized achievement tests. o 45% of children with ADHD qualified for a diagnosis of a learning disability (Barkley & Mash, 2014). o Inattention dimension of ADHD is more closely associated with academic achievement problems than is the hyperactive-impulsive dimension. o Higher prevalence of speech and language disorders has been found in children with ADHD. o Deficiencies in both fluid and crystalized intelligence have been noted o Inattention more associated with peer neglect o Hyperactivity/impulsivity more associated with peer rejection o Children with ADHD:
degree relatives. o Heritability of ADHD is about .70. o Concordance between Monozygotic twins is .5 to .8; concordance between dizygotic twins is .33. o Children who are born prematurely or who have markedly lower birth weight are at high risk for later hyperactivity or ADHD (Barkley & Mash, 2014). o Mothers of children with ADHD who conceive at younger age, may experience greater risk of adversity during pregnancy. o Season of a child's birth was significantly associated with risk for ADHD- viral infections (winter months) o Teratogens increase risk for ADHD- Alcohol exposure in utero
the results of the MTA study and what it entailed - ANSWER o Randomized controlled trial (N =579 children with ADHD) o Medication alone. Youths in this group received 14 months of medication, usually methylphenidate, which was carefully administered by researchers. o Behavior therapy alone. Youths in this group participated in 8 months of clinical behavior therapy during part of the academic year and an STP during the summer. These youths did not receive medication. o Combined treatment. Youths in this group received both medication and behavior therapy, both administered by the researchers. o Community care. Youths in this group were referred to mental health professionals (e.g., physicians, psychologists) in their communities. They were free to receive any treatment recommended by these professionals, but they did not receive treatment from the researchers. Most children who received community care (67%) were prescribed medication. Youths in this group served as a "treatment as usual" control condition.
