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ATTENTION DEFICIT HYPERACTIVITY DISORDER

Dr Tsui Kwing Wan Senior Medical Officer

Department of Paediatrics and Adolescent Medicine Alice Ho Miu Ling Nethersole Hospital!

Objectives

1. Define the scope ADHD in school age children

2. Is ADHD a real disorder ()?

3. Medical management of ADHD

4. Helping students in ADHD in school, from perspectives of a Paediatrician

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Identify the right subject first 1. Not pay attention, daydreaming and easily distracted 2. Fidgety and restless; leave seat inappropriately; running and

jumping in corridors 3. Not listening and difficult to follow instructions 4. Fail to start work and cannot complete assigned tasks 5. Blurting into conversation and calling out 6. Frequent missing of needed items, e.g. completed homework,

memo, stationery and own belongings!7. Unpopular for their irritating and intrusive behaviours; conflicts

with peers; and even bully 8. Erratic academic performance; committing many careless mistake

and impulsive in answering question 9. Lagging behind in academic performance and important skills

Common reasons of academic underachievement / behavioral problems

1. Sensory deficit (hearing and vision)

2. Receptive / expressive language disorder

3. Anxiety 4. Specific learning disorder 5. Intellectual disability 6. Autism spectrum disorder 7. Oppositional defiance

disorder / Conduct disorder 8. Attention-deficit /

hyperactivity disorder 9. Developmental coordination

disorder 10.Physical health problems, e.g.

chronic illness 11.Other mood problems 12.Not motivated

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ADHD Historical Timeline

1900 1955 1960 1980 1987 1994 2000 2013

Dr George Still first described

ADHD symptoms!

MPH!

ADHD!(DSM-III-R)!

Attention deficit disorder +/-

hyperactivity!DSM-III!

Minimal brain dysfunction!

DSM-IV!Update criteria!

DSM-IV-TR!

DSM-V!Update criteria!

EPIDEMIOLOGY ADHD is among one of the most common neurobehavioural problem in children Prevalence:

" US: 7.2% at age 8 (Kashani et al, 1989) DSM III, 5-8% of childhood population (AACAP,1997)

" 4.4% of Adults in US, DSM IV (Kessler et al, 2006) " Hong Kong:

q 6.1% DSM III, 8.9% DSM III-R (Leung et al,1996) q 3.9 % in grade 7, 8 and 9 students (Leung et al, 2008)

" Male to female ~ 4:1!

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DSM IV Diagnostic Criteria for ADHD

Symptoms criteria!6/9 for inattention and / or

hyperactivity!(at least six months)!

Pervasiveness!Two or more settings!

Impairment!Onset!

Before 7 years of age!

ADHD!

INATTENTION (DSM IV) 1.Often fails to give close

attention to details or makes careless mistakes in schoolwork, work, or other activities

2.Often has difficulty sustaining attention in tasks or play activities

3.Often does not seem to listen when spoken to directly

4.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)

5.Often has difficulty organizing tasks and activities

6.Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

7.Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)

8.Is often easily distracted by extraneous stimuli

9.Is often forgetful in daily activities !

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HYPERACTIVITY / IMPULSIVITY (DSM IV) 1.Often fidgets with hands or

feet or squirms in seat 2.Often leaves seat in classroom

or in other situations in which remaining seated is expected

3.Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

4.Often has difficulty playing or engaging in leisure activities quietly

5. Is often on the go or often acts as if driven by a motor

6.Often talks excessively 7.Often blurts out answers

before questions have been completed

8.Often has difficulty awaiting turn

9.Often interrupts or intrudes on others (e.g., butts into conversations or games)

CLINICAL FEATURES OF ADHD DSM IV

" 9 Inattention criteria (at least six), maladaptive and impairing " 9 Hyperactivity / Impulsivity criteria (at least six), maladaptive

and impairing) " Symptoms persist for at least six months " Before 7 years old " 2 or more settings, e.g. home and school / work

(pervasiveness) " Significant impairment in academic, social and occupational

functioning " Not caused by other conditions!

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EXCLUSIONS

1. Pervasive Developmental Disorder (not present in new DSM V diagnostic criteria)

2. Schizophrenia, or other Psychotic Disorder

3. Other mental disorders, e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder

New DSM V Criteria Published last year

Major changes

Age of onset increased to 12 years

Allow diagnosis in children with autism

Specify current subtypes / in partial remission / current severity

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Is ADHD a real disorder?

Story of a hunter

Co-existing disorders (co-morbidities)

Adverse consequences

Neurobiological base

CO-MORBIDITIES OF ADHD Up to 2/3 of children with ADHD has comorbidities 1.Oppositional defiant

disorder 2.Fine motor and

coordination problem 3.Tics and Tourette

syndrome disorde 4.Anxiety disorder 5.Sleep disturbance

6.Depressive disorder 7.Conduct disorder 8.Learning disabilities 9.social and

communication problems

10.Substance abuse

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What causes ADHD

Genetics

Environment

Brain structure

Neuropsychological

NEUROBIOLOGY OF ADHD - GENETIC

Genetic and environmental

Twin studies - concordance rates of ADHD in monozygotic and dizyotic twins

" mean heritability is estimated to be 76% for children and adolescents

Adoption studies - ADHD rates was found to be greater in biological relatives of ADHD children than in adoptive families!

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NEUROBIOLOGY OF ADHD - ENVIRONMENTAL

1.Maternal stress

2.Prenatal exposure to tobacco and alcohol

3.Low birth weight / prematurity

4.Neonatal anoxia and seizure

5.Brain injury

6.Exposure to toxins, lead and polychlorinated biphenyl

7.Psychosocial adversity and high level of family conflict

8.Inconsistent parenting

9.Early institutional deprivation!

G x E

Manifestation of ADHD is a result of interaction between genetic and environmental influences.

Genetic factors predispose an individual to adverse prenatal and later life circumstances; contribute more to the development of behavioural symptoms in a context of high environmental adversity. (Hicks et al. 2009)!

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Brains in ADHD

Involved areas including frontal and parietal cortexes, basal ganglia, cerebellum, hippocampus and corpus callosum.

Longitudinal studies showed developmental delay of cortical thickness in ADHD

fMRI study showed decreased connectivity in a fronto-striato-parieto-cerebellar network; which was normalised by methylphenidate.!

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Delayed cortical development

Shaw et al. 2007

FUNCTIONAL MRI Placebo!

Methylphenidate!

BJ Casey, et al. New potential leads in the biology and treatment of attention deficit-hyperactivity disorder. Current Opinion in Neurology 2007;20:119- 124 !

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NEUROCOGNITIVE MODEL

Dual pathway model of ADHD

Links inattention and deficits in executive functions to impairments in prefrontal-striatal circuits; whereas

Hyperactivity to dysfunctions of reward response and motivation, related to frontal-limbic system.!

EXECUTIVE FUNCTIONS Involve

" Self-regulation (monitoring and checking) " Flexibility in thinking / Shifting " Impulse control / Response inhibition " Emotional control " Planning / Prioritizing " Organisation " Task initiation " Accessing working memory

Allows a person to think about oneself, what may happen in future and how one can influence it !

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Outcome of children with ADHD

14%!

34%!

22%!

26%!

55%!

21%!

68%!

42%!

1%!

15%!

10%!

1%!

23%!

78%!

100%!

13%!

0%! 10%! 20%! 30%! 40%! 50%! 60%! 70%! 80%! 90%! 100%!

Ever convicted*!

Ever arrested*!

3 or more car accidents*!

Parent at early age!

Fired from employment!

Enrolled in College!

Graduated high school!

Retained in grade!

Control!

ADHD!

Pediatrics, August 2011; *Psych Res, May 2011

FRAMEWORK OF EVALUATION Full clinical and psychosocial assessment

" meeting criteria in DSM-IV " At least moderate impairment in psychological,

educational or social aspects " Cross domains

Assessment of co-existing condition (developmental / mental), familial and school conditions; Physical health; Understanding of patients and familys needs.!

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Investigations Questionnaires

CBCL, SDQ, SWAN and Conners rating scale Judicious use of questionnaires not diagnostic , serves as screening tools

Blood tests are not needed most of time EEG for suspected epilepsy, e.g. absence

seizure Brain scan not indicated unless brain lesion is

suspected!

Age!

Demands!

Ability!

Ability!

Behavioral Intervention!

Drugs!

When to treat

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A 14-MONTH RANDOMIZED CLINICAL TRIAL OF TREATMENT STRATEGIES FOR ATTENTION-

DEFICIT/HYPERACTIVITY DISORDER, 1999 Multimodal Treatment of Attention-Deficit Hyperactivity Disorder

" Six independent research teams " 579 children with ADHD (combined type)

Treatment groups " Medication management " Intensive behavioural therapy " Combined (medication with intensive behavioural

therapy) " Community care!

MTA STUDY Implication, 1999 Combined (group 3) and Medication Mx (group 1) outcomes did not differ in degree of improvement of core ADHD symptoms Taking into consideration that vast number of patients with ADHD have comorbidity, use of combined provides additional benefits. Proportion of children have a restoration to normal or near-normal functioning:

" Combined group 68% " Medication group 56 % " Behavior group 34 % " Community group 25 %

Factors for success of MTA trial: " Self-selection process highly motivated " Good compliance with intervention " Quality of intervention " Education of peers and family!

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Effects of ADHD Medications

Consistently significant effect on core symptoms (inattention, hyperactivity and impulsivity)

Believe to have no direct effect on cognition, learning and achievement !

ADHD Medications

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ADHD Medications

AVAILABLE DRUG FOR ADHD IN HONG KONG

CNS stimulant Methylphenidate (active ingredient) " Ritalin 10 mg (short acting) " Ritalin LA 20 mg (intermediate acting) " Concerta 18mg, 27mg, 36mg and 54mg (long acting)

Non-stimulant - Atomoxetine

" Strattera 10mg, 18mg, 25mg, 40mg (atomoxetine)

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Duration of action

CHOICE OF DRUGS

First line: Rilatin / Ritalin LA

Second line: Rilatin LA, Concerta, atomoxetine (good for child with anxiety and tics)

Drug Holiday not advisable for short holiday or at weekend

Cost concern

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RITALIN Short acting methylphenidate

Rapid absorption, onset of action ~ 30 minutes

Last ~ 4 hours, needs to be taken 2 to 3 times a day (morning, lunch and after school)

May be Used in conjunction with intermediate / long acting drug

Compliance problems, in particular at lunch hour!

RITALIN LA Intermediate acting, last 8 hours

Each capsule contains half immediate-release beads and half as enteric-coated, delayed-release beads

Onset of action similar to Ritalin

Less peak and trough fluctuation

May need pm dose of short short acting methylphenidate after school

Only 20 mg capsule available in HK !

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CONCERTA Long acting methylphenidate

Onset ~ 30 minutes (coated with immediate release methylphenidate)

Last up to 12 hours after single dose

Advantages: decrease stigma and improved compliance; less drug level frustration

Disadvantages: Cost; if side effects emerge, they may extend later into the day!

SIDE EFFECT OF METHYLPHENIDATE Linearly associated with dose Usually mild and most patients can tolerate after short period

of time. Decreased appetite, insomnia, anxiety, irritability and

emotional liability in more than 50 % Abdominal pain and headache 1/3 Slight increase in heart rate and blood pressure, clinically

insignificant Mood disturbance, tics, anxiety, nightmares and social

withdrawal less frequent Behavioural / mood rebound Risk of abuse is not proven!

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Strategies to reduce side effects of stimulants

1. Verify side effect is medication related

2. Brief trial off medication 3. Try a lower dose 4. Administer the medication

with meal 5. Use long acting preparation,

if problems with peaks 6. Use short acting preparation

if problem with appetite at lunch

7. Encourage trial off medication (over weekend or summer)

8. Treat side effect 9. Placebo trial 10.If side effect only seen on

Monday, change from 5 day/week to 7 days/week dosing regime to reduce frustration in drug level

11.Change to non-stimulant !

Story of a driver

He has the brake and steering wheel but no one ever taught him how to drive!

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Management overview

Parents education! Parenting skills! Structured environment

!

Choice of drugs! Monitor response and

side eects !

Positive reinforcement! Rewards! Limit setting and

consequence! Organization skill! Social skills !

Structured setting! Academic support! Organization skill! Social skill !

Educational support!

Psychosocial intervention /

Behavioral therapy!

Family support!

Medication Management!

School Based Intervention - Benefits

1. Schools are ideal setting for implementation of effective intervention as these are normal environment of the children with easy access;

2. Benefits from a more structured and predictable classroom setup (environment);

3. Provide clear behavioural rules and a system of consequences that can be consistent in all areas of school;

4. Aims at preventing or minimizing academic, social and behavioural problems;

5. To provide success experiences for cultivation of self confidence and esteem

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Targeted problem areas for students with ADHD in school

1. Noncompliance; difficulty following rules and directions, discipline problems

2. Easily distracted and off task 3. Disorganized, loses things 4. Task initiation difficulties 5. Difficulty making transitions 6. Low rate of work completion, inability to complete timed tests / exam

Poor note taking and test taking skills 7. Poor hand writing 8. Academic performance below ability level 9. Weak emotion and anger control; difficult to socialise and cant keep

friends

Psychosocial interventions Inconsistent performance

child knows how to perform but not consistent in outcome

environmental adaptation and accommodation

Lack of skills

child does not yet possess the skills

provide direct instruction and increase opportunities!

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School accommodation Modified seating arrangement, sitting closer to teacher

and away from sources of distractions (windows, doors and other children with attention problems);

Better to work in smaller groups Provide attention cue by the teachers, e.g. good eye

contact Check school diary for completeness (providing a buddy) Reduce workloads Provide an Extended time for tests Allow to take tests / examinations in a quiet room Provide buddy!

BEHAVIOURAL INTERVENTION (THERAPY) Designed to affect antecedents and / or consequences of

behaviours Positive Reinforcement focus on appropriate behaviours Token economy Daily report card promotes family-school collaborations Self-management in older children to improve on-task

behaviour, academic accuracy and organisational skills. Social skills and anger control training Organisational skills training Homework strategies need parents education and support Praise Praise Praise!

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Is the child lazy? Not motivated; often reluctant to initiate tasks and

procrastinate Questions to ask:

1.Does the child know what to do? 2.Does child know how to do? 3.Is the child easily frustrated? 4.Does the child lack motivation?

Give cue or checklist, avoid perception of challenges, include kids interests and hobbies, provide choices, offer a reward and PRAISE!

Ways to improve learning 1. Clear and concise instructions, which is limited to as

few as possible 2. Break down works in small steps; to complete easier

step first 3. Incorporate short breaks in between lengthy task 4. Use of timer for transitions and completion 5. Use multi-sensory approach, providing auditory and

visual illustrations through various means 6. Use lists, daily report cards and charts to aid

organisation!

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Ways to improve behaviours 1.Clear and specific rules 2. Involve the student in the management plan 3.Minor disruptions are best ignored 4.Manage transition times, e.g. recess and lunch hour 5.Target a specific areas of weakness, executive dysfunction 6.Frequent use of praise and rewards (specific and immediate;

be sincere and not overdo) 7.Catch opportunities for social skill training 8.Punishment should be brief and given calmly, for specific

misbehaviour and involve a reminder of the required task.!

Unique features of school children with ADHD in NTEC (HK)

1. Both parents are working or one of parents in Mainland cannot provide direct supervision and lack of quality time with children

2. Cared by grandparents consistent parenting cannot be carried out effectively due to different upbringing experience and cultural background.

3. Diversity of cultural background and educational attainments among parents / carer some of them are not able to assist children on homework or revision, especially English, lack of academic support at home

4. Private tutorial class after-school almost as norm training of tutors and quality of academic support varies and may not able to provide most appropriate support for children with SEN.

5. Too many extracurricular activities after school unstructured after-school routine, and late homework time;

6. Work till late at night lack incentive to complete tasks and no drug cover at late evening

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School-Family-Hospital as partners

1.Mutual sharing of knowledge 2.Maintain good communications, e.g. parents as

bridge, questionnaires and direct contact 3.Drug supervision in school 4.Streamline the interventional programs provided

in different settings (school, home and hospital) to minimize duplication

5.

Conclusions 1.ADHD is a real neurodevelopmental problems with

strong neurobiological base. 2.It is a chronic disability and leads to long term

adverse consequence if untreated. 3.Medication and psychosocial interventions have

been proven effective. 4.School is an ideal setting to support children to deal

with their academic and social difficulties. 5.Treatment goal: change repeated failures to

frequent successes, no matter how trivial they are.

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THANK YOU