ADHD (ATTENTION DEFICIT HYPERACTIVITY DISORDER)

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ADHD, AD/HD, ADD

A neurobehavioral D: affects children, teens, adults.

>15 million Americans are affected. x 3 in males

3 features:

• Inattention

• Hyperactivity

• Impulsivity

–more frequent-severe than seen in ones peers

3 subtypes

• Inattentive type (formerly ADD): not hyperactive; usually don't disrupt the class

• Hyperactive/Impulsive type: fidgety and can't control their impulses

• Combined type (commonest)

Usually starts not before 7

… fidgety; can't control their impulses

Who are those children

• Are restless, disobedient, untidy

• Have poor schooling, - performance

• Are embarrassing for parents

• Have few friends, poor social relation

• Not intellectually retarded. Not violent

• Struggle with low self-esteem, failed career, broken marriage, etc

Cause is unknown

Genetics

• ADHD tends to run in families

Neurotransmitters

• Imbalance of NTs

Environment

• Smoking in or complications from pregnancy, delivery, or infancy

5-9.% of U.S. SCHOOL children have ADHD

Inattention

• No sustained attention, careless mistakes, losing things, forgetfulness, poor listening, easy boredom

• Can't follow tasks/instructions. Poor organization

• Avoids tasks requiring sustained mental effort

• Easily distracted

Symptoms typically interfere with his/her functioning in social and academic setting

Symptoms may persist into adulthood

Often fails to give attention to details; careless mistakes

Often has difficulty sustaining attention in tasks or play

No sustained attention

has trouble listening, following directions

Often does not seem to listen

Typically Dx at 5 or 6y, but SS start much earlier

Often not follows through on instructions, though understands

Often has difficulty organizing tasks and activities

Often avoids, or is reluctant to engage in schoolwork/HW)

Often loses necessary things

Often easily distracted by extraneous stimuli

Often forgetful in daily activities

Hyperactivity

• Fidgeting/squirming, difficulty seating still, inappropriate running/climbing

• Difficulty with quiet activities, “on the go”, talkative

• Dash around, touching or playing with anything and everything in sight

Symptoms may persist into adulthood

Often fidgets with hands or feet or squirms in their seat

Often runs or climbs excessively which it is inappropriate

Often has difficulty playing or engaging in leisure activities quietly

Often talks excessively

Symptoms of Impulsivity

• Blurting out answers, can’t wait for turn: very impatient

• Intrusive: often interrupts others

• Inappropriate comments, show emotions without restraint, act without regard for consequences

Often blurts out answers before the question is completed

Often experiences difficulty awaiting his/her or her turn

Often interrupts/intrudes on others (butts into conversations/games)

How Do I Know If My Child Has ADHD?

• Many ADHD symptoms are normal in childhood; majority

typically outgrown. Other conditions may have these. So,

very detailed evaluation is needed. But don't delay! Early

Dx can improve social and academic success

Symptoms must be

– ≥6 for 6 mo in >1 settings (home, school, community)

– started <7 y of age

– inconsistent with the age and severe enough to

interfere with social or academic functioning

… severe enough to interfere with social or academic functioning

Diagnosis

• Clinical. Varies P2P

• No single test

• Dx criteria: must have ≥6 symptoms x 6 mo in at least 2 settings: home, school, society

– must cause significant impairment in functioning

– Cannot be better explained for another disorder

Dx by exclusion

Early Dx can improve social and academic success

DD

• Depression, anxiety disorders, mania

• Others: epilepsy, lead toxicity, deafness, liver D, OSA, drugs, head injury

What Should I Do if …?

• Talk to pediatrician for evaluation and involve

various disciplines for

– comprehensive medical,

developmental, educational and

psychosocial Rx

• Early recognition is key to Rx

Treatment

Medications

• Relieve SS of ADHD, but don't cure! may not be

right for all, may be a part of a total Rx

• Stimulants: methylphenidate, dextroamphetamine,

lisdexamfetamine

• Non-stimulant: atomoxetine

• Antidepressants: bupropion, desipramine,

clonidine, guanfacine

• may take several weeks for full effect

No antipsychotic!

Parenting a ADHD child is a special challenge!

Set Clear Rules and Expectations

• These are essential in both school and at home

• Post the rules for the home

• Provide fair and consistent rewards and consequences for these rules

• The aim is behaviour modification

.. fair and rewards and consequences for these rules

Give Clear Instructions

• Not vague! "clean up your mess" or "play nicely“. Say: "please put dirty clothes in the bowl," “put toys back on shelves,“ "let's allow your friend to have a turn for the toy"

• Let your child repeat the instructions back to you

• Use calm and clear voice and kind eye contact

• Break down larger tasks into simple steps

“put all toys back on shelves“

Discipline, Rewards, and Consequences

• They respond better to rewards and consequences

• Reward good behaviors with praise or special time with you or outing or favorite activity. Offering foods or toys not ideal

• It's best to reward and praise than negative comments: smile and say, "I liked your HW" or "you did a great job clearing the table”

"I liked your HW"

Consequences (contd.)

• These can include time-outs. It is essential that these occur immediately for a negative behavior

• are to be fair, fit, consistent, predictable

• ideally should be explained in advance

• But events like holidays or BD should never be withdrawn

It is essential that these occur immediately after negative behavior

time-outs.

Use Time-Outs Effectively

• Particularly for children, time-outs can be effective

• Time-outs not last longer in minutes than the

child's age in years (5-min for a 5-y-old)

• Longer time-out is too difficult (defiance)

A time-out is an immediate consequence

Ignore Within Reason

• Ignoring a negative behavior may be an effective behavior-modification technique

• Don’t ignore risky or injurious behavior, but ignore whining, nagging, arguing until these stop

• S/he can crave attention with these. Ignoring can be effective if done consistently. If he is increasingly loud if ignored, tell him gently that talk can resume when he is calm

Ignoring an negative behavior may be an effective

Define Schedules and Routines

• Not-inflexible enjoyable daily routine: wake-up, getting ready, breakfast, preparing school lunch, playing, HW, sleep: s/he knows your expectations. Post it to remind him/her what to do at a time

• Clocks can be used as cues

• Allow him/her check off completed items

• S/he becomes more structured and stays on task

"morning checklist“: making bed, brushing, preparing school lunch.

Education

• Most can be educated in standard classrooms

• Some do better in a more structured environment

• Special education is tailored to meet the specific needs of children

Some do better in a more structured environment

Develop Organizational Aids

• They have poor skills: trouble organizing tasks. Provide color-coded notebooks for each subject, and a HW sheet on top for each day

• A 2nd set of books for home is useful if he forgets to bring them back

• Help him develop a system for his/her room and belongings and stick to it

Develop a system for his room and belongings and stick to it

Eliminate Distractions

• Home environments may be chaotic and full of distractions

• Ensure plenty of quiet time and space for him to complete HW and chores

• Room should be free of distractions like TV and video games, not where most people gather

Let your child have plenty of quiet time and space for tasks

Set Small Attainable Goals

• You cant go for Marathon (26miles) from never

running! So is unrealistic on your child to change 5

behaviors immediately. This causes unbearable

stress for you and child leading to failure

• No overnight changes! Ask him not interrupting a

conversation for 5 min, remaining seated for 10

min, etc. Praise and reward for these small goals

Focus on 1 or 2 Challenging Behaviors/Time

Plenty of praise and rewards when small goals are met

… can create unbearable stress for both and leads to failure

Find Areas the Child Succeeds in

• No one enjoys constant criticism: it causes more

negative behaviors to get attention

• Everyone needs to feel good at something, find an

area of his/her success: sport, music, lesson, art,

etc. that can greatly improve his/her self-esteem

• Let his/her interests and enthusiasm be your guide

Let his/her interests and enthusiasm be your guide

Promote a Healthy Lifestyle - Nutrition

• Also for the whole family. Avoid junk foods or

"empty" calories on >1 occasions

• Sugary foods are not a c/of ADHD, but lots of these

may worsen ADHD. He/she may skip meals or eat

irregularly. Small frequent meals are effective

• Teach him/her good food choices by modeling these

upon yourself

Teach him make good food choices by modeling these choices yourself

Promote a Healthy Lifestyle - Exercise

• Exercise, sports can help excitable children "burn

off" extra energy. It promotes well-being and sleep

• Constant-activity or motion sports are better

• Many children with ADHD do well in martial arts or

yoga that affect mental as well as physical health

Regular exercise promotes well-being and sleep

Promote a Healthy Lifestyle – Sleep

• Sleep is essential! Not well-rested, he/she will have more difficulty paying attention

• Set bedtime routine. Use a checklist

• No caffeine. Provide a calming ritual (cuddling or sharing a story)

• Turn off computer; remove cell phones and others out of room for the night

If not slept, s/he will have more difficulty paying attention

Show Your Unconditional Love

• Be sure s/he is aware of your unconditional love,

no matter how s/he behaves

• Withdrawal of affection is never appropriate

• It's OK to let him/her know you are unhappy with

his/her behavior, but remember to say "I love you"

every day. S/he will know that he/she is a valued

member of the family

"I love you”

Take Care of Yourself!

• Never forget to take care of the caregiver!

• It is a joy of accomplishment, though can bring on

frustration, anger, guilty-feeling, anxiety, worry!

• Remember! his/her behaviors are due to a

disorder not under his/her full control

• Take a break: accept help from friends. Take

pastime to recharge yourself!

Take pastime to recharge yourself

Prevention

• No surefire way

• Steps to reduce the risk

– avoiding alcohol, drugs, tobacco in pregnancy

– balanced food

Children whose mothers smokes during pregnancy are twice as likely to develop ADHD

Balanced food

Outlook

• With Rx, majority of ADHD improve

• Many grow out of the disorder

• But >50% continue having it into adulthood

Many grow out of the disorder

QUIZESADHD denotes commonly

• A Attention Deficit Hypersensitivity Disorder

• B Affliction Diffusion Hyperactivity Disorder

• C Attention Deficit Hyperactivity Disorder

• D Affection Deficit Hypersensitivity Disorder

Which is NOT a symptom of ADHD?

• A inattention

• B impulsivity

• C fidgeting

• D Stuttering

ADHD symptoms must be present for

• A Three weeks total

• B Six consecutive weeks

• C Three months total

• D At least 6 mo

1. You have to be stricter with ADHD kids

• True

• False

2. Kids with ADHD have discipline problems because they can’t focus

• True

• False

• It depends

To help your child concentrate, make sure her breakfast is rich in

• Protein

• Unrefined sugars

• Gluten

1. Using a chart can help with discipline; you should

• Add points for good behavior

• Remove points for bad behavior

• Both

2. Use short-term goals to motivate kids with ADHD

• True

• False

1. Bad parenting can cause ADHD

• True

• False

2. Cutting out sugar from diet can reduce disruptive ADHD behavior by

• Up to 30%

• 10%

• 0 -- it doesn't help

Which is more likely to lessen disruptive ADHD behavior?

• Controlling allergic triggers

• Getting more sleep

• Neither

ADHD can be an inherited condition

• True

• False

Which class of drugs is NOT used to Rx ADHD?

• A Psychostimulant medications

• B Antidepressant medications

• C Antipsychotic medications

• D B and C

Which supplements have no benefit for ADHD?

• A Zinc

• B St. John's wort

• C Fish oil

• D Multivitamins

ADHD usually resolves itself by adulthood

• True

• False

There are no differences in stimulant use for Rx ADHD across racial and ethnic groups

• True

• False

What conditions are closely associated with ADHD?

• A Cigarette smoking

• B Drug and alcohol abuse

• C Heart disease

• D A and B only

The best definition for "diversion“ related to ADHD Rx is

• A Giving, trading, or selling prescribed medications

• B An ADHD patient's continued inability to concentrate

• C The federal government's method of managing ADHD in schools

• D Parental denial of childhood ADHD despite diagnosis

What % of children with ADHD will have persistent symptoms into adulthood?

• A At least 10%

• B At least 25%

• C At least 50%

• D At least 75%

In teens with ADHD, a major area of concern is

• A Overeating

• B Driving

• C Antisocial behavior

• D Acts of violence

ADHD has also been named

• A Superkinesis

• B Hyperkinesis

• C Hyperreality

• D Behavioral extremism

Which problems are common in adult ADHD?

• A Poorer educational performance

• B A lower socioeconomic status

• C Multiple marriages and divorces

• D All of the above

Pregnant women who smoke or drink alcohol have more risk of having a child with ADHD

• True

• False

MCQ: ADHD

• Stuttering is a symptom

• SS must be persistent for minimum 9mo

• Usually resolves by adulthood

• 50% childhood ADHD continue in adulthood

• Antipsychotic drugs are DoC

• Effective parenting is the most important thing in

Rx ADHD

How do I know my child has ADHD and not something else?

• Only a trained health care professional can accurately diagnose ADHD. Get the facts about how ADHD is diagnosed.

How can I get help?

• Always talk to your child's doctor first. Check out your local resources to meet other parents and professionals with ADHD expertise. Your child's school, your human resources department at work, and neighborhood clinics may also have lists of resources for managing or treating ADHD.

Working with Your Child's Doctor

• Sometimes my child's doctor's appointments go by so quickly, I forget to ask the questions I have. Any tips to help me remember them?

• Try writing down your questions ahead of time. Then be sure to hand your questions to the health care professional as soon as he/she enters the room! If you’ve already left the office, pick up the phone and call back. Don’t let a moment of embarrassment keep you from getting the important information you need for your child.

Why is the doctor changing the dosage of my child's medicine?

What if my child is struggling in school?

• For children dealing with ADHD and school, there can be additional challenges and difficulties. Here are three steps you can take to help your child.

• Step 1: Get a professional diagnosis in writing.

• Step 2: See below to learn about federal laws that ensure students with disabilities receive educational opportunities equal to those of their peers.

• Step 3: Be patient. You may need to involve your school, as well as teachers and counselors, to make the arrangements and get

What accommodations may be available to my child in school?

• If after weighing the benefits and risks of pursuing learning accommodations for your child, you decide to proceed, you have several options:

• Section 504 of the Rehabilitation Act provides for accommodations such as providing students with ADHD clear and simple directions for homework and in-class assignments, a quiet place to work, or access to a computer in school for written work.

The Individuals with Disabilities Education Act (IDEA) provides for an individualized education program, also known as an IEP.

• is a written document with specific goals for the child based on their current level of performance, and with a list of services that will be granted as discussed by the parent and school.

What are some things to consider when seeking learning accommodations for my child?

• Before pursuing special learning arrangements for your child, keep these points in mind:

• Consider if your child with ADHD would be embarrassed when accommodations are made in class. You may wish to keep any agreements about changes between your child and his/her or her teachers.

• Consider if your child with ADHD would be upset with accommodations that may call them out from their peers. You may want to avoid implementing major new strategies until absolutely necessary.

• It’s important to remain positive. It can be challenging to get the

How can I work with my child's school?

• Meet with teachers to share your concerns and explore accommodation options

• Ask them for written assessment of your child

• Take an active role in educational plan

• FU each meeting with your child’s school

• Find a local support group

ADHD associated disorders

• In 2⁄3. Learning disabilities in 30%. ADHD, is not a learning disability but can significantly impact academic performance

• Tourette syndrome more common in ADHD

• Oppositional defiant disorder (ODD) and conduct disorder (CD) in 50% and 20%. SS: stubbornness, aggression, temper tantrums, deceitfulness, lying, and stealing. 50% of those with hyperactivity and ODD or CD develop antisocial personality disorder in adulthood

• .[37] Brain imaging supports that conduct disorder and ADHD are separate conditions.[38]

• Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.[36]

• Mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the combined ADHD subtype are more likely to have a mood disorder.[39] Adults with ADHD sometimes also have bipolar disorder, which requires careful assessment to accurately diagnose and treat both conditions.[40]

Often leaves seat in places where remaining seated is expected