Medical Update on ADHD

Realising possibilities

Volume 6 No 2 June 2018

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Volume 6 No 2 June 20182

Editorial

Guest editor: Dr Chris van den BergPsychiatrist

Valerida Sentrum/Centre, StellenboschWestern Cape

Disclaimer: The content contained in this publication contains medical or health sciences information and is intended for professional use within the medical field. No suggested test or procedure should be carried out unless, in the reader’s judgement, its risk is justified. Because of rapid advances in the medical sciences, we recommend that the independent verification of diagnoses and drug dosages should be made. Discussions views, and recommendations as to medical procedures, products, choice of drugs, and drug dosages are the views of the authors. The views expressed by the editor or authors in this newsletter do not necessarily reflect those of the sponsors or publishers. The sponsors, publishers and editor will not be liable for any damages or injuries of any kind arising from the use or misuse of information provided in this publication and do not support the use of products for off label indications.

Production Editors: Ann Lake Publications: Ann Lake/Helen Gonçalves Design: Jane Gouveia Sponsor: Janssen Enquiries: Ann Lake Publications, Tel:(011) 802 8847 Email: lakeann@mweb.co.za; www.annlakepublications.co.za

ome refreshing perspectives on ADHD await the reader of this edition! The focus points here are preventative and non-pharmacological interventions in ADHD. I welcome it when patients ask about additional measures to address their ADHD and so

the first article gives us some backing for psychotherapeutic interventions, especially for CBT adapted for adult ADHD. Psychotherapy not only has the potential to address associated problems of ADHD, but can directly address core symptoms as well. I was glad to see that mindfulness principles are useful in ADHD treatment too: Improving attentional control, affect regulation and impulse control. To all the psychologists out there, I think there is huge gap in the market: Therapists with a special interest in treating adult ADHD.

ADHD has become a “wanted” diagnosis amongst many university/college students for the potential gains: Access to medication for non-medical use (see the alarming statistics quoted in the article) and for academic concessions (e.g. extra writing time in examinations). This puts the doctor (especially general practitioners) in a precarious position: To prescribe or not to prescribe the first prescription - as this could become a slippery slope! Fortunately, the recently published SASOP adult ADHD guidelines are of assistance, but it still boils down to comprehensive assessment (especially good quality collateral and functional impairment measurement), exclusion of conditions resembling ADHD and to diagnose positive cases correctly. “Thus, it is important to be certain of the diagnosis prior to treating ADHD to avoid the morbid cascade that may follow methylphenidate misuse.”

In “Why parenting matters in ADHD” a strong argument is made for the epigenetic influences of parenting in the development of this neurodevelopmental disorder. What seems to be true of most psychiatric disorders, now also seems to be true of ADHD: The big role of the environment (and in this article especially “expressed emotion”, maternal and paternal warmth and intrusive, insensitive paternal behaviour) in the pathogenesis of ADHD. The negative impact of parental mental illness (e.g. untreated adult ADHD with emotional dysregulation) can now be understood in this context. Knowing this gives us another focus for intervention in ADHD: Conscious parenting strategies. In my view this news should be preached from the rooftops and access to this information should be made easily accessible to all parents, soon-to-be-parents and teachers. “It would serve us well to pay special attention to the role of the parent in the management, and perhaps even prevention, of this common childhood condition”.

The good and the bad about screen time is well described in the last article. The potentials hazards (speech delays, reduced parent-child interaction, sleep disturbances, inactivity and metabolic syndrome, attention problems, poorer academic achievement, increased risk for depression, etc.) of technology makes one think twice before handing over the iPad to your toddler when you want to pay some attention to your Instagram and Facebook account! The policy statement from the American Academy of Pediatrics that is mentioned at the end is worthwhile reading.

Thank you to all the authors for a stimulating read!

Volume 6 No 2 June 2018 3

Psychotherapeutic Treatments for Adult ADHD

Dr Eleanor HolzapfelPsychiatrist

Akeso Crescent Clinic, Randburg

ttention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that is usually first diagnosed in childhood or adolescence.1 Research has shown that children and adolescents usually do not grow out of it and the symptoms and effects of ADHD

extend into adulthood.1 ADHD is a disorder that affects executive functioning.1 Executive functioning can be defined as: Behaviours that allow individuals to develop and follow through on goal directed plans to improve future outcomes for which there is no immediate reinforcement (Figure 1).1,2

Thus ADHD and particularly adult ADHD is a serious disorder which greatly impacts the lives of the affected individuals and their families.1,3-5 The greater impairment in functioning in adults is due to the multiple roles, expectations, demands and responsibilities held by the adult.1

The first line of treatment is usually stimulant medication. However, a number of individuals with adult ADHD do not respond to, can’t tolerate or only partially respond to medication.3-6 Thus the use of psychotherapeutic treatments is an important part of managing adult ADHD, as functional improvement in adults requires core symptom treatment and an opportunity to develop and apply new skills.3-6

Psychological therapy The targets of psychotherapeutic treatment for adult ADHD should include treating the core symptoms and associated problems such as mood, anxiety, anger, low self-esteem, distorted thinking, poor social skills, sleep problems, relationship and employment issues and substance abuse (Figure 2).3-7

The following psychological therapies have been evaluated and have demonstrated efficacy in treating adult ADHD:3-6

• Cognitive behavioural therapy (CBT)This therapy focuses on thoughts and behaviours that occur in the present and cause distress and dysfunction in patients with adult ADHD.

• Dialectical behavioural therapy (DBT)This therapy uses CBT and acceptance/mindfulness based skills. DBT was initially used to manage borderline

ExEcutivE FunctionBehavioural categories

the ability to manage feelings by thinking

about goals

the ability to monitor and

evaluate your own performance

the ability to create and maintain systems

to keep track of information or

materials

the ability to stop and think before acting

the ability to change strategies or revise plans when conditions change

the ability to hold information in mind and use it to complete a task

the ability to recognise when it is time to get started on something and begin without procrastinating

the ability to create steps to reach a goal and to make decisions about what to focus on

Emotional control

Self-monitoring

Organisation

impulse control

Flexibility

Working Memory

task initiation

Planning/ Prioritising

Figure 1. Executive function skills.2

Figure 2: Conceptual model of the impact of ADHD.7

Volume 6 No 2 June 20184

personality disorder. The use of DBT in treating ADHD came about from observing similar features in borderline personality disorder and ADHD, including affect regulation, impulse control, self-esteem and interpersonal skills.

• Meta-cognitive therapyThis therapy uses CBT methods but focuses more on executive functions such as time management, organisation and planning. It aims to improve self-management and daily structure.

• Cognitive remediation programmeThis programme uses CBT and coaching methods. A support person (coach) makes contact directly and telephonically between sessions to review goals and discuss any problems. The programme focuses on organisational skills, management of impulsivity, anger, self-esteem and motivation.

• Mindfulness based therapyMindfulness exercises such as yoga and meditation focus on attention control. This is linked to improved sustained attention and emotional regulation in adult individuals with ADHD.

• Cognitive rehabilitation programmeThis programme aims to improve cognitive function through medication, biofeedback and promoting a healthy lifestyle. It promotes the development of compensatory strategies to improve functioning and encourages environmental changes to make home and work ADHD friendly. Compensatory strategies include: Use of a planner, setting a timer to get things done, maximise prompts and reminders such as post it notes, use of a calendar and use of personal digital assistants.

The above therapies all have common aspects. These include:3-6

• Short term therapy that is structured.• Use of manuals.• Mostly group therapy.

• Use of hand-outs to guide outside work and homework, emphasis on between session practice of skills.

• Focus on psych education, organisation, planning, time management, address motivation and target thoughts/feelings that may affect skill use and associated symptoms.

All the above therapies have shown significant reduction of core ADHD symptoms and a modest effect on reducing associated symptoms such as anxiety, depression and low self-esteem.3-6 Of all the treatments reviewed, CBT adapted for adult ADHD when given as group or individual therapy has been proven to be the most effective psychotherapeutic model for treating adult ADHD.3-6

A Cognitive Behavioural Therapy Model for Adult ADHDThe conceptual basis for the CBT treatment model (Figure 3) begins with the understanding that neuropsychological impairments are at the centre of ADHD.4 Safren et al4 state in their CBT treatment model that: “These deficits contribute to functional impairment and produce disruption in adaptive behaviour, including use of higher-level organisation and planning strategies that might prevent symptom-related difficulties. Thus, these underlying neuropsychological impairments prevent individuals with ADHD from acquiring and using the very compensatory strategies that might support their areas of need resulting in symptom maintenance and exacerbation and further contributions to functional impairment.”4

The aim of therapy according to Safren et al4 would be to: “Adapt the environment around the individual in an attempt to make it one in which one can achieve success and to help the individual develop skills to achieve set goals and develop constructive strategies to deal with life challenges and stress.”4

This model supports using behavioural skills training to target the acquisition and especially the maintenance of compensatory skills.4 Essential to this model is the repeated practice of these compensatory skills. These compensatory

Figure 3: The Conceptual basis for cognitive behavioural treatment of ADHD.4

core (neuropsychiatric) impairments in• Attention• Inhibition• Self-regulation

(impulsivity)

Mood Disturbance• Depression• Guilt• Anxiety• Anger

History of• Failure• underachievement• Relationship problems

Dysfuntional Cognitions and Beliefs

Functional impairment

Failure to utilise compensatory strategies - examples:• organising• Planning (i.e. task list)• Managing procrastination

avoidance, distractibility

Volume 6 No 2 June 2018 5

Congratulations, youv’e got ADHD! Now what?

Get a good map: Learn

about ADHD (an ongoing project)

• Read: Experts’ books, websites, e.g. Tuckman, Barkley, Solden, Sakaris, Levrini

• Listen: Podcasts e.g. adultadhdbook.com, addtalkradio.com

• Watch: Videos e.g. TouTube/Vimeo, totallyadd.com• Discuss: Support groups e.g. CHADD.org, ADD.org,

online support communities• involve: Your family and partner - they need to

learn too

Get effective treatment

• Medication: Runs from helpful to essential, don’t give up until you find what works

• therapy: CBT is a good fit - be sure your therapist really knows about ADHD

• coaching: Helps you figure out the steps to take and how to actually get them done

• Deal: With related conditions like anxiety and depression

Creat a “prosthetic

enivronment”

• ADD-friendly ways to run your life: time/task management, organise your stuff

• Backup brain: Planners, calendars, alarms, apps• Write things down: Give up expecting you’ll

consistently remember to remember• Accommodations as needed - it’s okay to leave

the playing field

Cultivate an ADHD-friendly lifestyle and

mindset

• Mindfulness: Antidote for stress/anxiety and best training for concentration/focus

• Sleep: To de-fragment your brain so put down that device and go to bed!

• Exercise: “MiracleGrow” for your mind and major stress relief

• Nutrition: Go for Omega 3s, protein for breakfast, greens, limit sugar/caffeine

• clean living: Ease up on the intoxicants, get active outside, have fun - laugh a lot

• Attitude: It’s about progress, not perfection. Aim to improve your batting average

behavioural strategies can reduce functional impairment.4 Cognitive interventions will target dysfunctional patterns of thought and associated emotions that contribute to avoidance, procrastination, attention shifts, depression, anxiety and low self-esteem.4 Thus cognitive behavioural interventions can play an essential role in breaking the link between core symptoms and continued failure and underachievement.4

The focus of CBT therapy for adult ADHD includes:1,5

• Time managementTime awareness, schedules, prioritise, to do lists.

• Organisational skillsGoal setting, manageable tasks, use of a note-book and appointment book, rewards for important tasks completed.

• Planning and problem solving skillsFocus on immediate problems and solutions, break problems down into manageable obstacles, think about and use strategies that were successful in the past, discuss barriers and difficulties experienced during implementation of plan.

• Impulse controlTeach self-regulation such as stop and think, consider consequences of action or thought and generate appropriate alternative action or thought.

• Anger managementRole play, talk problems over, assertiveness skills, conflict resolution skills, analyse cognitive distortions, restructuring of an event, learn to self-monitor and regulate emotions.

• CognitivemodificationLook at cognitive and emotional factors which can interfere with the implementation of skills, goals, tasks.

• Resilience and persistence in treatmentNormalise setbacks, re-evaluate goals, keep at it.

• Interpersonal skillsSocial skills training, role play, improve social perception skills, analyse cognitive distortions.

• Anxiety and depressionTreat comorbid problems.

• Establish good health and wellbeing patternsRoutine, eat healthy, exercise, avoid substances, avoid excessive use of computers and technology, be aware of cues that affect concentration, fatigue and stress.

Other Therapeutic InterventionsThese therapeutic interventions may be helpful. However, there are no studies demonstrating efficacy in adult ADHD.8

• Psycho-education work.• Motivation/self-esteem work.• Occupational or vocational intervention.• Liaise with employer.• Family and couples intervention.• Substance abuse work.• Supportive therapy.• Coaching is seen as a partnership and the coach and client

work personally together to direct and manage life and work challenges.

• Stress management.

ConclusionInternational and South African treatment guidelines recom-mend a multi-modal treatment approach with psychothera-peutic treatments as complementary to pharmacological in-terventions.10 Psychotherapeutic interventions in particular CBT adapted for adult ADHD are beneficial, especially when combined with medication in the management of adult ADHD. Therapy aims to assist the individual with adult ADHD to change their environment and change themselves and thus improve their treatment outcomes and long term prognosis.5

References available on request.

Figure 4: Treatment summary hand out for patients.9

Volume 6 No 2 June 20186

In our setting, a study conducted in South Africa to explore prevalence and treatment of adult ADHD, found a prevalence rate of between 3-5%. However, there were limitations to this study which might have lead to underestimating the true prevalence of adult ADHD in SA.8 The data from this study was collected from the private health care sector and it identified that there was lack of funding for treatment of adult ADHD due to the lack of knowledge of the condition. These factors then lead to problems with diagnosis and treatment of the condition. Therefore, it is possible that the prevalence rates found were an underestimation.

The prevalence of ADHD amongst students in institutions of higher learning in the US, Italy and New Zealand ranged between 0-7%.9 However, a study conducted by Atwoli et al to determine the prevalence of self-reported ADHD symptoms among university students in Eldoret, Kenya found a prevalence of 21.8%.9 This was significantly higher than reported in other studies. This brings to the fore the issue of how to best correctly diagnose patients and how reliable self-report scales are in this population. It is important to enquire about presence of symptoms in childhood and to better yet get collateral information from a parent or guardian about early symptoms. In students or in adulthood, it would be beneficial to consult someone (preferably an independent and objective party) who has seen the individual in different settings to get collateral information.1

Screening toolsIn the assessment of adult ADHD, self-report behavioural rating scales are commonly used.10 The current challenge with published versions of existing screening scales is that they are still

calibrated to DSM-IV diagnostic criteria.11 There is, however, an updated version of the World Health Organisation Adult ADHD Self Report Scale. The DSM5 criteria requires a reduced number of symptoms and later age of onset which should increase the prevalence of adult ADHD.12 The specificity of these rating scales may be lower in clinical practice, especially in the background of the high rates of other mental conditions and substance use in this population. Therefore, positive screens should always be followed by full psychiatric evaluation.8

Dangers of overdiagnosing ADHDAn important reason for a correct diagnosis of ADHD in students is to prevent the misuse of methylphenidate (MPH), which is a stimulant medication used for the treatment of adult ADHD. Stimulant medications themselves have a potential for

ttention-Deficit/Hyperactivity Disorder (ADHD) as de-scribed in the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM5) is characterised by a persistent pattern of inattention and/or hyperac-tivity-impulsivity that interferes with functioning or de-

velopment.1 The disorder falls under the neurodevelopmental disorders which reminds us that the symptoms should be pres-ent from childhood, prior to 12 years of age.1

The presentation of ADHD in adults often differs from that seen in children. Firstly, there is a decrease in symptoms of hyperactivity compared to symptoms of inattention.2 In children where hyperactivity may present as excessive motor activity or fidgeting, in adults that may manifest as extreme restlessness or wearing others out with their activity.1 Inattention in adulthood may manifest in difficulty carrying out tasks e.g. meeting deadlines,3 or completing assignments in students. These symptoms need to be present in two or more settings (e.g. at school and home). They also need to interfere with social and academic functioning and, lastly, they should not be caused by any other condition or substance use.

The diagnosis of ADHD in adults is further complicated by common co-occurrence of other psychiatric conditions, most frequently substance-use disorders, generalised anxiety disorder and mood disorders.2 Hence the importance of establishing the presence of the symptoms since childhood.

The diagnostic criteria seem clear but what are the challenges when you are faced with a bright university student who presents for the first time in adulthood complaining of the above symptoms?

Prevalence of adult ADHDAmongst children, ADHD is the most common psychiatric disorder, affecting 2.0 – 16.0% of the school-age population.4 The population prevalence for ADHD is estimated as 3.0 – 5.0%.5 With adult ADHD, however, there is a wide variation across studies due to the different methodologies used. Although there is no global consensus, meta-analyses have estimated the worldwide ADHD prevalence at 3.4% (range 1.2–7.3%) in adults.6 Leading to the acceptance that an estimated 60 – 70% of patients’ symptoms from childhood persist into adulthood.7 The previously perceived decline in prevalence of symptoms in adulthood could be attributed to the DSM-IV-TR criteria which was formulated with children in mind. The newer DSM5 has the inclusion of specific examples of how ADHD is manifest in adults.1 The change incorporates the chronicity of the disorder and the different manifestations with age.

Is adult ADHD the new student trend?

Dr Ntokozo Ngcobo MBChB Registrar, Department of Psychiatry, Nelson R Mandela School of MedicineUniversity of KwaZulu-Natal

Prof Bonginkosi Chiliza MBChB FCPsych PhD, Head of Department of Psychiatry, Nelson R Mandela School of MedicineUniversity of KwaZulu-Natal

In children, where hyperactivity may present

as excessive motor activity or fidgeting, in

adults, that may manifest as extreme restlessness

or wearing others out with their activity.

Volume 6 No 2 June 2018 7

abuse. They exert their effect by increasing levels of dopamine in the human brain, which is the same mechanism that drugs of abuse exert their rewarding effects.2 Patients with a history of substance use disorders thus have an increased risk of MPH abuse, especially if using it for non-medical purposes.2

A study conducted at a South African university amongst undergraduate students found that there was a self-reported use of MPH among 17,2% of respondents but only 2,9% of the respondents had been diagnosed with ADHD.13 The study also showed that MPH users were more prone to use other substances and most of them obtained the MPH illegally.13 Thus it is important to be certain of the diagnosis prior to treating ADHD to avoid the morbid cascade that may follow MPH misuse. MPH abuse may be a gateway to abuse of other substances, ultimately leading to medical and psychiatric conditions that may be caused or precipitated by the substances and also social and occupational consequences that may follow.

Stimulant medications themselves are not without side effects, namely, increasing blood pressure and pulse rate, thus inappropriate prescription of these medications may lead to medical complications that could have been avoided. In the student population, a diagnosis of ADHD may also offer other benefits, including academic accommodations, which would motivate students to exaggerate sypmtoms.14

Dangers of under-diagnosing ADHDOn the other side of the coin, missed or undiagnosed students with ADHD may never reach their full academic potential due to the symptoms of the disorder. Inattention will impair their ability to perform well in school. Adults with ADHD have reduced responses to rewards and are less motivated to engage and follow through on everyday activities which will also lead to poor academic performance.2

As stated above, the high rates of self-reported ADHD in the Atwoli et al study also warrant the clinician to be alert if confronted with students experiencing interpersonal and academic difficulties as this may be due to untreated ADHD. If left untreated, ADHD in adults is associated with interpersonal problems (e.g. social maladjustment), employment and financial difficulties and comorbid psychiatric and substance use disorders (e.g. depression and anxiety).2

ConclusionThe assessment of adult ADHD is challenging, particularly as there is no one fault-proof diagnostic test. There is a high prevalence rate of self-reported ADHD symptoms in university students.9

Due to the limitations associated with self-report of symptoms, getting collateral information from a friend or family member about the presence of symptoms prior to the age of 12 years is critical. Comprehensive interviews, use of symptom rating scales and exclusion of other medical and psychiatric

conditions or substance related disorders that may be causing the symptoms presented should be the approach used to make and confirm a diagnosis of ADHD in our student population.

References1. DSM-5 development. Arlington, VA: American Psychiatric

Association; 20122. Volkow N, Swanson J. Adult Attention Deficit-Hyperactivity

Disorder. N Engl J Med. 2013 November 14; 369(20):1935-1944

3. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006;36: 159-65.

4. National Resource Centre on AD/HD. Statiscal prevalence of ADHD [homepage on the Internet]. c201. Available from http://www. help4adhd.org/en/about/statisics

5. Wichen H, Jacobi F, Rehm J, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011;21(9):655–679. h ps://doi.org/10.1016/j.euroneuro.2011.07.018

6. Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry 2007; 190: 402-409.

7. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: A meta-analysis of follow-up studies. Psychol Med. 2006;36(2):159–165. h ps://doi.org/10.1017/S003329170500471X

8. Schoeman R, De Klerk M. Adult attention-deficit hyperactivity disorder: A database analysis of South African private health insurance. S Afr J Psychiat. 2017;23, a1010. https://doi.org/10.4102/sajp.v23.1010

9. Atwoli L, Owiti P, Manguro G, Ndambuki D. Attention deficit hyperactivity disorder symptom self report among medical students in Eldoret, Kenya. African Journal of Psychiatry 2011

10. Woods S. P, Lovejoy D. W, Ball, J. D. (2002). Neuropsychological characteristics of adults with ADHD: A comprehensive review of initial studies. Clinical Neuropsychologist, 16, 12-34.

11. Adler L. A, Shaw D.M, Alperin S. ADHD diagnostic and symptom assessment scales for adults. In: Adler LA, Spencer TJ, Wilens T, eds. Attention-Deficit Hyperactivity Disorder in Adults and Children. New York, NY: Cambridge University Press; 2014:224-232.

12. Ustun B, Adler L.A, Rudin C, Faraone S.V, Spencer T.J, Berglund P, Gruber M.J. Kessler R.C. The World Health Organization Adult Attention-Deficit/ Hyperactivity Disorder Self-Report Screening Scale for DSM-5. JAMA Psychiatry. Published online April 5, 2017.

13. Steyn F. Methylphenidate use and poly-substance use among undergraduate students attending a South African university. South African Journal of Psychiatry 2016

14. Davidson M. ADHD in adults, A review of the literature. Journal of Attention Disorders 2008

Volume 6 No 2 June 20188

ttention Deficit Hyperactivity Disorder (ADHD) is a neu-robiological condition affecting around 6% of school-go-ing children and causing impairments in concentration, hyperactivity and impulsivity. Twin studies, family stud-ies and adoption studies attest to the heritability of

ADHD, whilst imaging studies and the robust effectiveness of pharmacological treatments underscore the biological underpin-nings of the disorder. Nonetheless there remains a vigorous de-bate, in both the lay press and scientific literature, about the role of the environ-ment in the pathogenesis and manage-ment of ADHD. The child’s intrauterine environment, the early attachment expe-rience, dietary factors and quality of par-enting have all been implicated as possi-ble contributory factors to the condition.

It is well-established that parents of ADHD children are particularly stressed and experience dissatisfaction with their parenting. In clinical practice it is also common for parents to question their role in their child’s symptoms, and to seek out behavioural and other non-pharmacological approaches to treatment, either complementary to medication or in preference thereto. At the very least, parents require education about the condition, and the effectiveness of prescribed treatment is predicated upon parental co-operation.

Certainly in the preschool age-group, non-pharmacological approaches are particularly important in view of the greater risk of side-effects with stimulant medications. The quality of parenting is one of several important pathway moderators in this age group, influencing the progression from at-risk to diagnosable ADHD. Parent management training is an intervention which can be employed at various stages of the child’s development but is usually most effective when implemented in the preschool years. It involves a system of positive reinforcement, which employs a ‘token economy,’ (star charts, points system) which selectively reinforces appropriate behaviour.

Evidence-based parent training programmes include STEP (Systematic Training for Effective Parenting), the Incredible Years Basic Parenting programme, the Positive Parenting Programme and the New Forest Parenting Programme. Not all of these are available in South Africa but there are many competent practitioners who incorporate the important aspects of these programmes into the process of parent counseling. Several studies have shown a reduction in ADHD symptoms in preschoolers and an increase in maternal wellbeing with parent training interventions.1

Central to the understanding of parenting in ADHD is the concept of expressed emotion, a measure of family relationships which quantifies the attitudes and emotions of family members towards one another. A commonly used measure of expressed emotion is the Five Minute Speech Sample, in which the parent talks about the child and factors such as the initial statement, critical comments, positive comments, parental warmth and parent-child relationship are

rated. Another approach involves the direct observation of a family interaction, such as a family activity or discussion, and the coding of measures such as the total parental verbalisations and commands, percent of praise (number of praise statements divided by total verbalisations), negative talk (number of negative statements divided by total verbalisations), ratio of commands to total verbalisations, and responsiveness (number of child requests that were answered by the parent divided by the total number of child requests and questions).

Studies employing these measures have shown that in general parents express more negative emotions towards children with an ADHD diagnosis compared with controls or unaffected siblings. In prospective studies examining expressed emotion, higher maternal warmth is protective against later ADHD, intrusive, insensitive paternal behaviour is predictive of hyperactive-impulsive behaviour at school, and a lack of paternal warmth is associated with later

substance abuse in ADHD children. These predictions held after statistical adjustment for the effects of preschool ADHD behaviours and conduct problems and pertinent parental psychopathology.2,3

But what is the mechanism by which expressed emotion influences the ADHD phenotype? The differential susceptibility theory4 posits that some children are more genetically susceptible to adverse environments (such as parental expressed emotion) than others. Children carrying certain risk alleles will be more at a disadvantage in negative, but conversely, more at an advantage in positive environments.

According to this theory these ‘vulnerability genes’ are best conceptualised as plasticity genes because they are modifiable by environmental influences. In recent years, geneticists have discovered an increasing number of environmental influences which can actually change gene activity. Furthermore, these changes – known as epigenetic changes – can be transmitted from one generation to the next. Both the physical and the

Dr Brendan BelshamChild and adolescent psychiatrist

Robindale, Randburg, Johannesburg

Why parenting matters in ADHD

Certainly in the preschool age-group, non-pharmacological approaches are particularly important in view of the greater risk of side-effects with stimulant medications.

Volume 6 No 2 June 2018 9

psychological environment can have such effects. There are a number of mechanisms by which these gene changes can occur. One example is methylation.

A methyl group is a basic unit in organic chemistry - one carbon atom attached to three hydrogen atoms. It takes only the addition of a methyl group to a specific spot on a gene, to cause it to be activated or deactivated. Certain plasticity genes seem to make individuals more susceptible to environmental influences - for better and for worse. Associations between low maternal warmth and comorbid conduct problems in children with ADHD have been found to be moderated by variants of such risk genes, including the dopamine and serotonin transporter genes.5

Many parents of ADHD children have the condition themselves; this is not surprising given its well-documented heritability. For a number of reasons, untreated parental ADD often has a significant effect on offspring. From a general parenting perspective, being disorganised, forgetful, impatient and impulsive will impact on the parent’s capacity to provide the necessary structure, routine and discipline important for all children, especially those with ADHD. This may negatively affect the child’s adherence to prescribed medication; even the process of interacting with the pharmacy around a high schedule medication requires a significant degree of planning and organisation.

Furthermore, it is important for parents to facilitate several important lifestyle factors known to be important in managing ADHD, such as sleep routine, regular exercise, healthy diet and moderation with respect to electronic screen exposure. These lifestyle factors need to modelled at home by the parents, which is again more difficult if one or both parents have the condition themselves.

Lastly, emotional dysregulation, a significant symptom in many adults with ADD, is likely to aggravate the emotional environment in the home as discussed earlier, with adverse consequences for the child’s prognosis. It follows therefore that identification and treatment of adult ADD should improve parenting performance and the management of the child’s condition, and there is a growing literature suggesting that this is the case.6

Apart from adult ADD, other parental psychopathology may impact significantly on children with or without the condition. Post-partum depression has been shown to be predictive of ADHD in later childhood This may be mediated by a shared genetic vulnerability, the impact of postnatal depression on infant attachment or on hitherto unidentified mechanisms. Mental illness of any sort is likely to impact on parenting performance as discussed earlier, especially with respect to expressed emotion.

Exciting breakthroughs in our understanding of the neurobiological nature of ADHD have deflected attention away from important environmental influences germane to the pathogenesis and management of this disorder. One should also not think dichotomously about the nature/nurture debate, as there is an increasing body of evidence linking the two, as evidenced by the role of epigenetic influences on gene expression.

The most important aspect of the child’s early environment is the quality of his relationship with his parents. Parenting performance influences childhood ADHD in several ways, operating from very early on in child development. Given the massive economic burden of ADHD, as well as the scarcity and cost of appropriate specialist care, it would serve us well to pay special attention to the role of the parent in the management, and perhaps even prevention, of this common childhood condition.

References1. Jones D et al. Efficacy of the Incredible Years Basic parent

training programme as an early intervention for children with conduct problems and ADHD. Child Care Health Dev. 2007 Nov;33(6):749-56.

2. Keown LJ. Predictors of boys’ ADHD symptoms from early to middle childhood: the role of father-child and mother-child interactions. J Abnorm Child Psychol. 2012 May; 40(4): 569-81

3. Tandon M et al. Parental warmth and risks of substance abuse in children with ADHD: findings from a 10-12 year longitudinal investigation. Addict Res Theory. 2014 Jun 1; 22(3): 239-250

4. Belsky J, Pluess M. Beyond diathesis stress: differential susceptibility to environmental influences. Psychol Bull. 2009 Nov;135(6):885-908

5. Buitelaar J et al. Differential Susceptibility to Maternal Expressed Emotion in Children with ADHD and their Siblings? Investigating Plasticity Genes, Prosocial and Antisocial Behaviour. Eur Child Adolesc Psychiatry. 2015 Feb; 24(2): 209–217

6. Pelham WE et al. A Pilot Study of Stimulant Medication for Adults with Attention-Deficit/Hyperactivity Disorder (ADHD) Who Are Parents of Adolescents with ADHD: The Acute Effects of Stimulant Medication on Observed Parent–Adolescent Interactions. J Child Adolesc Psychopharmacol. 2014 Dec 1; 24(10): 582–585.

The most important aspect of the child’s early environment is the quality of his relationship with his parents. Parenting performance influences childhood ADHD in several ways, operating from very early on in child development.

Volume 6 No 2 June 201810

creen time (ST) has become an obsession of mine. Not only because technology has become all consum-ing, but because I worry that it is affecting our future generation in multiple ways. I hope that once you have read through this article, you will include a question in

your history taking about screen time and help parents out there in establishing healthy screen time habits.

DefinitionThe amount of time a person spends in front of a “screen”, including television (TV), computers, video games, IPAD or smart telephones. It is scary to think, that over the course of childhood, children spend more time watching TV than they spend in school.1 When including computer games, internet, DVDs, by the age of 7 years, a child born today will have spent one full year of 24 hour days watching screen media. By the age of 18 years, the average European child will have spent 3 years of 24 hour days watching screen media, at this rate, by the age of 80 years, they will have spent 17.6 years2 glued to media screen.

The average ST in British adolescents is 6.1hr/d,3 Canadian children 7.8 hr/d and American children 7.5hr/d.4 Needless to say, these numbers reflect an ever growing number of children exposed to appropriate or inappropriate content of what is on the screen, and it has now become as Aric Sigman (UK psychologist) says “a medical issue”, as papers have often described dose response relationship with disease risk. Furthermore, most of these screens are now also linked to increased exposure to electromagnetic fields, which again is linked to neurological disease.5

Early brain development60% of all the energy a baby expends is concentrated in the brain. The fastest rate of brain development occurs between 1-3 years of age, forming 1000 trillion connections. It has been shown that babies whose parents talk to them, know 300 more

Source: in Brief: the Science of Early childhood Development. center on the Developing child, Harvard university.

Human Brain DevelopmentNeural Connections for Different Functions Develop Sequentially

Sensory Pathways(vision, Hearing)

LanguageHigher Cognitive Function

Birth (Months) (Years)

Excessive screen time, when should we worry?

Dr Tiziana AducPaediatric Neurologist

Sunninghill Hospital

words by age 2 than those whose parents rarely speak to them. Furthermore we know that babies learn what is important to pay attention to, by following the eye gaze of adults, they use facial expression of adults to decide how they feel. We also know that holding and stroking an infant stimulates the brain to release important hormones that allow him/her to grow. “Floor time” and reading are the best ways to stimulate brain development and unstructured play helps children develop socially and cognitively. Knowing that, we can then extrapolate and assess whether children (under the age of 3) can learn from media. Researchers have found that certain high-quality programmes have educational benefits for children older than 2 years. Children who watch these programmes have improved social skills, language skills and even school readiness.6 However, the educational merit of media for children younger than 2 years remains unproven. To be beneficial, children need to understand the content of programmes and pay attention to it. A further point is that young children have difficulty discriminating between events on video and the same information presented by a live person, referred to as video deficit.7,8,9 New research presented at the 2017 Pediatric Academic Societies Meeting, suggest that children exposed to a hand held device for as little as 28 minutes may be at higher risk for speech delays.10 For each 30-minute increase in hand held device ST, researchers found a 49% increased risk of expressive speech delay. More research is needed to understand the type and contents of screen activities behind the apparent link. An earlier study by Zimmerman FJ et al, published in Journal of Pediatrics, October 2007, also found that increased screen viewing time was associated with poor speech development, and concluded that further research was required.

Second hand screen time i.e. foreground to the parent, distracts the parent and decreases parent-child interaction.11 Heavy TV use in a household can interfere with a child’s language development simply because parents spend less time talking to their children.

Sleep is the dominant activity of an infant and plays an important role in neurodevelopment and synaptic plasticity.12,13,14 Neural plasticity is at its greatest during infancy and toddlerhood,15 and sleep is likely to have the most impact on the brain and on cognition during this critical period of early development. Data from 715 UK infants and toddlers, aged 6-36 months, indicated a strong association between frequency of touch screen use and sleep quantity: Reduced total duration, with reduced duration of night time and increased daytime sleep, as well as longer sleep onset.16 The cause of this has not been adequately studied, although hypotheses are extrapolated from studies in older children. This was further proven in another study, published in Pediatrics Feb 2016, indicating that regardless of the developmental stage of the youth, higher levels of youth ST were associated with more sleep disturbances, which, in turn, were linked to higher levels of youth behavioural health problems.17

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Health RiskNumerous studies continue to find a highly significant dose responsive association between ST and type 2 diabetes and cardiovascular disease (CVD) amongst adults. Further studies in children and adults, have confirmed unfavourable dose-response associations between ST and a host of biomarkers for CVD and type 2 diabetes and metabolic syndromes.18

ST is clearly associated with unhealthy dietary behaviours in children, adolescents and adults. Positive associations between TV viewing and levels of overweight and obesity have been shown in the literature.19,20 If a child had a TV in his/her bedroom, the odds of being overweight jumped an additional 31% for every hour watched. In children it can act as a distraction away from vital satiation food cues towards non- food cues (screen) thereby disrupting the development of habituation to food and, therefore, increasing energy intake while children are viewing. Eating a meal while viewing also disrupts the encoding and memory formation of the meal. Impaired memory for recent eating may increase food intake hours after viewing stops.18

Several studies looking at ST and development of ADHD in later childhood, adolescence and adulthood, all conclude that there is a clear association in a dose-dependent manner with subsequent attention problems.21-24 Dopamine is central to the ability of paying attention and implicated in attention problems. It is produced in response to screen novelty. Significant dopamine release within the striatum is found to occur quickly in young adult brains while playing computer games. It is also a key component of the brain’s reward system, and is heavily implicated in the formation of and maintenance of addictions.

ST is strongly associated with measures of child mental well being. It is negatively associated with self-esteem and associated with an increased risk of depression.18 A Canadian study reports that higher levels of early TV exposure predicted greater chances of peer rejection experiences, which in turn may present specific risks of developing inadequate social skills.25 Conversely, face to face communication was strongly associated with positive psychosocial well being.26 Hoare E et al recently reviewed 32 articles and examined the associations between sedentary behaviour and mental health problems in adolescents.27 Strong consistent evidence was found for the relationship between both depressive symptomatology and psychological distress, and time spent using screens for leisure. Poorer mental health status was found among adolescents using screen time more than 2-3 hrs per day.27

AcademicsIn 2015, Cambridge researchers noted that an additional hour of screen time, beyond 4 hours was associated with the equivalent of dropping a grade in 2 subjects. A further two hours of screen time was associated with dropping a grade in 4 subjects.28 Children who are heavy users of electronics, may become adept at multi-tasking, but they lose the ability to focus on what is important- a trait critical to deep thought

and problem solving. Some studies associate prolonged TV viewing with lower cognitive abilities, especially related to short term memory, early reading, maths skills, and language development.29-33 Today’s children have less idea of weight and length measurements because the more time is spent in virtual worlds, the less they are involved in the real world. This is the finding from two expert reports from 2007 and 2009: “Thirty years on - a large anti-Flynn effect? The Piagetian test Volume & heaviness norms” by Michael Shayer and Denise Ginsburg.

Our pre-frontal cortex is responsible for the development of our basic cognitive functions (our thoughts, experiences and senses). The frontal lobe is the area of the brain that controls executive functioning (the ability to plan, organise, prioritise and impulse control as well as our cognitive skills, such as judgement and emotional regulation.) In the early developmental years, the growth in the pre-frontal cortex is greater, which explains why there is such a strong correlation between memory and academic learning. Research has shown that anatomical changes in the brain, namely, grey matter atrophy, volume loss predominantly of the frontal lobes, the striatum and the insula – (responsible for empathy and the ability to read social cues), impaired frontal-basal ganglia connectivity are all proven consequences of internet gaming addiction.34,35 I ask, what about the children who are not “addicted”? We need to be more aware of the risk that excessive screen time is creating subtle damage in children’s brains, and may be contributing or causing sensory overload, lack of restorative sleep and a hyper-aroused nervous system.

I would have liked to discuss a little about the effects of electromagnetic fields on the developing brain, as well as the risks of internet addiction in children as I feel that both are intricately linked to excessive ST. However, the scope of this subject goes beyond that of this article.

In conclusion I would like to refer you to a policy statement from the American Academy of Pediatrics, Media and young minds, published online October 21,2016, for guidance on managing screen time in children as a whole.

However it all starts with awareness and asking the question: “How much time does your child spend on screens per day?”

References1. American Academy of Child and Adolescent Psychiatry.

Children and Watching TV. Facts Fam 2001;54:1-22. Sigman A. The impact of screen media on children: A Eurovision

for Parliament. In: Clouder cet al.eds. Improving the quality of childhood in Europe 2012. Vol3. European Parliament group on the Quality of Childhood in the European union,2012:88-121

3. OfCom. Children and parents: media use and attitudes report.2011

4. Leatherdale ST, Ahmed R. Screen-based sedentary behaviours among a nationally representative sample of youth: are Canadian kids couch potatoes? Chron Dis Injuries canada2011;13:141-6

Volume 6 No 2 June 201812. PHZA/CONC/1117/0012

5. Murat Terzi et al. Review The role of electromagnetic fields in neurological disorders. Journal of clinical Neuroanatomy 75 (2016) 77-84

6. Anderson DR et al. Early childhood television viewing and adolescent behaviour. Managr Soc Res Child Dev.2001;66(1): 1-V111,1-147

7. Kremar M et al. Can toddlers learn vocabulary from television? An experimental approach. Media Psychol. 2007;10:41-63

8. Muentener P et al. Transferring the representation: infants can imitate from television. Presented at: annual meeting of the Easter Psychological association;April 15-17,2004;Washington DC

9. Anderson DR, Pempek TA. Televison and very young children. Am Behav Sc.2005:48(5):505-522

10. Pediatric Academic societies meetings, Dr Birkin, University of Toronto, (Hospital for Sick children)

11. Policy statement. Media use by children younger than 2 years old. Pediatrics, Nov2011;Vol128/5

12. Benington J.H & Frank M.G. Cellular and molecular connections between sleep and synaptic plasticity. Prog Neurobiol 69, 71-101 (2003)

13. Ednick M et al. A review of the effects of sleep during the first year of life on cognitive, psychomotor, and temperament development. Sleep32, 1449-1458 (2009)

14. Muzur A et al. The prefrontal cortex in sleep. Trends Cogn Sci 6, 475-481 (2002)

15. Stiles J. Neural plasticity and cognitive development. Dev Neuropsychol 18,237-272.

16. Celeste H.M Cheung et al. Daily touch screen use in infants and toddlers is associated with reduced sleep and delayed sleep onset. Sci Rep 2017;7:46104

17. Parent J et al, Youth screen time and Behavioural Health Problems: The role of sleep Duration and Disturbances, J Dev Behav Pediatr. 2016 Feb 17iPediatric

18. Aric Sigman. Time for a view on screen time. Arch Dis child2012;97:935-942

19. Armstrong CA et al. Children television viewing, body fat and physical fitness. Am J health promotion 1998,12(6):363-8

20. Crespo C et al. Obesity and its relation to physical activity and Television watching among US children. Med Sci Sports Exerc 1998;30(5):supple:p 80. In Granich et al. Understanding Children’s sedentary behaviour: a qualitative study of the family home environment. Health education research,2010,125(2)199-210

21. Lanhuis CE et al. Does childhood television viewing lead to attention issues in adolescence? Results from a prospective longitudinal study. Pediatrics 2007;120:532-7

References 22-35 available on request.