ADHD AND OTHERS

ATTENTION DEFICIT HYPERACTIVITY DISORDER

      

           Attention Deficit Hyperactivity disorder (ADHD) is an early onset, biological disorder, classically characterized by a triad of symptoms: hyperactivity, inattention and impulsivity. These 3 symptoms are persistent and at developmentally inappropriate levels.

HISTORY OF ADHD

18th century

        In 1798, a Scottish-born physician and author, Sir Alexander Crichton (1763–1856), described inattentive subtype of ADHD In the chapter "Attention", Crichton described a "mental restlessness".

       Dr. Heinrich Hoffman in 1845 first described ADHD in a children’s book, “The Story of Fidgety Philip,” which contained an accurate description of a child with attention deficit hyperactivity disorder.

20th century

         On 4th, 6th and 11th March 1902, the father of British pediatrics Sir George Frederick Still (1868–1941) .He was describing ADHD over 100 years ago. He called it "Morbid Defect of Moral Control."

          In 1922 the name ADHD was changed to "Post-Encephalitic Behavior Disorders" and "Minimal Brain Dysfunction" in 1960. The term "Attention Deficit Disorder +/- Hyperactivity" (now ADHD) came into being, after "Hyperkinetic Reaction" in 1968.

            In the 1960's and '70's much of the focus on ADHD was on hyperactivity, with an awareness of the "daydreaming" and distractibility coming only in the 1980's.

          In 1980 the National Institutes of Mental Health recognized Attention Deficit Disorder with or without Hyperactivity as a disorder. ADHD was on its way to becoming recognized as a "real" illness.

          The term Attention Deficit Disorder was renamed in 1994 by theAMERICAN PSYCHIATRIC ASSOCIATION.

         In 1998 the American Medical Association (AMA) stated that ADHD is "one of the best-researched disorders in medicine."

DEFINITION OF ADHD

According to the 1994, Diagnostic and Statistical Manual of Mental Disorders, Ed. IV, (DSM-IV)

         ADHD is a Disruptive Behavior Disorder characterized by the presence of a set of chronic and impairing behavior patterns that display abnormal levels of inattention, impulsiveness, hyperactivity, than what is usual for their age. These behaviors contribute to significant problems in relationships, learning and behavior. For this reason, children who have ADHD are sometimes seen as being "difficult" or as having behavior problems.

It’s a childhood mental disorder with onset before 7 years of age and involving impaired or diminished attention, impulsivity, and hyperactivity. Also calledhyperactive child syndrome in the twentieth century.

A National Institute of Neurological Disorders and Stroke (NINDS/NIH)

          ADHD is a neurobehavioral  developmental disorder. ADHD is generally achronic disorder. It is characterized by a persistent pattern of impulsiveness and inattention, with or without a component of hyperactivity. These characteristics arise in early childhood, typically before age 7, are chronic, and last at least 6 months. Children with AD/HD may also experience problems in the areas of social skills and self esteem.

Glossary - Pediatrics

          ADHD Characterized by a very short attention span, impulsiveness, and hyperactivity. (ADHD) - A syndrome (a group of symptoms or signs) that is usually characterized by serious and persistent difficulties, resulting in inattentiveness or distractibility, impulsivity, and hyperactivity.

INCIDENCE

        ADHD is twice as common in boys as in girls. The ADHD/HD worldwide-pooled prevalence was 5.29%. This means in a class of 25 to 30 students, it is likely that at least one student will have this common condition.

         NIMH estimates that between

                  3% and 5% of preschool age children and

                  4% to 12% of school aged children with

                  30% to 50% of individuals diagnosed in childhood continuing to have symptoms of ADHD into adulthood.

As of 2003:

·        Approximately 4.4 million children ages 4 to 17 were reported to have a history of ADHD diagnosis.

       In India it was found that the prevalence of ADHD increases with age; the prevalence at the age of 3-4 years was 5.2% [ARCHIES OF IRANIAN MEDICINE 2007] the prevalence rate of ADHD ranges from 10%-20%.In India among children between the age of 3 to 12 years [INDIAN PAEDIATRICS 2000].

CLASSIFICATION OF ADHD ACCORDING TO DSM-IV

ADHD: Predominantly hyperactive-impulsive

·        Most symptoms (six or more) are in the hyperactivity-impulsivity categories.

·        Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.

ADHD: Predominantly inattentive

·        Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.

ADHD: Combined hyperactive-impulsive and inattentive

·        Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.

·        Most children have the combined type of ADHD.

SYMPTOMS OF ADHD

             Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age.

Children who have symptoms of inattention may:

·        Be easily distracted, miss details, forget things, and frequently switch from one activity to another

·        Have difficulty focusing on one thing

·        Become bored with a task after only a few minutes, unless they are doing something enjoyable

·        Have difficulty focusing attention on organizing and completing a task or learning something new

·        Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities

·        Not seem to listen when spoken to

·        Daydream, become easily confused, and move slowly

·        Have difficulty processing information as quickly and accurately as others

·        Struggle to follow instructions.

·        inability to pay attention to details or a tendency to make careless errors in schoolwork or other activities

·        difficulty with sustained attention in tasks or play activities

·        apparent listening problems

·        difficulty following instructions

·        problems with organization

·        avoidance or dislike of tasks that require mental effort

·        tendency to lose things like toys, notebooks, or homework

·        distractibility

·        forgetfulness in daily activities

Children who have symptoms of hyperactivity may:

·        Fidget and squirm in their seats

·        Talk nonstop

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

·        Have trouble sitting still during dinner, school, and story time

·        Be constantly in motion

·        Have difficulty doing quiet tasks or activities.

·        difficulty remaining seated

·        excessive running or climbing

·        difficulty playing quietly

·        always seeming to be "on the go"

·        blurting out answers before hearing the full question

·        difficulty waiting for a turn or in line

·        problems with interrupting or intruding

Children who have symptoms of impulsivity may:

·        Be very impatient

·        Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences

·        Have difficulty waiting for things they want or waiting their turns in games           often interrupt conversations or others' activities.

CHARACTERISTICS AND SYMPTOM CHECKLIST FOR ADHD SUB –CATEGORIES:

According to DSM-IV

Inattention

·        Often fails to give close attention to details, making careless mistakes in schoolwork or other activities

·        Often has difficulty sustaining attention in tasks or play activities

·        Often appears to not be listening when spoken to directly

·        Often has difficulty following through on instructions; may fail to finish schoolwork, chores, or duties (not due to oppositional behavior or failure to understand instructions)

·        Often have difficulty organizing tasks and activities

·        Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (schoolwork and homework)

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

·        Is often easily distracted by extraneous stimuli

·        Is often forgetful in daily activities.

Hyperactivity

·        Often fidgets with hands or feet or squirms in seat

·        Often leaves seat in classroom or in other situations in which remaining seated is expected

·        Often runs about or climbs excessively in situations in which this is inappropriate

·        Often has difficulty playing or engaging in leisure activities quietly

·        Often is "on the go" or acts as if "driven by a motor"

·        Often talks excessive

Impulsivity

·        Often blurts out answers before questions have been completed

·        Often has difficulty awaiting turn

·        Often interrupts or intrudes on others (during conversations or games).

·        A professional uses this symptom checklist to make the diagnosis of ADHD.

·        Criteria: Inattention or Hyperactivity-Impulsivity Behavior has persisted for at least six months and to such a degree that it is maladaptive and inconsistent with developmental level. Must present with six or more of these symptoms.

CAUSES OF ADHD

          While the exact cause of ADHD remains a mystery, researchers have discovered important differences in the brains of people with ADHD.

        For ex: - Neurotransmitters –the brain’s chemical messengers aren’t used properly in people with ADHD. Additionally, there appears to be less activity in the areas of the brain that control activity and attention in people with ADHD. In addition, brain scans have revealed that, on average, children with ADHD have up to 4% smaller brain volumes than do children without ADHD.

Ø Genetic factors

ADHD is highly heritable and that genetics are a factor in about 75% of ADHD cases. Arise from a combination of various genes, many of which affect dopaminetransporters.

Candidate genes include:

·        Dopamine transporter, dopamine receptor D4,

·        Dopamine beta-hydroxylase, monoamine oxidase A,

·        Catecholamine-methyl transferase, serotonin transporter promoter (SLC6A4),

·        5-hydroxytryptamine 2A receptor (5-HT2A),

·        5-hydroxytryptamine 1B receptor (5-HT1B),

·        The 7-repeat allele of the DRD4 gene, 

·        The dopamine beta hydroxylase gene (DBH TaqI)

·        The 10-repeat allele of the DAT1 gene

Ø Maternal smoking, drug use and exposure to toxins

Pregnant women who smoke are at increased risk of having children with ADHD. Alcohol /Drug abuse during pregnancy may decreases activity of the nerve cells [neurons] that produce neurotransmitters.

Pregnant women who are exposed to environmental poisons. Such as polychlorinated biphenyl’s [PCBs], also may be more likely to have children with symptoms of ADHD. PCBs are industrial chemicals that were widely used in the past.

Ø Childhood exposure to environmental toxins

Preschool children exposed to certain environmental toxins, particularly lead and PCBs are at increased risk of developmental and behavioral problems, many of which are similar to those found in children diagnosed with ADHD.Exposure to lead, which is found mainly in paint and pipes. In older buildings, has been linked to disruptive and even violent behavior and to a short attention span. Exposure to PCBs in infancy may also increase a child’s risk of developing ADHD.

DIAGNOSING OF ADHD

  1. The first step - visiting a specialist

     The first visit is a chance for the clinician to meet the parents and the child. This first visit will also involve the "parent interview" part of the diagnostic process. The interview with the parents will involve questions about the child's past. Questions will deal with issues such as:

• age of symptoms onset
• the child's history
• the child's conduct at home and school
• relationship with parents and other family members
• medical history (both the child and extended family)
• psychosocial adversities (such as poverty, parental absence, family conflict,)

This interview will highlight any possible alternative explanations of the ADHD-like behavior, or additional problems. The child should be involved in this initial visit. This will give the clinician a chance to meet the child, build a rapport, and view first hand any of the ADHD symptoms.

   2. The diagnostic criteria

       Diagnostic criteria outline the symptoms of particular disorders, thus allowing independent doctors to make similar diagnostic decisions concerning a particular patient.

   3.Ratingscales
       During the parent interview process, the parents are usually asked to fill in a "rating scale" of the child's behavior. A rating scale is simply a list of questions (or behaviors) on paper that requires the parent to answer via a range of values.

Commonly used rating scales for ADHD include

• Conner’s Teacher and Parents Rating scales (CTRS,CPRS)
• ADD-H Comprehensive teacher rating scale (ACTeRS)
• Child Attention Problems (CAP) Rating scale
• The Child Behavior Checklist (CBCL) 
• Vander built parent and teacher rating scales

    4.School-relatedassessment
       It is essential to gather reports of behavior across different settings. The most commonly used setting other than the home or clinician's office is the classroom environment.

5. Observation

        Informal observations of the child in their natural settings (home, office, classroom, or playground) can provide important information regarding the child's behavior, useful for the treatment programmer.

   6.Tests
        while there is no single test for ADHD, there are several tests that can be conducted and the results can be compared with average results. These tests are useful in differentiating between the 3 sub groups of ADHD. They measure how long the child can maintain their attention and how impulsive the child can be over time.

Test that used in diagnosing ADHD:

• The Conners' Continuous Performance Test
• The Stroop test
• The Integrated Visual and Auditory Continuous Performance Test (IVA)
• The Gordon Diagnostic Systems
• Yale Children's Inventory (YCI)
• Attention Battery (includes Continuous Performance Task Progressive Maze Test and Sequential Organization Test (SOT)
• Wechsler Intelligence Scales for Children (WISC-R)
• T.O.V.A - Test of Variables of Attention
• Learning Efficiency Test II (LETT-II)
• Developmental Test of Visual Motor Integration (VIM)
• Wide Range Achievement Test (WRAT-R)

    7. Medical evaluation

     Conducted by a qualified pediatric specialist. The medical evaluation is basically conducted to rule out other disorders that have similar symptoms,

 Such as:

• Thyroid dysfunction
• Fragile X syndrome
• Fetal Alcohol Syndrome (FAS)
• G6PD deficiency
• Phenylketonuria (PKU) 

TREATEMENTS OF ADHD

Pharmacological drugs

        Some medicines used to treat ADHD are called psycho stimulants and "controlled" drugs. It’s best to take the medicine 30 to 45 minutes before a meal.

Medicines for ADHD are methylphenidate

          Ritalin,Concerta, dextroamphetamine, Norpramin, Imipramine,Tofranil buproprion,Wellbutrin.

Occupational therapy in ADHD

      Children and adults with ADHD often greatly benefit from counseling/ behavior therapy, which may be provided by a psychiatrist, psychologist,occupational therapy, social worker /other mental health care professionals. Some people with ADHD may also have other conditions such as anxiety disorder/ depression. In these cases, counseling may help both ADHD and the coexisting problems.

 Counseling therapies may include;

       Psychotherapy, behavioral therapy, family therapy, social skill training, support group, parenting skills training.

Ø Behavior therapy

      When looking to control the behavior of a child, to begin by clarifying what the child likes (rewards) and dislikes (punishments).
For most children rewards will involve:

• Television
• Play time/time with friends
• Computer games
• Sweets & Lollies
• And lots more...

Likewise, for most children punishments will involve:

• Chores (e.g. Cleaning up one's bedroom)
• Homework
• Timeout
• And lots more...

Second step: Using Rewards and Punishments
by defining, rewards and punishers, one can control the behavior of a child with great success by simply applying or removing punishments and rewards.

Some Simple Behavioral Interventions

Children with ADHD may need help in organizing. Therefore:

·        Schedule. Have the same routine every day, from wake-up time to bedtime. The schedule should include homework time and playtime (including outdoor recreation and indoor activities such as computer games). Have the schedule on the refrigerator or a bulletin board in the kitchen. If a schedule change must be made, make it as far in advance as possible.

·        Organize needed everyday items. Have a place for everything and keep everything in its place. This includes clothing, backpacks, and school supplies.

·        Use homework and notebook organizers. Stress the importance of writing down assignments and bringing home needed books.

Ø Family therapy

·        Make a schedule. Encourage the parents to set specific times for waking up, eating, playing, doing homework, doing chores, watching TV or playing video games, and going to bed. Post the schedule where the child will always see it. Have to explain the changes to the routine in advance.

·        Make simple house rules. It's important to explain what will happen when the rules are obeyed and when they are broken. parents should Write down the rules and the results of not following them.

·        Make sure the directions are understood. Get the child's attention and look directly into his or her eyes. Then tell the child in a clear, calm voice specifically what they want. Keep directions simple and short. Ask the child to repeat the directions back .

·        Reward good behavior. Congratulate the child when he or she completes each step of a task.

·        Make sure the child is supervised all the time. Because they are impulsive, children who have ADHD may need more adult supervision than other children their age.

·        Watch the child around his or her friends. It's sometimes hard for children who have ADHD to learn social skills. Reward good play behaviors.

·        Set a homework routine. Pick a regular place for doing homework, away from distractions such as other people, TV and video games. Break homework time into small parts and have breaks.

·        Focus on effort, not grades. Reward the child when he or she tries to finish school work, not just for good grades. They can give extra rewards for earning better grades.

·        Talk with the child's teachers. Find out how the child is doing at school-in class, at playtime, at lunchtime. Ask for daily or weekly progress notes from the teacher.

Ø Individual therapy

        Once diagnosed, ADHD children themselves may need counseling. This counseling would focus on:

• Low self esteem
• Demoralization
• Compliance to treatment
• Relationship issues
• Adaptation to issues created by ADHD

Ø Social skills training.

         Helps children to learn new behaviors. The therapist discusses and models appropriate behaviors important in developing and maintaining social relationships, like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance to practice.

      For ex:-a child might learn to “read” other people’s facial expression and tone of voice in order to respond appropriately. Social skill training helps the child to develop better ways to play and work with other children.

Ø Support groups

         Help parents connect with other people who have similar problems and concerns with their ADHD children. Members of support groups often meet on a regular basis (such as monthly) to hear lectures from experts on ADHD, share frustrations and successes, and obtain referrals to qualified specialists and information about what works.

Ø Parenting skills training

         Offered by therapists or in special classes, gives parents tools and techniques for managing their child’s behavior. One such technique is the use of token or point systems for immediately rewarding good behavior or work. Another is the use of “time-out” or isolation to a chair or bedroom when the child becomes too unruly or out of control. During time-outs, the child is removed from the agitating situation and sits alone quietly for a short time to calm down. Parents may also be taught to give the child “quality time” each day, in which they share a pleasurable or relaxing activity. During this time together, the parent looks for opportunities to notice and point out what the child does well, and praise his or her strengths and abilities. This system of rewards and penalties can be an effective way to modify a child’s behavior.

Ø Experimental treatment

·        Biofeedback

·        Brain wave feed back

·        Special diets and supplements

Ø Alternative treatment

A number of other alternative therapies are promoted and tried by parents including: Megavitamins, Body treatment, diet manipulation, allergy treatment, chiropractic treatment, SI, alert programme, AIT.

INATTENTION:

           Lack of attention or reduced attention span. Common in ADHD children.

Characteristics of Inattention in Children with ADHD

Ø They seem to not listen. Children may often seem as if they are not listening when someone speaks to them. Often they are simply distracted by the many things going on around them. They may just be having a hard time focusing on the conversation.

Ø Trouble following directions. This may occur for a number of reasons. The child may have gotten distracted while being given directions and therefore did not hear all of the instructions. They may get distracted while following the directions and begin a new task completely. Or they may become distracted and then forget what they were doing and what they are supposed to be doing next.

Ø Lack of organization. Children may have problems working through the steps needed to complete a project. They may have a hard time organizing their thoughts in a logical manner. Many children with ADHD are conceptual thinkers, and although they can visualize the end result, they may not be able to break the task down into simple steps.

Ø Failure to complete tasks. Children that are easily distracted often move from one task to another. They may completely forget what they were doing first and move on to another activity.

                 FOR EX: They may begin to do their homework, get up to sharpen a pencil and start to play with the dog, become distracted again and go and get a snack.

IMPULSIVITY [IMPULSIVENESS]     

            It is a type of human behavior characterized by the inclination of an individual to act on impulse rather than thought. Although part of the normal behavior, impulsivity also plays a role in many mental illnesses. People, who are overly impulsive, seem unable to curb their immediate reactions or think before they act. As a result, they may blurt out answers to questions or inappropriate comments, or run into the street without looking. It is hard for a child to wait for things they want or to take their turn in games.

  FOR EX:   They may grab a toy from another child or hit when they are upset.

Impulsivity can be decomposed as a combination of

·           Attentional ("getting easily bored"),

·           Motor ("going into action")

·           Cognitive ("inability to plan") factors.

Recent theories

•  Urgency, the feeling of negative affects for resisting the urge, is linked to neuroticism
• Lack of premeditation, the inability to anticipate consequences, is linked to conscientiousness
• slack of perseverance, the inability to stick to one's task, is also linked to conscientiousness
• Sensation-seeking, the experience positive feelings towards risky actions, is linked to extraversion

It may be linked to other psychopathological conditions like addiction, ADHD,bulimia, and borderline personality.

Impulsivity is found in two areas:

·        Behavioral Impulsivity - the things that you do

·        Cognitive Impulsivity - the way that you think and make choices

Behavioral Impulsivity

ADHD individuals with behavioral impulsivity don't stop and think first before they act.

ADHD children with behavioral impulsivity often:

·        Act without thinking first,

·        Cut in line,

·        Can’t wait their turn in line or in a game,

·        Blurt out answers in class,

·        Speak when they're supposed to be quiet,

·        May show aggressive behaviors,

·        Are often a little too loud,

·        Sometimes fight,

·        Often have poor social skills, which of course is the death socially for teenagers with ADHD,

·        Impulsively say the wrong thing at the wrong time.

Cognitive Impulsivity

       Cognitive impulsivity means that they guess a lot. Guessing is their problem solving method of choice. Cognitively impulsive ADHD kids will make a multiple number of guesses in a short period of time. Cognitively impulsive ADHD kids have very limited problem solving strategies. Being fast and accurate is not a problem. Fast and inaccurate is a problem with these kids