Struwwelpeter

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Struwwelpeter By Heinrich Hoffmann
The Story of Fidgety Philip
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See the naughty, restless child, Growing still
more rude and wild, Till his chair falls over
quite. Philip screams with all his might,
Catches at the cloth, but then That makes
matters worse again. Down upon the ground they
fall, Glasses, bread, knives forks and all. How
Mamma did fret and frown, When she saw them
tumbling down! And Papa made such a face!
Philip is in sad disgrace.
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This poem, about a little boy with attention
deficit hyperactivity disorder, was written by
Dr. Heinrich Hoffman, a physician who wrote books
on medicine and psychiatry. He first described
ADHD in 1845. Since then, there has been much
research on medications, behavioral
interventions, and educational options for those
diagnosed with this disorder.
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Attention Deficit Hyperactivity DisorderBy
Jennifer Kirkendall

• Also known as ADHD
• Developmental disorder featuring maladaptive
  levels of inattention, excessive activity, and
  impulsiveness.
• One of the most common reasons children are
  referred to mental health services in the US

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• DSM-IV-TR
• Diagnostic Criteria
• Six or more symptoms of inattention, persisting 6
  months or more, such as careless mistakes in
  school, difficulty sustaining attention in tasks
  or at play, often appearing not to listen when
  spoken to, failure to follow through with
  schoolwork or chores, frequent difficulty
  organizing tasks and activities, avoids/dislikes
  tasks that require sustained mental effort, often
  loses things necessary for tasks or activities,
  easily distracted, often forgetful.
• Six or more symptoms of hyperactivity and
  impulsivity, persisting 6 months or more, such
  as
• Hyperactivity-frequent fidgeting with hands or
  feet or squirming in seat, often leaves seat in
  classroom, often running or climbing at
  inappropriate times, difficulty engaging quietly
  in leisure activities, excessive talking
• Impulsivity-blurting out answers before questions
  have been finished, trouble waiting ones turn,
  interrupts or intrudes on others
• Inattention, hyperactivity, and impulsivity are
  maladaptive and inconsistent with developmental
  level
• Some of the symptoms present before age 7
• Some impairment from symptoms is present in two
  or more settings
• Significant impairment in functioning

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• 3 Subtypes
• Predominantly hyperactive-impulsive type does
  not show significant inattention
• Predominantly inattentive type does not show
  significant hyperactive-impulsive behavior
• Combined type displays both inattentive and
  hyperactive-impulsive symptoms
• Note Adults often continue to be impaired by
  ADHD. They are currently diagnosed under the
  same criteria. Usually have more symptoms of
  inattention and fewer of hyperactivity or
  impulsiveness than children. Most often
  suffering in areas of self-control,
  self-motivation and executive functioning

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• Current Issues with Diagnosis
• There needs to be more research on diagnosing
  females and adults with this disorder
• Over-diagnosis of children
• Co-morbid Disorders
• Oppositional Defiance Disorder-as many as 1/3-1/2
  (mostly boys)
• Learning Disorder-20-30
• Tourette Syndrome-a small portion
• Conduct Disorder-20-40 may develop
• Anxiety and Depression-Some, if treated can
  better cope with ADHD
• Biopolar Disorder-No statistics

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• Differential Diagnostic Considerations
• Medical Disorders Sensory impairment (visual or
  auditory), Seizure disorders, Lead poisoning,
  Iron deficiency anemia, Thyroid disorders,
  Substance abuse, Sleep disorder, Fetal alcohol
  syndrome, Tourette Syndrome, Sequelae of
  infection/trauma (an abnormal condition resulting
  from a previous disease
• Developmental Disorders/Differences Cognitive
  impairment, Giftedness, Learning disabilities,
  Perceptual/processing disorders, Pervasive
  developmental disorders, Fragile X syndrome,
  Normal variation
• Emotional/Behavioral Disorders Depression or
  other Mood disorders, Anxiety disorders,
  Oppositional defiant disorder, Conduct disorder,
  Adjustment disorder
• Environmental Disorders Child abuse or neglect,
  Inadequate parenting, Inappropriate educational
  setting, stressful home environment, negative
  responses from parents, teachers and peers
  affected by a childs impulsivity and
  hyperactivity may contribute to low self-esteem,
  frequently getting into trouble for their
  behavior may produce a negative self-image

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• Typical Course
• Chronic
• First identified as different from their peers
  around age 3 or 4
• Disorder is usually first diagnosed in school-age
  children
• Stable through early adolescence
• Over time impulsivity lessens, but inattention
  continues
• 68 continue on to experience problems into
  adulthood

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• Statistics
• Prevalence
• 4-8 in school-age children
• Incidence
• The number of children diagnosed with the
  disorder has definitely increased over the last
  15 years. This may be due to a couple of
  different reasons
• Researchers suggest that children are being
  labeled much too quickly and without proper
  testing.
• The change in criteria for ADHD from DSM-III-R to
  DSM-IV because of the inclusion of the
  Predominantly Hyperactive-Impulsive and
  Predominantly Inattentive Types (which would have
  been diagnosed as Attention-Deficit Hyperactivity
  Disorder Not Otherwise Specified in DSM-III-R)

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• Demographic Data
• Age
• First identified as different from their peers
  around age 3 or 4
• Approximately, 6 of school aged children
• Approximately, 68 of those diagnosed as children
  continue to be affected into adulthood
• Gender
• Boys outnumber girls from 21 to 91 depending on
  the type. The significant difference is possibly
  due to susceptibility, parent tolerance for
  girls, and/or different presentation in boys vs.
  girls
• Culture/Ethnic
• Historically there has been a significant
  difference in the number of people diagnosed with
  this disorder in the US compared to other
  countries, but this is changing as education is
  spread worldwide

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• Etiology
• Biological
• More common in families with one person having
  the disorder, suggesting that shared genetic
  deficits may contribute
• More than one gene is probably responsible
• Most research to date has focused on genes
  associated with the neurochemical dopamine.
  Specifically dopamine D4 receptor gene, dopamine
  transporter gene, and dopamine D5 receptor gene
• New research is showing that the neurochemicals
  norepinephrine, serotonin and GABA are also
  implicated in the cause of ADHD
• Brain size is smaller (in particular the frontal
  cortex, basal ganglia and cerebellar vermis)
• Psychological/Social
• Mothers who smoke or drink alcohol while pregnant
  are 3 x more likely to have a child with ADHD
• High levels of lead (living in old buildings
  where there might be lead in paint and/or
  plumbing

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• Treatment
• Biological
• Biological treatments work at reducing
  inattention, impulsivity and hyperactivity
• Atomoxetine (Strattera) a non-stimulant
  medication currently being tested
• Tricylic Antidepressants (imipramine and
  desipramine) but sudden death is an issue due to
  cardiac side effects
• Most common medications prescribed are
  psychostimulants. Stimulant medication reduces
  hyperactivity and impulsivity and improves
  concentration
• Methylphenidate (Ritalin, Metadate, Concerta)
• D-amphetamine (Dexedrine, Dextrostat)
• Pemoline (Cylert)-has the greatest number of side
  effects
• Adderall, a longer-lasting psychostimulant,
  reduces the need for multiple does, but has the
  same positive effects
• Amphetamines like Adderall displace noradrenaline
  from the presynaptic neuron and do not act as
  reuptake inhibitors. The increased flow of
  dopamine and norepinephrine into the
  extraneuronal space causes the patients brain to
  experience a more intense level of concentration,
  causing an increased ability to focus for
  extended periods of time, and a heightened
  interest in performing focus based tasks
• Issues with This Type of Treatment

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• Treatment Continued
• Psychosocial
• Psychosocial treatments work towards improving
  academic performance, decreasing disruptive
  behavior and improving social skills
• Reinforcement Programs work by rewarding the
  child for improvements and punishing for
  incorrect behavior. Such tasks are worked on by
  setting goals for such things as
• 1. Increasing the amount of time one stays in
  their seat
• 2. The number of assignments completed
• 3. Appropriate play with peers
• Behavior therapy is used to work with parents and
  teachers to teach them how to respond
  constructively to misbehavior and how to
  structure the day to prevent problems
• Issues with this Type of Treatment
• It doesnt offer short-term results

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• Treatment Continued
• Combined Treatment
• Both Biological and Psychological/Social
  contributions need to be addressed when designing
  treatment for ADHD for several reasons
• Medication offers short-term gains, while
  psychotherapy offers more long-term gains
• Not all children respond to medication
• Not all children respond to psychosocial
  treatment
• But mainly because their behavior and the
  attempts at controlling it can cause those
  suffering from ADHD to be rejected by parents,
  teachers, and peers, which in turn, contributes
  to a poor self-image

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• Current Controversies
• Over-diagnosis in children
• Use of stimulant medication in children, leads to
  future substance abuse problems
• There needs to be more research on ADHD in girls
  because their symptoms may be quite different
• There needs to be more research on ADHD in adults
  because diagnosis is more difficult, their
  symptoms are different, and medication for
  children vs adults may need to be different