Consequences of inattention

1
Consequences of inattention

• Incomplete assignments, messy works, careless
  errors
• Tuning out activities that are dull and
  uninteresting
• Losing track of conversations, not listening to
  directions

2
Six or more of the ff symptoms of Hyperactivity
impulsivity gt 6 mos and is maladaptive and
inconsistent with developmental level

• Hyperactivity
• Fidgets with hands /feet, squirms
• Leaves seat in classroom
• Runs about or climbs excessively in situations
  where it is inappropriate
• Has difficulty playing quietly
• Talks excessively
• Often on the go, driven by a motor

3
Issues in Hyperactivity

• Most visible sign
• Always on the go
• As these children get older, they exhibit
  excessive fidgeting and restlessness rather than
  gross motor activity

4
Six or more of the ff symptoms of Hyperactivity
impulsivity gt 6 mos and is maladaptive and
inconsistent with developmental level

• Impulsivity
• Has difficulty awaiting turn in games or group
  situations
• Blurts out answers to questions before they have
  been completed
• Interrupts or intrudes on others

5
CLINICAL PICTURE
Course of the Disorder Psychosocial
Impairments
Functional Impairments SELF low self esteem
accidents substance abuse
delinquency SCHOOL- academic
difficulties
underachievement HOME- Family
stress Parenting difficulties SOCIAL
- Poor peer relation ships
Symptom domains Inattention
Hyperactivity Impulsivity

Lead to
Psychiatric Co-morbidities Conduct
disorder Oppositional Defiant Disorder Anxiety
and Mood Disorders
Zuddas, ADHD in Europe, 2004
6
Low self esteem, poor social skills , challenging
behavior
Substance abuse School Extension Mood
disorder Conduct disorder Complex LD
UNMANAGED ADHD leads to COMPLICATIONS
ADHD only
Disruptive behavior
ODD LD
Age 6
10 14-16
Adapted from American Psychiatric Association m
DSM IV TR 2000
7
How is a diagnosis made?

• Look for alarm signals
• Exclude ADHD lookalikes
• Use some objective pointers towards diagnosis
• Take a detailed history tuned to the subtleties
  of ADHD

8
ADHD ADHD lookalikes

• Normal active preschooler
• Intellectual disability
• Hearing impaired child
• Specific learning disabilities
• Autism Aspergers syndrome
• Family dysfunction

9
ADHD Alarm signals

• Underfunctions at school inspite of normal
  intellect and no major learning disabilities (
  chronic underachiever)
• ADHD package of behavior problems inspite of
  equal love and discipline at home

10
DIAGNOSISReactions in Families

• Common reactions
• Adjustment
• Changing values
• A sense of loss
• Loss of independence
• Comparative neglect of other family relationships
• Lack of respite
• Nally, The National Autistic Society 1999

He is different
He is helpless
I knew something was wrong
Should I give up my job??
11
The Importance of
Developmental Screening

HISTORY
Neuro exam
RISK FACTORS
PE
Developmental Screening
REFER IF SUSPECT
REPEAT AND REFER IF SUSPECT
WATCH
12
ADHD Treatment Goals

• Decrease disruptive/setting inappropriate
  behaviors
• Improve relationship with parents, siblings,
  teachers or peers
• Improve academic performance
• Improve self esteem
• Improve organizational skills and overall
  executive functioning

American Academy of Child and Adolescent
Psychiatry, 2004
13
ADHD Treatment Goals

• Recognize and treat co-existing conditions
• In most cases of ADHD comorbidity an initial
  stimulant trial is warranted
• In cases of ADHD severe depression or
  psychosis, the comorbidity should be treated
  first. Stimulants may still be given later.

Greenhill, L. J A, Acad Child Adol Psych, 2002
14
ADHD Treatment Options

• Educational Accomodations
• Classroom placement, special education, tutoring,
  private schools
• Behavior Therapy
• Parent training, social skills training, behavior
  modification, daily report card
• Medications
• Stimulants, nonstimulants, tricyclic
  antidepressants

15
ADHD Non standard therapies
HYDROTHERAPY
Promotes relaxation, improves function and
coordination
OCCUPATIONAL THERAPY
VITAMINS
16
Stimulants When to prescribe?

• There is no black and white test for this
• Depends on severity of ADHD, predominant
  behavior, degree of learning difficulties, how
  well parents and school are managing

17
Medication in ADHD a quick guide

• First line
• Stimulants Methyphenidate, Dexamphetamine
• Second line
• Non-stimulants Clonidine, Imipramine,
  Risperidone, Moclobemide

18
FDA-Approved Pharmacotherapy
Stimulant Medications

• Methylphenidate
• Ritalin
• Concerta
• Ritalin LA
• Methylin
• Focalin
• Metadate CD
• Amphetamine Mixed Salts
• Adderall
• Aderall XR

Not available in drugstores
19
ADHD Issues in the use of Medications

• Decision to treat the ADHD child is based
  foremost on a diagnosis of ADHD
• The childs physical examination and medical
  history must reveal no medical contraindication
  for treatment
• Patient should be at least 6 years old
• Administration of medication must be supervised
  by an adult

20
Stimulants What do they do?

• Increases the neurotransmitter chemicals dopamine
  and noradrenaline in certain parts of the brain
• They are not new ( 1937 but widely used in 1950)
• They are NOT SEDATIVES

21
Stimulants benefits and side effects

• BENEFITS
• Reduces restlessness
• Improves classroom productivity
• Increase self monitoring and accuracy
• Less impulsive and disruptive
• Neater work

• SIDE EFFECTS
• Withdrawn, teary , upset
• Appetite reduction
• Tics ( 30)
• Sleep problems
• Rebound behavior
• Headache/stomach ache ( rare)

22
What if stimulants dont work?

• 90 will respond to stimulant medication
• When a trial of medication has failed, check
  dosage and response before trying another drug
  preparation
• Otherwise go to second line drugs
• Stimulants do not cure dyslexia and has no
  effect on hostile behaviors of ODD

23
Teacher tribulations Other therapies

• Parent training
• Classroom management
• Cognitive behavioral training
• Group social skills training

24
Prognosis of ADHD

• Symptoms of ADHD persist throughout childhood
• 70 continue to have the disorder in adolescence,
  with 10-60 to adulthood
• More likely to persist in those with aggression
  or conduct problems
• Untreated adults have increased incidence of
  aggressive behavior, antisocial and conduct
  disorder, divorce, alcohol and drug abuse

25
Life Expectancy

• Adults with ADHD may achieve lower socioeconomic
  status and have more marital problems than do the
  general population
• They have the same life expectancy

26
The Spectrum of Developmental
Disabilities

• PRIMARY DIAGNOSIS
• Down syndrome
• Mental retardation

27
The Continuum of Developmental
Disabilities

• Associated Dysfunctions
• Mental retardation
• Hearing impairment
• Visual impairment
• Epilepsy
• Attention and hyperactivity issues

28
Gaps in Management

• The burden of
• illness
• Resources
• Expertise
• Cost

29
Next Steps Prevention
Preparation for parent hood Optimal prenatal
care Newborn screening Developmental
screening Early intervention
30

Working collaboratively with parents

• Active participation of parents in problem
  solving
• improved cooperation between families and
• professionals
• The need for and value of early education in
• autism
• Parent training programs
• Parent empowerment is a key to coping and an
• essential step towards healing

31
Developmental Disabilities
Down Syndrome
Autistic Spectrum Disorders
Learning Disabilities
Birth---Infancy-----Early Childhood----School Age
---Adolescence
Cerebral palsy
ADHD
32
The real voyage of discovery lies not in seeking
new landscapes, but in having new eyes Marcel
Proust