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  1. 1. IDENTIFYING AND TREATING ADHD - A RESEARCH FOR SCHOOL AND HOME Presented by Guided by Dr Harish Kumar singhal Prof Abhimanyu Kumar M.D Scholar Head of Department Department of Bal Roga Department of Bal Roga N.I.A,JAIPUR N.I.A, JAIPUR
  2. 2. INTRODUCTION <ul><li>ADHD has many faces and remain one of most talked about and controversial subjects in education. Hanging in balance of heated debates over medication diagnostic methods and treatment options are children, adolescents and adults who must manage the condition and lead productive life on a daily basis. </li></ul><ul><li>ADHD is a neurological condition that involves problem with inattention and hyperactivity - impulsivity that are developmentally in consistent with age of child. </li></ul>
  3. 3. <ul><li>ADHD is not a disease of attention as had long been assumed. Rather it is a function of a developmental failure in the brain circuitry and monitors inhibition and self control. The high energy level and subsequent behavior are often misperceived as purposeful non-compliance when infact they may be a manifestation of disorder and require specific intervention. </li></ul>
  4. 4. PREVALANCE <ul><li>In United States - an estimated 1.46 to 2.46 million children (3-5% of student population have ADHD. (APA, 1994, Anderson et al., 1987) </li></ul><ul><li>ADHD affect 3-7% of all children in U.S. as per DSM IV-TR, 2000 edition. </li></ul><ul><li>Indian scenario has showing a prevalence rate 5-10% in school going children (P. Malthi, et al., 2001) </li></ul><ul><li>Males are 4 to 9 times more likely to be diagnosed and disorder is found in all culture although prevalence figures differ from Cross and Ross, 1992 </li></ul><ul><li>Male to female ratio was 6.4:1 (Maya Mukhopadhyaya, et al., 2003) </li></ul>
  5. 5. MODERN CAUSES <ul><li>It is still unclear what the direct and indirect causes of ADHD. Although scientific and technological advances in field of neurological imaging technique and genetics promise to clarity this issue in near future. </li></ul><ul><li>A 1996 study conducted at NIMH, found that the right prefrontal cortex and at least 2 of clusters of nerve cells known collectively as basal ganglia are significantly smaller in children with ADHD (Barkley et al., 1998). </li></ul><ul><li>Some nongenetic factor been linked to ADHD including premature birth, maternal alcohol and tobacco use, high level of exposure to lead. And prenatal neurological damage. Although some people claim that food addiness - sugar, yeast or poor child rearing methods lead to ADHD. (Neuwirth, 1994, NIMH, 1999). </li></ul>
  6. 6. AYURVEDIC CAUSES <ul><li>Sahaja; </li></ul><ul><li>Garbhaja </li></ul><ul><li>Ajarajanya </li></ul><ul><li>Mansika </li></ul><ul><li>Agantuja </li></ul>
  7. 7. CLASSIFICATION <ul><li>Behavioral and emotional disorder have been divided into two broad groups </li></ul><ul><li>Externalizing </li></ul><ul><li>Internalizing disorder </li></ul><ul><li>Children with ADHD typically exhibit behavior that is classified into two main categorizes - </li></ul><ul><li>Poor sustained attention </li></ul><ul><li>Hyperactivity impulsiveness </li></ul><ul><li>As a result, 3 subtypes have been proposed by AMA in DSM IV - </li></ul><ul><li>Predominantly in attentive </li></ul><ul><li>Predominantly hyperactive impulsive </li></ul><ul><li>Combined type. </li></ul>
  8. 8. IDENTIFICATION OF ADHD <ul><li>The criteria set forth by DSM IV are used as standardization clinical definition to determine presence of ADHD. </li></ul><ul><li>A person must exhibit several characteristics to be clinically diagnosed as having ADHD. </li></ul><ul><li>*Severity - The behavior in question must occur more frequently in the child than in older children at the severe developmental stage. </li></ul><ul><li>*Early onset - At least some of symptoms must have been present prior to age. </li></ul><ul><li>*Duration - symptoms must also have been preventing for all least 6 months prior to evaluation. </li></ul><ul><li>*Impact - symptoms must have a negative impact on child's academic /social life. </li></ul><ul><li>*Setting - symptoms must be present in multiple setting </li></ul>
  9. 9. COMPONENTS OF A COMPREHENSIVE EVALUATION <ul><li>Behavioral </li></ul><ul><li>Educational </li></ul><ul><li>Medical </li></ul>
  10. 10. BEHAVIORAL EVALUATION <ul><li>Specific questionnaires and rating scales are used to revive and quantify the behavioral characteristics of ADHD. They suggest using ADHD -specific rating scales including - </li></ul><ul><li>CPRS-R: L-ADHD Index </li></ul><ul><li>CTRS-R: L-ADHD Index </li></ul><ul><li>CPRS-R: L-DSM-IV Symptoms </li></ul><ul><li>CTRS-R: L-DSM-IV- Symptoms </li></ul><ul><li>SSQ-O-I </li></ul><ul><li>SSQ-O-II </li></ul>
  11. 11. EDUCATIONAL EVALUTION <ul><li>An educational evaluation assesses the extent to which a child's symptoms of ADHD impair his or her academic performance at school. The evaluation involves direct observations of the child in the classroom as well as a review of his or her academic productivity. </li></ul><ul><li>It is best to collect this information during two or three different observations across several days. Each observation typically lasts about 20 to 30 minutes </li></ul>
  12. 12. MEDICAL EVALUATION <ul><li>Medical evaluation assesses whether the child manifesting symptoms of ADHD, based on the following three objectives - </li></ul><ul><li>To assess problems of inattention, impulsivity and hyperactivity that the child is currently experiencing </li></ul><ul><li>To assess the severity of these problems </li></ul><ul><li>To gather information about other disability that may contributing to the child's ADHD symptoms. </li></ul>
  13. 13. Contd…. <ul><li>In May 2000, the American Academy of Pediatrics (AAP) published a clinical practice guideline that provides recommendations for the assessment and diagnosis of school-aged children with ADHD. The recommendations are designed to provide a framework for diagnostic decision making and include the following - </li></ul><ul><li>Medical evaluation for ADHD should be initiated by the primary care clinician, questioning parents regarding school and behavioral issues, either directly or through a pre-visit questionnaire, may help alert physician to possible ADHD. </li></ul><ul><li>In diagnosing ADHD, physicians should use DSM-IV criteria. </li></ul><ul><li>The assessment of ADHD should include information obtained directly from parents or caregivers, as well as a classroom teacher o r other school professional, regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms and degree of functional impairment </li></ul>
  15. 15. BEHAVIORAL MODIFICATION <ul><li>Dividing large assignment into smaller more manageable tasks. </li></ul><ul><li>Providing records for completing certain task. </li></ul><ul><li>Rewarding good behaviour instead of punishing bad. </li></ul>
  16. 16. PHARMACOLOGICAL APPROCH <ul><li>It includes :- </li></ul><ul><li>*Psycho stimulants </li></ul><ul><li>*Antidepressants </li></ul><ul><li>*Anti-anxiety </li></ul><ul><li>*Antipsychotic </li></ul><ul><li>*Mood stabilizers (NIMH 2000) </li></ul><ul><li>Stimulants predominate in clinical use and have been found to be effective with 75 - 90% of children with ADHD (DHHS 1999). </li></ul><ul><li>Stimulants include Methylphenidate (Ritalin), Dextroamphetamine (Dexedrine) and Pemoline (Cylert). </li></ul><ul><li>Other types of medication (Antidepressants, anti-anxiety medications, antipsychotic and mood stabilizers) are used primarily for those who do not respond to stimulants. </li></ul>
  17. 17. ADHD AFFECT SCHOOL PERFORMANCE <ul><li>Studies found that students with ADHD as compared to student without ADHD had persistent academic difficulties that resulted in the following, lower average marks, more failed grades, more expulsions, increased dropout rates and a lower rate of college undergraduates’ completion. </li></ul>
  18. 18. SUGGESTIONS FOR PARENTS <ul><li>Focus on discrete rewards and consequences for appropriate and inappropriate behaviour. </li></ul><ul><ul><li>Tangible rewards and treats. </li></ul></ul><ul><ul><li>Movie night for a good week at school. </li></ul></ul><ul><ul><li>Removal of privileges ; and </li></ul></ul><ul><ul><li>Time-out from reinforcing activities; the child is essentially removed from situation that foster inappropriate behaviour. </li></ul></ul><ul><li>Set a daily routine and stick to it, bedtime and preparation for school are much easier if there is a structure already in place. </li></ul><ul><li>Have tangible reminder - </li></ul><ul><ul><li>A big clock in the bedroom; </li></ul></ul><ul><ul><li>Charts for chores; </li></ul></ul><ul><ul><li>Assignment pad to record homework and a specific folder to put work in upon completion; and </li></ul></ul><ul><ul><li>Gain the child's attention before speaking to him or her. Have the child repeat back directions for things that are really important. </li></ul></ul>
  19. 19. Contd…. <ul><li>Avoid the following </li></ul><ul><ul><li>Repeating patterns of inappropriate behaviour followed by ineffective punishment; </li></ul></ul><ul><ul><li>Administering consequences without prior warning or without the child understanding why he or she is receiving them; and </li></ul></ul><ul><li>Responding inconsistently to inappropriate behaviour. </li></ul>
  20. 20. TIPS FOR TEACHER AND SCHOOL <ul><li>Work on the most difficult concept early in the day. </li></ul><ul><li>Give directions to one assignment at a time instead of directions to multiple tasks all at ones. </li></ul><ul><li>Vary the pace and type of activity to maximize the student's attentions. </li></ul><ul><li>Structure the student's environment to accommodate his or her special needs. For examples, the student can be seated away from potentially distracting areas (such as doors, windows and computers) or seated near another student who is working on a shared assignment. </li></ul>
  21. 21. THANK YOU