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ADHD CU

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  • 1. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Dr Elspeth Webb Attention deficit hyperactivity disorder ADHD
  • 2. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  A condition comprising a degree of impulsivity & hyperactivity and/or inattention to a point that is disruptive and inappropriate for developmental level  Pervasive & present for at least 6 months  Two sub types: Inattentive and Hyperactive/impulsive  Hyperactive/impulsive subtype also referred to as hyperactivity or hyperkinetic disorder But what is “inappropriate”? A condition that is, in part, socially constructed. Definitions: ADHD (DSM-IV TR)
  • 3. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  1/10  1/20  1/50  1/100  1/200 Have a guess Prevalence: – how common is it?
  • 4. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  UK/USA/Australia/Scandinavia • 5% for total (mixed or just hyperactive/impulsive or just inattentive) • About 3% for hyperactivity ( i.e. mixed or just hyperactive impulsive • 1% for mixed ICD10 (hyperactive & inattentive) Politics: Administrative vs. real prevalence USA : administrative prevalence greater than real - 10% of children on medication for ADHD (Driven by litigation) UK: real prevalence more than administrative – about 1% UK children between 6 and 12 yrs are medicated (see http://www.ncbi.nlm.nih.gov/pubmed/22712630 ) Prevalence
  • 5. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Problems with : Attention Executive function Neuro-psychological basis
  • 6. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  detecting a stimulus  encoding or processing information  sustaining attention to relevant stimulus whilst filtering out others  shifting attention when appropriate  inhibiting involuntary shifting (distractibility)  organising a response to incoming information Attention
  • 7. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  Studies suggest that the attentional problem is not at the level of “going in”, but at the level of stimuli processing  So children with ADHD do not have difficulties with receiving information, but with subsequent processing and selection of appropriate response  i.e. it’s not that they don’t pay attention, but they act as if they don’t pay attention, because they do not respond appropriately. Attention in ADHD
  • 8. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  A set of brain functions unique to humans, concerned with self regulation, sequencing of behaviour, flexibility, response inhibition, planning and organisation of behaviour  Allows us to think about ourselves, what may happen in the future, and how we can influence it. For example, these allow us to control impulses, because we think about and consider what will happen if we do x or y. A child with ADHD has already done x or y before the considering has started to process. As children with ADHD get older and enter adolescence these are the areas of function in which they get more different from their peers, precisely when we start to ask more of them in these areas Executive function
  • 9. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  Some diseases are “all-or-nothing”, e.g. influenza  Others are “dimensional” in that the disorder or disease fades into normality ADHD “normal” For children on the cusp, it is difficult to distinguish disorder from personality. To some extent it is a socially constructed diagnosis which is a disorder “here and now” because it is hard to accept that 5% of all children are “abnormal” ADHD as a dimensional disorder
  • 10. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  Linked  Co-ordination problems  Speech and language disorder  Autistic spectrum  Tourette syndrome  Coincidental  Hearing impairment  Pseudo link  Oppositional/defiant disorder and Conduct disorder Co-morbidity/overlap
  • 11. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  Any intellectual activity is much more difficult for these children both in getting started and in sustaining that activity  They have to put in far more effort for any particular task compared to their peers – everything is at least twice as hard  This is very tiring  They will therefore do anything to avoid intellectual effort because it is so hard Effort avoidance
  • 12. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  Genotype – our genetic inheritance and makeup – what our DNA says, which genes we carry  Phenotype – how our genotype is expressed . E.g. gene for cystic fibrosis results in a phenotype that involves chest infections, digestive problems, infertility in males. Genes for ADHD result in ADHD phenotype  Phenocopy. – when another set of factors, usually environmental, result in a set of signs symptoms and behaviours very similar to a genetic phenotype. Most famous example – Romanian orphans and autism  ADHD phenocopies – violence, abuse, and anxiety Phenocopy of ADHD
  • 13. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  The infant human brain at birth is very immature in comparison to other mammals  ++ growth, development, cellular interconnections and cell culling in the first year or two  Direction and pattern of these processes is partly genetically, partly environmentally driven  Our children’s brains are sculpted irreversibly by their early (and perhaps even prenatal) life experiences  Children exposed to violence are hard wired to be anxious, distractible, highly aroused in situations of conflict, and impulsively aggressive – this is largely irreversible Impact of early violence on brain development
  • 14. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  Children living with violence are anxious, highly aroused, and have raised cortisone  Although for older children this does not have the same long term impact on brain structure, fearful highly aroused children are:  distractible/inattentive/overactive/impulsive  How? - Weinstein et al, 2000:  difficulty concentrating caused by re-experiencing trauma (PTSD)  hyperactivity caused by hyper-vigilance Impact of current violence on behaviour
  • 15. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD  Higher prevalence of violence in low income families, including domestic abuse (DA) and child abuse Poverty associated with other risk factors for “ADHD”  LBW and prematurity  Intrauterine exposure to illegal drugs and alcohol (itself strongly linked to DA) Demography of violence
  • 16. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Aetiology:- what causes it? Genes Exposure to violence in infancy Teratogens (esp alcohol) Prematurity/low birth weightPrematurity/low birth weight Some of these factors are linked e.g. violence, Low birth weight, and foetal alcohol exposure. ADHD phenocopy
  • 17. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD treatment • Medication AND • Psychological approaches Should depend on cause but doesn’t. Evidence base not addressed heterogeneity 17
  • 18. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD “….programmes on television in the UK exploring ADHD ……..ignored children’s rights in that they were exploitive, contravened a child’s right to privacy, and were certainly not in the best interests of the children involved. They provided inaccurate presentations of ADHD with most of the cases presented being conduct disordered children in very disadvantaged circumstances. ….(The programmes) had a focus on these children not as in distress, but as ….. bad. ” Webb E. Health services: who are the best advocates for children? Archives of Disease in Childhood 2002;87:175-177 ADHD & the Media
  • 19. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD -a badly behaved, impulsively aggressive, morally deficient child ADHD media stereotype But children with ADHD can be impulsively anything:- brave, empathetic, witty, cautious, clever, unkind, generous, reserved, oppositional, adventurous, imaginative, energetic, creative, destructive, etc.. Don’t stereotype or you will miss cases Don’t confuse personality with disorder
  • 20. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Summary  ADHD is common, but under-diagnosed in the UK  Affected children form a highly heterogeneous population: each child with ADHD requires a tailored strategy depending on context  Stimulants are effective in management (but they are not everything)  The severity of ADHD, and adult outcomes, are strongly affected by how a child is treated by the adults in his/her life Further reading (for those interested ) Webb E. Arch Dis Child doi:10.1136/archdischild-2012- 303578 Poverty, maltreatment and attention deficit hyperactivity disorder see http://adc.bmj.com/content/early/2013/04/04/archdischild-2012-303578.full

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