CU ADHD

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CU ADHD

  1. 1. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDDr Elspeth WebbAttention deficit hyperactivity disorderADHD
  2. 2. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Over-activity & Impulsiveness&/or Inattentiveness/distractibilityPervasive: in all contextsEarly onsetWhat is ADHD?
  3. 3. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD A condition comprising a degree of impulsivity & hyperactivity and/or inattentionto 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 hyperkineticdisorderBut what is “inappropriate”? - this is a condition that is, in part,But what is “inappropriate”? - this is a condition that is, in part, sociallysociallyconstructed.constructed.p.s. DSM-V -- which is currently in the planning stages and is expected to be published in 2013 -- will bringchanges, perhaps by treating these as two separate disorders, rather than subtypes of the same conditionDefinitions: ADHD (DSM-IV TR)
  4. 4. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD 1/10 1/20 1/50 1/100 1/200Have a guessPrevalence: – how common is it?
  5. 5. 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 (Driven by litigation)UK: real prevalence less than administrative2001administrative = 20,000real = 70,000Prevalence
  6. 6. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Highly heritable.• ? evolutionary advantage neurological damageNot bad parents:- c.f. Kanner’s originaldescription of autism, (will return to this)Aetiology:- what causes it?
  7. 7. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDAttentionExecutive functionNeuro-psychological basis
  8. 8. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD detecting a stimulus encoding or processing information sustaining attention to relevant stimulus whilstfiltering out others shifting attention when appropriate inhibiting involuntary shifting (distractibility) organising a response to incoming informationAttention
  9. 9. 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 receivinginformation, but with subsequent processing and selection ofappropriate response i.e. it’s not that they don’t pay attention, but they act as if theydon’t pay attention, because they do not respond appropriately.Attention in ADHD
  10. 10. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD A set of brain functions unique to humans, concerned with selfregulation, sequencing of behaviour, flexibility, response inhibition,planning and organisation of behaviour Allows us to think about ourselves, what may happen in the future, andhow we can influence itExecutive function
  11. 11. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD3 components are limited:– working memory - ‘open file’ on the hard drive• non-verbal working memory• verbal working memory– self-regulation– reconstitution; using working memory to plan and organise andreflectAs children with ADHD get older and enter adolescence these are the areas offunction in which they get more different from their peers, precisely when we startto ask more of them in these areasExecutive function in ADHD:deficits in inhibition
  12. 12. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Any intellectual activity is much more difficult for these childrenboth in getting started and in sustaining that activity They have to put in far more effort for any particular taskcompared to their peers – everything is at least twice as hard This is very tiring They will therefore do anything to avoid intellectual effortbecause it is so hardEffort avoidance
  13. 13. 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 normalityADHD “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 andnow” because it is hard to accept that 5% of all children are “abnormal”ADHD as a dimensional disorder
  14. 14. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Clinical interview Rating scales Observation (preferably not in clinic) Cognitive assessment– learning difficulties/unrecognised superior skills Psychological evaluationMultidisciplinary/multiagencyAssessment - all
  15. 15. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD hearing chromosomes if associated with dev. Delay EEG ( if suggestion of epilepsy) Occupational Therapy if child has associated co-ordination difficulties Speech and Language AssessmentAdditional assessment
  16. 16. 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 disorderCo-morbidity/overlap
  17. 17. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDabuse/violence/poor parentinginappropriate classroom managementContributory/exacerbating factors
  18. 18. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Genotype – our genetic inheritance and makeup – what our DNA says, whichgenes we carry Phenotype – how our genotype is expressed . E.g. gene for cystic fibrosis resultsin a phenotype that involves chest infections, digestive problems, infertility inmales. Benes for ADHD result in ADHD phenotype Phenocopy. – when another set of factors, usually environmental, result in a setof signs symptoms and behaviours very similar to a genetic phenotype. Mostfamous example – Romanian orphans and autism ADHD phenocopies – violence, abuse, and anxietyPhenocopy of ADHD
  19. 19. 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 yearor two Direction and pattern of these processes is partly genetically, partlyenvironmentally driven Our children’s brains are sculpted irreversibly by their early (and perhaps evenprenatal) life experiences Children exposed to violence are hard wired to be anxious, distractible, highlyaroused in situations of conflict, and impulsively aggressive – this is largelyirreversibleImpact of early violence on braindevelopment
  20. 20. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Children living with violence are anxious, highly aroused, and haveraised cortisone Although for older children this does not have the same long termimpact 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-vigilanceImpact of current violence on behaviour
  21. 21. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Higher prevalence of violence in low income families,including domestic abuse (DA) and child abusePoverty associated with other risk factors for “ADHD” LBW and prematurity Intrauterine exposure to illegal drugs and alcohol (itselfstrongly linked to DA)Demography of violence
  22. 22. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDChild health outcomes – reduction in health problems if all children hadoutcomes of wealthiest 5th(courtesy of Nick Spencer)Child health outcomes % reductionBirth weight*: <2500g<1500gDisability**:Cerebral palsyIntellectual disabilityPsychological problems***:Emotional disordersConduct disordersHyperkinetic disordersRegistration for Child Abuse**30%32%30%39%34%59%54%53%* Based on 210,000 births in the West Midlands region of the UK, 1991-‘93** Based on data on 150,000 births in the West Sussex region of the UK, 1983-2001***Based on the UK survey of mental health among 5-15 year olds (Meltzer et al 2000)
  23. 23. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDAbuseADHD1. Neurocognitive effects2. Anxiety/disordered attachmentOveractivityDistractabilityImpulsivityIncreasesrisk ?exacerbatesConductdisorderco-morbid withIn care•? hard to place•? breakdown of placementmimicscausalassociatedwithParent withADHDIn summary:Relationshipbetween ADHD and child maltreatment
  24. 24. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDProblems for diagnosis,management, and researchMaltreatment and ADHD phenocopies
  25. 25. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD These children can be clinically indistinguishable from those with geneticADHD (although some differences from population studies) In both cases symptoms may be lessened by treatment with stimulants This poses not just a diagnostic dilemma but an ethical one too intherapeutics It raises doubts about the validity of much research – what is beingstudied?Challenges
  26. 26. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDMedication Stimulants (short acting or slow release) OthersBehaviouralPsychologicalManagement of hyperactivity
  27. 27. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDShort term effects- improves attention/decreases impulsivity/decreases over-activityConsistently shown in researchEffectiveness of stimulants
  28. 28. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Dose related: decreased appetite, insomnia, irritability, anxiety, abdominal pain,headaches, mood disturbance. Tics Behavioural rebound Socialisation: some negative effects on pro-social behaviours Rare: psychosis, obsessive/compulsive disorder (OCD), cardiomyopathy, effectson blood count.“My friends say I’m boring on the tablet and I don’t have any ideas”Adverse effects
  29. 29. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDThe decision to put a child on stimulants is not an easy one for parents, clinicians,or children.Everyone must feel comfortable with the decision to treat or continue treatmentNo child should be coerced to take stimulantsMedication must always be backed up by appropriate parenting and schoolstrategies.Improvement on stimulants should not be used as an excuse to removerecognition of special educational needs - their ADHD remains.
  30. 30. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDBehaviouralPsychological Depressingly there is a very poor evidence base for either in thatneither achieve much without stimulantsBut parenting education helpful with stimulants – notbecause “poor” parents, but because it’s much harderto be a parent to a child with ADHD, and often requirescounter-intuitive responses.Management approaches
  31. 31. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD3 groupsGroup 1:- do well and not distinguishable from matched normal controlsin adulthood - 30%Group 2:- continue to have significant problems with concentration,impulsivity and social interaction - 50% (but can these be a strength –stand up comics)Group 3:- significant psychiatric or antisocial problems or both - 10%(severe depression, bipolar affective disorder, suicide, drug/alcohol abuse;delinquency leading to serious crime)Overall an increased risk of school failure, unemployment, poverty,imprisonmentPrognosis
  32. 32. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDChildFamilyTreatmentSchoolsFactors predicting outcome
  33. 33. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDIQ - lower the IQ poorer the outcomeInattention – underachieve academicallyacademicallyHyperactive - poor socialsocial outcomePoor social skills - greater risk of CD and substance abuseCo-morbidity - poorer outcomeChild
  34. 34. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDPoor parental mental health, poor mother /child relationship -poor outcomeParenting style consistency and firmness - good inconsistent/permissive/restrictive/punitive – badSE status - low SE status possibly associated with persistence ofADHD into adolescenceFamily
  35. 35. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Medication alone - no difference in outcome, but medication and ‘goodfamily’ - good outcome In general medication in childhood does not seem to affect adultoutcome except some evidence for improved social skills and self-esteem. But this research may be invalid in that more severely affected childrenare medicatedTreatment
  36. 36. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD There is very little research on looking at educationalinterventions and long term outcomes, whether1. Classroom strategies2. Educational approaches Inclusion vs. specialised Adapting teaching to how these children learn How do they learn – not even much on that!Schools
  37. 37. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDhttp://www.acer.edu.au/documents/Kos_PrimaryTeachers-ADHAD.pdf“The classroom may represent one of the mostdifficult places for children with ADHD, mostprobably because this setting requires childrento engage in behaviours that are contrary to thecore symptoms of the disorder”
  38. 38. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD Increases anxiety Makes symptoms worse Pushes children further along the dimension Reduces self esteem Contributes in the longer term to alienation, conduct disorder,delinquencyPoor school experience
  39. 39. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD“….programmes on television in the UK exploring ADHD ……..ignoredchildren’s rights in that they were exploitive, contravened a child’s right toprivacy, and were certainly not in the best interests of the children involved.They provided inaccurate presentations of ADHD with most of thecases presented being conduct disordered children in very disadvantagedcircumstances. ….(The programmes) had a focus on these children not as indistress, but as ….. bad. ”Webb E. Health services: who are the best advocates for children?Archives of Disease in Childhood 2002;87:175-177ADHD & the Media
  40. 40. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD-a badly behaved,impulsivelyaggressive, morallydeficient childADHD media stereotypeBut children with ADHD canbe impulsively anything:-brave, empathetic, witty,cautious, clever, unkind,generous, reserved,oppositional, adventurous,imaginative, energetic,creative, destructive, etc..Don’t stereotype or youwill miss casesDon’t confuse personalitywith disorder
  41. 41. Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHDSummary ADHD is common, but under-diagnosed in the UK 1oschools: a major role in recognising affected children Affected children form a highly heterogeneous population: eachchild with ADHD requires a tailored strategy Stimulants are effective in management (but they are noteverything) The severity of ADHD, and adult outcomes, are strongly affected byhow a child is treated by the adults in his/her life Educational practice underpinned by poor research andevidence base Educational research is possibly not asking the right questions

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