Transcript Attention deficit hyperactivity disorder (ADHD)

Attention deficit
hyperactivity disorder
(ADHD) and conduct
disorder/problems
Paul McArdle
The true measure of a nation’s standing is
how well it attends to its children – their
health and safety, their material security,
their education and socialization, and
their sense of being loved, valued, and
included in the families and societies into
which they are born.
Unicef (2007) Child Well-Being in Rich
Countries. Innocenti Research Centre
http://www.unicef.ca/portal/Secure/Communi
ty/502/WCM/PRESS/IRC7/RC7.pdf
ADHD history
► Moral
disorder
►Still
1905
► Minimal
brain damage - 1950
► Hyperkinetic syndrome
►Ounsted
► Attention
1955
deficit disorder with hyperactivity
►American
Psychiatric Association 1981
Diagnostic symptoms
► Inattention
► Over-
or hyper-activity
► impulsivity
symptoms
► Inattention
►Often
fails to give close attention to details, makes
careless mistakes
►Has difficulty sustaining attention in tasks or play
►Does not seem to listen
►Fails to finish tasks
►Often avoids… sustained mental effort
►Often forgetful, loses things
►Easily distracted by extraneous stimuli
►Difficulty organising tasks and activities
Symptoms II
► Hyperactivity/impulsivity
►Often
fidgets,
►Leaves seat in classroom
►Often runs about or climbs excessively in situations
in which it is inappropriate
►Is on the go as if driven by a motor
►Talks excessively
Symptoms II
► Hyperactivity/impulsivity
► Often
fidgets,
► Leaves seat in classroom
► Often runs about or climbs excessively in situations in which it
is inappropriate
► Is on the go as if driven by a motor
► Talks excessively




Often blurts out answers
Has difficulty waiting turn
Often interrupts or intrudes on others
[Runs out in the street, goes off with strangers]
Further criteria
► Early
onset before 7 years of age
► Present in more than one setting
► Clear evidence of ...significant impairment in
social, academic or occupational functioning
How common is ADHD
► 5%
is usual US figure
► More boys than girls
► But less in non-urban and more traditional
societies.
► Of 2048 adolescents interviewed in Goa, 4
had ADHD!
►Pillai
et al (2008) Non traditional lifestyles and
prevalence of mental disorders in adolescents in Goa,
India. British Journal of Psychiatry 192(1):45 – 51.
Associated features
►
►
►
►
►
►
►
Rejection by peers
Rigid insistence on requests being met and bossiness
Learning and communication disorders
Tics and Tourette's syndrome
Increased accidents, including driving accidents and fatal
crashes
Mood lability, unhappiness, demoralization
Antisocial behaviour, substance misuse, crime
►
Barkley RA. Cox D. A review of driving risks and impairments
associated with attention-deficit/hyperactivity disorder and the effects
of stimulant medication on driving performance. Journal of Safety
Research. 38(1):113-28, 2007.
Even if IQ is unaffected
► Children
with ADHD
 Cannot
►Concentrate,
communicate, read and write, selforganize, befriend and play to the same level as
other children of the same age
►Are often judged by parents to be at greater risk
than others and
►Are typically distressed and unhappy even to the
degree of 'clinical depression'
What is thought to be the cause of
ADHD
► Nature
– a neurological or brain condition
► Nurture – a product largely of environment
(but perhaps also affecting brain
development)
► Both nature and nurture – both brain and
environment
Further ADHD comorbidity
► With
pragmatic language/ social interaction
deficits similar to PDD
► Geurts
et al (2004) Can the Childrens Communication
Checklist differentiate between children with autism,
ADHD and normal controls? JCPP (45) 1437-1453
► Bishop & Baird (2002) Parent and teacher report of
pragmatic aspects of communication. Use of the CCC in
a clinical setting. Developmental Medicine and Child
Neurology 43:809-818
► Gilmour J. et al (2004) Social communication deficits in
conduct disorder: a clinical and community survey. JCPP
45(5):967-78.
A neurological/brain condition
► Executive
function deficit, deficit of frontal
cortical functioning
 'goal directed behaviour'
 Barkley et al (1997) ADHD and the Nature of Self Control
New York Guilford Press
►Working
memory deficits
 Rapport MD. et al (2008) Working memory deficits in boys
with attention-deficit/hyperactivity disorder (ADHD): the
contribution of central executive and subsystem processes.
Journal of Abnormal Child Psychology. 36(6):825-37.
Trends CD and comorbidity
14
12
1.2
10
1
0.8
8
girls
boys
0.6
HA +CD
6
0.4
4
0.2
2
0
1974
1986
1999
0
1974 1986 1999
Increased disturbance: parental
report
18
25
16
20
14
boys
[ep]
girls
[ep]
15
10
12
boys
[cp]
girls
[cp]
10
8
6
4
5
2
0
0
1974
1986
1999
1974
Collishaw et al (2004) JCPP 45: 1350-1362
1986
1999
Increased disturbance: self-report
40
35
30
25
n/m
III
IV/V
20
15
10
5
0
1987
1999
West & Sweeting 2003
JCPP 44:399-411
Trends GHQ scores west of scotland
30
25
20
male
female
15
10
5
0
1987
1999
2006
18
16
14
12
10
8
6
4
2
0
R>10
reading
rejection
isolation
1973
1994
Mortality 15-19 year olds
ADHD and CD
► 'ADHD+CD
is a quantitative variant of ADHDrelated behaviours’
► Thapar
2001
► Heritability
of antisocial behaviour is mediated by
a ‘callous unemotional’ trait (Viding et al 2005)
► Also:
► ‘Gene environment correlations …geneenvironment interactions…Genetic influences …
are strong and pervasive but rarely determinative”
► Rutter
2002
Shaw et al 2008
Proceedings of the
National Association of
Science
Nature
► Brain
 injury – trauma, anoxia or chemical
 Development affected by genetic factors
 E.g. Martin et al (2002) Observer effects and heritability of
childhood ADHD symptoms British Journal of Psychiatry
180:260-265
Nurture
► Extreme
early deprivation
 'neurodevelopmental programming'
► Stevens
et al (2008) inattention/overactivity following
severe early institutional deprivation – presentation in
early adolescence. Journal of Abnormal Child
Psychology 36(3):285-293.
Nurture
► Extreme
early deprivation
 'neurodevelopmental programming'
► Stevens
et al (2008) inattention/overactivity following
severe early institutional deprivation – presentation in
early adolescence. Journal of Abnormal Child
Psychology 36(3):285-293.
► Subtle
deprivation
Subtle deprivation
► “A
major study by Play England, part of the
National Children's Bureau, found that 51%
of children had been stopped from climbing
trees, 21% from playing conkers and 17%
from playing games of tag and chase...
'Children are not allowed the freedoms that
were taken for granted when we were
children'”
 Observer Aug 3rd 2008
Subtle deprivation
► 'In
the West, children are not only socialized
into a system that promotes individualism,
competitiveness, and inequality and rejects
forms of authority but also have to live in
the unstable family structures such an
ideology produces (including) ..ambivalence
towards children'
 Timimi S (2005) the effect of globalization on children's
mental health BMJ 331:37-39
Subtle deprivation
► 'In
the West, children are not only socialized into a
system that promotes individualism,
competitiveness, and inequality and rejects forms
of authority but also have to live in the unstable
family structures such an ideology produces
(including) ..ambivalence towards children'
 Timimi S (2005) the effect of globalization on children's mental
health BMJ 331:37-39
► Highest
rates of disorder among those with ‘nontraditional life-styles
► Pillai
et al 2008
Later perpetuating or aggravating
factors: mechanism
► ‘social
and executive function
demands of late adolescence overload
the late developing prefrontal cortex,
giving rise to prefrontal dysfunction
and a lack of inhibitory control over
antisocial, violent behavior that peaks
at this age’
 Raine (2002) The role of prefrontal deficits, low
autonomic arousal, and early health factors in the
development of antisocial and aggressive behavior
in children JCPP43:410434
ADHD and creativity
►
‘His most extraordinary quality… was his titanic energy. He
could not sit still or stay long in the same place. He walked
so quickly … that those in his company had to trot to keep
up with him. When forced to do paperwork, he paced
around a stand up desk. Seated at a banquet, he would
eat for a few minutes, then spring up to see what was
happening in the next room or to take a walk outdoors…
When he had been in one place for a while, he wanted to
leave… The most accurate image … is of a man who
throughout his life was perpetually… restless, perpetually in
movement.’ From Peter the Great by Robert K Massie.
ADHD and creativity
►
‘His most extraordinary quality… was his titanic energy. He
could not sit still or stay long in the same place. He walked
so quickly … that those in his company had to trot to keep
up with him. When forced to do paperwork, he paced
around a stand up desk. Seated at a banquet, he would
eat for a few minutes, then spring up to see what was
happening in the next room or to take a walk outdoors…
When he had been in one place for a while, he wanted to
leave… The most accurate image … is of a man who
throughout his life was perpetually… restless, perpetually in
movement.’ From Peter the Great by Robert K Massie.
treatment
► Structure
and support in school
► Opportunities for active play
► Mentors
► Parent training
► Supportive medication