Transcript ADHD - Integrated care pathways for mental health

ADHD
TRAINING MORNING
Programme







What is ADHD?
Core Symptoms
Assessment Process
Aetiology and Risk Factors
Management
Support strategies in the classroom
Questions
Multi-Disciplinary Team
(MDT) Approach


A MDT approach is key within the assessment,
treatment and management of children with ADHD
Key members of the team:
Doctor
Specialist Nurse
Community Mental Health Worker
Occupational Therapist
Liaison with Educational Psychologist
The children, parents and
education staff
are integral
What is ADHD?





Medically diagnosed condition
Neurodevelopmental condition
3 Core Features or Behaviours
 Inattention
 Impulsiveness
 Hyperactivity
3P’s: Pre-school/Pervasive/Persistent
The symptoms must be having an impact on
the child’s academic, psychological or social
functioning
What is ADHD?





Those affected often fail to achieve their
potential and have many co-morbid
difficulties…
It is thought to affect 2 to 5% of the
childhood population.
More boys diagnosed (4:1)
ADHD is on a continuum and symptoms can
vary from mild to severe
3 main types – individuals can be strongly
influenced by external factors
Core features of ADHD
Inattention
Hyperactivity
Impulsivity
Inattention

Difficulty sustaining attention, particularly boring,
repetitive tasks, those which they are not interested
in or require sustained mental effort.

Poor attention to detail or makes careless mistakes

Easily distracted

Forgetful in daily activities

Often does not seem to listen - even when spoken to
directly

Fails to follow directions

Poor self-organisation-possessions/work

STM
Impulsiveness

Blurts out answers too soon

Easily led

Difficulty waiting turn

Interrupts/intrudes on others’ activities

Talks excessively without response to social constraints




Does/says things without thinking of the
consequences.
Reacts quickly without thinking
Completes activities quickly and without attention/care
to detail
Risk-taker
Think before you act…..
Hyperactivity

Fidgets, squirms

Noisy, can’t play or work quietly
Persistent over-activity
- not moderated by social demands
- no ‘off switch’
 Often leaves seat in classroom or in other
situations where expected to remain seated



Runs around or climbs excessively where it is
inappropriate
Talks excessively and goes off on tangents
Assessment procedure

Referral from school or GP

Carer interview

Child interview

School and Home ADHD Rating Scales

School observation

Teacher interview

Occupational Therapy questionnaire/discussion

Educational Psychology liaison if appropriate

Liaison with external agencies
Input needed to
make a diagnosis...
Teacher
Diagnosis
Child
Parent
Aetiology

NICE Guideline 2008 p 30

“… the presence of psychosocial adversity risk
factors should not exclude a diagnosis of ADHD. The
aetiology of ADHD involves the interplay of multiple
genetic and environmental factors. ADHD is viewed
as a heterogenous disorder with different sub-types
resulting from different combinations of risk factors
acting together.”
Risk factors for ADHD?



Strong genetic influences
No single gene has been identified
in ADHD
Approximately 75% of cases of
ADHD appear to have genetic links
Risk factors for ADHD?
Environmental

Maternal substance misuse
during pregnancy

Very low birth weight

Foetal hypoxia

Brain injury





Some link between additives
and preservatives in the diet
and levels of hyperactivity
(McCann et al 2007) Not ADHD
Evidence for lack of Omega 3
and 6 fish oils as a risk factor
requires further research
Exposure to toxins such as
lead

Certain disorders increase
risk of ADHD e.g fragile X

Harsh, critical parenting
Dietary

ADHD in the parents

Domestic violence

Physical/sexual abuse
Severe early psychosocial
adversity
Video


‘Kid in the Corner’
During the break, reflect on the implications
of the child’s ADHD for:



The child
The parents
Siblings
COFFEE BREAK!
Management

Behaviour management at home and school

Occupational Therapy

Education and promoting understanding

Medication

Psychosocial interventions
Top 10 tips….
General…….


Calm and positive environment
Routines – written and practiced (entering and leaving
classroom, equipment, toilets)

5 simple agreed + rules

Small, immediate consequences

Praise – specific

Consistency – say what you mean – mean what you say

Avoid power battles – discuss away from class

Show and tell

Stay calm – model!

Build relationships
How does your engine run?
Low
“Just Right”
High
We all do things that help us feel more alert or that help us
relax and calm down . . . . . . .
Think of your own sensory preferences
What does the child’s behaviour tell
you about them?
SEEKING
Smell
AVOIDANT
Does the child like/dislike strong smell?
Can they smell things other people can’t smell?
Touch
Does the child like to fidget?
Does the child dislike certain clothes?
Does the child like cuddles?
Do they respond excessively to light touch?
Hearing
Do they jump or cover their ears
when they hear a loud noise?
Do they make a lot of strange noise?
Are they easily distracted?
What does the child’s behaviour tell
you about them?
SEEKING
AVOIDANT
Movement Does the child find it hard to sit still?
Does the child rock on their chair?
Do they like or strongly dislike
roundabouts/rollercoasters?
Do they get travel sick?
Taste
Does the child have a restricted diet?
Does the child like strong tastes, different textured food?
Does the child like to chew?
Sight
Is the child easily distracted by moving objects?
Do they notice all movement in the room?
Do they like/dislike bright lights?
So what is next?...
What can we do next?



Provide opportunity for your child to get the
sensory experience they like (and that changes
their level of alertness) in an appropriate way!
Creating a sensory diet
Reduce the sensations they don’t like or that
distracts them
Warn your child in advance of any situations
which might include a sensory experience they
dislike i.e. a loud noise
Top 5 tips….
Classroom Management
In three groups come up with
TOP FIVE tips for:

Over activity

Impulsiveness

Inattention
Overactivity
Movement breaks
 Creative seating
 Allowing fidgeting
 Stimulus through activity

Impulsivity:
Positive Expectations
Stop / Start
When / Then


Redirection
I need you to...
Impulsivity

Visual symbols and non-verbal cues
to avoid over use of name

Give them a job

Pick your battles
Inattention


Use of small post-its between words
Breaking tasks down sentence by
sentence

Task list on post-its

Half tennis ball under chair leg

Use a cushion

Concentration station
Medication

Stimulants (Affect Dopamine and Noradrenalin)



Methylphenidate (Ritalin, Equasym, Concerta XL,
Equasym XL, Medikinet, Medikinet XL)
Dexamphetamine (Dexedrine)
Noradrenergic agents

Atomoxetine (Strattera)
Thank you...
Any questions?
Reading list:





Atwood, T. ADD. The Parent’s Handbook. ISBN 1860831427.
Barkley RA (1995) Taking charge of ADHD: The complete
Authoritative guide for Parents. New York: The Guilford
Press.
Brown, T.E (2005) Attention Deficit disorder: The unfocused
mind in Children and Adults. Yale: University Press.
Casey, Nigg and Durston (2007) New potential leads in the
biology and treatment of attention deficit hyperactivity
disorder. Current Opinion In Neurology (20) p119-124
Chu S (2003a) Attention Deficit Hyperactivity Disorder
(ADHD) part one: a review of literature. International
Journal of Therapy and Rehabilitation, 10(5), 218-227.





Dunn W and Bennett D (2002) Patterns of sensory
processing in children with attention deficit hyperactivity
disorder. The Occupational Therapy Journal of Research,
22(1), 4-15.
Green C, Chee K. (1997) Understanding ADHD: A Parents
Guide to Attention Deficit Hyperactivity Disorder in
Children. London: Vermillion.
Goldman LS et al (1998) Diagnosis and treatment of ADHD
in Children and Adolescents. JAMA;279: 1100-1107.
Hartmann T. (2000) Complete Guide to ADHD. Underwood
Books.
“Kid In the Corner” Channel 4




National Institute for Health and Clinical Excellence (NICE)
2006 Guideline on the use of methylphenidate for
Attention Deficit Hyperactivity Disorder (ADHD) in
Childhood. London: National Institute For Clinical
Excellence .
National Institute for Health and Clinical Excellence (NICE)
2008 Attention Deficit Hyperactivity Disorder (Full
Guideline). www.nice.org.uk/Guidance/CG72
SIGN Guidelines 2009, Number 112
(www.sign.ac.uk/guidelines/fulltext/112/index.html)
Steer C R (2005) Managing attention deficit/hyperactivity
disorder: unmet needs and future directions. Archives of
Disease in Childhood 90(suppl1): i19-i25.
References

Tharpar, Langley, Asherson and Gill (2007) geneenvironment interplay in attention-deficit hyperactivity
disorder and the importance of a developmental
perspective. British Journal of Psychiatry, 190, P1-3.