Transcript cloth baby bed

ADHD
Dr S.L Seape
By Dr S.L Seape
Phil, stop acting like a worm
The table is no place to squirm
This speaks father to his son
Severely says, not in fun
Mother frowns and looks around although she
doesn’t make a sound
But Phillip will not advice he’ll have his way at
any price
He turns and turns, he wriggles & jiggles here
and there on the chair
Phil, these twists I can not bear.
ADHD – NO SMALL MATTER
School drop out
32 – 40 %
Underachieve
70 – 80 %
Teen Pregnancy
40 %
20 – 30 %
Also
Associated
with
Depression
Drug, alcohol and tobacco abuse.
Speed and Motor Vehicle Accidents.
Endanger their lives
ADHD – NO NEW MATTER
Sir Alex Crichton 1763-1856-a Scottish
physician.
In 1798 described Disease of Attention “the
incapacity of attending with a necessary
degree of constancy to any object”
“it becomes evident at a very early period
of life and has a very bad effect, but it
seldom is to so great a degree as to totally
impede all instruction and what is
fortunate is, it generally diminishes with
age”.
ADHD – NO NEW MATTER
Dr. Heinrich Hoffman 1809-1894 German physician
- Wrote poems for kids
- Protagonist was Fidgety Phillip
See the naughty restless child growing still more
rude and wild till his chair falls over quite
Phillip screams with all his might catches at the
cloth but then
That makes matters worse again.
Down upon the ground they fall glasses, plates,
knives, forks and all.
How mamma did fret and frown when she saw
them tumbling down.
ADHD – NO NEW MATTER
1902- Sir George F Still British paediatrician
Describe what is now ADHD
“serious problems with sustained attention
and self-regulation, showed little inhibitory
volition excessively emotional or
passionate could not learn from the
consequences of their actions though their
intellect was normal and defiant and
resistant to disciple.”
DIAGNOSIS
Who Should Diagnose
Child and adolescent psychiatrist
• Neuro developmental paediatricians
• Paediatric neurologist
• GP & paediatricians with special interest in ADHD
Associated myths
•
•
•
•
•
•
ADHD is a made-up diagnosis
Due to bad parenting
Can be diagnosed by EEG
M >F
Sole treatment is medication
THREE CLUSTERS OF SYMPTOMS
First cluster- Inattention
i. abnormally short concentration span
ii. frequent resistance to sustained mental effort especially with boring repetitive
tasks
iii. Easy distractibility
iv. marked forgetfulness
v. tendency to loose things
vi. difficulty organizing tasks, with poor planning
vii. not listening properly to instruction
viii. A tendency to rush work, giving poor attention to detail and making frequent
careless mistakes
ix. Often not completing tasks
THREE CLUSTERS OF SYMPTOMS
Second Cluster :Hyperactivity
i. constantly on the go
ii. runs about or climbs excessively
iii. restless, unable to stay seated
iv. fidgets excessively
excessively talking
vi. plays loudly
THREE CLUSTERS OF SYMPTOMS
Third Cluster: Impulsivity
i. Often interrupts or intrudes on others
ii. Can not wait his/her turn
iii. Blurts out answers
DIAGNOSTIC PROCESS TO INCLUDE
Observing child at work and play
1
2
Must interview child, especially re-subjective distress
3
Collect info from as many sources as possible
4
Use of scales – Connors Assessment
5
Copeland Checklist
CONNORS ASSESSMENT
1.
2.
3.
4.
CHILD’S NAME:
SCHOOL:
GRADE:
TEACHER’S/PARENTS NAME
……………………………
……………………………
……………………………
……………………………
5. Observation (Mark the appropriate block with an “X”
Not at
all
A Little
Pretty
Much
Very
Much
Restless or overactive
Excitable, Impulsive
Disturbs other children
Fails to finish things he starts, short attention span
Day-dreaming
Constantly fidgeting
Inattentive, easily distracted
Demands must be met immediately, easily frustrated
Isolates him/herself from other children
Cries often and easily
Moods changes quickly and drastically
Temper outburst, explosive and unpredictable
6. TEACHER’S COMMENTS:
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
7. IMPROVEMENT (IF ANY)
____________________
TEACHER SIGNATURE
__________________________
DATE
COPELAND CHECKLIST
Name of child:
Completed by:
Directions:
____________________________________________________________
___________________________________________________________
Place a checkmark (✔ ) by each item below, including the degree to
Which the behavior is characteristic of you child/ student.
Not at all
Just a much
Pretty much
Very much
Score %
I.INATTENTION/DISTRCTIBILITY
1.Has short attention span, especially for low-interest activities
2.Has trouble with completing task
3.Daydreaming
4.Easily distracted
5.Nicknames such as “spacey” or “dreamer”.
6.Forgetful
7.Start many things – finishes few
/21%
II.IMPULSIVITY
1.Easily excited
2.Become frustrated easily
3.Does not think before acting
4.Is disorganized
5.Does not plan
6.Constantly moves from one activity to another.
7.Dislikes group activities that require patience and taking turns
8.Requires much supervision
9.Constantly in trouble for doing things wrong or for forgetting to do things.
10.Interrupts and talks out of turn
/30%
III.ACTIVITY LEVEL PROBLEMS
A.Overactivity/hyperactivity
1.Restlessness-either fidgets or is constantly on the go.
2.Reduced need for sleep
3.Talks too much
4.Constantly running, jumping and climbing
5.kicks covers off- moves around constantly while sleeping.
6.Difficulty staying seated at meals, in class ect.
CONFOUNDING VARIABLES
1. TEMPERAMENT
•
•
•
•
2. REIFICATION
Mood
Sensitivity
Distractibility
Activity level
Falsely calling something and
entity when it is not
•
•Areas of Impairment
1. CLASSROOM
•
2. SOCIAL FUNCTION
Very important in early school
where foundation skills are
learned
•
Impaired secondary to
hyperactivity and impulsivity
3. DISTRESS AND DEMORALIZATION
CONTRIBUTING CAUSES AND RISK FACTORS
Heritability
•Neuroscience
– 2 most important neuro
transmitters are norpinephrenine, NE and
dopamine DA
•Dopamine receptor transport DRT
•7 repeat allele
•Most kids with 7R are ADHD
CONTRIBUTING CAUSES AND RISK FACTORS
Environmental factors
Prenatal
– Smoking in pregnancy.
- Alcohol consumption in pregnancy.
-Maternal stress.
Perinatal
-prematurity with birth complications.
-decrease blood flow to brain.
Medical causes-epilepsy, encephalitis, HIV
other congenital and genetic conditions.
ATTACHMENT
-Close emotional bonds of affection which develop between
baby and primary care giver.
-Not bonding –bonding from mother to baby and
instantaneous.
-Attachment is in the baby and develops overtime.
-Attachment has time period – should have been happening
by 18/12.
-Secure attachment needs consistency of primary care giver
and caregiver to be in tune with child’s needs, i.e attention,
affection and stimulation.
-Important for child to feel valued sees others as good.
-Offers protection in later life situations.
-Offers capacity for steady relations.
Expressed emotion
-Emotional milieu of the home
Interaction of nurture & nature
Orchids and dandelions
Genetic volume - methylation
DIFFERENTIAL DIAGNOSIS
•
•
•
•
Great Smoky Mountain Study.
57% of prescribed did not meet
criteria.
4% of unaffected got medication.
72% of those meeting criteria were
not getting medication.
1. Anxiety often overlooked for
ADHD
2. Depression
3. Bipolar Mood Disorder
Shared symptoms irritability,
hyperactive, poor impulse
control, distractibility
4. Learning Disorder
5. Problems of executive function
-Planning
-Prioritizing
- Delayed gratification
6. Medical Reductionism
COMORBIDITY – Very Common
• RAD –
• Reactive Attachment Disorder
• Excessive exposure to severe
conditions
• They remain restless, fidgety and
impulsive for ever
• 2. Adjustment Disorder
• After exposure to trauma, for about
3 months, have symptoms which
include inattention, restless
• should not continue for greater than
6, if the trauma stops
OTHER IMPORTANT FEATURES
•
•
Poverty
not many referrals
from poorer
communities
•
•
•
•
Gender Differences
Old notion was that
male is greater than
female, but actually
similar
girls less hyperactive
Girls have different
comorbidity- ↑
mood & anxiety
•
•
Race & ethnicity
Less numbers
picked up in poorer
areas
PREVENTION
•
Primary prevention
1. Education re-dangers in pregnancy
2. Attachment
3. Most important-good antenatal classes
 Mothers and fathers to attend
 Parenting skills
 Stresses in pregnancy
 Mother going back to work
 Identifying post natal depression
 Issues of outsourcing helpers
4. Turn off the TV -nil before 2 yrs. – no more than 2
hours/day thereafter
 no direct contact with humans
 decreased attachment
 No stimulation at most important time in
development
 No waiting so impulsivity & poor self control of
ADHD
PREVENTION
Secondary Prevention
1. Parental training American
National Institute of mental health
study.
2. Exercise and cognitive
stimulation.
PREVENTION
Dietary strategies
No scientific studies
1. Restrictions diet
2. Food colorants& artificial foods
3. Fish oils –omega 3
4. Many others –no sugar
PREVENTION
Medication
• Must be well considered
• correct diagnosis
Medication
• 1937 Charles Bradley, USA paediatrician.
Benzedrine an ampheltamine
(Treating headache, kids improve behavior
and academic performance)
• Arithmetic pills
•
•
•
1944 Leandro Panizzon-Chemist
Synthesized methylphenidate for low BP
for wife-Marguerite,
Nickname was Rita!!, so the drug
became Ritaline
PREVENTION
•1954-Ritalin registered by
Ciba Geigy (for chronic
fatigue, Mild depression,
narcolepsy)
• Ritalin
• 1963-Ritonic registered for children
by Ciba Geigy
• Methylphenidate and vitamins
hormones for children
• 1963-first trails of Ritalin for
hyperkinetic reaction-unequivocal
results
STIMULANTS
Block Dopamine Transporter Protein
therefore
1.Methylphrenidate
• Ritalin
• Concerta
Ritalin effective 4-6 hrs.
Ritalin LA effective 6-8 hrs
Concerta effective 10hrs.
• Favorable side effects profile
• Not addictive
• Non sedating
• Improve attention, improve
behaviour
Reduce restlessness, forgetfulness
• Improve ability to relate socially
• Improve confidence & self esteem
•
NON STIMULANTS
Similar to stimulants, improve executive
function
i. Atomoxetine
• Strattera
• Work 24 hrs
• Important in anxiety
ii. Antidepressants
• Imipramine, amytryptiline, venlafaxine
• Long acting
• Can use in under 6 yrs.
• Important in anxiety
• Important in comorbidity
iii. Antihypertensive
• Clonidine
• Controls impulsivity
• Helps with sleep
• Mostly used in combination with
stimulants
SIDE EFFECTS
•
•
•
•
•
•
•
•
•
Stimulants
Headache, abdominal discomfort & decreased appetite
Stunting of growth, discontinued if serious, greater than
1cm/yr of expectation
Weight loss
Careful in epilepsy
Sudden death – lower than reported
Emotional – sullen, zombie, depressed
Suicidal thinking - Minor and no reported completed
suicide
Rebound effects – tearful as medication wears off / in
afternoon counter with eating a snack
SIDE EFFECTS
Anti Depressants
-Sedating
-Dry mouth
-Constipation
-Increased heart rate
-Blurred vision
-Urinary retention
NB - Fatal in overdose
Atomoxetine
-Headaches
-GI symptoms & heartburn
-Sedating
Cloridine
-Sedating, confusion, light headedness
and headaches
PRESCRIBING
•
Prepare child
•
Time to effect
•
Full effect
•
Side effects
•
Duration of treatment
•
Engage adjunct treatment & skills
•
e.g.
•
OT - gross motor, fine motor, visual spatial sensory processing
•
Psychologist – IQ assessment
•
Remedial teacher - as indicated
•
•
Speech and language therapist - linguistic ability, auditory
perceptual disorder
Social worker - family disruption, family help
ADULT ADHD
All children grow
• Many missed in childhood
Consider if one is disorganized
• Always late
• Overwhelmed, can not remain
calm
• Disorganized
• Forgetful
•
FOUR SYMPTOM CLUSTERS IN ADULTS
1.
2.
3.
4.
Sustained attention
Inhibiting behavior and
emotional regulation
Resisting distraction
Regulating level of activity
COMMON SYMPTOMS IN ADULTS
1. Inattention
• Concentration and focus
• Easily disrupted by irrelevant sights
and sounds
• Can’t complete tasks
• Overlook details
• Poor listening skills
• Move from activity to the next
• Zoning out
• Become bored
• Hyper focus
COMMON SYMPTOMS IN ADULTS
2. Inhibiting behavior
• Can’t inhibit behavior, comments,
responses, act without thinking of
consequences,
• Interrupts others
• Addictive tendencies
• Act recklessly and spontaneously
without regard
• Can’t delay gratification
• Irresponsible behavior e.g fast
reckless driving, promiscuous sex,
gambling and drug taking
COMMON SYMPTOMS IN ADULTS
3. Resisting Distraction
• Disorganized& forgetful
• Chaotic life
• Can not sift important information
• Can not prioritize
• Can not keep up with tasks and
responsibilities
• Loses things
• Underestimates time
• Chronically late
• Forget appointments, meetings
and commitments
COMMON SYMPTOMS IN ADULTS
4. Hyperactivity & Restlessness
• not like children
• have increased energy, fidgety,
on the go
• often feeling of inner restlessness
and agitation
• risk taking
• easily bored
• racing thoughts
• craving excitement
COMMON SYMPTOMS IN ADULTS
5. Emotional difficulties
• Can’t manage feelings
• Poor frustration management
• Irritable with mood swings
• Can’t stay motivated
• Short, explosive temper
• Insecure
Effects in Adults
Physical & Mental
• Compulsive eater
• Substance abuse
• Anxiety
• Depression
• Poor self-care
Work & financial
• Career difficulties &
underachievement
• Can’t keep a job, not meeting
deadlines
• Can’t follow cooperative rules
• Unpaid bills, lost paperwork and
impulsive spending
Effects in Adults
Relationships
• They are a strain – work, home,
family
• Often fed up
• Embarrassment, frustration,
disappointment, loss of
confidence
But, can be:
• Very creative
• Passionate
• Lots of energy
• Out of the box thinking
• Original ideas
Strategies for Adults
i. Psycho education
ii. Psychological techniques
iii. Medication
iv. Identify co-existing conditions
v. lifestyle change
• regular exercise, sleep hygiene,
avoidance of substances,
routines, balanced diet
• time management
vi work on relationship
We are not like the rest,
Yet we desire to do our best.
Not meaning to disappoint or anger,
We want you to love and accept her,
Right where she is at,
But not because of obedience, no, not that.
My brain chemistry is very different,
My Dopamine non-existent.
Please, it’s not our fault,
and it often sends us into a downward catapult.
Is there a Monster under his bed?
No, but there is one is his head,
Telling him he is stupid and bad,
and that he is nothing but a Discipline case to his Dad.
We want to BE like everyone else,
Honest, it’s true.
-GingerSnaap