OVERVIEW OF ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

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OVERVIEW OF ATTENTION DEFICIT HYPERACTIVITY
DISORDER (ADHD)

• Dr. Nor Hamidah Mohd Salleh
• Consultant Psychiatrist M.D.,M.Med.(Psy)

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WHAT IS ADHD

• ADHD is a developmental disorder of self control
  (executive function of the brain)
• Symptoms arise from abnormalities in the brain
• Their main problems are
• Attention span
• Impulse control
• Activity level

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WHAT IS ADHD

• It is not caused by parental failure to
  discipline or control the child, and it it not a
  sign of some sort of inherent badness in the
  child.
• ADHD is a real disorder, a real problem and often
  a real obstacle. It can be heartbreaking and
  nerve wrecking.

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TYPES OF ADHD

• 1. PREDOMINANTLY HYPERACTIVE IMPULSIVE TYPE
• A child must have six or more symptoms of
  hyperactivity/impulsivity
• 2. PREDOMINANTLY INATTENTIVE TYPE
• A child must display six or more symptoms of
  inattention
• 3. COMBINED TYPE
• A child must show six or more symptoms both of
  inattention and hyperactivity-impulsivity

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Symptoms of Inattention

• Fails to pay close attention to details or makes
  careless mistakes
• Has difficulty maintaining attention in tasks or
  play activities
• Does not seem to listen when spoken to directly
• Does not follow directions and fails to complete
  schoolwork, chores, or, in adolescents, on the
  job duties

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Symptoms of Inattention

• Has difficulty organizing tasks or activities
• Avoids or dislike task that require sustained
  mental effort
• Losses things necessary for task or activities
• Easily distracted
• Often forgetful in daily activities

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Symptoms of Hyperactivity

• Fidgets with hands or feet or squirms in seat
• Leaves seat in classroom or in other situation in
  which remaining seated is expected
• Runs or climbs excessively when inappropriate

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Symptoms of Hyperactivity

• Has difficulty playing or engaging in leisure
  activities quietly
• Always on the go or act as if driven by a motor
• Often talks excessively
• In adolescence, may exhibit feeling of
  restlessness

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Symptoms of Impulsivity

• Blurts out answers before questions have been
  completed
• Has difficulty waiting in turn
• Interrupts or intrudes on others (for example
  butts into conversations or games)

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WHATS WRONG WITH ADHD CHILDREN

• Research suggests that there is a chemical
  imbalance affecting the neurotransmitters
  dopamine, norepineprine and serotonin.
• An imperfection in the brain that causes the
  constant motion and other intolerable behavioral
  problems in ADHD.

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ADHD Diagnostic Evaluation

• 1. Physical examination
• 2. Parent-rated child behavior scales
• 3. Teacher-rated child behavior scales
• 4. Parent and child interviews
• 5. Parent self report measures

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ADHD Diagnostic Evaluation

• 5. Parent self-report measures
• 6. Clinic-based psychological test
• 7. Review of prior school and medical reports
• 8. Intelligence testing (IQ tests) and
  educational achievement testing

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COEXISTING DISORDERS

• 1. Depressive disorder
• 2. Anxiety disorders
• 3. Learning disorders
• 4. Conduct disorder
• 5. Bipolar disorder
• 6. Oppositional defiant disorder

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Why we need to treat ADHD?

• Neurobiological maturational delay that involves
  the brain executive and cognitive functions
• A chronic condition that may extend into
  adulthood
• The risks if untreated
• Learning difficulties/disabilities
• Conduct disorder
• Substance abuse disorder
• Mood disorder
• Poor work performance
• Social problem
• Relationship problem

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When to start treatment?

• Early identification and intervention is the best
  approach that helps to avoid or minimize the
  risks
• Depending on the types and severity of the ADHD
• Early intervention program for ADHD started as
  early as 3 years old.

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What to expect in treatment of ADHD?

• Pharmacotherapy
• Behavior therapy/cognitive behavior therapy
• Family therapy/guidance
• Home management
• Parenting and stress management
• Classroom management

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What kind of treatment?

• Early intervention program (EIP)
• Middle childhood intervention program (MCIP)
• Adolescent intervention program (AIP)
• Young Adult intervention program (YAIP)

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Early intervention program

• Preschool children with ADHD/HKD
• Assessment
• Types or severity of ADHD (CPRS, CTRS)
• Co morbidity e.g. speech delay, autistic
  disorder, mental retardation, epilepsy
• Temperament
• Parental awareness and support
• IQ or general mental ability (WISC, KBIT, DTLA)
• Speech, social and personal development
• Quick neurological screening test
• Behavioral and emotional problem
• Academic ability and placement (WRAT)

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Early Intervention Program

• Rehabilitation
• Sensory motor integration program
• Speech therapy
• Academic placement and support
• Send them early (3-4 years old) to play school
  which has sensory motor developmental program and
  trained/empathic teacher
• Special educational placement- private, NGO or
  public is recommended if the child has learning
  disability
• Communicate with the school about the childs
  developmental problem and establish teacher
  support program

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Early Intervention Program

• Home management 8 steps to Better Behavior
• Learn to pay positive attention to your child
• Use your powerful attention to gain compliance
• Give more effective commands
• Teach your child not to interrupt your activities
• Set up a home token system
• Learn to punish misbehavior constructively
• Expand your use of time out
• Learn to manage your child in public places

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Middle Childhood Intervention Program

• Aims
• To improve attention, behavior, mood and learning
• To help develop further the childs neurological,
  sensory, motor, social and psychological maturity
• To provide parental guidance and family therapy

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Middle Childhood Intervention Program

• Treatment approaches
• Psychological therapies
• Behavior/Cognitive behavior therapy
• Focus therapy
• Play therapy
• Art therapy
• Relaxation therapy
• Anger management
• Social group therapy

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Middle Childhood Intervention Program

• Pharmacotherapy
• Stimulant, non stimulant monitoring and
  maintenance
• Rehabilitation program
• For child with delay maturity
• Academic placement and support
• Consider special placement for children with
  moderate to severe learning disability
• Assess the childs learning aptitude and provide
  support accordingly
• Monitor the child academic progress and
  attainment
• Psychological development reassessment yearly
• Communicate with school about the childs need
  and behavioral strategies in learning

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Adolescent Intervention Program

• Aims
• To improve attention, behavior, mood and learning
• To help develop further the childs psychological
  and social maturity
• To provide parental guidance and family therapy

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Adolescent Intervention Program

• Assessment
• Co morbidity such as conduct disorder, substance
  abuse, mood disorder, adolescent-parent conflict
  and academic difficulties
• The adolescents insight into her/his problem
• Parental awareness and support
• Psychological therapies
• Individual psychotherapy
• Group therapy
• Anger management
• Relaxation therapy
• Family therapy/guidance

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Adolescent Intervention Program

• Pharmacotherapy
• Stimulants, non stimulants
• Monitoring, dose adjustment and maintenance
• Consider tailing dose if the child reach the
  maturity to cope on his/her own
• Academic placement and support
• Monitoring of academic progress
• Reassess the childs psychological development
  and learning aptitude
• Assess the child potential for future vocation

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Young Adult Intervention Program

• Aims
• To improve attention, behavior, mood and learning
• To enhance the young adults psychological,
  intellectual and social maturity
• To guide them learn and cope effectively in their
  chosen vocation
• To provide parental guidance and family therapy
• To provide school guidance and/support

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Young Adult Intervention Program

• Assessment
• Psychological therapies
• Cognitive behavior therapy
• Supportive psychotherapy
• Relaxation therapy
• Individual psychotherapy
• EEG biofeedback therapy
• Medications
• Academic placement and support

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Who can treat ADHD?

• Specialist with expertise in ADHD
• Child and adolescent psychiatrist
• Psychiatrist
• Clinical psychologist

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Effective Treatment of ADHD

• Multidiscipline
• Medical
• Psychological
• Educational
• Rehabilitation

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Medical Treatment

• Medication is used to treat the symptoms and help
  the child with ADHD function more effectively
• Examples are
• Ritalin, Stratera and Concerta

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Documented Specific Beneficial Effects of
Stimulants

• I. MOTOR EFFECTS
• Reduce activity to the level of normal peers
• Decrease excessive talking, noise and disruption
  in the classroom
• Improve hand writing
• Improve the fine motor coordination

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Documented Specific Beneficial Effects of
Stimulants

• II. SOCIAL EFFECTS
• Reduce anger
• Reduce bossiness with peers
• Reduce verbal and physical aggression with peers
• Reduce defiance and oppositional behavior with
  adults
• Decrease intensity of behavior
• Improve peer social status
• Improve ability to play and work independently
• Improve mother-child and family interactions

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Documented Specific Beneficial Effects of
Stimulants

• COGNITIVE EFFECTS
• Improve sustained attention
• Improve short term memory
• Reduce distractibility
• Reduce impulsivity
• Increase the amount of academic work completed
• Increase the accuracy of academic work

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THE TEAM

• Parents
• Family
• School officials
• Health care professionals

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GIMC Child Developmental Team

• Consultant Child and Adolescent Psychiatrist
• Clinical Psychologists
• Occupational Therapists
• Speech Therapists