approach to adhd
DESCRIPTION
ADHD ,Autism is increasing in India,Psychological problems are increasing with great speed.If these children are not identified in early childhood most of the children can land up in adult personality disorders or psychiatric disordersTRANSCRIPT
Approach to ADHD in children
Dr vijay warad
Sai speciality clinic,satara road
Inamdar and sahyadri hospitals,pune
What comes to your Mind ?
INTRODUCTION
ADHD is one of the most common childhood Neurobehavioural disorders
First described by Dr. Heinrich Hoffman in 1845 “The Story of Fidgety Philip”
In 1902, Sir Geroge Still described the condition
First published report in 1937 of stimulant medication in ADHD
ADHD often continues into Adolescence and Adulthood
What Is ADHD?
ADHD, or attention deficit hyperactivity disorder, is a Behavioral Condition characterized by inattention, impulsiveness, and/or hyperactivity.
Approximately 1-20% of Indian children have ADHD
Source – Indian Academy of Pediatrics
Persistent pattern of inattention and / or hyperactivity and impulsive behaviour that is more severe than that expected in children of that age and level of development.
Definition
PREVALENCE
Prevalence of ADHD 3 -10% ( Rowland et al 2002)
Affects 5% of school children (1/ class room)More common in boys 4 – 9:1 (Gender bias)Recent revised estimate 2 – 4:1 (Safer & Malever 2000)
ASSOCIATED FEATURES
School failurePoor planning, organization and task performance
Speech and language problemsPoor motor co-ordinationEnuresisInstabilityHigh stimulus seekingLow frustration tolerance
ASSOCIATED CO-MORBID CONDITION
Language and learning disability (10-15% have ADD)
Tourette’s syndrome (70% have ADHD)Oppositional Defiant Disorders (33% of ADHD)
Conduct Disorders (25 -50% of ADHD)Major Depression (20% of ADHD)Anxiety Disorders (25% of ADHD)
ADHD COMORBIDITY
Secondary Complicationsof RhinitisAllergic inflammation does not necessarily limit itself to the nasal airway Asthma : up to 80% of asthma patients have accompaning AR,38% of AR have
asthma Chronic sinusitis Otitis media Hearing difficulties Facial changes Failure to thrive Behavioural disorders (hyperactivity) Increased Social & emotional issues affect learning & ability to integrate with
peers Uncontrolled AR & adverse effects of sedating medications affect cognitive
functions Pneumonias COPD
What Are the Symptoms of ADHD?
Hyperactivity
Impulsivity
Inattention
Child's functioning in social and academic settings, Interfere…
Paying attention to tasks at home or schoolMaking careless errorsBeing easily distractedNot following through with tasks or completing instructions
Bored, losing things, being forgetful, having difficulty organizing tasks
Being fidgety, seated at one placeTalking excessively
How Do I Know if a Child Has ADHD?
Many of the symptoms of ADHD are also symptoms seen during normal childhood and development
Exhibiting one or more of the symptoms does not mean that a child has ADHD
The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) Below is the Diagnostic Criteria for diagnosing Attention Deficit (Hyperactivity) Disorder:
A. Either (1) or (2)
1) Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with the developmental level:
Inattention
often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
often has difficulty sustaining attention in tasks or play activities often does not seem to listen when spoken to directly
often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure of comprehension)
often has difficulty organizing tasks and activities often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework) often loses things necessary for tasks or activities at school or at home
(e.g. toys, pencils, books, assignments) is often easily distracted by extraneous stimuli if often forgetful in daily activities
2) Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level:
Hyperactivity
often fidgets with hands or feet or squirms in seat often leaves seat in classroom or in other situations in which remaining
seated is expected often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
often has difficulty playing or engaging in leisure activities quietly often talks excessively is often 'on the go' or often acts as if 'driven by a motor'
Impulsivity
often has difficulty awaiting turn in games or group situations often blurts out answers to questions before they have been completed often interrupts or intrudes on others, e.g. butts into other children's games
B. Some hyperactivity - impulsive or inattentive symptoms that cause impairment were present before the age of 7 years.
C. Some impairment from the symptoms is present in more than two or more
settings (e.g. at school or work or at home).
D. There must be clear evidence of clinically significant impairment in social,
academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder, and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
Symptoms of Hyperactivity in ADHD
The child often fidgets with hands or feet or squirms in their seat
The child often leaves the seat in the classroom or in other situations in which remaining seated is expected
The child often talks excessively.
Symptoms of Impulsivity in ADHD
The child often blurts out answers before the questions have been completed
The child often experiences difficulty awaiting his or her turn
The child often interrupts or intrudes on others
Symptoms of Inattention in ADHD
The child often fails to give attention to details, or makes careless mistakes in schoolwork, work, or other activities.
The child often has difficulty sustaining attention in tasks or play activities.
LIFE TIME COMORBID DISORDERSShekim WO, et al Comprehensive Psychaitry 1990; 31(5):416-425Biedermen J, et al. Am. J. Psychiatry 1993; 150(12): 1792-1798
PSUD: Psychoactive substance use disorder; MDD: Major PSUD: Psychoactive substance use disorder; MDD: Major Depressive Disorder ; LD: Learning disability; Depressive Disorder ; LD: Learning disability; ASP: Antisocial personalityASP: Antisocial personality
PRESENTING FEATURES
Look for features of dyslexia, dysgraphiaCruelty towards people, animalsDestruction of property, stealing Delinquent behaviorArgumentative, disobedient, defiant, Back answers, quick to take offense
PRESENTING FEATURES
Excessive crying or worry
Preoccupation with death or suicides
Neglect of self environment, antisocial
Low self esteem
Substance abuse
DIFFERENTIAL DIAGNOSIS
Mental Retardation with Hyperactivity
Under stimulation for highly intelligent children
Hyperthyroidism
Lead poisoning
Seizures (Petit Mal, Non Convulsion Status)
Medication – AED’s, antihistaminic, decongestants etc.
Chronic illness, sleep disorders
COMPREHENSIVE MANAGEMENT PROTOCOLS
Screening in pre-school and school children
Assessment to fit DSM IV CriteriaEvaluation for co-morbid conditionsInvestigations when indicatedPharmacological treatment Psychological treatment Lifestyle modification
TREATMENT PLAN
Psycho-education of parent, teacher, child
BT initially for mild to moderate ADHD
Psycho-stimulants strongly recommended for moderate to severe ADHD
Combination of both is most beneficial
Constant follow up since it’s a chronic condition
Medicines
Automoxetin: Axpeta (25 mg,50 mg)
Above 6 years preffered
Methylphenidate:- Inspiral,Adwise 10 mg,20 mg
ALTERNATIVE THERAPIES
Omega-3 fatty acids
Hypnosis
EEG biofeedback
Yoga, meditation
Ginkgobiloba
Mega-Vitamin Therapy
OMEGA -3 FATTY ACIDS
3 Major Type ingested in food
ALA – Alpha Linolenic Acid
EPA – Eicosapentaenoic Acid
DHA – Docosahexaenoic Acid
Once ingested Body converts ALA to EPA & DHA
DIETARY SOURCES
ALA – in Flax seeds, Canola Oil, Walnuts
DHA – in Seafood, Tuna, Salmon
EPA – Whole Grains, Garlic, Olive Oil
MECHANISM OF ACTION
Blocks action of cytokinesEnhance Neurotrophic activity in SynapsesForms an essential part in physicochemical properties of cell membranes, oligodendrocytes and astrocytes
(Purdue Study, Durham Study, Richardson and Puri Study)
STUDY WITH OMEGA 3 FATTY ACID
Study on pre school children with LD and ADHD showed significant improvement in cognitive & behavioural functions after 12 weeks of O3 Fatty Acid (Richardson + Puri Oxford Univ.)
Study of Pregnant ladies given O3 Fatty Acid supplement --- Children followed upto 5-6 years age significant different in learning capabilities and academic performance (Meherban Singh)
Docosahexaenoic Acid for Reading, Cognition and Behavior in Children Aged 7–9 Years: A Randomized, Controlled Trial (The DOLAB Study)
Alexandra J. Richardson*, Jennifer R. Burton, Richard P. Sewell, Thees F. Spreckelsen, Paul Montgomery
Centre for Evidence-Based Intervention, University of Oxford, Oxford, United Kingdom
PROGNOSISAbout 60-80% of childhood ADHD continue into Adolescent & adults.
They may out grow Impulsivity and Hyperactivity.
Inattention and Disorganization persist and may worsen.
Adults with H/o ADHD in childhood have higher rates of antisocial, criminal behaviour, Injuries, accidents, teen pregnancies
Employment and Marital difficulties.
May need treatment and follow up lifelong.
ADHDADHD
Low selfLow selfesteemesteem
AcademicAcademiclimitationslimitations
RelationshipsRelationships
Smoking andSmoking andsubstance abusesubstance abuse
InjuriesInjuries
Motor vehicle Motor vehicle accidentsaccidents
LegalLegaldifficultiesdifficulties
Occupational/Occupational/vocationalvocational
Childhood
Childhood
Adulth
ood
Adulth
ood
AdolescenceAdolescence
Symptoms of ADHD through the life cycle
Treatment Option…Very IMPORTANT…
COGNIUM SYP CLINICAL TRIALS
Proven in a Comparative clinical trial with 60 ADHD Childrens,for 16 weeks
-Conducted by Dr.Vwarad,MD(Paed)in Pune-Conducted on 2 Group of 300 children
each,Gr A&Gr B-group A with cognium syrup and Behavioral
therapy-Group B with Behavirol therapy alone
-Assesssed by VANDERBILT ASSESSMENT SCALE