ADHD Cathy Laver-Bradbury Consultant Nurse ADHD Solent NHS Trust

Learning Outcomes for session- What I hope you learn. 1. Identify the presenting symptoms of ADHD 1. Describe the treatment options for ADHD

1. Understand why it is important to recognise and help a child with ADHD

Overview of Session-the how I hope to help you learn it! Recognition of ADHD –what does it look like? – How is it Caused? – How and why we Diagnose?

•ADHD – the treatments •ADHD – How to help •Questions

ADHD – What does it look like?

What is ADHD? • ADHD is a neurodevelopmental disorder1 that begins in early childhood and can continue into adulthood2,3 • Core symptoms are3,4 – inattention – hyperactivity – impulsivity

1. NIH, 2000. 2. Waslick &Greenhill, 1997. 3. AACAP Official Action, 1997. 4. APA DSM-IV-TR 2000.

ADHD is the most common neuro-developmental disorder in children1 • Prevalence in school-age children ranges from 3−16%1,2,3 3%

4.5% 7%

16%

1. AAP, 2000. 2. APA DSM-IV-TR, 2000. 3. Rowland et al, 2001.

What might you see in the Classroom

Inattention

Hyperactivity

• Disorganized • Poor concentration • Forgetful • Failure to persist with tasks

• Unable to sit • Impatience still/remain seated • Interrupting others • Excessive and • Difficulty in inappropriate delaying response over-activity • Restlessness

1. APA DSM-IV-TR, 2000.

Impulsivity

ADHD Brain Processes

Working Memory Problem solving/Organization/E xecution

ADHD Neurocognitive deficits

ADHD Symptoms

Does not follow through on instructions and fails to finish tasks

Impulsivity

Effort full control emotions/behavi our

Reactive control of emotions Reward size and proximity Sustained attention Selective attention

Arousal

Loses things necessary for tasks or activities Has difficulty organizing tasks Makes mistakes in tasks/homework Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort

Self Regulation

Has difficulty awaiting turn

Reward and Motivation

Blurts out answers before questions have been completed

Hyperactivity

Leaves seat in classroom or in other situations in which remaining seated is expected Fidgets with hands or feet or squirms in seat Runs about or climbs excessively in situations in which it is inappropriate

Delay Aversion

is "on the go" or often acts as if "driven by a motor"

Top Down Attention

Interrupts or intrudes on others (e.g., butts into conversations/games) Has difficulty playing or engaging in leisure activities quietly

Distractibility

Alertness

ADHD Behaviours Often is forgetful in daily activities

Executive function Concept/Perce ption of Time

ADHD Diagnostic Threshold Reached

Bottom Up Attention

Inattention

Often talks excessively

Difficulty sustaining attention Often is distracted by extraneous stimuli Does not seem to listen to when spoken to directly

A child is seen to have significant Impairment in any domain if: 1.At least two items scored 2, 2.One item scored 3 3.There is a mean

The Causes

S

Is ADHD a genetic disorder?

1. Biederman & Faraone, 2005. 2. Faraone & Biederman, 1998.

Transmission of messages in the brain Pre-synaptic axon terminal

Mitochondrion Synaptic vesicle

Synaptic cleft

Neurotransmitter (ligand) Post-synaptic dendrite

Receptor + ligand = ion channel

Receptor (no ligand)

Gene x Environment Interaction • .

The Diagnosis

The Diagnosis

Meeting the DSM-IV or ICD 10 diagnostic criteria1 •

Symptom criteria

– presence of six or more symptoms •

Duration

– symptoms present for at least the past six months •

Age of onset

– some symptoms present before 12 years of age •

Pervasiveness

– symptoms present in two or more settings (e.g. school or home) •

Impairing

– Symptoms are causing the child distress or impairing their learning 1. APA DSM-IV-TR, 2000.

Complexity-Introducing models to use when diagnosing/formulating in ADHD Hereditary, biological and acquired Factors

Beliefs and thoughts of child and family that influence decisions

Psychodynamic influencesearly attachment

Systemic Influences

Behavioural model

Hoyos C. 2010 Solent NHS

Hoyos, C. 2010 Solent NHS

Complexity Family history ADHD, in utero exposure to substances, prematurity

Unmanageable at school, lives in overcrowded house, father has new partner

Repeated expression that everyone hates her and that she kills people

Main care giver death within 6 months-poor relationship and neglect prior to this

Behavioural issues from 2 years, excessive activity poor emotional regulation

ADHD is associated with coexisting conditions

Tic

Depression

disorders

Conduct disorder

Anxiety disorder

Figure reproduced from Selikowitz, 2004

1. Selikowitz, 2004. 2. NICE, 2000.

• Oppositional defiant disorder • Specific Learning Difficulties • Obsessive–compulsive disorder • Bipolar disorder • Asperger syndrome • General Learning Difficulties • Conduct Disorder • ADHD as a result of Developmental Trauma

ADHD – The affects

STOP2

What are the long-term affects of ADHD?

1. NIH,2000. 2. Waslick & Greenhill, 1997.

Educational Outcomes -190 days •

Sexual Activity in ADHD

Substance Abuse in Adolescence

• Treatment of ADHD with stimulants decreases substance abuse (Huss, 2003)

Helping young people with ADHD

STOP 3

Whole School Considerations

Helping inattentive symptoms?

• •

•

•

1. APA DSM-IV-TR, 2000.

Giving instructions in various formats helps, consider lists, reminders, audio and/or visual prompts Work out the young persons attention span build in small breaks or tasks to help, secret prompts can also help Young people with ADHD have poor time perception help them by practicing starting tasks and how long they take Rewards work well make sure they are given regularly, praise tokens and earshotting

What are inattentive symptoms? The Ideas to help • Use charts, time lines lists and prompts • Work out if YP responds better to auditory reminders or visual use a variety of these to help check they have the things they need • Make sure you have eye contact when speaking to the young person –but only for positive interactions • Remember they have very poor short term memory • Limit the number of tasks you ask of them

What are hyperactive symptoms?1 The ideas to help • Build in breaks • Allow them to fiddle • If challenging make them aware you are on their side trying to help • Be prepared to be challenged • Stick to arranged boundaries

1. APA DSM-IV-TR, 2000.

What are impulsive symptoms?1 The ideas to help • Acknowledge their difficulties using eye contact ask them to wait but remember to return to them- they often shout out to prevent forgetting may work getting them to write it down • Using timers may help with time perception and delay • Allow them to use note pads to write things down they may forget. • Practice quiet times within the classroom

1. APA DSM-IV-TR, 2000.

There are many ways to learn! • Peer rejection3 • Low selfesteem4

1. APA, 2000. 2. Selikowitz, 2004. 3. NIH, 2000. 4. NICE, 2005.

Social skills • Few or no friends2

Children naturally move away from other children who get in trouble all the time until about teenage-then they may find children want to be friends with the ‘naughty’ child in the classroom-helping them to make friends early –children that can help them understand the rules is crucial to their long term wellbeing. 1. Selikowitz, 2004. 2. International consensus statement on ADHD, 2002.

Individuals with ADHD often exhibit non-compliant, defiant behaviour What do you do when faced with a child who is continuously oppositional? Try not to become oppositional in response! Children who are oppositional are trying to seek a power battle with you-resist the temptation! Get Sad not Mad- help them to realise this is an issue which will not help them in the workplace and with relationships and that you are sad that they feel the need to push you in this way. Keep sanctions reasonable but consistent and keep in mind what you are trying to help them learn-this may take a long time!

The impact of ADHD extends throughout the family • The problems experienced by children with ADHD can impact on the whole family, including1 – parents’ emotional health – parents’ time to themselves – family activities – family cohesion

1. Klassen et al, 2004.

Treatments

STOP 4

Psychosocial Interventions • New Forest Parent Program which includes

– Education for young person and family – Behaviour interventions – Attention Training and Delay restructuring – Systemic support

Also may be needed • • • •

Cognitive behaviour therapy Psychodynamic psychotherapy Family therapy Medical Therapy

Are we prescribing too often?

Medication for ADHD Class

Neurotransmit Brands ter system (launched products)

Methylphenidate

dopaminergic

Amphetamine

dopaminergic and norepinephrine

Ritalin® Equasym™XL Concerta® Medikinet XL

Dexedrine

Atomoxetine

Norepinephrine Strattera

Lisdexamfetamine

Pro drug

Elvanse®

Features

Most commonly prescribed medication for ADHD in Europe1,2,3 Established efficacy and good tolerability3 50 years of successful clinical experience3,4 Newer once-daily formulations provide long duration of effects5 Widely used in the US, but not in most European countries2 Established efficacy and good tolerability3 First non-stimulant6 Superior efficacy over stimulants unproven7

How does methylphenidate work? 3 MPH blocks reabsorption of DA or NE from the synapse

DA or NE transporters DA or NE DA or NE receptors Methylphenidate (MPH)

DA, dopamine NE, norepinephrine

Pre-synaptic axon terminal

DA or NEcontaining vesicles

1 DA or NE is released into the synapse

2 DA or NE reversibly attaches to receptors

Post-synaptic dendrite

 DA/NE in the synapse   post-synaptic neurotransmission

1. Kuczenski & Segal, 1997. 2. Volkow et al, 2001.

What are the side-effects of stimulant therapy?1 • Common side-effects – – – – – – –

delay of sleep onset decreased appetite weight loss stomach-ache headache jitteriness tics

1. Greenhill et al, 2002.

Stimulants: no evidence for increased risk of substance abuse • Adolescents with ADHD are at high risk of substance abuse1 • Therapy for ADHD may have a protective effect against substance and alcohol abuse1,2

1. Biederman et al, 1999. 2. Wilens et al, 2003.

ADHD – the problem 

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It is caused by an impairment in brain function, involving the neurotransmitters dopamine, norepinephrine and serotonin genetic factors, and problems during pregnancy and birth may also play a role Two classification schemes exist for diagnosing the core symptoms of inattention, hyperactivity and impulsivity ADHD is a common neurodevelopmental disorder in children that may continue into adulthood The management of ADHD involves a comprehensive treatment approach using both drug and non-drug therapies The costs to patients are also high, with educational, occupational and social functioning all affected

ADHD – The Chance The way you work with young people with ADHD is important in helping them achieve their potential Understand the symptoms it will help you to know when they need extra support Be creative work with them, try out new ideas, consistence and persistence pays Be positive remember to listen and be fair in your approach Seek help and support in managing difficult behaviour

• http://www.bbc.co.uk/news/health-19910955

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“Here’s to the crazy ones, the misfits, the rebels, the troublemakers, the round pegs in the square holes… The ones who see things differently — they’re not fond of rules… You can quote them, disagree with them, glorify or vilify them, but the only thing you can’t do is ignore them because they change things… They push the human race forward, and while some may see them as the crazy ones, we see genius, because the ones who are crazy enough to think that they can change the world, are the ones who do.” Steve Jobs