cu adhd

Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD

Dr Elspeth Webb

Attention deficit hyperactivity disorder

ADHD


Over-activity & Impulsiveness

&/or

Inattentiveness/distractibility

Pervasive: in all contexts

Early onset

What is ADHD?


A condition comprising a degree of impulsivity & hyperactivity and/or inattention to a point that is disruptive and inappropriate for developmental level

Pervasive & present for at least 6 months

Two sub types: Inattentive and Hyperactive/impulsive

Hyperactive/impulsive subtype also referred to as hyperactivity or hyperkinetic disorder

But what is “inappropriate”? - this is a condition that is, in part, But what is “inappropriate”? - this is a condition that is, in part, socially socially constructed. constructed.

p.s. DSM-V -- which is currently in the planning stages and is expected to be published in 2013 -- will bring changes, perhaps by treating these as two separate disorders, rather than subtypes of the same condition

Definitions: ADHD (DSM-IV TR)


1/10

1/20

1/50

1/100

1/200

Have a guess

Prevalence: – how common is it?


UK/USA/Australia/Scandinavia

• 5% for total (mixed or just hyperactive/impulsive or just inattentive)• About 3% for hyperactivity ( i.e. mixed or just hyperactive impulsive• 1% for mixed ICD10 (hyperactive & inattentive)

Politics: Administrative vs. real prevalence

USA : administrative prevalence greater than real (Driven by litigation)UK: real prevalence less than administrative2001

administrative = 20,000real = 70,000

Prevalence


Highly heritable. • ? evolutionary advantage

neurological damage

Not bad parents:- c.f. Kanner’s original description of autism, (will return to this)

Aetiology:- what causes it?


Attention

Executive function

Neuro-psychological basis


detecting a stimulus encoding or processing information sustaining attention to relevant stimulus whilst filtering out others shifting attention when appropriate inhibiting involuntary shifting (distractibility) organising a response to incoming information

Attention


Studies suggest that the attentional problem is not at the level of “going in”, but at the level of stimuli processing

So children with ADHD do not have difficulties with receiving information, but with subsequent processing and selection of appropriate response

i.e. it’s not that they don’t pay attention, but they act as if they don’t pay attention, because they do not respond appropriately.

Attention in ADHD


A set of brain functions unique to humans, concerned with self regulation, sequencing of behaviour, flexibility, response inhibition, planning and organisation of behaviour

Allows us to think about ourselves, what may happen in the future, and how we can influence it

Executive function


3 components are limited:

– working memory - ‘open file’ on the hard drive• non-verbal working memory • verbal working memory

– self-regulation– reconstitution; using working memory to plan and organise and

reflect

As children with ADHD get older and enter adolescence these are the areas of function in which they get more different from their peers, precisely when we start to ask more of them in these areas

Executive function in ADHD: deficits in inhibition


Any intellectual activity is much more difficult for these children both in getting started and in sustaining that activity

They have to put in far more effort for any particular task compared to their peers – everything is at least twice as hard

This is very tiring

They will therefore do anything to avoid intellectual effort because it is so hard

Effort avoidance


Some diseases are “all-or-nothing”, e.g. influenza

Others are “dimensional” in that the disorder or disease fades into normality

ADHD “normal”

For children on the cusp, it is difficult to distinguish disorder from personality. To some extent it is a socially constructed diagnosis which is a disorder “here and

now” because it is hard to accept that 5% of all children are “abnormal”

ADHD as a dimensional disorder


Clinical interview

Rating scales

Observation (preferably not in clinic)

Cognitive assessment– learning difficulties/unrecognised superior skills

Psychological evaluation Multidisciplinary/multiagency

Assessment - all


hearing

chromosomes if associated with dev. Delay

EEG ( if suggestion of epilepsy)

Occupational Therapy if child has associated co-ordination difficulties

Speech and Language Assessment

Additional assessment


Linked Co-ordination problems Speech and language disorder Autistic spectrum Tourette syndrome

Coincidental Hearing impairment

Pseudo link Oppositional/defiant disorder and Conduct disorder

Co-morbidity/overlap


abuse/violence/poor parenting

inappropriate classroom management

Contributory/exacerbating factors


Genotype – our genetic inheritance and makeup – what our DNA says, which genes we carry

Phenotype – how our genotype is expressed . E.g. gene for cystic fibrosis results in a phenotype that involves chest infections, digestive problems, infertility in males. Benes for ADHD result in ADHD phenotype

Phenocopy. – when another set of factors, usually environmental, result in a set of signs symptoms and behaviours very similar to a genetic phenotype. Most famous example – Romanian orphans and autism

ADHD phenocopies – violence, abuse, and anxiety

Phenocopy of ADHD


The infant human brain at birth is very immature in comparison to other mammals

++ growth, development, cellular interconnections and cell culling in the first year or two

Direction and pattern of these processes is partly genetically, partly environmentally driven

Our children’s brains are sculpted irreversibly by their early (and perhaps even prenatal) life experiences

Children exposed to violence are hard wired to be anxious, distractible, highly aroused in situations of conflict, and impulsively aggressive – this is largely irreversible

Impact of early violence on brain development


Children living with violence are anxious, highly aroused, and have raised cortisone

Although for older children this does not have the same long term impact on brain structure, fearful highly aroused children are: distractible/inattentive/overactive/impulsive

How? - Weinstein et al, 2000: difficulty concentrating caused by re-experiencing trauma (PTSD) hyperactivity caused by hyper-vigilance

Impact of current violence on behaviour


Higher prevalence of violence in low income families, including domestic abuse (DA) and child abuse

Poverty associated with other risk factors for “ADHD”

LBW and prematurity

Intrauterine exposure to illegal drugs and alcohol (itself strongly linked to DA)

Demography of violence


Child health outcomes – reduction in health problems if all children had outcomes of wealthiest 5th

(courtesy of Nick Spencer)

Child health outcomes % reduction

Birth weight*: <2500g <1500gDisability**: Cerebral palsy Intellectual disabilityPsychological problems***: Emotional disorders Conduct disorders Hyperkinetic disordersRegistration for Child Abuse**

30%32%

30%39%

34%59%54%53%

* Based on 210,000 births in the West Midlands region of the UK, 1991-‘93** Based on data on 150,000 births in the West Sussex region of the UK, 1983-2001***Based on the UK survey of mental health among 5-15 year olds (Meltzer et al 2000)


Abuse

ADHD

1. Neurocognitive effects2. Anxiety/disordered attachment

Overactivity DistractabilityImpulsivity

Increasesrisk ?

exacerbates

Conduct disorder

co-morbid with

In care•? hard to place•? breakdown of placement

mimics

causal

associatedwith

Parent with ADHD

In summary:Relationship between ADHD and child maltreatment


Problems for diagnosis, management, and research

Maltreatment and ADHD phenocopies


These children can be clinically indistinguishable from those with genetic ADHD (although some differences from population studies)

In both cases symptoms may be lessened by treatment with stimulants

This poses not just a diagnostic dilemma but an ethical one too in therapeutics

It raises doubts about the validity of much research – what is being studied?

Challenges


Medication

Stimulants (short acting or slow release)

Others

Behavioural

Psychological

Management of hyperactivity


Short term effects

- improves attention/decreases impulsivity/decreases over-activity

Consistently shown in research

Effectiveness of stimulants


Dose related: decreased appetite, insomnia, irritability, anxiety, abdominal pain, headaches, mood disturbance.

Tics

Behavioural rebound

Socialisation: some negative effects on pro-social behaviours

Rare: psychosis, obsessive/compulsive disorder (OCD), cardiomyopathy, effects on blood count.

“My friends say I’m boring on the tablet and I don’t have any ideas”

Adverse effects


The decision to put a child on stimulants is not an easy one for parents, clinicians, or children.

Everyone must feel comfortable with the decision to treat or continue treatment

No child should be coerced to take stimulants

Medication must always be backed up by appropriate parenting and school strategies.

Improvement on stimulants should not be used as an excuse to remove recognition of special educational needs - their ADHD remains.


Behavioural

Psychological Depressingly there is a very poor evidence base for either in that

neither achieve much without stimulants

But parenting education helpful with stimulants – not because “poor” parents, but because it’s much harder to be a parent to a child with ADHD, and often requires counter-intuitive responses.

Management approaches


3 groups

Group 1:- do well and not distinguishable from matched normal controls in adulthood - 30%

Group 2:- continue to have significant problems with concentration, impulsivity and social interaction - 50% (but can these be a strength – stand up comics)

Group 3:- significant psychiatric or antisocial problems or both - 10% (severe depression, bipolar affective disorder, suicide, drug/alcohol abuse; delinquency leading to serious crime)

Overall an increased risk of school failure, unemployment, poverty, imprisonment

Prognosis


Child

Family

Treatment

Schools

Factors predicting outcome


IQ - lower the IQ poorer the outcome

Inattention – underachieve academicallyacademically

Hyperactive - poor socialsocial outcome

Poor social skills - greater risk of CD and substance abuse

Co-morbidity - poorer outcome

Child


Poor parental mental health, poor mother /child relationship - poor outcome

Parenting style consistency and firmness - good inconsistent/permissive/restrictive/punitive – bad

SE status - low SE status possibly associated with persistence of ADHD into adolescence

Family


Medication alone - no difference in outcome, but medication and ‘good family’ - good outcome

In general medication in childhood does not seem to affect adult outcome except some evidence for improved social skills and self-esteem.

But this research may be invalid in that more severely affected children are medicated

Treatment


There is very little research on looking at educational interventions and long term outcomes, whether

1. Classroom strategies2. Educational approaches

Inclusion vs. specialised Adapting teaching to how these children learn How do they learn – not even much on that!

Schools


http://www.acer.edu.au/documents/Kos_PrimaryTeachers-ADHAD.pdf

“The classroom may represent one of the most difficult places for children with ADHD, most probably because this setting requires children to engage in behaviours that are contrary to the core symptoms of the disorder”


Increases anxiety

Makes symptoms worse

Pushes children further along the dimension

Reduces self esteem

Contributes in the longer term to alienation, conduct disorder, delinquency

Poor school experience


“….programmes on television in the UK exploring ADHD ……..ignored children’s rights in that they were exploitive, contravened a child’s right to privacy, and were certainly not in the best interests of the children involved.

They provided inaccurate presentations of ADHD with most of the cases presented being conduct disordered children in very disadvantaged circumstances. ….(The programmes) had a focus on these children not as in distress, but as ….. bad. ”

Webb E. Health services: who are the best advocates for children? Archives of Disease in Childhood 2002;87:175-177

ADHD & the Media


-a badly behaved, impulsively aggressive, morally deficient child

ADHD media stereotype

But children with ADHD can be impulsively anything:- brave, empathetic, witty, cautious, clever, unkind, generous, reserved, oppositional, adventurous, imaginative, energetic, creative, destructive, etc..

Don’t stereotype or you will miss casesDon’t confuse personality

with disorder


Summary ADHD is common, but under-diagnosed in the UK

1o schools: a major role in recognising affected children

Affected children form a highly heterogeneous population: each child with ADHD requires a tailored strategy

Stimulants are effective in management (but they are not everything)

The severity of ADHD, and adult outcomes, are strongly affected by how a child is treated by the adults in his/her life

Educational practice underpinned by poor research and evidence base

Educational research is possibly not asking the right questions

cu adhd

Health & Medicine