1. ADHD

2. What is ADHD?

3.  Attention Deficit Hyperactivity Disorder  Developmental behavioural disorder characterised by:  1. Hyperactivity  2. Poor attention  3. Impulsivity

4. How common is ADHD?

5.  1% school age children medicated in Europe  3% school age children medicated in US  Estimated prevalence of ADHD much higher  5% school age children in UK

6. Which children get ADHD?

7.  Little variance inter-culturally  Boys : girls 3:1  Urban > rural

8. What causes ADHD?

9. Environment causes? Associated with  poverty  large family size  parental discord  family psychopathology and criminality  early maltreatment  pregnancy and delivery complications  lead contamination

10. Genetic causes?  Twin studies show 80% concordance  Molecular studies: dopaminergic genes such as DRD4 associated with 2 times the risk of ADHD

11. Brain function in ADHD children

12. Areas of Brain Dysfunction in ADHD? Pre-frontal Cortex

13. Areas of Brain Dysfunction in ADHD?  Neuroimaging suggests significantly smaller, less symmetrical prefrontal and basal ganglia structures in ADHD children vs controls  Executive function, self-regulation, arousal and motivation are regulated by these areas  The neurones in these regions of the brain are rich in dopamine, adrenaline and noradrenaline

14. Diagnosing ADHD

15.  3 ‘core signs’  1. hyperactivity  2. inattention  3. impulsivity  But only if..  Last for at least 6 months  Before the age of 7  Functioning impaired  Present in two or more settings

16. Making the diagnosis  3 symptoms of hyperactivity  6 symptoms of inattention  1 symptom of impulsivity

17. Hyperactivity At least 3 symptoms of hyperactivity fidgets with hands / squirms in seat leaves seat in classroom or inappropriately in other settings runs / climbs excessively unduly noisy in playing excessive motor activity unmodified by social context

18. Inattention At least 6 symptoms of inattention  Careless  Poor attention to detail  Fails to sustain attention to tasks / play  Distractible  Appears not to listen  Disorganised in tasks  Forgetful

19. Impulsivity At least one symptom of impulsivity  often blurts out answers before question has been asked  fails to wait turn in queue or in games  intrudes into conversations  talks excessively without appropriate response to social restraints

20. What if it’s not ADHD?

21. If it’s not ADHD it could be...  Physical (organic) impaired hearing, seizures/epilepsy, head trauma, poor sleep/nutrition, metabolic disorders  Drugs alcohol, illegal drugs  Psychiatric Autism, conduct disorder, anxiety, attachment disorder  Environmental Abuse, neglect  Normal

22. What other problems go with ADHD?  ODD (35-50%), CD (25%)  Learning disorders (15-40%)  Anxiety (25%)  Depression (15%)  Tic disorders

23. In the clinic

24. Clinical assessment  Careful history and examination  Observation/reports from home, school and clinic  Use of questionnaires – Connor’s and/or SDQ  Consider psychometric testing

25. Treatment for ADHD

26. “This pill reduces class-clownism by 44 percent!” -The Simpsons

27. First steps Psychosocial interventions:  Parent training programmes based on social learning theory  Cognitive Behavioural Therapy (CBT)  Social skills training

28. Second steps Medication:  Stimulant medication:  methylphenidate (Ritalin, Concerta)  atomoxetine (Strattera)

29. And also...  Specialist help for specific strategies and support  Good liaison with other services

30. What can be done at home?

31.  Parent-training courses  Based on social learning theory  Calm, consistent, confident parenting  Enjoying and playing with your child  Improving communication  Rewarding good behaviour  Ignoring bad behaviour  Consequences for unacceptable behaviour  Modelling behaviour

33. What can be done at home?  Physical exercise  Healthy, regular diet  Encouraging activities that extend attention and concentration

34. What can be done at school?

35.  Special Educational Needs coordinator  Know your child!  Indentify strengths and weaknesses

36. What can be done at school?  Limit distractions eg. desk near teacher  Small groups, one to one attention  Clear, simple rules regularly repeated and followed  Encourage to seek extra help if doesn’t understand  Keep tasks short (‘chunking’)  Simple, clear instructions – check understanding  ‘Motor breaks’

37. What can be done at school?  Clarity regarding expected behaviour – what rewards and consequences  Encouragement of on-task behaviour praise and rewards  Ignore minor misbehaviour ignored  More serious misbehaviour immediately addressed  Encourage to make friends as social skills may impede this skill

38. The future for ADHD children

39. Prognosis  Hyperactive symptoms settle down in mid-teens  Some problems such as restlessness and inattention continue into adulthood  Adult ADHD increasingly recognised  Meta analysis of 32 studies of children with ADHD reported 15 % still met the criteria at age 25, 65% partial criteria

40. Children with ADHD vs peer group  Poor academic performance  More LD diagnoses  Premature school drop-out  Delinquency  Substance misuse  Lower pay and status jobs  Higher accidental injuries, suicide attempts and death

41. Does ADHD exist?

42. ADHD controversy and debate  Societal changes?  Pathologizing normal behaviour?

43. Any questions?