🧠ADHD
Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children. ADHD also affects many adults. Symptoms of ADHD include inattention (not being able to keep focus), hyperactivity (excess movement that is not fitting to the setting) and impulsivity (hasty acts that occur in the moment without thought).
An estimated 8.4% of children and 2.5% of adults have ADHD.1,2 ADHD is often first identified in school-aged children when it leads to disruption in the classroom or problems with schoolwork. It is more common among boys than girls.
• Introduction.
• The ability to pay attention is an important
prerequisite to success. Any difficulty with attending
skills can have adverse effect on learning.
• ADHD is the term used when the primary
characteristic is significant inattentiveness and
impulsivity with or without hyperactivity.
Hyperactivity often occurs with inattentiveness and
impulsivity.
• ADHD is a neurobiological condition seen primarily in
the school aged population that affects one’s ability
to maintain attention.
• ADHD involves an underlying impairment of
executive function – the cognitively based control
system that regulates behavior. It is possible that
this executive dysfunction interferes with
performance on certain tasks used to identify
language impairment
• Defining ADHD
• ADHD is a neurobehavioral condition characterized
by inattention, hyperactivity, and impulsivity that is
displayed at developmentally inappropriate levels
when compared to peers, (American Psychiatric
Association, 2000).
Etiology
• Children with ADHD show a multitude of deficits in
attention- executive functions, planning and
inhibitory control, sustained attention, and selective
attention. (Barkley, 1997; Shalev and Tsal, 2003),
• Genetic factors
• ADHD inherited in 80% cases. It was found that
polymorphism in DA receptor D4 gene located on
chromosome 11p15.5 is associated with blunted
sensitivity of D4 receptor present in brain areas
which play a role attentional control.
•
• Neurobiological factors
• Extensive studies reveal that nigrostriatal and
front striatal connections and interrelated structures
abnormal in children with ADHD (Denkler & Reiss, 1997).
• Right hemisphere abnormalities and anomalous
cerebral asymmetry was also observed in patients
with ADHD. showed decreased anterior superior
frontal volume, anomalous asymmetry of caudate
nucleus
.
• Environmental factors
• Following factors are also found to be associated
with ADHD
.
• Exposure to toxins during pregnancy
• Exposure to lead
• Family environment adversity
Neurotransmitters:
• The two primary neurotransmitter systems most
directly involved in ADHD are dopamine and
norepinephrine systems
.
• The neurotransmitters dopamine is involved in
controlling emotions and reactions, concentrating
,reasoning and coordinating movement.
• An abnormally low level of dopamine can cause the
three symptoms of ADHD: inattention, impulsiveness
and hyperactivity.
4. Maternal smoking, drugs and
exposure to toxins:
• Smoking, alcohol consumption and drug intake in pregnant
women are at the risk of having children with ADHD as it may
reduce activity of the nerve cells (neurons) that produce
neuro transmitters.
Mercury exposure during pregnancy may be associated with a
higher risk of ADHD
Prevalence of ADHD:
• Children with ADHD usually have impairments across
multiple settings- home, social interactions and
school (Barkley, 2000)
• ADHD is more prevalent than schizophrenia,
obsessive-compulsive disorder(OCD),and panic
disorder, affecting an estimated 4-12% of school aged children in the world( Polansky, de Lima et al.,
2007)
.
• With survey and recent epidemiologically derived data
showing that 4-5% of collage-aged students and adults have
ADHD (Kessler, Adler et al.,2006).
• ADHD affects both boys and girls. Data indicates that high
rates of boys to girls (3:1) with ADHD presenting for
treatment, in adults, the gender ratio is about 1:1(Biederman,
Furanone et al.,2004).
The signs and symptoms a child with
ADHD
• The child with ADHD who is inattentive will show the
following symptoms:
• Inattentive behaviors in Preschool and Early School-Age
classrooms:
• Difficulty paying attention when given directions by the
teachers.
• Difficulty staying focused on a school task or play activity for
an extended period of time compared with other children in
the classroom
.
• Do not seem to be listening when spoken to or given
directions.
• Often does not complete school tasks.
• Is often forgetful and fails to remember daily rules or
activities.
• Inattentive in classroom discussions and need constant
reminders to ‘join the group’.
• Plays alone and is often “in his or her own world”.
• Frequently daydreams.
• The child with ADHD who is hyperactivity will have following
symptoms:
• Hyperactivity behavior is defined as inappropriate motoric
responses in a context which is inconsistent with
expectations. Such excessive motor , and sometimes verbal ,
activity has typically been found to be variable. It may be
influenced by setting or the activities within a setting.
Hyperactivity is not just high level of activity, but disorganized
and purposeless activity.
• Hyperactive behaviors seen in Preschool and School age
classrooms
:
• Often fidgets with hands or feet or squirms in seat or falls out of
seat.
• Often leaves seat during lesson when remaining seated is expected.
• Often runs about or climbs excessively in situations where it is
inappropriate.
• Has difficulty playing or engaging in leisure activities quietly.
• Often talks excessively or makes noises
.
• Often tosses toys or other objects.
The child who is impulsive will have
the following symptoms
• Impulsivity, or failure of inhibition, coupled with inattention,
appear to be the primary and the most serious and sustained
symptoms of ADHD in children and adults. (Barkley, 1990)
• Blurts out answers without waiting to be called on
hear the whole question
• Has difficulty waiting for his or her turn
• Often interrupts others
• Intrudes on other people’s conversations or games
• Inability to keep powerful emotions in check,
resulting in angry outbursts or temper tantrums.
Language difficulties in ADHD
• Phonology and Semantics:
• There is no evidence that children with ADHD as a group have
disproportionate difficulties with phonology or speech sound
production
• deficits in naming speed associated with effortful semantic
processing.
syntax
• Avoiding tense markers
• Avoiding tensed verbs
• Preference for direct speech.
• The main hypothesis was that children with ADHD
use strategies for discourse production, which reduce
the burden for themselves, but increase it for the
hearer
• Several language areas where such strategies might be at
work were identified. In the tense domain, several differences
were found that were near significant.
• Combined in a general complexity-reducing strategy (avoiding
perfect tenses, avoiding tensed verbs, preference for direct
speech), the difference with the typically developing children
was significant.
pragmatic
• "Pragmatic language" refers to how we use language in
everyday conversation.
This includes the ability to:
• plan what to say
• plan when to say it
• plan how to get the message across
• respect the rules of taking turns
• Children with ADHD may have difficulty with these
skills. This is because communication requires
executive function skills: the ability to create a plan,
carry out the plan, and evaluate how well the plan
worked. Executive function skills are often weak in
children with ADHD.
As a result, they may:
• blurt things out
• interrupt others
• talk too much at the wrong time
• speak for a long time, but with pauses that are too short for
the child to organize his thoughts or to let others take a turn
• speak too loudly
Auditory processing:
• Children with ADHD with language problems can have
auditory processing difficulties such as:
• short term auditory memory weakness
• Problems following instructions
• Slow speed of processing written and spoken language
• difficulties listening in distracting environments eg; classroom
difficulty in reading comprehension
• They can also have language difficulties related to
their impulsivity and poor organizational skills
resulting in
• Problems with classroom discourse
• Poor writing skills
• Tangential narratives and conversations
• Word finding difficulties
• Difficulties inferring meaning
• Problems in making conclusions
• Social language problems
• Problems can be found in the areas of speed of processing,
auditory memory, auditory attention, processing of auditory
information, auditory analysis and auditory discrimination
ADHD has 3 subtypes:
• 1. Predominantly hyperactive-impulsive:
At least 6 symptoms
are in the hyperactivity-impulsive categories. No more than 6
symptoms of inattention are present, although some
symptoms of inattention may be present
.
• 2. Predominantly inattentive:
At least six symptoms are in the
inattention category and there are fewer than six symptoms
of hyperactivity-impulsivity.
• 3. Combined hyperactive-inattentive and impulsive:
The
patient has six or more symptoms of inattention and six or
more symptoms of hyperactivity-impulsivity.
DSM 5 criteria
:
• DSM-IV required documenting symptoms before the
age of 7
.
• In diagnosing ADHD, DSM-5 raises the age of when
symptoms should be documented to middle
childhood (age 12 years)
• Additionally, the new criteria describes and gives
examples of how the disorder appears in adults and
adolescents
.
• DSM-IV, the three types of ADHD were referred to as
“subtypes." This has changed; subtypes are now
referred to as “presentations."
• When diagnosing ADHD, clinicians can specify
whether a individual has mild, moderate or severe
ADHD.
• Several symptoms of ADHD now need to be present
in more than one setting rather than just some
symptoms in more than one setting.
• In making the diagnosis, children still should have
six or more symptoms of the disorder. In people 17
and older the DSM-5 states they should have at
least five symptoms.
• As ADHD symptoms affect each individual to varying
degrees, the severity can be formulated :
• Mild: Few symptoms beyond the required number for
diagnosis are present and symptoms result in minor
impairment at home, school, work and/or in social settings.
• Moderate: Symptoms or impairment between "mild" and
"severe" are present
.
• Severe:
Many symptoms are present beyond the number
needed to make a diagnosis, or multiple symptoms are
particularly severe, or symptoms extremely impair an
individual at home, school, work and/or in social settings.
Assessment of ADHD
• The clinical evaluations of ADHD must be comprehensive and
multidimensional in nature, so as to capture its situational
variability, its a
associated features, and its impact on home,
school, and social functioning
.
• The multi-method assessment approach should include:
• Parent and child interviews
• Parent- and teacher-completed child behavior rating scales
• Parent self-report measures
• Clinic-based psychological tests
• Review of prior school and medical records
• Individually administered intelligence testing, educational
achievement testing, or screening for learning disabilities
(only necessary if not completed within the past year
• A standard pediatric examination or neurodevelopment
screening to rule out any unusual medical conditions that
might produce ADHD-like symptoms
• Additional assessment procedures may be recommended,
including vision and hearing screening, as well as formal
speech and language assessment.
• Parental interview:
• The parental interview often serves several purposes.
• It establishes a necessary rapport among the parents, the
child, and the examiner.
• The interview is a source of descriptive information about the
child and family, revealing the parents’ particular views of the
child’s apparent problems.
• It can readily reveal the degree of distress the child’s
problems are presenting to the family
.
• Hypotheses as to the presence of parental personality or
psychiatric problems (depression, hostility, marital discord,
etc.) may be revealed
.
• The parental interview often serves several purposes.
• Review of Major Developmental Domains:
• Following this part of the interview, the examiner should
review with the parents potential problems that might exist in
the developmental domains of motor, language, intellectual,
academic, emotional, and social functioning.
• Such information greatly aids in the differential diagnosis of
the child’s problems. To achieve this differential diagnosis.
• Family, and Treatment Histories:
• The family history must include a discussion of potential
psychiatric difficulties in the parents and siblings, marital
difficulties, and any family problems cantered on chronic
medical conditions, employment problems, or other potential
stress events within the family.
• Information about prior treatments received by the child and
his or her family for these presenting problems
.
• The examiner should also obtain information on the school
and family histories. The family history must include a
discussion of potential psychiatric difficulties in the parents
and siblings, marital difficulties, and any family problems
cantered on chronic medical conditions, employment
problems, or other potential stress events within the family.
• Information about the child’s family is essential for two
reasons. First, while ADHD is not caused by family stress or
dysfunction, such adverse family factors can contribute to
oppositional behavior . Therefore, the family history can
help to clarify whether the child’s attentional or behavioral
problems are developmental or actually a reaction to or
product of stressful events that have taken place
.
• Second, a history of certain psychiatric disorders in the
extended family might influence diagnostic impressions or
treatment recommendations. For example, because ADHD is
hereditary, a strong family history of ADHD in biological
relatives lends weight to the ADHD diagnosis, especially when
other diagnostic factors are questionable.
•
Formal assessment
• The Behavior Assessment System for Children (BASC)-
Reynolds and Kamphaus,1992:
• A comprehensive set of rating scales and forms including the
Teacher Rating Scales (TRS), Parent Rating Scales (PRS), Self Report of Personality (SRP), Student Observation System
(SOS), and Structured Developmental History (SDH).
• The Assessment System for Children evaluates problems such
as: Aggression, Anxiety, Attention Problems, Atypicality
(Psychoticism), Conduct Problems, Depression, Hyperactivity,
Learning Problems, Somatizations Withdrawal, Externalizing
Problems Composite, Internalizing Problems Composite,
School Problems Composite, Behavior Symptoms Index,
Adaptability, Leadership, Social Skills, Adaptive Skills
Composite
• These behaviors are categorized as very low, low, average, at
risk or clinically significant. It focuses on assessing both
adaptive and maladaptive behaviors
• Information below pertains to the parent rating scale for ages
2-5.
• General population norms are included.
• This scale measures adaptive and problem behaviors in
school, home and community settings.
• There are 130 items in this test
The Attention Deficit Disorders Evaluation Scale
(ADDES-3) - Stephen McGarney,1989
• Aim of the test is to evaluate and diagnose Attention Deficit/Hyperactivity Disorder
• Age group: 4-18 years of age
• Administration: 12-20 minutes – Individual
• It is Based on DSM-IV definition of Attention Deficit/Hyperactivity Disorder
• Specific versions for home environment and educational
situations
• Separate norms by gender and age group
• The ADDES-3 is available in two versions: School and Home
.
• The 60-item School Version covers behaviors easily observed
and documented by educational personnel
.
• The 46-item Home Version is completed by a parent or
guardian and covers behaviors exhibited in the home
environment.
• The ADDES-3 consists of two subscales -- Inattentive and
Hyperactive-Impulsive, which are based on the current
subtypes of ADHD.
Conner’s Rating Scales ,Conners, 1997
:
• An instrument that uses observer ratings and self-report
ratings to help assess attention deficit/hyperactivity disorder
(ADHD) and evaluate problem behavior in children and
adolescents.
• Administered to Parents and teachers of children and
adolescents ages 3–12 and adolescent self-report ages 12–17
• Reading level: 6th–9th grade (varies with version)
• Completion time: Long Version: 15–20minutes, Short Version:
5–10 minutes
• Norms: 8,000+ children and adolescents, males and females
ages 3 to 10
Conner’s Teacher Rating Scales
Revised
•
Long Version (CTRS-R:L)
The CTRS-R:L is typically used with teachers who have time to complete
the long form and when extensive information and DSM-IV consideration
are required.
This scale has 59 items. Scales include:
• Oppositional
• Cognitive Problems/Inattention
• Hyperactivity
• Anxious-Shy
• Perfectionism
• Social Problems
• Conners’ Global Index
• ADHD Index
• DSM-IV Symptom Subscale
• Short Version (CTRS-R:S)
The short Quick Score form for teachers contains 28 items.
The scale should be used when time is of the essence and
when multiple administrations over time are desired.
Scales
include:
• Oppositional
• Cognitive Problems/Inattention
• Hyperactivity
• ADHD Index
• Scoring and interpretation
• When the profile forms are completed, an easy-to-interpret
graphical display of the results is produced to help present
results to parents, teachers, or other relevant parties.
Treatment
• Treating ADHD in children requires medical, educational,
behavioral and psychological interventions. This
comprehensive approach to treatment is called
“multimodal” and consists of parent and child education
about diagnosis and treatment, behavior management
techniques, medication, and school programming and
supports.
• Biophysical:
• 1. Pharmacotherapy
• Stimulants are among first-line agents for pediatric
and adult groups with ADHD based on their
extensive efficacy and safety data(Greenhill,Pliszka
et al.,2002.
• The most common stimulant medications are:
• Methylphenidate (Ritalin)
• Dextroamphetamine (Dexedrine)
• Mixed amphetamine salts (Adderall).
• Non-stimulant drugs
• Atomoxetine (Strattera)
• guanfacine (Intuniv)
• clonidine(Kapvay)
.
• Dietary Interventions
• Dietary and nutritional approaches to controlling
hyperactivity offer another form of treatment for
children with ADHD.
• These approaches rely on the premise that over
activity is related to the digestion of food
substances containing such items as refined sugars
and salt compounds.
• Thus by eliminating such products from the diet of
hyperactive children, it is presumed that overall
behavior should improve.
• Feingold proposed that the elimination of food
containing artificial colors, flavors could result in
the remission of symptoms for 30-50% of
hyperactive children.
• Nonetheless many studies fail to find positive result
for dietary control.
• Behavioral Interventions:
• Behavioral modification is very effective in the short
term and in the long term it may be more effective
than drug treatment in controlling impulsivity,
interpersonal behavior and academic performance.
• Treatment programs to control hyperactive
behaviors involve strengthening or weakening of
target behaviors. Through the delivery of reinforces
and punishers.
• Strategies:
• REINFORCEMENT
• POSITIVE REINFORCER
• SOCIAL REINFORCERS
• FEEDBACK
• TOKENS
• SHAPING
• CONTINGENCY CONTRACTING
• PUNISHMENT
• RESPONSE COST
• TIME OUT
• Cognitive Behavioral Modification:
• Refers to the general category of intervention techs
that attempt to modify behavior by altering the
thought patterns of individuals.
• CBM combines the manipulation of environmental
changes with an individual self control processes
which may include self instruction, self monitoring
and self reinforcement in order to create a more
durable and prolonged changing behavior through the
manipulation of the child’s meditational cognitions.
• Behavior modification: ABCs—Antecedents (things
that happen before behaviors that influence
them), Behaviors (things the child does that
parents and teachers want to change), and
Consequences (things that happen after behaviors
that influence them).
• In behavioral programs, adults are taught to
modify antecedents (e.g., how they give commands
to children) and consequences (e.g., how they
follow-up if a child obeys or disobeys a command)
to change the child’s behavior (that is, the child’s
response to the command).
• (1) Parent Training:
• Behavioral approach
• Focus on parenting skills, child behavior in the
home and neighbourhood, and family relationships
(e.g., getting along with siblings, complying with
parent requests)
• Parents are taught skills by therapists and
implement them at home
• Continually evaluate and modify what is being done
to identify what works best and continue it as long
as necessary
• Plan for what will be done if parents or child
backslides
• Re-establish contact with therapist for major
developmental transitions (e.g., entry to middle
school).
• 2. School Intervention:
• Behavioral approach
• Focus on classroom behavior, academic
performance, and peer relationships
• Teachers are taught classroom management skills
by a consultant (e.g., therapist, school psychologist
or counsellor) and implement them with the ADHD
child during school hours
• Two to 10 hours of training are necessary
depending on the teacher’s prior knowledge and
skills, as well as the child’s severity and
responsiveness
• Continually evaluate and modify what is being done
to identify what works best and continue it as long
as necessary
• Monitor and modify as needed based on what
works best; provide as long as necessary (e.g.,
multiple years or when deterioration occurs)
• Plan for what to do if backsliding occur
s
• Integrate with school and parent treatments
• Re-establish contact with consultant for major
developmental transitions (e.g., middle school
entry)
• 3: Child intervention:
• Systematic teaching of social skills
• Social problem solving
• Teaching other behavioral competencies that
other children consider important
• Decreasing undesirable and antisocial behaviors
• Developing a close friendship
• Social-Skills Instruction:
• Social skills instruction is designed to increase interpersonal skills in critical life situations
.
• Many impulsive children my know how to interact
appropriate with adults and less frequently with
peers, yet cannot maintain this skill due to
impulsivity in responding.
• For this reason, children with ADHD are appropriate
candidates for social skills training.
• Problem-Solving interventions:
• The purpose of problem solving training is to teach
child to generate alternative solution to interpersonal problems and to evaluate cause-effect
relationships.
• Strategies that support Social skills development
and Problem solving skills:
• Ignoring: Children with ADHD often ruminate or
fixate on a thought or feeling and have difficulty
regulating and recognizing their emotions. This
strategy also help in regulating locus of control.
• Turn taking skills: A child with ADHD will often find
this task difficult, often resulting in playing out of
turn, pushing in line, or being impulsive.
• Reinforcing appropriate behaviors.
• In language intervention sessions:
• 1. Begin intervention only after medication
• 2. Schedule frequent short sessions
• 3. Give personalized individual attention
• 4. Remain calm, steady and consistent
• 5. Use highly structured tasks with lots of physical
involvement in holding, placing or moving things
• 6.Reinforcement should be rapid and there should
be frequent shifts in activities
• 7. Encourage making choices within the
intervention program, eventually allowing the client
to choose answer arrange the sequence of 4 or 5
activities within a session
• 8. Target social-pragmatic and more traditional
speech and language goals such as following:
• a. good listening skills i.e., looking at the speaker,
repeating what was heard to check the
comprehension
• b. waiting till the entire question is asked before
answering
• c. looking for cues as to when it is appropriate to
take a conversational turn
• d. learning to not to interrupt or intrude in
conversation
.
• e. complimenting others rather than criticizing or
complaining
• f. learning strategies for persuasion
• g. practising empathy.
•THANK YOU
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