Childhood Psychiatric Disorders (ADHD)

CHILDHOOD PSYCHIATRIC DISORDERS

Dr. Shewikar El BakryAss. Prof. of Psychiatry

Objectives

Why childhood mental disorders What is mental disorder and warning

signs Why early intervention DSM V classification ADHD

Let us consider…….

Why is it important for parents, caregivers & professionals to know about children’s mental health?

One in five (21%) of children have a diagnosable mental, emotional, or behavioral disorder.

One in 10 suffer from a serious emotional disturbance.

70% of children, however, do not receive mental health services

Why?? “The prevalence of mental disorders

among children is predicted to rise in the next 15 years by 50%, becoming a major cause of morbidity, mortality and disability.”

Suicide is already:

4th leading cause of death between ages 10-14 years

3rd leading cause of death between ages 15-24 years

Why??

All children pass through a rough time at school, with friends or with their families.

Children can be stressed too. Development and life incidents

Brain development

Brain development depends on interaction between the brain cells and their immediate environment.

Both biological and psychosocial factors influence the development of the brain and brain disorders.

Stressful life events, injury, infection, malnutrition, exposure to toxins. childhood maltreatment may lead to mental health disorders.

Stigma Barrier

Negative attitudes and beliefs Fear, rejection, avoidance Disrespect and discrimination Discourages individuals and families from

getting the help they need

Definition of a Mental Disorder

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.

There is usually significant distress or disability in social or occupational activities.

Recognize Warning signs

Consider three things if you suspect a child may be experiencing an emotional problem:Frequency: How often does the

child exhibit the symptoms?Duration: How long do they last?Intensity: How severe are the

symptoms?

Early intervention

Can reduce the effects an emotional or mental health disorder may have on children and their families.

Can lessen the duration and severity of the disorder.

Can help children learn positive coping strategies and prevent academic and social failure.

DSM V Neurodevelopmental Disorders Bipolar Disorders Anxiety Disorders Obsessive compulsive related disorders Trauma and stress related disorders Feeding and eating disorders Elimination disorders Sleep disorders Disruptive, Impulse control and conduct

disorders Others

Most common pediatric mental health disorders include: Anxiety disorders (most common) Mood disorders Attention Deficit Hyperactivity Disorders Autism Spectrum Disorders Conduct Disorders Eating Disorders Substance abuse

DSM-IV-TRThe five axes of the DSM-IV-TR.

Axis I Clinical syndromes. (All mental disorders & criteria for rating them except personality disorders/mental retardation, also abuse/neglect)

Axis II Personality disorders, Mental retardation. (Life long deeply ingrained, inflexible & maladaptive)

Axis III General medical condition. (Any medical condition that could effect the patients mental state.)

Axis IV Psychosocial & environmental problems. (Stressful events that have occurred within the previous year)

Axis V global assessment functioning. (How well the patient performed during the previous year)

WHY study ADHD

Symptoms affect all areas of life – academic, social, cognitive and behavioral performance.

Symptoms persist to adulthood in 60-70% Children, adolescents, and adults with ADHD are

at greater risk for experimentation with and abuse of alcohol and drugs, school and job failure, and accidental injuries.

Effective treatment is indirect & adult dependent

Attention-Deficit/HyperactivityDisorder:A Chronic Disorder

♦ADHD is a common neurobehavioral disorder of childhood.

♦Symptoms persist into adolescence andadulthood for majority of patients. ♦Hyperactivity and impulsivity may

diminish at a higher rate than inattention.

ADHD KEY SYMPTOMS

•Must have symptoms for at least 6-Months

•Symptoms must be present prior to age 7

•Impairment Across Settings (2 or more) •Evidence of significant functional

impairment •Symptoms are extremes of normal

behavior

ADHD: Hyperactive/Impulsive

fidgets or squirms can’t stay seated restless loud, noisy always “on the go” talks excessively blurts out impatient intrusive

Often…

ADHD: Inattentive

Appears to not be listening Follows through poorly on

obligations Disorganized Dislikes sustained mental effort Loses needed objects Easily distracted Forgetful Careless errors, inattentive to

detail Sustains attention poorly

Often…

Typical Vulnerabilities

Low self esteem Humiliation Feeling “dumb” Always “in trouble” Quick to lie about behavior Become defensive Feel defeated

Other ADHD qualities

Sometimes work harder at avoiding work than actually doing it

Academic progress is often a roller coaster – up and down all year

Moody Really do want to do well Frustration

Strengths and “Gifts”

Creative Charming Funny Social Sensitive and caring Hyperfocus Enthusiasm

What's it like to have ADHD_.mp4

How to Recognize ADHD Symptoms in Children.mp4

Incidence 5% (one out of twenty) children. 30% to 70% of these cases persist

into adulthood. Often have ADHD children.

Most common psychiatric disorder of childhood.

Often misdiagnosed as an anxiety disorder, manic state, or personality disorder.

ADHDEtiology

ADHD is a heterogeneous behavioral disorder with multiple possible etiologies

CNS = Central Nervous System

Neuroanatomic Neurochemical

Genetic Origins

Environmental Factors

CNS Insults

ADHD

What Causes AD/HD?(we’re not really sure)What we do know It is a “brain-based” disorder the basis of which is

largely genetic – likely due to multiple interacting genes

Some cases may be caused by external factors such as prenatal or perinatal complications or exposures

Dietary factors – continuing area of research Several differences in structure and function ofprefrontal and frontal cortices and basal ganglia have

been shown. Possible increase of norepinephrine with

decrease of inhibition by dopamine

ADHD: Current Working Theory

Symptoms of ADHD are caused by

abnormality in the Executive Function of the brain.

Brain Regions Implicated in ADHD

Prefrontal CortexFrontal LobesLimbic SystemBasal Ganglia

Caudate nucleusCerebellum

AnxietyAnxietyDisorderDisorder

(35%)(35%)

ADHDADHD

CONDUCT (10%) CONDUCT (10%) OppositionalOppositional

Disorder (40-50%)Disorder (40-50%)

MoodMoodDisorderDisorder(5-25%)(5-25%)

Comorbidity Comorbidity Is Common With ADHDIs Common With ADHD

ADHD Only (50%)ADHD Only (50%)

Tools

1. Compliant: onset course duration 2. History : Developmental Medical Family Social 3. Rating scales: Conner’s BASC CBC Vanderbilt SNAP Re evaluate with no improvement or

worsening

ADHDRating Scales

Preschool The Early Childhood Attention Deficit Disorder Evaluation

Scale (ECADDES) Elementary School

Child Behavioral Checklist (CBCL) - Parent, Teacher, or Youth forms

Conners Parent and Teacher Rating Scales (CPRS and CTRS)

Adolescent Conners/Wells Adolescent Self Report of Symptoms

(CAAS) Adolescent Symptom Inventory-4 (ASI-4)

Adults Conners Adult Attention-Deficit Rating Scale (CAARS)

ADHDComponents of Treatment

Education

Medical Interventions

Psychosocial Interventions

Treatments

Behavioral Management: helps patients change or control their ADHD behaviors. Identifies unwanted behaviors and helps to replace them.

Counseling: Helps patients and families identify unwanted behaviors and teaches how to cope with and change them. Can also help with low-self esteem, depression and stubborn behaviors.

Medication: different medications help to improve symptoms so your child can manage better at home, at school, and with friends. Is most helpful when combined with behavioral management and counseling.

Medication Classes

Stimulants Stimulants are the best studied medications in

child & adolescent psychiatry

Antidepressants Antihypertensives Wake-promoting agent used in

narcolepsy

Stimulants First line medication treatment of ADHD

Approximately 70% of children will respond to the first stimulant prescribed

Up to 90% respond to the first or second stimulant attempted

Do NOT “make” children perform better – he/she has to do the work themselves Helps improve executive functioning so they

can successfully complete work

Why give a stimulant to a hyperactive child?

Work by “stimulating” the brain to make more of the neurotransmitters (brain chemical) that help focus attention, control impulses, organize and plan, keep with routines

Increase dopaminergic and noradrenergic activity in frontal cortex (responsible for executive functioning)

Research shows other treatments are more likely to work if the child is taking a stimulant

Medications

Ritalin: (Methylphenidate): helps increase attention span during the day, helps with staying on task, and helps with rapid ADHD morning symptom control so it is

easier to start the day

Dexedrine (Dextroamphetamine): Stimulant Also helps with attention, disruptive behavior and

relationship problems*other medications include Adderall, Straterra, Concerta and

Wellbutrin

Atomoxitine (Strattera)

A noradrenergic reuptake inhibiter that appears to have relatively good effectiveness in decreasing levels of hyperactivity and in helping with increasing attention, concentration, and organization. It has been approved for use in children as young as 6 years old weighing above forty pounds. It generally has lasting effects throughout the day and into the evening. Problems have included changes in appetite and also nausea along with some sleep problems

Atomoxetine (Strattera)

Good points 24 hour coverage, once a day Not abusable

May help co morbid anxiety

Maintains a blood level and dosing can be adjusted

Side effects limited with slower titration

ADHDBupropion (Wellbutrin®)

Advantages may decrease

hyperactivity and aggression

may improve cognitive performance

Double-blind, placebo- controlled studies demonstrate effectiveness

Disadvantages Not as effective as

stimulants for cognitive symptoms

Available dosage forms inappropriate for younger children

may decrease seizure threshold

may exacerbate tics

4.

ADHDClonidine (Catapres®)

Advantages may be useful to

treat very hyperactive or aggressive patient

improves ability to fall asleep

Disadvantages clinical effects may take

several weeks does not affect inattention

symptoms sedation risk of adverse CV effects,

depression, and decreased glucose tolerance

Guanfacine (Tenex®) has a more favorable side-effect profile than clonidine but has only been studied in open trials.

.

Texas Medication Algorithm Project: ADHD Without Comorbidity

Stage 0: Assessment, discussion of treatment alternatives

Stage 1: Monotherapy: Amphetamine vs. Methylphenidate

Stage 2: Monotherapy: Stimulant not used in Stage 1

Stage 3: Monotherapy: Alternate class (Cylert®)-q 2 week LFT’s

Stage 4: Buproprion, Nortryptyline, Imipramine

Stage 5: Antidepressant not used in Stage 4

Stage 6: Alpha-agonists, monitoring cardiovascular status

ADHDPsychosocial Interventions

House rules Appropriate commands (specific, clear, positive) Ignore mild inappropriate behaviors and praise

positive behavior Contingency management with positive

reinforcement (eg, a point chart) and prudent negative consequences (eg, privilege loss)

Behavioral “contracting” in adolescent children

.

Parent TrainingParent Training

ADHDPsychosocial Interventions

Largely employ techniques taught in parent training Daily behavioral report cards

serve to define target behaviors facilitate school-home communication and allow parents to

provide rewards for good school behavior and performance Special classroom accommodations

clearly and consistently posting daily schedules breaking assignments into smaller chunks providing rewards for task completion and consequences

for rule violations

School Interventions

School Interventions

.

ADHDPsychosocial Interventions

Sometimes used to teach the child skills needed in peer relationships and other settings

Interaction skills Conflict resolution Problem-solving skills Anger management

Results of studies of this strategy are inconsistent More effective when taught in group settings such

as summer camps, school-based, and after-school settings

.

Social Skills Training

Behavioral Management

Basic Principles: – The “ABC’s” – Antecedent, Behavior,Consequences – Parents and teachers can intervene in

the antecedent event and set consequences to change behavior.

– Baby steps: Pick one behavior or habit at a time to work on and build up

Behavioral Modification

Topics addressed in Parent Training “Establishing house rules and structure Learning to praise appropriate

behaviors…and ignoring mild inappropriate behaviors (choosing your battles)

Using appropriate commands Using “when…then” contingencies(withdrawing rewards or privileges inresponse to inappropriate behavior)

Planning ahead and working with children in public places

Time out from positive reinforcement (using time outs as a consequence for inappropriate behavior)

Daily charts and point/token systems with rewards and consequences

School-home note system for rewarding behavior at school and tracking homework”

Family Coping with ADD/ADHD

Create a routine Help your adolescent organize Avoid distractions Limit choices Change your interactions Use goals and rewards Help your teen discover a talent

DAILY GOAL

MY GOAL FOR TODAY IS:

Effective Participation in Classroom InstructionDIRECTIONS FOR MY GOAL…. I WILL:

•Raise my hand before answering questions•Look at my teacher when she is talking to the class

•Stay at my desk until given permission to move•Listen without talking to others

DAILY CHECK-IN TO DESCRIBE HOW I DID…….I think that my performance today:

NEEDS IMPROVEMENT 1 2 3 WAS THE BEST My Teacher thinks that my performance today:NEEDS IMPROVEMENT 1 2 3 WAS THE BEST

Tomorrow I will____________________________ :Teacher’s Signature & Comments ___________:

__________________________________

Conclusions ADHD is a valid disorder ADHD is universally found ADHD largely results from biological factors

Genetics, neurology, acquired injuries and interactions ADHD is a disorder of inhibition and executive

functioning (self-regulation), not merely attention Social environment important for its impact on

creating prosthetic environments, reducing impairment, affecting comorbidity and resource availability

ADHD can be successfully managed as a disorder of EF leading to improved life course and outcomes

THANK YOU