Approach to ADHD in children

Dr vijay warad

Sai speciality clinic,satara road

Inamdar and sahyadri hospitals,pune

What comes to your Mind ?

INTRODUCTION

ADHD is one of the most common childhood Neurobehavioural disorders

First described by Dr. Heinrich Hoffman in 1845 “The Story of Fidgety Philip”

In 1902, Sir Geroge Still described the condition

First published report in 1937 of stimulant medication in ADHD

ADHD often continues into Adolescence and Adulthood

What Is ADHD?

ADHD, or attention deficit hyperactivity disorder, is a Behavioral Condition characterized by inattention, impulsiveness, and/or hyperactivity.

Approximately 1-20% of Indian children have ADHD

Source – Indian Academy of Pediatrics

Persistent pattern of inattention and / or hyperactivity and impulsive behaviour that is more severe than that expected in children of that age and level of development.

Definition

PREVALENCE

Prevalence of ADHD 3 -10% ( Rowland et al 2002)

Affects 5% of school children (1/ class room)More common in boys 4 – 9:1 (Gender bias)Recent revised estimate 2 – 4:1 (Safer & Malever 2000)

ASSOCIATED FEATURES

School failurePoor planning, organization and task performance

Speech and language problemsPoor motor co-ordinationEnuresisInstabilityHigh stimulus seekingLow frustration tolerance

ASSOCIATED CO-MORBID CONDITION

Language and learning disability (10-15% have ADD)

Tourette’s syndrome (70% have ADHD)Oppositional Defiant Disorders (33% of ADHD)

Conduct Disorders (25 -50% of ADHD)Major Depression (20% of ADHD)Anxiety Disorders (25% of ADHD)

ADHD COMORBIDITY

Secondary Complicationsof RhinitisAllergic inflammation does not necessarily limit itself to the nasal airway Asthma : up to 80% of asthma patients have accompaning AR,38% of AR have

asthma Chronic sinusitis Otitis media Hearing difficulties Facial changes Failure to thrive Behavioural disorders (hyperactivity) Increased Social & emotional issues affect learning & ability to integrate with

peers Uncontrolled AR & adverse effects of sedating medications affect cognitive

functions Pneumonias COPD

What Are the Symptoms of ADHD?

Hyperactivity

Impulsivity

Inattention

Child's functioning in social and academic settings, Interfere…

Paying attention to tasks at home or schoolMaking careless errorsBeing easily distractedNot following through with tasks or completing instructions

Bored, losing things, being forgetful, having difficulty organizing tasks

Being fidgety, seated at one placeTalking excessively

How Do I Know if a Child Has ADHD?

Many of the symptoms of ADHD are also symptoms seen during normal childhood and development

Exhibiting one or more of the symptoms does not mean that a child has ADHD

The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) Below is the Diagnostic Criteria for diagnosing Attention Deficit (Hyperactivity) Disorder:

A. Either (1) or (2)

1) Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with the developmental level:

  Inattention

often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

often has difficulty sustaining attention in tasks or play activities often does not seem to listen when spoken to directly

often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure of comprehension)

often has difficulty organizing tasks and activities often avoids, dislikes, or is reluctant to engage in tasks that require

sustained mental effort (such as schoolwork or homework) often loses things necessary for tasks or activities at school or at home

(e.g. toys, pencils, books, assignments) is often easily distracted by extraneous stimuli if often forgetful in daily activities

2) Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level:

  Hyperactivity

  often fidgets with hands or feet or squirms in seat often leaves seat in classroom or in other situations in which remaining

seated is expected often runs about or climbs excessively in situations in which it is

inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

often has difficulty playing or engaging in leisure activities quietly often talks excessively is often 'on the go' or often acts as if 'driven by a motor'

Impulsivity

  often has difficulty awaiting turn in games or group situations often blurts out answers to questions before they have been completed often interrupts or intrudes on others, e.g. butts into other children's games

B. Some hyperactivity - impulsive or inattentive symptoms that cause impairment were present before the age of 7 years.

  C. Some impairment from the symptoms is present in more than two or more

settings (e.g. at school or work or at home).

  D. There must be clear evidence of clinically significant impairment in social,

academic, or occupational functioning.

  E. The symptoms do not occur exclusively during the course of a Pervasive

Developmental Disorder, Schizophrenia, or other Psychotic Disorder, and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

 

Symptoms of Hyperactivity in ADHD

The child often fidgets with hands or feet or squirms in their seat

The child often leaves the seat in the classroom or in other situations in which remaining seated is expected

The child often talks excessively.

Symptoms of Impulsivity in ADHD

The child often blurts out answers before the questions have been completed

The child often experiences difficulty awaiting his or her turn

The child often interrupts or intrudes on others

Symptoms of Inattention in ADHD

The child often fails to give attention to details, or makes careless mistakes in schoolwork, work, or other activities.

The child often has difficulty sustaining attention in tasks or play activities.

LIFE TIME COMORBID DISORDERSShekim WO, et al Comprehensive Psychaitry 1990; 31(5):416-425Biedermen J, et al. Am. J. Psychiatry 1993; 150(12): 1792-1798

PSUD: Psychoactive substance use disorder; MDD: Major PSUD: Psychoactive substance use disorder; MDD: Major Depressive Disorder ; LD: Learning disability; Depressive Disorder ; LD: Learning disability; ASP: Antisocial personalityASP: Antisocial personality

PRESENTING FEATURES

Look for features of dyslexia, dysgraphiaCruelty towards people, animalsDestruction of property, stealing Delinquent behaviorArgumentative, disobedient, defiant, Back answers, quick to take offense

PRESENTING FEATURES

Excessive crying or worry

Preoccupation with death or suicides

Neglect of self environment, antisocial

Low self esteem

Substance abuse

DIFFERENTIAL DIAGNOSIS

Mental Retardation with Hyperactivity

Under stimulation for highly intelligent children

Hyperthyroidism

Lead poisoning

Seizures (Petit Mal, Non Convulsion Status)

Medication – AED’s, antihistaminic, decongestants etc.

Chronic illness, sleep disorders

COMPREHENSIVE MANAGEMENT PROTOCOLS

Screening in pre-school and school children

Assessment to fit DSM IV CriteriaEvaluation for co-morbid conditionsInvestigations when indicatedPharmacological treatment Psychological treatment Lifestyle modification

TREATMENT PLAN

Psycho-education of parent, teacher, child

BT initially for mild to moderate ADHD

Psycho-stimulants strongly recommended for moderate to severe ADHD

Combination of both is most beneficial

Constant follow up since it’s a chronic condition

Medicines

Automoxetin: Axpeta (25 mg,50 mg)

Above 6 years preffered

Methylphenidate:- Inspiral,Adwise 10 mg,20 mg

ALTERNATIVE THERAPIES

Omega-3 fatty acids

Hypnosis

EEG biofeedback

Yoga, meditation

Ginkgobiloba

Mega-Vitamin Therapy

OMEGA -3 FATTY ACIDS

3 Major Type ingested in food

ALA – Alpha Linolenic Acid

EPA – Eicosapentaenoic Acid

DHA – Docosahexaenoic Acid

Once ingested Body converts ALA to EPA & DHA

DIETARY SOURCES

ALA – in Flax seeds, Canola Oil, Walnuts

DHA – in Seafood, Tuna, Salmon

EPA – Whole Grains, Garlic, Olive Oil

MECHANISM OF ACTION

Blocks action of cytokinesEnhance Neurotrophic activity in SynapsesForms an essential part in physicochemical properties of cell membranes, oligodendrocytes and astrocytes

(Purdue Study, Durham Study, Richardson and Puri Study)

STUDY WITH OMEGA 3 FATTY ACID

Study on pre school children with LD and ADHD showed significant improvement in cognitive & behavioural functions after 12 weeks of O3 Fatty Acid (Richardson + Puri Oxford Univ.)

Study of Pregnant ladies given O3 Fatty Acid supplement --- Children followed upto 5-6 years age significant different in learning capabilities and academic performance (Meherban Singh)

Docosahexaenoic Acid for Reading, Cognition and Behavior in Children Aged 7–9 Years: A Randomized, Controlled Trial (The DOLAB Study)

Alexandra J. Richardson*, Jennifer R. Burton, Richard P. Sewell, Thees F. Spreckelsen, Paul Montgomery

Centre for Evidence-Based Intervention, University of Oxford, Oxford, United Kingdom

PROGNOSISAbout 60-80% of childhood ADHD continue into Adolescent & adults.

They may out grow Impulsivity and Hyperactivity.

Inattention and Disorganization persist and may worsen.

Adults with H/o ADHD in childhood have higher rates of antisocial, criminal behaviour, Injuries, accidents, teen pregnancies

Employment and Marital difficulties.

May need treatment and follow up lifelong.

ADHDADHD

Low selfLow selfesteemesteem

AcademicAcademiclimitationslimitations

RelationshipsRelationships

Smoking andSmoking andsubstance abusesubstance abuse

InjuriesInjuries

Motor vehicle Motor vehicle accidentsaccidents

LegalLegaldifficultiesdifficulties

Occupational/Occupational/vocationalvocational

Childhood

Childhood

Adulth

ood

Adulth

ood

AdolescenceAdolescence

Symptoms of ADHD through the life cycle

Treatment Option…Very IMPORTANT…

COGNIUM SYP CLINICAL TRIALS

Proven in a Comparative clinical trial with 60 ADHD Childrens,for 16 weeks

-Conducted by Dr.Vwarad,MD(Paed)in Pune-Conducted on 2 Group of 300 children

each,Gr A&Gr B-group A with cognium syrup and Behavioral

therapy-Group B with Behavirol therapy alone

-Assesssed by VANDERBILT ASSESSMENT SCALE