Attention Deficit Hyperactivity Disorder (ADHD) Hyperkinetic Disorder

1. This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation • In Slide Show, click on the right mouse button • Select “Meeting Minder” • Select the “Action Items” tab • Type in action items as they come up • Click OK to dismiss this box • This will automatically create an Action Item slide at the end of your presentation with your points entered. Attention Deficit Hyperactivity Disorder (ADHD) Hyperkinetic Disorder Joint Agency Development & Training Group Induction Training

2. Contents • Aims • Characteristic Features • Restlessness • Inattention/Poor Concentration • Impulsivity • Associated Conditions • Causation • Referral Pathways • Treatment/Management • Further Information

3. All About ADHD Aims • to raise awareness of ADHD • to help recognise ADHD • to increase understanding of the nature of ADHD • to ensure appropriate pathways of referral including where to go for further help • to understand there are management/treatment methods available

4. All about ADHD Prevalence: 6 % of School population have ADHD • 1 – 2% –severe (Hyperkinetic disorder). • 3-5 % as moderate • 8-12% subclinical ADHD Male – female children 3:1

5. Characteristic Features • Marked restlessness • Poor concentration and inattention • Impulsivity • Onset before 7 years of age • Pervasive and chronic

6. Restlessness • Fidgetiness • Difficulty remaining seated • Rushing around • Climbing on things • Difficulty doing things quietly • Always ‘on the go’

7. Inattention/Poor Concentration • Persistence in tasks/activities • Flitting from one activity to another • Difficulty completing tasks • Poor organisational skills • Loses things or forgetful • Does not appear to listen • Easily distracted

8. Impulsivity • Interrupts or intrudes on others • Blurts out answers • Frequent calling out • Talks excessively • Difficulty waiting their turn

9. Video presentation • ADHD

10. ADHD Differential Diagnosis • Sensory impairment. • Epilepsy and related states. • Effects of head injury • Acute or chronic medical Illness • Poor nutrition. • Sleep disorders. • Side effects of medication. • School or classroom difficulties

11. ADHDPsychiatric conditions. • Autism Spectrum Disorder • Obsessive Compulsive Disorder • Tic Disorders • Conduct Disorders • Attachment disorders. • Depression and emotional disorders. • Anxiety disorder • Psychosis

12. Associated Conditions • Conduct disorder • Poor social relationships • Learning difficulties • Dyspraxia • Developmental delay

13. Possible causes. • Genetic influences are strong. • Epilepsy and other brain disorders (minority) & Low birth weight/prematurity • Major disruptions of attachments. • Excessive drinking and smoking in pregnancy. • Prenatal exposure to benzodiazepines and anticonvulsants also predict later hyperactive beh. • Exposure to lead in utero and childhood.

14. Maintaining factors. Psychosocial factors • Response of parents. • Response of teachers. • Peer influences.

15. Case Scenario • Adam – 11 just commenced in secondary school. He is finding it hard to adjust to the new demands. He has difficulties in relating to peers. Involved in regular fights and easily led into trouble. Teachers are finding it difficult to control him in class, he disruptive, challenging and confrontational. Lives with mother, step father and 6 siblings. Father in prison for violent offences had similar difficulties as a child. Adam has been cautioned by the police for neighbourhood nuisance

16. Adam Questions: • What are the possible explanations for this child’s behaviour? • What resources are available to you and how would you access them? • What further information would you seek from home?

17. Referral Pathways The preferred referral to CAMHS is through the Community Paediatrician or the GP with supporting information from the family

18. Assessment • Child and family assessed • Full history including developmental • Observation of child in clinic/school • School and home liaison

19. Diagnosis • Over activity • Inattention/poor concentration • Impulsiveness • Cross-situational • Onset before 7 years

20. Terms Used. • Hyperkinetic disorder • Attention deficit Hyperactivity Disorder (ADHD) • Attention Deficit Disorders (ADD) • Hyperactivity. ICD Vs DSM – Diagnostic criteria

21. Treatment/Management • Cognitive & Behavioural management • Educational management • Parental management • Diet. • Environmental • Medication

22. Medication 1 • Methylphenidate • Ritalin (short and long acting forms) • Equasym (short form) • Concerta XL (lasts for 12 hours) • Equasym XL (lasts for 8 hours) • Medikinet (short and long acting forms) • Dexamphetamine

23. Medication 2 • Atomoxetine (Brand name Strattera) • Is not a stimulant unlike Methylphenidate • Takes about 8 weeks to start working • 24 hour mechanism of action • Clonidine • Imipramine

24. Side effects of Methylphenidate • Reduced appetite • Sleep disturbance • Tics • Headache • Stomach ache • Emotional • Listlessness.

25. Prognosis. • Wanes in Adolescence. • 60% continue to have difficulties in adult life • Educational attainments are poor. • Hyperactivity +Conduct disorder – at risk of Antisocial personality disorder & substance abuse. • Hyperactivity only – vulnerable but less at risk

26. NICE Guidelines 1 • New NICE Guidance addressing ADHD in children, young people and adults (2008) • Medication is recommended as part of a comprehensive treatment programme. Uses the same stepped approach as depression. • Methylphenidate is the first line recommended medication for severe ADHD • Methylphenidate is licensed for children over 6, currently up until puberty.

27. NICE Guidelines 2 Atomoxetine is licenced for prescription in adulthood, if started in childhood. Assessment and treatment should be lead by Child psychiatry or paediatricians with expertise in ADHD. Should involve children, parents, carers, school and college

28. NICE Guidelines 3 • Consider cultural factors and environmental factors. • Comprehensive treatment programme desirable this includes psychoeducation and if necessary behavioural treatment • Regular monitoring and drug holidays can be useful.

29. Classroom Strategies 1 • Arrange the classroom to minimise distractions, for example seating pupils with ADHD away from windows, avoiding the use of tables with groups of pupils. • Include a variety of activities during each lessons, alternating physical and sitting- down activities. • Set short achievable targets and give immediate rewards when the child completes the task.

30. Classroom Strategies 2 • Use large type and provide only one or two activities per page. Avoid illustrations which are not directly relevant to the task. • Choose the child with ADHD to write ideas or words on the board etc. • Use checklists for each subject, outlining the tasks to be completed and individual homework assignment charts. • Keep classroom rules clear and simple.

31. Classroom Strategies 3 • Encourage the pupil to verbalise what needs to be done first to the teacher and then silently to themselves • Use teacher attention and praise to reward positive behaviour. • Give the pupil special responsibilities so that other children can see them in a positive light. (Adapted from Hampshire county council, ADHD information and guidance for Schools 1996)

32. Further Information • ADD Information Services PO Box 340 Edware, Middlesex HA8 9HL. Tel: 0208 905 2013 • ADDNET UK: The UK website. www.web-tv.co.uk/addnet.html. • Contact a family – 020 7383 3555. • SENCO • EPS • Handouts e.g. 101 Tips for Teachers • www.nice.org.uk