Download Case Scenarios in Pediatrics

Case Scenarios in Pediatrics
Dr. Muhammad S. Tahir, MD
General/Child and Adolescent Psychiatrist
Ex-Assistant Professor of Psychiatry, New York Presbyterian Hospital
Chairman
American Wellness Center - DHCC
Historical Perspective
Timeline of ADHD
1613
1798
1809
1845
1902
1908
1913
1917
1931
1934
William Shakespeare’s play King Hennery VIII
‘Mental Restlessness’ (Critchton)
‘Observations on Madness and Melancholy.’ (Haslam)
‘Hyperkinetic Syndrome’ and ‘Fidgety Phil’ (Hoffman)
‘Deficits in Moral Character’ (Still)
‘Minimal Brain Damage’ (Tredgold).
‘Partial Moral Dementia’ (Stein)
Post-encephalitis behavioural disorders
‘Hyperkinetic child’ (Winnicott)
‘Hyperkinetic Disease’ (Kramer – Pollnow)
1937
1940
1957
1960
1968
1972
1977
1980
1987
Charles Bradley study of Benzedrine.
‘Minimal Brain Damage’.
‘Hyperkinetic’ Impulse Disorder / Behaviour Syndrome
‘Minimal Brain Dysfunction’
‘Hyperkinetic Reaction of Childhood’ in the DSM-II
V. Douglas’s research on inattention
‘Hyperkinetic Syndrome of Childhood’ in the ICD -9
‘Attention Deficit Disorder’ (ADD) in the DSM-III
ADHD in the DSM-III-Rremoved sub-typing
ADHD FACTS Under 18
 Approximately 3-7% of school-aged children have the disorder.
Prevalence rates seem to vary by community, with some research
indicating that larger cities may have rates as high as 10-15%.
Eyes can not see what
mind does not know
General Symptoms
 Failure to pay attention or a failure to retain learned information
 Fidgeting or restless behavior
 Excessive activity or talking
 The appearance of being physically driven or compelled to constantly move
 Inability to sit quietly, even when motivated to do so
 Engaging in activity without thinking before hand
 Constantly interrupting or changing the subject
 Poor peer relationships
 Difficulty sustaining focused attention
 Distractibility
General Symptoms Continued
 Forgetfulness or absentmindedness
 Continual impatience
 Low frustration tolerance
 When focused attention is required, it is experienced as unpleasant
 Frequent shifts from one activity to another
 Careless or messy approach to assignments or tasks
 Failure to complete activities
 Difficulty organizing or prioritizing activities or possessions
Brain Chemistry in ADHD
INFANCY
SYMPTOMS OF INATTENTION
 Difficult to soothe
 Less babbling speech the first year
 Poor sucking or crying during feeding
 Smiles less often. May not enjoy soft touch
INFANCY
SYMPTOMS OF HYPERACTIVITY
 An aversion to being cuddled or held
 Strained/negative mother/child relationship
 More frequent crying
INFANCY
SYMPTOMS OF IMPULSIVITY
 Frequent crying and colic (painful bowel problems)
 Frequent infections, more allergies, etc
PRESCHOOL YEARS
SYMPTOMS OF INATTENTION
 Strong will; unresponsive to discipline
 Some language difficulties
 Difficulties with structured play
 Toilet training problems
 Failing to pay close attention to details or making careless mistakes
when doing schoolwork or other activities
 Trouble keeping attention focused during play or tasks
 Appearing not to listen when spoken to
 Failing to follow instructions or finish tasks
PRESCHOOL YEARS
SYMPTOMS OF HYPERACTIVITY
 Higher activity levels than peers
 Problems noticeable in structured play
 Aggressive behavior
 Difficulty going to sleep
 Motor restlessness during sleep
 Strong will, "difficult to manage"
 Family disorganization and parents feeling overwhelmed
DOPAMINE MISTERY
PRESCHOOL YEARS
SYMPTOMS OF IMPULSIVITY
 Extreme excitability
 Gross/fine motor difficulties (awkward, clumsy)
 Fearlessness, may endanger self or others
 Low frustration tolerance
 Peer problems begin
ELEMENTARY YEARS
SYMPTOMS OF INATTENTION
 Failing to pay close attention to details or making careless mistakes
when doing schoolwork or other activities
 Trouble keeping attention focused during play or tasks
 Appearing not to listen when spoken to
 Failing to follow instructions or finish tasks
 Avoiding tasks that require a high amount of mental effort and
organization, such as school projects
 Frequently losing items required to facilitate tasks or activities, such as
school supplies
 Excessive distractibility
 Forgetfulness
 Procrastination, inability to begin an activity
 Associated problems such as low self-esteem, depression, or anxiety
ELEMENTARY YEARS
SYMPTOMS OF HYPERACTIVITY
 Diminished need for sleep
 Fidgeting with hands or feet, or squirming in seat
 Leaving seat often, even when inappropriate
 Running or climbing at inappropriate times
 Difficulty with quiet play
 Frequent feelings of restlessness
 Excessive speech
ELEMENTARY YEARS
SYMPTOMS OF IMPULSIVITY
 Social immaturity
 Frequent arguments with parents and peers
 Disregards socially-accepted behavioral expectations
 Requires more supervision than average
 Inconsistent with responsibilities and chores
 Continually striving to be the center of attention
 Answering a question before the speaker has finished
 Failing to await one's turn
 Interrupting the activities of others at inappropriate times
 Poor peer relationships
ADOLESCENCE
SYMPTOMS OF INATTENTION
 Frequently shifting from one uncompleted task to another
 Difficulty organizing activities
 Serious academic inconsistencies
 Ongoing underachievement
 Difficulties with household activities (cleaning, paying bills, etc.)
 Often viewed as lazy or disinterested
 Associated mood or behavior problems become more pronounced
ADOLESCENCE
SYMPTOMS OF HYPERACTIVITY
 Decreased hyperactivity
 Pronounced feelings of restlessness
 Low self-esteem
 Intense need to stay busy and/or to do several things at once.
 Discipline problems
 High-risk behavior
ADOLESCENCE
SYMPTOMS OF IMPULSIVITY
 Continued poor peer relationships
 Low self-esteem
 Discipline problems
 Continued frequent arguments
 Drug and alcohol abuse
 Risk-taking behavior
 Impulsive spending, leading to financial difficulties
GENERAL PARENT REPORT
CAUSES
 Low Dopamine level in different brain areas can produce ADHD like
symptoms.
 Genes Monozygotic twin studies
PREREQUISITE FOR
DIAGNOSIS
 Symptoms, present before 7 years
 Symptoms present for at least 6 months
 Symptoms can not be explained by other illness
DIAGNOSIS
 Inattention
 Hyperactivity
 Impulsivity
TYPES OF ADHD
 Hyperactive-Impulsive Type
 Inattentive Type
 Combined Type
COMORBIDITIES
Living with ADHD
Driving during adolescent with ADHD study shows 2 to 4 times
more chance sf accidents
Other family members with ADHD
Parentings the Child with ADHD can exhausting.
ADHD and School
Sit in front of the class.
Extra time during test.
Written instructions.
Use daily report card
MANAGEMENT
 Behavior Modification plan
 Rewarding the good behavior is more helpful then punishing the
bad behavior
 Medication Treatment
 Stimulants ( Ritalin, Concerta)
 Non Stimulant Atmoxetine ( Strattera)
 Miscellaneous ( Tenex, Clonidine)
 etc
Stimulants
Methyphenidate
Concerta, Focaline, Metadate, Methylin Ritalin
Short acting and long acting.
Methylephenidate, patch Daytrana is available.
Amphetamine
Adderal, Dexdrine, dextrostat and Vyvanse
Common Side effects
Sleep problems,
Decreased appetite
Weight loss
Less Common Side effects
Less common side effects include increased heart rate and blood pressure,
headache,
social withdrawal,
nervousness, irritability,
stomach pain,
poor circulation in the hands and feet,
and moodiness.
Contraindications
Cardiac side effect: With Serious heart problems.
There are reported cases of sudden death
Psychiatric side effects. Stimulants may cause suicidal thinking,
hallucinations
and/or aggressive behavior
Warning about Alternative Therapy
If you are considering a complementary or alternative treatment for your child, ask the following
questions:
●
If it claim to cure ADHD. There is currently no known cure for ADHD, and no single treatment is
likely to cure multiple health problems.
●
●
If it claim to be harmless or natural. Natural does not necessarily mean safe.
Is it offered by only one individual or is it a secret that only certain people can share?
Reputable treatments that work well should be available from any licensed healthcare
professional.
Warning Continued
Is it based on multiple studies that have been published? To confirm the safety and
benefit of a treatment, multiple clinical studies should be published in mainstream
medical journals (see www.pubmed.gov).
●
Is it expensive? Spending a large amount of money on a treatment that is not proven
is risky.
●
Is the group or person promoting the treatment an expert in ADHD treatment? Verify
the education and licensing of any person who claims to be an expert.
MESSAGE
 ADHD is not hard to diagnose
 Very Treatable
 Treatment can prevent complication ( under achievement,
depression, anxiety, etc)
What is ADHD
Behavior Management?
 Non-medicinally based intervention
 Uses relationship between patient and therapist, patient and parent,
patient and teacher and other relevant support person in patient’s life.
 Quality of relationship is important
 Patient needs to feel that there is a sense of trust and relationship is not punitive
 Goal is to correct the patient’s behavior while helping them to:
 Increase awareness of their actions
 Minimize impulsivity
 Identify, praise, and reinforce appropriate behavior
 May act as a visual guide or reminder for appropriate behavior
Behavior Plan
 Empirically supported intervention
 Non punitive, focuses on behaviors we want the child to display.
 Highly personalized
 Caution: Often not implemented correctly because there is no consistency
in delivery.
 Consistency is KEY!
 Check in with parents to provide support and offer alternatives as needed
Successful Behavior Plan Tips
 Set up rules for home, classroom, social setting
 Give immediate rewards or consequences
 Provide frequent feedback
 Be consistent
 Establish routines
 Create checklists, visual reminders
 Set timers
 Focus on the positive
 Plan for potential problems
Sample Behavior Plan
REFERENCES
 Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the
assessment and treatment of children and adolescents with attentiondeficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry.
2007;46(7):894-921.
 Tresco KE, Lefler EK, Power TJ. Psychosocial interventions to improve the
school performance of students with attention-deficit/hyperactivity
disorder. Mind Brain. 2010;1(2):69-74.
 Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering
Committee on Quality Improvement and Management. ADHD: clinical
practice guideline for the diagnosis, evaluation, and treatment of
attention-deficit/hyperactivity disorder in children and adolescents.
Pediatrics. 2011:128(5):1007-1022, SI1-SI21.
QUESTIONS
Dr. Muhammad S. Tahir
[email protected]
www.americanwellnesscenter.ae
www.dubaipsychiatrist.com
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Phone No.: +971 4 514 4042