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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 Facebook: Dubaipsychiatrist Twitter: dubaipsychiatry Phone No.: +971 4 514 4042