Attention Deficit
Hyperactive
Disorder
Ms. Fouzia Saleemi
Speech Language Pathologist/Peadatric
Psychologist
M.Phil. (Speech Language Pathology)
M.A (Special Ed), ABS (Trainer), B.ED, PGD (SLT)
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What is ADHD?
People with ADHD show a
persistent pattern of inattention
and/or hyperactivity-
impulsivity that interferes with
functioning or development.
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Core Symptoms of ADHD
Hyperactivi Inattention Impulsivity
ty EINAQ & ©ATC
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What is ADHD?...
For a layman:
ADHD or Attention Deficit
Hyperactivity Disorder is a
medical problem that effects the
way someone can sit still, focus
and pay attention.
It is a chronic disorder which is
lifelong. It is manageable but
does not have permanent cure.
Many people with ADHD can be ©
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Attention Deficit Hyperactivity
Disorder
ADHD is a common behavioural
disorder that affects about 10% of
school-age children.
Boys are about three times more likely
than girls to be diagnosed with it.
People with ADHD act without thinking,
are hyperactive, and have trouble
focusing.
ADHD symptoms are present in
different settings. They hurt a child's
ability to function socially,
academically, and at home.
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Diagnostic Statistical Manual – Fifth
Edition (DSM-V) Criteria for ADHD
Criteria –A:
Inattention: Six or more symptoms of
inattention for children up to age 16, or
five or more for adolescents 17 and older
and adults; symptoms of inattention
have been present for at least 6 months,
and they are inappropriate for
developmental level:
Often fails to give close attention to details or
makes careless mistakes in schoolwork, at
work, or with other activities.
Often has trouble holding attention on tasks or
play activities. EINAQ &
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ATC
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DSM-V (cont..)
1. Often does not follow through on instructions
and fails to finish schoolwork, chores, or
duties in the workplace (e.g., loses focus,
side-tracked).
2. Often has trouble organizing tasks and
activities.
3. Often avoids, dislikes, or is reluctant to do
tasks that require mental effort over a long
period of time (such as schoolwork or
homework).
4. Often loses things necessary for tasks and
activities (e.g. school materials, pencils,
books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
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5. Is often easily distracted
DSM-V (cont..)
Criteria-B:
Hyperactivity and Impulsivity: Six or more
symptoms of hyperactivity-impulsivity for children
up to age 16, or five or more for adolescents 17
and older and adults; symptoms of hyperactivity-
impulsivity have been present for at least 6
months to an extent that is disruptive and
inappropriate for the person’s developmental level:
◦ Often fidgets with or taps hands or feet, or squirms in
seat.
◦ Often leaves seat in situations when remaining seated is
expected.
◦ Often runs about or climbs in situations where it is not
appropriate (adolescents or adults may be limited to
feeling restless).
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DSM-V (cont..)
1. Often unable to play or take part in
leisure activities quietly.
2. Is often "on the go" acting as if "driven
by a motor".
3. Often talks excessively.
4. Often blurts out an answer before a
question has been completed.
5. Often has trouble waiting his/her turn.
6. Often interrupts or intrudes on others
(e.g., butts into conversations or
games) EINAQ & ©ATC
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Differential Diagnosis
Substance Autism
Bipolar
Use Spectrum
Disorders
Disorders Disorders
Oppositio
Specific
Intellectua nal
Learning
l Disability Defiant
Disorders
Disorder
Personalit
Anxiety
y
Disorders
Disorders
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CLINICAL PICTURE
Duration Symptom criteria must
have been met for the
past 6 months
Age of onset Some symptoms
must have been present
before 12 years of age
Pervasiveness Some impairment
due to symptoms must
have been present in 2
or more settings
(eg school, work or
Clinical picture Assessment Differential diagnosis Conclusions
Prevalence of
ADHD
100
90
80 Combined
70
Prevalence (%)
Hyperactive/ impulsive
60 Inattentive
50
40
30
20
10
0
Girls with ADHD Boys with ADHD
Biederman et al 2002
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Case description Core symtoms Emergence of a concept Classification
Classification Epidemiology Aetiology Comorbidity Cost Implications
Prognosis
Approximately 70-80% of ADHD patients
treated with stimulant medication
experience significant relief from
symptoms, at least in the short-term.
Approximately half of ADHD children
seem to "outgrow" the disorder in
adolescence or early adulthood; the
other half will retain some or all
symptoms of ADHD as adults.
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Pathophysiology
Brain uses multiple chemical substances
for operation, regulation and
communications. T
These are called neurotransmitters
serving many functions in brain.
Neurotransmitters stimulates or represses
the stimulation in brain cells to pay proper
attention.
To have proper control of our impulses,
area of brain must be adequately,
controlled, repressed or slowed down.
In ADHD children both system stimulation
and repression are not working properly. EINAQ & ©ATC
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Pathophysiology
There are two neurotransmitters which
are released in brain are implicated in
the pathophysiology of ADHD:
Dopamine (DA)
Norepinephrine (NE)
Dopamine is a neurotransmitter
involved in reward, Risk taking,
impulsivity and mood.
Norepinephrine modulates attention,
arousal and mood.
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Acquired Biological
Factors
◦ Extreme prematurity and low birth
weight
◦ Brain disorders :
syndromes - inter related marriages
Encephalitis
brain trauma
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Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Comorbidity Cost Implications
Psycho-Social
Factors
de
Family Instability
Partner conflict
Parental mental disorders
Lack of parenting competence
Negative parent-child relationship
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Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Comorbidity Cost Implications
Co-Morbidity of ADHD
Tics Motor
Problem
11%
50%
Reading Oppositional
Disorder Defiant Disorder
50% 40%-70%
ADHD alone
ASD
Conduct
disorder 31%
14%
20-50%
Anxiety
Depression
Disorder
4% OCD
34%
Development of Symptoms of ADHD
(School) drop out!, Mood swings, job
learning problems, problems,
social problems, Negative self image,
smoking, criminal Marital problems,
Behavioural
behaviour, depression, domestic
problems,
accidents, addiction violence
Sleep issues
Toddler Adolescent Adult
School age Young Adult/Student
Behavioural Learning
problems, problems,
learning problems, Choosing the
social problems, Profession,
Fear of failure/ Fear of failure
negative self-esteem Addiction ©
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Course of the Disorder
Increasing Complications with Age
Low
Low self-
self-
esteem
esteem
Family
Family Poor
Poor social
social
disruption
disruption skills
skills
Disruptive
Disruptive Learning
Learning
behaviour
behaviour problems
problems
Complex
Complex Oppositional
Oppositional
learning
learning defiant
defiant
difficulties
difficulties ADHD
ADHD only
only disorder
disorder
Lack
Lack of
of Mood
Mood
motivation
motivation disorder
disorder
Conduct
Conduct Provocative
Provocative
disorder
disorder behaviour
behaviour
Substance
Substance Antisocial
Antisocial
abuse
abuse behaviour
behaviour
School
School
exclusion
exclusion
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Clinical picture Assessment Differential diagnosis Conclusions
MULTIMODAL
ASSESSMENT
Family
History Family
◦Clinical interview Stress
Child Rearing
(Parents’) Parent- Practices
Child
Relationshi
p
Daily
◦Overall Functioning
Emotional &
Functioning Behavioral
Functioning
Psychosocial
Functioning
Physical Handicap
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Clinical Assessme Differential Conclusio
MULTIMODAL ASSESSMENT
• General Observation
• Information (teacher and caregivers)
Conner‘s Rating Scale (Parent‘s and
Teachers)
IQ Tests
Achievement Tests EINAQ & ©ATC
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Presentation of ADHD
ADHD may not be ADHD typically
observable: worsens:
in highly structured in unstructured
settings situations
during interesting in boring situations
activities where there is a lot
when receiving of distraction
one-to-one when sustained
attention attention or
where there are mental effort is
frequent rewards required
Observation in varying contexts is
important
Clinical picture Assessment
Assessment Differential diagnosis
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Conclusions
Aims of Treatment
1. Reduce symptoms of ADHD
2. Reduce risks in the future
3. Educate the patient and
the environment about the
disorder
4. Adapt the environment to
the patient’s needs
5. Enhance coping skills of
patients, parents, teachers
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Overview Efficacy of interventions Psychoeducation PsychopharmacotherapyBehaviour modification Algorithm QA Conclusions
Management of ADHD
ADHD is best treated with a combination
of behaviour therapy and medication
Following are treatment options for
ADHD:
Psycho-education and Counseling of
Parents’
Medication
Behavioural intervention strategies
Parents’ training
School accommodations and
interventions EINAQ & ©ATC
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General Recommendations
Cut down sugars (not only candies or
chocolates but fizzy drinks, ketchup, preserved
juices or preserved foods etc).
Channelize excessive energy through
different games like football, basket ball,
running, climbing, skipping rope etc.
For sustaining attention, give variety of
activities to the child. As ADHD children get
bored quickly, they need lots of activities.
For improving attention span, fine motor
skills and handwriting use Lacing, Buttoning,
Beading activities etc. These activities will help
the child to sustain attention. ©
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PSYCHOEDUCATION AND
COUNSELLING
◦ Inform all the people involved about
ADHD and its associated problems, and
interventions
◦ Treatment plan should be developed in
coordination with parents, teachers,
therapists and the child.
◦ Counsel parents and teachers about
how to interact with the child in daily
life
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Overview Efficacy of interventions Psychoeducation PsychopharmacotherapyBehaviour modification Algorithm QA Conclusions
MEDICATION
Stimulant Non-Stimulant
Methylphenidate Atomoxetine
Risperidone
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Overview Efficacy of interventions Psychoeducation PsychopharmacotherapyBehaviour modification Algorithm QA Conclusions
Medication
Stimulants are the most recommended
drug for clinical management.
The most commonly used drug is
methylphenidate or Ritalin.
Side effects of these drugs are headache,
stomachache, irritability, and sensitivity to
the criticism, specially in the beginning of
the treatment.
Loss of appetite and insomnia are
disturbing for parents.
Teacher should check the proper dosage
intake time and confirmation of intake of
medicine. EINAQ & ©ATC
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Medication
A few children develop tics (involuntary
muscle movements) in the form of facial
grimaces, sniffing, coughing and other
vocal sounds on stimulant medication.
Teachers can be very helpful when they
observe these symptoms or change in
behavior.
Communication if teacher with physician
an nurse are also very important.
Tricyclic anti-depressants are given, who
are unable to take stimulants.
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Executive Functions
Affected by ADHD
These include:
Plan
Organize
Prioritize
Sequence
Time Management
Problem Solving
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Executive Functions
Affected by ADHD
ADHD children do not lack skills
and abilities, its just that their
internal camera which supervises
the executive functions of the
brain, which is sleeping.
Teachers need to wake up that
internal camera and clean up the
camera lens by employing
different strategies.
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CONCLUSION
• A multimodal treatment
programme must be individually
customised, continually
monitored and optimised
• Psychoeducation is the key for
all the teatment of ADHD.
• Medication plays a central role
in many cases
• Effective treament includes
behavioral therapy at home and EINAQ & ©ATC
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Overview Efficacy of interventions Psychoeducation PsychopharmacotherapyBehaviour modification Algorithm QA Conclusions
