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27/2/14!

ATTENTION DEFICIT
HYPERACTIVITY DISORDER
Dr Tsui Kwing Wan
Senior Medical Officer
Department of Paediatrics and Adolescent Medicine
Alice Ho Miu Ling Nethersole Hospital!

Objectives
1. Define the scope ADHD in school age
children
2. Is ADHD a real disorder ()?
3. Medical management of ADHD
4. Helping students in ADHD in school, from
perspectives of a Paediatrician

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Identify the right subject first


1. Not pay attention, daydreaming and easily distracted
2. Fidgety and restless; leave seat inappropriately; running and
jumping in corridors
3. Not listening and difficult to follow instructions
4. Fail to start work and cannot complete assigned tasks
5. Blurting into conversation and calling out
6. Frequent missing of needed items, e.g. completed homework,
memo, stationery and own belongings!
7. Unpopular for their irritating and intrusive behaviours; conflicts
with peers; and even bully
8. Erratic academic performance; committing many careless mistake
and impulsive in answering question
9. Lagging behind in academic performance and important skills

Common reasons of academic


underachievement / behavioral problems
1. Sensory deficit (hearing and
vision)
2. Receptive / expressive
language disorder
3. Anxiety
4. Specific learning disorder
5. Intellectual disability
6. Autism spectrum disorder
7. Oppositional defiance

disorder / Conduct disorder


8. Attention-deficit /
hyperactivity disorder
9. Developmental coordination
disorder
10.Physical health problems, e.g.
chronic illness
11.Other mood problems
12.Not motivated

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ADHD Historical Timeline


Dr George Still
first described
ADHD symptoms!

ADHD!
(DSM-III-R)!
Minimal brain
dysfunction!

1900

1955

MPH!

1960

DSM-V!
Update criteria!

1980

1987

Attention deficit
disorder +/hyperactivity!
DSM-III!

1994

2000

2013

DSM-IVTR!
DSM-IV!
Update criteria!

EPIDEMIOLOGY
ADHD is among one of the most common neurobehavioural
problem in children
Prevalence:
"

US: 7.2% at age 8 (Kashani et al, 1989) DSM III, 5-8% of


childhood population (AACAP,1997)

"

4.4% of Adults in US, DSM IV (Kessler et al, 2006)

"

Hong Kong:

"

6.1% DSM III, 8.9% DSM III-R (Leung et al,1996)

3.9 % in grade 7, 8 and 9 students (Leung et al, 2008)

Male to female ~ 4:1

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DSM IV Diagnostic Criteria


for ADHD
Symptoms criteria!
6/9 for inattention and / or
hyperactivity!
(at least six months)!

Pervasiveness!
Two or more settings!

ADHD!

Impairment!

Onset!
Before 7 years of age!

INATTENTION (DSM IV)


1.Often fails to give close
attention to details or makes
careless mistakes in schoolwork,
work, or other activities
2.Often has difficulty sustaining
attention in tasks or play
activities
3.Often does not seem to listen
when spoken to directly

5.Often has difficulty organizing


tasks and activities
6.Often avoids, dislikes, or is
reluctant to engage in tasks that
require sustained mental effort
(such as schoolwork or
homework)
7.Often loses things necessary for
tasks or activities (e.g. toys,
school assignments, pencils,
books, or tools)

4.Often does not follow through


on instructions and fails to finish
8.Is often easily distracted by
schoolwork, chores, or duties in
extraneous stimuli
the workplace (not due to
Oppositional behavior or failure to
9.Is often forgetful in daily
understand instructions)
activities !

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HYPERACTIVITY / IMPULSIVITY (DSM IV)


1.Often fidgets with hands or
feet or squirms in seat

5.Is often on the go or often


acts as if driven by a motor

2.Often leaves seat in classroom 6.Often talks excessively


or in other situations in which
7.Often blurts out answers
remaining seated is expected
before questions have been
completed
3.Often runs about or climbs
excessively in situations in
8.Often has difficulty awaiting
which it is inappropriate (in
turn
adolescents or adults, may be
limited to subjective feelings
9.Often interrupts or intrudes
of restlessness)
on others (e.g., butts into
conversations or games)
4.Often has difficulty playing or
engaging in leisure activities
quietly

CLINICAL FEATURES OF ADHD


DSM IV
"

"

9 Inattention criteria (at least six), maladaptive and impairing


9 Hyperactivity / Impulsivity criteria (at least six), maladaptive
and impairing)

"

Symptoms persist for at least six months

"

Before 7 years old

"

"

"

2 or more settings, e.g. home and school / work


(pervasiveness)
Significant impairment in academic, social and occupational
functioning
Not caused by other conditions!

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EXCLUSIONS
1. Pervasive Developmental Disorder (not
present in new DSM V diagnostic criteria)
2. Schizophrenia, or other Psychotic Disorder
3. Other mental disorders, e.g., Mood
Disorder, Anxiety Disorder, Dissociative
Disorder, or a Personality Disorder

New DSM V Criteria


Published last year
Major changes
Age of onset increased to 12 years
Allow diagnosis in children with autism
Specify current subtypes / in partial remission /
current severity

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Is ADHD a real disorder?


Story of a hunter

Co-existing disorders (co-morbidities)


Adverse consequences
Neurobiological base

CO-MORBIDITIES OF ADHD
Up to 2/3 of children with ADHD has comorbidities
1.Oppositional defiant
disorder

6.Depressive disorder
7.Conduct disorder

2.Fine motor and


coordination problem

8.Learning disabilities

3.Tics and Tourette


syndrome disorde

9.social and
communication
problems

4.Anxiety disorder

10.Substance abuse

5.Sleep disturbance

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What causes ADHD


Genetics
Environment
Brain structure
Neuropsychological

NEUROBIOLOGY OF ADHD GENETIC


Genetic and environmental
Twin studies - concordance rates of ADHD in
monozygotic and dizyotic twins
"

mean heritability is estimated to be 76% for


children and adolescents

Adoption studies - ADHD rates was found to be


greater in biological relatives of ADHD children
than in adoptive families!

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NEUROBIOLOGY OF ADHD ENVIRONMENTAL


1.Maternal stress
2.Prenatal exposure to
tobacco and alcohol
3.Low birth weight /
prematurity
4.Neonatal anoxia and
seizure
5.Brain injury

6.Exposure to toxins, lead


and polychlorinated
biphenyl
7.Psychosocial adversity
and high level of family
conflict
8.Inconsistent parenting
9.Early institutional
deprivation!

GxE
Manifestation of ADHD is a result of
interaction between genetic and
environmental influences.
Genetic factors predispose an individual to
adverse prenatal and later life circumstances;
contribute more to the development of
behavioural symptoms in a context of high
environmental adversity. (Hicks et al. 2009)!

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Brains in ADHD
Involved areas including frontal and parietal
cortexes, basal ganglia, cerebellum,
hippocampus and corpus callosum.
Longitudinal studies showed developmental
delay of cortical thickness in ADHD
fMRI study showed decreased connectivity in
a fronto-striato-parieto-cerebellar network;
which was normalised by methylphenidate.!

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Delayed cortical development

Shaw et al. 2007

FUNCTIONAL MRI
Placebo!

Methylphenidate!

BJ Casey, et al. New potential leads in the biology and treatment of attention
deficit-hyperactivity disorder. Current Opinion in Neurology 2007;20:119- 124

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NEUROCOGNITIVE MODEL
Dual pathway model of ADHD
Links inattention and deficits in executive
functions to impairments in prefrontalstriatal circuits; whereas
Hyperactivity to dysfunctions of reward
response and motivation, related to frontallimbic system.!

EXECUTIVE FUNCTIONS
Involve
"

Self-regulation (monitoring and checking)

"

Flexibility in thinking / Shifting

"

Impulse control / Response inhibition

"

Emotional control

"

Planning / Prioritizing

"

Organisation

"

Task initiation

"

Accessing working memory

Allows a person to think about oneself, what may happen in


future and how one can influence it

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Outcome of children with


ADHD
13%!

Retained in grade!

42%!

Graduated high school!

100%!

68%!

Enrolled in College!

78%!

21%!
23%!

Fired from employment!


1%!

Parent at early age!

55%!

26%!
10%!

3 or more car accidents*!

22%!

Control!

15%!

Ever arrested*!

ADHD!

1%!

Ever convicted*!
0%!

34%!

14%!
10%!

20%!

30%!

40%!

50%!

60%!

70%!

80%!

90%!

100%!

Pediatrics, August 2011; *Psych Res, May 2011

FRAMEWORK OF EVALUATION
Full clinical and psychosocial assessment
"

"

"

meeting criteria in DSM-IV


At least moderate impairment in psychological,
educational or social aspects
Cross domains

Assessment of co-existing condition (developmental /


mental), familial and school conditions;
Physical health;
Understanding of patients and familys needs.!

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Investigations
Questionnaires
CBCL, SDQ, SWAN and Conners rating scale
Judicious use of questionnaires
not diagnostic , serves as screening tools
Blood tests are not needed most of time
EEG for suspected epilepsy, e.g. absence
seizure

Ab
i

lit

When to treat

y!

Brain scan not indicated unless brain lesion is


suspected!

s!

d
an

em

Drugs!
Behavioral Intervention!

ity
Abil

Age!

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A 14-MONTH RANDOMIZED CLINICAL TRIAL OF TREATMENT


STRATEGIES FOR ATTENTIONDEFICIT/HYPERACTIVITY DISORDER, 1999

Multimodal Treatment of Attention-Deficit Hyperactivity


Disorder
"

Six independent research teams

"

579 children with ADHD (combined type)

Treatment groups
"

Medication management

"

Intensive behavioural therapy

"

"

Combined (medication with intensive behavioural


therapy)
Community care!

MTA STUDY Implication, 1999


Combined (group 3) and Medication Mx (group 1) outcomes did not differ in degree of
improvement of core ADHD symptoms
Taking into consideration that vast number of patients with ADHD have comorbidity, use of
combined provides additional benefits.
Proportion of children have a restoration to normal or near-normal functioning:
"

Combined group 68%

"

Medication group 56 %

"

Behavior group 34 %

"

Community group 25 %

Factors for success of MTA trial:


"

Self-selection process highly motivated

"

Good compliance with intervention

"

Quality of intervention

"

Education of peers and family

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Effects of ADHD Medications


Consistently significant effect on core
symptoms (inattention, hyperactivity and
impulsivity)
Believe to have no direct effect on cognition,
learning and achievement !

ADHD Medications

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ADHD Medications

AVAILABLE DRUG FOR ADHD IN HONG KONG


CNS stimulant Methylphenidate (active ingredient)
"

Ritalin 10 mg (short acting)

"

Ritalin LA 20 mg (intermediate acting)

"

Concerta 18mg, 27mg, 36mg and 54mg (long acting)

Non-stimulant - Atomoxetine
"

Strattera 10mg, 18mg, 25mg, 40mg (atomoxetine)

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Duration of action

CHOICE OF DRUGS
First line: Rilatin / Ritalin LA
Second line: Rilatin LA, Concerta,
atomoxetine (good for child with anxiety and
tics)
Drug Holiday not advisable for short
holiday or at weekend
Cost concern

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RITALIN
Short acting methylphenidate
Rapid absorption, onset of action ~ 30
minutes
Last ~ 4 hours, needs to be taken 2 to 3
times a day (morning, lunch and after
school)
May be Used in conjunction with
intermediate / long acting drug
Compliance problems, in particular at lunch
hour!

RITALIN LA
Intermediate acting, last 8 hours
Each capsule contains half immediaterelease beads and half as enteric-coated,
delayed-release beads
Onset of action similar to Ritalin
Less peak and trough fluctuation
May need pm dose of short short acting
methylphenidate after school
Only 20 mg capsule available in HK

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CONCERTA
Long acting methylphenidate
Onset ~ 30 minutes (coated with
immediate release methylphenidate)
Last up to 12 hours after single dose
Advantages: decrease stigma and
improved compliance; less drug level
frustration
Disadvantages: Cost; if side effects
emerge, they may extend later into
the day!

SIDE EFFECT OF METHYLPHENIDATE

Linearly associated with dose

Usually mild and most patients can tolerate after short period
of time.

Decreased appetite, insomnia, anxiety, irritability and


emotional liability in more than 50 %

Abdominal pain and headache 1/3

Slight increase in heart rate and blood pressure, clinically


insignificant

Mood disturbance, tics, anxiety, nightmares and social


withdrawal less frequent

Behavioural / mood rebound

Risk of abuse is not proven!

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Strategies to reduce side effects of stimulants


1. Verify side effect is
medication related
2. Brief trial off medication
3. Try a lower dose
4. Administer the medication
with meal

7. Encourage trial off


medication (over weekend
or summer)
8. Treat side effect
9. Placebo trial

10.If side effect only seen on


Monday, change from 5
5. Use long acting preparation,
day/week to 7 days/week
if problems with peaks
dosing regime to reduce
frustration in drug level
6. Use short acting preparation
if problem with appetite at
11.Change to non-stimulant
lunch

Story of a driver

He has the brake and steering wheel but


no one ever taught him how to drive!

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Management overview

Structured setting!
Academic support!
Organization skill!
Social skill !

Choice of drugs!
Monitor response and
side eects !

Educational
support!

Psychosocial
intervention /
Behavioral
therapy!

Medication
Management!

Family
support!

Positive reinforcement!
Rewards!
Limit setting and
consequence!
Organization skill!
Social skills !

Parents education!
Parenting skills!
Structured environment
!

School Based Intervention - Benefits


1. Schools are ideal setting for implementation of effective
intervention as these are normal environment of the
children with easy access;
2. Benefits from a more structured and predictable
classroom setup (environment);
3. Provide clear behavioural rules and a system of
consequences that can be consistent in all areas of
school;
4. Aims at preventing or minimizing academic, social and
behavioural problems;
5. To provide success experiences for cultivation of self
confidence and esteem

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Targeted problem areas for


students with ADHD in school
1. Noncompliance; difficulty following rules and directions, discipline
problems
2. Easily distracted and off task
3. Disorganized, loses things
4. Task initiation difficulties
5. Difficulty making transitions
6. Low rate of work completion, inability to complete timed tests / exam
Poor note taking and test taking skills
7. Poor hand writing
8. Academic performance below ability level
9. Weak emotion and anger control; difficult to socialise and cant keep
friends

Psychosocial interventions
Inconsistent performance
child knows how to perform but not consistent in
outcome
environmental adaptation and accommodation
Lack of skills
child does not yet possess the skills
provide direct instruction and increase opportunities!

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School accommodation
Modified seating arrangement, sitting closer to teacher
and away from sources of distractions (windows, doors
and other children with attention problems);
Better to work in smaller groups
Provide attention cue by the teachers, e.g. good eye
contact
Check school diary for completeness (providing a buddy)
Reduce workloads
Provide an Extended time for tests
Allow to take tests / examinations in a quiet room
Provide buddy!

BEHAVIOURAL INTERVENTION (THERAPY)


Designed to affect antecedents and / or consequences of
behaviours
Positive Reinforcement focus on appropriate behaviours
Token economy
Daily report card promotes family-school collaborations
Self-management in older children to improve on-task
behaviour, academic accuracy and organisational skills.
Social skills and anger control training
Organisational skills training
Homework strategies need parents education and support
Praise Praise Praise!

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Is the child lazy?


Not motivated; often reluctant to initiate tasks and
procrastinate
Questions to ask:
1.Does the child know what to do?
2.Does child know how to do?
3.Is the child easily frustrated?
4.Does the child lack motivation?
Give cue or checklist, avoid perception of challenges,
include kids interests and hobbies, provide choices,
offer a reward and PRAISE!

Ways to improve learning


1. Clear and concise instructions, which is limited to as
few as possible
2. Break down works in small steps; to complete easier
step first
3. Incorporate short breaks in between lengthy task
4. Use of timer for transitions and completion
5. Use multi-sensory approach, providing auditory and
visual illustrations through various means
6. Use lists, daily report cards and charts to aid
organisation!

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Ways to improve behaviours


1. Clear and specific rules
2. Involve the student in the management plan
3. Minor disruptions are best ignored
4. Manage transition times, e.g. recess and lunch hour
5. Target a specific areas of weakness, executive dysfunction
6. Frequent use of praise and rewards (specific and immediate;
be sincere and not overdo)
7. Catch opportunities for social skill training
8. Punishment should be brief and given calmly, for specific
misbehaviour and involve a reminder of the required task.

Unique features of school children with ADHD in


NTEC (HK)
1. Both parents are working or one of parents in Mainland cannot provide
direct supervision and lack of quality time with children
2. Cared by grandparents consistent parenting cannot be carried out
effectively due to different upbringing experience and cultural background.
3. Diversity of cultural background and educational attainments among
parents / carer some of them are not able to assist children on
homework or revision, especially English, lack of academic support at home
4. Private tutorial class after-school almost as norm training of tutors and
quality of academic support varies and may not able to provide most
appropriate support for children with SEN.
5. Too many extracurricular activities after school unstructured after-school
routine, and late homework time;
6. Work till late at night lack incentive to complete tasks and no drug cover
at late evening

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School-Family-Hospital as partners
1.Mutual sharing of knowledge
2.Maintain good communications, e.g. parents as
bridge, questionnaires and direct contact
3.Drug supervision in school
4.Streamline the interventional programs provided
in different settings (school, home and hospital)
to minimize duplication
5.

Conclusions
1.ADHD is a real neurodevelopmental problems with
strong neurobiological base.
2.It is a chronic disability and leads to long term
adverse consequence if untreated.
3.Medication and psychosocial interventions have
been proven effective.
4.School is an ideal setting to support children to deal
with their academic and social difficulties.
5.Treatment goal: change repeated failures to
frequent successes, no matter how trivial they are.

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THANK YOU

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