1. Consequences of inattention Incomplete assignments, messy works, careless errors Tuning out activities that are dull and uninteresting Losing track of conversations, not listening to directions

2. Six or more of the ff symptoms of Hyperactivity – impulsivity > 6 mos and is maladaptive and inconsistent with developmental level Hyperactivity Fidgets with hands /feet, squirms Leaves seat in classroom Runs about or climbs excessively in situations where it is inappropriate Has difficulty playing quietly Talks excessively Often on the go, driven by a motor

3. Issues in Hyperactivity Most visible sign Always on the go As these children get older, they exhibit excessive fidgeting and restlessness rather than gross motor activity

4. Six or more of the ff symptoms of Hyperactivity – impulsivity > 6 mos and is maladaptive and inconsistent with developmental level Impulsivity Has difficulty awaiting turn in games or group situations Blurts out answers to questions before they have been completed Interrupts or intrudes on others

5. Symptom domains Inattention Hyperactivity Impulsivity Psychiatric Co-morbidities Conduct disorder Oppositional Defiant Disorder Anxiety and Mood Disorders Lead to Functional Impairments SELF – low self esteem accidents substance abuse delinquency SCHOOL- academic difficulties underachievement HOME- Family stress Parenting difficulties SOCIAL- Poor peer relation ships Zuddas, ADHD in Europe, 2004 + CLINICAL PICTURE Course of the Disorder – Psychosocial Impairments

6. Age 6 10 14-16 ADHD only Disruptive behavior ODD LD Low self esteem, poor social skills, challenging behavior Substance abuse School Extension Mood disorder Conduct disorder Complex LD UNMANAGED ADHD leads to COMPLICATIONS Adapted from American Psychiatric Association m DSM IV TR 2000

7. How is a diagnosis made? Look for alarm signals Exclude ADHD lookalikes Use some objective pointers towards diagnosis Take a detailed history tuned to the subtleties of ADHD

8. ADHD: ADHD lookalikes Normal active preschooler Intellectual disability Hearing impaired child Specific learning disabilities Autism – Aspergers syndrome Family dysfunction

9. ADHD: Alarm signals Underfunctions at school inspite of normal intellect and no major learning disabilities ( chronic underachiever) ADHD package of behavior problems inspite of equal love and discipline at home

10. DIAGNOSIS Reactions in Families Common reactions Adjustment Changing values A sense of loss Loss of independence Comparative neglect of other family relationships Lack of respite Nally, The National Autistic Society 1999 He is helpless He is different I knew something was wrong Should I give up my job??

11. The Importance of Developmental Screening HISTORY PE Developmental Screening WATCH REFER IF SUSPECT REPEAT AND REFER IF SUSPECT Neuro exam RISK FACTORS

12. ADHD : Treatment Goals Decrease disruptive/setting –inappropriate behaviors Improve relationship with parents, siblings, teachers or peers Improve academic performance Improve self esteem Improve organizational skills and overall executive functioning American Academy of Child and Adolescent Psychiatry, 2004

13. ADHD: Treatment Goals Recognize and treat co-existing conditions In most cases of ADHD + comorbidity an initial stimulant trial is warranted In cases of ADHD + severe depression or psychosis, the comorbidity should be treated first. Stimulants may still be given later. Greenhill, L. J A, Acad Child Adol Psych, 2002

14. ADHD: Treatment Options Educational Accomodations Classroom placement, special education, tutoring, private schools Behavior Therapy Parent training, social skills training, behavior modification, daily report card Medications Stimulants, nonstimulants, tricyclic antidepressants

15. ADHD: Non standard therapies HYDROTHERAPY Promotes relaxation, improves function and coordination VITAMINS OCCUPATIONAL THERAPY

16. Stimulants: When to prescribe? There is no black and white test for this Depends on severity of ADHD, predominant behavior, degree of learning difficulties, how well parents and school are managing

17. Medication in ADHD a quick guide First line: Stimulants: Methyphenidate, Dexamphetamine Second line: Non-stimulants: Clonidine, Imipramine, Risperidone, Moclobemide

18. FDA-Approved Pharmacotherapy Methylphenidate Ritalin ® Concerta ® Ritalin LA ® Methylin ® Focalin ® Metadate CD Amphetamine Mixed Salts Adderall ® Aderall XR ® Stimulant Medications Not available in drugstores

19. ADHD: Issues in the use of Medications Decision to treat the ADHD child is based foremost on a diagnosis of ADHD The childs physical examination and medical history must reveal no medical contraindication for treatment Patient should be at least 6 years old Administration of medication must be supervised by an adult

20. Stimulants: What do they do? Increases the neurotransmitter chemicals dopamine and noradrenaline in certain parts of the brain They are not new ( 1937 but widely used in 1950) They are NOT SEDATIVES

21. Stimulants: benefits and side effects BENEFITS Reduces restlessness Improves classroom productivity Increase self monitoring and accuracy Less impulsive and disruptive Neater work SIDE EFFECTS Withdrawn, teary, upset Appetite reduction Tics ( 30%) Sleep problems Rebound behavior Headache/stomach ache ( rare)

22. What if stimulants dont work? 90% will respond to stimulant medication When a trial of medication has failed, check dosage and response before trying another drug preparation Otherwise go to second line drugs Stimulants do not cure dyslexia and has no effect on hostile behaviors of ODD

23. Teacher tribulations Other therapies Parent training Classroom management Cognitive behavioral training Group social skills training

24. Prognosis of ADHD Symptoms of ADHD persist throughout childhood 70% continue to have the disorder in adolescence, with 10-60% to adulthood More likely to persist in those with aggression or conduct problems Untreated adults have increased incidence of aggressive behavior, antisocial and conduct disorder, divorce, alcohol and drug abuse

25. Life Expectancy Adults with ADHD may achieve lower socioeconomic status and have more marital problems than do the general population They have the same life expectancy

26. The Spectrum of Developmental Disabilities PRIMARY DIAGNOSIS Down syndrome Mental retardation

27. The Continuum of Developmental Disabilities Associated Dysfunctions Mental retardation Hearing impairment Visual impairment Epilepsy Attention and hyperactivity issues

28. Gaps in Management The burden of illness Resources Expertise Cost

29. Preparation for parent hood Optimal prenatal care Newborn screening Developmental screening Early intervention Next Steps: Prevention

30. Active participation of parents in problem solving improved cooperation between families and professionals The need for and value of early education in autism Parent training programs Parent empowerment is a key to coping and an essential step towards healing Working collaboratively with parents

31. Developmental Disabilities Birth---Infancy-----Early Childhood----School Age ---Adolescence Down Syndrome Cerebral palsy Autistic Spectrum Disorders ADHD Learning Disabilities

32. The real voyage of discovery lies not in seeking new landscapes, but in having new eyes Marcel Proust