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Kathy Morris Consultant Clinical Psychologist 12 th June 2014.

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1 Kathy Morris Consultant Clinical Psychologist 12 th June 2014

2 ADHD is… ADHD is not simple to define. There is more than one explanation ADHD is also called Hyperkinetic Disorder (HD). Attention Deficit Disorder (ADD) also has features of ADHD However, the main features of ADHD are: a. Inattention b. Hyperactivity c. Impulsivity (From ‘Diagnostic and Statistical Manual of Mental Disorders Fourth Edition’ [DSM IV])

3 Inattention Inattention is… a. Not paying close attention to detail b. Making careless mistakes c. Difficulty in sustaining attention d. Not seeming to listen when spoken to e. Not following instructions f. Failing to finish activities g. Organisational difficulties (e.g. losing things) h. Forgetful i. Easily distracted

4 Hyperactivity Hyperactivity is… a. Fidgety b. Restless c. Often running around or climbing excessively d. Noisy e. Often ‘on the go’ f. Talking excessively

5 Impulsivity Impulsivity is… a. Blurting out answers before questions are finished b. Interrupting or intruding on others c. Difficulty waiting in turns

6 Defining ADHD – Medical Research ADHD occurs in 3-9% of children with 3 times more boys than girls being diagnosed. (Swanson et al., 1998) Children with ADHD have been shown to have areas of the brain that are under-active and smaller e.g. frontal lobes, cerebellum, basal ganglia. (International Consensus Statement on ADHD, 2002) ADHD has been associated with low levels of dopamine in the brain. Dopamine is a naturally occurring brain chemical, that acts as a signal between brain cells. Genetic studies suggest that a variation in the genes that regulate the dopamine signal increases the risk for ADHD. Role of genetics as well as social and environmental factors

7 Prevalence Prevalence estimates are highly dependent on: – The population sampled, methods used and diagnostic criteria applied US estimates higher than UK estimates Most estimates vary between 5% and 10% for ADHD About 0.5-1% of school age children have HKD Taylor (1994) suggests that a point prevalence for HKD is 1:200 in the whole child population Male to Female ratio is at least 4 to 1

8 What else could it be? Anxiety ADHD Sexual abuse Social/ environmental factors Specific Learning Difficulty/ Dyslexia ASD

9 Secondary Symptoms: co-morbidity Antisocial Disorders (25%-50%): CD, ODD Affective Disorders – 25% have co-existing anxiety disorder – 20% have co-existing mood disorder Developmental Disorder (20%) – Dyslexia – Dyspraxia – Specific language impairment – Discalculia – Learning disability – Autism Spectrum Disorder – Tic disorder

10 Outcomes and co-existing problems Long-term outcomes are poor Children with ADHD are 4 times more likely to have mental heath problems in later life if not treated Example of such mental health problems are: - conduct disorder - anxiety disorder - bi-polar disorder - depression (Barkley, 2002)

11 Other problems associated with ADHD Poor self-esteem Poor social skills – relationship difficulties Mood swings Sleep problems Never feeling satisfied Extreme stubbornness Poor organisation and management of time Underachievement at school Lack of motivation Problems with rules Over-sensitivity Vulnerability to stress Short-term memory difficulties Physical symptoms (e.g. headaches, stomach aches)

12 Assessment Parent and Teacher Conners’ Rating Scales Strengths and Difficulties Questionnaire (SDQ) ADHD Information Questionnaire Other information that will be useful for assessing a child with suspected ADHD e.g. observations of behaviour, sleep patterns

13 Treatment of ADHD – medication how does it work?  Medication is not a cure, but it can help improve concentration and reduce impulsive behaviours  The National Institute for Clinical Excellence (NICE) recommends that medication be used together with therapies  There are different types of medication – some are ‘short- acting’ (e.g. Ritalin) and others are ‘slow-release’ (e.g. like Concerta XL, Equasym XL)

14 Treatment of ADHD – medication (continued) Why is it important to monitor medication? When paediatricians and psychiatrists first prescribe medication, they need feedback regarding the impact of the medication upon behaviour and possible side effects. The child’s parents may ask you to comment on any changes in the child’s behaviour. This is to ensure that the medication is at the right dosage; it may need to be adjusted

15 N.I.C.E. guidelines 2008 Specialist teams DSM IV or ICD 10 criteria Consider co-existing conditions: social, familial, educational, health, m.h. of carers Diagnosis not on rating scales/observation alone Significant, pervasive, impact on life Behaviour interventions in class: training for teachers

16 N.I.C.E. guidelines 2008 (continued) Moderate : group parent training ? with social skills group/CBT for child Severe : drug treatment and group parent training Drug treatment always part of comprehensive treatment plan Take account of child/young person’s views

17 What should you do if you think that a child has ADHD? Care pathways Discuss any concerns with other professionals who work with the child Discuss the child’s presentation with the parents If in school the child may be referred to: the Educational Psychology Service and the Core Panel The parents may wish to discuss the child’s behaviour with their GP, who may in turn decide to refer the child on to a paediatrician or psychiatrist There is a multidisciplinary team at the Phoenix Centre

18 Things that can help Always address the child by name Try to make eye contact wherever possible Provide clear instructions, both in verbal and written/pictorial form Break big tasks into smaller ones and tell them what the end objective is Raise the profile of the child (e.g. running errands, sharing successes, interests and areas of strength) Give the child a ‘fresh start’ once the cause of their difficulties has been identified

19 Things that can help (continued) Work with the parents and child to enable them to tackle associated areas of difficulty e.g. reading and peer relationships Assist in monitoring medication and behavioural interventions if asked to do so Encourage the child to participate in activities that will help to develop self-confidence and social skills Ensure clear communication with parents and other professionals, so action can be taken promptly before things get out of control

20 Learn best from activities that are: Hands on, practical Novel Have a range of different elements Short Frequently changing An opportunity to be in the limelight In a distraction-free place for written work Enabling physical movement in a group or class

21 Learn least from activities that: Require passive listening or watching Are routine and predictable Demand high attention to detail Require staying still for long periods Demand high level of repetition/ practice

22 Dealing with inattention Provide children with a brief outline of the task to be completed Break instructions and activities down into manageable chunks Have realistic expectations about what is achievable Keep targets to one or two activities Use special cue phrases when attention appears to be waning e.g. ‘Wait for it’, ‘Now for the interesting bit’, ‘The next bit is amazing!’

23 Dealing with hyperactivity Give restless and fidgety children opportunities to move e.g. in seat :squeezable balls, doodle book, tangle toys, blue tac or small building blocks that do not make a noise Try to keep children busy e.g. give them a job or task that allows them to be active in a controlled and positive way e.g. handing out books, equipment, delivering a message

24 Dealing with impulsivity This can be difficult and frustrating to manage but not impossible! Children with ADHD act first and think later. We need to reverse this process Encourage the child to do things in 3 stages: a. Stop and listen b. Look and think c. Decide what to do

25 Praise Using praise improves concentration and self-esteem When praising focus on the particular behaviour that you are wanting to encourage If the child has behaved well during a specific task – praise them

26 Rewards Children with ADHD respond very well to rewards related to short-term targets Agree specific achievable targets e.g. sitting still for 10 minutes Negotiate rewards with the child and vary them regularly to maintain interest Build on success e.g. activities that the child does well. Nothing succeeds like success!

27 Identify small ways of complimenting the child for positive behaviour e.g. ‘Well done, Peter, you… …asked a good question …solved a problem …encouraged someone …listened well’ (From ‘Practical Ideas that Really Work with Students with ADHD’ McConnell & Ryser) Little things mean a lot

28 How to deal with challenging behaviour Be specific and realistic about the behaviour you are expecting from the child Do not try to address all behaviours at once Address the behaviour and not the child e.g. ‘I like it when you put your hand up to answer questions’ Clearly state what behaviour is unacceptable and the consequences of such behaviour e.g. ‘If you continue to push Ryan you will have time out. Please take a step away from him’

29 How to deal with challenging behaviour Children with ADHD may not be doing what you’ve asked because they have forgotten the task. Instead of saying ‘please get on with it’, remind them of the actual task and be specific Children with ADHD can have explosive outbursts due to feelings of extreme frustration with themselves but take it out on those around them Try to remain calm and emotionally neutral. Show the child that you are in charge of the situation

30 Think Positive! Many negative characteristics of ADHD can have a positive side Impulsive Decisive and enthusiastic Distractible Creative and open-minded Restless Energetic and lively  Although it may not always be easy to see a situation in this way it will help to maintain a positive relationship with the child  Although you may feel frustrated at times, the way you react to any child can strongly affect the way others behave towards them.

31 Further information ADDISS (Attention Deficit Disorder Information and Support Service) via / 020 8906 Google Scholar – recent articles ADDERS UK via ‘123 Magic’ by Thomas W Phelan ‘Understanding ADHD’ by Christopher Green & K Chee

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