ADD/ ADHDDEFINITION:

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) IS A GROUP OFBEHAVIOURAL SYMPTOMS THAT INCLUDE INATTENTIVENESS, HYPERACTIVITYAND IMPULSIVENESS.

• ADHD CAN OCCUR IN PEOPLE OF ANY INTELLECTUAL ABILITY,ALTHOUGH IT IS MORE COMMON IN PEOPLE WITH LEARNINGDIFFICULTIES.

• SYMPTOMS OF ADHD TEND TO BE FIRST NOTICED AT AN EARLY AGE,AND MAY BECOME MORE NOTICEABLE WHEN A CHILD'SCIRCUMSTANCES CHANGE, SUCH AS WHEN THEY START SCHOOL.MOST CASES ARE DIAGNOSED IN CHILDREN BETWEEN THE AGES OF 6AND 12.

• THE SYMPTOMS OF ADHD USUALLY IMPROVE WITH AGE, BUT MANYADULTS WHO ARE DIAGNOSED WITH THE CONDITION AT A YOUNG AGEWILL CONTINUE TO EXPERIENCE PROBLEMS.

(NHS, 2014)

Symptoms

Inattentiveness (ADD) Hyperactivity / Impulsiveness (HD)

Short attention span, easily

distracted

Unable to sit still especially in calm

quiet environment

Making careless mistakes Constantly fidgeting

Appearing forgetful / losing things Being unable to concentrate on

tasks

Unable to stick to task that is time

consuming or tedious

Excessive physical movement

Unable to listen or carry out

instructions

Excessive talking

Constantly changing activity or

task

Unable to wait their turn

Having difficulty organizing tasks Acting without thinking

Interrupting conversations

No sense of danger

Explanatory ModelBarkley (1997, 1998, 2000)

notes that persons with ADHD have difficulties with executive functions.

Executive functions involve a number of self-directed behaviors, such asworking memory, inner speech, and self-regulation of emotions.

Working memory is the ability to hold things in mind while also engaging inother cognitive tasks.

Problems in working memory can affect the ability of the person with ADHDto have hindsight and foresight

Inner speech is the inner "voice" we use to "talk" to ourselves when facedwith difficult problems. This speech may start out as talking out loud and thenbecome internalized over time.

Self-regulation of emotions also presents problems for many students withADHD. They often overreact to emotionally charged situations.

Barkley hypothesizes that such problems in regulating emotions contribute tomotivational problems for individuals with ADHD. They are unable to channeltheir emotions to help them persist in the pursuit of future goals. And havinglearning disabilities in combination with ADHD makes it even more difficult tomaintain motivation in the face of failure.

Response inhibition is essential for all behavioural function

Neuroscience view studies and the cognitive neuroscience literature, those using

functional imaging have tended to focus on brain region that arenormally involved in attention/cognition, executive function, workingmemory, motor control, response inhibition, and/or reward/motivation

implicated fronto–striatal abnormalities (particularly dysfunction ofdACC (dorsal Anterior Cingulate Cortex) lateral prefrontal cortex, andstriatum) as possibly playing roles in the production of ADHDsymptomatology.

(Bush et al, 2005)

dACC, also referred to as the “cognitive division,” has been shown toplay important roles in attention, cognition, motor control, andreward-based decision making;

Counting Stroops test (considered to measure selective attention,cognitive flexibility and processing speed, and it is used as a tool in theevaluation of executive functions) has shown Hyperactivity in dACCfor children and adults Go-NoGo test (used to measure a participant'scapacity for sustained attention and response control) has shownhypoactivation in dACC

(Tamm et al, 2004, Bush et al, 2000)

fails to follow Mendelian patterns of inheritance and is classified as

a complex genetic disorder

(Cardinal et al, 2001)

Critical points to consider:

Brain imaging results are much too inconsistent to be interpreted

meaningfully and may be confounded by prior medication

exposure

Less attention has been paid to orbitofrontal cortex, even though

lesions of this region are associated with social disinhibition and

impulse control disorders

some of the most important tasks facing researchers in the future

will involve actively searching for similarities and differences

among different age groups and placing findings within a

developmental perspective

(Bush et al, 2005)

Environmental/ Parental hyperactivity/inattention were found to be predicted by the interaction between

inconsistent discipline and child age. In previous cross sectional research,inconsistent discipline has been uniquely associated with ADHD symptom severity

relatively little research has examined the unique associations between specificparenting variables and hyperactivity/inattention across development

(Ellis & Nigg, 2009)

It has also been implicated in a gene x environment interaction, with finding aspecific dopaminergic gene to be associated with increased risk for ADHD only inthe presence of highly inconsistent discipline (Martel et al.2011, Hawes et al, 2013)

Parental involvement: high level parental involvement has been associated withlow level of ADHD, however only among children of lower age range

disruptions to environmental contingencies—as seen in inconsistent discipline –appear to operate most adversely on these capacities later, in middle childhood.

(Hawes et al, 2013)

Poor parental skills strongly contributes to children’s self control deficits and to thedevelopment of other disruptive behaviours associated with ADHD

Behavioural parent training for families of children with ADHD may improveparental functioning and reduce children’s oppositional and aggressive behaviour;however, poor attendance and parental psychopathology may limit the usefulnessof parent training.

(Modesto – Lowe et al, 2008)

Critical points to consider:

There are three main ways that psychiatric geneticists and behaviourgeneticists have made the case for the genetic basis of ADHD: family,twin, and adoption studies

Although family studies might be able to demonstrate the familiality ofADHD, due to the fact that families share a common environment aswell as common genes does not permit any conclusion about agenetic component for the diagnosis.

(Joseph, 2000)

Effect of ADHD on parental functioning: These parents typically displayhigh levels of over- reactivity and tend to be more critical of theirchildren, less rewarding, and less responsive than parents of childrenwithout ADHD.

Moreover, the degree of parental dysfunction appears to correlatewith the presence and severity of ADHD-related disruptive disorderssuch as ODD and CD.

Social learning theory (Bandura, 1977) is important to consider as rootof many psychiatric disorders in children

(O’connor & Scott, 2007)

Comorbidity About 67 % of children with ADHD has one or more other

neurodevelopmental disorders or learning disability compared to11 % of children with no ADHD. (33 % had one 18% two or three 16% two comorbid condition)

Learning disorders (46% vs 5%)

Conduct disorder (27% vs 2%)

Anxiety (18% vs 2%)

Depression (14% vs 1%)

Speech problems 12% vs3%)

Autism spectrum Disorder (6% vs0.6%)

Epilepsy/Seizures (2.6% vs0.6%)

Oppositional Defiant Disorder

Sleep Disorder

Bipolar Disorder

(Patel et al, 2012)

Over 50 % children with ADHD have a learning disorder, however, it must betreated separately, as treating the symptoms of ADHD will not eliminate LDs

Dyslexia is very common in children with ADHD, while Dyscalculia is moreprevalent in children with ADD only

(Shaywitz, 1992)

The causal pathways leading to co-morbidity between ADHD and dyslexiaare not well understood, but researchers agree that their coexistence is notartifactual because associations have been observed in differentepidemiological samples and across diverse settings

each is evaluated by different methods: ADHD by parent and teacher ratingsof behaviour and dyslexia by direct tests of reading performance.

Two major theories on ADHD comorbidity with dyslexia:

1. phenocopy hypothesis This model proposes a bi-directional influence suchthat behavioural problems associated with ADHD disrupt learning to read,hence making the child appear dyslexic or, by the same logic, frustrationsdue to reading problems making the dyslexic child appear inattentive

2. cognitive subtype hypothesis makes an association with etiological factorsand posits that co-morbid groups in fact represent a third disorder that isdue to either etiological factors that are distinct relative to those related toeach disorder alone

(Rucklidge & Tannock, 2002)

Classroom Intervention

Task Duration (due to short attention span, assignments should be brief, and immediate feedback given on accuracy i.e.long term project broken into smaller parts)

Task difficulty (matching tasks to student’s skill level, as students with ADHD tend to give up and become frustrated quicker iftask is too hard, or bored and inattentive if it is to easy)

Direct Instruction ( Behaviour can be improved if child is engaged in teacher led activity rather than independent seat work,direct explicit instruction improves on-task behaviours)

Peer tutoring ( shown to be effective in academic and behavioural gains, peer tutor has to have higher academicachievement and better behaviour and the same gender and age as the student with ADHD)

Scheduling (on task behaviour of ADHD students worsen during the day, therefore critical instruction has to be given in themorning, and more active non-academic activities should be scheduled in the afternoon)

Novelty (reduces activity, increases attention, for example; teacher could use brightly coloured papers, animations, evendifferent intonations when giving instructions or teaching a lesion students with ADHD respond positively to novelty)

Productive Physical environment (it is useful to include active breaks for these children, such as stretch breaks, or to givethem any physical activity, watering plants, taking note to another teacher, feeding animals)

Passive/ Active Involvement (could help hyperactive students t channel their disruptive behaviour if they are activelyinvolved in the classroom i.e. writing important points on the board, assist the teacher)

Powerful external reinforcement (these reinforcements are beneficial for any student, however it is better to provide thesequicker and more frequently to ADHD children)

Choice (having more choices of activates or assignments for ADHD student can increase on- task behaviour)

Clear, Direct instructions ( instruction have to be short, clear, using more direct words, teachers have to be prepared torepeat directions frequently, may even ask student to rephrase directions in her/ his own way to ensure understanding)

Structure and organization (ADHD students respond positively to having daily routine and predictability, they should benotified well before changes happen to any routine)

(Brock et al, 2006)

Medical Intervention

Since most ADHD children have comorbid disorders, combination

of different treatment modalities is usually indicated

In both European and US guidelines, stimulants (including

methylphenidate and dexamphetamine) are mentioned as the

first-choice drugs in the pharmacological treatment of ADHD

stimulants also improved associated behaviour, including on-task

behaviour, academic performance and social functioning on a

short term

pharmacotherapy of ADHD in children is proven to be effective.

(Mejier et al, 2009)

Methylphenidate (Ritalin): Methylphenidate is the most commonlyused medication for ADHD. It belongs to a group of medicinescalled stimulants that work by increasing activity in the brain,particularly in areas that play a part in controlling attention andbehaviour. (can be used over age of 6)

Dexamfetamine (Dextedrine, Focalin): works same way as above,can be used over age of 3

Lisdexamfetamine (Vyvanse): works same way, can be used overage of 6

Atomoxetine (Strattera): It is known as a selective noradrenalineuptake inhibitor (SNRI), which means it increases the amount of achemical in the brain called noradrenaline. This chemical passesmessages between brain cells, and increasing the amount can aidconcentration and help control impulses. Can be used over age of6

(NHS, 2015)

Adverse effects: loss of apetite – reduction in expected growth,Sleep disorder, possible cardiovascular effects – especially in caseof Atomoxetine

(Mejier et al, 2009)

Therapeutical Intervention CBT: the child can be helped to talk about upsetting thoughts and feelings, explore self-defeating

patterns of behaviour, learn alternative ways to handle emotions, feel better about him or herselfdespite the disorder, identify and build on their strengths, answer unhealthy or irrational thoughts, copewith daily problems, and control their attention and aggression. Such therapy can also help the familyto better handle the disruptive behaviours, promote change, develop techniques for coping with andimproving their child’s behaviour.

Behaviour Therapy: is a specific type of psychotherapy that focuses more on ways to deal withimmediate issues. It tackles thinking and coping patterns directly, without trying to understand theirorigins. The aim is behaviour change, such as organizing tasks or schoolwork in a better way, or dealingwith emotionally charged events when they occur. In behaviour therapy, the child may be asked tomonitor their actions and give themselves rewards for positive behaviour such as stopping to thinkthrough the situation before reacting.

Social Skills Therapy: Social skills training teaches the behaviours necessary to develop and maintaingood social relationships, such as waiting for a turn, sharing toys, asking for help, or certain ways ofresponding to teasing. These skills are usually not taught in the classroom or by parents — they aretypically learned naturally by most children by watching and repeating other behaviours they see. Butsome children — especially those with attention deficit disorder — have a harder time learning theseskills or using them appropriately.

Support Groups for ADHD

(Martin, 2007)

SDBT (Structured Dyadic Behaviour Therapy): it is a novel behavioural therapy for children aged 7 – 12.combines self regulation techniques and social learning, highly structured and model driven, usesintensive contingency management methods, based on operational and classic conditioning usesmodelling, interactive rehearsal, peer feedback intended to teach children social management oftheir behaviour. It is a collaborative, children work in pairs, which includes: Establishing CollaborativeBehavioural Goals, Behavioural Benchmarking , Orienting Attention and Redirecting Using EffectiveCommands. The main aim of the therapy is self- regulation.

( Curtis, 2014)