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Theory Base Session Notes Theory base ADHD See Time Out for Parents – Children with Special Needs Facilitator Guide pages FG11 to FG18 for theory base. Additional theory base for the material in this course is set out within the appropriate session notes below. Session notes Session 1 Diagnostic information There is no single, simple, objective medical test for diagnosing attention deficit hyperactivity disorder (ADHD). Positron emission tomography (PET) scans taken in a study by Zametkin (1990) found lower glucose metabolism in the brains of patients with ADHD than those without. These tests are not conclusive and are not yet being used in routine diagnosis. However, it would appear that there are abnormalities in the frontal cortex, basal ganglia, brain stem and cerebellum of the person diagnosed with ADHD. Making a diagnosis requires a specialist assessment, usually done by a child psychiatrist or specialist paediatrician. The diagnosis is made by observing the child, recognising patterns of behaviour and obtaining reports of their behaviour at home and at school. Sometimes a computerised test may be done to aid the diagnosis. Some children also need specialised tests by a clinical or educational psychologist. ADHD was first described by physician Heinrich Hoffman in 1845, but it was not until 1902 that the medical community studied the characteristics of this condition. Different operational definitions have been used over the decades. Currently, the American Psychiatric Association’s Diagnostic and Statistical Manual and the World Health Organisation’s International Classification of Diseases and Related Health Problems, in their latest versions, DSM-IV and ICD-10, have come to an almost identical operational definition of ADHD with a set of 18 core symptoms. The fifth edition (DSM-5) is currently in consultation, planning and preparation, and is due for publication in May 2013. There are proposals being considered to do away with the three ADHD subtypes and perhaps to treat these as two separate disorders – attention deficit (AD) and hyperactivity disorder (HD). In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) the signs of ADHD are given the name ‘hyperkinetic disorders’. © Copyright Care for the Family 2013 The ICD classification places attention deficit and hyperactivity/impulsivity under the heading of hyperkinetic disorder. To be diagnosed with hyperkinetic disorder, the child must have at least 6 out of 9 symptoms of inattention, 3 out of 5 symptoms of hyperactivity and 1 out of 4 symptoms of impulsivity. At present the DSM classification puts ADHD and ODD (oppositional defiant disorder) under the one heading of attention deficit and disruptive behaviour disorder along with the following list: Attention deficit hyperactivity disorder Predominantly hyperactive impulsive subtype Predominantly inattentive subtype Attention deficit hyperactivity disorder NOS (not otherwise specified) Oppositional defiant disorder Attention deficit hyperactivity disorder DSM classification states that in order to have a diagnosis of ADHD there needs to be: - some hyperactive-impulsive or inattentive symptoms that caused impairment and was present before the age of 7 years - some impairment from the symptoms present in two or more settings (e.g., at school [or work] and at home) - clear evidence of clinically significant impairment in social, academic or occupational functioning - symptoms not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder or a personality disorder). NICE describes ADHD as a common behavioural disorder in children and young people that usually starts in early childhood, which some people will continue to have as adults. The symptoms of ADHD include being: inattentive – unable to concentrate for very long or finish a task; disorganised, often losing things; easily distracted and forgetful, unable to listen when people are talking hyperactive – fidgety and unable to sit still; restless (children may be running or climbing much of the time); talking constantly, noisy, having difficulty doing quiet activities impulsive – speaking without thinking about the consequences; interrupting other people, unable to wait or take their turn. © Copyright Care for the Family 2013 Not all people with ADHD have all these symptoms and everyone can be inattentive, hyperactive or impulsive some of the time, particularly children. However, a person with ADHD has symptoms most of the time that can seriously affect their everyday life. They may also be clumsy, unable to sleep, have temper tantrums and mood swings and find it hard to socialise and make friends. It can sometimes be difficult to work out if a person has ADHD because there are conditions that can cause similar behaviour, such as conduct disorder, autism spectrum disorder (ASD), learning difficulties and anxiety. http://guidance.nice.org.uk/CG72/PublicInfo/pdf/English ADHD can present with different behaviours depending on age, setting (i.e. school, home or playground) and even motivation (e.g. when doing an activity or something a child likes). Not all children have all the symptoms. This means some can just have problems with poor attention, while others are mainly hyperactive. Children with problems of attention can appear forgetful, distracted, disorganised, unable to listen, can take a long time to begin a task and then, when they do, rarely finish it. Children with hyperactivity seem restless, fidgety, full of energy and ‘always on the go’. They may seem loud, noisy, with continuous chatter. Children with symptoms of impulsivity do things without thinking. They have difficulty waiting for their turn in games or in a queue and they interrupt people in conversation. Children with ADHD can have other problems such as learning difficulties, autism, conduct disorder, anxiety and depression. Neurological problems like tics, Tourette’s and epilepsy can also be present. Children with ADHD can have problems with coordination, social skills and seem to be disorganised. (Mental Health and Growing Up, factsheet produced by the Royal College of Psychiatrists) DAMP Deficiency in Attention, Motor control and Perception has been in clinical use in Scandinavia for about 20 years and is occasionally used in the UK by practitioners. DAMP is diagnosed on the basis of concomitant attention deficit/hyperactivity disorder and developmental coordination disorder (DCD) in children who do not have severe learning disability or cerebral palsy. Diagnostic criteria for DAMP: ADHD as defined by DSM 1V DCD as defined by DSM 1V © Copyright Care for the Family 2013 Condition not better accounted for by cerebral palsy Not associated with severe learning disability (IQ above 50) Other diagnostic categories often apply but are not required to make a diagnosis (ASD, ODD, depression) (Gillberg, 2003, pp905) Oppositional defiant disorder In the UK, oppositional defiant disorder (ODD) is often called “pathological demand avoidance” (PDA). This disorder, usually occurring in younger children, is primarily characterised by markedly defiant, disobedient and disruptive behaviour. Some children with ADHD will have difficulties in complying with even simple instructions, so it is difficult to diagnose. Hyperlexia This is an exceptional ability to read, not necessarily with any understanding of what is being read. This is sometimes seen in children with ADHD. History of ADHD 1798 Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his book, An inquiry into the nature and origin of mental derangement written in 1798. Dr. Heinrick Hoffman – 1845 The German psychiatrist first described the symptoms of ADHD. His description was not in a medical journal or paper, but rather in a book of children's poems. Unable to find any suitable books to read to his four year old son, he wrote and illustrated a series of poems for children, entitled ‘Struwwelpeter’. One poem entitled, ‘The Story of Fidgety Phillip’ perfectly describes the behaviour of a child with ADHD. Dr. Hoffman thought the problem was poor behaviour, rather than a condition inherited from his parents. Sir George Still – 1902 to 1920 Presented a series of lectures to the Royal College of Physicians in England, in which he described a group of impulsive children with behavioural problems. He suggested that the cause was genetic, not poor child rearing. His lectures started an avalanche of studies and papers from the medical community on ADHD, giving information on the cause, symptoms, diagnosis, and treatments. Historically, the origins of the concept of hyperkinetic disorder and inattention were in the idea that some disturbances of behaviour were the result of brain damage or ‘minimal brain dysfunction’ (MBD), such as were seen in the pandemic of encephalitis in the 1920s or after traumatic birth. These theories were called into question when scientists systematically examined the causes of behaviour problems in childhood. © Copyright Care for the Family 2013 The terminology used to describe the symptoms of ADHD has gone through many changes over history including: ‘minimal brain damage’, ‘minimal brain dysfunction’ (or disorder), ‘learning/behavioral disabilities’ and hyperactivity. 1937 The use of stimulant medication to treat hyperactivity was first reported. 1968 The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM-II) used the term ‘Hyperkinetic Reaction
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