HYPERACTIVITY IN CHILDREN. Stacey KH Tay, Low Poh Sim

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1 HYPERACTIVITY IN CHILDREN Stacey KH Tay, Low Poh Sim Hyperactivity is a common complaint in children, and Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent chronic behavioural disorder in pre-adolescent children. The primary health care physician is often the first to see such children, and either the parents or the teachers may have initiated a distress call because of the child s restlessness and at home. Contents Definition Causes of hyperactivity Evaluation of a hyperactive child Guidelines for referral of a hyperactive child Management of hyperactivity Prognosis for hyperactivity 1

2 Definition Hyperactivity is defined subjectively as an increase in motor activity to a level that interferes with the child's functioning at school, at home or socially. Hyperactive behaviour encompasses characteristics such as aggressiveness, constant activity, impulsiveness, poor concentration and easy distractibility. Such children may have difficulty in school especially, not only because of their disruptive behaviour, but also because their state of continuous motion prevents the child from participating in quieter activities such as reading and writing, and the child's work may suffer as a result. Attention deficit hyperactivity disorder lies at a severe end of the spectrum of hyperactivity. It is a distinct entity with diagnostic criteria that allows doctors to identify patients with the disorder and therefore to treat them appropriately. ADHD has an incidence of about 3-5% in school-going children. Poor concentration, hyperactivity and restlessness and an impulsive personality characterize the disorder. There is a definite male predominance ranging from a male to female ratio of 4:1 to 9:1. There are specific criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV) for the diagnosis, and there are also three subtypes of the disorder, namely: 1. the predominantly inattentive type, 2. the predominantly hyperactive-impulsive type and 3. the combined type (see page 2) Autism may often present with hyperactivity and speech delay. In such children, there is a deficit in social interactive skills, communicative skills and behavioural disturbance such as preoccupation with routines and ritualistic behaviour. The precise etiology is unknown although associated abnormalities have been found in imaging and metabolic studies of the brain. Mental retardation is commonly associated although there are high functioning autistics known as autistic savants like the character played by Dustin Hoffman in Rain Man. Autism and attention deficit hyperactivity disorder may co-exist in the same child. Causes of hyperactivity 1. Normal personality variant 2. Exogenous factors (a) Medication - sedative-hypnotic and anti-epileptic drugs like phenobarbitone. (b) An intolerant parent or teacher may bring about factitious hyperactivity. 3. Pre-existing disorders (a) CNS disease - any CNS abnormality such as previous head trauma, or cerebral palsy or mental retardation may cause hyperactivity. 2

3 (b) Prematurity - premature babies with birth weight below 1500g are well known to have hyperactivity, negative temperament characteristics and lower levels of social competence. 4. Psychological disorders (a) Anxiety - due to post-traumatic anxiety or anxiety from chronic stress. (b) Depression - sad feelings may be expressed by means of increased activity. 5. Psychiatric disorders (a) Gilles de la Tourette syndrome -affected children have an increased incidence of hyperactivity. 6. Developmental disorders (a) Language disorders - difficulty in communication may result in frustration and misunderstanding and may result in hyperactive behaviour. (b) Learning disabilities - Autism, which is a developmental disorder with impaired social interaction, communication and limited imagination with repetitive stereotyped activities, may often present as a hyperactive child that interacts poorly with his caregivers. 7. Attention deficit hyperactivity disorder - see DSM-IV criteria. Below are the clinical criteria for the diagnosis of ADHD in a child under the DSM IV criteria. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the American Psychiatric Association, classifies three types of Attention Deficit/ Hyperactivity Disorders: predominantly inattentive, predominantly hyperactive, and combined. Six of nine symptoms of inattention (A - 1) are needed to diagnose the predominantly inattentive type of ADHD, and six of nine symptoms of hyperactivity and impulsivity (A - 2) are necessary for diagnosis of the predominantly hyperactive type. The presence of 6 symptoms from either category (A- 1 or A- 2) is needed to make a diagnosis of the combined type of ADHD. In each case, the symptoms must be present for at least six months to a degree that is maladaptive and inconsistent with developmental level. There are additional criteria (B - E) that must be met in addition to the symptoms of hyperactivity and inattention. A. Either (1) or (2) (1) Inattention: Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities often has difficulty sustaining attention in tasks or play activities often does not seem to listen to what is being said to him or her often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) 3

4 often has difficulties organizing tasks and activities Often avoids, expresses reluctance about, or has difficulties engaging in tasks that require sustained mental effort (such as schoolwork or homework) often loses things necessary for tasks or activities (e.g. school assignments, pencils, books, tools, or toys) is often easily distracted by extraneous stimuli often forgetful in daily activities (2) Hyperactivity - Impulsivity: Hyperactivity often fidgets with hands or feet or squirms in seat leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) often has difficulty playing or engaging in leisure activities quietly is always "on the go" or acts as if "driven by a motor" Often talks excessively Impulsivity often blurts out answers to questions before the questions have been completed often has difficulty waiting in lines or awaiting turn in games or group situations often interrupts or intrudes on others (e.g., butts into others' conversations or games) B. Some symptoms that caused impairment were present before age seven. C. Some symptoms that cause impairment are present in two or more settings (e.g.,at school, work, and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. Does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder, and is not better accounted for by Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder. Evaluation of a hyperactive child History regarding the hyperactivity should be obtained in detail. A review of the school and home environment is usually necessary. The physical examination includes a full neurological examination and a thorough psychological examination. In the flow chart below, it should be remembered that not all the conditions mentioned exist independently, and indeed, autism and ADHD, for example may often co-exist in the same child. 4

5 5

6 Management of the hyperactive child A good number of normal children are hyperactive and may cause problems in school predominantly. Such children do not need any medical therapy, but clear guidelines on their behaviour in school and at home need to be delineated. Should the child be diagnosed to have attention deficit hyperactivity disorder, then there are several modalities of therapy that have been found to be useful: 1. Medication Stimulant medication has been found to be useful in decreasing hyperactive behaviour, such as methylphenidate (Ritalin). Methylphenidate has been used in children from about 4-5 years of age, but may worsen tics and seizure disorders. Growth charting is necessary for children on stimulant medications as poor appetite and growth suppression are common side effects. Tolerance to psychostimulants may develop, necessitating drug holidays. Clonidine has also been used as an alternative to psychostimulants, but may cause sedation and orthostatic hypotension as side effects. Antidepressants such as desipramine and bupropion are also effective in some children. 2. Diet Although no direct effects of diet have been found in relation to hyperactivity, yet many parents report an improvement in the hyperactivity through reduction of sugar intake. In the 1970s, Dr. Benjamin E Feingold, a pediatric allergist in San Francisco, claimed that childhood hyperactivity was caused by food colors, artificial flavorings and preservatives. He prescribed a diet eliminating these ingredients, as well as other foods containing natural chemicals called salicylates, including almonds, cucumbers, tomatoes, apples and berries. Based on anecdotal reports, Feingold stated that up to 50 percent of children on such a restricted regimen improved during treatment. Needless to say, this created quite a stir as Feingold had singled out common everyday food substances that most every child consumed regularly. To test the Feingold hypothesis scientifically, the Nutrition Foundation supported a variety of research studies using experimental and control diets. After reviewing the results of seven independent studies involving approximately 200 subjects, the Foundation's National Advisory Committee on Hyperkinesis and Food Additives concluded in 1980 that there was no evidence linking artificial food colors, flavors, or preservatives to hyperactivity or learning. The committee reported that dietary restriction was sometimes beneficial because of the "placebo" effects of the treatment. In other words, it sometimes worked because people believed it would or because of increased involvement and attention of family members. In January 1982, the National Institutes of Health also convened a panel of biomedical investigators, practicing physicians, consumers and advocacy groups to 6

7 examine available evidence on hyperactivity. The 13member consensus development panel concluded that controlled scientific studies do not support the claim that food additives, colorings, or preservatives cause hyperactivity. The NIH panel also stated that special restricted diets should not be used universally to treat hyperactivity, since there is no evidence to predict which children may benefit. 3. Behaviour modification programmes Programmes to help the child to concentrate, increase the attention span and coaching on turn-taking activities have been shown to help such children. These programmes are usually run by child psychologists 4. Environmental modification Children with ADHD do not adapt well to change and do not function well in highly stimulating environments. In school, they should be put in the front row rather than the rear so that they can attend better to the teacher. Study carrels are also helpful in blocking distracting stimuli. Often, they benefit more from one-to-one teaching or small group teaching. Class routines should be predictable and only one task should be given to the child at a time. At home, parents can reward the child for behaviour that requires concentration. Routines at home should also be well structured and regular. Families should avoid crowds, supermarkets and large shopping centres as these can create too much stimulation for the child. Fatigue should also be avoided as self-control breaks down and hyperactivity increases once the child becomes tired. Advice from the psychiatrist, the paediatrician and the social worker may be necessary in individual cases as there may be a need for special school placement or special programmes for behaviour modification. Autistic children do need special care, and adjunctive therapies such as speech therapy, occupational therapy, and psychotherapy are available in the STEP programme at Margaret Drive Special School. Brighter children can also be placed in a normal schooling programme with the help of the REACH ME programme. Medication is rarely indicated unless there is a specific indication such as hyperactivity or mood instability. Prognosis of hyperactivity Children who learn to handle hyperactivity can go on to successful careers as adults. Even people with ADHD diagnosed in childhood may make good as adults. About a third of these have been shown to be successful at conducting their own business by their mid-thirties. A good number of hyperactive children do however experience difficulties in many areas of social functioning and personal well being when they become adolescents and adults. Immature 7

8 and impulsive behaviour may continue to persist. In adolescence, too, there may be anti-social behaviour causing brushes with the law. Some prognostic features have been found for ADHD. Conduct disturbance, aggressiveness and poor peer relationships are important predictors of poor outcome. In such patients, long-standing educational difficulties and lack of achievement have been reported commonly. Absence of such factors has been associated with a much better outcome. 8

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