ADHD Attention Deficit Hyperactivity Disorder

Transcription

1 ADHD Attention Deficit Hyperactivity Disorder What is ADHD? While everybody to some extent, and at certain times, occasionally has trouble sitting still, paying attention, or controlling impulsive behaviour, many others experience impulsivity, hyperactivity, and inattention at such maladaptively high levels that their daily lives at home, at school, at work, and in social settings are disrupted to a considerable and sometimes disabling extent. These people may have a common neurobiological disorder called Attention Deficit Hyperactivity Disorder (ADHD). There is also a less common and more severe form of ADHD called Hyperkinetic Disorder. Although ADHD is a neurobiological disorder, it is defined at a behavioural level. That means that the symptoms are based upon observations about how people behave: impulsivity signifies premature and thoughtless actions; hyperactivity a restless and shifting excess of movement; and inattention is a disorganised style preventing sustained effort. These symptoms are shown by individuals to different extents, and are influenced by context as well as by the constitution of the individual. People with ADHD may also be clumsy, unable to sleep, have temper tantrums and mood swings and find it hard to socialise and make friends. Until recently, it was believed that children outgrew ADHD in adolescence, because sometimes hyperactivity seems to lessen in teen years. It is now known, however, that many symptoms continue into adulthood and hyperactivity may instead be experienced as internal restlessness. Undiagnosed ADHD in adults may have severe consequences including academic failure, substance abuse, criminal activity, failed relationships, troubled work relationships, and emotional difficulties such as anxiety and depression. The symptoms of ADHD fall into three main areas: Hyperactivity Impulsivity Inattention. To get a diagnosis of ADHD, symptoms must: Have been present for at least six months Be greater than expected for the child's age and intelligence (i.e. more than just being a busy toddler) Have a negative impact (or cause 'impairment') in at least two settings, for example at home, work, school. Sometimes parents don't feel there's a problem at home either because they don't have other children to compare the ADHD child to, or because they've adjusted to their child's behaviour and are handling it well Have developed before the age of seven Not be caused by another condition, such as a mood, anxiety, personality or autistic spectrum disorder that could cause the same symptoms. The presence of six or more of the nine symptoms of hyperactivity, impulsivity and inattention are necessary for a diagnosis. Three ADHD 'subtypes' are currently recognised. The most common are: The 'severe' or 'combined' type when significant degrees of hyperactivity, impulsivity and inattention are observed 'Predominantly inattentive' subtype (seen more commonly in girls) The 'predominantly hyperactive and impulsive' subtype (observed most in younger children. Hyperactivity Your child often: 1

2 fidgets with hands or feet or squirms in seat leaves seat when expected to remain there runs about excessively and inappropriately has difficulty in playing quietly is 'on the go' Talks excessively. Effect on social relationships and self-esteem Your child might: go on and on about a subject and can take over a conversation 'act silly' in a group to get attention but not fit in damage other children's toys etc., without meaning to play too roughly in the playground and hurt other children Have poor motor skills (egg can't catch or throw a ball). Other children may feel your child is being bossy, silly, clumsy, and too rough or will make their team lose. So, they may avoid your child in the playground and won't invite her to parties. Your child may be the last one chosen for a team. This can make your child feel rejected and develop low selfesteem. Isolation in the playground can also make your child more at risk of being bullied or becoming a bully themself. Effect on parents Keeping up with your child to make sure they're safe can be exhausting! You may worry that you've done something wrong because your child doesn't behave as well as their peers. It can place a strain on friendships with other parents, particularly if their children are hurt or things are damaged by your child. Effect on educational success Your child can miss things because they are fidgeting and doesn't hear what's being said. They may fall behind without extra help to cover the ground missed. Impulsivity Your child often: blurts out answers before the question is complete cannot wait for his or her turn Interrupts or intrudes on others. Effect on social relationships and self-esteem Impulsivity means your child might: speak without thinking, so they will be socially clumsy barge into games have volatile moods, so other children won't know what to expect from them Have a short fuse and lash out when frustrated. These behaviours will make them unpopular, leading to feelings of rejection and reduced self-esteem. It's also likely that other children will egg them on to bad behaviour or tease, knowing they are easily wound up and will overreact. 2

3 Your child will need monitoring to make sure they aren't aggressive with other children. They may be tempted more than others to try alcohol, drugs or abuse substances because they do not think about the consequences until it's too late. Effect on parents Your child will say things that may hurt or embarrass you or others, putting a strain on relationships. Inability to wait will mean they will interrupt you constantly, which can be wearing. Effect on educational success Your child may focus on only part of a question and rush answers leading to underachievement in tests. This may mean they are placed in a group with a lower ability, which they may find frustrating and embarrassing and so rush through things even more. Inattention Your child often: has poor attention to detail and makes careless mistakes in schoolwork, work or other activities has difficulty in sustaining attention does not appear to listen when spoken to directly does not follow instructions or finish tasks has difficulty organising tasks and activities avoids or dislikes tasks that require sustained mental effort loses things necessary for tasks or activities is easily distracted Is forgetful in daily activities. Effect on social relationships and self-esteem She'll forget the rules of a game won't answer or makes silly mistakes so other children won't choose her to be on their team or will tease her in the playground. Your child may believe she's stupid and her selfesteem will drop. She'll need lots of reassurance. Effect on parents When your child loses things, doesn't answer or do what you ask her to do, it can be exasperating. You may end up shouting and then feeling guilty because your child didn't do it deliberately. Effect on educational success Children with symptoms of inattention often don't perform to their full potential and are therefore more likely to get lower grades, fail more exams and spend less time at school. Symptoms of inattention may also affect short-term memory, making it difficult for your child to do two things at once, so handwriting and presentation may be poor. Your child may therefore have problems structuring schoolwork and may find it hard to know where to start with a project or homework. In middle or senior school, your child may be confused by the constant change of teacher and room. Outcome of ADHD 3

4 Unsurprisingly, the combination of difficulties presented in children and young people diagnosed with ADHD is associated with increased rates of observed social and educational failure, anxiety and depression which are often accompanied by a marked reduction in self-esteem. Early use of cigarettes, alcohol and illicit drugs, together with problems of adolescent adjustment and behaviour are more common, may lead to inappropriate sexual experimentation, delinquency, offending and involvement with the criminal justice system. Fortunately, there's some evidence that early diagnosis and management may help some of these adverse long-term consequences. This is the main challenge for professionals and families setting out to treat, support and care for this group of children and young people towards adulthood. Based on a text by Dr Dan Rutherford, GP Read more: Follow on Twitter NetDoctorUK on Facebook Causes of ADHD The exact cause is not fully understood but is thought to be a mixture of genetic and environmental factors. Tends to run in families (inherited) Brain function differs to that of a person who does not have the condition. Some research shows that the frontal lobe (the part of the brain that controls decision making) does not work as it should. Imbalances of certain levels of certain chemicals such as dopamine and noradrenaline. Exposure to toxins during pregnancy such as smoking and drug abuse. Males are more commonly diagnosed and are pinpointed by loud disruptive behaviour. It is more likely missed in females as they tend to be more inattentive. Other possible causes are premature birth, low birth weight and early brain damage. Treatments/medication There is no cure for attention deficit hyperactivity disorder (ADHD), but treatment can alleviate your symptoms and make the condition much less of a problem in day-to-day life. ADHD can be treated using medication or therapy, but it is widely agreed a combination of both is the best way to treat it. Treatment will usually be arranged by a specialist, such as a paediatrician or psychiatrist (an expert in mental and emotional health), although your condition may be monitored by your GP. Medication There are three types of medication for ADHD: methylphenidate dexamfetamine atomoxetine Medications for ADHD are not a permanent cure. Methylphenidate- and dexamfetamine-based medications give a period of treatment during each day (between four and 12 hours depending on the preparation). Atomoxetine usually gives a longer period of treatment. Medications help someone who has ADHD to: 4

5 concentrate better be less impulsive feel calmer learn and practise new skills In the UK, all three of these medications are licensed for use in children and teenagers. Atomoxetine is licensed for use in adults who were diagnosed with ADHD as children. However, there are no medications currently licensed for treating newly diagnosed adults, or for use specifically in adults. If you have been diagnosed with adult ADHD, your GP and specialist can discuss which medications and therapies may be suitable for you. Methylphenidate and dexamfetamine are controlled drugs, which means their availability and use are more closely controlled than other prescription medicines. With all ADHD medications, if you or your child is prescribed one of these treatments, you will probably be given small dosages at first, which may then be gradually increased. Medication is most effective if used every day. Treatment breaks are not normally recommended apart from in specific situations. You or your child will need to see your GP for regular check-ups to ensure the treatment is working effectively. Your specialist will discuss how long you should take your treatment. Generally, children with ADHD will need to continue treatment at least until after GCSE examinations. Methylphenidate Methylphenidate comes in a number of different brands and is the most commonly used medication for ADHD. Methylphenidate is known as a psych stimulant or central nervous system (CNS) stimulant. It is not completely clear how it works, but it is thought it stimulates a part of the brain that changes mental and behavioural reactions. Methylphenidate can be used by teenagers and children with ADHD over the age of six years. Although methylphenidate is not licensed for use in adults, it may be taken under close supervision from your GP and specialist. Methylphenidate cannot be taken: by women who are pregnant or breastfeeding if you or your child has glaucoma if you or your child has severe depression Methylphenidate should be used with caution: if you or your child has a tic (a repeated involuntary movement or sound) if you or your child has Tourette's syndrome if you or your child has epilepsy if the frequency of the fits increases the medicine may need to be stopped Methylphenidate can be taken as either immediate-release tablets (small doses taken two to three times a day), or as modified-release tablets (taken once a day in the morning, and they release the dose throughout the day) as this will cover the whole school day or last into the evening. Modified-release capsules can be opened and sprinkled on food so are suitable for young children who may not be able to swallow tablets. 5

6 Methylphenidate can cause side effects, which may include: a small increase in blood pressure and heart rate loss of appetite, which can lead to weight loss (if your child is prescribed methylphenidate, your GP will monitor their weight to ensure they are growing properly) trouble sleeping headaches stomach aches mood swings There are ways to ease these side effects. For example, loss of appetite may be avoided by taking the medication with a meal or snack. Teenagers and adults should avoid drinking alcohol during treatment because this can make side effects worse. Dexamfetamine Dexamfetamine works in the same way as methylphenidate. It is also classed as a psych stimulant or CNS stimulant, and may be particularly effective in controlling hyperactivity. Dexamfetamine can be used by teenagers and children with ADHD who are over three. Although it is not licensed for use in adults, it may be taken under close supervision from your GP and specialist. Dexamfetamine cannot be taken: by women who are pregnant or breastfeeding if you have cardiovascular disease, such as moderate to severe high blood pressure (hypertension) if you have an overactive thyroid (hyperthyroidism) Dexamfetamine should be used with caution if you or your child has epilepsy. Dexamfetamine is usually taken as a daily tablet once or twice a day and may have side effects similar to those of methylphenidate. Atomoxetine Atomoxetine works differently from methylphenidate and dexamfetamine. Atomoxetine is known as a selective noradrenaline uptake inhibitor (it increases the amount of a chemical in the brain called noradrenaline). This chemical passes messages between brain cells, so by increasing the amount the atomoxetine aids concentration and helps control impulses. Atomoxetine can be used by teenagers and children over six. It is also licensed for use in adults who are continuing treatment after taking the medication as a teenager. It is not licensed for use in adults newly diagnosed with ADHD, but your GP and specialist may prescribe it under their supervision. Atomoxetine cannot be taken: by women who are pregnant or breastfeeding if you or your child has glaucoma Like other medications, the use of atomoxetine must be closely monitored by your GP and specialist. 6

7 Some studies have shown a small number of children and young people who take atomoxetine are more likely to think about suicide. If either you or your child begins to feel depressed or suicidal while taking this medication, see your GP to ask about switching to a different medication. Also, in rare cases, there is evidence that atomoxetine can cause liver damage. Arrange to see your GP regularly if you or your child is taking this medication. Atomoxetine comes in capsule form you or your child takes once or twice a day. Capsules are long-acting, so your child will not need to take them at school. It may be prescribed as an alternative to methylphenidate or dexamfetamine if these are ineffective or cause adverse effects. Atomoxetine can cause side effects, which may include: a small increase in blood pressure and heart rate nausea (feeling sick) waking early in the morning dizziness stomach aches irritability If you or your child needs medication for ADHD, your GP and specialist will take several factors into account before recommending a treatment. These will include: any other conditions you or your child may have side effects of each treatment whether or not dosage times interfere with school or work Therapy As well as taking medication, different therapies can be useful in treating ADHD in children, teenagers and adults. Therapy is also effective in treating additional problems, such as conduct or anxiety disorders, that may appear with ADHD. Therapies outlined below can be carried out with the help of a number of healthcare professionals, including: counsellors experts trained to provide talking therapies that aim to help people cope better with their life and mental health condition psychiatrists qualified medical doctors who have done further training in treating mental health conditions psychologists healthcare professionals who specialise in the assessment and treatment of mental health conditions social workers experts often used to bridge the gap between mental health services and the wider social service provision, and provide advice on a variety of practical issues Psychotherapy Psychotherapy is a type of talking therapy, which means you or your child will be encouraged to discuss ADHD and how it affects you. It can help children, teenagers and adults make sense of being diagnosed with ADHD, and can help you to cope and live with the condition. Read more information about psychotherapy. Behaviour therapy 7

8 Behaviour therapy provides support for carers of children with ADHD, and may involve teachers as well as parents. Behaviour therapy usually involves behaviour management, which uses a system of rewards and penalties to encourage your child to try and control their ADHD. If your child has ADHD, you can identify types of behaviour you want to encourage, such as sitting at the table to eat. Your child is then given some sort of small reward for good behaviour, and a small penalty for poor behaviour. For teachers, behaviour management involves learning how to plan and structure activities, and to praise and encourage children for even very small amounts of progress. Parent training and education programmes If your child has ADHD, parent training and education programmes can help you learn specific ways of talking to your child, and playing and working with them to improve their attention and behaviour. You may also be offered parent training before your child is officially diagnosed with ADHD. These programmes are usually arranged in groups and can last several weeks. They aim to teach parents and carers about behaviour management (see above), while increasing your confidence in your ability to look after your child and improving the relationship between you and your child. Social skills training Social skills training involves your child taking part in role-play situations, and aims to teach them how to behave in social situations by learning how their behaviour affects others. Cognitive behavioural therapy (CBT) Cognitive behavioural therapy (CBT) is an alternative form of therapy based on the idea that your problems are often created by you. It is not the situation itself that is causing problems, but how you think about it and how you react to it. A CBT therapist would try and change how your child feels about a situation, which would in turn change their behaviour. Read more information about cognitive behavioural therapy (CBT). Other methods of treatment There are other ways of treating ADHD that some people with the condition find helpful, such as cutting out certain foods and taking supplements. However, there is no medical evidence these methods work, and they should not be attempted without medical advice. Diet People with ADHD should eat a healthy balanced diet. Do not cut out foods without medical advice. Some people may notice a link between types of food and worsening ADHD symptoms. For example, sugar and caffeine are often blamed for aggravating hyperactivity, and some people feel they have intolerances to wheat or dairy products that may add to their symptoms. If this is the case, keep a diary of what you eat and drink and what behaviour this causes. Discuss this with your GP, who may refer you to a dietician (a healthcare professional who specialises in nutrition). However, do not change your (or your child's) diet without medical advice. 8

9 Supplements Some people consider certain supplements, such as omega 3 fatty acid, to be beneficial in people with ADHD. However, there is no medical evidence to support this. If you do wish to try using a supplement, talk to your GP first, as some can react unpredictably with other medication or make it less effective. Also remember that supplements should not be taken long-term, as they can build up to dangerous levels in your body. Exercise People with ADHD should take regular exercise. Read about health and fitness for more information on getting active, and how much activity you and your child should be doing. Notes taken from lesson and internet wesites. 9