INCLEN Module on Attention-Deficit/Hyperactivity Disorder

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1 NEURODEVELOPMENTAL DISABILITIES AMONG CHILDREN IN INDIA: AN INCLEN STUDY INCLEN Module on Attention-Deficit/Hyperactivity Disorder THE INCLEN TRUST INTERNATIONAL - 1 -

2 1. LEARNING OBJECTIVES OF THE MODULE OBJECTIVES After completing this module, the participant should be able to: Describe the clinical features of ADHD and understand the subtypes of ADHD Use the Consensus Clinical Criteria to diagnose ADHD 2. INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) refers to a constellation of inappropriate behaviors found in many children and adults. The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity. These features are more frequently displayed and more severe than typically observed in a child at a comparable level of development. A child with ADHD may be unusually active and/or impulsive for their age. Children with ADHD have trouble paying attention in various settings like at school, at home or at work. These behaviors may contribute to significant problems in social relationships and learning. For this reason, children with ADHD are sometimes seen as being "difficult" or as having behavior problems. Critical concepts 2.1 Definition Although there is no single, comprehensive and concise definition of ADHD, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text revision (DSM-IV-TR; American Psychiatric Association, 2001) defines three specific elements of Attentiondeficit/hyperactivity disorder. Inattention Impulsivity Hyperactivity Diagnosis of ADHD Developmentally inappropriate levels of Inattentiveness, Impulsivity and Motor activity AND In at least two (2) settings (home/ school / play) AND Symptoms present for at least 6 months Onset before 7 years of age Behaviours result in significant handicap in academic, occupational and social functioning The symptoms should be inconsistent with developmental level and should have persisted for at least six months, to a degree that is maladaptive and inconsistent with developmental level and causes impairment. The symptoms should be present in two or more settings (e.g. at school or - 2 -

3 work, and at home) and there must be clear evidence of clinically significant impairment in social, academic or occupational functioning. 2.2 Description Based on the predominant symptoms, ADHD may be one of the three subtypes: ADHD predominantly inattentive type ADHD predominantly hyperactive-impulsive type ADHD combined type 3. CLINICAL SPECTRUM 3.1 Clinical Features Symptoms of ADHD appear gradually over the course of many months, often with the symptoms of impulsiveness and hyperactivity preceding those of inattention. Parents may seek help when the child's hyperactivity, distractibility, poor concentration and impulsivity begin to affect performance in school, and social relationships with other children or behavior at home. In order to meet the diagnostic criteria, the abnormal behaviors must be excessive, long-term, and pervasive, as described below. Although the behaviors must appear before the age of seven years and should continue for at least six months; the child should be at least 6 years old before a diagnosis of ADHD can be made with certainty. A crucial consideration is that the behaviors must create a handicap in the academic and social settings of a child's life. Some common symptoms of ADHD include: Often fails to give close attention to details or making careless mistakes Often blurts out answers before hearing the whole question Often has difficulty sustaining attention to tasks Often appears not to listen when spoken to directly Often fails to follow instructions carefully and completely Loses or forgets important things Feels restless, often fidgets with hands or feet Runs or climbs excessively in inappropriate situations Often talks excessively Often has difficulty in waiting for his/her turn while playing The DSM-IV TR diagnostic criteria list the common clinical features which are helpful in making the diagnosis. Early Pointers to ADHD Motor Restlessness Aggressive play Argumentative and excessive temper tantrums Often blurts out answers before hearing the whole question Excessive demand for parents / teachers attention Hates waiting and gets bored easily Attention Deficit /Hyperactivity Disorder - 3 -

4 3.2 Early Pointers to ADHD There are some unusual features in the behavior of the child even in early years of childhood which may hint towards this disorder. Toddlers and pre-school children Hyperactivity Always moving Being on the go Changes the focus of activity frequently Appears to be without purpose or goal Marked clumsiness, accident prone Examples: Frequently leaves table during meal, can t sit still while listening to a story, in continuous state of motion even when watching television. Impulsivity Shifts activities unpredictably Behavior may be disruptive and dangerous even without provocation Often blurts out answers before hearing the whole question Does not listen to parents Does not learn from mistakes Unresponsive to praise or punishment Example: The child can not wait for his/her turn during play activities Inattention Easily distractible Does not complete activities Cannot play alone Very disorganized Common comorbidities in children with ADHD Cannot deal with complex stimuli in a planned way Example: The child cannot concentrate on a single activity for more than a few minutes and shifts to another activity frequently. However, since these features may be a reflection of the upper limit of normal development (for that age) or inappropriate parental responses to maladaptive behavior, it is imperative that the child is not labeled as suffering from ADHD until he is at least 6 years old. Learning disabilities Conduct disorders 3.3 Significant Co morbidities Learning Disabilities: Approximately 20 to 30 percent of ADHD children may also have a learning disorder. Behavior of disobedience, defiance and stealing are not uncommon in older children with ADHD and may progress to Oppositional Defiant Disorder or Conduct Disorder

5 3.4 Natural History/Course The course of ADHD is highly variable. Symptoms may remit at puberty or persist into adolescence or adulthood. In some cases, the hyperactivity may disappear but the attention span and problems with impulse control may persist. Overall, the outcome of ADHD in childhood seems to be related to the degree of persistent co-morbid psychopathology, especially conduct disorder, social disability and chaotic family factors (no rules in family, no proper communication among the family members etc.) 4. DIFFERENTIAL DIAGNOSIS Vision and /or hearing impairment Other psychiatric disorders like Conduct Disorder, Oppositional Defiant Disorder. Learning disorders are often mistaken for ADHD because of the poor school performance common to both conditions. Psychosocial stresses such as child abuse or neglect, loss of close family member may result in symptoms mimicking inattention Some drugs such as phenytoin, phenobarbitone may also result in side effects similar to ADHD especially attention deficit type Absence epilepsy Inappropriate school or home environment 5. DIAGNOSIS 5.1 Diagnostic Criteria Consensus Clinical Criteria: The criteria for diagnosis of Attention-Deficit/Hyperactivity Disorder in children are based on the best currently available evidence and/or consensus among the National and International experts, using minimal investigations, to serve the needs of resource-constrained settings. In this community based study, DSM IV TR criteria will be used to make definite diagnosis for children aged 6-9 years. Consensus Clinical Criteria (CCC) for diagnosis of Attention-Deficit/Hyperactivity Disorder 1 A. Either (1) or (2) 1 Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is inconsistent with developmental level and maladaptive Inattention (a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities. (b) Often has difficulty sustaining attention in tasks or play activities. (c) Often does not seem to listen when spoken to directly. Tick()if symptom present 1 Source: Diagnostic & Statistical Manual of Mental Disorders Fourth Edition- Text Revision (DSM IV-TR) Attention Deficit /Hyperactivity Disorder - 5 -

6 (d) Often does not follow through on instructions and fails to finish school work, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions). (e) Often has difficulty in organizing tasks and activities. (f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework). (g) Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools). (h) Is often easily distracted by extraneous stimuli. (i) Is often forgetful in daily activities. 2 Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is inconsistent with developmental level and maladaptive: Hyperactivity (a) Often fidgets with hands or feet or squirms in seat. (b) Often leaves seat in classroom or in other situations, in which remaining seated is expected. (c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness). (d) Often has difficulty playing or engaging in leisure activities quietly. (e) Is often "on the go" or often acts as if "driven by a motor. (f) Often talks excessively Impulsivity (g) Often blurts out answers before the questions have been completed (h) Often has difficulty awaiting turn Tick() if present (i) Often interrupts or intrudes on others (e.g. butts into conversations or games) B Some hyperactive-impulsive or inattentive symptoms that cause impairment were present before age 7 years. C Some impairment from the symptoms is present in two or more settings [e.g. at school (or work) and at home]. D There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E The symptoms do not occur exclusively during the course of autism spectrum disorder or not better accounted for by another mental disorder ADHD subtypes ADHD Combined type - if both criterion A1 and criterion A2 are met for at least 6 months ADHD Predominantly inattentive type if criterion A1 is met but criterion A2 not met for the past 6 months ADHD Predominantly hyperactive-impulsive type if criterion A2 is met but criterion A1 is not met for the past 6 months The diagnosis of ADHD can not reliably be made in children younger than 6 years of age. Hence the consensus clinical criteria should be applied only to children aged 6 years and above. All the criteria i.e A1 / A2, B, C and D must be fulfilled to make a diagnosis of ADHD according to CCC

7 5.2 Evaluation procedure for diagnosing ADHD Assessment for ADHD Age < 6 years DO NOT apply CCC for ADHD 6 years Evaluate for ADHD using CCC A1 Positive B, C, D fulfilled ADHD Inattentive type * A2 Positive B, C, D fulfilled ADHD (Hyperactiveimpulsive type)* A1 and A2 Positive B, C, D fulfilled ADHD Combined type* A1 & A2 negative, B not fulfilled and C, D fulfilled A1 & A2 negative and BCD fulfilled A is positive and B not fulfilled but C, D fulfilled A1 and A2 negative and B, C, D not fulfilled A1 positive or A2 positive or A1 & A2 positive and B C D not full filled Indeterminate No ADHD *Those with criteria fulfilling as ADHD but if symptoms can be explained by autism and or ID they should be categorized as indeterminate and TAG review to be obtained Source: Developed and validated by INCLEN TAG members

8 5.3 INCLEN Instrument for Diagnosis of Attention-Deficit/Hyperactivity Disorder (II-FDA) This instrument consists of a parental questionnaire to look for the characteristic behaviours based on the DSM-IV TR criteria for diagnosis of ADHD (Annexure-1). An essential prerequisite for use of this instrument is that the mother / primary caregiver be present during the assessment. The psychologist administering the questionnaire will read the questions verbatim aloud to the mother / primary caregiver. The questions can be repeated and elaborated if the mother / primary caregiver is unable to understand. Age and culturally appropriate examples have been provided within the instrument and if the need arises, then further examples may be provided by the psychologist to help the mother / primary caregiver understands the question. Responses are recorded in the form of Yes or No. There are eighteen questions in the instrument to elicit eighteen criteria of DSM-IV TR. These eighteen questions are divided into two major domains i.e. inattention and hyperactivity-impulsivity, with nine questions in each domain. There are additional questions to elicit information regarding onset and duration of symptoms, and to look for presence of impairment due to these symptoms at school, home or in social settings. Management / Treatment Behavioral and psychological treatment Pharmacological Management of associated problems / comorbidities 5.4 Other Relevant Investigations [NOTE: Not included as part of the this study] Thyroid function tests and blood lead level estimation may be carried out if suggestive features are present. These include cold intolerance, constipation and short stature in hypothyroidism and residence in an industrial area with likelihood of exposure to lead in chronic lead exposure. Hemogram and/or serum iron status to rule out iron deficiency, as iron deficiency may also cause symptoms similar to ADHD. 6. BROAD PRINCIPLES OF MANAGEMENT 6.1 Management of Primary Problem There are various treatment options for symptoms of inattention and hyperactivity which may be given concurrently. These are mentioned in detail below. Behavioral and Psychological Treatment This is an integral component of management and complete elaboration is beyond the scope of this module. Readers may refer to relevant texts. Some of the techniques that are used are: Reinforcement of positive behaviors by praise or by providing incentives like (gold star or happy face ) in daily consistency charts Provide a distraction-free environment in school and at home for children Social skills training Adapting tasks to the child s abilities - 8 -

9 Pharmacological treatment It includes use of: Stimulant medications: Methylphenidate and Norepinephrine reuptake inhibitors (Atomoxetine) Non-stimulant medications: These are useful in around 30% of children who may not tolerate or respond to stimulant medicines. These include Tricyclic antidepressants, selective Serotonin Receptor Inhibitors etc. 6.2 Management of Associated Problems/ co-morbidities Specific learning disability: special education and remedial teaching Oppositional Defiant Behavior (negativistic, defiant, disobedient, and hostile behavior toward authority figures): Behavior modification techniques and management. Conduct Disorder: Behavior modification and appropriate medication Anxiety and depression: Medication and psychological intervention Epilepsy: use of anti epileptic drugs Tourette Syndrome (A disorder of recurrent, multiple motor and vocal tics with onset before the age of 18 years): Pharmacological treatment has some role, 6.3 Steps for Prevention Primary Avoiding environmental risk factors such as maternal smoking during pregnancy and lead exposure. Secondary Early identification of the symptoms and early institution of appropriate treatment Tertiary In school Provision of integrated and inclusive education in schools Close monitoring in the classroom, preferably seated in the front row in the class Predictable schedules and brief study periods Special education and remedial teaching At home Regular daily routine Reinforcement of good behavior Loving but consistent and firm behavior with the child Support groups help parents connect with other people who have similar problems and concerns Attention Deficit /Hyperactivity Disorder - 9 -

10 6.4 Referral Pattern High index of suspicion and early identification: o By increasing awareness among parents, primary physicians, pediatricians and teachers (play schools and regular schools). Creating a network of agencies that can diagnose such children so that appropriate and timely referral can be possible. 6.5 Special Benefits There are no special benefits for children with ADHD except in the State of Maharashtra, where extra time and writer for examinations are allowed. 6.6 Support to the family with an affected child The multidisciplinary team can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other. Assist the family in finding better ways to handle the disruptive behaviors and promote change. In a young child, parents should be taught techniques for coping with and improving the child's behavior

11 7. CASE VIGNETTES Case vignette 1: Understanding the symptoms of ADHD Prabhat, aged nine, has been referred to a child Psychiatrist at the request of his school teacher, because of the difficulties he creates in class. His teacher complains that he is so restless that the rest of the class is unable to concentrate. He is hardly ever in his seat and roams around in the class, talking to other children while they are working. He seems to have no control over his behavior which is unpredictable and can even be quite outrageous. His mother says that Prabhat s behavior has been difficult since he was a toddler. Even when he was around 4-years old he was unbearably restless, demanding and forgetful about his daily activities. He required little sleep and awoke before anyone else. When he was five, he had managed to unlock the door of the house and wander off into a busy main street. Fortunately, he was rescued from the oncoming traffic by a passerby. He was asked to leave a play school because of his difficulty in following instructions and paying attention in class. Presently he avoids doing his home work. He has minimal interest in TV (only a few selected programs), and dislikes games or toys that require prolonged concentration or patience. At home he prefers to be outdoors. However, he is not popular with other children because he cannot await his turn and picks up fights easily. When he plays with toys, his games are messy and destructive, and his mother cannot get him to keep his things away tidily. A clinical diagnosis of ADHD is made based on DSM IV TR criteria. Q. What symptoms of ADHD does Prabhat have? List out his symptoms of inattention, hyperactivity & impulsivity separately? A. Hyperactivity: Restlessness, difficult to sit at one place Impulsivity: Starts doing something outrageously, demanding, messy and destructive Inattention: Failing to give close attention to details, problem in concentration, not following instructions despite understanding them, difficulty in organizing his activities, forgetful about daily activities and avoiding activities that require sustained mental effort. Q. Why do you think Prabhat fits into the diagnosis of ADHD? A. Only inattention Prabhat s behavior typically demonstrates the characteristic inattention symptoms of ADHD (A1-a, b, d, e, f, i). Attention Deficit /Hyperactivity Disorder

12 Case vignette 2: Application of CCC to diagnose ADHD Harpreet, an 8 year old boy was brought to the OPD with complaints of pharyngitis. Through the open door, the physician noted that the child was pushing others, running about and jumping from one bench to the other when he was waiting outside. His mother was having trouble trying to restrain him. However, on entering the doctor s room, he was an alert, quiet child who however kept on getting distracted by noises outside. On inquiry, the parents said that the child has been like this since 6 years of age and frequently engages in dangerous activities like jumping from walls, running on the road and breaking household objects,. His teachers also frequently complain that his behavior disturbs others in the classroom during classes. He often leaves the seat in class and when seated fidgets with hands or feet. Nobody wants to sit next to him. Even while playing in school he cannot remain engaged in one game for more than ten minutes. While playing cricket he can not wait for his turn for batting. There is a history of changing three schools (from convent to Hindi medium to government school) with in one year time due to inability to cope with studies. His parents have consulted three different doctors. All reassured them that the child was slightly hyperactive, but would eventually grow out of the problem. Q. Apply consensus clinical criteria to see if Harpreet has ADHD? A. Harpreet fulfills the following criteria A2- a, b, c, d, e (Hyperactivity) and h (Impulsivity). These symptoms have been persisting for about one year and affecting his school performance. Onset of symptoms was around 6 years of age. Hence, a diagnosis of ADHD can be made using CCC. Q. Do you think is he likely to grow out of the problem? A. Growing out of hyper activity is a misconception among many doctors, educationalists and parents Case Vignette 3: Application of Consensus Clinical Criteria Ramesh, a six year old boy, was admitted in school 4 months back. He was brought to the psychologist by his mother along with his school teacher. She was concerned that, Ramesh has difficulty in concentrating in the class and got easily distracted. She had been noticing these behaviours during past three months. She also felt that Ramesh talked too much and often made careless mistakes in his home work book. His mother complained that he often lost pencils and note books in school. However she said that he could organize his activities like preparing his school bag and keeping his toys in their place. He could also get ready for school on his own including tying shoe laces and buttoning. Q: Can we make a diagnosis of ADHD based on CCC? Justify your answer? A: No; although Ramesh has some symptoms of inattention and hyperactivity, he does not have ADHD. Reasons are: these symptoms are mainly present in school environment. He has no problems at home. Moreover, he has these symptoms for past three months only. Hence, at this point of time, he does not fulfill the CCC for diagnosis of ADHD

13 ANNEXURE I INCLEN Instrument for Diagnosis of Attention-Deficit Hyperactivity Disorder Name of the Child: Date of Birth: DD/MM/YYYY Age (In months): Sex: (Male-1; Female-2) Complete Address: Phone number: Date of Assessment: DD/MM/YYYY Name of the Assessor: INSTRUCTIONS FOR ADMINISTRATION Primary caregiver must be present during the assessment for history along with child The informant should have been staying with the child for at least 6 months The behavior in question i) should be present currently and a usual feature ii) should have been present for the last 6 months Explain to the parents that the behaviors should be compared with children of same age and background Ask the questions verbatim Question can be repeated if the respondent cannot understand. Still, if the respondent cannot understand, examples for the particular behavior may be provided which are appropriate to the child s background (rural/ urban, school going/ not school going) No further elaboration is allowed Attention Deficit /Hyperactivity Disorder

14 SECTION: A Questionnaire for eliciting ADHD diagnostic criteria A 1 Inattention a Does your child often fail to give close attention to details (e.g., makes careless mistakes in school/homework or is careless/ messy in other activities)? b Does your child often have difficulty in concentrating while playing or doing his/ her homework? c Does your child often have trouble in paying attention when somebody is talking to him/her? d Does your child often does not follow instructions despite understanding them and not due to disobedience? If Yes, due to this is he/she often unable to complete his/her works in time? (If response to BOTH the questions is YES, then mark it as YES If response to first part is YES and second part is NO, then mark it as NO ) e Does your child often have difficulty in doing his/her home work, getting ready for school, putting toys back to their place on his own? f Does your child often avoid activities that require sustained mental efforts? (e.g., homework/class work, looking at picture book, listening to story). Encircle the appropriate response g Does your child often loses things e.g. books, pencils, toys etc. Yes No h Does your child often lose concentration due to little distractions (e.g., traffic, road vendors, animal sounds) and lose track of what he/she was doing at that time? Yes No i Is your child more forgetful in daily activities compared to other children of his/her age? (e.g., bathing, dressing, brushing teeth) Yes No A 2 Hyperactivity- Impulsivity a Does your child often appear restless (e.g., tapping finger, moving hands and feet, twisting the body when seated, squirming) Yes No b Does your child often leave his/her seat in the middle of a class or meal? Yes No c Does your child often run about/ climb excessively in places where it is inappropriate? e.g., Excessive running/jumping/climbing in the class room or at Yes No home, running about during prayers. d Does it seem that often he/she is unable to engage in play quietly? (e.g., playing board games, building mud houses, playing with dolls [add group activity relevant Yes No to culture]) e Is your child running around most of the time, even while inside the house or in the market (as if driven by a motor) Yes No f Does your child often talk excessively? Yes No g During conversations, does your child often start answering questions even before the question has been completed? Yes No h While participating in group activities, is it often difficult for your child to wait for his/her turn? Yes No i Does your child frequently interrupt others conversation? (OR) Does your child frequently interrupt the games being played by other children? Yes No Yes Yes Yes Yes Yes Yes No No No No No No

15 SECTION B: Complete this section based on the responses from section A (1-2) and further history taking (3-7) 1. Number of YES responses in A1 of section A (Inattention) 0: Less than six 1: Six or more 2. Number of YES responses in A2 of section A (Hyperactivity-Impulsivity) 0: Less than six 1: Six or more 3. Did the child have some of these symptoms or problems before 7 years of age? 0: No 1: Yes 4. Have these symptoms led to any of the following problems? (Tick () the problems present in the child) - Frequent fights with other children - No / few friends - Frequent scolding by parents - Very frequent injuries - Frequent complaints from teachers - Poor school performance 0: No (None of the above problems) 1: Yes (One or more of the above problems is present) 5. Can these symptoms be explained by Autism and/or Intellectual Disability? 0: No 1: Yes 6. Brief comments about the child s condition: (Additional notes & observation during the interview) 7. Diagnosis 0: No ADHD (Response to both 1 to 4 is 0 and / or 5 is 0 or 1 ) 1: ADHD (Response to 1 and or 2 is 1, 3& 4 is 1 and 5 is 0 ) 8: Other NDD (Response to 1 to 4 is 0 and 5 is 1 ) 9: Indeterminate (Response to 1, 2 and 3 is 0 But 4 is 1 OR Response to 1 & 2 is 0 & 3, 4 is 1 OR Response to 1 & 2 is 1 & 3 is 0 & 4 is 1) 8. If Q No. 7 is 0 or 9, then enquire Is the child on any medication or any non medical intervention for ADHD 0: No 1: Yes Name of the Assessor Signature of the Assessor Date of assessment Attention Deficit /Hyperactivity Disorder

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