Saturday, May 18, 2013

Attention Deficit Hyperactivity Disorder (ADHD)

What is ADHD?

Attention-deficit Hyperactivity Disorder is a developmental disorder characterized by developmentally inappropriate degrees of inattention, hyperactivity, and impulsivity.

According to DSM IV (Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition)
ADHD is a condition characterized by
a.       Persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and is more severe than is typically observed in individuals at comparable level of development.
b.      Some hyperactive-impulsive or inattentive symptoms must have been present before seven years of age.
c.       Some impairment form the symptoms must be present in at least two settings.
d.      There must be clear evidence of interference with developmentally appropriate, social, academic or occupational functioning.
e.       The disturbance does not occur exclusively during the course of Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorders and is not better accounted by another mental disorder.

According to IDEA
ADHD is under the “Other Health Impairment” category of IDEA. Other Health Impairment is defined as “…having limited strength , vitality or alertness, including a heightened alertness to  environmental stimuli that results in limited alertness with respect to the educational environment that is due to chronic or acute health problems such as… attention deficit hyperactivity disorder…; and adversely affects a child’s educational performance.

Three Subtypes of ADHD
A.      Predominantly Inattentive Type-used if 6 or more symptoms of inattention but fewer than 6 symptoms of  hyperactivity-impulsivity have persisted for at least six months
B.      Predominantly Hyperactive-Impulsive Type- used if 6 or more symptoms of hyperactivity-impulsivity but fewer than 6 symptoms of  inattention have persisted for at least six months
C.      Combined Type- used if 6 or more symptoms of inattention and 6 or more symptoms of  hyperactivity-impulsivity have persisted for at least six months

Symptoms of inattention
·         fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
·         has difficulty sustaining attention in tasks or play activities
·         does not seem to listen when spoken to directly
·         does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
·         has difficulty organizing tasks and activities
·         avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)
·         loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
·         is easily distracted by extraneous stimuli
·         is forgetful in daily activities

Symptoms of hyperactivity
·         fidgets with hands or feet or squirms in seat
·         leaves seat in classroom or in other situations in which remaining seated is expected
·         runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
·         has difficulty playing or engaging in leisure activities quietly
·         is “on the go” or acts as if “driven by a motor”
·         talks excessively

Symptoms of impulsivity
·         blurts out answers before questions have been completed
·         has difficulty awaiting turn
·         interrupts or intrudes on others (e.g., butts into conversations or games)

Guidelines for Assessment of ADHD

In 2000, the American Academy of Pediatrics (AAP) published guidelines for doing an assessment of ADHD. Among its recommendations were:
(1) The primary care clinician should initiate an evaluation of children ages 6 to 12 who present with inattention, hyperactivity, or impulsivity;
(2) The diagnosis of ADHD requires that a child meet the DSM IV criteria;
(3) The assessment requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset of symptoms, duration of symptoms, and the degree of functional impairment;
(4) The assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional);
(5) The assessment should include evaluation for associated conditions; and
(6) Other diagnostic tests are not routinely indicated to establish a diagnosis of ADHD but may be used for the assessment of co-existing conditions (e.g., learning disabilities, mental retardation).

Persons Involved in Assessment of ADHD

The physician’s role:
·         takes a history provided by the parents that may alert the doctor to health problems, which could account for the development of ADHD symptoms
·         reviews information about the pregnancy and delivery including maternal health during pregnancy, use of alcohol, smoking, toxemia or eclampsia, postmaturity of the fetus, and extended labor
·         gathers detailed information about the early development of the child, educational progress, and behavior at home, at school, and within the community are essential parts of the history
·         collects information about family relationships with particular concern to any stresses on the child, which could affect behavior and performance
·         looks out for other medical conditions that might predispose the child to ADHD including fragile X syndrome, fetal alcohol syndrome, and phenylketonuria
·         may conduct certain laboratory tests done to determine the overall health of the child or adult such as chromosome studies, electroencephalograms (EEGs), magnetic resonance imaging (MRI), or computerized axial tomograms (CAT scans) but not to be used routinely for evaluation of ADHD

The psychologist’s role:  
·          administers and interprets psychological and educational tests of cognition, perception, and language development (such as intelligence, attention span, visual-motor skills, memory, impulsivity), as well as tests of achievement and social/emotional adjustment
·          integrates data collected from parents and teachers who complete behavior rating scales about the child

The school’s role:
·         Is required by federal law to evaluate students suspected of having a disability  and follow specific procedures and standards to perform such evaluations
·         initiates child study team, made up of school personnel such as the guidance counselor, a learning specialist, the principal or his designee, one or more of the student’s teachers, or others at the school to discuss the student
·         collects  information about the student that will indicate that the student is showing signs of a disability,   and will include information about the student’s current and past classroom performance, academic skill strengths and weaknesses, attention span, and other social, emotional, and behavioral characteristics
·         gathers information through teacher interviews, review of cumulative records, analysis of test scores, and direct observation of the student in class
·         determines the needs of the student and provides accommodations in the regular classroom

The parents’ role:
·         provides information on the child’s previous development and current adjustment acquired through interview or through questionnaires
·         drives the assessment process so that no unnecessary delays occur and that the child receives a thorough assessment by qualified professionals
·         speaks to the professionals involved if there is any doubt that an appropriate assessment was done, and gets a second opinion if unsure of the findings

The child’s role:
·         offers the clinician an opportunity to observe the behavior first-hand that can yield valuable information about his/her social and emotional adjustment, feelings about him/herself and others, and attitudes about school and other aspects of daily life
·         if adolescent or adult, tells the clinician if  he/she is having problems with attention span, self-control, restlessness, organization, or other difficulties and can describe the situations in which such problems most often occur and to what degree they impair functioning
·         can complete self-report rating scales, which yield quantifiable information about difficulties he/she is experiencing

Tests for ADHD

VANDERBILT Rating Scales compiles information from various tests covering numerous aspects of a patient’s life in order to make a comprehensive and thorough determination. This ADHD rating scale involves assessing aptitude and cognitive ability along with academic achievement, information processing and behavior. Potential patients typically undergo an interview process, and clinicians gather information from other individuals. A complete family, medical and medication history is also required for proper diagnosis.

The SNAP-IV Rating Scale is a revision of the Swanson, Nolan and Pelham (SNAP) Questionnaire (Swanson et al, 1983). The items from the DSM-IV (1994) criteria for Attention-Deficit/Hyperactivity Disorder (ADHD) are included for the two subsets of symptoms: inattention and hyperactivity/impulsivity. Also, items are included from the DSM-IV criteria for Oppositional Defiant Disorder   since it often is present in children with ADHD.  
The SNAP-IV is based on a 0 to 3 rating scale: Not at All = 0, Just A Little = 1, Quite A Bit = 2, and Very Much = 3. Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the subset and dividing by the number of items in the subset.  

SWANSON Rating Scale. This instrument was developed by Swanson and his colleagues and measures attentiveness and hyperactivity on a continuum, from attention problems to positive attention skills, using a seven-point scale of behaviour: “far below average” to “far above average”.

CONNER'S Rating Scale. Developed by C. Keith Conners, Ph.D., the Conners' Rating Scales-Revised (CRS-R) are paper and pencil screening questionnaires designed to be completed by parents and teachers to assist in evaluating children for attention-deficit/hyperactivity disorder (ADHD).

The Wender Utah Rating Scale can be used to assess adults for Attention Deficit Hyperactivity Disorder with a subset of 25 questions associated with that diagnosis.

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