Cristiana Leite 46434S. Monica Cardoso 464323, Rita Almeida 464279 Alexander Crichton (1798) "The incapacity of attending with a necessary degree of constancy to any one object". Encephalitis Epidemics (1915-1920) "Minimal Brain Dysfunction" (MBD) Late 1950s and 1960s The Diagnostic and Statistical Manual of Menial Disorders, DSM-1I, presented for the first time a range of childhood disorders that included the "Hyperkinetic Reaction of Childhood" (1968). In the 1970s Douglas's Modet (wn) - "Attention Deficit Disorder" (ADD) DSM-III revised edition (1937) - 'Attention-Deficit Hyperactivity Disorder" (ADHD) DSM-IV [1994) - Two distinct yet correlated dimensions or domains of behavior DSM-V - Definition and Classification Hyperactivity Impulsivity s7 Inattention a. Often fails to attend to details b. Difficulty sustaining attention c. Docs not seem to listen when spoken to directly d. Does not follow instructions and fails to finish tasks e. Difficulty organizing tasks f. Avoids sustainded mental effort g. Loses things necessary to tasks h. Distracted by extraneous stimuli i. Forgetful in daily activities Hyperactivity - Impulsivity a. Often fidgets with hands or feet or squirms in seat b. Leaves seat in situations when remaining seated is expected c. Runs about or climbs when it's inappropriate d. Difficulty playing or engage in leisure quitly e. Motor excess ("on the go") f. Talks excessively g. Blurts out an answer to questions; h. Often has difficulty waiting his turn; i. Often interrupts or intrudes on others. Specifiers TlillMiHII^IlJUIIiHlNiiUHhlEI JllllHilll II In pjrtjjl remisaiEin HldJ M.u Jlt.i Lu A Combined presentation Predominantly inattentive presentation Predominantly hyperactive/impulsive presentation Comorbility The existence of a diagnosis of ADHD is often accompanied by another disease in the individuals, and, therefore, the existence of comorbid disorders in ADHD is very frequent. Oppositional Defiant Disorder Anxiety Disorders Di srnptivc M rjrjd DysrcguIjtLon Disorder Conduct Disorder Specific Learning Disorder Definition and Classification ICD-IO E Hyperkinetic Disorder (HKD) • early onset • combination of overactive, poorly modulated behaviour with marked inattention and lack of persistent task involvement • pervasiveness over situations and persistence over time (Organization, 1992) Characteristic problems early in development Abnormalities associated with HKD reckless and impulsive prone to accidents breache rules without thinking unreserved with adults unpopular with other children cognitive impairment specific delays in motor and language development scholastic problems Diagnostic Guidelines Associated features ■ Disinhibttion In social relationships • Recklessness in situations involving danger ■ Impulsive flouting of social rules Presence of both impaired attention and overactivity in more than one situation (e.g. home, classroom, clinic) Impaired Attention lack of preserverance in tasks s involving thought and atten^n^"'^ tendency to move from one activity to the next without completing any ——K Overview of the ICD-io medical classification system for ADHD • Require hyperactivity, impulsivity, and inattention all to be present • Symptoms prior to 6 years of age and of long duration - Impairment present in two or more settings • An exclusion of the diagnosis if mania, depression, and/or anxiety disorders are also present subgroup of patients with combined type ADHD with the most severely Q f) impairing symptomatology HKD Epidemiology Prevalence of HKD diagnosis around 1,5% in school-age children ADHD Gender: more frequent in males than females (2:1 in children and 1.6:1 in adults) Age: most commonly diagnosed in school-aged children ($% of children and about 2.5% of adults) Etiology - Causes and Theories "Does ADHD qualify as a "nature" or a "nurture" disorder, or some combination of factors?" NATURE ^rnrtlLuiaclDiiphciik, Gicnu: iirtuKC :n (be lii:n * NURTURE O ' NATURE Genetic cause (Dopheide, 2001) <2 Chemical imbalance in the brain - a ^ dopamine deficiency (Evans, 2013) Organic theory of ADHD (Millichap, 2007) NURTURE Theories of ADHD Top-down Models Unifying theory of Barkley (1997) Bottom-up Models Motivational and emotional regulation theories Assessment Observations / Interviews adhdI Questionnaires \ Full Assessment: ■ Clinical interview with the parents; ■ A separate interview with the child; ■ Preshool, Kindergarten and school information; ■ School observation and investigations; Collection of data from every possible sources (Cfrildre n, Parents, Theache rs) Interview schedules Clinical interview with the parents General Evaluation Specific questioning of the child, their problems and the context within which they a re occuring e.g. Clarify presenting complaints Make evaluation of symptoms Family history of ADHD Pregnancy and birth history Early developmental history Medical history Medication family functioning and family problems Social networks and other resources about ADHD and its common comorbidities [ 1 Separate interview with the child The interview should focus on: * Functioning in the family, the school and the peer group; • A general evaluation of psycho pathology (especially emotional problems and self esteem); ■ child's attitude to, and coping with, their disorder. Self report rating scales may be helpful as an adjunct to an interview Preschool, kindergarten and school information School observations 1 n fLjrmat bn frctm st hoitl: Potential domains of interest in a school nbscrvalirm Behaviour and beh avionr ptoblcmsr Dc.-ve.-lup muni; Social functioning; Situational variation in behaviour ind symptom* that may indicate enmorbid or differential diagnoses L ED General inforrnition age of child, time of day, setting, number os children, rj urnber m adults, atl i v ity, rnxsm. lyand set up Observed behaviours overactivity, irnpulsmry, inattention,oppositional behaviour*, evident!? g["mygd lability, level ofcommanicaiion and interaction with others ability to use comprehend and use language, ability to socially interact with others, reti protal sudal j rj Ltractiotis, repetitive bsliaviours, ability to imitate others, ability to play appropriately, ::LidiTia-dl .lntinlv. Treatments Treatment approache be matched with an individual child's needs Strongest empirical support: stimulant medications, parent training programs, classroom-based interventions and ADHD summer programs Stimulant medications vs. Psychosocial treatments Psychosocial Treatments For dealing with the psychological and behavioral problems and thus increase the psychosocial functioning of the patient and their quality of life Psychoeducarion (child, parents and teachers) Individual Appro aches to Intervention • School-based Interventions • Peer I n te rventi on s a n d soc i al skill s tTai n i n g s • Cognitive Behaviour Therapy Family-based psychosocial interventions - Parent Training (BPT) Psychoeducation New Information It is important for teachers to know more about ADHD so that the likelihood of implementing psychosocial interventions within the school is increased. School-based Interventions Classroom Interventions Classroom Structure individual and separated desks to achieve a decrease of distraction use of visual aids as posters and signals traditional classroom settings with rows and opposite-sex seating to increase task engagement and lead to lower levels of distractability Behavioural classroom management Teachers are instructed regarding the use of specific behavioral techniques as praise, planned ignoring, effective commands, daily report cards as well as the use of contingency management techniques (e.g. incentives, reward programs, point systems, time-out) r Academic interventions Focus primarily on manipulating antecedent conditions such as academic instruction or materials in order to improve both behavioral and academic outcomes Task and instructional modifications Peer tutoring Computer~assisted instruction Strategy training Peer Tutoring Instructional strategy whereby two students work together on an academic task with one student providing assistance, instruction and feedback to the other EH Task modification involve revision of the curricula Modification of Modification of instructions involves adapting the content tilshs (Old instructions and delivery of instructions to meet the needs of ADHD children • match the tasks to each child's ability « reduce task length • increase specificity or visual stimulation in instruction, use enthusiastic yet task-focused presentation * use brief and one-at-a-time presentation of academic assignments ■ intercalate academic periods with brief periods of physical exercise * schedule the more academic subjects into the morning hours ■ allow extra time for written tests CAI entails the manipulation of the task format: ■ highlighting of essential material ■ using of multiple sensory modalities - dividing content material into smaller chunks of information • providing immediate feedback • limiting the presentation of nonessential and distracting features Peer interventions and social skills trainings Instruction in social skills, social problem-solving ami behavioral competencies. Aim: to enhance social competence by encouraging close friendships, and decreasing undesirable and antisocial behaviors Group format is associated with better outcomes (clinic, summer treatment program, or in school-based settings) Summer treatment programs includes social skills training, a reward and response cost system, group practice and instruction in sports skills and team membership. -a jW- Cognitive Behavior Therapy /l\ Self-Control Self-reinforcement Q_3 Homework-focused interventions Specific routines Goals Reinforcement Behavioral parent training (BPT) Several studies with children with ADHD and their parent showed conflicted parent-child interaction patterns and less positive parenting practice (DcaultT 2010). Reward Positive Negative it Behaviors VS Contingencies Raise Loss of rewards Positive arte nrio n Time-out Tangible reward Ignoring Gerald Patterson (1982) Parents of children between the ages of 6 to 16 and it helps parents to identify their sons' specific problematic behaviors. Videotape Modeling Parent Training Videotaped lessons that arc showed in group situation with a therapist. Structural Family Therapy Structural Family Therapy Q Q / Strategic family therapy 1 Brief solution-focused therapy Barkley and collaborators (1992) 8-10 weekly one hour sessions Psychodynamic Psychotherapy of ADHD Two major theoretical camps: Ego Psychology and Object Relations key concepts used to understand the child's pathology, both important for treatment Key practice components for the positive outcomes: • positive transference • therapeutic relationship with the child • developing ego functions • educative supportive interventions ■ encouragement, reassurance and empathy • expressive component • active listening at ■ facilitative comments to encourage expression and re Election • summarizing a child's statement • directing artention; interpretations ■ "he re-andmow" interpretations ■ parent work • collaborative conferences with teacher(s) Dietary Interventions Essential omega-3 and omega-6 fatty acids exert a positive effect on neurotransmission / '\\ lack of those fatty acids may play a major r°le m tne pathogenesis of ADHD Need to be obtained from foodstuffs or added as food supplements Sugar, several preservatives, food colourings, and potentially allergenic foodstuffs Their elimination or restriction from the diets of children with ADHD will decrease ADHD-symptoms Meditation I ■ jii-: "i il ''i: ui m fil »bt: Concent ration Techniques Con te m plati on Tech ni que s A Mindfulness Transcendental Meditation Neurofeedback and BCI Uses electroencephalography (EEG) to measure ihe individual's brain activity. Y Based onan operant conditioning process in which only the desired brain activity is rewarded fMayer et al, 2015). Tries to achieve self-control through feedback and positive reinforcement hoping to implement these setf-rcgulation skills in every day activities (MicoulaudTranchi et al 2014) Neurofeedback and BCI Ali & Puthusserypady (2015) DaU acquisition g USBamp amplifier US8 transfer ot data ■ 1 Subject SEW BCI computer with Matlab and Application Neurofeedback and BCI Wronska and collaborators (2015) Neurofeedback and BCI Wronska and collaborators (2015) Individual Counseling and Support Groups Children partrcipiUng in ind[vidua! counseling learn ro better understand their disorder and to identify and develop their strengths. Support groups are important in providing information and education about the disorder, as well as a social support system. Pharmachological Treatments Methylphenidate Decrease concentration of Dopamine Transporters Increase of Dopamine Levels A Better ^ Concentration Conclusion Interventions