ADHD & AUTISM

DR. S. NAMBI
MD, DPM. PROFESSOR & HEAD, DEPT. OF PSYCHIATRY, CHRI

ATTENTION DEFICIT HYPERACTIVE DISORDER (ADHD)

ADHD The most common neurobehavioral disorder of childhood. Most prevalent chronic health conditions affecting school aged children. Characterized by combination of over-activity, poorly modulated behavior with marked inattention and lack of persistent task involvement. Seen in 4-5% of children in general population. Boys are 2-3 times more affected than girls. Manifest before the age of seven.

CHARACTERISTICS OF ADHD
ADHD is a complex condition, one child with ADHD may have different symptoms from another child with ADHD. ADHD is a medical condition characterized by a persistent pattern of: I. Inattention. II. Hyperactivity, III. Impulsivity.

SUBTYPES OF ADHD
I. Predominantly Inattentive Type. II. Predominantly Hyperactivity/Impulsive Type. III. Combined Type

THREE SUBTYPES OF ADHD

1. Predominantly Inattentive ADHD: Main problem is inattention, children here are more passive- consisting of day dreaming, hyperactivity and impulsiveness are sometimes present, but to a lesser degree.

2. Predominantly Hyperactivity/Impulsive ADHD: Hyperactivity and Impulsive behaviors are present. Inattention may be present. Although, this sometimes is not as obvious.

3. Combined ADHD: All three ADHD behaviors, hyperactivity, inattention and impulsivity are present in fairly equal measures.

HYPERKINETIC BEHAVIOR
As children they: 1. Are restless and cannot sit still. 2. Fiddle with everything around. 3. Cannot concentrate on any given task (leading to scholastic difficulties) 4. Emotionally excitable. 5. Show episodes of rage or crying. 6. Impulsive 7. Show temper tantrums.

POOR ATTENTION SPAN

1. These children do not concentrate on any task and leave most tasks unfinished. 2. These patients may have many other associated symptoms like: impulsivity, emotional liability, poor scholastic progress and antisocial behavior.

ETIOLOGY OF ADHD
I. Genetic factors seem to play some part. II. Majority of these patients do show developmental delays. III. Soft neurological signs are common. IV. Others believe that the disorder occurs due to maturational lag of the central nervous system. V. The condition improves with maturation. VI. Psychosocial factors may play some part. VII. The disorder is more common in orphanages where proper raring atmosphere is not available.

CLINICAL FEATURES OF ADHD

I. Inattention. II. Hyperactivity III. Impulsivity IV. Onset not later than seven years of age. V. Pervasiveness the problems should be present at home, school, and other settings also. VI. Causing significant disturbance, distress, or impairment in social, academic or occupational functioning.

COMORBIDITIES
Oppositional defiant disorders Conduct disorders. Mental Retardation Epilepsy OUTCOME: 1. 16 to 80% of children tend to suffer till their adolescents. 2. Hyperactive symptoms improve with age, but inattention symptoms tend to persist.

MANAGEMENT OF ADHD
1. Drug Therapy 2. Psychosocial Therapy

DRUGS USED IN THE TREATMENT OF ADHD

CNS STIMULANTS:
1. Dextroamphetamine and Methylphenidate are the drug of choice. 2. These drugs reduce hyperactivity and improve attention span. 3. They are to be given in the morning and at noon because nightime dose may produce sleep difficulty. 4. Dextroamphetamine is given in a dose of 5-10 mg/day. 5. Methylphenidate in doses of 0.25-1 mg/kg/day is effective.

DRUGS USED IN THE TREATMENT OF ADHD NON-STIMULANT: Atomoxetine (1-1.4 mg/kg qd) ANTIDEPRESSANTS, like imipramine in the dosage from 50-150 mg/day have been used in India

PSYCHOSOCIAL THERAPY
Behavioral Therapy: Behavioral Therapy in conjunction with medication provides very good improvement. Behavioral Therapy reinforces positive behaviors such as completing homework, household chores, and discourages negative behaviors.

Some Tips For Behavioral Therapy

I. Rewarding the good behavior.

II. To punish for the bad behavior. III. Set goals that have a reward such as a prize or privilege. IV. Consistently encourage and praise the child for her good performance.

PSYCHOTHERAPY
Children with ADHD have trouble adjusting with social and academic events. This may lead to anxiety, ODD, self-esteem problems and emotional troubles which in turn aggravate the symptoms. Psychotherapy is of beneficial to these children . Psychotherapy should also be focused to parents and teachers.

FIVE STEPS
1. LOOK FOR SIGNS OF ADHD. 2. LEARN THAT ADHD IS AN ILLNESS THAT CAN BE TREATED. 3. ASK YOUR CHILDS DOCTOR FOR HELP. 4. TALK TO YOUR CHILDS TEACHERS. 5. WORK TOGETHER TO HELP YOUR CHILD.

CHILDHOOD AUTISM

Introduction
 A condition 1st described by LEO KANNER in 1943.  Characterized by marked and sustained impairment in: 1. Social interaction, 2. Deviance in communication, and 3. Restriction are stereotype patterns of behavior and interest.  Abnormalities in nonverbal communication are present since infancy.  3 to 4 types more common in boys than girls.  Prevalence rate 4-5/10,000.

CHARACTERISTICS OF AUTISM
Difficulties with social interactions. Marked impairment in the use of non-verbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction. A decrease or lack of spontaneous seeking to share enjoyment, interests, or achievements with other people. Decreased or lack of social reciprocity. Failure to develop peer relationships appropriate to developmental level.

CHARACTERS OF AUTISM
Impairments in communication. Delay or total lack of development of spoken language. Stereotyped or repetitive use of language or idiosyncratic language. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.

AUTISTIC DISORDERS
Usually starts during infancy. Usually between 2-3 years of age. The child fails to develop normal, verbal and interpersonal communication. They are referred to as Autistic because they appear to be withdrawn and self observed.

CLINICAL FEATURES
Clinical features are described under four heads: 1. Impairment in reciprocal social interaction: Poor eye to eye contact. Poor use of non-verbal expressions like facial expression. Poor relations with the peer, no expression of common interest. Poor response to other peoples emotions. Lack of seeking to share enjoyment or achievements.

REPETITIVE BEHAVIOR
2. Restricted repetitive stereotype behavior. 3. Compulsive non-functional rituals or routine. 4. Mannerism, hand flicking, head banging. Preoccupation with non-functional aspects of objects or toys like smell of toys.

ASSOCIATED FEATURES
Erratic sleep patterns PICA, eating non-edible things. Self-injurious behavior. Echopraxia. Poor affect modulation.

ETIOLOGY AND OUTCOME

Poorly understood Genetic factors considered to be important. OUTCOME: Poor outcome. Condition remains stable for long years. The early diagnosis and effective management. 10% can achieve some social skills.

TREATMENT
Behavioral, psychotherapeutic as much as pharmacological approaches can be used to address numerous problems, but, unfortunately, there is no cure for the core disorder. The goal of treatment is not merely to lessen symptoms, but to help the individual achieve the maximally feasible quality of life.