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Attention deficit hyperactivity disorder

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Attention deficit hyperactivity disorder Powered By Docstoc
					FM SEMINAR



Dr SH SO
   C1
Child & Adolescent
Psychological Problems
 ADHD
 Autism
 Childhood depression


   Your role = diagnosis/ reasurrance
    +/- referral
Part 1

   ADHD
    Attention-Deficit Hyperactivity
    Disorder
ADHD
Epidemiology
    Prevalence rate in HK Chinese school boy
     6.1 % ( Leung et al, 1996)
    The prevalence of ADHD in HK ( 6.1% )is
     lower compare to US (19%) , UK
     (16.6%) , New Zealand (10.8%) But
     corresponding well to the 5.8% ADHD
     prevalence in Urban mainland China
     ( Shen, Wang and Yang,1985)
Etiology
Unknown
Multi factorial hypothesis
 Biological factor
   Base on the observation of the beneficial effects of stimulants on hyperactive, it was
    postulated that possible neurotransmitter dysfunction or imbalance may occur in
    individuals with ADHD (Bymaster et al., al 2002: Kirley et al.,2002)


   Genetic factor
   Studies of dizygotic and monozygotic twins who have grown up in same
    environment , concordance rates reported for ADHD ranged from 51%-
    80% form monozygotic twins VS 29-33% for dizygotic twins( Gilger,
    Iacono & McGue ,1997)
   Other risk factor
   maternal history of smoking during pregnancy
    ( Linnet et al,. 2003)
   mothers had abused alcohol throughout
    pregnancy (Aroson, Hagberg and Gilllberg 1997)
   however, Parental expectations ,Parenting
    stress, Marital conflict….etc Play a role in
    determining the outcomes of the disorder but
    less a role in primary causation
   ? MSG, diet
Key features
A .At least 6 months of significant
 developmentally inappropriate levels of
1) Inattention
2) hyperactivity and impulsiveness
B . Onset no later than 7 years of age
C. Symptoms must be present in 2 or
   more suitations
D. clinically significant distress or impairment in
 social ,academic functioning
To established a dx
 History obtained from at least three
 sources :parents, The child and
  teachers
 Method via questionnaires
  ( Connor’s rating scale ) for parents
  and teaher
 PE : neurological exam for
  assessment of vision /hearing levels
Management:
multidisciplinary approach
   Pharmacological intervention
   CNS Stimulants ( 1st line): methylphenidate (Ritalin)
    ,TCA (2nd line)
   Parental intervention
   Using tokens or points as immediate rewards
   breaking up a large task into smaller steps, and
    encouraging them as each step is completed
   Involves teachers
   Parents and teachers are encouraged to discuss systematic
    and consistent approaches to managing children ‘s
    behavior
   Referral to Child psychiatry
Part 2

   autism
Autistic spectrum disorder
 Autistic disorder自閉症
 Asperger's disorder亞斯伯格症
 childhood disintegrative disorder
 Rett's disorder雷特氏症
 pervasive developmental disorder
  not otherwise specified. ( PDDNOS)
Autistic spectrum disorder

 Epidermiology :
 2.3 in 1000 In children aged 2-5
  years ( New cases of ASD
  diagnosed in Child assessment
  Service of HK in 2004)
 boys: Girls 7.4 :1 ( Lam , Lee, Tso,
  Yau& Mark 1995)
Etiology
Exact etiology unknown
 However genetic probably play a role…..
 concordance rate in identical twins very
  much higher than in non-identical twins
 20-25% of Tuberous sclerosis develop
  autism, 25% of autistic individuals have
  15q Chromosomal anomalies
Diagnosis
 Key      features
   Three set of core symptoms:
    1. Delay and deviance in language development
    2. Delay and deviance in social interaction
    3. repetitive and stereotyped behaviours
Alerting signals of possible
ASD( NAISA,2003)
Early childhood
Communication        1.No pointing ,babble by 12 months
                     2.no single word by 18 months


Social interaction   1.Lack of showing with toys or other
                     object
                     2.lack of interest in other


Interests            1.Oversensitive to sound or touch
activities ,other    2.overliking for sameness or
behaviour            inability to cope with change eg turn
                     light switches on and off etc
Primary school age
communication                    1.Muteness, persistent
                                 echolalia
                                 2. reference to self as you/ or
                                 ‘she/he’ beyond 3 yrs
Social interaction               1.inability to join in with the
                                 play of other children
                                 2.extreme reactions to
                                 invasion of personal space

Interest ,activities,behaviour   Lack of flexible
                                 inability to cope with change
                                 or unstructured situation eg
                                 schol trips
Management
 Explanation about organic aetiology
 behavior training for deficit or
  difficult behaviors ( involving
  parents) eg《自閉症兒童社交及溝通行
  為量表》香港痙攣協會
 special education needs
Part 3

   Childhood depression
Childhood depression
   epidermiology
   prevalence rates of depression to be
    about 2% among children and about 4%
    to 8% among adolescents.
   prepubertal : similar prevalence boys
    and girls.
   With the beginning of puberty, The
    female-to-male ratio approaches 2:1 in
    adolescence
Criteria for Major Depressive
Episode in Children, and
Adolescents
two-week period and represent a
 change from previous functioning
 at least one of the symptoms is (1)
 depressed mood or (2) loss of
 interest or pleasure
Adult vs Child

 Depress mode VS vague physical
  complaints, sad facial expression, or
  poor eye contact
 Loss of interest VS Inactive in peer
  play or school activities
 Weight loss VS fail to make
  expected weight gain rather than
  losing weight.
Adult VS child

 Psychomotor Retardation vs
  hyperactive behavior
 Fatigue VS school refusal, or
  frequent school absences may be
  symptoms of fatigue
 Worthlessness vs self-depreciation
  (e.g., “I’m stupid,” “I’m a retard”)
Adult vs child

   Insomnia or hypersomnia nearly
    every day Similar to adults

   Poor concentration vs behavioral
    difficulties or poor performance in
    school
Management
Cognitive behavior therapy is effective for the
treatment of mild to moderate depression
 1)educating patients about healthy coping
   skills, problem solving,conflict resolution,
   relaxation techniques
 2) educating parents about realistic ,age
   appropriate expectations and nonjudgment,
   noncritical patterns of communciation
Pharmacological therapy
 should be reserved for treatment of severe
  major depression.
 Tricyclic antidepressants should not be used to
  treat childhood or adolescent depression.
 Selective serotonin reuptake inhibitors have
  limited evidence of effectiveness in children
 Children and adolescents taking antidepressants
  should be monitored closely for suicidal thoughts
  and behavior.
 Depression should be treated for a minimum of
  six months .
http://www.ha.org.hk/kch/
adhd/help.html#
References
   A Primer in Common development disabilities , experience
    at child assessment service ,Hong Kong
   Depression in children and adolescents
    Kathy P M Chan 陳葆雯,Se-Fong Hung 熊思方 The Hong
    Kong Practitioner VOLUME 28 / January
   childhood and adolescent depression, American family
    physician vol 75 Number 1 Jan 2007
Thank You

				
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