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Attention deficit hyperactivity disorder (ADHD) – Article series: “How to treat the soul?” Part 21!

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What does it mean?

Attention deficit hyperactivity disorder is one of the most common types of psychiatric disorders in childhood, with an onset in preschool age that can persist into adolescence and adulthood. The main manifestations of UDHS are concentration difficulties (attention deficit), hyperactivity (motor restlessness) and impulsivity (impulse control disorders), which significantly interfere with social functioning and limit the child’s ability to successfully integrate into the educational system and other environments. The consequences of these disorders can be observed throughout life and can significantly worsen the patient’s social adaptation, as well as increase the risk of developing other psychiatric disorders, such as behavioral and/or emotional disorders, addiction, if UDHS is not detected and treated. The symptoms are not the same for all children, some may have more pronounced direct attention disorders, others – more manifestations of hyperactivity, others all together. [1, 2, 8, 9]

What are the signs of UDHS?

Criteria from the US disease classification DSM-5, which are similar to the SSK-10 criteria used in Latvia.
Inattention (6 or more symptoms in children up to age 16; 5 or more symptoms from age 17 and adults; symptoms of inattention must persist for at least 6 months and are developmentally inappropriate (DSM 5)):
  • Often loses focus or makes careless mistakes when completing assignments at school, doing homework, or participating in other activities.
  • Difficulty staying focused while studying or playing.
  • It gives the impression that the child does not hear what is being said to him.
  • Often unable to follow directions/instructions, unable to complete homework, assignments.
  • Planning your tasks and activities is often difficult.
  • Often avoids, dislikes or reluctantly performs tasks that require mental effort for a long period of time (eg homework, assignments).
  • Often loses items needed for tasks and activities (eg school materials, pencils, books, keys, wallet, phone).
  • Often, attention is easily distracted by surrounding irritants.
  • Often forgetful in everyday life [2nd, 3rd, 4th]
Hyperactivity and impulsivity (6 or more symptoms in children up to age 16; 5 or more symptoms from age 17 and adults; symptoms of hyperactivity and impulsivity must persist for at least 6 months and are developmentally inappropriate (DSM 5)):
  • He often moves his hands restlessly, swings his legs, farts, cannot sit still.
  • Often leaves his seat/chair in situations where he should be sitting.
  • Often starts running or crawling in situations where it is not allowed or out of place.
  • Often unable to play quietly or participate in leisure activities.
  • Often excessively mobile, as if driven by a motor.
  • Often excessive in his speech.
  • Often blurts out his answer before the questioner has finished the question.
  • It is often difficult to wait your turn
  • Often interrupts others or intervenes [2, 3, 4]
In Latvia, symptoms of hyperactivity and impulsivity are divided into 2 groups according to SSK-10 – 1.-5. the criteria belong to hyperactivity symptoms, there must be at least 3 criteria within 6 months; symptoms of impulsivity 6.-9. criteria, of which there must be at least one within 6 months. [1.]

In addition, the following criteria must be met:

  • Symptoms of inattention or hyperactivity-impulsivity should be observed until age 12 according to DSM-5 or until age 7 according to ISK-10.
  • Symptoms must appear in 2 or more situations – at school, at home, etc.
  • The symptoms are associated with clinically significant distress or disturbances in the person’s social, pedagogical and future professional life.
  • The symptoms do not correspond to other psychiatric disorders (general developmental disorder criteria, depression criteria, mania criteria, anxiety criteria). [1., 3.]
IOWA Conners Rating Scale (Inatension with Overactivity and Aggression) Adapted from: Loney J., Milich R., 1982
[1.].Not observed (0) Mildly expressed (1) Moderately pronounced (2) Very pronounced (3)

Inattention and hyperactivity subscale

  • 1. Restlessness
  • 2. Humming and making other strange sounds
  • 3. Irritable and impulsive
  • 4. Unsustainable attention
  • 5. Unable to finish what is started

Subscale of oppositional defiant behavior

  • 6. Argumentative, quarrelsome
  • 7. Behaving “cunningly”
  • 8. Outbursts of anger,
  • explosiveness
  • 9. Challenging behavior
  • 10. Non-cooperation
The maximum value of each subscale is 15 points. The scale can be used for a structured evaluation of the intensity and clinical features of UDHS.

What happens in adulthood?

Approximately 30% to 70% of UDHS symptoms persist into adulthood, affecting quality of life and ability to fit into the environment. Retained symptoms of UDHS in adulthood are associated with a higher risk of developing comorbidities and social maladaptation. In adulthood, patients with UDHS more often complain of difficulty concentrating, short-term memory disorders, mood swings, rather than impulsivity and poor attention. Mood, personality disorders, addictions (substance abuse, gambling) are layered on the classic, UDHS scene. In general, there is no reason to believe that people with UDHS are intellectually impaired, more often the problem is that patients with UDHS have not been able to get enough education due to the symptoms and behaviors mentioned above. [1.]
NB Previously undiagnosed UDHS should also be detected and diagnosed in adulthood. Diagnosis and adequate treatment of UDHS in adulthood allow to significantly reduce the risks of developing incapacity, antisocial behavior, substance addiction and other mental disorders and avoid long-term consequences. There is a self-test for detecting UDHS in adulthood, which can be found in “Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents Clinical algorithm” https://www.spkc.gov.lv/lv/media/6045/download 1. in the appendix (instructions and test).

What is happening in Latvia and elsewhere?

In Latvia, according to SPKC data, in 2016 hyperkinetic disorders, which include UDHS, were diagnosed in 964 patients, of which 43 were detected in 2016. [5.] The number of children with ever-diagnosed UDHS in the US in 2016 was 6.1 million (9.4%) (NSCH2016) [4., 6.]

Help options.

The treatment of UDHS is complex, it involves the child, the child’s parents, teachers (both in preschool institutions and schools), social workers and doctors (child psychiatrist, neurologist, psychotherapist, pediatrician, family doctor). The American Academy of Pediatrics (AAP), as well as the Latvian UDHS treatment algorithms, recommend that children up to the age of 6 start with non-pharmacological interventions, but after the age of 6, the recommendations, in parallel with non-pharmacological interventions, also include drug therapy. [2nd, 3rd, 7th]
Non-pharmacological interventions include psychoeducation, psychosocial interventions in preschool and school environments (educational activities for pedagogues on UDHS, analysis of classroom structure and academic requirements, identification of problem situations), behavior-focused family interventions, social skills training, CBT, nutritional therapy. [2nd, 3rd]
A treatment program/plan developed by a professional involves different people to help a child with UDHS fit into different environments. For example, teachers are informed about the treatment plan and individual characteristics/needs. Drawing up this plan and informing the people involved helps ensure the necessary support measures, such as classroom layout, use of visual support materials, allocation of extra time and longer tasks, involvement of support staff in the learning process, etc. [2nd, 3rd, 7th]
The drugs of first choice are methylphenidate preparations (short or long-acting dosage forms). The drug of second choice is atomoxetine (a noradrenaline reuptake inhibitor), a non-stimulant drug, which is recommended if the patient has side effects from methylphenidate or there is insufficient therapeutic effect when using methylphenidate for more than 6 weeks. [2nd, 3rd]
NB When using drug therapy, make sure you give your child the right dose of medicine at the right time. Do not entrust the use of medicines to children and adolescents without supervision. Keep medicines out of reach of children. Do not take medicines with your child to school, if their use is necessary during the day, then take them to the school nurse on your own. [8.]

What should relatives do?

  • Establish a daily routine (regular routine, waking up and going to bed at the same time every day).
  • Be organized (encourage the child/relative to put things in their designated places to reduce the possibility of losing them).
  • Regulate irritants (turn off the TV, reduce noise, provide the child/relative with a clean work surface when doing homework).
  • Reduce choices.
  • Be clear and specific when talking to the child/relative.
  • Help make a plan.
  • Create a reward system.
  • Discipline effectively, do not use yelling, condemnation, but use clear instructions, interruptions, reduction of privileges.
  • Use positive opportunities where your child/loved one can gain success or positive experiences.
  • Stick to a healthy lifestyle [3, 7].

References