SOME COMMENTS ABOUT CHILDREN WITH ADHD IN THIEN PHUOC POLYCLINIC (SANTA MARIA CLINIC), HO CHI MINH CITY IN 2009 AND 9 MONTHS IN 2010.

 

                                                                                                                                                                                                                                                             Phan Thieu Xuan Giang, MD et al

Parents and teachers become more concerned about  many problems in children that related to ADHD, the number of children who come to children hospital and clinic are increasing significantly. In our daily clinical practice, we recognize some features and experiences when we work with children with ADHD in Ho Chi Minh city in 2009 and 2010.

Description and history of the disorder:

Attention deficit/ hyperactivity disorder (ADHD) describes children who frequently have attention deficit, overactivity and impulsive symptoms  that are not appropriate with their age, these symtopms are strong enough to cause impairment in daily main activities (APA, 2000). In 1845, Heinrich Hoffman, a German neurologist wrote in a book for children, this book was known as the first book that talked about children with ADHD.

This was not a medical book, the author composed a humorous  poem which described a meal time of a child named “ Fidgety Phil” , the child could not sit quitetly, he always acted and finally, he turned over his chair. When the chair fell down, he screamed loudly and took the table-cover and pulled it strongly, all glasses, cups, dishes and knives fell down (Hoffman, 1845).

In 1994, Time newspaper also described a case, the child name was Dusty N,this article wrote about impulsive and hyperactive behaviors during  meal.

Althougt time is 150 years long, the behaviors in meals of the two boys are characterized for symptoms of ADHD. Children with attention deficit are always inattentive to demands and behave carelessly. Hyperactive children are frequently acted. Impulsive children work absentmindedly. Behaviors of  ADHD children are complicated and contradicted. Impulsive and disorganized behaviors of the children are always the origin of  distress for themselves, parents, siblings, teachers and peers. Why the child can not complete his tasks? Why does he cause many careless mistakes? In some period of time, some situations, children with ADHD appear to be good.

These contradicted behaviors make the others think that the child can perform his or her tasks better if he or she is more attempted or if the parents or teachers set limitation firmly. Nevertheless, increasing atttempt and difficult rules are not helpful because the child has tried many many time to be good at their tasks. The child try to carry out his or her work better but this is a big challenge because of his self- control ability is limited. Consequently, he feels that he is confused, depressed and misunderstood because of being inattentive.

Definition and features:

Definition: There are 3 types of ADHD, inattentive type, hyperactivity/impulsive type and combination between the two.

Age of onset: According to DSM-IV-TR: The age of onset is before 7 years of age. Onset could be different in each type.

Time of symptoms:  6 month (DSM-IV-TR) is too short, especially with young children, researches show that time of symptoms is about 12 months, that could be appropriate with preschool age children (Barkley, 2003).

Settings: The symptoms and signs need to be appear in at least two settings: at home and another setting such as: school.

Studies show that ability to maintain attention and control impulsivity of the children become problematic following these changes:

-The end of the day

-Tasks become more complex and need more organized skills

-Inhibition of behavior is necessary when the child is sitting  in some places such as: church and restaurant

-When stimulation threshold is low, for example exessive boring topic

-Lacking of supervision from adult

-When tasks need to be persistent

In ICD-10 (WHO), there are also criteria for diagnosing ADHD. These criteria focus on presenting of abnormal level of attention and hyperactivity at home and school settings and direct observation of these behaviors.

It is not similar to DSM-IV, criteria for ADHD in ICD-10 are not allowed comorbidities such as mood disorder, anxiety and psychosis.

Trip et at found that most children who are diagnosed as ADHD following ICD-10 criteria are also meet criteria in DSM-IV. However, less than a haft of children who are diagnosed as ADHD following DSM-IV meet criteria in ICD-10.

In another study of Lahey and collegues in 2006, all children who have enough criteria that suitable for diagnosing ADHD in ICD-10 are also meet criteria in DSM-IV and only 26% children who are diagnosed as ADHD in DSM-IV meet criteria in ICD-10. The criteria in DSM-IV can help to  detect ADHD with lager number compare to ICD-10.

Prevalence:

ADHD is one of disorders that is most diagnosed in children. The prevalance varies largely depending on difference in research population, assessment methodology, diagnostic criteria and applying methods.

Around 3-5% in school age children. This disorder is reduced following the increasing of the age, especially in boy. According to Collesto et at (2003), it appear in age 9: 2,2% ; age 12: 1,4% and age 16: 0,3%. Girl : 0,3% and boy: 1,5%.

In epidermiology researches, inattentive type is the most common type, it accounts for 4,5%-9% in common population. Combination type: 1,9-48% and hyperactive/impulsive type: 1,7-3,9% ( Brown, 2000). This rate is opposite to clinical samples , in this population, combination type is the most common type. This incompability may reflect that children with hyperactive/impulsive symptoms are easy to detect and brought to the clinic or hospital because of these externalization behaviors.

Gender difference:

Boys are usually sent to the clinic, boy: girl ratio in clinical population is about 6:1 to 9:1 while the ratio in common population is about 2:1 to 3:1. Behavioral criteria for diagnosing ADHD are more likely to be consistent with boy than girl , so threshold for detected diagnosis for girl is higher than boy ( Barkley, 2003). In an analysis about differences between boy and girl with ADHD, Gaub and Carlson (1997) recognized that girls with ADHD are more intellectual impaired and have less impulsive symptoms , externalization behaviors than boys. This finding makes reseachers raise questions about the value of criteria in DSM-IV diagnosis for detecting ADHD symptoms in girls.

Neuropsycholgy factors:

There are 4 areas in the brain that related to ADHD:

-Prefrontal cortex: its functions are: planning for behaviors, keeping the target in mind, inhibiting inappropriate responses

-Basal ganglia/corpus striatum: a group of structure in subcortical region that play an important role in controlling responses

-Cerebellum: playing an imporant role in processing temporary information and controlling movement

-Corpus callosum: integrating information to respond successfully

 The best evidence for neurocircuit that connect prefrontal cortex and subcortical region is corpus striatum, this circuit is considered as a crucial path in responses.

Some characteristics about children who come to our clinic:

-In 2009: there were 137 times of visit with ADHD symptoms, 66 new cases, 77 repeated cases; ADHD: 50; ADD: 16; boy: 52; girl: 14; age: most common is from 5-7 years of age; it accounts for over 50%, above 10 years of age: 8 cases.

In 2010 ( in 9 months): 100 times of visit with ADHD symptoms, 63 new cases, 37 repeated cases, ADHD: 33; ADD: 11; boy: 39; girl: 11; 6-8 years of age: 70%.

Comorbidities: Enuresia, sleep disorders, reading disorder, oppositional defiant disorder, conduct disorder….are common problems. The repeated cases  shown some improvement in attention span and impulsivity.

Preventions:

1)   Pharmacotherapy: Psychostimulants are the first choice, these medications are not available in Vietnam, for example:Methylphenidate ( Ritalin). The effect of  stimulants is high, 70%-96% children improve attention ability.

2)   Alternative medications:

-Antidepressants: TCA (Tricyclic Antidepressant). Currently, we use Anafranil and Tofranil, and recognized some possitive outcomes: attention improvement, enuresia reduce. Side effects are sweating , cold hands and feet, difficult to sleep,  cardiac problems. Cardiology check is needed before taking the medication, the dose needs to be small first and increase gradually.

-Clonidine: (Catapress, catapressant): Central alpha antihypertensive agent, it reduces hyperactivity, especially in children who are sensitive to different stimulation. It can result in exessive sleep. We can prescribe this medication if children have sleep difficuty, the first dose should be given at bed time.

There are also some other medications such as : Atomoxetine ( Staterra) and Bupropion …they are rarely used in Vietnam.

3)   Comorbidities: Sleep difficulties, enuresia, oppositional defiant disorder, conduct disorder…

4)   Psychosocial intervention:

Although children with ADHD respond to pharmacotherapy, the result are different in every individual. Social skills and family problems could not be resolved by using the medication only.

Examination and evaluation in our clinic:

-Examination and diagnosis following criteria in DSM-IV-TR (2000). Each session could be 30 minutes or more depending on difficulties in every family

-It is cructial to rule out autism and mental retardation because the therapy could be different

-Explaining for parents the child’s disorder, helping them understand the nature of this, it is from neuropsychological factors that make the child difficult to control and inhibit his behaviors

-Explaining for parents their maladaptive way to their child could cause stress in the child and make parents more stress as well

-Explaining different therapies including: pharmacotherapy and psychosocial therapy

Personal therapy for the child:

Each session lasts for 45 minutes, 1-2 sessions per week, encouraging adaptive behavior, reducing opposional behavior, helping the child manage and control anger, increasing social skills.

Encouraging parents working with teachers in order to understand the child better

Comments: Number of children come to clinic become more and more, this may be from the information of this disorder in media communication such as TV and newspaper.

-Majority of children respond to pharmacotherapy in combination with personal therapy and family support

-Boy: girl ratio:boy is more than girl

-Most of families are difficult to cope with their child’s behaviors

-Teachers and peers do not understand the child, he or she  is easy to be social isolated

-Psychostimulants are not available in Vietnam

-Most parents are worried about  taking medications could cause some side effects in their children

-It is important to have time to explain to the parents different types of therapy including : medication, psychotherapy, long- term working with parents…

-Collaboration between medical team and educational team has not developed yet, many children still meet difficulty when their teachers do not understand them and do not have enough time to work with them

References: DSM-IV-TR(APA,2000); ICD-10(WHO, 1992);Developmental psychopathology (Charles Wenar, Patricia Kerig, 2006); Child and adolescent psychopathology (Theodore P.Beauchaine, Stephen P.Hinshaw, 2008); Abnormal psychology (Eric J. Mash, David A. Wolfe, 2005); Neurodevelopmental disablities in Infancy and Childhood (Pasquale J. Accardo, 2008); the clinician’s guide to Psychotropic Prescribing in Children and Adolescents ( CAMHSNET, Australia, 2003); child and adolescent psychiatry (Melvin Lewis, 2002).