Attention Deficit Hyperactivity Disorder European Description
For professionals giving evidence to the Family Courts
An intensive one day course
For professionals giving evidence to the Family Courts
Challenges in Diagnosing Adults With ADHD
Russell A. Barkley, PhD
Department of Psychiatry, State University of New York
Upstate Medical University, Syracuse
Supported by an educational grant from
Eli Lilly and Company
For years, Attention-Deficit/Hyperactivity Disorder (ADHD) has been conceptualized as a developmental disorder of age-inappropriate inattention and hyperactivity.1 As a developmental disorder, ADHD arises early in life, typically before 7 years of age and certainly by age 16 years. The ADHD diagnosis requires not only a childhood onset of symptoms but also a childhood onset of impairment.1 Symptoms are the behavioural and cognitive expressions of a psychiatric disorder, whereas impairments are the social consequences that result from those symptoms. A diagnosis of ADHD requires a cross-setting occurrence of symptoms—that is, the significant symptoms must be present in 2 or more settings. Just as important is the requirement that there be impairment in major life activities. Having a high level of symptoms without evidence that the symptoms have significantly impaired major life activities is not sufficient for a diagnosis of ADHD.
When making the diagnosis of ADHD, clinicians are urged to exclude other disorders that may mimic the symptoms of ADHD.1 Many disorders are frequently comorbid with ADHD, including, but not limited to, depression, anxiety, conduct disorder, and antisocial personality disorder. However, these disorders cannot fully account for the symptom expression.
Diagnostic Assessment of Adult ADHD
Recommended practices for assessing adults for ADHD are listed in AV 1. Assessment begins with evaluating the patient’s symptoms using the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).1
Symptoms
The consensus criteria of ADHD currently manifested in the DSM-IV-TR1 were developed for use with children and were never meant to be used for adults. However, given that many children with ADHD will maintain the disorder into adulthood, and not all of them will have been diagnosed as children, clinicians need criteria for diagnosing ADHD in adults.
The phrasing of some DSM-IV symptoms in terms of “playing” or other typical childhood activities is inappropriate for use with adults.2 Better symptom criteria for an adult diagnosis would incorporate elements such as time management and executive function. A study5 undertaken to investigate adult ADHD symptomatology identified 9 essential symptoms for diagnosing adults with ADHD, retaining only a few useful symptoms from DSM-IV-TR (AV 2).
The current diagnostic threshold requires that the patient have 6 of the 9 symptoms,1 but because the criteria were developed for children, this cut-off is too high for adults.2 Until criteria better suited to adults, such as those in AV 2, are accepted, an appropriate cut-off for the diagnosis of adult ADHD would be 4 of the 9 DSM-IV symptoms.
Besides adjusting symptom descriptions for adults, the diagnostic criteria should address problems with gender-appropriateness, age at onset, developmental deviance, self-report corroboration, and appropriate life activities and impairment.
Sex-referenced rating scales.
Early research that was used to develop the DSM-IV-TR criteria for ADHD comprised more boys than girls,3 so the criteria may be biased against diagnosis in girls and women. New criteria should be developed using a field trial with equal representation of the sexes. With adult patients, clinicians should use sex-referenced rating scales, such as the Conners’ Adult ADHD Rating Scales.4
Age at onset.
The DSM-IV-TR requires onset of symptoms prior to 7 years of age for an ADHD diagnosis.1 An age at onset prior to 16 years would be appropriate for a diagnosis of adult ADHD because adults and their families can give unreliable reports concerning age at onset.5
Developmental deviance.
Guidelines for determining the developmental inappropriateness for the symptoms of inattention and hyperactivity or impulsivity are not provided by the DSM-IV-TR criteria.1 One suggestion is to use the 93rd percentile, or 1.5 standard deviations above the mean, on a well-normed rating scale of ADHD symptoms for adults as the indicator of developmental deviance.3,5
Corroboration of reports
New DSM criteria for the diagnosis of adult ADHD should require that clinicians corroborate information provided by the patient about current and past symptoms and impairment. Symptom severity and impairment in current major life activities are often underreported by patients under 30 years of age.5 Conversely, over reporting of symptoms and impairment also occurs, particularly when a financial or legal outcome is contingent on the evaluation. Corroborative reports should be obtained from family members, close friends, or a spouse or partner with long-term knowledge of the patient. Parents of adult patients may underreport early-life symptoms because of guilt for not getting their son or daughter treated earlier. A patient’s school, driving, or criminal records also might indicate problems in adolescence or earlier.
Developmentally referenced life activities and impairment
Besides the settings of home, school, and work that are described in current diagnostic criteria,1 appropriate major life activities for adults should be added. Diagnostic criteria need to include marriage, child-rearing, personal financial management, driving, health maintenance, social relationships, and sexual activity. Impairment is a requirement for the diagnosis of ADHD,1 but impairment is not defined in the DSM-IV-TR. According to the Americans With Disabilities Act of 1990,6 impairment substantially limits 1 or more major life activities. When determining impairment, patients should be compared with the average person in the population, regardless of the patient’s peer group or station in life. Further, just because an individual’s behaviour and its consequences fall below expectations for his or her level of intelligence does not mean he or she has ADHD.2
Subtypes of ADHD in Adults
Because symptoms of ADHD may change significantly with age, some childhood ADHD symptoms are no longer useful in discriminating adults with ADHD from adults with other clinical disorders. The subtypes of ADHD (i.e., inattentive, hyperactive/impulsive, and combined) specified in the DSM-IV-TR1 need to be revised. The hyperactive form of ADHD is rare in adults because children with this subtype of ADHD usually move into the combined type as executive and attention deficits develop.2 If hyperactivity disappears by adulthood, then adults cannot meet criteria for either the hyperactive type or the combined type, leaving only the inattentive type. Adult ADHD can be separated into 3 groups: (1) people who have outgrown hyperactive symptoms and no longer meet criteria for combined type ADHD so are considered to have the inattentive type, (2) individuals who almost meet the requirements for the combined type and are viewed as having the combined type, and (3) a group that exhibits sluggish cognitive tempo, which comprises individuals who do not have difficulties with hyperactivity or impulse control but who appear shy or withdrawn; have problems with staring, daydreaming, passivity, or confusion; and have difficulties focusing on the important versus the unimportant.7
Conclusion
Adult ADHD can be diagnosed using the criteria offered in the DSM-IV-TR with some adjustments. Until the updated diagnostic criteria for adult ADHD are listed in a future version of the DSM, clinicians should understand that the current criteria apply primarily to children. Issues such as symptomatology and impairment still apply, but the standards by which these categories are evaluated may differ greatly for adults.
Drug Names
No drugs were mentioned in this activity.
Attention Deficit Hyperactivity Disorder
European Description
The
ICD-10 Classification of Mental and Behavioural Disorders
World Health Organization, Geneva, 1992
Contents
-
F90 Hyperkinetic Disorders
-
F90.0 Disturbance Of Activity And Attention
-
F90.1 Hyperkinetic Conduct Disorder
F90 Hyperkinetic Disorders
This group of disorders is characterized by: early onset; a combination of overactive, poorly modulated behaviour with marked inattention and lack of persistent task involvement; and pervasiveness over situations and persistence over time of these behavioural characteristics.
It is widely thought that constitutional abnormalities play a crucial role in the genesis of these disorders, but knowledge on specific etiology is lacking at present. In recent years the use of the diagnostic term "attention deficit disorder" for these syndromes has been promoted. It has not been used here because it implies a knowledge of psychological processes that is not yet available, and it suggests the inclusion of anxious, preoccupied, or "dreamy" apathetic children whose problems are probably different. However, it is clear that, from the point of view of behaviour, problems of inattention constitute a central feature of these hyperkinetic syndromes.
Hyperkinetic disorders always arise early in development (usually in the
first 5 years of life). Their chief characteristics are lack of persistence
in activities that require cognitive involvement, and a tendency to move
from one activity to another without completing any one, together with
disorganized, ill-regulated, and excessive activity. These problems usually
persist through school years and even into adult life, but many affected
individuals show a gradual improvement in activity and attention.
Several other abnormalities may be associated with these disorders.
Hyperkinetic children are often reckless and impulsive, prone to accidents,
and find themselves in disciplinary trouble because of unthinking (rather
than deliberately defiant) breaches of rules. Their relationships with
adults are often socially disinhibited, with a lack of normal caution and
reserve; they are unpopular with other children and may become isolated.
Cognitive impairment is common, and specific delays in motor and language
development are disproportionately frequent.
Secondary complications include dissocial behaviour and low self-esteem. There is accordingly considerable overlap between hyperkinesis and other patterns of disruptive behaviour such as "unsocialised conduct disorder".
Nevertheless, current evidence favours the
separation of a group in which hyperkinesis is the main problem.
Hyperkinetic disorders are several times more frequent in boys than in
girls.
Associated reading difficulties (and/or other scholastic problems) are
common.
Diagnostic Guidelines
The cardinal features are impaired attention and over activity: both are necessary for the diagnosis and should be evident in more than one situation (e.g. home, classroom, clinic).
Impaired attention is manifested by prematurely breaking off from tasks and leaving activities unfinished. The children change frequently from one activity to another, seemingly losing interest in one task because they become diverted to another (although laboratory studies do not generally show an unusual degree of sensory or perceptual distractibility). These deficits in persistence and attention should be diagnosed only if they are excessive for the child's age and IQ.
Overactivity implies excessive restlessness, especially in situations requiring relative calm. It may, depending upon the situation, involve the child running and jumping around, getting up from a seat when he or she was supposed to remain seated, excessive talkativeness and noisiness, or fidgeting and wriggling. The standard for judgment should be that the activity is excessive in the context of what is expected in the situation and by comparison with other children of the same age and IQ. This behavioural feature is most evident in structured, organized situations that require a high degree of behavioural self-control.
The associated features are not sufficient for the diagnosis or even necessary, but help to sustain it. Disinhibition in social relationships, recklessness in situations involving some danger, and impulsive flouting of social rules (as shown by intruding on or interrupting others' activities, prematurely answering questions before they have been completed, or difficulty in waiting turns) are all characteristic of children with this disorder.
Learning disorders and motor clumsiness occur with undue frequency, and should be noted separately when present; they should not, however, be part of the actual diagnosis of hyperkinetic disorder.
Symptoms of conduct disorder are neither exclusion nor inclusion criteria for the main diagnosis, but their presence or absence constitutes the basis for the main subdivision of the disorder (see below).
The characteristic behaviour problems should be of early onset (before age 6 years) and long duration. However, before the age of school entry, hyperactivity is difficult to recognize because of the wide normal variation: only extreme levels should lead to a diagnosis in preschool children.
Diagnosis of hyperkinetic disorder can still be made in adult life. The grounds are the same, but attention and activity must be judged with reference to developmentally appropriate norms. When hyperkinesis was present in childhood, but has disappeared and been succeeded by another condition, such as dissocial personality disorder or substance abuse, the current condition rather than the earlier one is coded.
Differential Diagnosis
Mixed disorders are common, and pervasive developmental disorders take precedence when they are present. The major problems in diagnosis lie in differentiation from conduct disorder: when its criteria are met, hyperkinetic disorder is diagnosed with priority over conduct disorder. However, milder degrees of overactivity and inattention are common in conduct disorder. When features of both hyperactivity and conduct disorder are present, and the hyperactivity is pervasive and severe, "hyperkinetic conduct disorder" (F90.1) should be the diagnosis.
A further problem stems from the fact that overactivity and inattention, of a rather different kind from that which is characteristic of a hyperkinetic disorder, may arise as a symptom of anxiety or depressive disorders. Thus, the restlessness that is typically part of an agitated depressive disorder should not lead to a diagnosis of a hyperkinetic disorder. Equally, the restlessness that is often part of severe anxiety should not lead to the diagnosis of a hyperkinetic disorder. If the criteria for one of the anxiety disorders are met, this should take precedence over hyperkinetic disorder unless there is evidence, apart from the restlessness associated with anxiety, for the additional presence of a hyperkinetic disorder. Similarly, if the criteria for a mood disorder are met, hyperkinetic disorder should not be diagnosed in addition simply because concentration is impaired and there is psychomotor agitation. The double diagnosis should be made only when symptoms that are not simply part of the mood disturbance clearly indicate the separate presence of a hyperkinetic disorder.
Acute onset of hyperactive behaviour in a child of school age is more probably due to some type of reactive disorder (psychogenic or organic), manic state, schizophrenia, or neurological disease (e.g. rheumatic fever).
Excludes:
 |
anxiety disorders |
|
|
mood (affective) disorders |
|
|
pervasive developmental disorders |
|
|
schizophrenia |
F90.0 Disturbance Of Activity And Attention
There is continuing uncertainty over the most satisfactory subdivision of hyperkinetic disorders. However, follow-up studies show that the outcome in adolescence and adult life is much influenced by whether or not there is associated aggression, delinquency, or dissocial behaviour. Accordingly, the main subdivision is made according to the presence or absence of these associated features. The code used should be F90.0 when the overall criteria for hyperkinetic disorder (F90.-) are met but those for F91.- (conduct disorders) are not.
Includes:
|
|
Attention Deficit Disorder or syndrome with hyperactivity |
|
|
Attention Deficit Hyperactivity Disorder |
Excludes:
Hyperkinetic disorder associate with
conduct disorder (F90.1) F90.1 Hyperkinetic Conduct Disorder
This coding should be used when
both the overall criteria for hyperkinetic disorders (F90.- and the overall
criteria for conduct disorders (F91.-) are met.
ICD-10 copyright © 1992 by World Health Organization.Internet Mental Health
(http://www.mentalhealth.com/p.html ) copyright © 1995-2005 by Phillip W. Long, M.D.
Asperger Syndrome
AUTISM AS A FRUIT SALAD
Why there is no one thing called an Autism Spectrum Condition
A Lecture by Donna Williams
What if Autism Spectrum Conditions are the combined developmental effect of combinations of things and not single conditions? What if they are “cluster conditions?” What if an Autism Spectrum Condition is not like a piece of fruit but more like a fruit salad? The combinations in those fruit salads might differ from person to person and, so, the best collection of approaches, treatments and adaptations would differ too. One-size-fits-all-approaches which assume they address a single condition would be limited. But if we could identify the ingredients in each person’s “fruit salad”, then we might have the basics for an individualised programme based on the systems at work for that particular person.
All people with an Autism Spectrum Condition have an “information processing difference” to Non-Autistic people. Commonly though, they may also have anxiety, mood or compulsive disorders and combinations of more “Autistic” personality traits, each with their own set of natural motivations and distresses, which may run counter to Non-Autistic “normality” and which many Non-Autistic people find as “odd”, “strange”, “abnormal” or alien as the Non-Autistic person’s world may look to the person on the Autistic Spectrum!
This lecture will lay out the ingredients commonly found in those “fruit salads” and the very different treatments, approaches and adaptations found useful in reducing the disability issues associated with each so that the abilities can more easily shine through.
Donna Williams is a person diagnosed with Autism, a Sociologist and qualified teacher and the author of eight published books including Autism: An Inside Out Approach and her international best-selling autobiography, Nobody, Nowhere (all available from Jessica Kingsley Publishers www.jkp.com).
Donna is an international public speaker, a consultant, as well as a painter, sculptor and composer.
DATE: 27th May 2006TIME: 7pmVENUE: St Mary’s Church and Community Centre,Bramall Lane,SheffieldS2 4QZCONTACT: christine.breakey@spectrumfirst.co.uk orTELEPHONE: 0113 2669731TICKETS: £15 for professional and £10 for parents/carers and people with ASDCHEQUES PAYABLE TO:Spectrum First Ltd.
13 Spring Hill,
Crookesmoor,
Sheffield
S10 1ET
Conduct Disorder
Key messages
 |
Conduct disorders are the most common reason for referral of young children to mental health services. |
|
|
The prevalence of conduct disorders in 5–10-year-olds is 6.5% for boys and 2.7% for girls. |
|
|
Sixty-two per cent of three-year-olds with conduct disorders were found to continue these problems through to the age of eight. |
|
|
Children who become violent as adolescents can be identified with almost 50% reliability as early as age seven. |
|
|
Approximately 40–50% of children with conduct disorders may develop antisocial personality disorder as adults. |
|
|
The estimated annual cost per child if conduct disorder is left untreated is £15,270. |
|
|
Five aspects of parenting which have been repeatedly found to have a long-term association with antisocial behaviour are: poor supervision, erratic harsh discipline, parental disharmony, rejection of the child, and low parental involvement in the child’s activities. |
DEFINITIONS AND TERMINOLOGY
The term ‘conduct disorder’ is generally used to describe a pattern of repeated and persistent misbehaviour. This misbehaviour is much worse than would normally be expected in a child of that age. The essential feature is a persistent pattern of conduct in which the basic rights of others and major age-appropriate societal norms and rules are violated (American Psychiatric Association, 2000).
Professionals and researchers use a variety of terms to describe conduct disorders. These include disobedient, aggressive, antisocial, challenging behaviour, oppositional, defiant, delinquent and conduct problems. For the purposes of this report we have chosen to use the term ‘conduct disorders’ to cover children who are described as having either conduct disorder (CD) or, as is more frequently the case in young children, oppositional defiant disorder (ODD). For the full ICD– 10 and DSM–IV classifications for CD and ODD see Appendix 1.
Obviously there are a frequency and a severity of certain disruptive behaviours which are expected in young children and are considered part of ‘normal’ development, and children will usually grow out of them. These behaviours occur as part of the child’s developmental process; although they may be difficult for the parents to deal with, they will not be discussed in this report. A number of programmes are provided by various voluntary organisations to address less severe behaviour problems (Smith, 1996).
PREVALENCE
Epidemiological studies suggest that approximately half of those who meet diagnostic mental health criteria for CD will also meet criteria for at least one other disorder. The most frequent combination of problems is hyperactivity with CD, found in about 45–70% of those with CD.
The prevalence of CD in children between the ages of 5 and 10 years is 1.7% for boys and 0.6% for girls (Meltzer et al, 2000). Meltzer et al (2000) found the prevalence of ODD in 5–10-year-olds to be 4.8% for boys and 2.1% for girls. Although symptoms are generally similar in each gender, boys may have more confrontational behaviour and more persistent symptoms. There are also differences regarding gender in relation to the age of onset of conduct disorders. Robins (1966) found that the median age of onset for children referred to mental health clinics with antisocial behaviour was in the 8–10-year age range. Fifty-seven per cent of boys had an onset before the age of 10 years, whereas for girls the onset was mainly between 14 and 16 years of age.
LONG-TERM OUTCOMES
Conduct disorders have been described as being either those which start in young children and become persistent for the life course or those which emerge in adolescence. Research has shown that there is a particularly poor prognosis attached to early onset, which indicates that early treatments in these groups are essential (Moffit et al, 1996). Early starting patterns of conduct disorder are remarkably stable (Farrington, 1989). Richman et al (1982) found that 62% of 3year-olds with conduct disorders continued these problems through to the age of 8. Almost half of all youths who initiated serious violent acts before the age of 11 continued this type of offending beyond the age of 20, twice the rate of those who began their violent careers at age 11 or 12 (Elliott, 1994).
A number of theorists have suggested there should be strong links between disruptive and externalising behaviours in pre-school years and externalising behaviours in adolescents (Rutter, 1985; Loeber, 1990). The hypothesised early-onset pathway begins with the emergence of ODD in early pre-school years and school years and progresses to both aggressive and non-aggressive symptoms (e.g. lying and stealing) of conduct disorders in middle childhood and then to the most serious symptoms by adolescence.
The Isle of Wight study showed that children with conduct disorders at ages 10 and 11 fared worse at follow-up at ages 14 and 15 than children with other problems (Graham & Rutter, 1973). Farrington (1989, 1990), in the Cambridge Study in Delinquent Development, found half of the most antisocial boys at ages 8–10 were still antisocial at age 14 and 43% were still among the most antisocial at age 18. The Conduct Problems Prevention Research Group (1999a), which consists of a group of American researchers involved in the Fast Track project (described in more detail in Chapter 5), argues that although there will be false positives, the probability of identifying the majority of those children who are at serious long-term risk at school entry is high.
Loeber et al (1993) demonstrated that children who became violent as adolescents could be identified with almost 50% reliability as early as age 7, as a result of their aggressive and disruptive behaviour at home and at school. Robins (1966, 1978) noted that it was rare to find an antisocial adult who had not exhibited conduct disorders as a child, even though no more than half of the children identified as having conduct disorders go on to become antisocial adults. Studies have
shown that approximately 40–50% of children with conduct disorder go on to develop antisocial personality disorder as adults (Robins, 1966; Loeber, 1982; Rutter & Giller, 1983; American Academy of Child and Adolescent Psychiatry, 1997). Children with conduct disorders who do not go on to develop antisocial personality disorder may develop a range of other psychiatric disturbances, including substance misuse, mania, schizophrenia, obsessive–compulsive disorder, major depressive disorder and panic disorder (Robins, 1966; Maughan & Rutter, 1998). Higher rates of violent death have been shown to occur in young people diagnosed with conduct disorder (Rydelius, 1988). Farrington (1995) found that, as well as developing psychiatric problems, many children with conduct disorder develop non-psychiatric antisocial behaviours, which include theft, violence to people and property, drunk driving, use of illegal drugs, carrying and using weapons, and group violence.
Conduct disorders in childhood have also been linked to: failure to complete schooling; joblessness and consequent financial dependency; poor interpersonal relationships, particularly family break-up and divorce. They have also been shown to lead to abuse of the next generation of children, thus increasing the chance of them developing conduct disorders (Rutter & Giller, 1983; Robins, 1991).
Robins (1991) states, ‘because conduct disorder is common and has pervasive long-range effects, it is a very important public health problem’.
The cost of conduct disorders,
both in terms of the quality of life of those who have conduct disorders
(and the people around them) and in terms of the resources necessary to
counteract them, is high. It is therefore important that treatment for
conduct disorders is both effective and cost-effective.
Knapp et al (1999) state that the NHS resources spent on children with
conduct disorders are considerable. Thirty per cent of child consultations
with general practitioners are for conduct disorders. Forty-five per cent of
community child health referrals are for behaviour disturbances, with an
even higher level at schools for children with special needs and in clinics
for children with developmental delay, where challenging behaviour is a
common problem. Psychiatric disorders are present in 28% of paediatric
out-patient referrals.
Social services departments expend a lot of energy trying to protect
disruptive children whose parents can no longer cope without hitting or
abusing them. Often this may include a brief time with a foster family or
the placement of the child in residential care.
Education costs include funding special schools for emotionally and
behaviourally disturbed children, as well as providing extra staff to
support and provide special-needs education. Law enforcement agencies and
the probation service have to detect and prevent delinquency and bring the
delinquents to justice. The rate of unemployment and receipt of state
benefits is also high among young people with conduct disorders (Rutter et
al, 1998).
All agencies will spend considerable amounts of money in supporting a child
or young person with conduct disorder over the life span if nothing is done
to treat the child. Knapp et al (1999)
Voluntary sector 56
Fig. 1. Annual costs (£) per child with conduct disorder. Data from paper by Knapp et al (1999), based on a sample of 10 children.
examined the cost of treating children diagnosed with conduct disorder. The
total direct costs for all agencies (see Fig. 1 for a breakdown) were £8258.
The indirect costs, which included loss of employment for some parents,
additional housework and repairs, and allowances and benefits, were
estimated to be £7012. The total cost annually per child with conduct
disorder was likely to amount therefore to a staggering £15,270.
The House of Commons Health Committee (1997), in its report on child and
adolescent mental health services, cited two recent outcome studies of
projects in the US aimed at improving the behaviour of children from
disadvantaged backgrounds. The two studies also looked at the costs saved by
early intervention for conduct disorders.
The Perry Pre-school Project worked with 3–4-year-olds and looked at real-life outcomes to 19 years of age. This study found fewer delinquent acts, less use of special education and better peer relationships. Compared with controls, there were savings of $14,819 per child (Barnett, 1993; Schweinhart & Weikart, 1997).
The Yale Project ran a family support programme in the pre-school years and found that at the age of 13 years the children involved got better grades, attended school more regularly and had fewer behaviour problems. Compared with controls, there were savings of $20,000 per family in community resources expended (Seitz et al, 1985).
A consultation document for the National Assembly for Wales (2000) explains that if the NHS were successfully to treat a child with conduct disorder, with an expensive investment in childhood, this would not only save the NHS money over the person’s lifetime, but also other public sector.
Organisations could save significant amounts of money in the long run.
This approach emphasises the importance of multi-agency working.
RISK FACTORS
Conduct disorders present a significant public health problem for both the individual and the economy. To reduce the frequency of conduct disorders, the first step is to recognise the risk factors for them. These may in turn suggest the causes of conduct disorders and help to identify the children most likely to develop them. Risk factors for the development of conduct disorders may be considered in terms of child, parenting and environmental factors. The interaction of these factors is outlined in Fig. 2.
Child factors
TEMPERAMENT
Temperament refers to a number of characteristics that show some consistency over time (Normand et al, 1996). These characteristics appear soon after birth (Coffman et al, 1992). A number of studies suggest that infants assessed as having a difficult temperament are more likely to show problems with behaviour later on (Greenberg & Speltz, 1993; Prior et al, 1993). A difficult temperament may make children more likely to be the target of parental anger, which in turn may be linked to conduct disorders later on (Marshall & Watt, 1999). However, Wooton et al (1997) demonstrated a possible strong relationship between ‘callous-unemotional’ temperament and behaviour problems despite good parenting practices. The authors concluded that these children, with a lack of empathy, lack of guilt and emotional constrictedness, develop conduct disorders through causal factors distinct from other children with conduct disorders.
Genetic
Conduct disorder is thought to differ from attention-deficit hyperactivity disorder (ADHD) in terms of genetic influence.
For children with ADHD, the magnitude of the genetic influences is thought to be 60–90% (Goodman & Stevenson, 1989; Thapar et al, 1995; Silberg et al, 1996).
There is, however, little evidence to suggest that genetic factors alone contribute to conduct disorder. Plomin (1994) found genetic factors accounted for half the variation of externalising behaviour.
Genetic factors plus adverse environmental factors accounted for more of the variation in children with conduct disorders (Eaves et al, 1997).
As Walters (1992) states, it is very unlikely that a single gene or even a simple genetic model can account for complex behaviours such as conduct disorders or criminal activity.
Physical Illnesses
Rutter et al (1970) found that children with epilepsy or other disorders of cerebral function are at increased risk for conduct as well as emotional disorders. Rutter (1988) found that chronically ill children have three times the incidence of conduct disorders than their peers; if the chronic condition was found to affect the central nervous system (CNS), the risk factor rose approximately fivefold. It has also been shown that perinatal complications such as long labour, delivery with instruments and asphyxia predict conduct disorders and delinquency, although the effects of these complications may vary with other risk factors (Mednick & Kandel, 1988; Raine et al, 1994).
Social context
Cognitive Deficits
A number of studies have examined the cognitive correlates of conduct disorders in younger children and have found that they often have delays in language development and cognitive functioning (Cantwell & Baker, 1991; Hinshaw, 1992). Language problems, however, could also be considered not to be a child factor, as many factors associated with language development involve the parents’ and the child’s environment. An example of this is a study which found mother–child interactions and the home environment to be good predictors of language skill by the age of three years (Bee et al, 1982).
Cognitive deficits do lead to school underachievement and this has been
found to be associated with conduct disorder. Rutter et al (1970, 1976) in
the Isle of Wight study of 10–11-year-olds found that a third of children
with severely delayed reading levels had conduct disorder and a third of
children with conduct disorder were severely behind in their reading. Scott
(1995) emphasises the importance of turning around educational
underachievement in conduct-disordered children due to cognitive deficits,
as this leads to a continuing feeling of low self-esteem in the child. This
low self-esteem and belief that they are bad (when often the appropriate
assessments are not made and so specific reading and learning disabilities
may easily be missed) can cause marked misery and unhappiness and, as a
result, a higher incidence of depression (Scott, 1995). It has been
suggested that academic failure is a cause rather than a consequence of
antisocial behaviour; however, programmes that have improved the academic
skills of these children have not achieved reductions in antisocial
behaviours (Wilson & Herrnstein, 1985). Similar results have been found for
peer rejection, despite these children having been given social skills
training (Kazdin, 1987).
Poor Social Skills
Some of these children lack the social skills to maintain friendships and may become isolated from peer groups (Kazdin, 1995). Children engaging in problem behaviours are thought to have underlying distortions or deficits in their social information processing system (Dodge & Schwartz, 1997). Dodge & Price (1994) found that aggressive children were more likely to interpret social cues as provocative and to respond more aggressively to neutral situations. Children who are aggressive or antisocial are often rejected by their peers (Marshall & Watt, 1999). As Dishion et al (1991) show, peer group rejection is often a prelude to deviant peer group membership, which reinforces deviant behaviours. It has also been found that aggressive, antisocial children are socially inept in their interactions with adults. They are less likely to defer to adult authority, show politeness and to respond in such ways as to promote further interactions (Freedman et al, 1978).
Parenting factors
According to Carr (1999), neglect, abuse, separations, lack of opportunities to develop secure attachments, and harsh, lax or inconsistent discipline are among the more important aspects of the parent–child relationship that place youngsters at risk of developing conduct disorders. Parenting behaviour and parent characteristics such as depression are among the strongest predictors of child behaviour problems (Marshall & Watt, 1999).
Poor Parenting Skills
cott (1998) showed that five aspects of how parents bring up their children have been found repeatedly to have a long-term association with conduct disorders. These are:
|
|
poor supervision |
|
|
erratic harsh discipline; |
|
|
parental disharmony; |
|
|
Rejection of the child; |
|
|
Low parental involvement in the child’s activities. |
Such parenting appears to be a major cause of conduct disorders in children.
Webster-Stratton & Spitzer (1991) found parents of children with conduct disorders lack fundamental parenting skills and exhibit fewer positive behaviours. Their discipline involves more violence and criticism, and they are more permissive, erratic and inconsistent, and more likely to fail to monitor their child’s behaviour, to reinforce inappropriate behaviours and to ignore or punish pro-social behaviours.
Patterson’s work shows that parents of antisocial children are deficient in their child-rearing skills (Patterson, 1982; Patterson et al, 1989):
|
|
they do not tell their children how they expect them to behave; |
|
|
they fail to monitor the behaviour of their children to ensure it is desirable; |
|
|
they fail to enforce rules promptly and clearly with positive and negative reinforcement. |
Attachment
According to the attachment model proposed by Bowlby (1969), parental responsiveness is conceptualised as critical to the development of self-regulation skills. Therefore, differences in caregiver sensitivity and the resultant bond between the parent and infant are important factors in later patterns of the child’s behaviour (Lyons-Ruth, 1996). Greenberg & Speltz (1988) found that children who had received insufficient caregiving will act more disruptively to obtain the attention of their parent. They have less to lose in terms of love (Shaw & Winslow, 1997). Shaw & Winslow (1997) examined infant attachment security and observed the responsiveness of caregivers, and found that the parent–infant relationship correlated with externalising behaviour at a later age.
Poor interactions between mother and child can influence the child in many
ways (Marshall & Watt, 1999): the mother’s inappropriate modelling of
interactional behaviour (Bandura, 1986); the child’s development of
unrealistic goals and lack of knowledge of social rules within relationships
with adults and peers (Goodman & Brumley, 1990); the establishment of
coercive patterns of interaction within the parent–child relationship that
are carried forward to the peer group (Patterson, 1986); and the impact of a
lack of warmth on the child’s self-concept (Patterson et al, 1989).
Separation and disruption of primary attachments through neglect or abuse
may also prevent children from developing internal working models for secure
attachments.
Mental Health Problems in Parents
Offord et al (1989), in their longitudinal study of single- and two-parent families, found that mothers with psychological distress, major depression or alcohol problems were more than twice as likely to have children with externalising problems directed at others. Stein et al (1991) and Beck (1998) found that children older than one year whose mother is postnatally depressed display problems such as insecure attachment, antisocial behaviour and cognitive deficits. Depressed mothers are highly critical of their children, find it difficult to set limits and are often emotionally unavailable. Hall et al (1991) report that mothers who are depressed are more likely to perceive their child’s behaviour as inappropriate or maladjusted.
West & Farrington (1973) report strong links between the presence of an antisocial personality in one or both parents and similar behaviour in the child.
Substance Misuse and Criminality in Parents
Children coming from families where parents are involved in substance misuse or criminal activities are at particular risk of developing conduct disorders (Patterson et al, 1989; Frick et al, 1991).
Research has shown that when both parents are alcoholics this increases the chances of children developing ODD and CD (Earls et al, 1988). A number of researchers suggest that a combination of risk factors play a role in increasing behaviour problems. Miller & Jang (1977) found that children of alcoholics tend to come from lower-class homes with other problems, including parental mental illness, criminal activity, more marital breakdowns and more welfare assistance. Parents involved in crime may provide deviant role models for children to imitate and substance misuse may compromise parents’ capacity to care for their children correctly (Carr, 1999).
Teenage Parents
Marshall & Watt (1999) highlight the research showing that children of teenage mothers had more conduct disorders at age 8, 10, and 12 years compared with older mothers. However, as the research goes on to point out, the effects of teenage pregnancy may be due to the fact that children with teenage mothers tend to live on lower incomes, have absent biological fathers and suffer from poor child-rearing practices. Fergusson & Lynskey (1995) found maternal age, socioeconomic status, number of siblings at the time of the child’s birth and punitive parenting practices were all significant in the relationship between maternal age and conduct disorders.
Marital Discord
Marital problems, as previously mentioned, are a risk factor. Marital conflict leading to divorce can have detrimental effects on children (Marshall & Watt, 1999). Marital disruption is often associated with a change in economic circumstances and adjustments to altered living conditions; parents may be distressed and this may affect their parenting practices. Also, separated parents may not agree on rules and how they should be implemented. This may lead to a lack of communication about discipline and in turn to inconsistent disciplinary practices.
Some research suggests that when there is persistent conflict in families in which the parents do not separate, there are high levels of child behaviour problems and poor self-esteem in children (Marshall & Watt, 1999). In a recent study, negative marital conflict management skills on the part of parents (defined as the inability to collaborate and problem solve, to communicate positively about problems and to regulate negative affect) were a key variable in contributing to child conduct disorders (Webster-Stratton & Hammond, 1999).
Marital Violence
Marshall & Watt (1999) also provide evidence that marital conflict involving physical aggression is more upsetting to children than other forms of marital conflict. Children exposed to marital violence may imitate this in their relationships with others and display violent behaviour towards family, peers and teachers. Carr (1999) goes on to suggest that where children are exposed to negative emotions, their safety and security may be threatened and therefore they may express anger towards their parents.
Abuse
Abusive and injurious parenting practices are regarded as the most influential risk factors for conduct disorders (Luntz & Widom, 1994). Physically maltreated children were found to be commonly aggressive, non-compliant, to use acting-out behaviour and to perform badly on cognitive tasks. Sexually abused children had a variety of problems, including aggression and withdrawal, and were not liked by their peers (Erickson et al, 1989). Child maltreatment is a highly specific risk factor (Finkelhor & Berliner, 1995).
Single Parents
Where parents are living alone, they may find the constant pressure of looking after a child, along with domestic and work-related issues, difficult to manage, which can result in inconsistent discipline due to emotional exhaustion and lack of social support networks to help with the children. Parents of children with conduct disorder report major stressors two to four times more often than parents of children without conduct disorder (Webster-Stratton, 1990a).
Environmental factors Social disadvantage, homelessness, low socio-economic status, poverty, overcrowding and social isolation are broader factors that predispose children to conduct disorder (Hausman & Hammen, 1993; American Academy of Child and Adolescent Psychiatry, 1997; Carr, 1999). It seems that the longer the child has been living in poverty within the first four years of life, the more prevalent externalising behaviour problems become (Duncan et al, 1994). According to Graham (1991), children from large families and those living in homes where divorce or separation has occurred are at greater risk of conduct disorders. Children with conduct disorders are more likely to come from troubled neighbourhoods. Urban areas have higher rates of conduct disorders; Rutter et al (1975) found that conduct disorder was twice as high in inner London than on the Isle of Wight.
It becomes apparent that conduct disorders are extremely complex and pervasive. There are a number of risk factors for conduct disorders, and these can occur in combination. Apart from the direct link between poverty, socio-economic status and child behaviour problems, other factors, which include maternal depression, exposure to violence and poor parenting practices, seem to act as mediators to additional factors (Loeber & Dishion, 1983; Yoshikawa, 1994).
Resilience:
protective factors for conduct disorders Some children appear to have a number of risk factors associated with an increased risk of developing behavioural problems and yet do not go on to have conduct disorders. Rutter (1985) highlighted the importance of vulnerability and protective factors that modulate responses to stress. Werner’s (1992, 1994) longitudinal study investigated resilience in over 200 babies born in 1955 on a Hawaiian island, following and assessing the children at various times up to the age of 32 years. Werner found that the resilient children – those with the ability to cope with the internal stresses of their vulnerabilities and the external stresses of their environment – were similar in that they:
|
|
had the ability to elicit positive responses from others and the skills and values that led to an efficient use of their abilities; |
|
|
were engaging to other people; |
|
|
had good communication and problem-solving skills; |
|
|
were able to respond and relate to substitute caregivers; |
|
|
had a high IQ, had good abilities and good dispositions; |
|
|
had a hobby valued by their peers or elders; |
|
|
grew up with five children or less, with at least two years between the child and the next sibling, |
|
|
had parents with caregiving skills that led to competence and increased self-esteem. |
|
|
Pro-social peers and a school that creates success, responsibility and self-discipline have also been shown to be important in preventing behaviour problems (Rutter, 1979). |
ASSESSMENT
According to the American Academy of Child and Adolescent Psychiatry (1997), assessment requires the collection of data from a number of informants in multiple settings using multiple methods.
The assessment process is very important and other conditions (such as hyperkinetic disorder) need to be ruled out before a diagnosis of CD or ODD is made (see Appendix 1 for ICD–10 criteria). There are a number of assessment tools used to diagnose children with conduct disorders. Some of the most commonly used assessment tools are:
|
|
the Child Behaviour Checklist (Achenbach & Edelbrock, 1991), |
|
|
the Eyberg Child Behaviour Inventory (Eyberg, 1992), |
|
|
the Conners’ Parent–Teacher Rating Scales (Conners, 1989; Conners et al, 1998a,b). |
It has been shown that parent-training programmes are most effective for young children (under 10) with conduct disorders (Bank et al, 1991; Kazdin, 1995). This type of intervention is examined in greater detail throughout the rest of the report.
Most services will use the general principles in their practice if not specific parenting programmes. Chapter 7 presents the results of a survey which aimed to ascertain where parent-training programmes are available around the UK and whether current services vary from region to region.
The other main treatments offered to young children with conduct disorders include:
|
|
behavioural therapy; |
|
|
psychotherapy; |
|
|
family therapy; |
|
|
cognitive therapy; |
|
|
medication. |
Sleep Disorders
Treating Sleep Disorders
Improves Attention Deficit Symptoms
Treating Sleep Disorders Improves Attention Deficit Symptoms By treating sleep disorders, parents may find that their (ADHD) improves as well, according to a study released during the American Academy of Neurology's 50th Anniversary Annual Meeting April 25-May 2 in Minneapolis, MN.
The study involved children with ADHD as well as restless legs syndrome and/or periodic limb movements of sleep.
ADHD is a chronic, neurologically based syndrome characterized by restlessness, distractibility, and impulsivity.
Restless legs syndrome is a neurological disorder characterized by sensations of discomfort in the legs during periods of inactivity relieved by moving or stimulating the legs.
Periodic limb movements of sleep involve episodes of repetitive leg movements causing brief awakenings in brain activity.
Both sleep disorders can cause interrupted sleep and fatigue or sleepiness during the day.
In the study, five children were treated with the drug levodopa, which has been shown to improve symptoms of these sleep disorders but not ADHD.
"The children showed marked improvement," said neurologist Arthur S. Walters, MD, of the UMDNJ-Robert Wood Johnson Medical School and Lyons VA Medical Center in New Brunswick, NJ. "Their sleep disorders improved, and so did their behaviour and mental acuity."
The children's attention spans improved, along with their memory.
And parents also reported that their children's behaviour improved.
Walters said the sleep disruption may cause the children to be inattentive and hyperactive due to sleep deprivation.
The children also may have leg discomfort when sitting at their school desks that is relieved only by moving around, he said.
Walters cautioned, "It is not definitely proven that periodic limb movements of sleep leads to symptoms of ADHD.
An alternative possibility is that these disorders simply appear together frequently."
Children with ADHD have a higher incidence of periodic limb movements of sleep than children who don't have ADHD, Walters said.
Also, the parents of children with ADHD and periodic limb movements of sleep have a higher incidence of restless legs syndrome than other parents.
Researchers also have another theory why levodopa improves the children's ADHD symptoms.
"There may be a common link -- a dopaminergic deficiency in the brain that causes both the sleep disorders and the ADHD," Walters said.
One argument supporting this theory is that Ritalin(r), a common treatment for ADHD, promotes dopamine action in the brain, as does levodopa.
"No one understands why a stimulant -- Ritalin(r) -- improves hyperactive behavior," Walters said. "This could be why."
Walters said the benefits of the levodopa appear to last long term. The next step to confirm these results is a double-blind, placebo-control trial, he said.
The drug should also be tested with children with ADHD who do not have these sleep disturbances, he said.
Our thanks to Kathy West for bringing this to our attention
COMMENT
Dr.Billy Levin writes in reaction to the above article....
"There is a very clear association between A.D.H.D. and sleep disturbances starting with the infant who just does not sleep until he is exhausted.
|
|
Followed by the toddler who won't go to sleep on his own or will only sleep in the parent’s bed. |
|
|
The young child who is afraid of the dark, or takes ages to fall asleep or a very restless sleeper. |
|
|
The older child may go late to bed, have nightmares or wake at the crack of dawn. Separation anxieties may manifest here or bed wetting. |
All these to a greater or lesser degree and some or all may present.
As to Ritalin, the stimulating effect boosts the immature inhibitory function on the left hemisphere giving the patient on treatment better "brakes".
When many young A.D.H.D patients are given a sedative the opposite takes place. That is, they are stimulated and hyperactivity gets worse.
Clearly the inhibitory centers on the left hemisphere are sedated with fewer "brakes" and more activity takes place.
This is the well known "paradoxical reaction" often seen, to medications, in these children.
ADHD must be seen as an over developed right hemisphere giving behaviour problems or and immaturity of the left hemisphere giving rise to learning problems or a mixture of both in varying degrees."
Semantic Pragmatic Disorder
Compared with other conditions on the autistic spectrum, Semantic Pragmatic Language Disorder is one of the least known compared with its more famous brethren, Asperger Syndrome, ADHD and classic Kanner type Autism.
Persons may have SPLD alone, or semantic pragmatic impairments may co-exist with other autism spectrum disorders.
This account focuses on my experience with SPLD. I hope you find it useful and interesting.
Semantic Pragmatic Disorder is a linguistic term used to describe a set of abnormal language and communication developmental features, whose behaviours may "shade into autism at one extreme and normality at the other", with "unclear boundaries and differing outcomes over time" (Bishop and Rosenbloom, 1987, Bishop and Norbury, 2000).
Pragmatics is defined as the study of language in context and is all about the way in which a speaker performs both verbally and non verbally for a range of different purposes whilst:
Following a set of social do's and don'ts.
Taking into account the listeners needs and expectations
Providing the listener with just enough information to enable them to understand, interpret, and infer meaning from the communicative act
Semantics is defined as the study of meaning of words, phrases, sentences, and texts.
Semantic - Pragmatic combined deals with first of all getting at the meaning of the sentence through the actual words and the way in which they are structured, and then using context and what you already know to interpret and understand what is being said.
To put it in a nutshell, Semantic Pragmatic Disorder essentially means a child struggles with the meaning and use of language in the social context.
For example, consider the sentence “She cried on her mother’s shoulder”. We know from the knowledge of the meanings of words that “She” is a female, and we use what we know to work out that she is the daughter of the other person known as “Mother”.
We also know that she is no longer carrying out the action as the past tense is applied to the verb to cry, i.e. “cried”. We then need to use context and look for further clues in the text to provide us with some answers as to why she is crying on her mother’s shoulder, because it is not given explicitly in the sentence.
We also have to apply our knowledge of phrases and sentences to understand that what is written is not necessarily what is being implied, i.e. She is not actually crying, she is telling her mother about her problems in an attempt to gain sympathy.
Frequently, professionals refer to ‘semantic-pragmatic’ disorders, combining the two terms into one.
Whilst there is clearly some overlap in the concerns of the two disciplines and this can often make good sense, we should guard against assuming that the label suits all circumstances (Gagnon, Mottron and Joanette, 1997).
|
|
Children with pragmatic difficulties struggle to use language socially |
|
|
They do not understand how we take turns when we talk. |
|
|
They interrupt more than is acceptable. |
|
|
Their conversation often seems inappropriate or irrelevant. |
|
|
They can seem to be unaware of what their conversational partner needs to know - and can therefore say |
|
|
too much or too little about a subject. |
|
|
Some children have both semantic and pragmatic difficulties. |
Children with semantic and pragmatic disorders may use their language for a more restricted range of purposes than the rest of us, such as asking, directing, recounting experiences, imagining, and predicting.
They may also display some mild behaviours and features of autism coupled with the language difficulties too.
One should remain cautious and investigate a child for autism should they show autistic features alongside the following abnormal language development:-
|
|
Poor language processing, use and understanding literality |
|
|
Echolalia (parrot talk) and scripted language (copied phrases) |
|
|
Perseveration (repetition) and incessant chatter |
|
|
Poor turn taking and difficulty maintaining a topic of conversation |
|
|
Social difficulties, knowing how to be with people |
|
|
Difficulty responding to questions |
|
|
Talks around a subject rather than about it |
|
|
When young tends to speak in jargon with:-
|
SPD – Why does a child have these difficulties?
|
|
Children may have difficulties in the areas of Semantics and/or Pragmatics for a variety of reasons, including hearing impairment, expressive language disorder and delays in understanding language and vocabulary and autism. |
SPD - How does it affect a family?
|
|
·When a child is in his /her primary years it can be extremely difficult to cope with a child that has Semantic Pragmatic communication difficulties. |
|
|
They can often struggle to understand what you are saying, find it difficult to express their needs and may cry all of the time over the slightest of things. |
|
|
Parents are often under a great deal of stress and emotional upset during the early years and around the time a diagnosis is given. |
|
|
Parents need plenty of support from their friends and families to help them to come to terms with the diagnosis and what it means for their child’s future. |
They also need sound advice and ideas about how to help their child make good progress.
Communication Tips
|
|
Use a concrete consistent style of language |
|
|
Keep facial expressions and gestures simple and clear |
|
|
Be specific |
|
|
Be direct |
|
|
Limit vocabulary |
|
|
Address the child individually |
|
|
Be explicit with instructions |
|
|
Avoid sarcasm |
|
|
Explain humour, metaphors, idioms jokes, sarcasm, double meanings, nicknames and cutenames e.g. sweetheart. |
|
|
Break tasks down into manageable steps |
|
|
Check for understanding by asking "What are you going to do?" as opposed to "Do you understand?" as the latter will usually result in a "yes" regardless of whether the child actually understands. |
|
|
Practice social/pragmatic skills and vocabulary and generalise learning |
|
|
Give 1-2 step instructions |
|
|
Use visual cues and prompts |
|
|
Use familiar vocabulary |
|
|
Avoid open ended questions |
|
|
Prepare for transition, change |
|
|
Encourage suitable friendships to help your child with language development |
|
|
Encourage the child to ask for help, teach the child, give him the language and skills he/she needs in order to do this |
|
|
Use rewards schemes and praise, and link to the specific behaviour or performance |
|
|
Allow time for the child to respond |
|
|
Provide predictability and routine |
|
|
Help with organisational skills |
|
|
Boost the child's self esteem regularly and aim to raise confidence by giving tasks that are manageable and achievable for the child. |
|
|
Use social stories to address any behaviours or difficulties or to explain new events and situations that may create anxiety and rehearse and practice in different situations to generalise learning. |
|
|
Do not assume that the child understands difficult instructions, ideas and concepts especially to do with time and space, e.g. words such as later and soon may cause confusion. Break down, simplify and explain. |
|
|
Do not overload with information |
|
|
Don’t shout |
Tourettes Syndrome
Classification
Tics are sudden, repetitive, stereotyped, nonrhythmic movements (motor tics) and utterances (phonic tics) that involve discrete muscle groups. Motor tics are movement-based tics, while phonic tics are involuntary sounds produced by moving air through the nose, mouth, or throat.
Tourette's is one of several tic disorders, which are classified by the Diagnostic and Statistical Manual of Mental Disorders (DSM) according to type (motor or phonic tics) and duration (transient or chronic). Transient tic disorder consists of multiple motor tics, phonic tics or both, with a duration between four weeks and twelve months. Chronic tic disorder is either single or multiple, motor or phonic tics (but not both), which are present for more than a year.
Tourette's is diagnosed when multiple motor tics, and at least one phonic tic, are present for more than a year. Tic disorders are defined similarly by the World Health Organization (International Statistical Classification of Diseases and Related Health Problems, ICD10 codes).
Although Tourette's is the more severe expression of the spectrum of tic disorders, most cases are mild.
The severity of symptoms varies widely among people with Tourette's, and mild cases may be undetected.
Characteristics
Tics are movements or sounds "that occur intermittently and unpredictably out of a background of normal motor activity", having the appearance of "normal behaviors gone wrong."
The tics associated with Tourette's constantly change in number, frequency, severity and anatomical location. Waxing and waning— the ongoing increase and decrease in severity and frequency of tics—occurs differently in each individual.
Tics also occur in "bouts of bouts", which vary for each person.
Coprolalia (the spontaneous utterance of socially objectionable or taboo words or phrases) is the most publicized symptom of Tourette's, but it is not required for a diagnosis of Tourette's.
According to the Tourette Syndrome Association, fewer than 15% of Tourette's patients exhibit coprolalia. Echolalia (repeating the words of others) and palilalia (repeating one's own words) occur in a minority of cases, while the most common initial motor and vocal tics are, respectively, eye blinking and throat clearing.
In contrast to the abnormal movements of other movement disorders (for example, choreas, dystonias, myoclonus, and dyskinesias), the tics of Tourette's are stereotypic, temporarily suppressible, nonrhythmic, and often preceded by a premonitory urge.
Immediately preceding tic onset, most individuals with Tourette's are aware of an urge that is similar to the need to sneeze or scratch an itch. Individuals describe the need to tic as a build-up of tension which they consciously choose to release, as if they "had to do it".
Examples of the premonitory urge are the feeling of having something in one's throat, or a localized discomfort in the shoulders, leading to the need to clear one's throat or shrug the shoulders.
The actual tic may be felt as relieving this tension or sensation, similar to scratching an itch. Another example is blinking to relieve an uncomfortable sensation in the eye. These urges and sensations, preceding the expression of the movement or vocalization as a tic, are referred to as "premonitory sensory phenomena". Published descriptions of the tics of Tourette's identify sensory phenomena as the core symptom of the syndrome, even though they are not included in the diagnostic criteria.
Tics are described as semi-voluntary or "involuntary", because they to other movement disorders, is that they are suppressible yet irresistible; they are experienced as an irresistible urge that must eventually be expressed.
People with Tourette's are sometimes able to suppress their tics to some extent for limited periods of time, but doing so often results in an explosion of tics afterward.
People with Tourette's may seek a secluded spot to release their symptoms, or there may be a marked increase in tics, after a period of suppression at school or at work.
Some people with Tourette's may not be aware of the premonitory urge. Children may be less aware of the premonitory urge associated with tics than are adults, but their awareness tends to increase with maturity.
They may have tics for several years before becoming aware of premonitory urges. Children may suppress tics while in the doctor's office, so they may need to be observed while they are not aware they are being watched.
The ability to suppress tics varies among individuals, and may be more developed in adults than children.
Although there is no such thing as a "typical" case of Tourettes syndrome, he condition follows a fairly reliable course in terms of the age of onset and the history of the severity of symptoms.
Tics may appear up to the age of eighteen, but the most typical age of onset is from five to seven.
The ages of highest tic severity are eight to twelve (average ten), with tics steadily declining for most patients as they pass through adolescence.
The most common, first-presenting tics are eye blinking, facial movements, sniffing and throat clearing. Initial tics present most frequently in midline body regions where there are many muscles, usually the head, neck and facial region.
This can be contrasted with the stereotyped movements of other disorders (such as stims and stereotypes of the Autism Spectrum Disorders), which typically have an earlier age of onset, are more symmetrical, rhythmical and bilateral, and involve the extremities (e.g., flapping the hands).
Tics that appear early in the course of the condition are frequently confused with other conditions, such as allergies, asthma, and vision problems: paediatricians, allergists and ophthalmologists are typically the first to see a child with tics.
Among patients whose symptoms are severe enough to warrant referral to clinics, Obsessive-Compulsive Disorder and Attention-Deficit Hyperactivity Disorder are often associated with Tourette's. Not all persons with Tourette's have ADHD or OCD or other comorbid conditions (co-occurring diagnoses other than Tourette's), although in clinical populations, a high percentage of patients presenting for care do have ADHD.
One author reports that a ten-year overview of patient records revealed about 40% of patients with Tourette's have "TS-only" or "pure TS", referring to Tourette syndrome in the absence of ADHD, OCD and other disorders.
Another author reports that 57% of 656 patients presenting with tic disorders had uncomplicated tics, while 43% had tics plus comorbid conditions.
"Full-blown Tourette's" is a term used to describe patients who have significant comorbid conditions in addition to tics.
Dyslexia
The British Dyslexia Association National Helpline
Recognizing Dyslexia
What is dyslexia?
Dyslexia can be defined in many ways. However there is an increasing body of research evidence which suggests that people with dyslexia process information in a different way to non-dyslexic people. This has a range of effects, including difficulties with:
|
|
phonological processing (the way sounds within words are heard by the brain), |
|
|
working/short term memory (which can affect sequencing and multi-tasking), |
|
|
visual processing (managing fast incoming visual information), |
|
|
difficulties with reading, reading at speed or with certain types of words. |
The neurological difference can also confer strengths, such as skills in:
|
|
problem-solving, |
|
|
visualisation, |
|
|
creativity, |
|
|
spatial awareness, |
|
|
innovation and lateral thinking. |
In addition, dyslexia:
|
|
can vary from person to person, |
|
|
involves different combinations of difficulties and strengths, |
|
|
is a continuum: some people are mildly, some more severely dyslexic, |
|
|
can be identified at any age, |
|
|
is not related to intelligence, motivation, education, income, class, gender or ethnic origin. |
Dyslexia is usually identified by educational psychologists or suitably qualified specific learning difficulties teachers. It is important that these professionals have experience of adult dyslexia.
How can I tell if I might have dyslexia?
People with dyslexia will normally have all or some of the following:
|
|
a higher oral ability than written ability, |
|
|
difficulty with the structure and sequencing of written work, |
|
|
unexpected and persistent difficulty with spelling, |
|
|
slow reading speed, |
|
|
difficulty in taking notes in lectures, |
|
|
planning and organisational difficulties. |
What should I do if I think I might have dyslexia?
|
|
Step 1: Contact the Disability Service. |
|
|
Step 2: Consider a Screening Test. |
|
|
Step 3: Full Dyslexia assessment. |
|
|
Step 4: Follow up. |
Some of the information in this page is reproduced by kind permission of Bristol University Access Unit.