Attention Deficit
Attention Deficit Hyperactivity Disorder, apparent in preschool and school at about 5years of age, characterizes a child who cannot control his behavior or pay attention. 3 to 5% of children have it. One in 25-30 children suffer from it. It was first described by Dr. Heinrich Hoffman in 1845 and then by Sir George F. Still of the Royal College of Physicians who described a group of impulsive children with behavioral problems.
The principal characteristics are inattention, hyperactivity, and impulsivity. The features emerge over a year. Symptoms may not be obvious at first and maybe have to be differentiated from other illnesses. The children may just seem to be naughty when impulsive. When inattentive, the child may be neglected as their deficit may not be so obvious. Adults too are found having this deficit which has probably carried on from their childhood
Attention deficit has been classified into 3 varieties: the predominantly hyperactive-impulsive type, the predominantly inattentive type, and a combination of the two.
The hyperactive-impulsive child is always moving about. They dash around playing with anything in their path. They talk ‘nineteen to the dozen’. It is difficult to make them sit quietly and listen. They squirm and fidget or tap their feet noisily, altogether restless. Impulsiveness is expressed as quick responses before even thinking about it. Blurting out inappropriate comments can produce delicate situations. Their emotional display has no restraint. Growing up into teenagers does not change their behavior. They prefer to select activities that they can perform easily. No effort will be taken unless they are interested.
Inattentive children have difficulty concentrating on one action. Their minds wander and they simply cannot complete a task with concentration. Only if they enjoy the job do they stay otherwise they are distracted by sights and sounds. They can forget to write an assignment or bring home their book or finish their homework with many mistakes and erasures. Diagnosis of the condition is made if the problems were noticed early in life, before 7 and persist for more than 6 months. The behaviors must express themselves in 2 areas of the child’s life among school, home, playground, the community, or social settings. The inattentive type is missed or diagnosed late.
Children with ADHD sometimes have other associated illnesses like learning disabilities, Tourette syndrome (having repetitive tics or mannerisms), conduct disorder, or oppositional defiant disorder.
Normal people exhibit some of the characteristics of the ADHD however persistence of symptoms is diagnostic of illness. Teenage is the time for experimentation, with a desire to be independent and try new and forbidden things like drugs or indulge in indiscrete sexual activity. Many go into a phase of low self-esteem due to peer pressure and failure in examinations. Automobile accidents are another problem.
Many a time adulthood is reached before a person is diagnosed. Comorbidity with specific learning disabilities, anxiety, or affective disorders may accompany his condition.
Studies with fMRI (functional magnetic resonance imaging) and PET (Positron emission tomography) have shown a smaller brain volume in children with ADHD. Those children who had medications exhibited the same volume of white matter as the controls. Those who had no medications had an abnormally small volume. The white matter is composed of fibers that establish long-distance connections between brain regions and increase with maturation.
Interventions for Attention Deficit
The National Institute of Mental Health undertook a very intensive study for evaluating the treatment. 4 treatment programs were selected.
- Medical management
- behavioral treatment
- Combination of both
- routine community care.
The evaluation was done after a specific protocol of 14 months of treatment for the first 3 groups. They found that the meditation group and the combination group fared very well, much more than the other 2 groups.
Stimulants like Methylphenidate are prescribed for the preschool age group but given only after no response is seen with behavioral therapy. If a child cannot accept a particular medication, that is discarded. If a child has anxiety or depression, in addition, a treatment combining medication and behavioral therapy is selected. Pemoline is also used. Methyl phenate is also obtained as Ritalin SR and Ritalin LA. The stimulants act on dopamine. Strattera, or atomoxetine, acts on the neurotransmitter norepinephrine.
Medication helps the children to focus in school and they produce good results. 80% of children who take medication need it during their teenage too.
Family counseling for the child and parents may help them resolve issues with understanding. The therapist helps the children feel better about themselves, identify and build on their strengths, cope with daily frustrations and control their attention and aggression. Mental health professionals help the parents and child develop new skills, attitudes, and ways of improving their relationship with each other.
Psychotherapy helps the child to accept themselves and handle their emotions better. Behavioral therapy helps to make amendments for immediate issues. The child’s thinking and coping may be changed so that behavior itself changes. Practical assistance and solving emotionally shared events could be the support. Social skills training helps a child find new ways to occupy himself and may even uncover some of his hidden talents. The children can identify with friends and interact.
Support groups help parents connect with others dealing with similar problems. Sharing of experiences and meeting frequently, the ‘severity of their problem dissolves.
Through parental skills training, offered by therapists, parents are armed with tools and techniques to handle their children’s behaviors. ‘Time-outs’ are practiced to isolate the child in a quiet corner till he calms down or accepts his punishment. The importance of quality time with the child is emphasized. The system of rewards and penalties is highlighted. Scheduling his daily routine, organizing his homework, and stressing on certain home rules may help him adjust. He is bound to face difficulties in school due to his condition. Standing up for him helps his demeanor.
Teenagers have more rules to follow. Freedom of using the car must be controlled. The interventions for adults include medicines, education, and psychotherapy.
Perception Disorder
The cerebral cortex of the brain has the primary cortices, secondary cortices, and association cortices. The association cortices are found in the parietal-temporal-occipital area, limbic area, and prefrontal area. They are the anatomical basis for thought and perception. The parietal-temporal-occipital association cortex has 3 distinct regions for somatosensory, auditory, and visual projections. These association areas receive connections from the higher-order sensory cortex and project to the motor cortex.
The sensory association area posterior to the postcentral gyrus of the parietal lobe integrates tactile and visual stimuli to create an understanding of shape and form or evoke memory. A lesion that involves this area on the right side causes visuospatial deficits which makes the patient have difficulty in finding his way around previously familiar places (perception of surroundings). This person finds it difficult to place objects in space. Reading and mathematics are hindered too as these subjects require visuospatial
integrity. The person will be unable to perceive numbers and words as separate entities, has directionality problems in reading and maths, and has confusion with similarly shaped letters. Visual discrimination is hampered (Visual Processing Disorder, 1999). He is unable to make out shape or form or recognize numbers, symbols, charts, etc. He does not have the property of visual closure whereby he can recognize faces even if he did not see the whole face. Visual agnosia prevents him from recognizing familiar numbers, pictures, or symbols and so learning is disturbed. Some children perceive things as wholes and do not see the parts. Some others have the opposite faculty (Visual Processing Disorder, 1999).
Damage to this area on the left disturbs the patient’s perception of spoken or written language. There is a large association area behind the sensory cortex which controls our perception of texture, size, shape, and weight. Damage to this area causes our losing this quality.
The auditory association area, the angular gyrus in the temporal lobe, is involved in the comprehension of language. A patient with a lesion here cannot understand what he hears. He has sensory aphasia and cannot comprehend conversations or even reply sensibly to your questions, appearing to talk nonsense syllables. There is difficulty in analyzing information he takes in through the ears. This can interfere directly with speech and language and can be associated with reading and spelling problems. He cannot follow his class. The lack of phonological awareness is the main problem and is described as a loss of auditory discrimination. He does not have auditory memory so he cannot recall stories. Auditory sequencing is affected so he says ‘ephelant’ for elephant.
He has lost the faculty of auditory blending whereby he cannot put ‘o’ ‘go together to form ‘dog’ (Auditory Processing Disorder, 1999).
The visual association area is in the occipital lobe and is called the peristriate area. Injury to these areas produces defective spatial orientation and visual disorganization in contralateral homonymous visual fields.
The prefrontal association area is involved with the ability to concentrate and attend, think elaborately, judgment, inhibition, personality, and emotional traits. Damage to this area causes havoc on emotional stability and produces cognitive impairment. There is a lack of inhibition in sexual discretion. An uncontrolled emotional personality will be the result. The limbic association area is concerned with the integration of recent memory, emotions like sex, rage, and fear. The damage would produce cognitive impairment and loss of recent memory
Interventions for Perception Disorder
A visual perception disorder requires interventions aimed at each person or child Depending on what specific disability the child has, appropriate interventions are designed.
Enlarged print for reading material, special software (having large-sized fonts), writing with thick pencils, teaching him in a planned manner allowing him certain privileges which help him study are some of the interventions (Visual Processing Disorder, 1999).
The interventions for the auditory processing disorder need to be tailored to the individual problems of the person or child. An effective intervention utilizes a child’s strengths to develop what he misses. Resorting to several methods of conveying information might be helpful. Oral instructions may be supplemented with written or other visual cues (Auditory Processing Disorder,1999). Simple verbal instructions, slow speech, and minimal distractions may be good. Activities that help build auditory processing skills like phonological awareness and auditory discrimination using rhyming games are useful. Auditory memory can be enhanced by sorting games (Auditory Processing Disorder,1999 ).
Amnesia
Memory loss, a feature of cognitive impairment, is the delay or failure to recall recent or distant events. Amnesia is an extreme form of memory loss when caused by a more severe injury to the brain, probably in a road accident, bomb explosion, or shooting incident. Involvement due to injury or aging can produce loss of memory of varying levels. Loss can be a mild dysfunction (MCI) or severe and named as dementia. Old people of 55-80 years of age could have cognitive impairment without having any illness. Memory loss is seen in degenerative disorders or dementias like Alzheimer’s, traumatic brain injuries, following ECT, or in Korsakoff’s psychosis.
Mental slowing is the difficulty experienced when trying to perform learned tasks in time or processing new matter. This could happen in aging. The intellectual decline is when we lose the ability to do what we used to previously and also lose the memory of a familiar place or date, usually due to an illness.
Korsakoff’s disease or syndrome is characterized by a strong memory defect, especially for recent events. It occurs in chronic alcoholics by a direct effect of alcohol or due to the severe nutritional deficiencies associated. B Complex deficiency is noticed in this illness. The syndrome follows delirium tremens. It is also associated with severe brain dysfunctions in paralysis, poisonings, dementia, and infections.
The patient covers up his recent memory defect by churning up tales. It would be difficult to weed the tales from the true story. Confabulation is a prominent feature in the severe or classic form. Other symptoms would be delirium, anxiety, depression, confusion, insomnia, and delusions. Memory loss will progress. Korsakoff’s psychosis is alcoholic neuropathy with severe mental disturbances. Korsakoff’s syndrome is a nonalcoholic form resulting from a head injury, tumors, and encephalitis.
ECT-induced amnesia follows episodes of ECT in a psychiatric illness. The retrograde amnesia is transient and may last a year. It resolves to leave a little residual impact. Patients have been found to have implicit memory. The implicit memory is probably due to an automated process and is not dependent on the areas of the brain involved. Familiarity and retrieval could tap some memory processes (Dorf et al, 1994)
Natural Aging
There is a progressive decline in the cognitive functions in natural aging too. The ability to store and retrieve short-term memory is affected. Abstract reasoning becomes difficult. New information cannot be easily learned. Diabetes, Alzheimer’s Disease, or Parkinsonism may occasionally contribute to the onset and progress. The cumulative effect of damage to the brain by free radicals or a fall in the energy output could be reasons. Key hormones also decrease after the age of 40. Diminished oxygen availability to brain cells is seen in atherosclerosis, heart disease, limited exercise, poor diet, stress, excessive drinking, and drug abuse. These can contribute further. Changes in lifestyle and nutritional deficiencies can play a role also in causing cognitive impairment in the aged.
Parkinsonism
This illness is a physiological malfunction due to deterioration in the substantia nigra of the brain. It is characterized by intellectual decline and mental slowing, cognitive impairment, memory loss, anxiety, or depression. These dementia patients have hallucinations, delusions, or uninhibited behavior. Dementia may not be obvious to the patient. However, it would be apparent to the people around him (Memory/Cognitive Function loss, MedMemory)
Alzheimer’s Disease is a very serious illness affecting the pre-senile age group. It is attributed to biological and genetic causes The symptoms of aging and the degeneration of the brain cells would be seen prematurely, starting in the language areas and extending beyond. The foremost problem is the loss of memory. They would never be aware of their memory problem. Feeling confused and repeating questions are features that reveal the condition to family and friends. Forgetting their identity, they usually get lost while out on a walk. They would forget some phases of their life. Recent memory is the one most affected. The meanings of certain words would be lost forever. The stage where simple daily activities like dressing and brushing the teeth are lost. Soon they lose control of the sphincters. The condition worsens with age. Unable to make logical sentences, they would fumble for some answer. They become bedridden during the later stage. Their caretaker needs to be extremely patient as all her time would be spent looking after the patient (Ballenger, 2006).
Interventions
Various theories have been propounded for those who have little memory. Medicines are not known to have any definite impact or are possible to turn around the situation. Donepezil and Memantine have been tried in Alzheimer’s Disease. These appear to help in some cases. The patient loses control of the sphincters and has to be helped with napkins. However, training in ablutions like for small children can help to a certain extent. Compassion and sincere patient care are the means of approach. Being stimulated with mental exercises, sharing time with counterparts, and being able to converse may keep them from going into depression.
Posttraumatic amnesia may be treated with early rehabilitation by reality orientation. Subjective memory loss in older individuals has been treated with Cerefolin NAC as a food supplement (Rush University Medical center, 2008). Memantine has been used as a treatment for declarative memory changes (University of Texas South Western Medical Center, 2007) Behavioral problem solving and supportive therapy are being used as an intervention for older cognitively impaired individuals for depression and memory deficits (National Institute of Mental Health, 2008). Donepezil has been tried for ECT amnesia (BerrYakov Mental Health Center, 2007). Galantamine is being tried for post-traumatic headaches (Rapoport Alan, 2005). All the studies mentioned are some of the latest proposed interventions.
References
Attention deficit Hyperactivity disorder, Web.
National Institute of Mental Health, USA Gov.
Auditory Processing Disorder,1999 17/4/08, National Center for Learning Disabilities. Web.
Ballanger, F.Jesse; “Self Senility and Alzheimer’s Disease in Modern America”, 2006. Published by JHU Press.
BerrYakov Mental Health Center, 2007, Clinical trials.gov, US National Institutes of Health. Web.
Dorf et al, “Priming and recognition in ECT induced amnesia” Vol 2, Issue2, Pgs. 244-248, Psychonomic Bulletin and review, 1994.
National Institute of Mental Health, 2008, Clinical trials.gov, US National Institutes of Health.
Rapoport Alan, 2005, Clinical trials.gov, US National Institutes of Health. Web.
Rush University Medical center, 2008, Clinical trials.gov, US National Institutes of Health. Web.
University of Texas South Western Medical Center, 2007, Clinical trials.gov, US National Institutes of Health. Web.
Visual Processing Disorder, 1999, National Center for Learning Disabilities. Web.