Attention-Deficit Hyperactivity Disorder (ADHD)

Ruwan M Jayatunge M.D. 

Attention-Deficit Hyperactivity Disorder (ADHD) is a neurobehavioral developmental disorder affecting about 3–5% of the world’s population. ADHD was first described by Dr. Heinrich Hoffman in 1845. He eloquently wrote about children with ADHD and their characteristics. Contemporary studies concur that the symptoms of ADHD are caused by a neurological dysfunction within the brain, mostly due to a deficiency in a specific neurotransmitter in the lower area of the brain. The principle characteristics of ADHD are inattention, hyperactivity, and impulsivity.

Attention-Deficit Hyperactivity Disorder is a condition that becomes apparent in some children in the preschool and early school years. Sometimes it may persist into adulthood. About 60 percent of children diagnosed with ADHD retain the condition as adults. These children need care and attention. When hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships, or the ability to accomplish day-to-day activities, therefore, they need treatment.

According to the US-based statistics, an estimated three to five percent of school-age children suffer from ADHD. Although there are no statistics available in Sri Lanka, a considerable number of children are affected by ADHD, and many do not receive any treatment. In our school system, ADHD children are considered bad students who are disobedient. But the fact is, their behavior is caused by complex etiological factors, and they are not bad by nature.

They have a poor attention span. They have difficulty organizing tasks and activities. Furthermore, they act as if “driven by a motor” and cannot remain still. Difficulty remaining seated; Easily distracted; Gives answers to questions before they are completed; Difficulty following instructions from others. Difficulty sustaining attention in tasks or play activities shifts from one uncompleted task to another; Talks excessively; Interrupts others; does not seem to listen; Engages in physically dangerous activities without considering the possible consequences; is restless and does not follow the commands.

There are a number of risk factors associated with ADHD. Major etiologic contributors include adverse responses to food additives and intolerances to foods. Too much refined sugar, Chocolate and Genetically Modified Food can increase hyperativity in some children. Common food additives and colorings can increase hyperactive behavior; some artificial additives increase hyperactivity and decrease attention span in a wide range of children. Some have sensitivities to environmental chemicals, molds and fungi. Exposures to neurodevelopmental toxins, such as heavy metals and organohalide pollutants can precipitate the condition. 

General Strategies to combat ADHD are important. Parental Education is vital. The parents must be taught how to handle the children. Some parents use corporal punishment, which can lead to the damage the personality. Parent-coached social skill training gives insight and handiness to manage an ADHD child more effectively.  Medications are necessary since there is an imbalance in brain chemistry. The medications must be prescribed by a qualified medical professional. Ritalin (methylpenidate) is widely used to treat ADHD. Medications must be prescribed by a qualified Physician. 

Apart from drug therapy, special Psychotherapeutic approaches are essential. Behavior Modification Programs for Home and School can be used to minimize inattentiveness and improve concentration. Relaxation training advances emotional control and the child is able to face day-to-day activities without much tension. CBT, or Cognitive Behavioral Therapy is important to improve motivation, problem-solving skills, and self-esteem. Some experts recommend Fun Cognitive Rehabilitation Exercises (Brain Training) to improve attention span. 

Cybertherapy is another mode of treatment that can be used for ADHD. In cyber therapy especially designed computer animation programs are used to enhance attention, concentration, eye contact and fine motor movements.  The therapist should allow the child to change work sites frequently while completing homework or studying. Behavioral approaches can be attempted to help the child concentrate on sitting still, staying on task or thinking before acting. Many ADHD children can be managed via music therapy.  Music therapy reduces their excessive stress factors. In order to enhance their productivity, guidance must be given to the students to verbalize a plan before solving problems or undertaking a task. 

The therapist should provide opportunities for students to show divergent, creative, and imaginary thinking. On most occasions, ADHD children have a good IQ, and if their massive energy is used prolifically a good results can be expected. Art Benjamin, the famous Professor in Mathematics was an ADHD child and he was able to conquer the illness. Therefore, ADHD is not a paralyzing condition. If positive guidance is given to the child, he/she can be a productive person.

Motivational Interviewing (MI) in the Field of Addiction Medicine

    

Ruwan M Jayatunge M.D. PhD 

Motivational interviewing (MI) helps to change longstanding behaviors that pose significant health risks, and MI is considered an important tool in addiction treatment. Moreover, MI is a tool designed to facilitate behavioral change in the patient by resolving the ambivalence to change (Miller & Rollnick, 2002). MI is facilitating health-related behavioral change in substance abuse, such as tobacco, alcohol and others (Dunn et al., 2001). Sim and team (2009) state that MI is about creating a climate that facilitates change, and can help build motivation, commitment and confidence to change.  

As described by Hall and colleagues (2012), Motivational interviewing is a patient-centered counseling method that involves enhancing a patient’s motivation to change by means of four guiding principles, represented by the acronym RULE: Resist the righting reflex; Understand the patient’s own motivations; Listen with empathy; and empower the patient. MI can be described as a collaborative and evocative process that honors patient autonomy (Miller & Rollnick, 2002). It is focused on patient coaching rather than instructing the patient and is described as a non-confrontational, non-judgmental and supportive type of counseling (Al Ubaidi ,2017). MI helps to promote and increase patient motivation towards positive behavioral change, as well as to explore and then resolve any negative issue(s) or experience(s) of conflict. 

 

MI focuses on client desires, thoughts and feelings as a way to encourage clients to express their own barriers to change and to explore and resolve ambivalence toward behavioral change (Wu & Lin 2009). The patient's motivation cannot be imposed by an external entity; it is the patient's task to resolve their ambivalence, and the counselor should not concentrate on persuading the patient to change their behavior.  (Al Ubaidi ,2017). Readiness to change is a dynamic process, and ambivalence is hindering positive change. Ambivalence is a conflicted state where opposing attitudes or feelings coexist in an individual. Ambivalence is evident in substance abuse.

 

MI strategies reduce the paternalistic therapeutic style, and the practitioner avoids an authoritarian stance. During the sessions, a partnership between the patient and practitioner is formed. Joint decision-making occurs. The practitioner acknowledges the patient’s expertise about themselves. The practitioner activates the patient’s own motivation for change by evoking their reasons for change. It is the patient’s own reasons for change, rather than the practitioner’s, that will ultimately result in behavior change. The therapist is using reflective listening skills and accurate empathy, where the practitioner seeks to understand the patient’s perspective, thoughts and feelings without judging, criticizing or blaming. Assisting patients to identify discrepancies between their current behavior and future goals or values about themselves as a person, partner, parent, or worker is a powerful motivator that helps ‘tip the balance’ toward change.

 

MI activates motivation for change. It uses a guiding communication style that invites people to consider their own situation and find their own solutions to situations that they identify as problematic and that are preventing change (Christie & Channon, 2014). The counselor adopts a "goal-directed approach" with a "patient-centered counseling style" that may enhance the patient's desire to change and decrease resistance (Miller & Rollnick ,2002). Research indicates that MI is equivalent to or better than other treatments such as cognitive behavioral therapy (CBT) or pharmacotherapy (Burke et al., 2003).

References

Al Ubaidi BA (2017) Motivational Interviewing Skills: A Tool for Healthy Behavioral Changes. J Fam Med Dis Prev 3:069.

Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled trials. J Consult Clin Psychol 2003;71:843–61.

Christie D, Channon S. The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations: a clinical review. Diabetes Obes Metab. 2014 May;16(5):381-7. doi: 10.1111/dom.12195. Epub 2013 Sep 1. PMID: 23927612; PMCID: PMC4237607.

Dunn, C,. Deroo ,L., Rivara, F.P.(2001). Addiction. 96(12):1725-42.

Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques - facilitating behaviour change in the general practice setting. Aust Fam Physician. 2012 Sep;41(9):660-7. PMID: 22962639.

Miller, W.R., Rollnick, S. (2002).Motivational Interviewing: Preparing People for Change. 2nd ed. New York: Guilford Press.

Sim MG, Wain T, Khong E. Influencing behaviour change in general practice - Part 2 - motivational interviewing approaches. Aust Fam Physician. 2009 Dec;38(12):986-9. PMID: 20369152.

Wu CC, Lin CC. [The application of motivational interviewing in nursing practice]. Hu Li Za Zhi. 2009 Apr;56(2):89-93. Chinese. PMID: 1931

Alexander Pushkin and Mikhail Lermontov - Who Shared a Common Fate

 

Ruwan M Jayatunge M.D. 

Alexander Pushkin and Mikhail Lermontov were Great Russian romantic poets who lived in the 19^th century. They knew each other and adored each other’s work. Both were rebellious in nature. Alexander Pushkin was the pioneer of Russian literature. Among his major works Ruslan and Ludmila  , Evgenii Onegin, and Boris Godunov can be considered the greatest masterpieces of Russian literature. Although Pushkin was a genius in literature, the Russian Czar did not tolerate his poems, which carried elements of protests. Pushkin was a daring activist who was secretly involved with an underground revolutionary group and also publicly expressed his support for the Decembrist uprising, which demeaned feudal reforms. As a result of his rebellious attitude, Pushkin was banished from St Petersburg.

 

In 1827, he composed the ode titled The Poet

 

Until he hears Apollo's call

To make a hallowed sacrifice,

A Poet lives in feeble thrall

To people's empty vanities;

And silent is his sacred lyre,

His soul partakes of chilly sleep,

And of the world's unworthy sons

He is, perhaps, the very least.

 

Pushkin knew the suffering of the peasants under the Czar’s regime. As a member of the upper Russian social class, Pushkin was never fascinated by its glory. He had a mission in life. Pushkin often used his writing to express the agony and suppression of the Russian people. Hence, he was hated by the regime. But, the general public recognized Pushkin as a great poet and respected him. Gradually he became the envy of the Royal Palace.

 

Many conspiracies were launched against Pushkin, and finally, he was provoked to engage in a dual. In the ill-fated dual, he was fatally wounded and later succumbed to the injuries. After Alexander Pushkin’s tragic death, Lermontov published an elegy titled Smerta Poeta or The Death of a Poet, which criticized the conspiracy involved in Pushkin’s untimely death.

 

Alexander Pushkin and Mikhail Lermontov shared many things in common.  

Both were inspired by the novels of Sir Walter Scott. Both demanded social reforms and emerged as spokesmen for literary radicals. Their work provided fertile ground for Russian poets and novelists.  Both had a great influence on later Russian writers. From Gogol to Dostoevsky and from Dostoevsky to Boris Pasternak, their unique influence remained unchanged.

  

Ironically, Pushkin and Lermontov led reckless and generally cynical lives, but they expressed their inner feelings via prose and verse. Mikhail Lermontov had an influence on Lord Byron, and as a matter of fact, he adopted the Byronic cult of personality. Lermontov’s psychological novel A Hero of Our Time describes a reckless and a cynical character named Grigorii Pechorin.

 

The central character, Pechorin, is complex in nature. Pechorin is an impulsive, emotionally numbed and manipulative, capable of extreme bravery but generally bored by his life. Pechorin was a hero as well as a renegade, and according to some critics, the central character in A Hero of Our Time could really have been applied to Lermontov himself. Lermontov's best-known poem, The Demon a self-accusing poem,   exemplifies a fallen angel who loves a mortal woman reflecting the poet's self-image as a demonic creature.

 

Lermontov loved the Caucasus region and admired its natural beauty. The Caucasus had also inspired Pushkin. Their characters were somewhat similar. Both were sensitive, cynical, nihilistic, and possessed extreme arrogance. They stood against social injustice. Like Pushkin, Lermontov was killed in a duel in the Caucasus. Both died at a young age, leaving a deep void in the field of literature. Alexander Pushkin’s and Leonardo's lives can be viewed as some of the most epic and dramatic in the history of literature.

Tim Hortons-Double -Double

  

A KKK Member

A Black Panther 

A Jihad Fighter 

All three came to Toronto

They met near the CN Tower

Decided to challenge each other   

They all went to Tim Hortons

Before starting their violent debate 

They ordered three  medium coffee 

Specifically said  - Double -double 

They enjoyed their coffee 

With Boston Cream Donuts

After finishing their coffee   

They instantly became friends 

They embraced each other 

Then agreed to renounce violence 

Hey Dorothy where are you

 

Hey Dorothy where are you 

Where is Toto - the dog that you loved 

Have you been to the magical Land of Oz

How did you escape from the wicked Witch of the East 

Whose hand savaged the  Munchkins

Your  magical Silver Shoes are shining 

You may be heading to the Emerald City 

Wanna meet the great and powerful Wizard of Oz 

Then walk on the yellow brick road

I see you walk with the Scarecrow  

When you meet the Tin Woodman

Pour some oil on him 

He would walk with you 

Do you hear the Lion's roar

He is harmless -a cowardly Lion

He needs confidence and care 

Join hand in hand with him 

The  Scarecrow wants a brain

The Tin Woodman wants a heart

The Cowardly Lion wants courage

What do you need Dorothy

Anything special 

Be cautious-  you are being watched 

The wicked Witch of the West sees you

She might send the Winkie soldiers 

Ask the  Cowardly Lion to strike 

Dorothy your bucket of water 

Melted the Witch

She said What a world 

What a world 

It was an end of an era 

An era of tyranny

 

Ruwan M Jayatunge