Barn med uppmärksamhets-inlärnings- och

koncentrationssvårigheter

Data från en longitudinell, populationsbaserad studie

Ulla Ek, leg psykolog, professor

Arbetslaget

• Elisabeth Fernell

• Kirsten Holmberg

• Studenter på psykologprogrammet

• Joakim Westerlund

• Barntandläkarsektionen vid KI- My Blomqvist och Göran Dahllöf

• Personal vid skolhälsovården i Sigtuna- Märsta

• Och 591skobarn från åk4 till åk 9

Vad är unikt med projektet?

• ”School based” inte clinic based

• Litet bortfall

• Multi disciplinärt

• Longitudinellt

• Svenska förhållanden

Beteendeproblem hos barn och

ungdomar:Vanligt är: uppmärksamhets- och koncentrationssvårigheter

Över- eller underaktivitet

Svårt med omställning och flexibiltet

Utbrott

En del fyller kriterierna för diagnos

Andra inte

Symptomen kan variera över tid i barnets liv

ADHD…. ADD t.ex

Ofta undersöks inte bakomliggande kognitiva

orsaksfaktorer(Barkley)

Datainsamlingen

Syfte:

Att identifiera barn med beteende och inlärningsproblem- rapporterat från hem och skola- och försöka spåra kognitiva korrelat som möjlig förklaring

Utökad hälsokontroll i åk 4

Screeningformulär till föräldrar och lärare(2x2)

Lärarintervju

Inklusionskriteria för fortsatt studie:

Conners´+ EF formuläret över 1/3 av max från både hem och skola

el.

Utfall på ett formulär + dokumenterade svårigheter

Metod

10%?Nej 175 barn uppfyllde kriterierna=34%!!

Föräldrarna inbjöds till att delta (med sitt barn) i en klinisk studie: föräldraintervju, DSM- intervju avseende ADHD, psykologbedömning

med WISC, Jag tycker jag är samt Bar i Lan. Lärarintervju

Återkoppling:

Miniutlåtande från psykologen

Uppföljning av skolhälsovården.

Ev. vidare utredningar

144 barn kom att ingå

• 44 flickor

• 100 pojkar

• 9 gick i specialklass (4MMR)

• 3 gick i ”långsam studietakt”

• 2 i autismklass

• 4 i liten grupp

• Övriga i vanlig grundskoleklass

Behavioural and learning problems in schoolchildren related to cognitive test data

Acta Paed 2004; 93: 976-981.

• KOGNITIV KARTLÄGGNING AV GRUPPEN• IQ < 70 8 pojkar 10 flickor

• 70-84 31 pojkar 12 flickor

• 85-115 57 pojkar 21 flickor

• >115 4 pojkar 1 flicka

• VFI och POI över 90

• UI och SI 1 sd under medelv.

• Vad var tankeväckande?

Cognitive strengths and deficits in schoolchildren with ADHD

Acta Paed 2007;96: 756-761

• 32 barn ADHD

• 10 sub-treshold ADHD.

• 102 BLP en blandning av koncentrations/inlärnings och beteendeproblem. Några barn med andra diagnoser.

• When analysing the 13 subscales of the WISC III for the entire group of 144 children (42/102) on a group basis, the lowest scores, were obtained with the Arithmetic, Coding, Information, Digit span (ACID), and Symbol search indicating that the “screen positive” children in the population, regardless of whether or not they had actually received a diagnosis of ADHD or not, have specific problems with attention, processing speed, auditory sequencing and working memory.

• On an individual basis a complete or incomplete ACID profile was equally common in the two groups, being found in about 1/5 of the children, in the two groups comprised of those who had screened positive.

• .. Thus, the cognitive weakness reflected in this specific (and very common) cognitive profile seems to play a role in various developmental disorders, as an underlying factor.

Svårigheterna

• The lowest scores in both groups were found on subscales reflecting working memory, planning and fluency (Information, Arithmetic, Digit span, Coding and Symbol Search).

Resurserna då?

• The FSIQ, VIQ, PIQ and the four Kaufman indices were almost identical for the children in the groups comprised of those determined to have ADHD and those without. The highest scores for both groups were obtained for the Verbal Comprehension index, reflecting certain vocabulary-related tasks, reasoning, problem solving and abstract verbal thinking and the Perceptual Organization Index, reflecting non-verbal abilities and a capacity for spatial reasoning. This finding is in accordance with those of Lovecky (2004), who emphasised the relative talents of children with ADHD, specifically some

verbal abilities, capacities that are frequently overlooked.

Vad lärde vi oss?

• 1.

• 2

• 3

• ?

• ?

Self-esteem in children with attention and/or learning deficits:the importance of gender

Acta Paed 2008;97:1125-1130

• Findings regarding the nature of self-esteem in children with attention deficit hyperactivity disorder (ADHD) are contradictory. Hoza et al, for example, reported that children with ADHD tended to overestimate their own competence, reporting an inflated estimation of self-worth, called positive illusory bias. Furthermore, they overstated their perceptions of themselves most strongly in areas where they had the greatest skill deficit

• The authors commented that “because children with ADHD chronically encounter setbacks and failures in a variety of areas, they may be especially inclined towards a thinking style characterized by positive illusions”

• Edbom et al. reported, from a prospective longitudinal twin study, a long-term relationship between ADHD-symptoms and low self-esteem. High score of ADHD symptoms at age 8 was related to low self esteem, according to the “I think I am” self-esteem-scale, at age 13.

Hypotes

• Our hypothesis when embarking on this study was that children with ADHD/subthreshold ADHD would report lower self-esteem than the reference group.

Resultat

We found negative correlations between the teachers’ ratings of both impulsive/restless behaviour and emotional lability and the children’s own ratings of their physical appearance. Thus, children who were considered to be restless, impulsive and emotionally labile did not feel good about their self-image, their looks and their body. This was especially salient for the girls.

Flickorna

• The girls in our study (irrespective of ADHD or BLD) reported lower self-esteem in terms of mental well-being, and relationship with parents and others, when compared to the boys in the study. The problematic behaviour of these children, reported by teachers and parents, probably result in more troublesome relations with friends, teachers and parents, something that might effect the self-esteem in girls more heavily than in boys.

The Conners´ 10 item scale: findings in a total population of Swedish 10-11 year-old children

Acta Paed 2009;98:828-833

• To present normative data for the Swedish version of the Conners´10-item scale, to validate the scale by comparing children with and without ADHD, to explore the factor structure of this scale and to investigate behavioural characteristics and gender differences among 10-11-year old children, as rated by parents and teachers respectively.

Method

• Parents and teachers rated 509 10-11-year old children (261 boys and 248 girls) from a population-based cohort in a Swedish municipality.

En två faktorstruktur

• The Conners´ 10-item scale discriminated very well between children with and without ADHD.

• Confirmatory factor analyses confirmed a two-dimensional structure of the scale with items measuring restless/impulsive behaviour in one factor and items measuring emotional lability in another.

• An ANOVA revealed that parents and teachers reported different behavioural characteristics in boys as compared to girls.

Lärarna ser inte flickorna?

• The parents seem to perceive a more varied behavioural repertoire and are able to identify both the restless/impulsive behaviour and the low frustration tolerance of the girls. The teachers, on the other hand, seem to overly attend to disruptive behaviours and overlook more inattentive behaviours. Girls with attention spectrum disorders are less likely to be referred for relevant assessments, presumably because their behaviour is less disruptive and therefore has a reduced impact on their environment compared to boys. We speculate that the lag for diagnosing girls with ADHD might be a consequence of their problems being more invisible in the class-room setting.

Tandläkarstudierna

• Videostudie av barn i undersöknings situationen

• Cortisol

• Karies och tandhälsa

• Tandläkar rädsla

• Alla finns publicerade European Journal of Oral Sciences

How do children with attention deficit hyperactivity disorder interact in a clinical dental

examination ? A video analysis

Blomqvist M, Augustsson M, Bertlin C, Holmberg K, Fernell E, Dahllöf G, Ek U.

Eur J Oral Scy 2005; 113; 203-209

Genomförande

• Ca 200 barn videofilmades ”i stolen”

• Detaljerad analys av 22 barn med ADHD och 47 kontroller genomfördes

• Första fasen analyserades med avseende på interaktion

• Språklig och icke- språklig kommunikation skattades av 2 skattare.

Resultat

• Signifikant fler initiativ speciellt med annat fokus eller oklart fokus

• Färre verbala responser och fler uteblivna responser

• Fler ”missing responses” och lägre grad av samordning fråga- svar

• Längre latens- mindre samordning!

Academic performance of adolescents with ADHD and other behavioural and learning

problems- a population- based longitudinal study

• Ek U, Westerlund J, Holmberg,K och Fernell E

• Insänd till Acta för bedömning

Hur gick det i skolan?

• 536 av 591 slutbetyg fanns hos SCB

• Bortfall: särskola, ännu ej avslutat gymnasiet eller Waldorfskola

• 3 grupper:

ADHD/ subtr. ADHD 39 st

BLP 80 st

Jämförelsegruppen 417 st

Meritpoäng max. 16 x 20= 320

• ADHD 147.44

• BLP 158.94

• Jämförelsegruppen 216.15

Möjlighet söka vidare ?

• Godkända betyg i Svenska, Engelska och Matematik

• ADHD 72%

• BLP 68%

• Jämförelsegruppen 92%

Underprestera i förhållande till optimal kognitiv förmåga ?

BLP IQ – 26 percentilen

Meritpoäng 22 percentilen

ADHD IQ – 26 percentilen

Meritpoängen 16 percentilen

Underpresterar

Ett barn med ADHD behöver en IK som ligger 2 standardavvikelser över medelvärdet för att nå samma betygssumma som genomsnittet!

Barkley bl.a. nämner risker för underprestation men vi har inga direkta studier på det.

Vad har jag lärt mig av det här?

• Ekonomin

• Tvärprofessionellt samarbete

• 34%!

• Profilen! Hur fånga resurserna ?

• Beteendet- flickor/pojkar- lärare/föräldrar

• Det är en utsatt grupp

• Utmaningen- den ligger i skolan