El coaching es un arte que debe ser aprendido sobre todo con la experiencia (Timothy Gallwey). Por ello en este curso de especialización se le da importancia a la práctica, además de a la teoría (definición, evolución, marco teórico del proceso del coaching).
La Especialización en coaching educativo y de TDAH prepara coaches capaces de enfrentar los retos educativos del mundo de hoy. Esto implica: 1) el aprendizaje de las últimas tendencias educativas relacionadas con el avance de la ciencia y 2) el adquirir un profundo conocimiento sobre el TDAH. Todo ello con el fin de acompañar a los estudiantes a explorar sus características, visibilizar cuáles de ellas son las que frenan su desarrollo personal, hasta lograr que encuentren sus propias estrategias para optimizar su potencial.
Esta especialización exige un proceso interno del alumno de auto reflexión para vivir e incorporar las herramientas que utilizará en el ejercicio del coaching.
El coach educativo y de TDAH tiene las facultades para realizar procesos de coaching no solo con personas con TDAH, sino con toda persona interesada en mejorar su desempeño.
- Conocimiento de las últimas tendencias educativas.
- Conocimiento del coaching como práctica terapéutica.
- Conocimiento científico del TDAH.
- Conocimiento y buen manejo de la técnica del coaching educativo.
- Incorporación y práctica del Código Ético del Coaching de TDAH, del APDA.
- Manejo práctico de las herramientas del coaching de TDAH.
Teoría.- Se estudiará la teoría del coaching y del coaching educativo, a través de la discusión de lecturas de libros y separatas. También se analizarán videos y casos. Se realizarán prácticas entre los participantes. Cada uno tendrá la oportunidad de ser coach y coachee.
Práctica.- Se realizarán prácticas pre profesionales y en las reuniones semanales se discutirán los casos, además del material de lectura.
– Orígenes del coaching, escuelas, tipos de coaching, actitudes, competencias, mitos, aprendizaje, características del coach, errores frecuentes.
– Teorías educativas: constructivismo y conectivismo. Retos de la educación en el mundo actual.
– Diagnóstico, tratamiento y comorbilidades del TDAH. TDAH en las diferentes etapas del desarrollo. TDAH y género. Implicancias en la vida. Resultados de investigaciones científicas. Aspecto legal.
– Origen y desarrollo del coaching de TDAH, modelo de coaching educativo y de TDAH, práctica según edades, temas recurrentes, experiencias en colegios y universidades, estudios recientes, estatutos.
Desarrollo de las reuniones:
Exposición de tema.
Discusión de lecturas.
Práctica del coaching entre los participantes.
Compromiso de las responsables del curso:
Brindar el siguiente material: Carpeta de trabajo, libros publicados por el APDA, bibliografía, asesorar las prácticas internas y pre profesionales.
Compromiso de cada participante para la certificación del APDA:
- Finalizar el curso.
- Asistir con puntualidad a las sesiones de clase.
- Cumplir oportunamente con las lecturas y entrega de tareas.
- Entregar los informes sobre el trabajo con su peer coach en los plazos indicados.
- Presentar los informes finales de las prácticas pre profesionales.
- Aprobar las evaluaciones finales del curso:
- Sesión de coaching presencial.
- Examen final.
- Cumplir con los pagos puntuales de acuerdo al calendario establecido.
- Cumplir con el Código Ético del coaching de TDAH del APDA.
- Modalidad presencial.
- Días: martes.
- Horario: 6 pm a 8 pm.
- Día de inicio: martes 14 de marzo 2017.
- Día de fin de curso: martes 5 de diciembre 2017.
- Duración: 38 semanas
- Se entregan los libros publicados por el APDA al momento de la matrícula y libros online en el transcurso de la especialización.
- Costo total: S/. 5200 soles
- Forma de pago:
- Marzo S/. 700 soles
- 9 cuotas de S/. 500 soles (la primera semana de cada mes)
- Depósito de S/. 700 soles en la cuenta corriente del BCP del APDA en soles, número: 193-1846242-0-08
- Enviar el voucher escaneado a email@example.com
- Recibirás la confirmación de tu inscripción vía email.
Calle Batallón Concepción 273, dpto 501-B, SURCO.
CRONOGRAMA DE CLASES
|Marzo: 14, 21 y 28
Abril: 4, 11, 18 y 25
Mayo: 2, 9, 16, 23 y 30
Junio: 6, 13, 20 y 27
Julio: 4, 11 y 18 (25 feriado por Fiestas Patrias)
Agosto: 1, 8, 15, 22 y 29
Setiembre: 5, 12, 19 y 26
Octubre: 3, 10, 17, 24 y 31
Noviembre: 7, 14, 21 y 28
Total: 38 semanas
- Acreditación de Coach de TDAH a nombre de la Asociación Peruana de Déficit de Atención.
- Al finalizar el año de formación, quienes hayan cumplido con todos los compromisos estipulados tendrán la oportunidad de ser incorporados al listado de coaches egresados del Curso de especialización de coaching de TDAH, en la web del APDA.
Datos de las responsables del curso:
Beatriz Duda es Licenciada en Educación (Facultad de Teología Pontificia y Civil de Lima), con estudios de Literatura (Universidad Nacional Mayor de San Marcos), coach graduada en la Internacional School of Coaching – TISOC, Coachville, Barcelona; en la International Coaching Community (ICC); diplomada en Coaching y Consultoría por la Universidad Ricardo Palma; y en Coaching de TDAH en los Cursos Avanzados de Nancy Ratey (CHADD).
Presidenta fundadora de la Asociación Peruana de Déficit de Atención desde el año 2002. Miembro del CHADD. Miembro de ACO. Las actividades que desarrolla en este campo son dictado de conferencias y talleres en el Perú y en el extranjero; de cursos de herramientas de coaching dirigidos a padres de familia y profesionales de la salud y educación; capacitaciones en comorbilidades del TDAH, motivación y plan de vida, entre otros; desde el año 2008 forma a coaches especializados en TDAH; ejerce la práctica del coaching con jóvenes y adultos.
Autora del libro El coaching para el TDAH: aspectos teóricos y prácticos; coautora de: Estrategias para el aula; Manual de diagnóstico y manejo del TDAH; Llévame a aprender. Manual de coaching para el TDAH en la escuela primaria; Adolescencia + TDAH. Editora de los boletines electrónicos semestrales del APDA. Colaboradora en revistas y blogs de Educación.
Maya Echegaray es coach de TDAH (Trastorno por Déficit de Atención con Hiperactividad) acreditada por APDA, Asociación Peruana de Déficit de Atención y vice presidenta de dicha asociación. Coach certificada por la International School of Coaching TISOC, Coachville, Barcelona. Licenciada en Derecho por la Universidad Católica del Perú. Diplomatura por la Escuela de Trabajo Social de la Universiitat de Barcelona. Diplomado en la Especialización de Recursos Humanos por la Universidad Católica del Perú. Conciliación en asuntos de familia. Formación en negociación, mediación y facilitación de procesos por Partners Democratic Change. Diplomada en Autismo y Asperger por la Universidad Católica y CEPAL (Centro Peruano de Audición y Lenguaje), egresada de la Segunda Especialidad en Psicopedagogía de la Universidad Ricardo Palma, entre otros.
En la actualidad desarrolla diversas actividades en el campo del TDAH: dictado de conferencias en el Perú y en el extranjero, de cursos-taller de coaching para el TDAH para padres de familia y profesionales, cursos de formación en coaching para el TDAH; sesiones informativas y práctica privada del coaching con jóvenes y adultos. Capacitación a profesores en el tema del coaching
El curso es un espacio de aprendizaje y crecimiento personal. Bea y Maya comparten su profundo conocimiento sobre el tema y nos llevan a “tomar acción” a través de videos, lecturas, prácticas e intercambio de experiencias. Nos brindan no solo conocimientos, información actualizada, herramientas y estrategias sino también la posibilidad de ser parte de un reto: ayudar a aprender, generar nuevos hábitos, cumplir metas, lograr el cambio. Una vez más les digo: Cuánto se está haciendo, tanto por aprender… y difundir!
Ma. Amalia Puccinelli, psicóloga
14ª Promoción, 2016
Entrenarme como Coach de TDAH ha sido un proceso de autodescubrimiento y compromiso progresivo, ahondé en información científica y actual sobre el TDAH y el cerebro, conocí la poética visión de Barkley sobre las funciones ejecutivas y aprendí herramientas para empoderar a las personas con TDAH en sus vidas. Esta formación, además de naturalmente permitirme hacer Coaching grupal e individualmente, significó un impulso para sensibilizar a otros sobre el trastorno, brindar capacitación, escribir artículos, realizar investigación; creo que a través de ella puedo contribuir a que las familias y las escuelas sean espacios de aceptación e inclusión, así como, propicios para el el soporte y el desarrollo de la autoestima y potencialidades de los niños y jóvenes con TDAH.
José Antonio Panduro Paredes, psicólogo
11ª Promoción, 2015
Gracias por haber compartido sus conocimientos, experiencias y amor por la educación. Sin su generosa apertura a enseñar, mi vida no hubiera dado un vuelco completo como lo es hoy! Me formé con las mejores para ser la mejor para mi hija y para quienes ahora puedo apoyar!! Eternamente en mi corazón.
Fabiola Pastrana, educadora
Soy profesor y trabajo en Secundaria en un colegio particular de Lima. Tuve la gran oportunidad de seguir el curso sobre Coaching Educativo para el TDAH. Las enseñanzas aprendidas en el curso han complementado enormemente mi labor como maestro: al comprender mejor a mis alumnos (no solo con TDAH), al orientar a padres de familia y al complementar la comprensión de mis colegas con sus propios estudiantes con dificultades. Definitivamente recomiendo seguir este curso a todo el que trabaje dentro del área educativa.
Luis Eduardo Amado Velásquez
6ª Promoción, 2012
Thomas E. Brown, Ph.D.
For decades ADHD has been recognized as a disorder that affects young children, mostly boys, who are inattentive and hyperactive. Research over the past decade has made it increasingly clear that ADHD also impacts children who are not hyperactive and that it affects girls as well as boys. Current research suggests that this disorder occurs in about 7% of school-aged children, affecting one girl for every three boys. Research also demonstrates that ADHD is a disorder that usually persists into adulthood.
Does ADHD continue after childhood?
For decades it was assumed that children outgrow ADHD as they reach the middle of their teenage years. Research has now shown that 70% of children who have ADHD in childhood continue to suffer from significant ADHD impairments into adulthood.
Why did everyone assume that ADHD went away during adolescence?
In earlier years it was assumed that hyperactivity was the primary symptom of ADHD. Often the hyperactive symptoms of this disorder do improve a lot during adolescence. It is the inattention symptoms that tend to persist into adulthood, These symptoms were not recognized as important in ADHD until more recent years.
How does ADHD affect adults?
Usually adults with ADHD suffer most from problems with inattention. Even when they want to focus on a task, they become excessively distracted. Frequently they are unable to remember what they have just heard or read. They have difficulty organizing their work tasks and are often excessively forgetful about what they intended to do. These and other related problems can cause great difficulty for adults in their work, driving, social relationships, parenting and family life.
Are adults with ADHD ever able to be successful?
Yes, many adults with ADHD are very intelligent, creative, likeable people who can accomplish good things. Yet for many, living with ADHD as an adult is like running a long race while carrying a knapsack of bricks on one’s back. You can do it, but you have to work very hard and the results are not usually as good as for others with the same ability and effort who are not carrying such a heavy load.
Does ADHD run in families?
ADHD definitely runs in families. Out of every four children with ADHD, one has a parent who has ADHD, whether they know this or not. And the other three usually have a grandparent, an uncle, an aunt, or a brother or sister who has ADHD. ADHD is as inheritable as height.
Can ADHD occur with other psychiatric problems?
It is not only possible for someone to have ADHD with another disorder, it is very likely. It is two to five times more likely. ADHD in an inherited disorder often accompanied by depression, anxiety, substance abuse, mood problems or another disorder. Often doctors helping adults can recognize and treat their other problems, but do not recognize or know how to treat their ADHD.
What help is available for adults with ADHD?
The most important help for adults with ADHD is a careful evaluation, diagnosis, and scientifically accurate education about the nature and course of ADHD. Good information about ADHD is available from Adana and from chadd.org. The most effective treatment for ADHD is medication. Research has shown that 80% of adults with ADHD experience significant improvement when they are taking a carefully tailored regimen of appropriate medication. These medications cure nothing, but they can alleviate ADHD symptoms much as eyeglasses do not cure, but can improve vision when they are properly fitted and while they are worn.
Dr. Brown is a clinical psychologist who is Associate Director of the Yale Clinic for Attention and Related Disorders in the Department of Psychiatry at the Yale University School of Medicine in the U.S.
This article was originally published in Spanish in adananews nº 3 in 2003. Dr. Brown sent us this English text, which was translated into Spanish by us and published in the newsletter nº 3 issued by the Asociación Peruana de Déficit de Atención (APDA), on March 22, 2004.
Michael Finkel M.D.
Dr. Armando Filomeno met Dr. Michael Finkel (who also did his neurology residency at the Strong Memorial Hospital of the University of Rochester) at the Nashville CHADD Conference in October 2004. At his request, Dr. Finkel —who does an important job in the field of international relations in the above mentioned institution— sent this article, written as a letter, about a subject in which he is an expert.
February 21, 2005
I am grateful for the opportunity to discuss the issue of AD/HD in adults with you, with our colleagues, and with our patients and families in Peru. As a means of introduction, let me say that I am a parent and spouse of individuals with AD/HD, as well as a neurologist who has worked with children and adults with this disorder for 15 years.
DEFINING THE CONDITION. It is now widely recognized that AD/HD is a disorder that often extends beyond childhood, and rarely occurs by itself. comorbid conditions are medical syndromes which occur at a frequency greater than what would be expected by chance alone. These comorbid conditions can be subcategorized as follows. Neurological comorbities include migraine headaches, restless leg syndrome and periodic limb movement disorder of sleep, epilepsy, tic disorders, Tourette syndrome, stutter, and enuresis. Psychiatric comorbities include depression, bipolar disorder, anxiety disorders, obsessive compulsive disorder, oppositional defiant disorder, conduct disorder, antisocial behavior, and substance abuse/chemical dependency.
Migraine headaches can occur before puberty in males, with the peak occurrence during the second decade of life. For females, the migraines can begin with menarche and continue through the reproductive years, to diminish with menopause. Restless legs and periodic limb movement disorder of sleep usually do not become a problem until the third decade, although parents will frequently note that the child has excessive limb movements during sleep. Epilepsy tends to be in the teen age years, and is not a common comorbidity. It is usually absence seizures, consisting of staring spells and eye blinking. Tic disorders can begin around 9-10 years of age, more often in males, and consist of two types. Motor tics involve simple and/or complex movements of the head, eyes, face, and limbs. Verbal tics involve simple noises or throat clearing, or complicated ones whereby the person blurts out things that are offensive to those who are around them. Fortunately, both types tend to peak around age 15. However, if both types occur in the same person who has AD/HD, often with obsessive compulsive disorder, the diagnosis broadens to be called Tourette syndrome. Stutter can be a lifelong problem. Enuresis ends by age 15.
Depression can occur before puberty, and is not necessarily caused because the child is having difficulties in school. Puberty will exacerbate it in both sexes, and menstrual irregularities can provoke or intensify episodes of this condition. For many adults in their fourth and fifth decades, the mood disorder is more disabling than the AD/HD. Bipolar disorder has different types, with variable presentations and ages of onset. A manic or hypomanic episode can be mistaken for the first onset of AD/HD or an exacerbation, and a psychiatrist has to separate the two conditions to treat them. Anxiety disorder can manifest as separation anxiety in children, and generalized anxiety, with or without panic disorders, from the second decade onward. Obsessive compulsive disorder is part of Tourette syndrome, although it can occur as an independent comorbidity. It may begin in the first or second decades, and becomes more problematic with age. Oppositional defiant disorder involves disrespect for adult authority. When property damage, criminal behavior and physical threats occur before age 18, it is called conduct disorder. After 18, the name changes to antisocial behavior, as the individual has reached the arbitrary and statutory definition of adulthood. Substance abuse/chemical dependency involves use of tobacco by minors, tobacco as adults, and drug/alcohol abuse as a minor and/or an adult.
Frequently, the AD/HD is the presenting problem during the first decade of life. However, the comorbid conditions can occur later, in a sequence and at an age that can be predicted. By being aware of the different types of AD/HD, one can be prepared to recognize when a patient might develop a comorbid condition later in life, plan a strategy, and prevent or lessen the impact of the condition, and even cause remission. The patients, families, and doctors need to visualize AD/HD as if it is the tip of the clinical iceberg, warning us of future danger below the surface.
TREATMENT STRATEGIES. First, we establish that the patient has AD/HD, and decide how to treat it. Many adults have learned to cope with the problem at work by taking jobs that are not sedentary and boring, or which allow the individual to learn a repetitious sequence of events from which there is little deviation, or by becoming self employed, with no one else to make the rules. However, requirements at home may require behavioral modifications as well a medications. The medical treatments are primarily stimulants (dextroamphetamine or methylphenidate based medications), atomoxetine, tricyclic antidepressants, and new antidepressants like venlefaxine and buproprion. However, one has to use stimulants cautiously in hypertensive individuals, and men in the fifth decade and above may experience erectile dysfunction, loss of libido, and problems emptying the bladder with atomoxetine. Therefore, one needs to be thorough in evaluation before starting them.
Second, we establish which comorbidities are present, and how to treat them. The neurological and psychiatric conditions have several additional medications that can treat them, as well as behavioral strategies. Sometimes the comorbid condition is more serious at the moment than the AD/HD, so we treat the most significant problem first.
We try to use the fewest number of medications, but we often need more than one type of medication. Therefore, many patients need two or more medications, depending on the type and severity of the problems, and whether or not a medicine can treat more than one condition. For example, some anticonvulsants and antidepressants will reduce the frequency of migraines.
Third, we have to modify the plan as conditions change. Sometimes migraines and depressions may need only 6-12 months of intensive treatment, while AD/HD medications might be needed for long periods of time.
I hope that this clinical discussion will help our colleagues, patients, and families understand how we physicians approach treatment plans in adults.
Michael F. Finkel MD, FAAN
Cleveland Clinic Florida in Naples
A Spanish translation of this article appeared in the newsletter nº 7 issued by the Asociación Peruana de Déficit de Atención (APDA), on March 14, 2005.
Steven R. Pliszka, M.D.
ADHD is the most common behavioral disorder of childhood. Uncomplicated ADHD is a fairly straightforward disorder to diagnose and treat, but significant numbers of children and adolescents with ADHD have comorbid disorders. In these situations, the differential diagnosis is much more difficult and treatment can be quite complex. Over the last several decades, considerable research has been done to determine the prevalence of various comorbid diagnoses in children with ADHD. The most common comorbid diagnosis is that of oppositional defiant disorder, which can affect up to 60% of both boys and girls with ADHD. A smaller percentage of around 20% children with ADHD may develop conduct disorder. The prevalence rates for mood and anxiety disorders are somewhat more variable and less well defined, but at least a third of children with ADHD may develop an anxiety disorder. The rate of major depressive disorder (MDD) among children with ADHD has been estimated to range from 10 to 30%. Figures for the prevalence of mania on children with ADHD are somewhat more difficult to come by. Biederman and his colleagues found that up to 16% of their sample of ADHD children met criteria for mania. In contrast, U.S. National Institute of Mental Health Multimodal Treatment Study of Children with ADHD (MTA) did not find it necessary to exclude any children. Nonetheless, the MTA study did find a subgroup of ADHD children who showed very high levels of mood lability, aggression and hyperactivity. There is often disagreement among clinicians as to how many of these types of children truly have bipolar disorder.
Oppositional defiant disorder (ODD) is a pattern of negativistic, hostile and defiant behavior. Children with ODD lose their tempers easily, argue with and frequently defy adults, and show irritating behavior toward peers. They tend to remain angry and resentful for long periods of time and are often spiteful or vindictive. ODD varies greatly in its severity. It is important to note that both ODD and conduct disorder are descriptive diagnosis that do not imply any particular etiology. This is in contrast to the diagnosis of ADHD which is a primarily neuro-biological condition. ODD may be secondary to ADHD —a child with ADHD may be so impulsive that he reacts with anger and poor judgment to any adult request or to any stressor. Therefore it is important that when the child meets criteria for both ADHD and ODD, the clinician should consider the ADHD to be primary. A number of studies have now shown that oppositional behaviors improved with treatment of the ADHD. This is true for all of effective treatments for ADHD, including both stimulants and atomoxetine.
Conduct disorder is a much more severe disorder, because it involves aggression and antisocial behavior. Children with ADHD and conduct disorder can be differentiated from those with ADHD alone by a number of factors. ADHD children with comorbid ODD/CD are also more likely to have learning disorders, particularly in the area of language. They are more likely to have a family history of antisocial behavior and are at greater risk for developing delinquent behavior during adolescence. Children with ADHD alone have a higher risk of developing substance-abuse disorders as adults, but children with ADHD and comorbid ODD/CD often began experimentation with illegal substances during early adolescence.
It is important to bear in mind that children with ADHD and comorbid ODD/CD respond as well to stimulants as children with ADHD alone. There is no evidence that stimulants or other medications used to treat ADHD increase aggression at appropriate doses except in very rare circumstances. There has also been considerable research on whether treatment with stimulants itself is a risk factor for substance abuse. Timothy Wilens and his colleagues reviewed a number of studies examining the rate of substance-abuse disorders in children with ADHD as a function of their stimulant treatment history. In fact, children with ADHD who never received treatment with medication had a higher rate of substance abuse than those who received treatment. This suggests that effective treatment of the ADHD may actually prevent the development of later substance-abuse disorders.
If oppositional and aggressive behaviors persist after the ADHD has been adequately treated, then several approaches should be considered. The clinician should consider adding a behavior management program. This usually consists of identifying key oppositional behaviors that need to be targeted —for instance a child needs to improve on behaviors such as not hitting a sibling, doing things first-time asked and doing his homework promptly. Each day he receives points from the parent based on how well he has performed these tasks. His weekly allowance is then based on how many points he earns during the week. If he earns a particularly high level of points, then some special privilege is awarded. In contrast, if the number of points earned is extremely low, then some restriction from weekend activities is called for. Alpha agonists such as clonidine or guanfacine have been combined with stimulant medication to treat temper outbursts and aggression. Adverse events such as dizziness and low blood pressure may occur however, and parents should be warned about these risks. In severe situations, where the aggressive behavior is dangerous to the patient or to others, then mood stabilizing or atypical antipsychotic medication may be appropriate. I will return to this topic after our discussion of ADHD and bipolar disorder.
Studies examining the prevalence of depressive disorders in children and adolescents with ADHD have yielded variable results. Roughly 11% of the patient’s in the MTA of ADHD study met criteria for major depressive disorder. In most studies of children with depression the rate of ADHD is approximately 30%. When a child presents with both ADHD and MDD the clinician faces the dilemma as to which condition to treat the first. The Texas Children’s Medication Algorithm Project (CMAP) recommends that the clinician assess each disorder and determine which is the most severe; this disorder should be the focus of initial psychopharmacologic management. After the ADHD has been successfully treated, the clinician should assess whether the depressive symptoms remain problematic. If so, the clinician should begin treatment of the depression, usually with a serotonin reuptake inhibitor or institute a psychosocial intervention. In contrast, if the major depressive episode is quite severe (with a high level of the neurovegetative signs and/or suicidal ideation), then an antidepressant treatment should be the initial intervention. If the ADHD symptoms persist after the depression has remitted, then a stimulant may be added to the antidepressant regimen.
Up to one third of children with ADHD may also have a comorbid anxiety disorder. Quite often, these anxiety symptoms are mild in severity, and are related to the high level of stress that the child feels due to the dysfunction in his life. If the child’s worries are confined to the consequences of his ADHD behaviors, then the clinician can be reasonably optimistic that these anxiety symptoms will remit once the ADHD is under control. In other cases, however, the child will suffer from intense anxiety including phobias, obsessive-compulsive symptoms, or high levels of generalized anxiety associated with physiological symptoms such as racing heart, muscle tension or trouble sleeping. The Texas Children’s Algorithm Project (CMAP) recommended two different approaches for dealing with this situation. Atomoxetine has been shown to be effective for the treatment of both anxiety and ADHD, so it may be considered an initial treatment in this situation. Alternatively, the child may be treated with a stimulant, but if the anxiety symptoms do not remit after treatment of the ADHD, then a serotonin reuptake inhibitor can be added to the stimulant in the treatment of both anxiety and depressive disorders. One should not lose track of the fact that psychotherapy, particularly cognitive behavioral psychotherapy, is a very effective treatment for these disorders. Thus it is equally acceptable to combine pharmacologic treatment of the ADHD with a psychosocial intervention for the anxiety.
The treatment of the comorbidity of ADHD and bipolar disorder is perhaps one of the most difficult problems in child and adolescent psychiatry. For the purposes of this paper, we will include in the bipolar spectrum those patients with severe mood lability and aggression who may not have all of the classic DSM-IV symptoms of bipolar disorder. If a patient with ADHD is floridly manic, then mood stabilization is the priority and treatment of the ADHD should be deferred until this has occurred. In childhood and adolescence, lithium and valproate have been studied in controlled trials. Considerable open trial data suggests the efficacy of atypical antipsychotics. Atypical antipsychotics have the advantage that they have a rapid onset of action and very flexible dosing. They generally require less laboratory monitoring than lithium or valproate. Nonetheless they are associated with weight gain, a risk of diabetes, metabolic syndrome and elevated cholesterol. Children on atypical antipsychotics require monitoring of weight, and serum lipids at least twice a year. When mood stabilization has been achieved then treatment of the ADHD can progress. In situations in which the diagnosis of the mania is less clear or in doubt, then the initial treatment should address the ADHD. If the putative mania symptoms resolve with successful treatment of the ADHD then it is unlikely that the child was in fact suffering from a bipolar disorder. In contrast, if the child’s inattentive impulsive and mood symptoms do not resolve with treatment of the ADHD or if the child worsens, then the clinician may move to treatment with anti-manic agents.
The final issue to address is the comorbidity of tics and ADHD. At one time, it was believed that tics were an absolute contraindication to stimulant treatment. Recent evidence has shown, however, that there is no statistically significant difference between placebo and stimulants in terms of their propensity to cause tics in children with comorbid ADHD and tic disorders. However, most clinicians will encounter patients with comorbid ADHD and tics who have an increase in tics when they are started on a stimulant medication. In this situation, the clinician should try an alternative medication for the ADHD in an effort to control the ADHD symptoms without exacerbating the tics. In some situations however, the patient only responds to a stimulant in terms of the ADHD, but the stimulant worsens the number or severity of the tics. If this occurs the clinician should consider adding an alpha-agonist to the stimulant medication. Only in the most severe situations, should the clinician consider adding an atypical antipsychotic.
In summary ADHD can be comorbid with a wide range of disorders. Fortunately there is an equally diverse array of treatment approaches that the clinician can apply to these situations. As a result, we can substantially help these difficult patients.
Steven R. Pliszka M.D.,Professor and Vice Chair; Chief, Division of Child & Adolescent Psychiatry, Dept. of Psychiatry, University of Texas Health Science Center at San Antonio , San Antonio, Texas, USA.
Dr. Armando Filomeno, who met Dr. Pliszka at CHADD’s 17th Annual International Conference in Dallas, USA, October 2005, thanks the distinguished professional for this excellent article which he translated into Spanish for APDA’s electronic newsletter nº 12, issued on June 28, 2006.
Martha B. Denckla, M.D.
Whatever is distinctive about girls with ADHD must be viewed against the background facts concerning how girls in general differ from boys in general; the rate and consequent quality of development differs in well-known ways. Girls talk earlier and are more easily brought into compliance with social demands like toilet training and sitting still for a meal. Girls are more natural “people-pleasers” and less natural “environment-explorers” than are boys. It is likely that adult positive reinforcement of verbal and social skills throws a bias into girls’ choices and then experience/nurture further imbalances girls’ cognitive styles. In pre-school, only 20% of the little girls will seek out the block corner when free play choices are made available. The play-time choices are further crowded by girls’ earlier ease acquiring reading and writing skills, heavily positively praised and reinforced. The mix of nature, nurture, experience, and reinforcement starts so early that studies of gender differences must be interpreted with caution.
There is a biological/natural basis for observed developmental differences. From mid-gestation, the traditional “quickening” point of pregnancy right on up to puberty (which arrives, on average, earlier in girls than in boys) the brains of girls are more mature in all the stages of cellular migration, proliferation, connectivity, pruning, and myelination. The left side of the brain, so dominant in language and academic skills, gets such a “headstart” in girls that it may excessively dominate the right side, leading to the observed phenomena of girls excelling up to puberty in the language arts (emphasized in the skill set of elementary school) while boys are the “late bloomers” who emerge in the adolescence as the mathematics/science or even creative leaders. (Sometimes the male high-achievers in high school or college still cannot spell or write legibly!) A particularly useful piece of my research on normal coordination, the PANESS,1 shows that the timed motor skills curve for kindergarten girls fits perfectly over the one for first grade boys, and this pattern persists through fifth grade! It is because we have the “folk wisdom” of generations of observations of such developmental differences that we smile and shake our heads as we say, “Boys will be boys” but cannot come up with an analogous saying for a mischievous or messy little girl.
Consider then the plight of the little girl with ADHD, widely acknowledged and publicized mainly in the persons of little boys. Traditional diagnostic schemes capture four times as many boys as girls under the ADHD heading; but recently it has been suggested that estimated ADHD prevalence figures of 3-5% of the school-age population are under-estimates, due to under-diagnosis of many girls with ADHD. With the DSM-IV subtype of “predominantly inattentive” ADHD legitimized, some surveys redress the total diagnostic imbalance to the extent of three boys to every one girl with AD(H)D.
Still, it remains the case that girls with AD(H)D (the parenthetical H standing for the “predominantly inattentive” subtype) continue to be under-represented even as candidates for diagnosis because the girls are less disruptive, less likely to be oppositional, less blatantly or obviously off-task than the boys. Girls, with or without AD(H)D, following their “people-pleaser” tendencies, may appear outwardly attentive to a teacher or go docilely to a bedroom to “do” homework while in actuality day-dreaming, doodling, writing notes to classmates in school, or “instant messaging” on the homework-intended home computer! Girls with ADHD may appear “passive-aggressive” (and may eventually become so) by saying “yes” to requests to do chores and then forgetting to do them. Even when resembling boys in their ADHD-related physical restlessness or boisterousness, girls with ADHD are rarely as extreme in “physicality”. Many clinicians, however, are eager to introduce into ADHD diagnostic schemata the physical “hyperactivity and impulsivity” domain of the mouth; girls with ADHD talk more, blurt more, boss more, and even eat more than other girls or their age! Many clinicians see one subgroup of the current obesity-prone generation as girls with ADHD. Thus, a genuine physical health risk attaches to girls with ADHD, just as accident-proneness attaches to boys with ADHD.
Girls with ADHD may be more troublesome at home than at school, more impaired socially among peers than academically (at least in elementary school). They may control themselves in the structured school environment but “let down their hair” and irritate or agitate their families. Their messiness, sloppy eating habits or even neglect of personal hygiene may be far more alarming to parents than would similar characteristics in a boy. Psychological interpretations (often only partially relevant) other than possible ADHD may rise to greater prominence than warranted in a messy, sloppy, unkempt girl with ADHD. Add obesity and a whole chain of social rejection events may complicate the girl’s development. By middle school, social rejection can loom so large that emotional problems may overshadow the underlying ADHD; adding to the organizational deficits that ADHD (of even the mildest type) usually entail, the unhappy girl does not have the energizing and reinforcing social rewards of school life. The clinician asked to search for ADHD (any subtype) in a girl of 11 to 14 years is doing a kind of neuropsychiatric “archaeology,” attempting by careful history-taking and neurological/neuropsychological examination to piece together the neurodevelopmental diagnosis underlying an emotional collapse. Had the girl been referred earlier, the diagnosis of ADHD (not to speak of comorbid learning disabilities experienced by a third of those with ADHD) would have been more evident, less covered over by psychiatric complications and psychotropic drug effects.
What about treatment for girls with ADHD? As with boys, ADHD requires a customized multimodal treatment program (home/parental management training, school program of accommodations, facilitating achievement, individual psychotherapy or tutoring or both, and adjunctive use of a stimulant medication). Notice the “final position” of medication, which is “neither curse nor cure” and must be customized for each patient at each age level and task demand/supply ratio, titrated very individually towards short-term target improvements and re-addressed frequently! In this regard, the special needs of girls are simply that each set be described in terms of specific target signs or symptoms, acknowledging that in development all targets are “moving targets.” The home, school, and individual therapeutic programs for girls with ADHD are even more important than the appropriate adjunctive medications, because the social-emotional complications of ADHD so insidiously overtake the girls before medication may even seem worthy of consideration.
In summary, girls with ADHD present with less-obvious, later-recognized, more “internal” forms of the disorder that Russell Barkley has so succinctly educated us to understand as revealing the nature of all kinds of “self-control.” The price paid by girls with ADHD for their less-obvious, later-recognized course is that emotional complications have more time to gain a foot-hold as comorbid depression or anxiety or “passive-aggressive personality” before correct multi-modal therapeutic programming can be implemented for the ADHD syndrome itself. There is thus an urgent need to look at little girls with more sensitivity towards manifestations of ADHD, even of the non-disruptive, predominantly inattentive type, lest social rejection and “creeping” academic underachievement combine to make a much more seriously troubled adolescent girl who is, by the way, highly vulnerable to substance abuse.
Martha Bridge Denckla, M.D., Batza Family Endowed Chair; Director, Developmental Cognitive Neurology, Kennedy Krieger Institute; Professor, Neurology, Pediatrics, Psychiatry, Johns Hopkins University School of Medicine.
Dr. Armando Filomeno —who was at the Johns Hopkins Hospital as a fellow when the KKI’s name was John F. Kennedy Institute for Habilitation of the Mentally and Physically Handicapped Child— thanks Dr. Denckla for this interesting article, which he translated into Spanish for APDA’s electronic newsletter nº 9, issued on September 15, 2005.
(1) Physical and Neurological Examination for Soft Signs (editor’s note).
Prof. G. E. Berrios
The word and its referents
Names help or hinder in all walks of life, particularly when they behave as drifting signifiers. For example, since it first appeared in fin de siècle France as a double-barrelled word (‘neuro-psychiatrie’), the meaning of ‘neuropsychiatry’ has repeatedly changed. By the interbellum period, and now converted in ‘neuropsychiatrie’, it referred to the clinical doings of medics trained both in neurology and psychiatry. By 1918, the word appeared in the Anglo-Saxon to name a form of: “Psychiatry which relates mental or emotional disturbance to disordered brain function”. My own definition is narrower: “discipline that deals with the psychiatric complications of neurological disease”. On the other hand, American usage is broader and tantamount to “biological psychiatry”.
Currently, and first and foremost “neuropsychiatry” refers to overlapping clinical disciplines sharing the belief that mental symptoms are produced at disordered brain sites. It is also used to make a professional claim vis-à-vis rival views of mental disorder such as psychoanalysis. Lastly, it creates a social and economic space wherein like-minded researchers safely congregate to usufruct their fashionable ideas.
Whether there is ‘neuropsychiatry’ in a particular country, and whether it has a broad or narrow meaning will depend, to a large extent, upon the structure of its health services and on the quality of the relationship between neurology and psychiatry.
This is interesting and ironical as both specialisms are new. Alienism (the original name for psychiatry) and neurology developed by the 1830s and 1860s respectively as the direct result of the fragmentation of the old grand Cullean category of ‘Neurosis’, and of the broadening of the notion of ‘lesion’ which by the end of the century indistinctly referred to failures and solutions of continuity in putative ‘structural’, ‘physiological’ or ‘psychological’ domains. In Germany and France, the formation of alienists included neurological training and this facilitated the use of the term ‘neuropsychiatrist’. In Great Britain, on the other hand, and due to important socio-economic reasons (which there is no space to discuss), neurology and psychiatry had fully diverged by the 1880s. This means that for more than 90 years there was little communication between the two and that during the 1970s ‘neuropsychiatry’ had to be reinvented. It is not altogether surprising that those of us who were involved in such re-creation had both neurological and psychiatric training. This also explains why to this day we do not have in the UK a unified definition of neuropsychiatry. The American definition has become popular and this has encouraged psychiatrists holding a biological orientation au outrance to call themselves ‘neuropsychiatrists’. Others (like myself) continue defining neuropsychiatry in a narrow way. The former can be found in all venues of psychiatric care, the latter work in general hospitals and do a great deal of ‘neuro-liaison’ work (I introduced this term in a lecture given in Wellington, New Zealand some years ago).
Neuropsychiatry in Cambridge, UK
In keeping with the above, my own ‘neuropsychiatric’ clinical service is organize on the narrow view that neuropsychiatry is a branch of psychiatry that deals with the mental complications of neurological disease. I do not believe that such practice should in any way be interpreted as a statement about the nature of mental disorders in general. Even within the confines of my narrow definition, it seems clear that neurological patients who develop delusions, hallucinations, obsessions, sadness, anxiety, etc., etc. do so on account of a variety of mechanisms. On the one hand, there are the causal aetiologies. As my work on musical hallucinations and irritability states in Huntington’s disease patients showed years ago, a direct link can be demonstrated between symptom and brain site or CAG repeat, respectively. On the other hand, neurological patients have reasons for their symptoms, that is, neurological diseases happen to real people and hence have semantic contexts. This adds an entire new layer of meaning, hermeneutics and therapeutic response. Patients may show behavioural copies of mental symptoms and these do not have the same brain representation as the conventional symptoms.
Neuropsychiatric clinical work generates clinical templates which can be translated into research paradigms. There is nothing new in this and each university will use a different rhetoric to sell what they do. Some sell themselves as top-to-bottom research institutions (i.e. grand ideas governing action), others, are bottom-up ones (piecemeal, low level research converging upwards). This is the case of the Cambridge University Neuroscience Campus (the largest in the UK) which includes research institutes and a neuroimaging suite with inter alia 12 MRI magnets. My Neuropsychiatry Service (6 clinics) is linked with most of the research centres in the campus. For example, the PD Clinic provides patients for the large projects on receptor expression, fMRI, pharmacology, and neurosurgery. The HD Clinic is held in the ‘Brain Repair Centre’ where about 12 patients who have already received fetal cell implants in their caudate nuclei are followed up at 3 months intervals. The Traumatic Brain Damage clinic takes place in the ‘Oliver Zangwill Centre’, the leading cognitive neuropsychological rehabilitation clinic in Europe. The Sleep Disorders Clinic works closely with the ‘Respiratory Unit’ at Papworth hospital which includes the more advanced polysomnographic set up in the UK. The Memory Complaints Clinic services the large complex of memory research at the ‘Cognitive and Brain sciences Unit’, a ‘Medical Research Council’ facility where concepts such as executive functions and working memory were first developed; and my General Neuropsychiatry Clinic is linked up with the ‘Epilepsy Neurosurgical Unit’, the ‘Tinnitus Clinic’, etc. All these clinical- basic-sciences associations create ideal opportunities for translational research which has traditionally been the British way of developing new ideas.
Whatever the clinical context, neurological disorders are often accompanied by psychiatric appurtenances. The psychiatric component of some, like Parkinson’s disease, Multiple Sclerosis, Huntington’s disease, Wilson’s disease, Binswanger’s disease, etc., etc. has been known for a long time, and in some cases the severity and management of that component is more important for social re-entry than any motor or sensory disorder. In other cases, however, such as the taupathies, mitochondriopathies, CADASIL, X-Linked Adrenoleukodystrophy, etc. etc., not enough research has yet been carried out to identify the psychiatric component. In all situations, an intelligent practice provides the neuropsychiatrist with conundra whose resolution has direct relevance to psychiatry in general; two of such will be briefly discussed below.
The neuropsychiatrist often finds that there is a lack of fit between the clinical phenomena met with in neuro-liaison work and the conventional psychiatric categories of ICD-10 and DSM IV. Neurological patients exhibit a variety of mental symptoms but these are often isolated and/or fleeting and rarely achieve critical mass to qualify for a ‘psychiatric diagnosis’. This raises theoretical and practical issues. The former have to do with their nature and formation mechanisms, the latter with their management / therapy. In the UK psychiatric therapies are currently tightly governed by guidelines which themselves are based on meta-analytic exercises and health economy evaluations. Likewise, psychiatric drugs are licensed for specific disorders and share with the guidelines the same sets of random clinical trials. Before the time guidelines started to be issued, psychiatric treatments were based on a combination of psychopharmacological knowledge, therapeutic imagination and specific negotiations between doctor and patient. This no longer obtains and unless a patient qualifies for a clear diagnosis he will not be offered medication as this might expose the clinician to legal action. In neuropsychiatry, this is particularly acute as neurological patients have mostly mental symptoms and only rarely mental disorders. Furthermore, the expression of such symptoms may be distorted by the presence of cognitive, expressional or emotional deficits directly related to the neuropathological lesions.
Behavioural copies and the problem of symptom-formation
In view of the above, the neuropsychiatrist often wonders whether the mental symptoms (and occasional mental disorders) that he/she comes across in the context of his specialized practice are, in fact, the same clinical phenomena as those seen in general psychiatry. For example, are the visual hallucinations of Parkinson’s disease or Lewy body dementia the same phenomena as those seen by a melancholic elderly with Cotard’s syndrome? Is the affective disorder associated with frontal lobe strokes the same as the common garden depressive illness? Is the mania triggered by steroid treatment the same as the mania of a bipolar disorder?
These comparisons go directly to the core of psychopathology and call into question the epistemic capacity of the language of psychiatry, that is, its discriminating value. Over the years, these questions have been responded in different ways. There was a time when the answer was that so-called organic hallucinations were different phenomena from psychiatric hallucinations. Currently, the predictable view is that they are, that they must be the same phenomena. Biological psychiatry is ruthless in its reductionism and efforts to impose its causal mechanism. Many neuropsychiatrists with long clinical experience in their trade, however, are no longer that cocksure. They often wonder about multiple aetiologies and about the existence of mechanisms that generate behavioural copies of the organic symptoms; or they postulate the hypothesis that the expressional systems in the human may have a narrow repertoire and act as final common pathways to a variety of triggers, some organic, some semantic.
Such psychopathological hypotheses generate fresh approaches to the analysis of mental symptoms which can only be undertaken by trained psychiatrists. They offer a natural and privileged space for psychiatric research. Unfortunately, it is one space that it is being abandoned by psychiatrists who want to become mini-neurologists, -radiologists or -geneticists. Descriptive psychopathology remains the fons et origo of all others ancillary disciplines in psychiatry, and hence such diaspora must be deeply regretted.
Prof. G.E. Berrios
BA (Oxford); DPhilSci (Oxford); MD; FRCPsych; FBPsS; FMedSci
Dr. Med. honoris causa [Heidelberg; San Marcos]
Consultant Neuropsychiatrist, Head Neuropsychiatry Service;
Reader in the Epistemology of Psychiatry, University of Cambridge
Addenbrooke’s Hospital (Box 189) Hills Road, Cambridge, UK, CB2 2QQ
Voice: 44 (0)1223-336965; Fax 44 (0)1223 336968; email: firstname.lastname@example.org
Dr. Armando Filomeno —who translated this article into Spanish for its publication in the newsletter nº 8 issued by the Asociación Peruana de Déficit de Atención (APDA), on June 15.2005— thanks Dr. German Berríos, a distinguished peruvian physician and former classmate of his during their early years of medical studies at San Marcos University, for writing this excellent essay.
This article has been reproduced by: Revista Colombiana de Psiquiatría, vol.36 suppl.1, p.9-14,Oct. 2007. Link.