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March 2002


Issue 6

Inside this Issue:

2 "Attention-Deficit Hyperactivity Disorder", by Dr. Sanjeev Kothare

3 "When to Assess for AD/HD", by Dr. Smita Desai

3 "Visualization technique for AD/HD children", by Suzanne Ferreira

Our team at Drishti: Smita Desai (Ph.D) Anand Desai (M.Sc) Meghana B.W. (M.A.-Clinical) Suzanne Ferreira (M.Ed-Sp.Ed) Devika Vohra (M.S.W.) Vrucha Pandya (B.Ed-Sp.Ed) Shweta Choksi (B.Ed-Sp.Ed) Suzanne Dias (B.Ed-Sp.Ed) Karen Fernandes (DSE-MR) Christina Trindade (DSE-MR) Tanaaz Mistry (DSE-MR) Vibha Sharma (M.A.-Clinical) Sweta Vaswani (M.A.-Clinical) Lalitha A. (B.A.)

Dear Friends, At the very outset I must apologise for not being able to get this newsletter out on schedule, ie. in December last. We, in particular Suzanne, Smita and I, had been tied up, these past few months with work related to our new System for the Management of Individualized Programmes, or the SMIP. This has been a big task and a challenging one for all those involved (including Ravi & Hoshi, the software developers, for whom it was a unique subject). This is finally fully operational and we hope the benefits of using SMIP will accrue to all our children, as well as to all the hard working staff here at Drishti. A fair number of children that come to Drishti, not just for special education, but also for assessments, suffer from Attention Deficits, often coupled with Hyperactivity. The terms commonly used being ADD & AD/HD. We felt it thus important to devote the current issue to this subject. While I am as always grateful to all the contributors to this newsletter, I wish to particularly thank Dr. Sanjeev Kothare, a leading Pediatric Neurologist and Epileptologist of our city, who agreed to take time out from his busy schedule and contribute an article in this issue. We are sure that his article would prove extremely informative to persons from the medical fraternity as it would to other readers too. We do hope you will find all the contents of this newsletter of interest. As always, your comments and suggestions are most welcome and would go a long way in the evolution of this newsletter and to better our services to the community in general. Kind Regards. Editor Anand Desai (

206 Midas Chamber Andheri (W), Mumbai 400053 Phone: 022-6348732 Fax: 022-6348549

Experts Corner Attention-Deficit Hyperactivity Disorder (AD/HD) Sanjeev V. Kothare, MD, DCH, FAAP (USA). Pediatric Neurologist and Epileptologist Jaslok Hospital, Nanavati Hospital.

Attention deficit disorder with or without hyperactivity is a common problem seen in up to 5 10% of children in the school going age. It may be primary or secondary to mental retardation, learning disability, epilepsy, or effect of medications used for epilepsy. It is important to recognize it because there are effective medications and other therapies for treatment of the condition. These children are unnecessarily punished by the teachers, parents, and ridiculed by their peers.

Diagnostic Criterion of AD/HD (Diagnostic Statistical Manual - IV Revised) Inattention:  fails to give close details or makes mistakes in school, work, other activities.  difficulty sustaining attention in tasks or play activities.  does not seem to listen when spoken to directly.  does not follow through on instructions and fails to complete chores, schoolwork.  difficulty organizing tasks, activities.  dislikes tasks that require sustained mental effort.  loses things.  easily distracted by extraneous stimuli.  forgetful in daily activities. Hyperactivity:  fidgety and squirms around.  runs about excessively and inappropriately.  leaves seat in class inappropriately.  difficulty playing in leisure activity.  “on the go”; “driven by a motor”.  talks excessively. Impulsivity:  blurts out answers before question is complete.  difficulty awaiting turns.  interupts or intrudes on others. Six or more symptoms of inattention or hyperactivity-impulsivity; age of onset before 7 years; associated impairement in functioning due to above symptoms.


Associated: learning disability and oppositional defiant behavior. AD/HD may continue into adulthood when it is associated with. anxiety disorder, substance abuse, depression etc. AD/HD and Bipolar disorder, AD/HD and tics may co-exist. Pathogenesis: norepinephrine pathways, dopamine transporter gene defect, prefrontal cortex especially on the right side.

Treatment Educational Management: Minimize distractibility, preferential seating, one to one tutoring, eye contact, structured and predictable routines, teaching organizational skills, monitoring daily activities, use of calculator/computer, positive reinforcement for good behavior but no punishment for bad behavior.

Cognitive-Behavioral therapies Including self-monitoring, self-reinforcement and problem solving strategies. Pharmacotherapy: Stimulants:  Methyl phenydate 0.3 to 1 mg/kg/day in 2-3 divided doses.  Dextro-amphetamine 0.15 to 0.3 mg/kg/day in 2-3 divided doses.  Pemoline 0.5 to 3 mg/kg/day in 1-2 divided doses. Antidepressants:  Desipramine 3-5 mg/kg/day, in 2-3 divided doses; Nortriptiline 0.5 to 2 mg/kg/day in 1-2 divided doses, propriptine 0.2 to 1 mg/kg/day in 1-2 divided doses.  Bupropion 3-6 mg/kg/day in 2 divided doses.  Fluoxetin 0.3 mg/kg in morning, Venlafaxin 2-5 mg/kg/day in 2-3 divided doses. Miscellaneous:  Clonidine 0.5 to 2 mg a day in 2-3 divided doses; guanfacine 1-3 mg a day in 2-3 divided doses.  Modafinil (Provigil) 2 to 6 mg/kg/day in one morning dose. For more information, Dr. Kothare may be contacted at:; phone: 8820900

Recommended site with excellent resources on this subject: ww w. c h a d d . o r g

Views expressed in this newsletter belong to the individual authors.


Psychologists corner When to assess for AD/HD? By Dr. Smita Desai (Educational Psychologist & Special Educator)

For most parents and teachers, noticing that a child is displaying the symptoms of hyperactivity, lack of attention, and impulsivity is not a difficult task. These behaviours stand out like a sore thumb because of the disruption they cause in the home and at school. „He cannot sit for more than two minutes at one place‟ „He is always disturbing some other child in the class‟ „He sits for his studies for more than two hours, but has not finished studying anything‟ are the typical comments from the parent or teacher of the child displaying AD/HD.

At face value, establishing an AD/HD diagnosis would seem to be a relatively simple matter. You gather information to address the above guidelines and decide whether AD/HD is present or not. Unfortunately it‟s not that simple. There are the complicating factors of situational variability, cooccuring problems, environmental functioning which all play a part in arriving at the right diagnosis. A formal evaluation would thus become necessary. This should be comprehensive in nature and involve utilizing standardized test instruments. The professionals who would ideally qualify to diagnose this problem would be psychiatrists, neurologists, child psychologists (Ph.D). Treatment approaches for AD/HD would be multimodal in nature. Known effective treatments include pharmacological treatment (medication), cognitivebehavioural therapy.

Special Ed Corner

What is AD/HD? It is a neuro-biologically based developmental disability. Its hallmark features include inattention, impulsivity, and/or hyperactivity. No one knows exactly what causes AD/HD, but evidence suggests that it results due to a deficiency in certain neurotransmitters which are chemicals that help the brain to regulate behaviour. AD/HD can be obvserved as attention deficits with hyperactivity (AD/HD) or attention deficits without hyperactivity (ADD).

Visualization technique for AD/HD children

Although some people seem to think that one can tell from watching a child that he is AD/HD, arriving at such a conclusion needs a formal evaluation. Research shows that families would look to a pediatrician or family physician for information on learning, behavioural and emotional difficulties. Some guidelines given below would indicate clearly to the child‟s physician about the need for formal evaluation:  The child must display at least six of nine inattention symptoms and/or six of nine hyperactivity/impulsivity symptoms (as stated in DSM-IV R - see also article above by Dr. Kothare)  Such behaviours must have an onset before the age of seven  A duration of at least six months  A frequency above and beyond that expected of the same mental age  Must be evident in two or more settings  Have a clear impact on psycho-social functioning  Not be due to other types of mental health or learning disorders

There are a variety of techniques that have proven effective in helping children slow down their hyperactivity, focus awareness and improve attention. These include, laughter therapy, breathing techniques, yoga etc. Visualization is one such technique, which not only has therapeutic applications for AD/HD children but has also provided a framework for improving their learning and memory.


Ms. Suzanne Ferreira, M.Ed. (Special Education)

Children with AD/HD are often found to be in a state of stress, especially in school, either on account of their physiological state of arousal or difficulties encountered in learning and understanding -which again could increase their levels of activate.

Visualization is the process or result of mentally picturing objects or events that are experienced directly. The process of reading or listening to stories involves visual imagery or the forming such mental pictures, a skill which many children with AD/HD lack mastery in. Hence they tend to get only parts of what is presented, they are able to locate only a few facts, their writing is often not specific to the topic, they have difficulties in expressing their ideas in an organised manner, difficulties in following directions, connecting to conversations, understanding the concepts of cause and effect etc.. These difficulties lead to them losing attention in class, getting easily frustrated, losing their self-

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control and finding themselves being tagged with "behaviour problems". Nanci Bell1, developer of the Visualizing and Verbalizing for Language Comprehension and Thinking Programme says that learning to learn depends on how well a student has mastered the skills of reading to learn (i.e. comprehension). Comprehension requires symbol imagery, i.e. visualization of the letters and words as well as concept imagery/visualization of the concept Steps to help develop visual imagery: A) Search for the picture words: words in the text related to things, actions, feelings experienced or read about e.g. the seagull soared high above the sea. B) Create a scene: sometimes pictures in the text help create a backdrop for the image in mind. If there are no pictures, then you can create your own scenes C) Enter a lot of details: add in the finer details. The more specific the details the better the image created D) Name the parts: Describe the image and the action using your own words. This allows you to transform the information and make it more real for you to understand.

Through visualization children can be taught that, when their minds and bodies are relaxed they can think better, plan carefully and that they have the capacity to gain a certain amount of control over and regulate their bodies actions, feelings and thoughts. They can also be taught "success visualizations" i.e. visualize themselves in situations where they are able to achieve and are successful -especially in exam situations e.g. they must visualize themselves walking confidently in to the examination hall, sitting with a proper posture at their desks etc. More importantly, they must view themselves as being relaxed and confident, as they read each question and answer it, completing the paper within the time limit, rechecking for errors etc In this way, the visualization technique help children with AD/HD not only to deal with complex reading material and improve understanding but also it can help reduce their distractibility, anxiety and help them find a sense of inner peace. 1

The Lindamood Bell Learning process, 1998-2001

How to Reach & Teach AD/HD children, by Sandra Bell, Center for applied research in education, 1993 2

Centreplay: Focusing your Child's energy, Holly Huth, Fireside, 1984 3

E) Evaluate your picture: check if the picture you have created mentally, matches what has been read in the text or if you have missed any details or if it is unclear. This technique helps children with AD/HD work on their comprehension in an organized, systematic manner, by helping them link new information to previously learned information. It also helps them enhance their levels of attention by breaking the passage into smaller segments and requires their active interaction with the learning material "The ability to visualize with colorful vivid images, rich imagination and detailed actions are natural skills of children" (Sandra Rief2) Hyperactive and impulsive children can gain a lot from the visualization technique, to help them relax their minds and bodies, recognize their internal feelings and release inner tensions. When a child realizes certain signs of their own anxiety and stress such as tightening of muscles, clenching of fists etc they can be taught to use visualization. One such guided visualization recommend by Holly Huth3 is to have them imagine a colour that makes them feel relaxed. Imagine themselves blowing that colour throughout their bodies, slowly down their throat, neck, down to their stomachs and so on, until they are completely full of that colour and covered with relaxation. Other visualizations could involve …being in sailboats… rocking on a calm cool pond, a feather floating through the air, walking through space among the stars etc. etc.


SMIP System for Management of Individualized Programs  Exploiting the benefits of today's technology.  Efficient way of creating individualized programs.  Frees valuable time for educators and counselors to

devote to planning their individual sessions.  Allows close monitoring of each program by the

coordinators, in order to ensure greater efficiency in achieving the stated goals as well as ensuring intervention (where necessary) at the earliest possible time in the program.  Provides a method of achieving the basic objective, ie. transfer of learning from Drishti to the real world (ie. the school).

SMIP is designed with the sole purpose of benefiting each child through greater effectiveness of the individualized programs.

Views expressed in this newsletter belong to the individual authors.



In this issue we focus on ADHD - Attention Deficit, Hyperactivity Disorder.