About the ADHD Clinic
Overview of the ADHD and Disruptive Behaviour Disorder Clinic:
The ADHD and Disruptive Behaviour Disorder Clinic at CHEO is a multi-disciplinary team that offers consultation for children/youth under the age of 16 presenting with attentional and behavioural problems. Services are offered in English or French. Team members make diverse contributions to clinical services, with backgrounds from psychology, social work, pediatrics and psychiatry. The Children's Hospital of Eastern Ontario is a University affiliated hospital and the clinicians on the ADHD and Disruptive Behaviour Team supervise trainees in each of their disciplines and are involved in research activities.
- External referrals (from community physicians): have your child’s community physician
fax through a referral to the Mental Health Centralized Intake for CHEO and the ROH at 613-738-4235.
Once received, a staff member from
the Mental Health Centralized Intake Office will forward a referral form to your child’s community physician. This needs to be completed by your child’s physician and sent back to the Mental Health Centralized Intake Office where
it will be reviewed.
- Internal referrals from within CHEO: the attending physician, psychologist or social worker should send a yellow consultation form to the Centralized Intake office, located in the Social Work office in the main lobby at CHEO (ext. 2496).
The Centralized Intake office receives all referrals for mental health services for children and youth. They triage and direct referrals to the most appropriate team based upon information provided by the referring agent.
- Diagnostic consultation with recommendations regarding the treatment and
management of ADHD and Disruptive Behaviour:
- Diagnostic assessment and recommendations. A psychological assessment may be conducted upon recommendation of the psychiatrist or pediatrician who conducts the initial clinical interview.
- Psychosocial assessment/orientation to available resources available upon recommendation of the clinician who makes the diagnosis.
- Short-term intervention and follow-up including:
- Medication review. This includes determining whether medication is required.
- If so: which medication is appropriate and at what dosage, or a review of current medication(s), effectiveness, and side effects.
- If not: what other treatment options should be considered.
- A titration trial may be recommended: this is a four-week trial using a placebo and three doses (low, medium, high) of psychostimulants (methylphenidate, the most frequently prescribed medication). During these four weeks, the parents and the teachers fill out a daily questionnaires describing the positive and negative effects of the medication. They do not know what medication the child is taking, as the tablets prepared by the pharmacist are all identical and the order of the week is random. This trial allows for an unbiased assessment of the effect of the treatment and for determining the optimal dose for each child.
The Incredible Years Training Series image
- A Support Group for Parents of Children with ADHD is offered to parents of children with a confirmed diagnosis of ADHD. The specific program offered in this setting is called The Incredible Years and is appropriate for parents of children 3 to 12 years of age. The Incredible Years program is an evidence-based intervention and has been shown to be effective in reducing children's aggression and non-compliance as well as increasing social competence at home. This 12-to-14-week program consists of components that build upon one another. The short-term goals are to strengthen the relationship between parents and their children and to help parents to manage their child's challenging behaviour. Two groups are offered, one in the evening and another during the day, beginning in September and January. For additional information please visit www.incredibleyears.com.
- Individual/Family Counselling is available on a short-term basis upon the recommendation of the clinician who makes the diagnosis.
- Short-term follow-up is provided until the clinical situation is stable and allows for transferring the care to community resources.
- Medication review. This includes determining whether medication is required.
Due to the large number of referrals to the ADHD/Disruptive Behaviour Disorder Clinic, our services are limited to consultation, short-term intervention, and linking families to community resources.
Criteria for Referral:
The patients we see in our clinic are:
- Children and youth for whom a health care professional requires clarification of the diagnosis or treatment, and,
- Related to conditions such as:
- Disruptive Behaviours (e.g., impulsive behaviour or aggressive behaviours)
- Attention problems (i.e., difficulty regulating attention, contributing to learning disabilities, etc.)
- If the child or youth is already being seen by another mental health agency, or mental health professional (e.g. psychology, psychiatry), that service or professional will need to be made aware of the referral to the ADHD/Disruptive Behaviour Disorder Clinic.
Exclusion Criteria for Referral:
The patients better served by other teams are:
- Youth whose primary problem is:
- Addictions (alcohol or drug abuse and dependence)
- Mood disorders (e.g., Major depression, or Bipolar Disorder)
- Anxiety disorders (e.g., such as Generalized Anxiety Disorder, Obsessive Compulsive Disorder (OCD), Separation Anxiety Disorder, Social Phobias, Specific Phobia, and Selective Mutism)
- Acquired attentional problems secondary to a brain injury (i.e., accidental or treatment related)
- Developmental delay/disability
- Known diagnosis of Pervasive Developmental Disorder (PDD)
- Referrals made by the school for a psychological assessment will not be accepted
- Youths who would be more appropriately treated by one of the other mental health teams at CHEO, e.g. General Team for psychosis or behaviour problems; Mood and Anxiety Team for problems with depression or anxiety disorders; Dual Diagnosis Team for children with severe intellectual limitations and behavioural problems; Abuse and Trauma Team for problems with post-traumatic stress disorder (PTSD)
Team Members:(note most are part-time equivalents)
- Administrative Assistant: Della McCully
- Data Quality Assurance: Jennifer Munroe
- Psychology: Dr. Clairneige Motzoi, Psychology Interns, Research students
- Social worker: Anne Kerridge, Social Work students
- Pediatricians: Dr. Bill James, Dr. Fionnuala O'Kelly
- Psychiatry: Dr. Philippe Robaey, Dr. Dhiraj Aggarwal, Dr. Barbara Jones, Psychiatry residents
- Neuropsychiatry Laboratory: Benoit Décarie, eng.
- Data Systems Management: Marina Lifshin
- Research Assistant: Jennifer Munroe
Our team wishes to acknowledge various other MHPSU personnel (primarily psychiatrists) who also help with referrals to the ADHD and Disruptive Behaviour Disorder Clinic.
Children's Attention and the Challenges of Close Friendship
B.H. Schneider, P. Robaey, S. Kuehn.
This study looked at how the attention of 7 to 12-year-olds affects communication with their friends
and their ability to make and keep friends. In order to learn about this, children with different levels of attention,
from very good to very poor attention skills, participated in the study.
The specific objective was to find out how children’s attention is related to several characteristics of their relationship
with their good friend.
The characteristics of friendship that we were studying include the following:
1) how supportive and close the friendships are; 2) how the friends solve problems; 3) how satisfied the two friends are with their relationship; 4) how long they stay friends; 5) how the previous characteristics are changed by medication in those with Attention Deficit/Hyperactivity Disorder (ADHD) who are taking medication. Through this research, we hope to find new ways of helping children who do not have friends, do not keep friends, or do not have the right friends.
See the results of this study: www.ncbi.nlm.nih.gov/pubmed/20824323
Brain activity patterns associated with inattention, impulsiveness and restlessness in childhood Attention Deficit/Hyperactivity Disorder (KIDNET)
P. Robaey, S. Kuehn.
What we know from our previous research is that within a group of normally developing children,
the brain activity involved in the control of some aspects of movement, memory functioning,
and attention differs across subgroups of children.
What we want to learn from the current study is how the brain activity of children with ADHD compares with that of those without ADHD during tasks that place demands on their motor skills, memory and attention. We also want to learn which aspects of ADHD are the most important with regard to these differences in brain activity.
CHEO Neuropsychiatry Research Laboratory:
The CHEO Neuropsychiatry Research Laboratory is located at CHEO on the second floor on the research II building. The research team is closely associated with the multidisciplinary clinical team from the ADHD and Disruptive Disorder Clinic, which is part of the CHEO Mental Health Outpatient Service.
The laboratory is dedicated to research on children’s mental health. The research team is formed by researchers in neuroscience affiliated with the lab, students and research assistants. The director of the lab is Dr. Philippe Robaey, MD, PhD. All research studies are approved by the Research Ethic Board (REB) of CHEO, to ensure that the research meets the highest ethical and scientific standards.
The lab is composed of two rooms: the recording room and the control room. The two rooms are divided by a one-way mirror in order to monitor the recording session from the control room.
This first picture below shows the recording room where the subject sits on an adjustable chair, with the one-way mirror in the back. The brain activity is recorded through a large array high impedance electro-encephalogram channels (EEG) system.
To record the brain activity, an electrode cap designed according to the International 10–20 system is installed on the child’s head and plugged into the pre-amplifier. A cap is selected from the different cap sizes that are available to fit the child’s head circumference. In this image, the red cap (mid-size) was selected. The cap is connected to a pre-amplifier that is attached to the chair behind the child’s back. What you see in this image is the research assistant measuring the spatial coordinate positions of the EEG channels by using a three-dimensional digitization ultrasonic-based system: the transmitter is held by the assistant, while the T-shape structure in the back is the receiver.
Two monitors are in the recording room, one in front of the child and another on the top right of the picture. The latter is for monitoring the impedances of the electrodes during cap installation, in order to ensure that the current generated by the brain activity (less than one millionth of the voltage of an ordinary toy battery) is reliably transmitted through the EEG system. The monitor in front of the children is also used to present images or movies while the EEG is recorded. The child may look at the pictures without having to do anything, but generally the child is asked to respond to the images according to specific instructions (e.g., to press one button for one image and the other button for another image within a sequence of images). The child responds either by pressing a button or by squeezing a strain gauge inserted in a handle. Left and right buttons and handles are attached to a table top, which is attached to the arms of the chair. The eye and hand movements are recorded through electro-oculogram (EOG) and electro-myogram (EMG) electrodes placed around the eyes and on the forearms, respectively. They are used to measure the effect of eye movements on the EEG, or to detect partial responses that do not result in a button press or a handle squeeze.
The second picture shows the control room, and through the one-way mirror, you can see the child with a research assistant during a test recording. Note that there is always an adult with the child in the recording room. In the control room, there are two computers. The first computer presents the stimuli and records the behavioral responses; it is linked to the two monitors on the right. The second computer controls, collects and stores all the electrophysiological data (EEG, EOG, EMG) and is linked to the monitor on the left. All data are securely stored through the CHEO storage area network (SAN), which attaches remote computer storage devices (such as disk arrays and tape libraries) to the lab server.
The laboratory is also equipped with a Transcranial direct current stimulation (tDCS) system. tDCS is a form of neurostimulation which uses a constant, low current delivered directly to a specific brain area via small electrodes. tDCS is a promising treatment in various developmental neurocognitive disorders. Currently, tDCS is being tested in a safety and feasibility study in children and adolescents.
The laboratory is supported by research grants, the CHEO Psychiatry Associates Research Fund and the CHEO Research Institute. It is located in and hosted by the Ontario Centre of Excellence for Child and Youth Mental Health.