 Good day and welcome to Kalusugan ay Karapatan. We are pleased to bring to you another important episode, kaya ko ito, I can. Breaking means of differently abled, autistic and ADHD Filipinos. Good day to my lovely co-host Dr. Nili. Good day to you Chancellor Menchit and good day as well to our viewers. Yes, our episode today will shatter some false beliefs about autism and ADHD or attention deficit hyperactivity disorder, one of the most common neurodevelopmental disorders in children. As a pediatrician myself, I know that the diagnosis of autism or ADHD is usually made in childhood. However, some symptoms may persist as the child gets older and reaches adulthood. You know, I did a little research on this and I found out that in October 2016, according to the U.S. Center for Disease Control, 11% in children, 4-17 years of age and 5% of all children have ADHD. I'm also surprised to know that ADHD is more common among boys about 13.2% than in girls about 5.6%. The average age of ADHD diagnosis was 7 years of age, but children more severe ADHD were diagnosed earlier. Maybe our resource persons can tell us later why the statistics are like this and whether these are also true for the Philippines. I'm sure our viewers would like to ask the question, how do we know if a child is ADHD? Well, the symptoms are difficulty in paying attention, difficulty in controlling impulses and being very active. Also, there are other indications that one is suspected to be autistic. So let's enumerate some of them, Dr. Lili. Number one, your child often fails to give attention to details or makes careless mistakes. Two, your child often has trouble remaining attentive to tasks or play activities. Three, your child loses focus and fails to finish schoolwork or chores or has trouble being organized. Four, your child often loses things necessary for tasks and activities, such as school, materials, pencils, books, et cetera. Your child is often excessively distracted and often forgetful in daily activities. Your child often pijates with or with or tap hands or feet or scrims in his or her seat or leaves the seat in situation when remaining seated is expected. Your child often runs about or climbs in situations where it is not appropriate and is often on the go acting as if driven by a motor. Number eight, your child often talks excessively. Number nine, your child often has trouble waiting for his or her turn and often interrupts or intrudes on others such as patting into conversations or games. And ten, your child has had several of these symptoms before the age of 12 years and has had several symptoms in two or more settings such as at home, the school or work. Number 11, your child's symptoms interfere with or reduce the quality of social, school or work functioning. There are so many symptoms Chancellor mentioned but how do I know if what I see is ADHD if I observe only one or two of these symptoms? Can I say a child is already suffering from ADHD if a symptom is observed once or twice? That is the reason why we have resource persons today who will help us understand autism and ADHD. We are happy to say that one of our special persons is no less than the Secretary of the Department of Health. When I asked her for a name from the government who could come and join us in this session, she easily volunteered to be one of the resource persons because it is her new advocacy. I guess it's been a public servant for 27 years and has served 13 health secretaries. She rose from the ranks from voluntary health work in Kedapawan to assistant secretary and deputy head for the Office of Health Regulations to her current position as DOH secretary. With her vast experience, she has led and became the leader and champion of Kalusugang Pang Kalahatan with advocacy in mental health, women's health, tobacco control among others and many more children's health. Our resource person is a fellow UPN from UPIS and Zoology Department of UPP Dileman, UPPGH College of Public Health. Ladies and gentlemen, we are happy to introduce the Secretary of the Department of Health, Dr. Pauline Jean Rosel Obian. Yes, good day to all of you. Good day Chancellor Menchit and Commissioner De Lasyagas. Our secretary will be joined by another important resource person for developmental and behavioral pediatrician, an expert in child protection. She is a clinical associate professor of the Department of Pediatrics, College of Medicine, and of UPPGH, associate director of the Child Protection Unit, of UPPGH in the head of center for developmental pediatrics at the medical city. She is a true blue UPN, being a graduate of UP integrated school as a valedictorian, BA Zoology, as summa cum laude, and the UP College of Medicine class of 1987 as one of the top 20 graduates. She's advisor to other professional societies and support groups which she helps set up like the ADHD to site up the Philippines in the Philippine Association of Behavior Analysis. We're proud to introduce Dr. Stella Guerrero Manawa. Good day to everyone. To secretary Pauline Ubyal who's a classmate from high school and a batchmate in internship at UP and commissioner De Lasyagas and my chancellor Menchit Padilia. So let me start the first question, Dr. Stella. Can you help us distinguish, differentiate autism from ADHD? There are two very distinct and different conditions. However, if you're looking from the outside you tend to mix up the two. But the difference being that if you have autism your brain is really wired differently meaning you understand the world and understand about the world in a different way. On ADHD, these children are more neurotypical. They have normal social skills, normal interactions. It's just that they have a high level of hyperactivity but the most compromising problem that they have is inattention. Now, some people have ADHD and when you look at them they look very normal because they're just inattentive. They have an inattentive presentation and earlier the characteristics that you gave about how a child with ADHD is that is the diagnostic criteria for young children. But the presentation of ADHD changes over the lifespan. So that's a big debate actually yung mga conditions na yung. It's only for young children and adults present differently. So how do they present, Dr. Stella? Are the older ones for the adults? Well, it really depends if they've been managed early because adults who have been managed early with their ADHD, they're very normal. They can live a very normal life and they're excellent in their field of work. The problem is those who are not diagnosed and help through childhood. They're at higher risk for mental health problems and they're not atap yung potential nila because of difficulties learning. So they're the under achievers, yung sinasabi natin they're street smart but maybe not school smart. And those who despite apparent intelligence don't perform as well in the school setting and even if they're intelligent adults they're restless at work. So minsan yung characteristics nila they keep on changing jobs and they're never satisfied. They have an inner restlessness but everything else they're very normal. So you're saying that we see them out there both those with autism and ADHD. But do we have numbers? Let me start with Secretary Ubyal. Do we have statistics on patients with autism and ADHD? Actually we tried to get a registry going for persons with disabilities. So those with autism and ADHD and including physical as well as other mental disabilities but unfortunately the WHO actually estimates about 10% of the population have disabilities but we only get about 2% in the registry. And then some years ago we tried to get a prevalence study going particularly in the Visayas for autism but we got only one for every 1,200 children that were examined. So that's very very low compared to let's say the United States it's one in every 68 children but in Korea I think that's the highest rate it's one in 58 children. There's a registry that the private sector have but we actually have not collated it because it's really not showing us the true picture because we don't detect all cases. So if you look at the private sector there's a bias for those who are able to pay or are in the upper socioeconomic class. That's true. Actually there's a stigma to being identified nowadays. So there are many out there who may have these conditions but they'd rather not be identified. So our statistics will really be based on those who come to have themselves diagnosed and even our society we have a society of developmental and behavioral pediatricians we really can't get a registry going because the problem in the private sector is they also go doctor hopping. So if we cannot count one person may be counted five times because there's this confidentiality issue that we don't want to put their names out there so we're still trying to device some way such that there will be a registry but I think soon this will become a possibility in detecting how many children with disabilities we have because the DOH has a project that's coming up so we're coming up with a registry but it's an imperfect registry but I think because field health will soon be covering for disabilities it'll be the assessment and the therapy will be covered by field health. It will be an incentive for families to have their children diagnosed and maybe secretary Pauline can elaborate on this project of the DOH. Yes, actually we signed a benefit package for children with disabilities last February and we're rolling out this benefit package to nationwide so that it covers actually the cost for screening and diagnosis of children with disability and hopefully with that shall we say incentive to get diagnosed then we can get a better picture of what the autism and ADHD as well as other disabilities among children the prevalence in the country so hopefully after about a year we can have a more solid frame and a more solid data on the prevalence in the country. Can you share with us some data from the Philippine General Hospital? Our general clinics in BGH for the Pediatrics Department we see around 1200 to 1500 children a year and every month we have this audit and statistics and for the past 10 years every month in the top 10 we have the diagnosis of autism, ADHD global developmental delay and speech delay so these are four developmental problems that always appear in the top 10 of the outpatient consults in UPPGH and for the section of developmental and behavioral pediatrics we also have 1000 to 1200 consults a year and out of this 330% have autism another 30% have global developmental delay or intellectual disability and the rest is a combination of other developmental problems so talagang I think it's really I could say almost epidemic proportions because almost everybody you know has no somebody who has a child with autism or ADHD or other learning problems and also the waiting list to have yourself diagnosed with a developmental and behavioral pediatrician could run from 6 months to 2 years in PGH our waiting list for new patients is it used to be 2 years in waiting list now it's shortened to 1 year given the enumerated symptoms is there a standard diagnostic for this and is this global or the standard of diagnostic I think at the different listed symptoms about 10 when do we say that this is confirmatory diagnostic procedure for autism or ADHD well the tools that we use diagnostic criteria we use the standards international standards diagnostic and statistical manual fifth edition fifth edition means it has been evolving over time it's a dynamic process it refers to symptoms have been cropping up along the way that's why it's a dynamic process or there are better diagnostic tools basically I think is knowledge in the field is also evolving so before like example yung autism had 3 criteria but now it's been narrowed down to 2 criteria and then they've also recognized that it changes over the lifespan so there's always a constant debate and discussion before under the umbrella of autism was Asperger's syndrome now sa fifth edition they took out Asperger's and then they just said autism is a spectrum disorder and you just identify if they're low functioning if they're moderate functioning or high functioning and Asperger because these are the very very high functioning that they're almost normal so they're not considered to have a condition anymore because they're practically normal just kind of eccentric and different I'm a bit worried if you say that the waiting time for a correct diagnosis is one year I'd like to know what your society is doing and then I will pass on the question to the secretary later to talk about what are we going to do about this situation Yeah number one we have only a few professionals really who are trained to make this diagnosis in our society we're almost 70 and there are now I think four training institutions that from two before Philippine Children's Medical Center and UPPGH Medical City and De La Salle University have added to the list of training centers so we need more institutions to train specialists in this field and second over the years we've realized that the training of individuals young specialists for this field cannot keep up with the pace of increase in the prevalence of these conditions so we're trying to go public health meaning what we see is that even if they don't have the exact diagnosis when they're young when you just say maybe they're delayed we're already telling general pediatricians you can do your part and basically I think the part is in parenting you have to train parents and what they can do at home no matter what this diagnosis is how can you help stimulate the development of these children and the role of parents it's so big so you really don't need the therapist the very first for the first two to three years the parents play a crucial role in stimulating the development of their child so parents have to be educated how can they help these kids because the problem is even if they are identified the therapists are very few they're going abroad so we have very few therapists so I think the way to go is to educate parents to empower them to realize early what they can do in the early childhood years to kind of maybe rewire or remove the brains of their children so that's a big possibility and even in my practice what I've seen is even if these families have therapists who are the most successful in terms of outcomes of their children are parents who are on board parents who are also they learn the techniques and they also become the therapists of their children so yun na nakikita kung way to go so if one looks at a complete program to lessen perhaps the incidence I would see that one of the challenges would be perhaps there would be misdiagnosis as well in the part of the physicians because they're very few competent or skilled diagnostician so secretary levels of healthcare I would like to ask our secretary herself at the preventive level would be more early diagnosis and it would be at the level of household or parenting and then the second level is promoted care we really need to promote this things that one must do at the level of the household and then we have the curative care and then the rehabilitative care given the different levels of healthcare what would be the role of the department of health such that there will be less incidence later on actually addressing incidence is rather problematic at this time because we don't know the cost it's multifactorial and it really is not yet known to many of us what is the the etiology how come some children have autism some don't but what we're trying to address right now in the department of health is early detection so that children who are actually detected early have the chance of early intervention also and what doctora Manalo was saying that it need not be or a skilled specialist like a doctor or a therapist to do the intervention maybe the parents maybe the guardian in some incidents so what we did try to pilot was the parent skills training it's a module that the autism speaks in the United States in particular in New York has been using for their clientele the persons with autism in the U.S. and we're trying to adapt those modules into the local dialect so that's where we are and hopefully parents of children with autism because of their first hand experience and account at once teaching other parents and then in the process it will be a support group for the entire community and of course we're also working with UP and all the other institutions so that we'll have more developmental pediatricians across the country when we started this intervention in Tacloban three or four years ago we didn't have a developmental pediatrician in Tacloban, now we have so that's also one of the goals of the department of health to have a developmental pediatrician at least one per region and to develop our regional hospitals into child development centers meaning that these are the facilities where we can have the parents as well as the therapist trained in the regional level I am interested to know is there such a thing as a school based the school is the best side to detect for example hearing, vision there is such a thing as a school based prevention teachers being taught how to detect pupils inside a classroom relative to other pupils I have some issues about making teachers diagnosticians because I think the mandate of teachers is that whatever the kind of student you have you have to help this child learn so if you're a teacher and you have a child you notice has difficulties in learning maybe they should be the ones to suggest you have this child screened with a professional or a specialist but having teachers also being diagnosing also makes them they discriminate and they would say this kid has that and I don't want that for teachers I want teachers to be accepting of all children maybe they have to be blind to what the diagnosis is but maybe just try to help these children learn the best way they can so let me change the question because we have hundreds of thousands of teachers out in the field and if you are allowing parents to come up with a set of questions for screening wouldn't the workforce of the teachers give you an opportunity to at least pick up some problematic patients for referral because right now if the waiting time is one or two years and there are millions of children who need to be screened we need to find the workforce who will do the screening for us basically teachers because they are able to tell which children are sort of different or who have challenges and then usually it's the parents who know their child more than the teachers I'd like the teachers more to to embrace all children not discriminatory because what's happening now what I see in my practice is that the teachers would say ay parang may ADHD yan pa ting na na hindi yung pwede sa school namin parang iba siya, may special needs hindi siya pwede dito it goes against what we want so teachers already categorizing but they should maybe be trained to detect mukhang there's somebody something different but not to be the diagnosing this because what happens is their paradigm changes they already said ay ba siya, ay ba siya basically teachers really need more training in behavior management because they're trained to teach things but absolutely they don't know how to deal with the challenging behaviors of children with special needs and it's not rocket science because it's easy to train them but it has to be in their curriculum behavior management understanding behaviors and addressing these challenging behaviors I have a friend, she is a physician and she was called by the teacher the teacher said I talk to the guardian of this boy because the parents are working they're too busy they can't even look at their children watch them during the whole day, eight hours a day so who would be the one doing that it's not really the teacher giving them the full responsibility of diagnosing but perhaps trying to spot some odd behavior relative to the classmates to be in the context of reporting and calling the parents that's the thinking I think would be very beneficial to add up to this not really loading the teachers to diagnose but because children stay in the classroom eight hours a day and they have the best they're in the best position really to observe the beauty Commissioner, can I add Yes, I think one of the things that Stella was saying is that we want a society that's more accepting and less discriminatory meaning even the teachers or even other members of society that if there's a child that's unique or different from other children not to separate them or segregate them and then they have to have a special school and special training but to be able to accept that as a part of society a more inclusive society that we have so that's where the Department of Health is actually coming from we want to raise awareness we want to change the way society views these children with autism and with ADHD in fact one of the things that we're actually promoting in the Department of Health is to have a proportion of our human resource for persons with disability and in fact I have a person with autism in my office in the DOH and we hired a particular skill and he's doing very well and I think having this person in the office actually also educates the other people in the office because they they adjust to how to deal with him even if he's differently able it gives them the opportunity to actually develop their compassionate skills for compassion for taking care of differently able persons so I think that's how we also want to approach it for the Department of Health to help our people understand the situation and be more inclusive and accepting to differently able persons so that's the promoting care I have a follow up question for Secretary Obel because it has been mentioned already that students really spend eight hours a day in school and we need to find a way to be able to pick up this problematic student so that the parents can be informed and be brought to the right specialist so do you see an opportunity for the Department of Health Department of Education to partner so that a checklist of questions can be given to teachers so that they can properly refer the patients without necessarily making a diagnosis at that point? Yes, I think that's one of the things that we are actually working on with DEPED the school screening program like for children errors of refraction sometimes we think that the child is intellectually underdeveloped ayong pala malabu lang yung mata and some of the children they have other issues like maybe long term or chronic illnesses which makes it difficult for them to actually attend school on a regular basis so we have to detect that at the earliest possible time so I think we're at that we're trying to develop a screening tool not just for autism or ADHD ADHD but actually to have annual check up for all school children so that we can ensure that whatever illnesses or possible illnesses they have these are detected early and interventions are provided I just want to mention that about 2 weeks ago UP launched a program with DEPED on a screening tool for child abuse since we don't have enough I was looking at that model and since we don't have enough child protection units they decided to use the teachers just as a screening tool but I totally understand that they are there to screen and not to make a diagnosis and we may have to educate our teachers but that is their role their money is to teach and to be accepting but to be able to identify also these problematic students we agree I guess the secret there is especially the preschool teachers early detection that there is a problem because the most challenging part for children with developmental problems is really the intervention in the early years because if you do intervention early what happens is that you increase the possibility that these children will kind of normalize or they can function in regular society as they grow older because when they are young they need one-on-one intervention they have a lot of behavioral issues so that can only be addressed usually one-on-one that's why we need therapists or the parents then as they improve they can go into a setting of what you call group learning and of course must effective really is big group learning so it may not these children may not be ready for big group learning but as they improve usually from my experience by age 7 or 8 in terms of behavior they already improve so that they can already be included in a regular school setting because what are the benefits of putting these children in group learning or in school is their social learning they learn how to be with other children how to interact how the values of sharing, kindness, compassion cooperation they can learn that in the school setting but sana the school will also make use of that opportunity instead of just be full of just teaching these kids academics these are the values that have to be taught in the classroom and having children with special needs in a classroom with typical peers will teach these typical children to be more accepting and caring and teacher shouldn't be in a rush to teach academics because what I see now is the teachers are so stressed about they have to teach this curriculum they have to cover so much ground that so many children get left behind instead of the other values that it's the best place to learn these values instead of all these academics and knowledge and facts values and interacting and caring for each other those are the important values that can be learned in school I have a question for Dr. Stella because you did well wonder it's a range, he said, some are very mild and some are severe can you give our viewers maybe a mild form and then you said that they need a one-on-one intervention what sort of one-on-one intervention is this? Well like yesterday I had some follow-ups of my patients they're already high school or college so I remember them when they were three-year old when they were three-year old, they're non-verbal their behavior was off, they were so hyperactive and they were delayed so if you measure their skills they were really delayed but the intervention that they received they have occupational therapy and then later on speech therapy and the parents are also on board so every year these children improve and actually by the time they're five or six they're already verbal by the time they're seven they know how to behave and they can already be integrated in a regular classroom of course like if this my patient had autism because the deficits of a child with autism is they really cannot understand human behavior they cannot understand social cues that's an area of difficulty I'm saying area of difficulty because they can learn it they can learn anything as long as it is taught so this patient of mine was actually because high functioning memorized all the facts so academically perfect sila in school because their brain is like a video camera that memorizes everything the problem they had is with application and comprehension so if we target that they get better and then by high school they're okay but in high school the difficulties really are the social interaction because the complexities of social interaction are more difficult in high school but if you teach it you help them over this difficulty then they actually can learn it so one of my patients is already in college history ang kanyang major because he memorizes all the dates and all the facts and I was afraid that he's having a hard time adjusting but he told me he lives in the dorm and he says to my dorm mates because I realized that they were brought up by different parents with a different set of values and I was brought up by a different set of parents so we just have to tolerate each other so cognitive din yung approach niya to social interaction but he knows because we taught him and then the thing is he writes very well I was surprised because individuals with autism also have difficulty having a coherent flow of thought so for mga essays and stories parang they cannot get it organized but because we targeted sa kanya, we targeted written expression he won an award for his essay so he writes very well he memorizes things and he can tolerate other people and he's in a regular tertiary college doing very well so Dr. Stella that's for autism let's talk about ADHD just a mild one how do you manage this patient at home and then in school the most challenging actually sa ADHD is when they're young because being young children are naturally impulsive, they're naturally hyperactive so those with ADHD just have a parang higher level of this and they're misunderstood but as they get older and you teach the teachers and the parents how to deal with their behaviors as they get older by the time they're 7 ang kanilang challenges is no longer behavior but it's attention and performance in school so we address this for ADHD really the best practice is really for those who will benefit from medications to help them focus we give it to them but the milder ADHD ang problem lang nila is really focus, attention so if you medicate them then they have no problems in school and actually they're honor students I have a whole bunch that are honor students they're not even identified and then they can 50% of those who are diagnosed when they're young by the time they reach adolescence parang na overcome na nila so they no longer have to be diagnosed as having ADHD but those who are diagnosed later and not treated earlier persist, na persist symptoms nila up to college up to the workplace so those who are mild are actually very normal just listening to what you relate to us I want to ask now the secretary seems like the problem is big and we don't have enough people to make the diagnosis we have a lot of diagnosing in the community in terms of training people how far down are we going to go local government can you give us your plans right now we're developing the child development center in every regional hospital that's DOH we have at least 2 hospitals per region but eventually we want to bring it down to the province and also the district hospitals but right now we can develop the checklist as you mentioned for our frontline health workers that would be the nurses and the midwives that are on the barangay health workers because there's more of them there's one barangay health worker that's the community volunteer for every 20 households so if they have this checklist and they are trained on how to detect probably children with developmental delays and then we have a service delivery network that actually refers these children to the specialists then we can have a chance in this country to actually ensure the proper intervention is introduced early enough so that children with autism and ADHD can grow up to be functioning and well adjusted citizens of this country but I know that it's an enormous task because the infrastructure is not yet there we don't have the specialists we don't have the training that's required but we hope that with this strategic plan that we actually developed about three years ago that we can move it forward so we can say that we have no true picture of this health problem is concerned because we are still looking at the department of health program even to capture those in the community level and we have seen the role of the teachers simple question doctora how about the yayas the yayas are the ones attending to the children do they have a role here they also have to be trained sometimes because they are the ones who are the cause of the problem because the yayas nowadays they are the millennials they are the young ones and these are the ones who are impatient, they are hooked to their gadgets and they lack the compassion and the commitment actually to really interact with children for young children the secret is really human interaction because they have very little of that nowadays parents are busy yayas under the cell phone mga kapatid are under gadgets so these children, the young children with problems are left to their own devices playing by themselves watching TV by themselves that will not encourage the development of social emotional empathy which is actually I think one of the major problems in a lot of young children now na parang some are actually normal but because nobody has taught them nobody has engaged with them they have no eye contact they don't know how to talk to people because nobody is talking to them so just that alone even without you have to understand that the environment plays a big role in how these children develop so if we just modify this environment we can already decrease the problem by 50% kasi 50% of these kids who are brought to developmental pediatricians they don't actually have problems it's the environment that's problematic even bigger problem now looks like it's a complex thing may request Doctor Manalo what would you like to say? just a final word to our viewers all children are capable of learning no matter what their ability or disability is and I think all of us just have to give them a chance to learn the young kids we have to understand where their behavior is coming from so if you have delays like you have delays in communication and language how else will you express yourself behaviorally kaya your violent physical because that's the only way you can express yourself so instead of getting mad at these children we have to get to the bottom of this why are they behaving this way they may have a problem or maybe their environment has a problem so that's the way we look at these things is it the child is it in the environment or is it a combination of these two things the first thing that parents can do is fix the environment even without going to a specialist and having the child diagnosed you can improve this child a lot just by modifying the environment and that's what where parenting comes in and then if the proposition problem then maybe talaga there are child factors which have to be addressed and that's where the specialist comes in and all of these children no matter what I've seen through my practice is from delayed they can become advanced so let us not judge them early let's give them the chance to learn and we'll see how they come out but even those who may not be academically inclined they can learn other ways and in different ways and they can be very capable and competent and our country also needs workers people who work with their hands not just people who think so these children have a place later on even as people who work with their hands they do simple work but that's dignified work so talking about people maybe as secretary how? Filipino community should get from you our call is really increasing awareness of our people in the community so that we are more accepting of probably different behaviors people with developmental delays were more accepting and our call is for the parents and even the guardians the yaya, the lola, the lolo if you see something different in your children sa mga apo you approach a health worker so that we can help you now establishing the service delivery network so that even the children and the communities in the far best areas of the country we call the last mile towards universal health care has access to tertiary care facilities and to specialists the first step is to get to a health worker at a health center so that we can bring you to the appropriate level of care there you are dear viewers we are sure that we now have a better and broader understanding of our children and adults with autism and ADHD as well as their rights that they should enjoy as citizens of our country we would like to also thank our local viewers in this kalusugan ay karapatan episode thank you secretary obial thank you doctor Stella Manalo we'll see you again next time for a part 2 on autism and ADHD