Attention Deficit / Hyperactivity Disorder (ADHD)

1. Attention Deficit / Hyperactivity Disorder (ADHD) Common Symptoms, Differential Diagnoses, and Treatment Options Dr. Rachel Andaloro MetrowestNeuropsychology ASHPAC meeting 3/17

2. ADHD • One of the most common childhood disorders • ADHD affects about 9% of American children from 13-18 and about 4.1% of adults • Average age of onset is 7 years of age • Boys are four times more likely to be diagnosed than girls • The number of kids being diagnosed with ADHD is increasing

3. DSM-V ADHD Criteria • Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development • Inattention: (≥6 of following symptoms have persisted for at least 6 months; for >17 years ≥ 5 are required) • Fails to give close attention to details • Difficulty sustaining attention in tasks or play activities • Does not seem to listen when spoken to directly • Often does not follow through

4. DSM-V Criteria cont. (Inattention) • Difficulty organizing tasks and activities • Often avoids/dislikes/reluctant to engage in tasks that require sustained mental effort • Often loses things necessary for tasks and activities • Often distracted by extraneous stimuli • Often forgetful in daily activities

5. DSM ADHD Criteria cont. • 2) Hyperactivity/Impulsivity: (≥ 6, for >17 at least 5) • Often fidgets, squirms in seat • Often leaves seat • Often runs about or climbs • Often unable to engage in leisure activities quietly • Often on the go • Often talks excessively • Often blurts out an answer • Often has difficulty waiting his or her turn • Often interrupts or intrudes on others

6. ADHD Criteria cont. • Several symptoms were present < age of 12 • Symptoms are present in two or more settings • Symptoms interfere with social, academic, or occupational functioning • Symptoms are not better explained by another mental disorder (*mood disorder, anxiety, personality disorder, psychotic disorder, substance intoxication or withdrawal) • Can be combined presentation if both domains are met or predominantly inattentive presentation if criterion 2 are not met or vice versa

7. Neuropsychological Assessment • ADHD is diagnosed based on these criteria • But, it can be difficult to tease out other possible etiologies without a thorough evaluation. • Neuropsychological evaluation provides a thorough assessment of history as well as a broad measurement of overall cognitive functioning

8. ADHD and cognition • ADHD is associated with deficits in executive functioning • Executive functions affect many aspects of behavior • Determine our development of strategies to approach, plan, or carry out cognitive tasks, monitor or regulate behavior • Measure a broad range of cognitive functions, with emphasis on measures of executive skills

9. Other Possible Etiologies… • NP eval is important in ruling in or out other disorders • Depression and anxiety - associated with deficits in executive functioning, and can present with similar symptoms • Underlying mood disorder? • Other health issues? • Lyme Disease • Obtaining a thorough history is key in teasing these apart.

10. Comorbidities • ADHD is often comorbid with other mental health disorders: • Oppositional Defiant Disorder • Conduct Disorder • Autism Spectrum Disorders • Learning Disabilities • If co-morbid with LD, ADHD symptoms may be masking the LD (or LD may cause inattention)

11. Treatment • Options for treatment: • Behavioral interventions first • Medication as a last resort

12. Medications • 70% improve with use • Amphetamines (Adderall, Dexedrin) • Methylphenidate (Concerta, Metadate, Ritalin) • Strattera (non-stimulant option) • Clonidine and guanfacine (Intuniv): nonstimulant medicines approved to treat aggression and impulsivity not controlled by other ADHD medicines. • Antidepressants (Vyvanse, Wellbutrin)

13. Medications cont. • Stimulants may be related to slower growth in children. Most children seem to catch up in height and weight by the time they are adults. (medication holidays) • Stimulants can be abused • Can cause sleep disturbance • Research has shown that these medicines, when taken correctly, don't cause dependence.

14. Behavior Modification for ADHD • Preferential seating, additional time, separate room for quizzes and tests • Be on time, sit in the front row (limits distractions) • Work with ADHD coach, mentor / advisor to help establish a plan and organizational strategy • Frequent, brief contact with mentor • Audio record lectures- can be replayed in order to review missed information • Continuous note-taking to increase attention to lectures • Work closely with more organized students • Attend after-class help sessions whenever possible

15. Behavior Modification cont. • Provide simple instructions and repeat if necessary. • Have child repeat information/ instructions back in their own words, to ensure understanding • Gentle and repeated prompting/reminders to engage in tasks/remain on-task • Coached to quietly talk himself though tasks, step-by-step, as a means to maintain focus and sequence tasks appropriately. • Regular refresher breaks to help refresh and refocus (e.g., movement or water breaks), given before student becomes overwhelmed and starts to lose focus.

16. Behavior Modification cont. • Consistent praise for periods of (for example) ten minutes or more, when child remains on-task. • Consider other rewards at school and home for substantial periods of controlled and attentive behavior (including assignments successfully completed).

17. Organization • Clean workspace • Maintain planner and review notes with teachers to ensure that student has recorded each item and understands the purpose of each assignment. • Checklist for materials • Organized binder with sections devoted to each subject where hand-outs, notes, and assignments can be placed. • Structure!

18. Oppositionality • Time-out (approximately 5 – 10 minutes) in a quiet, supervised area (should not be able to use behavior as manipulation to avoid work) • Student should be given one calm, but firm warning when becoming disorderly. • If student does not heed warnings, there should be a consistent system in place for applying sanctions. The use of time-outs and/or taking privileges away for unruly behavior may be beneficial. • Oppositional students tend to respond best to both high structure and high warmth. • Consistent disciplinary procedures be followed at both school and home.

19. Positive Behavior Support • Proactive rather than reactive approach • Set basic and clear expectations for behavior • Be safe • Be respectful of others • Be responsible for students own well-being • Clear examples of what it means to meet these expectations in various contexts should be given. • PBIS.org

20. PBS cont. • Student should receive the most attention (and also praise) when meeting expectations. • Respond to any negative behaviors with brief redirection in a calm but firm manner, by stating and optimally demonstrating the type of behavior you want to see instead.

21. PBS cont. • Error corrections should be provided. • Set expectations and pre-correct as much as possible. Monitor his response to the pre-corrections and provide reinforcement accordingly. • Reward positive behaviors rather than punish negativeones (5:1 ratio) • Praise and error corrections should follow a NORMS format (Neutral, Observation-based, Reliable, Measurable, and Supportive).

22. PBS cont. • PBS approach should be extended into the home • If significant externalizing behaviors persist despite consistent behavioral intervention, a therapeutic school setting may be of benefit. • Provide emotional and behavioral support • Individualized attention, smaller class sizes

23. Thanks! Contact info: r.andaloro@metrowestneuropsych.com Metrowest Neuropsychology 1900 West Park Drive, Suite 280 Westborough, MA 01581 www.metrowestneuropsych.com