Attention Deficit -Hyperactivity Disorder Diagnosis & Intervention

1. Attention Deficit -Hyperactivity DisorderDiagnosis & Intervention Lisa Nalven, MD, MA, FAAP Kireker Center for Child Development - Valley Hospital Ridgewood, New Jersey

3. What is ADHD? • Most common neuro-developmental problem in children • Inattention • Hyperactivity • Poor impulse control • Distractibility • “Executive Dysfunction”

4. Occurrence • Between 3% and 7% of school- age children • 70% of cases inherited. Runs in families, especially through male family lines • 7 times more common in boys • may look different in girls (chatty, daydream, fidget)

5. Prevalence (internationally) • Canada (Montreal): 3.8-9.4% children (DSM-III-R) • Australia: 3.4%children, 2-3% teens (DSM-III-R) • New Zealand: 6.7% children, 2-3% teens (DSM-lll-R) • China: 6-9% children (DSM-lll) • Netherlands: 1.3% teens (DSM-lll-R) • Puerto Rico: 9.5% children & teens (DSM-lll) • Japan: 7.7% children (DSM-lll-R) • Colombia: 2-13% (DSM-lV) • Brazil: 5.8% of 12-14 year olds (DSM-IV) • R. Barkley, Ph.D

6. DSM-IV Criteria6 of 9 Inattention Symptoms • Fails to give close attention to details • Difficulty sustaining attention • Does not seem to listen • Does not follow through on instructions • Difficulty organizing tasks or activities • Avoids tasks requiring sustained mental effort • Loses things necessary for tasks • Easily distracted • Forgetful in daily activities

7. DSM-IV Criteria6 0f 9 Hyperactive-Impulsive • Fidgets, squirms in seat • Difficulty staying seated • Climbs or runs excessively • Is on the go or “driven by a motor” • Talks excessively • Blurts out answers before questions are completed • Difficulty with turn taking • Interrupts or intrudes • Forgetful in daily activities

8. Other DSM-IV Criteria • Developmentally inappropriate levels • Duration of 6 months • Cross-setting occurrence of symptoms • Impairment of major life activities • Onset of symptoms/impairment by age 7 • Exclusions: severe DD, PDD, psychosis • Subtypes: inattentive, hyperactive, or combined types

9. Etiology • Neurological/Biological • differences in functioning of frontal cortex • imaging studies show differences in neurotransmitter levels and brain structures • Factors that influence neurology/biology • heredity/genetics • prematurity • prenatal exposures (tobacco, alcohol, drugs of abuse) • adverse early experiences**

10. Things that can look like ADHD (but are not) • Language impairment • Learning Disability • Mild cognitive impairment (ID) • Pervasive Developmental Disorder • Anxiety/PTSD • Depression • Medication side effect • Parent/child: poor fit of style/temperament

11. Coexisting conditions: need to evaluate Prevalence % • Learning disability (40-60) • Oppositional defiant disorder (35) • Conduct disorder (25) • Anxiety disorder (25) • Depressive disorder (18)

12. Identification • Appropriate diagnosis of ADHD requires collaborative effort • Multiple sources of information should be gathered (family, teachers, other adults) • Multiple perspectives regarding symptoms are needed to assess their pervasiveness and severity

13. Sources of information regarding symptoms & impact • Formal observation in multiple settings • Interviews with student and relevant adults • Rating scales completed by family, teachers and student • Developmental, school, and medical histories • Tests to measure attention, persistence and related characteristics (CPT, TOVA) • Psychoeducational testing to rule out/in a learning problem or other causes. • Vision and hearing assessments • There is no ONE test

14. How young can you diagnose ADHD? • A reliable diagnosis can be made down to age 4 (see AAP clinical guidelines) • For younger children need to consider: • Very active toddler/preschooler • Maturational issues • Developmental delay • Unrealistic parental expectations • Permissive parent • Early signs of ADHD (time will tell)

16. How ADHD leads to impairments ScenarioFunctional Outcome • Hyperactive 5 yr old elicits irritation Strained and harsh punishment by mother family relations • 10 yr old who is impulsive, difficulty Poor self-esteem playing cooperatively with peers is rarely asked to sleep at friends’ houses Contemporary Pediatrics, 2/2003

17. How ADHD leads to impairments/2 ScenarioFunctional Outcome • Despite high IQ, college student fails Academic dysfunction courses due to disorganization, tardiness, poor writing skills • -Shy girl, believing school performance is Depression inadequate Contemporary Pediatrics, 2/2003

19. Childhood Academic Impairments • Children with ADHD evaluated using teacher reports and achievement tests: • Poor school performance (90%) (primarily reduced productivity) • Low academic achievement (10-15 point deficit) • Low average intelligence (7-10 point deficit) • Learning disabilities (24-70%) • Reading (15-30% in Barkley, 1990) • Spelling (26% in Barkley, 1990) • Math (10-60% in Barkley, 1990) • Handwriting (60%) • R. Barkley

20. Steps in Intervention • Assessment (appropriate diagnosis) • ratings scales from multiple informers • testing: IQ, achievement/educational, language • evaluate for other mental health or medical factors • Behavioral (skills training/counseling) • primary interventions for preschoolers • Educational • classroom strategies • interventions for comorbid learning issues • Accommodations at home, school and in the community • select and structure activities for success • Medication

21. Address MH and medical issues • Treat depression, anxiety and re-evaluate ADHD symptoms • Adequate and good quality sleep-may need sleep study • Balanced diet (not megadosing) • Exercise

22. Behavioral Interventions: • First line intervention for preschoolers • Behavior therapy • Parent training • Individual and family counseling • Parent/family services • Support groups (CHADD) • Social skills training

23. Behavioral techniques for home and school • Encourage eye contact before giving directions • Give short, clear, specific directions • Provide frequent reinforcement (praise) of appropriate behavior • Verbal reprimands directed at the child’s behavior--not at the child • Use “signals” to refocus or redirect • Preferential seating in the classroom

24. Behavior Management Strategies • Positive reinforcement: rewards or privileges given for desired behaviors • “Token” economy: earns points towards rewards or privileges and loses them for undesirable behavior • Use of “time-out”

25. Tips for Helping Child Control Behavior • Provide daily schedule and routines • Reduce distractions • Organize house and study area • Reward positive behavior • Set small, reachable goals • Help child stay “on task” • Find activities at which child can succeed • Use calm discipline

26. Other considerations • Appropriately structured activities-be practical • Provide outlet for release of energy • Try not to let child become fatigued/hungry • Avoid taking younger children to formal gatherings (e.g. stores, supermarkets, restaurants) if not necessary or do for short period of time. • Stretch attention span: reading, coloring, puzzles, board games • by age 5 child needs at least a 25 minute attention span

27. Services for children under 3 years • Early Intervention: 0-3 years. • Free evaluation for children “at risk” for or with developmental issues • Services vary by state (none, some, unlimited, free, sliding scale, full cost) • Services for behavior alone can be difficult to get approved • Call state agency responsible for EI (if not known, call local school district to get contact information)

28. Education Based Interventions (3-21 years) • Requires written request by parent for evaluation by the school district • Parent can pursue private evaluations and provide school with results for review • School and parent meet to review issues, decide on further evaluation and/or intervention.

29. Working with the school • Be aware of state mandated timelines for response, meetings, assessment, implementation of plan • If parents disagree at any stage in the process, they can work with advocate, request independent evaluation, pursue due process

30. Possible outcomes • School chooses not to intervene • Home/Classroom behavior modification • Home/Classroom work modification • Response to Intervention (RTI): written plan • ADA-rehabilitation act: section 504 • IDEA: classification for special education services

31. Modifications to support learning: • Organization skill support : color code books and folders; assignment pad, calendar for long term assignments, electronic reminders • Plans for initiation, completion, and transition between tasks; include cues, supplies, timers • Homework: divided into sessions, with short breaks in between; longer, more difficult assignment done first, easiest last; remove distractions • Teaching strategies: break down tasks, cue, reinforce, multisensory/hands on approach; work modified to address learning issues; small group instruction with breaks; quiet place to work

32. Response to Intervention RTI • Included under IDEA • For a child that is struggling in school; “evidence based interventions” are put in place and response is evaluated • Pros: can be done quickly; children who don’t qualify for spec ed service get support • Cons: child is never formally evaluated and there is no time line to assess response or move to testing/more intensive services

33. Section 504 • Does not meet criteria for IDEA (i.e., learning not significantly impacted) • Modifications in instructional program • Does not require, or not eligible for special education supports • Modifications may include: quiet work spaces, untimed tests, reduction in amount of written work , preferential seating

34. Special Education Classification- IDEA • “Other Health Impaired” • ADHD significantly impacts learning/academic achievement • Needs can not be met by a 504 • Modification of school environment and instruction • Push-in or pull-out support

36. Why Medication? • Dysregulation of neurotransmitters • Medications can increase the levels of neurotransmitters and improve function of nerve cells in frontal cortex that are responsible for attention, impulse control etc.

37. Impact of Medications? • Increases ability to pay attention • More control over behavior (impulsivity) • Improvement in schoolwork such as task completion, handwriting, classroom behavior as a result of improved attention, impulse control and on task behaviors • Reduces risk of substance abuse, car accidents • Make child more available to benefit from other interventions strategies • Will not treat comorbidities or wrong diagnosis

38. Medication issues • Not approved by FDA for children under 6, but many clinical studies document effectiveness/safety in preschool population • Individual and family history determines need for cardiac assessment (EKG) • Do for all children in foster care or who have been adopted due to incomplete histories • May take several tries to get the right medication and dose • Side effects are minimal if done properly

39. Medication options • “Stimulants” • Methylphenidate (Ritalin, Focalin, Concerta, Daytrana etc) • Amphetamine (Adderall, Vyvanse, Dexadrine etc) • Nonstimulant • Atomoxitine (Straterra) • Alpha agonists** • Intuniv (guanfacine) • Kapvay (clonidine)

40. Other interventions: • Omega supplements: studies do not find consistent positive results; need to look at why • Diet modification; remove additives (some studies show impact for subset of children) • Cog-Med, Q-EEG may have a role for some

41. Collaboration • Teamwork among doctors, parents, teachers, other health professionals and the child provides the best outcome for children who are affected by ADHD.

42. Resources • AAP Clinical Practice Guidelines http://aappolicy.aappublications.org/cgi/content/full/pediatrics;108/4/1033 • National Resource Center on ADHD www.help4adhd.org • Children and Adults with ADD www.chadd.org

43. Resources • Learning Disabilities Association www.ldanatl.org • National Center for Learning Disabilities www.ncld.org • Wrightlaw Special Education Advocacy www.wrightslaw.com

44. Books • ADHD: A Complete and Authoritative Guide. American Academy of Pediatrics. Edited by Michael Reiff MD • 1-2-3 Magic: Training Your Child To Do What You Want: by T. Phelan • www.addwarehouse.com • www.maginationpress.com

46. Lisa Nalven, MD, MA, FAAP Director, Developmental Pediatrics Adoption Screening & Evaluation Program Kireker Center for Child Development-Valley Hospital 505 Goffle Road Ridgewood, NJ 07450 T: 201-447-8151 F: 201-447-8526 www.valleyhealth.com/childdev www.valleyhealth.com/adoption