Unlocking Attention Deficit Hyperactivity (ADHD)

1. Unlocking Attention Deficit Hyperactivity (ADHD) Diagnosis Characteristics Management

2. Children with ADHD • Estimated 1.46-2.46 million children with ADHD (U.S.) • 3-5 % of student population • More boys than girls are diagnosed (4 to 9 times more) • While symptoms of the disorder may change many do not grow out of it.

3. Core Characteristics result in unique differences • Inattention: six of nine persistent symptoms (lasting at least 6 mos.) • Hyperactivity-Impulsivity: six of nine persistent symptoms (lasting at least 6 mos.) • At least some of the symptoms are present before the age of seven • Must impair the individual in 2 or more settings • Significant impairment in social, academic or occupational functioning.

4. Fidgeting with hands or feet, squirming in their seat, restless Difficulty remaining seated when required Difficulty sustaining attention, waiting turn Blurting out answers before questions are stated. Easily distracted Wide ranges in mood swings Difficulty following through on instruction and organizing Shifting from one unfinished activity to another Failing to give close attention to details, careless mistakes Losing things necessary for tasks or activities. Difficulty delaying gratification Diagnostic Statistical Manual of Mental Disorders (DSM-IV)

5. Three subtypes • Predominantly inattentive • Predominantly hyperactive-impulsive • Combined

6. Sometimes it is not just ADHD • 20 to 30 percent of Children also have learning disabilities • 30 to 50 percent (mostly boys) conduct or oppositional defiant disorders • About 20 to 40 percent of ADHD children may eventually develop conduct disorder (CD) • 13 to 51 percent anxiety or mood disorders • A very small proportion of people with ADHD have a neurological disorder called Tourette’s syndrome. • There are no accurate statistics on how many children with ADHD also have bipolar disorder. Differentiating between ADHD and bipolar disorder in childhood can be difficult.

7. Things that affect Inattention

8. Things that affect Level of Activity

9. Impulsive behavior

10. Who statistics • Going in • Boys are more likely to be referred and identified and are more likely to become part of clinic statistics • Best practice suggests waiting until five years old or later • Hyperactive and impulsive behavior results in more frequent referrals

11. Where does it come from? • "Why? What went wrong?" "Did I do something to cause this?" • Little compelling evidence at this time that ADHD can arise purely from social factors or child-rearing methods • Environmental factors may influence the severity of the disorder and suffering the child may experience, but do not seem to cause the condition by themselves • Most substantiated causes appear to fall in the realm of brain organization and genetics • There appears to be an acquired variety connected to some childhood diseases such as strep throat • Our focus should be on finding the best possible way to help these children.

12. Where does it really come from? • Growing evidence that ADHD does not come from the home environment, but from biological causes. • Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and risk for ADHD in the offspring of that pregnancy. • High levels of lead in the bodies of young preschool children is not as prevalent as it once was but appeared to be a possible cause of behaviors.

13. Brain Injury • One early theory was that attention disorders were caused by brain injury. Some similar behaviors seem to exist, but only a small percentage of children with ADHD have been found to have suffered a traumatic brain injury.

14. Food Additives and Sugar. In 1982, NIH held a scientific consensus conference to discuss this issue. • Diet restrictions helped about 5 percent of children with ADHD. • Mostly young children who had food allergies. • This remains an important rule out if allergies are present in child or family.

15. Some Sugar Studies Children whose mothers felt they were sugar sensitive were given aspartame as a substitute for sugar. • Half the mothers were told their children were given sugar. • Half that their children were given aspartame. • The mothers who thought their children had received sugar rated them as more hyperactive than the other children and were more critical of their behavior.

16. Another Sugar Study Using sugar one day and a sugar substitute on alternate days. • Without parents, staff, or children knowing which substance was being used. • Showed no significant effects of the sugar on behavior or learning.

17. Genetic Factors Attention disorders often run in families. • Studies indicate that 25 percent of the close relatives in the families of ADHD children also have ADHD, whereas the rate is about 5 percent in the general population. • Many studies of twins now show that a strong genetic influence exists in the disorder. • Researchers continue to study the genetic contribution, have identified some markers and predict there may be as many as twelve. Possibly as high as 80% of ADHD is genetic. The most inherited, more than IQ or height of any characteristic.

18. Impact areas of the Brain The search for a physical basis for attention deficit hyperactivity disorder. • frontal lobes of the cerebrum. The frontal lobes allow us to solve problems, plan ahead, understand the behavior of others, and restrain our impulses. (The executive, president or conductor)

19. Brain continued • All of these parts of the brain have been studied through the use of various methods for seeing into or imaging the brain. • The main or central psychological deficits in those with ADHD have been linked through these studies.

21. NIMH Study • By 2002 the researchers in the NIMH Child Psychiatry Branch had studied 152 boys and girls with ADHD, matched with 139 age- and gender-matched controls without ADHD.

22. A picture is worth…. • The children were scanned at least twice, as many as four times over a decade. • As a group, the ADHD children showed 3-4 percent smaller brain volumes in all. • Showed that the ADHD children who were on medication had a white matter volume that did not differ from that of controls. • Those never-medicated patients had an abnormally small volume of white matter.

23. The Treatment of ADHD To determine what treatment will be most effective for a child. • Needs to be answered by each family in consultation with their health care professional. • National Institute of Mental Health (NIMH) has funded many studies of treatments for ADHD and has conducted the most intensive study ever undertaken for evaluating the treatment of this disorder. • The NIMH is now conducting a clinical trial for younger children ages 3 to 5.5 years

24. MTA Details • One study is known as the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA). • The MTA study included 579 (95-98 at each of 6 treatment sites) elementary school boys and girls with ADHD, who were randomly assigned to one of four treatment programs:

25. Study Groups • (1) medication management alone; • (2) behavioral treatment alone; • (3) a combination of both; or • (4) routine community care. In each of the study sites, three groups were treated for the first 14 months in a specified protocol and the fourth group was referred for community treatment of the parents' choosing.

26. Study Details • All of the children were reassessed regularly throughout the study period. An essential part of the program was the cooperation of the schools, including principals and teachers. • Both teachers and parents rated the children on hyperactivity, impulsivity, and inattention, and symptoms of anxiety and depression, as well as social skills.

27. Study Groups • In the combined therapy group • Received both treatments, that is, • All the same assistance that the medication-only received, as well as • All of the behavior therapy treatments.

28. Study Groups • In routine community care • children saw the community-treatment doctor of their parents' choice one to two times per year for short periods of time • community-treatment doctor did not have any interaction with the teachers

29. Study Results • .The results of the study indicated that long-term combination treatments and the medication-management alone were superior to • intensive behavioral treatment and • routine community treatment. • the combined treatment was usually superior when • anxiety, academic performance, oppositionality, parent-child relations, and social skills issues were present and • children could usually be successfully treated with lower doses of medicine, compared with the medication-only group.

30. (Treatment of ADHD in Preschool-Age Children) • The NIMH is sponsoring an ongoing multi-site study, "Preschool ADHD Treatment Study" (PATS) • It is the first major effort to examine the safety and efficacy of a stimulant, methylphenidate, for ADHD in this age group. • Enrollment in the study will total 165 children. • Same kind of groups

31. Which Treatment Should My Child Have? • For children with ADHD, no single treatment is the answer for every child. • A child may sometimes have undesirable side effects to a medication that would make that particular treatment unacceptable. • If a child with ADHD also has anxiety or depression, a treatment combining medication and behavioral therapy might be best. • Each child's needs and personal history must be carefully considered.

32. MEDICATION INFORMATION • For decades, medications have been used to treat the symptoms of ADHD. The medications that seem to be the most effective are a class of drugs known as stimulants. • Following is a list of the stimulants, their trade (or brand) names, and their generic names. "Approved age" means that the drug has been tested and found safe and effective in children of that age.

34. Facts to Remember About Medication for ADHD • They treat symptoms but do not cure the disorder. • They will often assist the child to use knowledge and skills they already possess. • About 80 percent of children who need medication for ADHD still need it as teenagers. • Over 50 percent need medication as adults.

35. You are your child's best advocate • Learn as much as you can about ADHD and how it affects your child at home, in school, and in social situations. • If you suspect the possibility of this diagnosis, talk to the teacher and see if a request for evaluation is appropriate. • If you and the teacher disagree you can initiate the process yourself through either the director of Special Education or the Child Study Team.

36. Special Education Process and Procedures • A child diagnosed with ADHD may qualify for special education services, the school, working with you, must assess the child's strengths and weaknesses and design an Individualized Educational Program (IEP). • You should be able periodically to review and approve your child's IEP. • If special education is not needed a 504 plan may provide the safeguards necessary for success.

37. Once Diagnosed • Let his or her teachers know. They will be better prepared to help your child be successful. • Identify your child’s unique strengths and weaknesses. • Offer to supply additional information. • Most likely impact is on writing

38. Find support and resources • Each state has a Parent Training and Information (PTI) center as well as a Protection and Advocacy (P&A) agency. • Locally we have PREP (Sarah) at 975-9400

39. Plan for transition • Transition, unstructured times can be quite difficult for the child with ADHD. • Do what works • Recognize the skill lag problem • Beware of the middle school and teen years • It’s a good time to have a complete re-evaluation of your child's health.

40. Behavior Strategies to consider • Remember that inconsistency is a hallmark • Recognize/Identify Unique Strengths and weaknesses. • Go for fewer, clearer, straightforward rules • Use punishment sparingly • Time out may work • Model and support organization strategies. • Duplicate, duplicate, duplicate • Prepare, review, set expectations • Practice being firm • Charts may work (self monitor or reward)

41. Characteristics of Environment Gender of person in charge Match between ability and tasks demands Possibility of success or failure Degree of structure Frequency of feedback Characteristics of person Ability and desire to be compliant Intelligence Degree of impairment Internal vs External Control Gender Factors that affect success of self-management

42. Just some facts to consider… • Children with ADHD are more likely to have; • Poor peer relationships (75%) • Immature motor coordination (30-60%) • Increased sleep disturbances • Verifiable (MRI) brain differences • Higher levels of substance abuse and addiction (25-35% as teens, 10-15 as adults) • More police involvement (50%) Court 20%) • More grade retentions (25-35%)

43. Just some facts to consider… • Children with ADHD have • higher than normal rates of injury • at least one close relative who also has ADHD • High rates of school difficulty (90%) • Low frustration tolerance • Low self-esteem (65%) • Misattribution of intent of others acts

44. Just some facts to consider… • Youth with ADHD, in their first 2 to 5 years of driving, • have nearly four times as many automobile accidents • are more likely to cause bodily injury in accidents • have three times as many citations for speeding as the young drivers without ADHD.

45. The good news • The absolute level of symptoms declines • 60-70% have a satisfactory outcome • Most are living on own and are self-supporting • Predictors of Adult Outcome • Socio-economic status predicts work success and academic outcome • Degree of childhood conduct problems predicts social, legal and academic outcomes • Degree of peer relationship problems predicts ongoing social problems

46. Reading, Dyslexia, Learning Disabilities Who What How

47. Statistics • ¼ to 1/3 of Children diagnosed ADHD also have learning disabilities • 3.5 % of children ages 6-21(slightly more than 2 million are receiving educational services for a reading disability • A probable underestimate of children with reading difficulties • Large scale surveys of reading proficiency finds 50 to almost 70 % measured read below grade placement. • Boys are 4 to 6 times more likely to be identified but this may reflect referral bias and gender issues the actual prevalence is not that dissimilar

48. What is a learning disability (from the Greene County SE Handbook) A disorder in one or more of the basic psychological processes involved in understanding or using language, spoke or written, that may manifest itself in an imperfect ability to listen think, speak, read, write, spell or do mathematical calculations. The term includes such conditions as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia and developmental aphasia. The term does not include learning problems that are primarily the result of visual, hearing or motor disabilities ; of mental retardation, of emotional disturbance or of environmental, cultural, or economic disadvantage.

49. Agreement on certain factors: These various definitions suggest • The learning disabled have difficulties with academic achievement and progress. Discrepancies exist between a person's potential for learning and what he actually learns. • The learning disabled show an uneven pattern of development (language development, physical development, academic development and/or perceptual development). • Learning problems are not due to environmental disadvantage. • Learning problems are not due to mental retardation or emotional disturbance.

50. Reading Decoding Comprehension Writing Spelling Grammar Composition Handwriting Mathematics Computation Reasoning Language Spoken (Expressive) Listening (Receptive) AREAS of Disability