ADHD: A BIO-PSYCHO-SOCIAL APPROACH TO UNDERSTANDING

1. ADHD: A BIO-PSYCHO-SOCIAL APPROACH TO UNDERSTANDING Treatment Approaches

2. Goals & Objectives Discuss the essential need for and elements of a sound assessment and diagnostic evaluation. Discuss the elements and benefits of a multi-systemic treatment approach. Discuss the need for and options regarding pharmaceutical interventions.

3. Finding Qualified Professionals • This can be difficult to do: • Fewer than 6,500 child psychiatrists in the U.S. • Normally family members start with their pediatrician when they need guidance • Can be detrimental or beneficial depending on the doctor’s stance, knowledge level, diagnostic ability and referral sources

4. Finding Qualified Professionals Pediatricians can be very useful in ruling possible medical conditions out. Has an expertise in ADHD and uses a variety of assessment tools and procedures to get the diagnosis Communicates without jargon; and works well with parents and school systems

5. Finding Qualified Professionals Is aggressive –not afraid to initiate new medication trials to achieve stabilization Wants to work along with the family, not to blame them. Values parental input and has a good rapport with the child.

6. Finding Qualified Professionals Often there are specialty clinics in most larger cities who have specialized diagnostic and treatment programs for ADHD children and adolescents Look for them in Children’s Hospital wings or in University Hospitals

7. Critical Point for Mental Health Practitioners:

8. Differential Diagnosis ***Anger and prolonged tantrums and associated violence and rages are one of the most common features of pediatric, early on-set bipolar disorder.

9. Assessment Procedures • Energy Levels • Tracks • Mood • Severity of Energy Level Scale from (1-5 and -1/-5) • Functional Impairment

10. Neuropsychological TestingA Suggested Battery of Testing • Tests of General Intelligence • WISC-III • Both Bipolar and ADHD children have been found to: • Demonstrate significant disparity in scores • Subtests typically demonstrate a range of differences greater than a 3-5 pt. spread. • Called a “Scatter” and represents a considerable interest variability • Not Used to Diagnose: Just one of many observations gleaned from many tests

11. Neuropsychological Testing • Tests for Sustained Attention • Connors Continuous Performance Test • Tests of Variable Attention (TOVA) • Both of these are computerized tests • Tests of Academic Achievement • Tests Of Language • Motor Tests of Sequenced Movement • Projectives • Tests of Executive Function

12. Tests of Executive Functioning The Wisconsin Card sort Tower of London Tower of Hanoi Trails A & B Stroop color and Word Test Connors Rating Scale for Teachers Connors Rating Scale for Parents

13. Neuropsychological Testing • Tests of Executive Functioning: • Directly Test Frontal Lobe efficiency and health • Children have been found to: • Have deficits in “working memory” • Organization and problem assessment • Inflexible when off track • Get stuck when strategizing problem solutions • Evidence of “Dyspraxia”: The inability to interact successfully with the physical environment and to plan, organize and carry out a sequence of behaviors

14. Assessment Procedures/Treatment that Assesses • Medication Trials • It is common for psychiatrists to try different medications to find the right types and dosages • Family members should be coached regarding the validity of such procedures • Cycle charts should monitor types, times, dosages and efficacy of each medicine

15. Elements of The Therapeutic Team • Child Psychiatrist • Diagnosis • Medication • Trials/Monitoring • Psychoeducation • General support • Psychotherapist • Psychoeducation; family and child • Ability to help family understand and differentiate between Disease related/psychological/social problems

16. Elements of The Therapeutic Team • Psychotherapist • Plan and support behavioral and emotional treatment goals • Aid parents in the advocacy for child in school • School Personnel • School Psychologist • Aid in testing and education of teachers • Monitor IEP planning and follow through

17. Elements of The Therapeutic Team • Teacher • Educated about ADHD • Facilitation of IEP, monitoring, and willingness to maintain an open dialogue with parents

18. Pharmacological Treatment Stimulants, Antidepressants, Neuroleptics

19. Pharmacological Treatment

20. Pharmacological Treatment • Antipsychotic Medications • Clozapine Clozaril • Olanzapine Zyprexa • Quetiapine Seroquel • Risperidone Risperdal • Ziprasidone Geodon

21. Stimulants Stimulants include different formulations of methylphenidate: short acting, such as Ritalin and Focalin, with a duration of 3-5 hours intermediate acting, such as Ritalin SR, Metadate ER, and Methylin ER, with a duration of 3-8 hours long acting, such as Concerta, Rilatin LA and Metadate CD, with a duration of 8-12 hours and which can be used just once a day

22. The other type of stimulant includes different formulations of amphetamine: short acting, such as Dexedrine and Dextrostat, with a duration of 4-6 hours intermediate acting, such as Adderall and Dexedrine spansule, with a duration of 6-8 hours long acting, such as Adderall-XR

23. The Basics: Vyvanse is a treatment for ADHD. It is FDA approved and became available in July 2007. What it is Used For: Vyvanse is a once-a-day treatment for children who are six to 12 years old with ADHD. Vyvanse Fast Facts: It was formally known as NRP104. Its main ingredient is lisdexamfetamine dimesylate. It is a prodrug or 'conditionally bioreversible derivative' of dextroamphetamine, one of the main ingredients in Adderall, Adderall XR, and Dexedrine Spansules. Vyvanse can be taken either with or without food.

24. If your child can't swallow the Vyvanse capsules, you can open them and either sprinkle it onto a small amount of food or into a few ounces of water (which is a benefit over other 'beaded' ADHD stimulant medicines, which don't dissolve in liquids). Vyvanse is commonly misspelled as Vyvance. Benefits of Vyvanse: Vyvanse, unlike other stimulants, has to go through the stomach and be digested before it can become active. That means it's much less likely that Vyvanse will be abused, since it can't be snorted, etc., like other ADHD medicines. Another potential benefit of Vyvanse is that it lasts a full 12 hours, whereas other long-acting ADHD medicines tend to last 10 to 12 hours. Forms of Vyvanse: Vyvanse is available in three dosage strengths: 30mg, 50mg, and 70mg.

25. Other Treatments showing Efficacy • Cognitive Behavioral Therapy • Aid in developing the Internal Thought process • Family therapy; identifying and helping to combat unreasonable behaviors/thoughts/emotions • Aid in setting appropriate goals for the child and correcting any misinterpretations.

26. About.com Pediatrics http://pediatrics.about.com/cs/adhd/a/adhd_guidelines.htm

27. Side Effects of Vyvnase: Side effects of Vyvanse are similar to other ADHD stimulants and most commonly include abdominal pain, vomiting, weight loss, decreased appetite, headaches, insomnia, and irritability. Interestingly, side effects -- especially appetite suppression -- seem to quickly decrease over time. Warnings: Like other stimulant medications, Vyvanse should not be used by children with the following conditions: Heart disease or hardening of the arteries; moderate to severe high blood pressure; hyperthyroidism; glaucoma; high state of anxiety, tension, or agitation. It should also not be used by kids who have a history of drug abuse, who are taking or have taken within the past 14 days an anti-depression medicine (monoamine oxidase inhibitor or MAOI), or who are sensitive to, allergic to, or had a reaction to other stimulant medicines

28. Other Treatments showing Efficacy http://www.celebratecalm.com/

29. Other Treatments showing Efficacy

30. Psychosocial Interventions Sports, Girl Scouts, Boy Scouts, Summer programs Community action groups, volunteer programs, youth groups, church involvement. Peer support groups, leadership programs, summer camps.