Putting Solutions into Action ADHD and Learning Disorders in High School Robert Milin, MD

1. Putting Solutions into Action ADHD and Learning Disorders in High School Robert Milin, MD Director, Adolescent Day Treatment Unit Youth Psychiatry Program Royal Ottawa Mental Health Centre Clinical Scientist Institute of Mental Health Research Associate Professor Department of Psychiatry University of Ottawa Date: February 15, 2013

2. Disclosures of Potential Conflicts

3. Learning Disorders (LD) • DSM-IV definition: • Individual’s achievement as measured by standardized tests (academic achievement) in reading, math, or written expression is substantially lower than expected for age, schooling and intellectual level • Significant impairment in academic achievement or activities of daily living that requires the specific learning skill/ability

4. Learning Disorders • Prevalence rates range from 2-10% • 5% of US public school students identified with a learning disorder • Reading Disorder is believed to be the most prevalent LD at ~4% • It is important to differentiate and take into consideration such factors as lack of opportunity, poor teaching or culture

5. Learning Disorders • About 1.5 times greater school drop out rate • Common co-occurrence (10-25%) with Disruptive Behavioural Disorders • Conduct Disorder • Oppositional Defiant Disorder • ADHD

6. Communication Disorders • Types include: • Expressive Language Disorder • Mixed Receptive-Expressive Language Disorder • Phonological Disorder (formerly Developmental Articulation Disorder)

7. Intellectual Functioning • General intellectual functioning is defined by the intelligence quotient (IQ or IQ-equivalent) on individual assessment with a standardized intelligence test • Important that IQ testing procedures adequately reflect the individual’s ethnic, cultural or linguistic background

8. IQ

9. IQ Indices • Verbal Comprehension • Perceptual Reasoning • Working Memory (WM) • Processing Speed (PS) • WM & PS are referred to as the cognitive proficiency indices

10. Borderline Intellectual Functioning • DSM-IV definition: • When overall cognitive abilities fall within the IQ range of 71-84 • An IQ score of 85 is equivalent to the 16% rank

11. ADHD DSM-IV CRITERIA Either (1) or (2): Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that’s maladaptive and inconsistent with developmental level INATTENTION Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities Often has difficulty sustaining attention in tasks or play activities Does not seem to listen when spoken to directly Often does not follow through on instructions, fails to finish schoolwork, chores or duties in the workplace Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Often loses things necessary for tasks or activities Is often easily distracted by extraneous stimuli Is often forgetful in daily activities

12. ADHD DSM-IV CRITERIA A. Either (1) or (2): 2. Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that’s maladaptive and inconsistent with developmental level HYPERACTIVITY Often fidgets with hands or feet or squirms in seat Often leaves seat in the classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate Often has difficulty playing or engaging in leisure activities quietly Is often “on the go” or often acts as if “driven by a motor” Often talks excessively IMPULSIVITY Often blurts out answers before questions have been completed Often interrupts or intrudes on others

13. ADHD DSM-IV CRITERIA Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years Some impairment from the symptoms is present in two or more settings There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning The symptoms do not occur exclusively during the course of PDD, schizophrenia or other psychotic disorder and are not better accounted for by another mental disorder

14. Characterization of DSM-IV ADHD subtypes: ADHD/AD - academic problems, fewer behavioural problems and higher proportion of girls (20-30%), prevalence increases with age ADHD/HI - behavioural problems, few academic problems and low rate of anxiety or depressive symptoms (<10-15%) ADHD/CT - both behavioural and academic problems, most prevalent subtype and likely most impaired subtype with the worst prognosis (50-75%)

15. DSM-V Changes in ADHD Maximum age of onset of 12 years; up from 7 years Elimination of DSM-IV subtypes; include specifiers of current manifestation at the time of assessment Broaden age-related symptoms to include examples relevant to adults

16. DSM-V Changes in ADHD Broaden comorbidities to include Autism Spectrum Disorders (previously excluded) ADHD clustered under Neurodevelopmental Disorders rather than Disruptive Behavioural Disorders

17. Epidemiology Estimate of 3-7% of school-aged children in the U.S. Ontario Child Health Study-6.3%. Most common diagnosis, ADHD ages 4-11 and Conduct Disorder, ages 12-16. Adults ~ 4% in the US.

18. Gender ratio 3 Boys: l Girl, approaches 1:1 in adulthood. 30% - 50% of all child psychiatric outpatients demonstrate symptoms of ADHD. Cross culture differences in prevalence rates related to differences in nomenclature, diagnostic decision processes and cultural variations in perceptions of disruptive childhood behaviours.

19. ADHD: Worldwide Prevalence (%) Spain New Zealand NY, MI, WI Canada Ireland N. Carolina United Kingdom Virginia Israel Missouri Switzerland Netherlands/Belgium Oregon Germany Minnesota Ukraine Tennessee Brazil Iowa Japan New Zealand Pittsburgh Netherlands New York City China Puerto Rico India 20 0 5 10 15 0 5 10 15 20 Faraone SV et al. World Psychiatry 2003;2:104-113.

20. ADHD Types: Childhood vs. Adulthood 22% 56% Inattentive Type Inattentive Type Combined Type 44% Combined Type 78% Spencer,2005, Harvard Update; McGough, Smalley, McCracken et al. American Journal of Psychiatry, September 2005, Vol. 162, Page 1621 In Childhood In Adulthood 3:1 Male to Female 1:1 Male to Female

21. Assessment of ADHD in Youth Modified from Weiss & Murray, CMAJ, March 2003 Assess current ADHD symptoms using interview and rating scales with youth norms Establish childhood history of ADHD– retrospective parent or self-report - collateral history including elementary school report cards and previous psychological assessment Assess functional impairment in multiple domains

22. Assessment of ADHD in Youth Developmental history—especially behavioural and school history including indication of a learning disorder/disability Psychiatric history —rule out or establish comorbid disorder —particular attention to substance use history Family psychiatric history Rule out medical causes

23. ADHD remains a clinical diagnosis with clinician-administered interview as the cornerstone of diagnostic evaluation