ADHD Workshop- Introducing the AAP “Tool Kit”

1. ADHD Workshop- Introducing the AAP “Tool Kit” Presented by the Divisions of General and Community Pediatrics, Psychology, Psychiatry and Health Policy and Clinical Effectiveness Cincinnati Children’s Hospital

2. Outline • Introduction/Background • Assessment- DSM IV; Co-Morbidity; Impairment • Behavioral Treatment • Medication Treatment • Long Term Community Goals • Question/Answer

3. Controversial Topic

4. Frequent Topic for National Publications

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6. Demographics of ADHD • 9% of Males; 3% of Females in elementary school population (Cuffe 2001;Barbaresi 2002;Brown 2001; Worlraich 1996) • The most common chronic behavioral diagnosis for primary care physicians who care for children • Significant health care costs : $1151/yr vs norm of $712/yr (Chan 2002)

7. Demographics (Cont’d) • Increased annual injury-related health services ($498 vs $216)Liebson2001 • Comorbidity (30-50%) adds additional service costs (Green 1999; Brown 2001; August 1996)

8. GETTING STARTED • Cases present as a result of impairment • Concern usually raised by parent or teacher • “Any parental concern” warrants consideration: 87% sensitivity 47% specificity • Routine screening at annual check-ups

9. COMPONENTS OF ASSESSMENT • Behavioral assessment using DSM-IV criteria • Comprehensive review of medical history • Comprehensive PE • Screening for comorbidities

10. DSM-IV DIAGNOSTIC CRITERIA • Presence of ADHD symptoms • Presence of symptom associated impairment • Symptoms and impairment present in two separate environments • Evidence of chronicity • Alternative diagnoses ruled out

11. Diagnostic Specificity ProcessSpecificity DSM-based criteria 80-85% Physician H&P alone 65-70% Teacher report alone 55-60% Parent report alone 47%

12. Great American Ball Park- The “Right” Ballpark

13. Yankee Stadium- The “Wrong” Ballpark

14. DSM-IV: ADHD SYMPTOMS • Eighteen symptoms: consensus agreement • Diagnosis: 6 or more of 9 attention deficit symptoms and/or 6 or more of 9 hyperactivity/impulsivity symptoms

15. ADHD-INATTENTIVE TYPE • Does not pay attention to details or makes careless mistakes with, for example, homework. • Has difficulty keeping attention to what needs to be done. • Does not seem to listen when spoken to directly. • Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand). • Has difficulty organizing tasks and activities. • Avoids, dislikes, or does not want to start tasks that require ongoing mental effort. • Loses things necessary for tasks or activities (toys, assignments, pencils, or books). • Is easily distracted by noises or other stimuli. • Is forgetful in daily activities.

16. ADHD-HYPERACTIVE TYPE • Fidgets with hands or feet or squirms in seat. • Leaves seat when remaining seated is expected. • Runs about or climbs too much when remaining seated is expected. • Has difficulty playing or beginning quiet play activities. • Is “on the go” or often acts as if “driven by motor.” • Talks too much. • Blurts out answers before questions have been completed. • Has difficulty waiting his or her turn. • Interrupts or intrudes in on others’ conversations and/or activities.

17. DIAGNOSTIC NOMENCLATURE ADHD Subtypes: 1) Hyperactive-predominant 5% 2) Inattentive-predominant 30% 3) Combined type 65% 4) NOS ?

18. DSM-IV: IMPAIRMENT • Academic performance • Family relationships • Making and maintaining friendships • Age-appropriate execution of ADLs • Maintenance of self-esteem • Impulse control: limiting disruptive and unsafe behavior

19. AAP Tool Kit Contents • Diagnosis: initial eval form; parent/teacher forms (initial and follow-up) with scoring instructions and teacher cover letter • Treatment: management plans; daily report Card; stimulant Info • Parent Info/Support: educational rights; working with school; homework tips • Resources: coding sheet; encounter form; internet resources

20. SCREENING TOOLSTHE VANDERBILT FORM • Narrow band form developed for use by primary care practitioners • Validated for use in busy clinical settings • Addresses all DSM criteria • Endorsed by the AAP • Included in the ADHD toolkit • Public domain----FREE!

21. THE VANDERBILT FORM • Symptom and impairment screens • Brief comorbidity screen • Separate forms for teachers and parents • Forms for initial and follow-up evals • Short: one page/two sides • Easy: can be filled out in 5 minutes • Easy: can be scored in 30 seconds

22. VANDERBILT vs CONNERS VANDYCONNERS • 18 DSM symptoms x • Impairment screen x • Comorbidity screen x x • Public Domain x • AAP Toolkit x

25. Case Example

26. Case Example #1- L.Bird: 6 yo 1st grader First Teacher Conference: poor reading; can’t sit in seat; disrupting class Mother: teacher has it “in” for him because she doesn’t like her family Dx(s)? Treatment Plan?

27. MEDICAL HISTORY • Establish age of onset/duration of symptoms • R/O alternative medical/social diagnoses • Review PMH • Review family and social history • Review report cards, teacher comments, results of standardized tests

28. ALTERNATIVE DIAGNOSES • Obstructive sleep apnea • Disordered sleep patterns • Medication side-effects • Inadequately managed asthma, chronic pain • Physical, sexual, emotional abuse • Alcohol and substance abuse

29. PMH: HIGH RISK ASSOCIATIONS • Fetal cocaine, alcohol, other toxin exposure • Complex NICU course • Meningitis • Complicated head trauma • Lead exposure • Iron deficiency

30. PHYSICAL EXAMINATION • Chronic adenoidal-tonsillar hypertrophy • Visual, auditory impairment • Stigmata of hypothyroidism • Signs of anemia • Dysmorphic, syndromic features

31. LABORATORY TESTING No ROUTINE testing (unless clinically indicated • Lead testing NO • Thyroid testing NO • Chromosome testing NO • Psychological testing NO • EEG/MRI/CT NO • Continuous Perf. testing NO

32. COMORBID CONDITIONS • Present in 30-50% of ADHD patients • Often masquerade as ADHD • May result in sub-optimal treatment response • Often require referral to a consultant

33. COMORBIDITIES STUDIESCPRG • LD 12-25% 21% • ODD 35% 13%* • CD 25% 13%* • Anxiety D/O 25% • Mood D/O 18% 7%

34. THE OTHER 20% • Primary psychiatric disorders • Primary learning disability • Borderline low IQ • Developmental disorders • Psychosocial issues • High IQ

35. Treatment Choices • Medication? • Behavioral Therapy? • Combined?

36. Behavior Treatment

37. Behavior Therapy Goals • Replacing ways of living that do not work well with: • ways of living that work, and • ways of living that give people more control over their lives.

38. Target Behaviors • Do not target symptoms of ADHD • Overactivity • Inattention • Impulsivity • Target behaviors that if changed would contribute to improvement in the child’s functioning and positive long-term outcome • The specific problems that the symptoms of ADHD cause in day to day life

39. Behavior Therapy for ADHD Enhance daily functioning • At Home • Complies with requests from parent • Play well with siblings • Completes home chores • At School • Completes assignments • Improved accuracy of work • Follows classroom rules • With Peers • Decrease bossiness

40. Parents Teaching parents more effective ways of dealing with their child is one of the most important aspect of behavior therapy.

41. Parents • Parents are taught skills by a therapist • Typically in a group setting with other parents • Parents use skills with child in daily interactions to improve child’s functioning • Skills focus on understanding • Antecedents that influence behavior • The child’s behavior that parents want to change • Consequences that influences the behavior

42. Examples of Parenting Skills Taught • To give effective commands • Provide positive attention for desirable behavior (rule following, managing emotion) • Design and implement a formal contingency management plan (token economy, point system) • Shaping (setting gradual goals) • Time out

43. Benefits of Group Treatment Decreases stigma Provides peer to peer support to parents in making changes to their parenting style Increases receptivity of parents to making changes

44. School Interventions • Use same principles as described with parents • Structure classroom for success (post classroom rules, establish predictable environment) • Praise appropriate behaviors, ignore mild inappropriate behaviors (reprimand privately) • Use clear commands • Use Daily School-Home Report Card

45. Interventions with Child • Not useful when used in isolation • Need to be integrated with Parent training • Work with parent and child to identify behaviors that interfere with peer relationships (being bossy, intrusive) • Establish reward/consequence programs to reduce these behaviors and replace them with prosocial behaviors

46. Evidence for Behavior Therapy • 48 Classroom studies • (N > 900) • 80 Parent Training Studies • (N > 5,000) • Found improved parent ratings, parent functioning, academic achievement, clinician ratings, child self ratings

47. What Behavior Therapy is NOT • Traditional individual treatment where child spends time with therapist talking about problems, playing with dolls or toys • Family therapy where the dynamics of the family are the focus • Cognitive therapy

48. MTA • Medication and Combined Treatment better on core symptoms of inattention, impulsivity, and hyperactivity • Combined better, but not significantly different from Medication and Behavior on functional outcome of oppositional symptoms, parent-child relationship, and academic functioning

49. Jensen, P. S. Evidence Based Treatment of ADHD, Slide Presentation, NICHQ Annual Forum for Improving Children’s Health Care, March, 2003.

50. Pelham, W.E., Gnagy, E.M., Greiner, A.R., & MTA Cooperative Group. (2000, November). Parent and teacher satisfaction with treatment and evaluation of effectiveness. Poster presented at the annual meeting of the Association for the Advancement of Behavior Therapy, New Orleans, LA.