ADHD: Is it AS Common as ADHD: Is it AS Common as Everyone says it is? And if so, Everyone says it is? And if so,

What’s the best way to help my Child What’s the best way to help my Child Succeed?Succeed?

Lisa Benton Hardy, M.D.Lisa Benton Hardy, M.D.Private Practice San RamonPrivate Practice San Ramon

Former Director of Psychiatry, Childrens Former Director of Psychiatry, Childrens Hospital OaklandHospital Oakland

ObjectivesObjectives

Recognize common characteristics for Recognize common characteristics for ADHD: DiagnosisADHD: Diagnosis

How to Support the Child with ADHD- at How to Support the Child with ADHD- at home and at schoolhome and at school

Be familiar with non pharmacological Be familiar with non pharmacological supportive treatments options (Stimulant and supportive treatments options (Stimulant and Non-Stimulant)Non-Stimulant)

Be familiar with medication treatments Be familiar with medication treatments (Stimulant and Non-Stimulant)(Stimulant and Non-Stimulant)

Erikson’s Developmental TheoryErikson’s Developmental Theory

Infancy (birth – 1 yr): Trust Infancy (birth – 1 yr): Trust vs. Mistrustvs. Mistrust

Toddler (1-3 yr): Autonomy Toddler (1-3 yr): Autonomy vs. Shamevs. Shame

Preschool (3-5 yr): Preschool (3-5 yr): Initiative vs. GuiltInitiative vs. Guilt

School Age (5-12 yr): School Age (5-12 yr): Industry vs. InferiorityIndustry vs. Inferiority

Adolescence (12-19 yr): Adolescence (12-19 yr): Identity vs. Role ConfusionIdentity vs. Role Confusion

Young Adults (20-30 yr): Young Adults (20-30 yr): Intimacy vs. IsolationIntimacy vs. Isolation

Mid Adults (30-60 yr): Mid Adults (30-60 yr): Generativity vs. StagnationGenerativity vs. Stagnation

Mature Adults (60+ yr): Mature Adults (60+ yr): Ego-integrity vs. DespairEgo-integrity vs. Despair

Development: the MilestonesDevelopment: the Milestones

Emotional/SocialEmotional/Social

Language/CognitionLanguage/Cognition

Motoric/Physical/PhysiologicalMotoric/Physical/Physiological

Development: InfancyDevelopment: Infancy

Prenatal Factors – the beginning of Prenatal Factors – the beginning of attachmentattachment

Period of rapid reorganization and Period of rapid reorganization and enormous growth – when else do you enormous growth – when else do you double your height and triple your weight??double your height and triple your weight??

Major Milestone: Emotional and Social Major Milestone: Emotional and Social DevelopmentDevelopment

Infancy: MilestonesInfancy: Milestones

Emotional- social smiling and selective Emotional- social smiling and selective attachments ; the beginning of a sense of self as attachments ; the beginning of a sense of self as connected to another; the affects of connected to another; the affects of temperament/personalitytemperament/personality

Language/Cognition: Nonverbal more than Language/Cognition: Nonverbal more than Verbal (Receptive Skills > Expressive Skills); Verbal (Receptive Skills > Expressive Skills); establishing basic patterns – trial and errorestablishing basic patterns – trial and error

Physical : one word: MOBILE (fine motor too)Physical : one word: MOBILE (fine motor too)

Development: ToddlersDevelopment: Toddlers

Walking and Talking opens up a new Walking and Talking opens up a new world --- personal independence and world --- personal independence and autonomy (remember : “I CAN DO IT autonomy (remember : “I CAN DO IT MYSELF!!!!”)MYSELF!!!!”)

Major Milestone: Emotional and Social Major Milestone: Emotional and Social DevelopmentDevelopment

Toddlers: MilestonesToddlers: MilestonesEmotional/Social: ambivalence…solid limits to Emotional/Social: ambivalence…solid limits to

develop self control; separations & siblings; body develop self control; separations & siblings; body image developmentimage development

Language/Cognition: 200 words by 2 years; trial Language/Cognition: 200 words by 2 years; trial and error in thought rather than physical action; and error in thought rather than physical action; egocentric; FEARS (a little knowledge can be egocentric; FEARS (a little knowledge can be dangerous)dangerous)

Motoric/Physical/Physiological: solid physical Motoric/Physical/Physiological: solid physical skills; handedness; simple activities/choresskills; handedness; simple activities/chores

Development: PreschoolersDevelopment: Preschoolers

Increasingly independentIncreasingly independentPreparing for school – increasing Preparing for school – increasing

sophistication to think beyond themselvessophistication to think beyond themselves Major Milestone: Cognitive DevelopmentMajor Milestone: Cognitive Development

Preschoolers: MilestonesPreschoolers: Milestones

Emotional/Social: the importance of friends and Emotional/Social: the importance of friends and others outside of the family; gender differencesothers outside of the family; gender differences

Language/Cognition: the written word as well as Language/Cognition: the written word as well as the spoken; moving beyond egocentricity; basic the spoken; moving beyond egocentricity; basic concepts – space, time, causality; rigidity??concepts – space, time, causality; rigidity??

Motoric/Physical/Physiological: riding a bike and Motoric/Physical/Physiological: riding a bike and drawing real people; strong self care skills; drawing real people; strong self care skills; gender identitygender identity

Development: School AgeDevelopment: School Age

The impact of school – entering the “real” The impact of school – entering the “real” world – where things really countworld – where things really count

Major Milestone: Cognitive DevelopmentMajor Milestone: Cognitive Development

School Age: MilestonesSchool Age: MilestonesEmotional/Social: feelings/thoughts are important Emotional/Social: feelings/thoughts are important

and relevant; self identity; control of feelings and relevant; self identity; control of feelings (dramatic exceptions); rules and rituals; the peer (dramatic exceptions); rules and rituals; the peer group and imaginary friendsgroup and imaginary friends

Language/Cognition: moving from concrete to Language/Cognition: moving from concrete to more abstract thinking; logic and reason; more abstract thinking; logic and reason; judgment and consciencejudgment and conscience

Motoric/Physical/Physiological: normally quite Motoric/Physical/Physiological: normally quite active (the need for speed)active (the need for speed)

Development: Preteens and TeensDevelopment: Preteens and Teens

Integration of previous stages and Integration of previous stages and solidification of identitysolidification of identity

Major Milestone: PhysicalMajor Milestone: Physical

Preteens & Teens: MilestonesPreteens & Teens: Milestones

Emotional/Social: the peer group; Emotional/Social: the peer group; consolidation of identityconsolidation of identity

Language/Cognition: abstract/future Language/Cognition: abstract/future thinking (in theory)thinking (in theory)

Motoric/Physical/Physiological: one word: Motoric/Physical/Physiological: one word: PUBERTYPUBERTY

Development: When to worryDevelopment: When to worry

Delay of normal milestones without cause Delay of normal milestones without cause A child seems “held up” at a particular stage and A child seems “held up” at a particular stage and

is no longer progressingis no longer progressingRed flags: marked withdrawal or social isolation, Red flags: marked withdrawal or social isolation,

excessive fears/anxiety, disorganized excessive fears/anxiety, disorganized communication; inappropriate impulsive or communication; inappropriate impulsive or aggressive behavioraggressive behavior

ANY CHANGE FROM YOUR CHILD’S NORM: ANY CHANGE FROM YOUR CHILD’S NORM: YOU KNOW YOUR KID BETTER THAN ANYONE YOU KNOW YOUR KID BETTER THAN ANYONE ELSE EVER WILL (Trust in the Force)ELSE EVER WILL (Trust in the Force)

ADHD: Common CharacteristicsADHD: Common Characteristics

Common disorder, especially in males (prevalence 3-10%)Common disorder, especially in males (prevalence 3-10%)Accounts for most child mental health referrals- 6-10% of Accounts for most child mental health referrals- 6-10% of school age childrenschool age childrenInitially children believed to “outgrow it”- 65-85% persists to Initially children believed to “outgrow it”- 65-85% persists to adolescenceadolescenceApproach teen differently than young child – new issues as Approach teen differently than young child – new issues as decreased hyperactivity and increased impulsivity, decreased hyperactivity and increased impulsivity, inattentiveness continues and is more symptomatic inattentiveness continues and is more symptomatic Genetic aspect to etiology- multiple genes involved, multiple Genetic aspect to etiology- multiple genes involved, multiple brain regions involvedbrain regions involvedEnvironmental aspect to etiology- prenatal injury, low birth Environmental aspect to etiology- prenatal injury, low birth weight, prematurity, maternal smoking in pregnancy, cocaine weight, prematurity, maternal smoking in pregnancy, cocaine use in pregnancyuse in pregnancy

DSM 5 : ADHDDSM 5 : ADHD

Pattern of inattention and/or hyperactivity-impulsivity Pattern of inattention and/or hyperactivity-impulsivity for 6 months or morefor 6 months or moreInattentive sx incl: failure to complete projects, poor Inattentive sx incl: failure to complete projects, poor organization, easily distractedorganization, easily distractedhyperactivity-impulsivity sx incl: fidgeting, excessive hyperactivity-impulsivity sx incl: fidgeting, excessive talking, difficulty waiting turntalking, difficulty waiting turnPresent before age 12, impairment in 2 settingsPresent before age 12, impairment in 2 settingsPresentations: predominantly inattentive, Presentations: predominantly inattentive, predominantly hyperactive-impulsive, combined predominantly hyperactive-impulsive, combined Rule out: PDD, psychotic ds, mood ds, anxiety ds, Rule out: PDD, psychotic ds, mood ds, anxiety ds, dissoc ds, personality dsdissoc ds, personality ds

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ADHD: Potential Areas of ADHD: Potential Areas of ImpairmentImpairment

Academic IssuesAcademic Issues

Work/vocational issuesWork/vocational issues

Injuries and legal issuesInjuries and legal issues

Social Setbacks and effects on self esteemSocial Setbacks and effects on self esteem

MVA and substance abuseMVA and substance abuse

Diagnostic AssessmentDiagnostic Assessment

Child/AdolescentChild/Adolescent– Hx/MSEHx/MSE– PE (*neurological)PE (*neurological)– *Neuropsychological *Neuropsychological

TestingTesting– Labs, Dx studies, Labs, Dx studies,

Rating ScalesRating Scales

Family/SchoolFamily/School– HXHX– Rating Scales Rating Scales

(Vanderbilt, Conner, (Vanderbilt, Conner, Child Behavior Child Behavior Checklist, Achenbach Checklist, Achenbach scales)scales)

– School records School records (behavioral and (behavioral and academic)academic)

DDx of Hyperactivity-ImpulsivityDDx of Hyperactivity-Impulsivity

Anxiety Ds (incl Anxiety Ds (incl phobias and OCD)phobias and OCD)

Mood Ds (esp mania in Mood Ds (esp mania in BPD)BPD)

Medication effectsMedication effects

Drug abuse/Toxin Drug abuse/Toxin exposure (Pb)exposure (Pb)

Seizure disorderSeizure disorder

Thyroid/Endocrine Thyroid/Endocrine disorderdisorderTourette’s SyndromeTourette’s SyndromeADHDADHDODDODDCDCDIneffective disciplineIneffective disciplineFamily and social Family and social disruptiondisruption

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ADHD: Common ComorbiditiesADHD: Common Comorbidities

Other Psychiatric Disorders - Mood Other Psychiatric Disorders - Mood Disorders, Anxiety Disorders, other Disorders, Anxiety Disorders, other Disruptive Behavior DisordersDisruptive Behavior Disorders

Learning Disorders and Language Learning Disorders and Language DisordersDisorders

Associated conditions: Tourette’s, OCD, Associated conditions: Tourette’s, OCD, Autistic Spectrum Disorders, FAS, Sleep Autistic Spectrum Disorders, FAS, Sleep Disorders, PSA, PTSDDisorders, PSA, PTSD

Bipolar DisorderBipolar Disorder

It is not rare: 0.7-1.0% incidence in teensIt is not rare: 0.7-1.0% incidence in teens

It can present early: peek onset between It can present early: peek onset between age 15-20age 15-20

Its course is usually episodicIts course is usually episodic

Manic EpisodeManic Episode

abnormally and persistently elevated, or irritable abnormally and persistently elevated, or irritable mood for 7 days or moremood for 7 days or more

additional symptoms include: more talkative, additional symptoms include: more talkative, distractibility, psychomotor agitationdistractibility, psychomotor agitation

clinically significant impairmentclinically significant impairment

rule out substance abuse, general medical rule out substance abuse, general medical condition; rule out mixed episodecondition; rule out mixed episode

Differentiating ADHD and ManiaDifferentiating ADHD and Mania

irritability in mania is more severe, often irritability in mania is more severe, often associated with violence -“affective associated with violence -“affective storms”storms”

previous history of depressive episodeprevious history of depressive episode

family history of mood disordersfamily history of mood disorders

onset: ADHD before age 7, BPD usually onset: ADHD before age 7, BPD usually after age 12after age 12

course: ADHD is continuous, BPD episodiccourse: ADHD is continuous, BPD episodic

Treatment: How to Support the child Treatment: How to Support the child with ADHD at Home with ADHD at Home

Parent training- a different approach to Parent training- a different approach to parentingparenting

Family Organization/ StructureFamily Organization/ Structure

Study SkillsStudy Skills

Balance Between Academic Development, Balance Between Academic Development, Athletic Development, Artistic Development Athletic Development, Artistic Development and Social Developmentand Social Development

Treatment: How to Support the child Treatment: How to Support the child with ADHD at Schoolwith ADHD at School

Teacher consultation/paraprofessional or Teacher consultation/paraprofessional or aideaide

Structure within the classroom- behaviorally Structure within the classroom- behaviorally based interventions with daily report cards based interventions with daily report cards

SST/ IEP/504/AB3632 and other acronyms- SST/ IEP/504/AB3632 and other acronyms- task and instructional modification, task and instructional modification, homework assistance, peer tutoring, homework assistance, peer tutoring, computer-assisted instructioncomputer-assisted instruction

Teamwork and collaborationTeamwork and collaboration

Treatment: Supportive Treatments for Treatment: Supportive Treatments for ADHDADHD

Cognitive behavior therapy- modify Cognitive behavior therapy- modify distorted cognitions, attention regulationdistorted cognitions, attention regulation

Target study skills (planning and Target study skills (planning and organizing), social skills, sport skills/OTorganizing), social skills, sport skills/OT

Psychotherapy – individual/family/group - Psychotherapy – individual/family/group - developing personal goals, decision developing personal goals, decision making, problem solving, resiliency, affect making, problem solving, resiliency, affect regulationregulation

Treatment: Supportive Treatments for Treatment: Supportive Treatments for ADHDADHD

Behavioral Interventions- time management, Behavioral Interventions- time management, organization (environmental engineering), organization (environmental engineering), communication skills, assertiveness, frequent communication skills, assertiveness, frequent reinforcement, refocusing remindersreinforcement, refocusing reminders

Life Skills trainingLife Skills training

Summer camp programsSummer camp programs

Biofeedback, Mindfulness Training, Cognitive Biofeedback, Mindfulness Training, Cognitive Mediation (CogMed)Mediation (CogMed)

Treatment: Supportive Treatments for Treatment: Supportive Treatments for ADHD- ResourcesADHD- Resources

CHADD - CHADD - www.chadd.org

ADDA- ADDA- www.add.org

AAP - www. AAP - www. aap.org

AACAP - AACAP - www.aacap.org

Treatment: Medications - StimulantsTreatment: Medications - Stimulants

Stimulants are mainstay- initially introduced in the Stimulants are mainstay- initially introduced in the 1960s; most extensively studied psychotropic 1960s; most extensively studied psychotropic medicationmedicationMethylphenidate – Ritalin, Ritalin LA, Ritalin SR; Methylphenidate – Ritalin, Ritalin LA, Ritalin SR; Concerta (18-72mg) ; Metadate CD, Metadate Concerta (18-72mg) ; Metadate CD, Metadate ER; Focalin; Focalin XR max 40-60mg q dER; Focalin; Focalin XR max 40-60mg q dDextroamphetamine – Dexedrine, Dexedrine Sp; Dextroamphetamine – Dexedrine, Dexedrine Sp; Adderall, Adderall XR; Vyvanse max 40 mg q d Adderall, Adderall XR; Vyvanse max 40 mg q d Side effects (common): anorexia, insomnia, Side effects (common): anorexia, insomnia, irritability, ticsirritability, tics

Treatment: NonstimulantsTreatment: Nonstimulants

Atomoxetine (Strattera)Atomoxetine (Strattera)

SNRISNRI

Start 0.5 mg/kg/dy q am or bidStart 0.5 mg/kg/dy q am or bid

Target 1.2 mg/kg/dy q am or bid; max 1.4 Target 1.2 mg/kg/dy q am or bid; max 1.4 mg/kg/dy or 100mg per daymg/kg/dy or 100mg per day

Lower dose with SSRI Lower dose with SSRI

Side effects (common): headache, GI, Side effects (common): headache, GI, somnolence, anorexia, dizzinesssomnolence, anorexia, dizziness

Treatment: NonstimulantsTreatment: Nonstimulants

Buproprion (Wellbutrin, Wellbutrin SR, Buproprion (Wellbutrin, Wellbutrin SR, Wellbutrin XL); max 450mg q d – no single Wellbutrin XL); max 450mg q d – no single dose to exceed 150mg (IR) or 200mg dose to exceed 150mg (IR) or 200mg (SR/XL)(SR/XL)

Side effects: anorexia, insomnia, dry Side effects: anorexia, insomnia, dry mouth, rash, night sweats, dizzinessmouth, rash, night sweats, dizziness

Cautions/contraindications: h/o sz ds or Cautions/contraindications: h/o sz ds or eating disorders or head injuryeating disorders or head injury

Treatment: NonstimulantsTreatment: Nonstimulants

Tricyclic Antidepressants – Imipramine – 20-100 Tricyclic Antidepressants – Imipramine – 20-100 mg dailymg daily– Sedation, weight gain, anticholinergic side effects, Sedation, weight gain, anticholinergic side effects,

monitor cardiac functionsmonitor cardiac functions

Clonidine – 0.05 – 0.3 (divided) mg daily; Tenex Clonidine – 0.05 – 0.3 (divided) mg daily; Tenex - .5 - 3.0 (divided) mg daily- .5 - 3.0 (divided) mg daily– Sedation, weight gain, monitor blood pressureSedation, weight gain, monitor blood pressure

KapvayKapvay – 0.1 – 0.3 mg (divided) daily; Intuniv - 1- – 0.1 – 0.3 mg (divided) daily; Intuniv - 1- 3 (divided) mg daily3 (divided) mg daily– Sedation, weight gain, monitor blood pressureSedation, weight gain, monitor blood pressure

Course/PrognosisCourse/Prognosis

2/3 will continue with signif problems, 1/3 2/3 will continue with signif problems, 1/3 with full syndrome as adultswith full syndrome as adults

Overactivity tends to decrease with timeOveractivity tends to decrease with time

Compensatory behaviorsCompensatory behaviors

Excellent response to medication and Excellent response to medication and behavioral rx possiblebehavioral rx possible