Attention Deficit Hyperactivity DisorderJudith Axelrod, M.D.

Developmental-Behavioral Pediatrician

Square One: Specialists in Child and Adolescent Development

ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a chronic neurodevelopmental disorder

Attention Deficit Hyperactivity Disorder

The diagnosis of Attention Deficit Hyperactivity Disorder is given to individuals who have frequent failure to comply in an age appropriate fashion with situational demands for inhibition of impulsive responses and resistance to distracting influences. These behaviors interfere with the individual’s performance in social and academic settings.

ADHD: Current Working Theory

Symptoms of ADHD are caused by abnormality in the Executive Function of the brain.

ADHD and Inheritance

• Inherited 57-97% (mean 80%)– If parent has ADHD—offspring risk 20-54%– 25-30% of fathers– 15-20% of mothers– Identical twins 55-92%

• Child with ADHD– male sibling 35%– female sibling 15%

Core issues with ADHD

Impulsivity Poorly regulated activity—hyperactivity Distractibility—poor sustained attention Disorganization Diminished rule governed behavior Emotional over arousal Poor/No generalization of information Variability of task performance

Pathology

Pathology occurs when the core symptoms of ADHD are pervasive, prominent and impair functioning in all aspects of life.

What is it like to have ADHD

Behavioral disinhibition Dysfunction of cognitive ability Poor adaptive function Difficulty with rule governed behavior Delays in internalization of language

Other ADHD qualities

• Sometimes work harder at avoiding work than actually doing it

• Academic progress is often a roller coaster – up and down all year

• Moody• Really do want to do well• Frustration

Qualities: ADHD Inattentive Type (“ADD”)

• Often not identified until 5th grade, middle school, or even high school

• May see substantial drop in grades around middle school

• Compensate for struggles (mask it)• Often described as “lazy”, “doesn’t care”,

“unmotivated”, “doesn’t try”• Slower processing speed is common• Often very quiet and well behaved – so not on the

“radar screen”

Typical Vulnerabilities

• Low self esteem• Humiliation• Feeling “dumb”• Always “in trouble”• Quick to lie about behavior• Become defensive• Feel defeated

Differences in youth with ADHD: coping-temperament-subtypes

• ADHD with:– Anxiety– Obsessive Compulsive – Agitation– Mania– Defiance– Aggression– Mood reactivity

Strengths and “Gifts”

• Creative• Charming• Funny• Social• Sensitive and caring• Hyperfocus• Enthusiasm

Comorbid Conditions

Learning Disabilities Cognitive Deficits Tics / Tourette’s Disorder Drug or alcohol use

Comorbid Conditions

Depression Anxiety Obsessive Compulsive Disorder Behavioral Disorders:

Oppositional Defiant disorder Conduct Disorder

The Core Symptoms of ADHD are present as symptoms in a variety

of psychiatric diagnoses

Other diagnoses with shared symptoms

Depression Anxiety Bipolar Disorder Thought Disorder Autism Substance abuse

• Children with Attention Deficit Hyperactivity Disorder frequently have social skill difficulties which are manifested by intrusive behaviors and erratic or variable behaviors. They can be demanding and controlling. Maturity seems to lag and these children are often perceived as two years behind their aged peers in maturity.

• 30-40% of children with Attention Deficit Hyperactivity Disorder have affective disorders such as depression and anxiety

How is the Diagnosis of Attention Deficit Hyperactivity Disorder

made?

To make the diagnosis of ADHD

Psychological evaluation Medical evaluation

Treatment

Education Behavior Management/Family Counseling Medication Consultation with school personnel

Behavior Management/Family Counseling

Effective in teaching ways to be consistent Teaching problem solving techniques Support Breaking cycles of learned behavior

Help in the Classroom

• Be sure you are dealing with ADHD• Seek assistance to clarify diagnosis• Communicate with teachers/parents• Include the child in making a plan• Ask the child what will help• Help the child to take ownership

Help in the Classroom

• Avoid being punitive• Set positive goals• Attempt to reinforce effort and not just

accomplishment of goals (sometimes these children try their best and still don’t meet basic goals for behavior)

• Remember all ADHD is NOT alike

Help in the Classroom

• Use a “firm-flexibility” approach with the child – combination of support, accommodations, clear limits, and expectations

• Daily schedules may help - visual• Use visuals when possible• Be cognizant of “high risk” times (e.g.,

unstructured, less supervised times)

Help in the Classroom

• Keep in mind that many behaviors may reflect coping with frustration/anxiety

• Structure and clear expectations are vital for success

• Need for cues, reminders, and repetition• Be aware of and avoid “helping” strategies

that may humiliate the child

Help in the Classroom:

• ANY approach one takes should strive to minimize penalizing the student for struggles that are a direct result of ADHD. That is, attempt to differentiate behaviors that are much harder for the child due to ADHD versus those that may occur by choice

Help in the Classroom

• Initiate communication with parents and ask about:– Homework time– Student’s understanding of tasks– Time and effort spent with routine homework

Help in the Classroom

• If the child is clearly falling behind, take the initiative to notify parents

• Be careful not to assume that problem behaviors are intentional

• Try to stay positive• Work with the student to set goals (but not

too many at once)

Help in the Classroom: Distraction

• Remember a child may be “listening” to you but not attending to what you are saying

• Provide extended time as needed• Emphasize quality over quantity with

assignments and homework

Help in the Classroom: Distraction

• Have the student repeat directions and/or demonstrate understanding

• Monitor student’s progress in completing work so it doesn’t pile up

• Provide cues to help the child stay on task (e.g., agree on “secret” cues)

Help in the Classroom: Disorganization

• Consider allowing the student to have a second set of books at home

• Make sure the child has correctly recorded homework assignments

• Specifically request their homework and/or find a system that works

• Suggest simple ways to organize papers• Work with the child to organize locker

Help in the Classroom: Hyperactivity/Impulsivity

• Provide adequate breaks and opportunities to move or “reset”

• Use visual cues to help the child remember to “STOP & THINK”

• When entering into a “high risk” situation, talk through successful behavior with the student beforehand

Help in the Classroom: Working Memory

• A skill learned today is not necessarily remembered tomorrow

• Note taking is often harder – be sure they have relatively complete notes

• Suggest strategies that help the child compensate for this weakness

ADHD Treatment Multimodal Treatment Study of ADHD (n = 579)

Investigated effects of various treatment modalities on children with ADHD, combined type over 14 month period

Results Medication alone most effective treatment of core symptoms of ADHD Medication with psychosocial treatments was superior to other

treatments for non-ADHD areas of functioning – i.e. aggressive behaviors, parent-child relations, teacher-rated social skills

Medication Classes Stimulants Antidepressants Antihypertensives Wake-promoting agent used in narcolepsy

Stimulants

First line medication treatment of ADHD Approximately 70% of children will respond to

the first stimulant prescribed Up to 90% respond to the first or second

stimulant attempted

Mechanism of Action Increase dopaminergic and noradrenergic

activity in frontal cortex

Stimulants

Three types of stimulant formulations Short-acting

Duration of action 2-4 hours Must be given 2-4 times per day

Intermediate-acting Duration of action 6-8 hours

Long-acting Duration of action 10-12 hours

Current accepted practice is to initiate treatment with an intermediate or long-acting preparation

Methylphenidate Class

Short-acting Methylphenidate (Ritalin, Methylin) Focalin

Intermediate-acting Ritalin LA/Ritalin SR Metadate CD/Metadate ER

Long-acting Focalin XR Concerta Daytrana patch

Amphetamine Class

Short Acting Adderall

Abused in adolescent population

Dexedrine/Dextrostat Desoxyn (Methamphetamine HCl)

Intermediate-acting Dexedrine spansules

Long Acting Adderall XR Vyvanse

Prodrug – cleaved by stomach enzyme (less abusable)

Support

• CHADD (Children and Adults with Attention Deficit Disorders)

8181 Professional Place, Suite 201

Landover, MD 20785

http://www.chadd.org/.

800-233-4050

ADHD Parent Support Group

• LDA of Kentucky–www.ldaofky.org

Educational Intervention

• www.ed.gov

ADHD Recommeded Reading• Barkley, Russell. Taking Charge of ADHD: The Complete Authoritative Guide for Parents,• Fowler, M.C. (1990). Maybe You Know My Kid: A Parent’s Guide to Identifying,

Understanding, and Helping Your Child with Attention-Deficit Hyperactivity Disorder. New York: Carol.

• Hallowell. Edward and Ratey, John, Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder From Childhood through Adulthood. Patheon Books.

• Hallowell. Edward and Ratey, John, Delivered from Distraction: Getting the most out of Life with Attention Deficit Disorder. Patheon Books.

• Jensen, Peter. Making the System Work For Your Child with ADHD. Guilford Press. • Ingersoll, B. (1988). Your Hyperactive Child. New York: Doubleday. • Ingersoll, B. and Goldstein, S. (1993). Attention Deficit Disorder and Learning Disabilities,

New York: Doubleday. • Nadeau, K. A Survival Guide for High School and College Students with ADHD, New York:

Magination. • Honos-Webb, Lara. The Gift Of ADHD: How To Transform Your Child's Problems Into

Strengths. Oakland: New Harbinger.• Taylor, Blake. ADHD and Me: What I Learned from Lighting Fires and the Dinner Table.

New Harbinger: 2008.

For Parents

ADHD Recommended Reading• Nadeau, K. A Survival Guide for High School and

College Students with ADHD, New York: Magination.

• Kelly, K. and Ramundo, P. (1993), You Mean I'm Not Lazy. Stupid. or Crazy?! Cincinnati: Tyrell and Jerem Press.

• Murphy, K. and LeVert, S. (1995). Out of the Fog: Treatment Options and Coping Strategies for Adult Attention Deficit Disorder. New York: Hyperion.

• Quinn, P.O. (1994). ADD and the College Student: a Guide for High School and College Students with Attention Deficit Disorder. New York: Magination.

For Adults

ADHD Recommended Reading• Gehret, J. (1991). Eagle Eyes: a Child's Guide to Paying

Attention. Fairport, NY: Verbal Images Press. • Gordon, M. (1992), My Brother's a World-Class Pain: A

Sibling's Guide to ADHD/Hyperactivity. DeWitt, NY: GSI Publications.

• Nadeau, K.G. and Dixon, E.B. (1991), Learning to Slow Down and Pay Attention.

• Chesapeake Psychological Services, 5041 A&B Backlick Road, Annandale, Virginia 22003.

• Qujnn, P.O. and Stem, J.M. (1991). Putting on the Brakes: Young People's Guide to Understanding ADHD. New York: Magination Press.

For Children

Square One Specialistsin Child and Adolescent Development

• Developmental & Mental Health Specialists

• Comprehensive Evaluations• In-depth Collaborative Treatment

www.squareonemd.com

(502) 896-2606

Multidisciplinary Staff

• Judith Axelrod, M.D. – Developmental Pediatrician

• David Causey, Ph.D.– Licensed Clinical Psychologist

• Lisa Ruble, Ph.D.– Licensed Psychologist                              

• Ann Hayes Ronald, M.Ed.– Licensed Psychological Associate

• Sherri Stover, M.S. L.C.S.W.                    – Licensed Clinical Social Worker   

• Ashley Redenbaugh, M.S. CCC-SLP– Speech Language Pathologist

Our team of doctors and specialists are experts in child & adolescent development. More importantly, they are people who love to help children—who want nothing more than to see them succeed in everything they do. Regardless of what makes your child unique, you can trust that our staff has the expertise to help them reach their maximum potential.