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.