Attention Deficit -Attention Deficit -Hyperactivity Hyperactivity

DisorderDisorderDiagnosis & InterventionDiagnosis & Intervention

Lisa Nalven, MD, MA, FAAPLisa Nalven, MD, MA, FAAPKireker Center for Child Development - Valley Kireker Center for Child Development - Valley

HospitalHospitalRidgewood, New JerseyRidgewood, New Jersey

What is ADHD?What is ADHD?

Most common neuro-developmental Most common neuro-developmental problem in childrenproblem in children– Inattention Inattention – HyperactivityHyperactivity– Poor impulse controlPoor impulse control– DistractibilityDistractibility– ““Executive Dysfunction”Executive Dysfunction”

OccurrenceOccurrence

Between 3% and 7% of school-Between 3% and 7% of school-age childrenage children

70% of cases inherited. Runs in 70% of cases inherited. Runs in families, especially through male families, especially through male family linesfamily lines

7 times more common in boys7 times more common in boys– may look different in girls (chatty, may look different in girls (chatty,

daydream, fidget)daydream, fidget)

Prevalence Prevalence (internationally)(internationally)

Canada (Montreal): 3.8-9.4% children (DSM-III-R)Canada (Montreal): 3.8-9.4% children (DSM-III-R) Australia: 3.4%children, 2-3% teens (DSM-III-R)Australia: 3.4%children, 2-3% teens (DSM-III-R) New Zealand: 6.7% children, 2-3% teens (DSM-lll-R)New Zealand: 6.7% children, 2-3% teens (DSM-lll-R) China: 6-9% children (DSM-lll)China: 6-9% children (DSM-lll) Netherlands: 1.3% teens (DSM-lll-R)Netherlands: 1.3% teens (DSM-lll-R) Puerto Rico: 9.5% children & teens (DSM-lll)Puerto Rico: 9.5% children & teens (DSM-lll) Japan: 7.7% children (DSM-lll-R)Japan: 7.7% children (DSM-lll-R) Colombia: 2-13% (DSM-lV)Colombia: 2-13% (DSM-lV) Brazil: 5.8% of 12-14 year olds (DSM-IV)Brazil: 5.8% of 12-14 year olds (DSM-IV)

– R. Barkley, Ph.DR. Barkley, Ph.D

DSM-IV CriteriaDSM-IV Criteria6 of 9 6 of 9 Inattention Inattention SymptomsSymptoms

Fails to give close attention to detailsFails to give close attention to details Difficulty sustaining attentionDifficulty sustaining attention Does not seem to listenDoes not seem to listen Does not follow through on instructionsDoes not follow through on instructions Difficulty organizing tasks or activitiesDifficulty organizing tasks or activities Avoids tasks requiring sustained mental effortAvoids tasks requiring sustained mental effort Loses things necessary for tasksLoses things necessary for tasks Easily distractedEasily distracted Forgetful in daily activitiesForgetful in daily activities

DSM-IV CriteriaDSM-IV Criteria6 0f 9 6 0f 9 Hyperactive-Hyperactive-ImpulsiveImpulsive

Fidgets, squirms in seatFidgets, squirms in seat Difficulty staying seatedDifficulty staying seated Climbs or runs excessivelyClimbs or runs excessively Is on the go or “driven by a motor”Is on the go or “driven by a motor” Talks excessivelyTalks excessively Blurts out answers before questions are completedBlurts out answers before questions are completed Difficulty with turn takingDifficulty with turn taking Interrupts or intrudes Interrupts or intrudes Forgetful in daily activitiesForgetful in daily activities

Other DSM-IV CriteriaOther DSM-IV Criteria

Developmentally inappropriate levelsDevelopmentally inappropriate levels Duration of 6 monthsDuration of 6 months Cross-setting occurrence of symptomsCross-setting occurrence of symptoms Impairment of major life activitiesImpairment of major life activities Onset of symptoms/impairment by age 7Onset of symptoms/impairment by age 7 Exclusions: severe DD, PDD, psychosisExclusions: severe DD, PDD, psychosis Subtypes: Subtypes: inattentive, hyperactive, or inattentive, hyperactive, or

combined typescombined types

EtiologyEtiology

Neurological/Biological Neurological/Biological – differences in functioning of frontal cortexdifferences in functioning of frontal cortex– imaging studies show differences in imaging studies show differences in

neurotransmitterneurotransmitter

levels and brain structures levels and brain structures Factors that influence neurology/biologyFactors that influence neurology/biology

– heredity/geneticsheredity/genetics– prematurityprematurity– prenatal exposures prenatal exposures (tobacco, alcohol, drugs of abuse(tobacco, alcohol, drugs of abuse))– adverse early experiences**adverse early experiences**

Things that can look like ADHD (but are not) Language impairment Learning Disability Mild cognitive impairment (ID) Pervasive Developmental Disorder Anxiety/PTSD Depression Medication side effect Parent/child: poor fit of

style/temperament

Coexisting conditions: Coexisting conditions: need to evaluateneed to evaluate

Prevalence %Prevalence % Learning disability (40-60)Learning disability (40-60) Oppositional defiant disorder (35)Oppositional defiant disorder (35) Conduct disorder (25)Conduct disorder (25) Anxiety disorder Anxiety disorder (25) (25) Depressive disorder (18)Depressive disorder (18)

IdentificationIdentification

Appropriate diagnosis of ADHD requires Appropriate diagnosis of ADHD requires

collaborative effortcollaborative effort Multiple sources of information should be Multiple sources of information should be

gathered (family, teachers, other adults)gathered (family, teachers, other adults) Multiple perspectives regarding symptoms Multiple perspectives regarding symptoms

are needed to assess their pervasiveness are needed to assess their pervasiveness

and severityand severity

Sources of information Sources of information regarding symptoms & regarding symptoms & impactimpact

Formal observation in multiple settingsFormal observation in multiple settings Interviews with student and relevant adultsInterviews with student and relevant adults Rating scales completed by family, teachers Rating scales completed by family, teachers

and studentand student Developmental, school, and medical historiesDevelopmental, school, and medical histories Tests to measure attention, persistence and Tests to measure attention, persistence and

related characteristics (CPT, TOVA)related characteristics (CPT, TOVA) Psychoeducational testing to rule out/in a Psychoeducational testing to rule out/in a

learning problem or other causes.learning problem or other causes. Vision and hearing assessmentsVision and hearing assessments There is no ONE test There is no ONE test

How young can you diagnose ADHD? A reliable diagnosis can be made down

to age 4 (see AAP clinical guidelines) For younger children need to consider:

– Very active toddler/preschooler– Maturational issues– Developmental delay– Unrealistic parental expectations– Permissive parent – Early signs of ADHD (time will tell)

How ADHD leads to How ADHD leads to impairmentsimpairments

ScenarioScenario Functional OutcomeFunctional Outcome

Hyperactive 5 yr old elicits irritation StrainedHyperactive 5 yr old elicits irritation Strained

and harsh punishment by mother and harsh punishment by mother family relations family relations

10 yr old who is impulsive, difficulty Poor self-esteem10 yr old who is impulsive, difficulty Poor self-esteem

playing cooperatively with peers is rarely playing cooperatively with peers is rarely

asked to sleep at friends’ housesasked to sleep at friends’ houses

Contemporary PediatricsContemporary Pediatrics, 2/2003, 2/2003

How ADHD leads to How ADHD leads to impairments/2impairments/2

ScenarioScenario Functional OutcomeFunctional Outcome

Despite high IQ, college student fails Academic dysfunctionDespite high IQ, college student fails Academic dysfunction

courses due to disorganization, tardiness,courses due to disorganization, tardiness,

poor writing skillspoor writing skills

-Shy girl, believing school performance is Depression-Shy girl, believing school performance is Depression

inadequate inadequate

Contemporary PediatricsContemporary Pediatrics, 2/2003, 2/2003

Childhood Academic Childhood Academic ImpairmentsImpairments

Children with ADHD evaluated using teacher Children with ADHD evaluated using teacher reports and achievement tests:reports and achievement tests:– Poor school performance (90%) (primarily reduced Poor school performance (90%) (primarily reduced

productivity) productivity)– Low academic achievement (10-15 point deficit)Low academic achievement (10-15 point deficit)– Low average intelligence (7-10 point deficit)Low average intelligence (7-10 point deficit)– Learning disabilities (24-70%)Learning disabilities (24-70%)

Reading (15-30% in Barkley, 1990)Reading (15-30% in Barkley, 1990) Spelling (26% in Barkley, 1990)Spelling (26% in Barkley, 1990) Math (10-60% in Barkley, 1990)Math (10-60% in Barkley, 1990) Handwriting (60%)Handwriting (60%)

R. BarkleyR. Barkley

Steps in InterventionSteps in Intervention

Assessment (appropriate diagnosis)Assessment (appropriate diagnosis)– ratings scales from multiple informersratings scales from multiple informers– testing: IQ, achievement/educational, languagetesting: IQ, achievement/educational, language– evaluate for other mental health or medical factorsevaluate for other mental health or medical factors

Behavioral (skills training/counseling) Behavioral (skills training/counseling) – primary interventions for preschoolersprimary interventions for preschoolers

Educational Educational – classroom strategies classroom strategies – interventions for comorbid learning issuesinterventions for comorbid learning issues

Accommodations at home, school and in the communityAccommodations at home, school and in the community– select and structure activities for successselect and structure activities for success

MedicationMedication

Address MH and medical issues Treat depression, anxiety and re-

evaluate ADHD symptoms Adequate and good quality sleep-

may need sleep study Balanced diet (not megadosing) Exercise

Behavioral Interventions:Behavioral Interventions:

First line intervention for First line intervention for preschoolerspreschoolers

Behavior therapyBehavior therapy Parent trainingParent training Individual and family counseling Individual and family counseling Parent/family services Parent/family services Support groups (CHADD)Support groups (CHADD) Social skills trainingSocial skills training

Behavioral techniques for Behavioral techniques for home and schoolhome and school

Encourage eye contact before giving Encourage eye contact before giving directionsdirections Give short, clear, specific directionsGive short, clear, specific directions Provide frequent reinforcement (praise) of Provide frequent reinforcement (praise) of

appropriate behavior appropriate behavior Verbal reprimands directed at the child’s Verbal reprimands directed at the child’s behavior--not at the childbehavior--not at the child Use “signals” to refocus or redirectUse “signals” to refocus or redirect Preferential seating in the classroomPreferential seating in the classroom

Behavior Management Behavior Management StrategiesStrategies

Positive reinforcement: rewards or Positive reinforcement: rewards or

privileges given for desired behaviorsprivileges given for desired behaviors ““Token” economy: earns points towards Token” economy: earns points towards

rewards or privileges and loses them for rewards or privileges and loses them for undesirable behaviorundesirable behavior

Use of “time-out”Use of “time-out”

Tips for Helping Child Tips for Helping Child Control BehaviorControl Behavior

Provide daily schedule and routines Provide daily schedule and routines Reduce distractionsReduce distractions Organize house and study areaOrganize house and study area Reward positive behaviorReward positive behavior Set small, reachable goalsSet small, reachable goals Help child stay “on task”Help child stay “on task” Find activities at which child can succeedFind activities at which child can succeed Use calm disciplineUse calm discipline

Other considerationsOther considerations

Appropriately structured activities-be practicalAppropriately structured activities-be practical– Provide outlet for release of energyProvide outlet for release of energy– Try not to let child become fatigued/hungryTry not to let child become fatigued/hungry– Avoid taking younger children to formal Avoid taking younger children to formal

gatherings gatherings (e.g. stores, supermarkets, restaurants) (e.g. stores, supermarkets, restaurants) if not if not

necessary or do for short period of time.necessary or do for short period of time.

Stretch attention span: reading, coloring, Stretch attention span: reading, coloring, puzzles, board games puzzles, board games – by age 5 child needs at least a 25 minute attention by age 5 child needs at least a 25 minute attention

spanspan

Services for children under 3 years Early Intervention: 0-3 years. Free evaluation for children “at risk”

for or with developmental issues Services vary by state (none, some,

unlimited, free, sliding scale, full cost) Services for behavior alone can be

difficult to get approved Call state agency responsible for EI (if

not known, call local school district to get contact information)

Education Based Education Based Interventions (3-21 Interventions (3-21 years)years)

Requires written request by parent for Requires written request by parent for evaluation by the school district evaluation by the school district

Parent can pursue private evaluations Parent can pursue private evaluations and provide school with results for reviewand provide school with results for review

School and parent meet to review issues,School and parent meet to review issues,

decide on further evaluation and/or decide on further evaluation and/or intervention.intervention.

Working with the school Be aware of state mandated Be aware of state mandated

timelines for response, meetings, timelines for response, meetings, assessment, implementation of assessment, implementation of planplan

If parents disagree at any stage in If parents disagree at any stage in the process, they can work with the process, they can work with advocate, request independent advocate, request independent evaluation, pursue due processevaluation, pursue due process

Possible outcomes

School chooses not to intervene Home/Classroom behavior modificationHome/Classroom behavior modification Home/Classroom work modificationHome/Classroom work modification Response to Intervention (RTI): written Response to Intervention (RTI): written

planplan ADA-rehabilitation act: section 504 ADA-rehabilitation act: section 504 IDEA: classification for special education IDEA: classification for special education

services services

Modifications to Modifications to support learning:support learning:

Organization skill support : color code books and folders; Organization skill support : color code books and folders; assignment pad, calendar for long term assignments,assignment pad, calendar for long term assignments,electronic reminderselectronic reminders

Plans for initiation, completion, and transition between Plans for initiation, completion, and transition between tasks; include cues, supplies, timerstasks; include cues, supplies, timers

Homework: divided into sessions, with short breaks in Homework: divided into sessions, with short breaks in between; longer, more difficult assignment done first, between; longer, more difficult assignment done first, easiest last; remove distractionseasiest last; remove distractions

Teaching strategies: break down tasks, cue, reinforce, Teaching strategies: break down tasks, cue, reinforce, multisensory/hands on approach; work modified to multisensory/hands on approach; work modified to address learning issues; small group instruction with address learning issues; small group instruction with breaks; quiet place to workbreaks; quiet place to work

Response to Intervention RTI

Included under IDEA For a child that is struggling in school;

“evidence based interventions” are put in place and response is evaluated

Pros: can be done quickly; children who don’t qualify for spec ed service get support

Cons: child is never formally evaluated and there is no time line to assess response or move to testing/more intensive services

Section 504Section 504

Does not meet criteria for IDEA (i.e., learning Does not meet criteria for IDEA (i.e., learning

not significantly impacted)not significantly impacted) Modifications in instructional programModifications in instructional program Does not require, or not eligible for Does not require, or not eligible for

special education supportsspecial education supports Modifications Modifications maymay include: quiet work include: quiet work

spaces, untimed tests, reduction in spaces, untimed tests, reduction in

amount of written work , preferential seatingamount of written work , preferential seating

Special Education Special Education Classification- IDEAClassification- IDEA ““Other Health Impaired”Other Health Impaired” ADHD significantly impacts ADHD significantly impacts

learning/academic achievementlearning/academic achievement Needs can not be met by a 504Needs can not be met by a 504 Modification of school Modification of school

environment and instructionenvironment and instruction Push-in or pull-out supportPush-in or pull-out support

Why Medication?Why Medication?

Dysregulation of Dysregulation of neurotransmittersneurotransmitters

Medications can increase the Medications can increase the levels of neurotransmitters and levels of neurotransmitters and improve function of nerve cells in improve function of nerve cells in frontal cortex that are responsible frontal cortex that are responsible for attention, impulse control etc. for attention, impulse control etc.

Impact of Medications?Impact of Medications?

Increases ability to pay attentionIncreases ability to pay attention More control over behavior (impulsivity)More control over behavior (impulsivity) Improvement in schoolwork such as task Improvement in schoolwork such as task

completion, handwriting, classroom behavior ascompletion, handwriting, classroom behavior as a result of improved attention, impulse controla result of improved attention, impulse control and on task behaviorsand on task behaviors

Reduces risk of substance abuse, car accidentsReduces risk of substance abuse, car accidents Make child more available to benefit from otherMake child more available to benefit from other

interventions strategiesinterventions strategies Will not treat comorbidities or wrong diagnosisWill not treat comorbidities or wrong diagnosis

Medication issuesMedication issues

Not approved by FDA for children under 6, Not approved by FDA for children under 6, but many clinical studies document but many clinical studies document effectiveness/safety in preschool effectiveness/safety in preschool populationpopulation

Individual and family history determines Individual and family history determines need for cardiac assessment (EKG)need for cardiac assessment (EKG)– Do for all children in foster care or who have Do for all children in foster care or who have

been adopted due to incomplete historiesbeen adopted due to incomplete histories May take several tries to get the right May take several tries to get the right

medication and dosemedication and dose Side effects are minimal if done properlySide effects are minimal if done properly

Medication options

“Stimulants”– Methylphenidate (Ritalin, Focalin,

Concerta, Daytrana etc)– Amphetamine (Adderall, Vyvanse,

Dexadrine etc) Nonstimulant

– Atomoxitine (Straterra)– Alpha agonists**

Intuniv (guanfacine) Kapvay (clonidine)

Other interventions:Other interventions:

Omega supplements: studies do Omega supplements: studies do not find consistent positive not find consistent positive results; need to look at whyresults; need to look at why

Diet modification; remove Diet modification; remove additives (some studies show additives (some studies show impact for subset of children)impact for subset of children)

Cog-Med, Q-EEG may have a role Cog-Med, Q-EEG may have a role for some for some

Collaboration Collaboration

Teamwork among doctors, Teamwork among doctors, parents, teachers, other health parents, teachers, other health professionals and the child professionals and the child provides the best outcome for provides the best outcome for children who are affected by children who are affected by ADHD.ADHD.

Resources

AAP Clinical Practice Guidelines http://aappolicy.aappublications.org/cgi/content/full/pediatrics;108/4/1033

National Resource Center on ADHD www.help4adhd.org

Children and Adults with ADDwww.chadd.org

Resources

Learning Disabilities Associationwww.ldanatl.org

National Center for Learning Disabilitieswww.ncld.org

Wrightlaw Special Education Advocacy www.wrightslaw.com

Books

ADHD: A Complete and Authoritative Guide. American Academy of Pediatrics. Edited by Michael Reiff MD

1-2-3 Magic: Training Your Child To Do What You Want: by T. Phelan

www.addwarehouse.com www.maginationpress.com

Lisa Nalven, MD, MA, FAAPDirector, Developmental PediatricsAdoption Screening & Evaluation ProgramKireker Center for Child Development-Valley

Hospital 505 Goffle Road Ridgewood, NJ 07450T: 201-447-8151 F: 201-447-8526

www.valleyhealth.com/childdevwww.valleyhealth.com/adoption