TREATING ATTENTION DEFICIT DISORDER: BUILDING A PARTNERSHIP

BETWEEN HOME, SCHOOL AND TREATING PROFESSIONALS

Helene Boinski-Bartlett, Ph.D.

Welcome

Learning Objectives

At the conclusion of the session, participants will be able to:

• Identify the key criteria for establishing an ADHD diagnosis. • Describe the major R/O diagnoses and important co-

morbidities • List three critical considerations for building a

comprehensive strategy to assess ADHD. • Identify home and school-based strategies to promote

success in youth dealing with ADD/ADHD issues.

What is the Current View of ADHD?

A disorder featuring age-inappropriate : – Inattention

• Poor persistence of responding • Impaired resistance to distraction • Deficient task re-engagement following disruption

– Hyperactivity-Impulsivity (Disinhibition) • Impaired motor inhibition, • Poor sustained inhibition • Excessive and often task-irrelevant motor and verbal

behavior • Restlessness decreases with age, becoming more

internal, subjective by adulthood

• Most cases are developmental and involve delays in the rate at which these two traits are maturing

What is ADHD?

Most children with ADHD have impairments in executive functioning, including:

– Response inhibition

– Vigilance

– Working memory

– Difficulties with planning

Epidemiology

• Most commonly diagnosed mental health condition in children in the United States

• 2-16% prevalence in school-aged children – Parent reported diagnosis: 7.8% - 2003;

9.5% - 2007; 11% - 2011

– Psychiatric diagnosis: 8.7% - 2004

• Prevalence doubles from ages 4-10 to 15-17

• Male > Female, approximately 2:1

Why More ADHD?

• Improved recognition by physicians? • Increase in prevalence? • An easing of standards for making the diagnosis? • An easing of standards for prescribing

medication?...or the “Prozac” connection? • Increased scholastic demands? • Changing parental habits? • Managed care and the pharmaceutical industry? • 1991 amendments to IDEA?

Etiology

• Disorder arises from multiple causes

• All currently recognized causes fall in the realm of biology (neurology, genetics)

• Causes may compound each other

• Common neurological pathway for ADHD appears to be the areas of the brain controlling Executive Functions and Physical Activity (Smaller / Less Developed)

• Social causes have poor evidence

Etiology

• Genetic link: 55-90% concordance • Environmental factors:

– Prenatal alcohol RRI: 2.5 – Smoking pre/post natal RRI: 2.1 – Premature birth RRI: 2.1-2.6

• Suspected association: – Head injury < 2 yrs (trauma, infection, hypoxia) – Television viewing age 1-3 yrs, neglect or abuse

• No association: – Artificial colors or sweeteners, sodium benzoate, sugar

Heredity -- Family Studies

Familial Expression of ADHD:

• 25-35% of siblings

• 78-92% of identical twins

• 25-30% of fathers

• If parent is ADHD, 20-54% of offspring

(odds 8+)

Etiology -- Prenatal

• Maternal smoking in pregnancy (odds 2.5)

• Maternal alcohol drinking in pregnancy (same)

• Prematurity of birth, especially if brain bleeds (45%+ have ADHD)

• Total increased pregnancy complications

• Maternal high phenylalanine levels in blood (?)

• High maternal anxiety in second trimester (?)

• Cocaine/crack exposure not a risk factor after controlling for the above factors

Etiology -- Post-Natal (7-10%)

• Head trauma, brain hypoxia, tumors, or infection

• Lead poisoning in preschool years (0-3 yrs.)

• Survival from acute leukemia (ALL)

– Treatments for ALL cause brain damage

• Post-natal Streptococcal Bacterial Infection

– triggers auto-immune antibody attack of basal ganglia

• Post-natal elevated phenylalanine (dietary amino acid related to PKU)

– Prenatal – hyperactivity

– Post-natal – inattention

Pathophysiology

• Abnormal central dopaminergic and noradrenergic tone

• Lower activity in brain regions associated with executive function: prefrontal cortex, striatum, and cerebellum

• Smaller brain volume in prefrontal cortex, caudate nucleus, and vermis of the cerebellum.

• MRI shows decreased blood flow to precortical area

Complications/Comorbidities

• Lower academic performance • Increased risk of intentional and unintentional

injury • Increased risk of traffic citations and accidents • Earlier initiation or increased likelihood of smoking • Poorer social function • Lower self esteem

Treatment reduces, but does not completely eliminate the impact of these complications in ~70% of patients

Complications – Impact on Families

• Parents of children w/ADHD are 3-5x more likely to become separated or divorced

• Parents of children w/ADHD have a higher incidence of depression & family discord

• Majority of parents of children w/ADHD report making changes in work status

• 9 – 35% risk that a parent of a given patient has ADHD

Complications – Impact on Siblings

• Disruption in the family, where home is described chaotic and exhausting

• Potential for the victimization of sibs by aggressive or impulsive acts of ADHD child

• Sibs may experience a range of feelings, including: Resentment over the amount of time and attention their

sibling receives Anxiety about their sibling’s behavior and how that

impacts family activities such as vacations Sadness about being overlooked or about the lack of a

“normal” family and childhood They may feel their sibling is favored because different

methods of discipline are used to manage ADHD. 'I’d never get away with that' is a common complaint

•

DSM-V Diagnostic Criteria for ADHD

Consensus Criteria Highlights:

• Symptoms must present in two or more settings • For patients younger than 16 years, 6 or more symptoms

must persist > 6 months in at least one of the two categories Inattention Hyperactivity/Impulsivity

• Several symptoms must be present before age 12 • Symptoms must impair function in academic, social, or

occupational activities • Symptoms must be disruptive and excessive for the

developmental level of the child (compared to same age peers)

• Other mental disorders that could account for the symptoms must be excluded

Key Changes : DSM-IV to DSM-5

• Symptoms can now occur by age 12 rather than by age 6;

• Several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting;

• New descriptions were added to show what symptoms might look like at older ages; and

• For adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children

DSM-5 ADHD Sub-Types

• Predominantly inattentive type – Usually diagnosed at 9-10 years of age – Studied less commonly

• Predominantly hyperactive-impulsive – Usually diagnosed at 6-7 years of age – Cognitive performance may be unaffected

• Combined type – Usually diagnosed at 6-7 years of age – “Classic” type and most common

Co-Morbidities

• 50-60% of children with ADHD meet criteria for another psychiatric diagnosis.

• May be primary or secondary – Conduct disorder – Tourette syndrome – Autism – Depression – Learning disability – Anxiety – Speech problems – Epilepsy

Differential Diagnosis: Psychiatric

• Mood and/or Psychotic Disorder • Anxiety Disorder • Learning Disorder • Mental Retardation/Borderline IQ • ODD/Conduct Disorder • Pervasive Developmental Disorder • Substance Abuse • Axis II Disorders • Psychosocial Issues (e.g., abuse, parenting, etc.)

Differential Diagnosis: Medical

• Seizure Disorder (e.g., Absence, Complex-Partial) • Chronic Otitis Media • Hyperthyroidism • Sleep Apnea • Drug-Induced Inattentional Syndrome • Head Injury • Hepatic Ilness • Toxic Exposure (e.g., lead) • Narcolepsy

Case Study Review: 7 Year Old Matt

Handout #1: Read the Brief Case Study that Describes the Issues Occurring in Matt’s Family, and consider the following questions:

• What additional information would you collect from Matt’s mother?

• What are your initial diagnostic impressions?

• Which co-morbid issues are apparent?

• What would you include in your Plan?

Evaluation/Assessment Goals

Identify core symptoms: • Evaluate level of impairment. • Identify possible underlying or alternative causes. • Identify co-occurring (co-morbid) conditions.

By Assessing: • Academic performance • Peer relations • Sibling relations • Parent relations • Community activities

Assessment -- Multi-Rater It Takes a Team

• Medical Professionals

• Teachers

• Behavioral Health Professionals

• Parents

• The Identified Child or Adolescent

and Multi-Method • History and Physical, with Pertinent Labs • Interviews with Parent/Guardian and Child or

Adolescent • In-Depth Clinical Interview Includes:

Diagnostic Assessment of Primary Complaint Review of Psychiatric Systems (e.g., attention,

hyperactivity/impulsivity, oppositional & conduct difficulties, mood, anxiety, psychosis, trauma, neurovegetative systems, tics, substance abuse, etc.)

Medical, Psychiatric, & Developmental History Detailed Educational History Detailed Family & Social History

Behavior Rating Scales

• Many scales are available, including: Connors-EC for ages 2-6 yrs Connors Comprehensive and ADHD Rating Scale IV for

ages 4-5 yrs Connors-3 for ages 6-18 yrs SNAP IV for ages 5-11 yrs ADD-H Comprehensive Teacher’s Rating Scale for

kindergarten to eighth grade Academic Performance Rating Scale for grades 1-6 Home Situations Questionnaire-Revised School Situations Questionnaire-Revised

• Review the age range for which the scale may be used, to ensure the client meets the age and other criteria for its use.

Behavioral Observations in the Home, School and other Natural Settings

Conducted over time and across several settings to:

Determine A-B-C Chains

Count Specific Behaviors such as: Time on/Off Task

Number of Positive Statement Made by Parents

Frequency of identified problem behaviors within a given observation period

The overall goal is to understand the morphology of the behavior: Frequency, Intensity and Duration

Establishing a Definitive Diagnosis

Symptoms in ≥ 1 setting:

• An ADHD diagnosis should not be based on a 1:1 interview

• Individuals with ADHD can often function well in certain settings with no signs of symptoms when they are interested and maintain total focus (e.g., playing Nintendo, watching videos, etc.)

• Evaluating symptoms demonstrated in group settings are a must!

Developing an Effective Treatment Plan

• “The primary care clinician should establish a treatment program that recognizes ADHD as a chronic condition and a child with ADHD as a child/adolescent with special health care needs.” American Academy of Pediatrics

• So, how do we help parents and the child or adolescent to understand what this means and to help them to take the “long look?”

Effective ADHD Interventions

• Parent Education • Psychopharmacology • Parent Training in Child Management

– 65-75% of Children under 11 respond – 25-30% of Adolescents show reliable changes

• Family Therapy for Adolescents: – Problem-Solving and Communication Training – 30% show change (best combined with BMT)

• Teacher Education • Train Teachers in Classroom Behavior Management • Special Ed (IDEA, 504) • Regular Physical Exercise • Residential Treatment (5-8%) • Parent Family Services (25+%) • Parent/Patient Support Groups

Ineffective ADHD Interventions

• Elimination Diets: Sugar, Additives, etc. (Weak Evidence)

• Megavitamins, Anti-oxidants, Minerals: (No strong evidence or disproved)

• Sensory Integration Training (Disproved)

• Chiropractic Skull Manipulation (No Evidence)

• Play / Psychotherapy (Disproved)

• Neurofeedback (Experimental)

• Cognitive Self-Control Therapies (Effective in Clinic)

• Social Skills Training (Effective in Clinic Setting) – Better for Inattentive Type and anxious cases

Parent Education: Working with Families to Understand ADHD

• Educate parents and clients about ADHD. • Develop a partnership with the family. • Develop a management plan with specific

targeted goals. • Include the teachers in plan development. • Monitor plans on an on-going basis and anticipate developmental changes.

Psychopharmacology --- Stimulants

• These are the most well studied drugs in psychiatry – In use for over 40 years, and evaluated in over 350 studies – Thousands of cases – 80% of children taking ADHD medications take stimulant

medications – Designated as the first-line medications in most protocols

Stimulant Response Rate Ritalin (Methylphenidate) 77% Adderal (Amphetamine) 74% Dexedrine 73% Trying All 90%

Psychopharmacology -- Strattera

• Not Schedule II; no abuse potential

• Effective for children, adolescents, and adults

• Equal efficacy with Methylphenidate with previously unmedicated cases (75% positive response)

• Slightly lower efficacy with those previously on stimulants (55% positive response)

• Sustained response for up to 3 years

• Increasing improvement over time

• Can be given once daily (morning) or split (am/pm

Helpful Questions for Parents to Ask About Initiating ADHD Medications

• Has my child been helped by non-medication approaches?

• Has the school tried to teach my child to be more attentive and less active?

• Is the decision to put my child on medication the result of behavioral observations over time and in different settings, such as in school and at home?

• When is my child at his or her best? Help the physician understand how pervasive or selective the problem is.

• Does my child have other conditions that can be mistaken for hyperactivity?

Questions Parents May Ask About Developing an ADHD Medication Plan

• What ADD/ADHD treatments do you recommend?

• Can my child's symptoms be managed without medication?

• What medications do you recommend and what are the side effects?

• How effective is medication for my child's ADD/ADHD?

• How long will my child have to take medication?

• How will the decision be made to stop medication?

Parent Training in Child Management

Focuses on helping parents to learn effective strategies to address issues intrinsic to the ADHD

– The scientific literature on treatment for ADHD has shown that behavior therapy is the only type of psychosocial treatment that is effective for ADHD.

– Although teaching parents more effective ways of dealing with their children is the most important aspect of psychosocial treatment for ADHD, ideally parent, teacher, and child interventions should be integrated to yield the best outcome.

Parent Training: Essential Points

• Start with goals that the child can achieve and improve in small steps;

• Be consistent--across different times of the day, different settings, and different people;

• Don't expect instant changes--teaching and learning new skills take time, and children's improvement will be gradual;

• Constantly monitor the child's response and adjust treatment as necessary; and

• Begin intervention as early as possible--although behavior modification works for all ages, early treatment is more effective than later intervention.

Group Exercise

Please Review Handout #4, Parent-Described Discipline Issues with their ADHD Children

As a behavioral health professional, how might you respond to each statement?

Parent Training

• Parent training is typically provided in weekly individual or group sessions for 12 to 16 weeks. Parents are taught skills by a therapist (e.g., how to use time out effectively) and asked to go home and practice the skill for a week with their child, reviewing progress, problem-solving, and learning a new skill in subsequent sessions.

Key Focus Areas for Parent Training

When parents understand that their child can't get it all right all the time, they are ready to shape their child’s therapy. Key questions for a parent to consider are: • What do I want my child to do that she isn't doing? • How can I relay my instructions in a visual format (so I

won't have to tell her what to do)? • What would make it worthwhile for her to do it (i.e.,

something more powerful than what's on her radar screen at the moment she's engaged in inappropriate behavior)?

• How can I use my child’s strengths to develop a plan?

Educational Interventions

• One of the most important things that the parent of an ADHD child can do is to work closely with the teacher to support the implementation of classroom programs for their ADHD child.

• Typically an intervention is individualized and consists of several components based on the child’s needs, the child’s strengths, the classroom resources, and the teacher’s skills and preferences.

Classroom Interventions

Educational interventions are designed to provide the structure, expectations and support to promote positive behavior. Proactive strategies are particularly effective in supporting success and include: 1. Establish Classroom rules and structure 2. Praise appropriate behaviors and ignore mild inappropriate behaviors that are not reinforced by peer attention 3. Give appropriate directions(clear, specific, manageable) and private reprimands (at child’s desk as much as possible)—same characteristics as for good commands for parents described previously and not reinforced by peer attention.

Classroom Interventions

4. Define necessary accommodations and structure for individual child (e.g., desk placement, task sheets) 5. Focus on ways to increase academic performance 6. Develop When…then contingencies (e.g., recess time contingent upon completing work 7. Institute a Daily School-Home Report Card 8. Develop a Behavior c hart/reward and consequence program (point or token system) for the target child 9. Institute proactive Classroom-wide strategies and group contingencies to ensure the classroom supports positive student outcomes.

Strategies at Home and at School to Promote Educational Success

Help your child categorize his school materials – Backpack organization is key to ensure:

– Homework and other important papers arrive at home – Homework is completed and returned to school – Homework is turned in to the designated classroom location Ensure that a study location is identified at home and that all required materials and supplies are available Provide a shelf for books and a bulletin board for reminders. Keep an extra set of textbooks at home. Make the extra books part of the IEP, or request them from the teacher at the beginning of the term. Give your child a daily planner to keep track of deadlines, appointments, events, and so on. Encourage her to keep a daily to-do list Prepare for the next day by organizing returning all required materials and supplies to the back-back and laying out the next day’s clothing.

Promoting Effective Cooperation Between School, Home and the Community

• Families, schools, and service providers should stay in regular contact, devise management plans and monitor and adjust interventions over time.

• The parents role as their child’s advocate is on-going.

• The behavior health professional can provide the instrumental support, advocacy and guidance in navigating the multiple systems in which the child and family may be involved. – This is particularly important in advocating for

educational observations and evaluation , as well as IEP development if that is indicated by evaluation results.

Putting the Pieces Together

• Behavioral interventions are the only evidence-based nonmedical treatment for ADHD

• Behavioral treatments focus on problems in daily life functioning in family relationships, peer relationships,

classroom functioning, and academic achievement • Behavioral treatments teach skills to parents, teachers, and children with ADHD to cope and improve in these important areas of functioning. • Because ADHD is a chronic disorder, behavioral treatments (just like medication) need to be maintained by parents and teachers for as long as necessary for long term change • Behavioral and combined treatments are preferred by parents to medication alone. .

Putting the Pieces Together

• Based on their own preferences about treatments, the child’s severity, parent and teacher resources and skill development, and the child’s response to behavioral treatments, parents must decide whether (1) to start with behavioral treatments first and add medication if necessary or (2) to start with behavioral/pharmacological treatments simultaneously.

• If good behavioral treatments are started first and continued, many ADHD children will not require medication

• For children who need them, combined behavioral and medication interventions often produce better short-term effects with lower doses than either treatment alone.

Putting the Pieces Together

• Families, schools, and service providers should stay in regular contact monitor and adjust interventions over time.

• Start behavioral treatments early

In order to meet the challenges of helping a child with ADD/ADHD, we must to be able to master a combination of compassion and consistency. Living in a home that provides both love and structure is the best thing for a child or teenager who is learning to manage ADD/ADHD.

QUESTIONS?

ADHD Resources

• www.chadd.org offers scientifically reliable information in English and Spanish about ADD in children, adolescents, and adults. Sponsored by Children and Adults with ADHD (CHADD), the largest ADHD support and advocacy organization in the United States, it has downloadable fact sheets of science-based information for parents, educators, professionals, the media, and the general public. The site also includes contact information for two hundred local chapters of CHADD throughout the United States.

• www.help4adhd.org presents evidence-based information in English and Spanish about ADD in children, adolescents, and adults. This national clearing house of downloadable information and resources concerning many aspects of ADHD is funded by the U.S. government's Centers for Disease Control and Prevention and operated by CHADD. New material is added frequently, and questions directed to the site are responded to by knowledgeable health-information specialists.

• www.add.org is a resource in English for adults with ADD. Sponsored by Attention Deficit Disorder Association (ADDA), the world's largest organization for adults with ADHD, it provides information, resources, and networking opportunities.