Attention/activity level DTW

ADHD Basic Care

Definitions

ADHD has 3 core symptoms = Distractibility, Impulsivity, and Hyperactivity^[note] which must be relative to peers and causing difficulties.

Predominately inattentive type (requires 6 of 9 inattentive symptoms) is distinct from ADHD; " spacey"; generally shy/anxious passive "good kids" and not impulsive or oppositional; but inattentive.
Predominantly hyperactive-impulsive type requires only 6 of 9 hyperactive-impulsive symptoms.
Combined type dx requires both 6 of 9 inattentive and 6 of 9 hyperactive-impulsive symptoms.

Key Points

Assessment requirements:

Child data: H & P with Neuro exam.
Family data: Interview and ADHD-specific parent checklist^[note].
School data: Teacher ADHD-specific behavior checklist^[note]; and , if possible, descriptive^[note]; and schoolwork^[note].
Diagnosis of ADHD requires meeting DSM-IV criteria^[note] and rule outs (See: Differential Diagnosis).

Not indicated:

Routine lab tests.
Use of general behavior rating scale^[note] without ADHD- specific scale although these may point to comorbidity.
Behavior therapy is not as effective as stimulant medication but can help with oppositionality.

Recommended stimulants work equally well
Children who fail to respond to one stimulant medication may respond to another.

For 3-5 year old children with symptoms, consider other diagnoses before ADHD (See: Differential Diagnosis) but treat as ADHD if appropriate.

Look for common comorbid conditions initially and at follow up Including Oppositional Defiant Disorder, Conduct Disorder, Anxiety, Depression, and Learning Disorders (See: Comorbid Conditions).

Latest research on ADHD

Management

ADHD is a chronic condition and needs long term management.
Specify appropriate target outcomes to guide management through collaboration of parents, child, clinician and school personnel, should (e. g., including standard rating forms - link to Vanderbilt to print out)
Recommend stimulant medication and/or behavior therapy as appropriate to improve target outcomes. Medication is more effective than behavioral therapy but some advantage[note] to combination (See results of large MTA study) (See: Non Medical Treatment pt)
When target outcomes are not met reevaluate: the original diagnosis, use of treatments, adherence to the treatment plan and presence of coexisting conditions.
Medication Dosing: (See: Medication Table)

Begin with a low dose and titrate upward, (ideally through a placebo/dose finding approach (See: placebo trial))
Best dose is one that leads to optimal effects with minimal side effects.
Alert parent and child that side effects occur early in treatment (first 2-3 weeks) and tend to be mild except prolonged lunch anorexia.
If one stimulant does not work at the highest dose, recommend another as 80% will respond then.

Behavior techniques - only those with immediate reward/consequences are effective e.g.:

positive reinforcement
time-out for problem behavior
response cost
token economy

Follow up depends on severity - after stable, at least every 3 - 6 mos. to assess learning and behavior, vital signs and growth.

According to the Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version (Wolraich, M. (Ed.) 1996) the following are the definitions for Impulsive/Hyperactive or Inattentive Behavior variations and problems.

Variations

V65.49 Hyperactive/Impulsive Variation

Young children in infancy and in the preschool years are normally active and impulsive and may need constant supervision to avoid injury. Their constant activity may be stressful to adults who do not have the energy or patience to tolerate the bahavior.

During school years and adolescence, activity may be high in play situations and impulsive behaviors may normally occur, especially in peer pressure situations.

High levels of hyperactive/impulsive behavior do not indicate a problem or disorder if the behavior does not impair function.

Information for Parents:

Your Concerns about Restlessness, Fidgeting, Interrupting, Being too Active, or Acting without Thinking, Preschool

Your concerns about Restlessness, Fidgeting, Interrupting, Being too Active, or Acting without Thinking, School Age

V65.49 Inattention Variation

A young child will have a short attention span that will increase as the child matures. The inattention should be appropriate for the child's level of development and not cause any impairment.

Information for Parents:

Your Concerns about Lack of Attention or Short Attention Span, Preschool

Your Concerns about Lack of Attention or Short Attention Span, School Age

Problems

V40.3 Hyperactive/Impulsive Behavior Problem

These behaviors become a problem when they are intense enough to begin to disrupt relatipnships with others or begine to affect the acquisition of age-appropriate skills. The child displays some of the symptoms listed for the ADHD predominantly hyperactive/impulsive type. However, the behaviors are not sufficiently intense to qualify for a behavioral disorder such as ADHD, or of a mood disorder or anxiety disorder.

A problem degree of this behavior is also likely to be accompanied by other behaviors such as negative emotional behaviors or agressive/oppositional behaviors.

Information for Parents:

Your Concerns about Restlessness, Fidgeting, Interrupting, Being too Active, or Acting without Thinking, Preschool

Your Concerns about Restlessness, Fidgeting, Interrupting, Being too Active, or Acting without Thinking, School Age

V40.3 Inattention Problem

A problem exists when some of the symptoms for the ADHD predominantly inattentive type are present and they create some difficulties for the child's parents and teachers and begin to affect some areas of academic and social functioning. However, the behaviors are not sufficiently intense to qualify for a behavioral disorder.

Information for Parents:

Your Concerns about Lack of Attention or Short Attention Span, Preschool

Your Concerns about Lack of Attention or Short Attention Span, School Age

Disorders

Attention Deficit Hyperactivity Disorders

Either (1) or (2):
1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
  Inattention
  1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  2. often has difficulty sustaining attention in tasks or play activities
  3. often does not seem to listen when spoken to directly
  4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace ( not due to oppositional behavior or failure to understand instructions)
  5. often has difficulty organizing tasks and activities
  6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  7. often loses thing necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
  8. is often easily distracted by extraneous stimuli
  9. is often forgetful in daily activities
2. six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
  Hyperactivity
  1. often fidgets with hands or feet or squirms in seat
  2. often leaves seat in classroom or in other situations in which remaining seated is expected
  3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
  4. often has difficulty playing or engaging in leisure activities quietly
  5. is often "on the go" or often acts as if "driven by a motor"
  6. often talks excessively
  Impulsivity
  1. often blurts out answers before questions have been completed
  2. often has difficulty awaiting turn
  3. often interrupts or intrudes on others (e.g., butts into conversations or games)
Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

314.01 Attention-Deficit/Hyperactivite Disorder, Combined Type

If both Criteria A1 and A2 are met for the past 6 months.

Information for Parents:

Attention Deficit Hyperactivity Disorder, Combined Type, Preschool

Attention Deficit Hyperactivity Disorder, Combined Type, School Age

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type

If Criterion A2 is met but Criterion A1 is not met for the past 6 months.

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

Information for Parents:

Attention Deficit Hyperactivity Disorder, Predominantly Hyperactive/Impulsive Type, Preschool

Attention Deficit Hyperactivity Disorder, Predominantly Hyperactive/Impulsive Type, School Age

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type

If Criterion A1 is met but Criterion A2 is not met for the past 6 months.

Information for Parents:

Attention Deficit Hyperactivity Disorder, Predominantly Inattentive Type, Preschool

Attention Deficit Hyperactivity Disorder, Predominantly Inattentive Type, School Age

314.9 Attention-Deficit/ Hyperactivity Disorder Not Otherwise Specified

This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.

Information for Parents:

Attention Deficit Hyperactivity Disorder, Not Otherwise Specified (NOS), Preschool

Attention Deficit Hyperactivity Disorder, Not Otherwise Specified (NOS), School Age

Key Points

3 core symptoms^[note] = Distractibility, Impulsivity, and Hyperactivity -- Relative to peers and causing difficulties.

Predominately inattentive type ^[note] (requires 6 of 9 inattentive symptoms) is distinct from ADHD; " spacey^[note]"; generally shy/anxious passive "good kids" and not impulsive or oppositional; but inattentive^[note]
Predominantly hyperactive-impulsive type requires only 6 of 9 hyperactive-impulsive symptoms
Combined type dx requires both 6 of 9 inattentive and 6 of 9 hyperactive-impulsive symptoms

Not a disorder of "how to do it" or "What to do" but a dysfunction of WHEN^[note]

Can be thought of as a disorder of:

"What is boring" -adequate teaching of developmentally appropriate content does not capture their attention and the degree of interest and excitement needed to make it not boring is not reasonably possible -- this may be true even for bright children with challenging curriculum
Trouble shifting attention once engaged^[note]
Transition Problems^[note] result which are often judged morally^[note] leading to parent child conflict and defiance.

Assessment requirements ( [broken reference] )

Child data: H & P with Neuro exam
Family data: Interview and ADHD-specific checklist^[note]
School data: Teacher ADHD-specific behavior checklist^[note]; descriptive^[note]
Schoolwork^[note]
Diagnosis of ADHD requires meeting DSM-IV criteria^[note]
Ruling out common comorbid conditions^[note] including Oppositional Defiant Disorder, Conduct Disorder, Anxiety, Depression, and Learning Disorder (See also: Comorbid Conditons)
Not indicated

Routine lab tests
Use of broad band rating scale^[note] without ADHD specific scale

Behavior therapy is not as effective as stimulant medication
Recommended stimulants work equally well
Children who fail to respond to one stimulant medication may have a positive response to another
Once stable, a child should be followed every 3-6 months for assessment of learning and behavior When 3-5 year old children present with appropriate symptoms, consider other diagnoses before ADHD

Etiology/Epidemiology

Prevalence- 8-10%^[note] of school-age children (Szatmari, P 1989) , (Wasserman, RC 1999) (Wolraich, ML 1996) .
3:1 to 9:1 male: female^[note] (may be 2:1 RE: inattentive subtype)
<70% persist into adulthood
Often FH+ AD/HD
Inhibition and Executive Functioning suggest Frontal Lobe problems^[note]
Decreased size in frontal lobes, cerebellar vermis, basal ganglia, and corpus collosum (Hynd, G.W. 1993) , (Aylward, E.H. 1996) , (Castellanos, F.X. 1996)
Decreased perfusion in the striatum (Lou, 1990; 335: 8-11)) (Vaidya, C.J. 1998) .
Possible association with dopamine transporter gene (DAT1) and dopamine receptor (DRD4) (Cook Jr., E.H. 1995) , (Gill, M. 1997) , (Swanson, J.M. 1998)

See Clinical Guide Algorithm

Latest research on ADHD

Differential Diagnosis and Comorbidity

Age appropriate overactivity (i.e. the child does not have ADHD)-Age-related variations and temperamental characteristics
Any condition that affects CNS function may result in attention problems
Other Learning Problems^[note] (See: Learning Disorder, Mental Retardation, and PDD DTWs)
Other Psychiatric conditions^[note] (See: Repetitive Behaviors, Anxiety, OCD, and Sadness DTWs)
Medical/neurological primary diagnosis^[note]
Environmental or family problems*^[note]
Frequent Lay or educational diagnoses and associations^[note]

Management

Overarching Principles ( [broken reference] )

Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition.
The treating clinician, parents and child in collaboration with school personnel, should specify appropriate target outcomes to guide management.
The clinician should recommend stimulant medication and/or behavior therapy as appropriate to improve target outcomes in children with ADHD.
When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan and presence of coexisting conditions.
The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects, with information gathered from parents, teachers and the child.
Medication Dosing:

Clinicians should begin with a low dose and titrate upward, (ideally through a placebo/dose finding approach (see: placebo trial)).
Best dose is one that leads to optimal effects with minimal side effects.
Side effects occur early in treatment and tend to be mild.
If one stimulant does not work at the highest dose, the clinician should recommend another.

Children who do not show positive effects or experience intolerable side effects on one medication should be tried on another since most children^[note] who fail to respond to one medication will have a positive response to another.

Initial Visit

Explain/demystify diagnosis
- Connect concerns to diagnosis^[note]
- Temperament interpretation^[note]
- If positive family history, suggest possible link with potential for better outcome with treatment
- The disconnect with time^[note]
Interpret strengths^[note] uncovered in interview, observation and/or questionnaire
Explain "time-disconnect" implications for treatment (see Time Disconnect pt)
- Treatments at the site and moment of desired performance are the ones that work best^[note].
- Parents need to change their approach to time-related expectations^[note]
Discuss medication-clearly proven to be the most effective treatment
- Diffuse common myths^[note] and misinformation^[note] about medication (see Myths and Facts about Stimulant Medication pt)
- Discuss placebo rationale^[note] for placebo trial unless behavioral emergency, e. g., school suspension (see Placebo Trial pt)
- Discuss side effects and choice of medication (see Stimulant Medication Side Effects pt)
- Review FDA controversy re: possible very rare association between stimulant use and cardiac deaths^[note] (See Also: Questions and Answers: Safety of Pills For Treating ADHD pt)
- Ask child and parent about swallowing capsules consider sprinkle forms and/or hints for swallowing pills ^[note]
- Stimulants (see Stimulant Medication pt)
  - First Choice medications are long acting stimulants^[note] (see Medication Table)
  - Give medication 7 days/week at least at start so parents can observe reaction
  - Children benefiting from school dosing almost always benefit from a 3rd dose and newer long actings are now a reliable and usually preferred alternative to 3rd dose
- Non-stimulants
  - Non-stimulant medication is a now a reasonable alternative in new atomoxetine (Strattera) but it may be a second line medication (see Non-Stimulant Medication pt)
Convey concept that this is a chronic condition (see Prognosis of Children with ADHD pt)
- Need for Continued Medication
  - Weekends and summer (see Medication Holidays pt)
  - Into adulthood^[note]
  - Need for continued monitoring
Review Effective Non-Medical Treatments
- Note that medication is more effective than behavioral therapy but some advantage^[note] to combination (See results of large MTA study) (see Non Medical Treatment pt)
  - Effective Behavior Techniques -- mostly those with immediate consequences e.g.:
- Tips for Teachers for Children with ADHD (See Education Options pt)
  - Parent Training Groups Citations^[note]
  - Psychosocial Treatment Options
Define goals and target outcomes:
- Clarify the major overall goal: Preventing negative reactivity^[note] from expectations which are inappropriate, overly difficult, and/or not respectful of child's temperamental style to prevent or minimize the potential for oppositional and defiant behavior
- Identify 3 to 6 specific realistic and measurable target behaviors^[note] with parents and child
  - Suggest that they may want to add those behaviors to the rating forms
- Agree on a plan to identify and support specific child strengths for self-esteem building
  - Begins with identifying the areas of strength
  - Identify specific activities to try out and further these areas
Identify plan for monitoring
- Data to be obtained from school: e.g.: ratings, IEP, phone call, report card
- Set time for follow-up visit
  - E.g.: after 6 week placebo trial with data collection
  - but depends on severity -- at minimum twice per year
Suggest additional text for parent

Follow-up Visit:

Review progress on target goals
- If lack of progress consider: (see My Child's ADHD seems to be Getting Worse pt)
  - Were target goals were unrealistic?
  - Was diagnosis wrong?
  - Is there a co-morbid condition that's not being addressed (e. g.: anxiety, depression, or learning disability)?
  - Is there a study skills/disorganization problem?
  - Is the medication dose adequate?
  - Is there a lack of follow through on treatment plan?
Review of current functioning: school^[note], home^[note], friends^[note]
- Reconsider possible comorbid diagnoses
Sample achievement on weak areas of academics
- Reconsider possible learning disorder diagnoses
Review progress on identifying area of talent and getting related opportunities
Review of side-effects:
- amount of sleep^[note] (See: Sleep DTW)
- weight gain and concern about eating^[note]
Consider need for accommodations in class through a "504 plan"^[note]
Consider using a daily report card

Appendices

Medication Table

Medication Table
Methylphenidate
Forms	Duration	Dosage	Comments
d-isomer Immediate release tablets (Focalin) 2.5, 5, 10 mgs.	3 - 4 hours	Half regular dose or 0.15 - .3 mg/kg/dose -usually 3x/day
d-isomer Extended release capsules (Focalin XR) 5, 10, 20 mgs.	8 hours	Equivalent to two immediate release tablets of d-isomer. Half the extended release Ritalin dosage.	Can sprinkle on apple sauce. Acts like two immediate release tablets with two peaks 4 hours apart.
Immediate release Regular (Riltalin) 5, 10, 20 mgs.	3 - 4 hours	0.3 - .6 mg/kg/dose -usually 3x/day
Chewable Immediate release (Methylin) 2.5, 5, 10 mgs	3-4 hours	0.3 - 0.6 mg/kg -3x/day	Should wash down with liquid to avoid choking. Note Feb/ 2005 The FDA began a recall of 2.5-, 5-, and 10-mg methylphenidate HCl chewable tablets (Methylin CT) due to the potential for superpotent and subpotent lots. Expected to resume in March of 2006. High fat meals delay onset by 1 hour.
Oral Solution Immediate release (Methylin) 5 and 10 mg/5 cc	3-4 hours	0.3 - 0.6 mg/kg -3x/day	High fat meals delay onset by 1 hour.
Sustained-release (SR) 20 mgs.	2 - 8 hours	Variable 2x Ritalin dose or .6 - 1.2 mg/kg/dose -usually 1x/day
Spansule capsules (Metadate CD) 20 mgs.	6 hours	Variable 2x Ritalin dose -usually 1x/day; Before breakfast	Beads are 30% short and 70% long acting; food can delay early peak by one hour
Osmotic pump (Concerta) 18, 27, 54 mgs.	12 hours	3x Ritalin dose or 0.9 - 1.8 mg/kg/dose -usually 1x/day	Occasional sleep problems; Capsule is nondeformable and should not be administered to someone with intestinal narrowing; absorption not affected by food
Transdermal Patch (Daytranna) Patch Sizes 12.5 cm2 18.75cm2 25cm2 37.5cm	2 hour onset delay until at least 3 hours after patch removed	See Table Below	More nausea, anorexia, and insomnia than Concerta. Probably should be reserved for children who cannot take oral medication because of potential rare sensitizing to future oral methylphenidate if child develops a rash to the transdermal.
Patch size (cm2)	Mg/hr	Mg/ 9 hrs	Mg/patch	Concerta Equivalent
12.5	1.1	10	27.5	18 mg
18.75	1.6	15	41.3	27 mg
25	2.2	20	55	36 mg
37.5	3.3	30	82.5	54 mg
Dextroamphetamine
Forms	Duration	Dosage	Comments
Regular (Dextrostat) 5, 10 mg.	4 - 5 hours	0.15-0.25mg/kg/dose up to .4 mg/kg/dose 2 - 3 x/day
Spansule capsules (Dexedrine) 10, 15 mg.	6 - 8 hours	0.3 - 0.5mg/dose 1x/day	Occasional sleep problems
(Vyvanse) capsules Lisdexamfetamine dimesylate (l-lysine plus dextroamphetamine This 'pro-drug' combination rapidly breaks down in GI tract) 20, 30, 40, 50, 60, 70 mg	12 hours	Titrate by 20 mg per week until reaching optimized dose; Some children may need the highest recommended 'adult dose' of 70 mg	The advantage of the 'pro-drug' is that without being digested the dextroamphetamine is not active and therefore is not of use to substance users through the IV or nasal route; can be taken with our without food and can be opened and poured onto applesause
Mixed Amphetamine Salts
Forms	Duration	Dosage	Comments
Regular (Adderall) 5, 7.5, 10, 12.5, 15, 20, 30 mgs	6 - 8 hours	0.15--.25mg/kg/dose up to .4/kg/dose
Spansule capsules (Adderall XR) 10, 15, 20, 25, 30 mgs.	9 - 12 hours	0.3 - 0.5mg/dose 1x/day	Can open capsule and pour beads in applesauce

Clinical Placebo Trial for Stimulant Medication

Neither parent nor teacher is aware of medication
Weekly parent and teacher ratings establish objectivity
Helps parents carefully sort out their fears from fact
Helps establish an optimal dosage early
Usually a six-week trial
1. First week = A is placebo; 2nd is lower dose and 3rd week is highest dose
2. A, B, C weeks are repeated
3. Begin on weekend and complete parent, teacher and child (if 11 or older) questionnaires on Fridays
4. Placebos can be made by a pharmacist who will have a suggestion

Non-stimulant Medication Options for ADHD

Imipramine

1-4 mg/kg /2-3 doses/day
EKG monitoring

Clonidine

4-5 microgram/kg/day
Alternative: Guanfacine (Tenex) long acting, especially for aggression and when sedation
HS needed
CVS concerns

Bupropion (Wellbutrin)

Antidepressant with stimulant action (beta noradrenergic receptors and prefrontal lobe)
Significant effect on ADHD but less effect size than first line stimulants
Better than nicotine patch for smoking cessation ("Zyban")
Dosage: 3-6mg/kg (</=300/day); 75, 100, & 150mgSR
Side-effects (especially if increase fast)
1. a. Increased seizure threshold (rate = .06%)
2. b. Agitation, insomnia

Non-medical Treatment Options for ADHD

Parent counseling about ADHD (&ODD)
Parent training in child management
Teacher counseling and training in ADHD and classroom management
Special Ed when indicated
Individual counseling as needed
Residential Treatment
Parent/Family Counseling when indicated
Support groups for severe cases (e.g, CHADD, NADDA)

Results of Large ADHD MTA Study

579 children (aged 7 - 9) with ADHD combined type
Duration-14 months
6 sites
4 treatment groups:
1. Medical management (tailored dose design, TID dosing; monthly monitoring).
2. Behavioral therapy: 8-week summer program specialized for ADHD; patient training, in-class aids, teacher consultations and daily reports
3. Combined medication-psychosocial
4. Community standard treatment: evaluations and referrals; 67% on medication; id regimens)
Results showed:
1. Medical management (68% success) or combination therapy had better outcomes than behavioral therapy (or community care).
2. Combined therapy was equal to medical management for ADHD symptoms.
3. Combined therapy was slightly better for related problems.

Reference: NIMH Collaborative Multisite Multimodal Treatment Study of Children with Attention-Deficit Disorder. The MTA Cooperative Group. Arch. Gen. Psychiatry. 1999; 56: 1088-1096

Tips For Teachers for Children with ADHD

Avoid Embarrassment
Reduce Distracters, increase salience
1. Keep desk free from extraneous stuff
2. Use novel things/topics or ways of teaching
3. Try to intersperse things of low-interest to child with things of high interest
4. Organize child's tasks into small manageable sections
Keep them engaged-ask for immediate recall of information just presented
Clearly display classroom rules; give instruction visually as well as verbally.
1. Have child repeat the instruction out loud and softly to himself while completing the task.
Teacher can use subtle techniques to cue his/her attention
1. Closing classroom door
2. Flashing classroom lights.
3. Lightly tapping/touching child's desk
Swift, frequent, and immediate delivery of consequences
Varied and rich incentive for appropriate behavior
Consistent routine
1. Advise ADHD children of the day's schedule as early as possible in the day
Structure-ADHD children need reminders, previews, repetition, and direction
Organization-they need help in how to organize their lives. These can be helpful
1. Clipboard
2. Post-it notes for marking pages
3. Large 3-ring notebook
4. Color coded dividers
5. Highlighters for marking notes
6. Index cards
Environmental concerns-An ADHD child should be seated where the following are minimized:
1. Excessive noise
2. Temperature fluctuations
3. Visual stimulation (windows to look out of)
4. Doors
5. Traffic
ADHD children can benefit from doing some work on computers. This helps to hold their attention-especially when exercises are interactive

Parent Training Groups Citations

Anastopoulos, A. D., Shelton, T., DuPaul, G. J., & Guevremont, D. C. (1993). Parent training for attention-deficit hyperactivity disorder: Its impact on parent functioning. Journal of Abnormal Child Psychology, 21, 581-596.

Firestone, P. & Witt, J.E. (1982). Characteristics of families completing and prematurely discontinuing a behavioral parent training program. Journal of Pediatric Psychology, 7, 209-222.

Pisterman, S., Firestone, P. McGrath, P., Goodman, J. T., Webster, I., Mallory, R., & Goffin, B. (1992). The role of parent training in treatment of preschoolers with ADD-H. American Journal of Orthopsychiatry, 62, 397-408.

ADHD Follow-Up Visit Goals

To watch for and begin early intervention for co-morbid conditions
To monitor self concept of child, perception of parents and progress toward asset building (e.g., involvement in non-school skill building)
To adjust medication as needed
Teacher and parent check lists and work samples and report card data are usually needed
Repeat placebo trials are helpful
Also to monitor for side effects (growth, tics, BP)

Daily Report Cards

Parent should set up a meeting with teacher.
They should set 3-5 daily goals for the child (phrased in positive terms).
1. Examples of goals
2. academic performance
3. having necessary classwork materials (coming to class prepared)
4. remembering to bring in homework(regardless of accuracy)
5. completing tasks accurately (regardless of speed)
6. completing and returning homework.
7. Remains seated
8. Raises hand and waits to be called on to speak.
Once the goals have been identified, the parent and teacher can decide how many "yes's" the child need have to get certain privileges at home.
1. Rewards need to be selected carefully so that the child will want to work hard to meet those goals.
2. In addition to daily rewards, children often do well when they can work up to weekly or monthly rewards, too.
3. Parents will need to be continually involved in this process if it is to be successful. Goals need to be frequently reviewed and modified.
If parents can't navigate this on their own, they may want to get a consultant or therapist to help them set up such an arrangement with the school.

Note: There is limited research on the effectiveness of these daily report cards. However, research (Fuchs & Fuchs, 1989) suggests that if they are not carefully monitored they are often ineffective. (chapter by Pelham & Waschbusch (1999) entitled "Behavioral intervention in ADHD" in the Handbook of Disruptive Behavior Disorders (Edited by Quay & Hogan)]

Citations

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Aylward, E.H., Reiss, A.L., Reader, M.J., Singer, H.S., Brown, J.E., Denckla, M. B. (1996). Basal Ganglia Volumes in Children with ADHD. .
Barkley, R.A. (1990). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment..
Castellanos, F.X., Giedd, J.N., Marsh, W.L., Hamburger, S.D., Vaituzis, A.C., Dickstein, D.P., et al. (1996). Quantitative Brain Magnetic Resonance Imaging in Attention-Deficit Hyperactivity Disorder. .
Culbert, T.P., Banez, G.A., Reiff, M.I. (1994). Children who have Attentional Disorders: Interventions. .
Cook Jr., E.H., Stein, M.A., Krasowski, M.D., Cox, N.J., Olkon, D.M., Kieffer, J.E., et al. (1995). Association of Attention-Deficit Disorder and the Dopamine Transporter Gene. .
Diller, L.H. (1998). Running on Ritalin.
Gill, M., Daly, G., Heron, S., Hawi, Z., Fitzgerald, M. (1997). Confirmation of Association Between Attention Deficit Hyperactivity Disorder and a Dopamine Transporter Polymorphism. .
Giros, Bruno, Jaber, Mohamed, Jones, Sara R, Wightman, Mark R, Caron, Marc G (). Hyperlocomotion and Indifference to Cocaine and Amphetamine in Mice Lacking the Dopamine Transporter. .
Greenhill, L.L. (). Attention-deficit hyperactivity disorder. The stimulants.. .
Hynd, G.W., Hern, K.L., Novey, E.S., Eliopulos, D., Marshall, R., Gonzalez, J.J., et al. (1993). Attention deficit-hyperactivity disorder and asymmetry of the caudate nucleus. .
Lou, H.C., Henriksen, L., Bruhn, P. (1990). Focal cerebral dysfunction in developmental learning disabilities. .
The MTA Cooperative Group (1999). NIMH Collaborative Multisite Multimodal Treatment Study of Children with Attention-Deficit Disorder. .
Rapoport, J.L., Buchbaum, M.S., Zahn, T.P., Weingartner, H., Ludlow, C., Mikkelsen, E.J. (1978). Dextroamphetamine: cognative and behavioral effects on normal prepubertal boys. .
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3 core symptoms = Distractibility, Impulsivity, and Hyperactivity: In addition, academic underachievement and behavior problems.
In addition, academic underachievement and behavior problems.
ADHD-specific parent checklist: e.g., CHADIS-DSM or Vanderbilt in CHADIS or Connors for follow-up
e.g., CHADIS-DSM or Vanderbilt in CHADIS or Connors for follow-up
Teacher ADHD-specific behavior checklist: e. g., Conners or Vanderbilt teacher forms
e. g., Conners or Vanderbilt teacher forms
descriptive: Teacher narrative including classroom behavior, learning patterns, classroom interventions and degree of functional impairment
Teacher narrative including classroom behavior, learning patterns, classroom interventions and degree of functional impairment
schoolwork: report card, samples of schoolwork
report card, samples of schoolwork
Diagnosis of ADHD requires meeting DSM-IV criteria: CHADIS-DSM questionnaire responses provides this documentation)
CHADIS-DSM questionnaire responses provides this documentation)
behavior rating scale: e. g.: Achenbach CBCL, Devereaux scales, CHADIS is not considered one of these
e. g.: Achenbach CBCL, Devereaux scales, CHADIS is not considered one of these
3 core symptoms: In addition, academic underachievement and behavior problems
In addition, academic underachievement and behavior problems
Predominately : Also called ADD without H
Also called ADD without H
spacey: Daydreamer; sluggish responses suggesting processing issues; excessive confusion; inconsistent memory retrieval
Daydreamer; sluggish responses suggesting processing issues; excessive confusion; inconsistent memory retrieval
inattentive: Tending to show deficits on measures of attention
Tending to show deficits on measures of attention
dysfunction of WHEN: Not a lack of skill or lack of knowledge but how to intrgrate capacities in proper TIME frame
Not a lack of skill or lack of knowledge but how to intrgrate capacities in proper TIME frame
once engaged: To something child finds stimulating enough such as an exciting videogame.
To something child finds stimulating enough such as an exciting videogame.
Transition Problems: Difficulty shifting from what child is doing to what adult is requesting
Difficulty shifting from what child is doing to what adult is requesting
judged morally: "Stubborn"; "he only does want he wants to do"
"Stubborn"; "he only does want he wants to do"
ADHD-specific checklist: e.g., CHADIS-DSM or Vanderbilt in CHADIS or Connors for follow-up
e.g., CHADIS-DSM or Vanderbilt in CHADIS or Connors for follow-up
Teacher ADHD-specific behavior checklist: e. g., Conners or Vanderbilt teacher forms
e. g., Conners or Vanderbilt teacher forms
descriptive: Teacher narrative including classroom behavior, learning patterns, classroom interventions and degree of functional impairment
Teacher narrative including classroom behavior, learning patterns, classroom interventions and degree of functional impairment
Schoolwork: report card, samples of schoolwork
report card, samples of schoolwork
DSM-IV criteria: CHADIS-DSM questionnaire responses provides this documentation
CHADIS-DSM questionnaire responses provides this documentation
Ruling out common comorbid conditions: CHADIS-DSM should help and see clinical algorithm
CHADIS-DSM should help and see clinical algorithm
broad band rating scale: e. g.: Achenbach CBCL, Devereaux scales, CHADIS is not considered one of these
e. g.: Achenbach CBCL, Devereaux scales, CHADIS is not considered one of these
Prevalence- 8-10%: 4 - 12% in various studies, 8 - 10% represents pooled data across studies
4 - 12% in various studies, 8 - 10% represents pooled data across studies
3:1 to 9:1 male: female: In the general population, 9.2% (range 5.8% - 13.6%) of males and 2.9% (range 1.9% to 4.5%) of females have ADHD consistent behaviors
In the general population, 9.2% (range 5.8% - 13.6%) of males and 2.9% (range 1.9% to 4.5%) of females have ADHD consistent behaviors
Inhibition and Executive Functioning suggest Frontal Lobe problems: No consensus yet regarding precise transmitter defect or anatomic localization Studies (MRI x6; PET x3; SECT x2) do show differences from controls
No consensus yet regarding precise transmitter defect or anatomic localization Studies (MRI x6; PET x3; SECT x2) do show differences from controls
Learning Problems: Learning Disability (25-40% of ADHD*), Specific Language Disorder*, Mental Retardation*, PDD*, Slow learner, Central Auditory Processing Disorder*, Sensory Motor Integration Problem*, low average ability esp. with high expectations, "under-productivity" in school (90%), classroom environment
Learning Disability (25-40% of ADHD*), Specific Language Disorder*, Mental Retardation*, PDD*, Slow learner, Central Auditory Processing Disorder*, Sensory Motor Integration Problem*, low average ability esp. with high expectations, "under-productivity" in school (90%), classroom environment
Psychiatric conditions: ODD (up to 65%)*, conduct disorder (1/3 of referred ADHD goes on to delinquency)*, Tourette's disorder*, tress of child/family*, anxiety disorders (0-30%)* incl. OCD, mood disorder (25% of referred have anx/depression; major depression series 0-30%)* and with manic features*, antisocial- delinquent (25%+), borderline personality disorder*, drug abuse*, psychosis/schizophrenia
ODD (up to 65%)*, conduct disorder (1/3 of referred ADHD goes on to delinquency)*, Tourette's disorder*, tress of child/family*, anxiety disorders (0-30%)* incl. OCD, mood disorder (25% of referred have anx/depression; major depression series 0-30%)* and with manic features*, antisocial- delinquent (25%+), borderline personality disorder*, drug abuse*, psychosis/schizophrenia
Medical/neurological primary diagnosis: 1. Endocrine- hyperthyroidism, generalized resistance to thyroid hormone 2. Neurological*- petit mal, migraine, chorea, lead poisoning, head injury, CNS tumor, CVA, CNS chemotherapy, CNS lupus, 3. Neurodevelopmental syndromes*: e. g.: Fragile X, Fetal Alcohol Syndrome 4. Sensory- mild hearing and or vision losses 5. Arousal- day time drowsiness associated with obstructive sleep apnea, lack of sleep 6. Drug induced- drug side effects (e.g. Phenobarbital, sympathomimetics, Theophylline, 7. Antihistamines, Systemic steroids) 8. Substance Use: Cocaine, Phencyclidine, Stimulants 9. Other: iron deficiencyEndocrine- hyperthyroidism, generalized resistance to thyroid hormone 10. Neurological*- petit mal, migraine, chorea, lead poisoning, head injury, CNS tumor, CVA, CNS chemotherapy, CNS lupus, 11. Neurodevelopmental syndromes*: e. g.: Fragile X, Fetal Alcohol Syndrome 12. Sensory- mild hearing and or vision losses 13. Arou! sal- day time drowsiness associated with obstructive sleep apnea, lack of sleep 14. Drug induced- drug side effects (e.g. Phenobarbital, sympathomimetics, Theophylline, 15. Antihistamines, Systemic steroids) 16. Substance Use: Cocaine, Phencyclidine, Stimulants 17. Other: iron deficiency
1. Endocrine- hyperthyroidism, generalized resistance to thyroid hormone 2. Neurological*- petit mal, migraine, chorea, lead poisoning, head injury, CNS tumor, CVA, CNS chemotherapy, CNS lupus, 3. Neurodevelopmental syndromes*: e. g.: Fragile X, Fetal Alcohol Syndrome 4. Sensory- mild hearing and or vision losses 5. Arousal- day time drowsiness associated with obstructive sleep apnea, lack of sleep 6. Drug induced- drug side effects (e.g. Phenobarbital, sympathomimetics, Theophylline, 7. Antihistamines, Systemic steroids) 8. Substance Use: Cocaine, Phencyclidine, Stimulants 9. Other: iron deficiencyEndocrine- hyperthyroidism, generalized resistance to thyroid hormone 10. Neurological*- petit mal, migraine, chorea, lead poisoning, head injury, CNS tumor, CVA, CNS chemotherapy, CNS lupus, 11. Neurodevelopmental syndromes*: e. g.: Fragile X, Fetal Alcohol Syndrome 12. Sensory- mild hearing and or vision losses 13. Arou! sal- day time drowsiness associated with obstructive sleep apnea, lack of sleep 14. Drug induced- drug side effects (e.g. Phenobarbital, sympathomimetics, Theophylline, 15. Antihistamines, Systemic steroids) 16. Substance Use: Cocaine, Phencyclidine, Stimulants 17. Other: iron deficiency
Environmental or family problems*: 1. Inadequate, disorganized chaotic environment 2. Ineffective parenting (incl. substance abuse)
1. Inadequate, disorganized chaotic environment 2. Ineffective parenting (incl. substance abuse)
Frequent Lay or educational diagnoses and associations: 1. Emotional problems including: Immaturity (50%+), Over reaction to situations, Low frustration tolerance 2. Social problems (50%) including: Selfish/self-centered, Rejected by peers due to intrusive behaviors, Little regard to social consequence, Immature play/ social interests, Misattribution of malicious intent of others' acts (aggressive sub group)
1. Emotional problems including: Immaturity (50%+), Over reaction to situations, Low frustration tolerance 2. Social problems (50%) including: Selfish/self-centered, Rejected by peers due to intrusive behaviors, Little regard to social consequence, Immature play/ social interests, Misattribution of malicious intent of others' acts (aggressive sub group)
most children: 80% of children will respond to one of the stimulants if tried systematically.
80% of children will respond to one of the stimulants if tried systematically.
Connect concerns to diagnosis: Briefly review parent/teacher/child concerns and any observations in your office and description of greatest impact as part of overall pattern of behavior - meeting the diagnostic criterion.
Briefly review parent/teacher/child concerns and any observations in your office and description of greatest impact as part of overall pattern of behavior - meeting the diagnostic criterion.
Temperament interpretation: or way of being built.wire from the start that makes some of the expectations we have these days for children feel less natural and more of a strain.
or way of being built.wire from the start that makes some of the expectations we have these days for children feel less natural and more of a strain.
time: It is not a problem of "How to do" of "What to do" but a dynfunction of WHEN
It is not a problem of "How to do" of "What to do" but a dynfunction of WHEN
Interpret strengths: e.g.: "He appears to be fast and athletic. We will have to figure out what sport will be best for him because how he does later depends as much on making sure he was opportunities to become as competant as possible in areas of strength as well as helping him with areas of weakness." Or "He appears to like to fiddle with things in his hands a lot. Have you thought about drumming lessons for him."
e.g.: "He appears to be fast and athletic. We will have to figure out what sport will be best for him because how he does later depends as much on making sure he was opportunities to become as competant as possible in areas of strength as well as helping him with areas of weakness." Or "He appears to like to fiddle with things in his hands a lot. Have you thought about drumming lessons for him."
Treatments at the site and moment of desired performance are the ones that work best: like positive reinforcement such as marks on the hand for a younger child or positive comments when doing well and physical touching on the shoulder or other cues to redirect off-task behavior
like positive reinforcement such as marks on the hand for a younger child or positive comments when doing well and physical touching on the shoulder or other cues to redirect off-task behavior
Parents need to change their approach to time-related expectations: such as getting ready in the morning/finishing what they are doing, and shifting from a high interest activity to something else - child will need non-confrontational structure not needed by other children at those moments such as the parent's physical presence to help move the action and provide clear and brief time warning eg., egg timer
such as getting ready in the morning/finishing what they are doing, and shifting from a high interest activity to something else - child will need non-confrontational structure not needed by other children at those moments such as the parent's physical presence to help move the action and provide clear and brief time warning eg., egg timer
common myths: 1) Addictive, 2) Paradoxical or sedative effects, 3) Stunt growth, 4) Cause brain damage or long-term effects
1) Addictive, 2) Paradoxical or sedative effects, 3) Stunt growth, 4) Cause brain damage or long-term effects
misinformation: 1. Data shows reduction in addiction as outcome, not increased. 2. Doesn't sedate, makes more alert to things that are usually boring to the child such as classroom instruction. 3. growth problems are related to nutrition which can be usually be maintained with habit of end of day eating and is regained when meds are discontinued. 4. No long term ill effects have been found. There is some evidence that stimulants may have a positive long term effect on the brain - e. g., history of long term increased caffeine intake is associated with enhanced memory in elderly.
1. Data shows reduction in addiction as outcome, not increased. 2. Doesn't sedate, makes more alert to things that are usually boring to the child such as classroom instruction. 3. growth problems are related to nutrition which can be usually be maintained with habit of end of day eating and is regained when meds are discontinued. 4. No long term ill effects have been found. There is some evidence that stimulants may have a positive long term effect on the brain - e. g., history of long term increased caffeine intake is associated with enhanced memory in elderly.
placebo rationale: Parents appreciate this approach and we have not had any refusals. The main advantage has been to help parents come to grips with their fears and expectations - but be ready for emergency calls about children on placebo who are experiencing feared symptoms. We feel this exercise makes it likely that parents will persist with the medication even after the inevitable scare from the media. It also provides an objective way to sort out any alternative remedies they wish to try in the future (or evaluate the continuing need for medication.) "If it is not harmful we will help you find out if it is truly effective by not telling the teacher and collecting objective data." In addition the trial allows you to come to an optimal dose in a short time. By comparing placebo to both a low dose and a relatively high dose you can avoid years of suboptimal therapy resulting from the "start low and go slow approach.! !"
Parents appreciate this approach and we have not had any refusals. The main advantage has been to help parents come to grips with their fears and expectations - but be ready for emergency calls about children on placebo who are experiencing feared symptoms. We feel this exercise makes it likely that parents will persist with the medication even after the inevitable scare from the media. It also provides an objective way to sort out any alternative remedies they wish to try in the future (or evaluate the continuing need for medication.) "If it is not harmful we will help you find out if it is truly effective by not telling the teacher and collecting objective data." In addition the trial allows you to come to an optimal dose in a short time. By comparing placebo to both a low dose and a relatively high dose you can avoid years of suboptimal therapy resulting from the "start low and go slow approach.! !"
possible very rare association between stimulant use and cardiac deaths: 25 cases/nearly 4 million over three years or 0.006% - We do not yet have a way of calculated potential life saving benefits in terms of reduced accidents and injuries; reduced substance abuse; and reduced auto accidents
25 cases/nearly 4 million over three years or 0.006% - We do not yet have a way of calculated potential life saving benefits in terms of reduced accidents and injuries; reduced substance abuse; and reduced auto accidents
: <link to McNeil handout information on swallowing pills. - Ray will get permission to use it
<link to McNeil handout information on swallowing pills. - Ray will get permission to use it
stimulants: MPH (methylphenadate) and DA Dextroamphetamine (or salts in Adderall) are approximately equivalent in efficacy (75%) & side effects; Cylert is no longer recommended due to serious liver toxicity; All have similar onset of action = 15 - 20 min.; Some children respond better to one than the other
MPH (methylphenadate) and DA Dextroamphetamine (or salts in Adderall) are approximately equivalent in efficacy (75%) & side effects; Cylert is no longer recommended due to serious liver toxicity; All have similar onset of action = 15 - 20 min.; Some children respond better to one than the other
Into adulthood: Consider various work demands: Air traffic controller vs. salesperson, Accountant vs. CEO with 3 secretaries, Pathologist vs. Pediatrician
Consider various work demands: Air traffic controller vs. salesperson, Accountant vs. CEO with 3 secretaries, Pathologist vs. Pediatrician
some advantage: Parents were more satisfied; improved scores on some adademic measures, conduct and anxiety symptoms improve
Parents were more satisfied; improved scores on some adademic measures, conduct and anxiety symptoms improve
positive reinforcement: Rewards contingent on performance. e.g.: marks on child's hand for cooperative behaviors; play on computer after ready in the morning or completing homework
Rewards contingent on performance. e.g.: marks on child's hand for cooperative behaviors; play on computer after ready in the morning or completing homework
time-out for problem behavior: Briefly removed from access to positive reinforcement; e.g. 3 minutes in the bathroom
Briefly removed from access to positive reinforcement; e.g. 3 minutes in the bathroom
response cost: Lose privileges with problem behavior; e.g.: can't watch TV if doesn't complete homework
Lose privileges with problem behavior; e.g.: can't watch TV if doesn't complete homework
token economy: Gets rewards for desired behavior and loses them for undesired. e.g.: marks on hand or stars for cooperative behavior and gets an eatable reward and sticker at the end of day and trip to dollar store on weekend for a week of stickers
Gets rewards for desired behavior and loses them for undesired. e.g.: marks on hand or stars for cooperative behavior and gets an eatable reward and sticker at the end of day and trip to dollar store on weekend for a week of stickers
Parent Training Groups Citations: Cognitive-behavioral interventions that reduce parenting stress and increase parent sense of competence and efficacy, do not necessarily improve child behavior, but give parent a sense of control over child behavior
Cognitive-behavioral interventions that reduce parenting stress and increase parent sense of competence and efficacy, do not necessarily improve child behavior, but give parent a sense of control over child behavior
negative reactivity: E.g., all children want to succeed in school and will do whatever it takes to save face and motivation loss; anger and alienations are late consequences of failure to do so - disorders such as oppositional defiant disorder, conduct disorder and depression of extrinsic etiology may be prevented or lessened by management of ADHD
E.g., all children want to succeed in school and will do whatever it takes to save face and motivation loss; anger and alienations are late consequences of failure to do so - disorders such as oppositional defiant disorder, conduct disorder and depression of extrinsic etiology may be prevented or lessened by management of ADHD
specific realistic and measurable target behaviors: E.g: At home it sounds like one major issue is switching from what your child likes to do to what you need him to do - such as come to the dinner table. Should we add "switching activities" to the rating forms because it is one of the problem behaviors we want to improve? Other examples: completing homework without an argument; improving grades on tests.
E.g: At home it sounds like one major issue is switching from what your child likes to do to what you need him to do - such as come to the dinner table. Should we add "switching activities" to the rating forms because it is one of the problem behaviors we want to improve? Other examples: completing homework without an argument; improving grades on tests.
school: To child: "Are you feeling like you have a nice teacher? What is the hardest work at school for you now?" To parent: "How did his last report card turn out?"
To child: "Are you feeling like you have a nice teacher? What is the hardest work at school for you now?" To parent: "How did his last report card turn out?"
home: To parent: "How are things at home with ..."
To parent: "How are things at home with ..."
friends: To child: "Do you play with any of the kids in your class?" "How are the kids in your class? Are the kids getting along there? Is there much teasing or bullying going on?"
To child: "Do you play with any of the kids in your class?" "How are the kids in your class? Are the kids getting along there? Is there much teasing or bullying going on?"
amount of sleep: When does ... actually fall asleep? ... get up? Get up on weekends? - note late arousal on weekend days suggests a sleep deficit
When does ... actually fall asleep? ... get up? Get up on weekends? - note late arousal on weekend days suggests a sleep deficit
weight gain and concern about eating: Note that appetite is usually suppressed at the dosage needed for efficacy. Focus should be on the "4th meal" = others join child for a bedtime snack while child gets a chance to eat a meal when appetite has returned at the end of the day.
Note that appetite is usually suppressed at the dosage needed for efficacy. Focus should be on the "4th meal" = others join child for a bedtime snack while child gets a chance to eat a meal when appetite has returned at the end of the day.
Consider need for accommodations in class through a "504 plan": Accommodations child is eligible for with a documented clinical diagnosis note from you. E g., may ask for extended time on tests
Accommodations child is eligible for with a documented clinical diagnosis note from you. E g., may ask for extended time on tests