Attention deficit hyperactivity disorder diagnosis intervention
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Attention Deficit -Hyperactivity Disorder Diagnosis & Intervention. Lisa Nalven, MD, MA, FAAP Kireker Center for Child Development - Valley Hospital Ridgewood, New Jersey. What is ADHD?. Most common neuro-developmental problem in children Inattention Hyperactivity Poor impulse control

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Attention deficit hyperactivity disorder diagnosis intervention

Attention Deficit -Hyperactivity DisorderDiagnosis & Intervention

Lisa Nalven, MD, MA, FAAP

Kireker Center for Child Development - Valley Hospital

Ridgewood, New Jersey


What is adhd

What is ADHD?

  • Most common neuro-developmental problem in children

    • Inattention

    • Hyperactivity

    • Poor impulse control

    • Distractibility

    • “Executive Dysfunction”


Occurrence

Occurrence

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

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

  • 7 times more common in boys

    • may look different in girls (chatty, daydream, fidget)


Prevalence internationally

Prevalence (internationally)

  • Canada (Montreal): 3.8-9.4% children (DSM-III-R)

  • Australia: 3.4%children, 2-3% teens (DSM-III-R)

  • New Zealand: 6.7% children, 2-3% teens (DSM-lll-R)

  • China: 6-9% children (DSM-lll)

  • Netherlands: 1.3% teens (DSM-lll-R)

  • Puerto Rico: 9.5% children & teens (DSM-lll)

  • Japan: 7.7% children (DSM-lll-R)

  • Colombia: 2-13% (DSM-lV)

  • Brazil: 5.8% of 12-14 year olds (DSM-IV)

    • R. Barkley, Ph.D


Dsm iv criteria 6 of 9 inattention symptoms

DSM-IV Criteria6 of 9 Inattention Symptoms

  • Fails to give close attention to details

  • Difficulty sustaining attention

  • Does not seem to listen

  • Does not follow through on instructions

  • Difficulty organizing tasks or activities

  • Avoids tasks requiring sustained mental effort

  • Loses things necessary for tasks

  • Easily distracted

  • Forgetful in daily activities


Dsm iv criteria 6 0f 9 hyperactive impulsive

DSM-IV Criteria6 0f 9 Hyperactive-Impulsive

  • Fidgets, squirms in seat

  • Difficulty staying seated

  • Climbs or runs excessively

  • Is on the go or “driven by a motor”

  • Talks excessively

  • Blurts out answers before questions are completed

  • Difficulty with turn taking

  • Interrupts or intrudes

  • Forgetful in daily activities


Other dsm iv criteria

Other DSM-IV Criteria

  • Developmentally inappropriate levels

  • Duration of 6 months

  • Cross-setting occurrence of symptoms

  • Impairment of major life activities

  • Onset of symptoms/impairment by age 7

  • Exclusions: severe DD, PDD, psychosis

  • Subtypes: inattentive, hyperactive, or combined types


Etiology

Etiology

  • Neurological/Biological

    • differences in functioning of frontal cortex

    • imaging studies show differences in neurotransmitter

      levels and brain structures

  • Factors that influence neurology/biology

    • heredity/genetics

    • prematurity

    • prenatal exposures (tobacco, alcohol, drugs of abuse)

    • adverse early experiences**


Things that can look like adhd but are not

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 need to evaluate

Coexisting conditions: need to evaluate

Prevalence %

  • Learning disability (40-60)

  • Oppositional defiant disorder (35)

  • Conduct disorder (25)

  • Anxiety disorder (25)

  • Depressive disorder (18)


Identification

Identification

  • Appropriate diagnosis of ADHD requires

    collaborative effort

  • Multiple sources of information should be

    gathered (family, teachers, other adults)

  • Multiple perspectives regarding symptoms

    are needed to assess their pervasiveness

    and severity


Sources of information regarding symptoms impact

Sources of information regarding symptoms & impact

  • Formal observation in multiple settings

  • Interviews with student and relevant adults

  • Rating scales completed by family, teachers and student

  • Developmental, school, and medical histories

  • Tests to measure attention, persistence and related characteristics (CPT, TOVA)

  • Psychoeducational testing to rule out/in a learning problem or other causes.

  • Vision and hearing assessments

  • There is no ONE test


How young can you diagnose adhd

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 impairments

How ADHD leads to impairments

ScenarioFunctional Outcome

  • Hyperactive 5 yr old elicits irritation Strained

    and harsh punishment by mother family relations

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

    playing cooperatively with peers is rarely

    asked to sleep at friends’ houses

    Contemporary Pediatrics, 2/2003


How adhd leads to impairments 2

How ADHD leads to impairments/2

ScenarioFunctional Outcome

  • Despite high IQ, college student fails Academic dysfunction

    courses due to disorganization, tardiness,

    poor writing skills

  • -Shy girl, believing school performance is Depression

    inadequate

    Contemporary Pediatrics, 2/2003


Childhood academic impairments

Childhood Academic Impairments

  • Children with ADHD evaluated using teacher

    reports and achievement tests:

    • Poor school performance (90%) (primarily reduced productivity)

    • Low academic achievement (10-15 point deficit)

    • Low average intelligence (7-10 point deficit)

    • Learning disabilities (24-70%)

      • Reading (15-30% in Barkley, 1990)

      • Spelling (26% in Barkley, 1990)

      • Math (10-60% in Barkley, 1990)

      • Handwriting (60%)

  • R. Barkley


Steps in intervention

Steps in Intervention

  • Assessment (appropriate diagnosis)

    • ratings scales from multiple informers

    • testing: IQ, achievement/educational, language

    • evaluate for other mental health or medical factors

  • Behavioral (skills training/counseling)

    • primary interventions for preschoolers

  • Educational

    • classroom strategies

    • interventions for comorbid learning issues

  • Accommodations at home, school and in the community

    • select and structure activities for success

  • Medication


Address mh and medical issues

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 preschoolers

  • Behavior therapy

  • Parent training

  • Individual and family counseling

  • Parent/family services

  • Support groups (CHADD)

  • Social skills training


Behavioral techniques for home and school

Behavioral techniques for home and school

  • Encourage eye contact before giving

    directions

  • Give short, clear, specific directions

  • Provide frequent reinforcement (praise) of appropriate behavior

  • Verbal reprimands directed at the child’s

    behavior--not at the child

  • Use “signals” to refocus or redirect

  • Preferential seating in the classroom


Behavior management strategies

Behavior Management Strategies

  • Positive reinforcement: rewards or

    privileges given for desired behaviors

  • “Token” economy: earns points towards rewards or privileges and loses them for undesirable behavior

  • Use of “time-out”


Tips for helping child control behavior

Tips for Helping Child Control Behavior

  • Provide daily schedule and routines

  • Reduce distractions

  • Organize house and study area

  • Reward positive behavior

  • Set small, reachable goals

  • Help child stay “on task”

  • Find activities at which child can succeed

  • Use calm discipline


Other considerations

Other considerations

  • Appropriately structured activities-be practical

    • Provide outlet for release of energy

    • Try not to let child become fatigued/hungry

    • Avoid taking younger children to formal

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

      necessary or do for short period of time.

  • Stretch attention span: reading, coloring, puzzles, board games

    • by age 5 child needs at least a 25 minute attention span


Services for children under 3 years

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 interventions 3 21 years

Education Based Interventions (3-21 years)

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

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

  • School and parent meet to review issues,

    decide on further evaluation and/or intervention.


Working with the school

Working with the school

  • Be aware of state mandated timelines for response, meetings, assessment, implementation of plan

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


Possible outcomes

Possible outcomes

  • School chooses not to intervene

  • Home/Classroom behavior modification

  • Home/Classroom work modification

  • Response to Intervention (RTI): written plan

  • ADA-rehabilitation act: section 504

  • IDEA: classification for special education services


Modifications to support learning

Modifications to support learning:

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

    electronic reminders

  • Plans for initiation, completion, and transition between

    tasks; include cues, supplies, timers

  • Homework: divided into sessions, with short breaks in

    between; longer, more difficult assignment done first,

    easiest last; remove distractions

  • Teaching strategies: break down tasks, cue, reinforce,

    multisensory/hands on approach; work modified to

    address learning issues; small group instruction with

    breaks; quiet place to work


Response to intervention rti

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 504

Section 504

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

    not significantly impacted)

  • Modifications in instructional program

  • Does not require, or not eligible for

    special education supports

  • Modifications may include: quiet work

    spaces, untimed tests, reduction in

    amount of written work , preferential seating


Special education classification idea

Special Education Classification- IDEA

  • “Other Health Impaired”

  • ADHD significantly impacts learning/academic achievement

  • Needs can not be met by a 504

  • Modification of school environment and instruction

  • Push-in or pull-out support


Why medication

Why Medication?

  • Dysregulation of neurotransmitters

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


Impact of medications

Impact of Medications?

  • Increases ability to pay attention

  • More control over behavior (impulsivity)

  • Improvement in schoolwork such as task

    completion, handwriting, classroom behavior as

    a result of improved attention, impulse control

    and on task behaviors

  • Reduces risk of substance abuse, car accidents

  • Make child more available to benefit from other

    interventions strategies

  • Will not treat comorbidities or wrong diagnosis


Medication issues

Medication issues

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

  • Individual and family history determines need for cardiac assessment (EKG)

    • Do for all children in foster care or who have been adopted due to incomplete histories

  • May take several tries to get the right medication and dose

  • Side effects are minimal if done properly


Medication options

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 not find consistent positive results; need to look at why

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

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


Collaboration

Collaboration

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


Resources

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 ADD

    www.chadd.org


Resources1

Resources

  • Learning Disabilities Association

    www.ldanatl.org

  • National Center for Learning Disabilities

    www.ncld.org

  • Wrightlaw Special Education Advocacy www.wrightslaw.com


Books

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


Attention deficit hyperactivity disorder diagnosis intervention

Lisa Nalven, MD, MA, FAAP

Director, Developmental Pediatrics

Adoption Screening & Evaluation Program

Kireker Center for Child Development-Valley Hospital

505 Goffle Road Ridgewood, NJ 07450

T: 201-447-8151 F: 201-447-8526

www.valleyhealth.com/childdev

www.valleyhealth.com/adoption


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