1 / 46

Attention Deficit -Hyperactivity Disorder Diagnosis & Intervention

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

Download Presentation

Attention Deficit -Hyperactivity Disorder Diagnosis & Intervention

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Attention Deficit -Hyperactivity DisorderDiagnosis & Intervention Lisa Nalven, MD, MA, FAAP Kireker Center for Child Development - Valley Hospital Ridgewood, New Jersey

  2. What is ADHD? • Most common neuro-developmental problem in children • Inattention • Hyperactivity • Poor impulse control • Distractibility • “Executive Dysfunction”

  3. 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)

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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**

  9. 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

  10. Coexisting conditions: need to evaluate Prevalence % • Learning disability (40-60) • Oppositional defiant disorder (35) • Conduct disorder (25) • Anxiety disorder (25) • Depressive disorder (18)

  11. 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

  12. 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

  13. 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)

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. Behavioral Interventions: • First line intervention for preschoolers • Behavior therapy • Parent training • Individual and family counseling • Parent/family services • Support groups (CHADD) • Social skills training

  20. 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

  21. 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”

  22. 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

  23. 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

  24. 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)

  25. 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.

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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.

  33. 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

  34. 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

  35. Medication options • “Stimulants” • Methylphenidate (Ritalin, Focalin, Concerta, Daytrana etc) • Amphetamine (Adderall, Vyvanse, Dexadrine etc) • Nonstimulant • Atomoxitine (Straterra) • Alpha agonists** • Intuniv (guanfacine) • Kapvay (clonidine)

  36. 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

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

  38. 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

  39. Resources • Learning Disabilities Association www.ldanatl.org • National Center for Learning Disabilities www.ncld.org • Wrightlaw Special Education Advocacy www.wrightslaw.com

  40. 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

  41. 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

More Related