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ADHD in the Home: Interventions and Strategies. Dr. Charles Pemberton, Ed.D, LPCC. Introduction. Charles Pemberton Ed.D. in Educational Counseling 16 years in Counseling and Mental Health Presented in England, South Africa, Central America, and US. Professor – UL and JCTCS

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ADHD in the Home:Interventions and Strategies

Dr. Charles Pemberton, Ed.D, LPCC


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Introduction

  • Charles Pemberton

    • Ed.D. in Educational Counseling

    • 16 years in Counseling and Mental Health

    • Presented in England, South Africa, Central America, and US.

    • Professor – UL and JCTCS

    • Private Practice – 60% children and families

      • ADHD

      • Depression

      • Aggression

      • Anxiety


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Today’s Schedule

  • Diagnosis and Identification

    • Comorbid disorders

  • Treatment

    • Behavioral Modification

    • Medication

  • Tools and Resources

  • Questions


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What won’t you get today

  • A plan that will work everywhere with everyone

  • Complete picture of medications


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Causes of ADHD

  • Biological Disorder

  • Neurological – dopamine/norepinephrine

  • Genetic

  • Toxins

  • Head injuries

  • No evidence:

    • Sugar

    • Food additives

    • Allergies

    • Immunizations


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Diagnosis Attention Deficit/Hyperactivity Disorder

  • Diagnostic and Statistical Manual IV- TR

    • DSM- IV-TR

  • Within the “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” grouping, then subgrouped by the category of “disruptive or self injurious behavior”


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ADHD, Major Diagnostic Features

  • Often will not complete tasks

  • Easily distracted by minor stimuli

  • Work often messy and completed w/o thought

  • Forgetful in day-to-day activities

  • Impulsive (interrupting others, cannot wait turn, etc.)

  • Fidgetiness

  • Excessive talking


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Subtypes of ADHD

  • 314.01 ADHD, Combined Type

    • Classical ADHD

  • 314.00 ADHD, Inattentive Type

    • Old ADD

    • Seen more in girls

  • 314.01 ADHD, Hyperactive-Impulsive Type

  • 314.9 ADHD NOS

    • Prominent symptoms but do not meet diagnostic criteria


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Diagnostic Criteria for ADHD - inattention

  • A 1. Must exhibit 6 or more symptoms of inattention, persisting for minimum of 6 months:

    • fails to give close attention to details

    • often has difficulty sustaining attention

    • often does not seem to listen when spoken to directly 

    • often has difficulty organizing tasks and activities 

    • often loses things necessary for tasks

    • often easily distracted by extraneous stimuli

    • often forgetful in daily activities 


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Diagnostic Criteria - Hyperactive

  • A 2. Must exhibit 6 or more symptoms of hyperactivity-impulsivity, persisting for minimum of 6 months

    • often fidgets with hands or feet or squirms in seat 

    • often leaves seat in classroom

    • often runs about or climbs excessively

    • is often "on the go" or often acts as if "driven by a motor“

    • often talks excessively

    • often blurts out answers

    • often has difficulty awaiting turn

    • often interrupts or intrudes on others


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Diagnostic Criteria, cont’d:

  • B. symptom onset PRIOR to age 7 years

  • C. impairment present in two or more environments

  • D. clear clinically significant impairment in functioning

  • E. cannot be accounted for by other mental disorder


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Prevalence

  • What percentage of children “should” be diagnosed with a form of ADHD?


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Prevalence of ADHD

  • Estimated at 3-7% of school age children

  • More common in males than females

  • Often diagnosed during elementary school years.


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Co morbidity

  • Oppositional Defiance Disorder

  • Conduct disorder

  • Mood Disorder

  • Anxiety Disorder

  • Learning Disorder

  • Tourettes

  • Hx abuse or neglect, multiple foster homes, lead poisoning, Mental Retardation


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Types according to Dr. Amen

  • Type 1: Classic ADD

  • Restlessness, hyperactivity, constant motion, troubles sitting still, talkative, impulsive behavior, lack of thinking ahead .

  • Type 2: Inattentive ADD

  • Short attention span (especially about routine matters), distractibility, disorganization, procrastination, poor follow-through/task completion.


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Types con’t

  • Type 3: Overfocused ADD

  • Worrying, holds grudges, stuck on thoughts, stuck on behaviors, addictive behaviors, oppositional/argumentative.

  • Type 4: Limbic ADD

  • Sad, moody, irritable, negative thoughts, low motivation, sleep/appetite problems, social isolation, finds little pleasure.


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Types con’t

  • Type 5: Temporal Lobe ADD

  • Inattentive/spacey/confused, emotional instability, memory problems, periodic intense anxiety, periodic outbursts of aggressive behavior seemingly triggered by small events or intense angry criticisms directed at himself for failures and frustrations, overly sensitive to criticism and slights by others, frequent headaches and/or stomachaches, learning difficulties, and serious misperceptions/distortions of people and situations.


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Types con’t

  • Type 6: Ring of Fire ADD

  • A ring of overactivity in the brain scan image which surrounds most of the brain is the source of the name for this type of ADD.

  • too many thoughts, very hyper behavior, very hyper verbal expressiveness, a hypersensitivity to light, sound, taste, or touch.


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Amen’s interventions

  • Type 1: Classic ADD

  • Stimulant medication (Ritalin, Adderall, etc.), a diet with more protein and less carbohydrates, intense aerobic exercise.

  • Type 2: Inattentive ADD

  • Stimulant medication, perhaps stimulating antidepressants (Welbutrin, for example), a diet with more protein and less carbohydrates, intense aerobic exercise.


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Amen’s interventions

  • Type 3: Overfocused ADD

  • An antidepressant that has a dual focus on two brain transmitters (seratonin and dopamine) (Effexor, for example), and/or an antidepressant that enhances seratonin (Prozac, Zoloft, Paxil, or others, for example). A stimulant medication may need to be added. A diet with less protein and increased complex carbohydrates will help, along with intense aerobic exercise.


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Amen’s interventions

  • Type 4: Limbic ADD

  • An antidepressant that is also stimulating (Effexor or Welbutrin, for example), with a stimulant medication could be added; a balanced diet, and intense exercise.


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Amen’s interventions

  • Type 5: Temporal Lobe ADD

  • Anticonvulsant medication (Neurontin, Depakote for example), a stimulant could be added; a diet with more protein and less simple carbohydrates.

  • Type 6: Ring of Fire ADD

  • Anticonvulsant medication (Neurontin, Depakote for example, a stimulant medication could be added; sometimes some of the newer, different anti-psychotic medications may help (Risperdal, or Zyprexa); a diet with more protein and less simple carbohydrates.


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Assessment – Am. Acad. Of Pediatrics

  • Evaluate any child 6 to 12 years of age who shows signs of school difficulties, academic underachievement, troublesome relationships with teachers, family members, peers, and other behavioral problems.

  • Use DSM-IV criteria; these require that ADHD symptoms be present in 2 or more of a child's settings, and that the symptoms adversely affect the child's academic or social functioning for at least 6 months.

  • Requires information from parents or caregivers and a teacher or other school professional regarding core symptoms of ADHD in various settings, age of onset, duration of symptoms, and degree of impairment.

  • Assessment for co-existing conditions: learning and language problems, aggression, disruptive behavior, depression or anxiety.


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Assessment Tools

  • No test available

  • Dx by:

    • Observation

    • Rating Scales

      • Vanderbilt

      • Conner’s

      • SNAP


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How do we treat ADHD?

  • Behavior Modification

  • Medication

    • Differences

    • Dosages

    • Timing

    • Side-effects

    • Efficacy


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Behavior Modification

  • Home and Classroom

  • Basics of Behaviorism


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Academics

  • Take medication while doing homework

  • Set a schedule to work on homework

  • Minimize distractions

  • Establish “study buddy”

  • Use color to code calendar

  • Minimize spaces

  • Work on discovering what is really happening


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Forgetting

  • 1- Need to notice

  • 2- Need to write/record

  • 3- Need to bring home

  • 4- Need to look

  • 5- Need to understand

  • 6- Need to start/finish

  • 7- Need to store

  • 8- Need to turn-in


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Academics cont’

  • Divide into smaller segments

  • Use white noise

  • Use daily/weekly forms

  • Limit time spent on homework

  • Review for ‘hasty’ errors

  • Focus on school, remembering later


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School Problems and symptoms

  • Hyperactivity

    • Give study breaks

    • Reward completion

    • Allow movement – multiple P.E.

  • Depression

    • Focus on small successes

    • Provide support, not challenge to prove

  • Defiance

    • Give choices

    • Teach problem solving

    • Lower voice

    • Use Time-out


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Steps in Behavior Modification

  • Identify behavior

  • Chart behavior for baseline

  • Identify motivators

  • Establish realistic goals

  • Match motivators with behavior changes

    • Short term

    • Long term

  • Implement Plan

  • Evaluate Plan

  • Modify and repeat


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Measurable/Realistic Goal

  • Measurable Long term and Short Term Goals

    • Who will measure?

    • What is the goal?

    • Where is the behavior now?

    • When will we measure?

    • How will we measure?




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Other Behavior Therapy techniques

  • Token Economy

  • Time outs


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Time-outs

  • Not - “stand in corner”

  • Not punishment

  • Time to “cool off” and rethink

  • Procedure

    • Call time out early

    • Establish time-in

    • Think about YOUR actions don’t prepare for battle


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Classroom Rewards

  • Homework reductions

  • Physical Contact

  • Computer Access

  • Additional recess

  • Free time in class

  • Tickets/stickers

  • Time to finish homework in class

  • Special pen or paper


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Helping a child control his behavior

  • Daily Schedule

  • Cut down distractions

  • Organize your house

  • Set small, reachable goals

  • Limit choices

  • Use calm discipline - distraction


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Types of Medications

  • Methylphenidate

  • Dextroamphetamine

  • Atomoxetene

  • Dexmethylphenidate

  • Antidepressants

    • SSRI’s

    • Tricyclics


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Basic Elements of Methylphenidate

  • Known as: Ritalin, Ritalin SR, Ritalin LA, Concerta, Metadate ER, Metadate CD, Focalin

  • Pharmacology: It is a CNS stimulant, which is chemically related to amphetamine

  • Preparations – 5, 10, 20 mg tabs; sustained release 20 mg tabs; LA 20, 30, and 40 mg capsules. The SR tablet should be swallowed and not crushed or chewed. Concerta comes in 18 and 36 mg extended release tablets. Metadate CD 20 mg capsules; Metadate ER 10 – and 20 – mg tabs. Focalin 2.5, - 5-, 10 - mg tabs.


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Methylphenidate, cont’d

  • Half-Life – 3-4 hours; 6-8 hours for sustained release

  • It’s a schedule II controlled substance, requiring a triplicate prescription

  • Pre-Drug Work-Up

    • Blood pressure and general cardiac status

    • baseline and periodic blood counts and liver function tests

    • Weight and growth should be monitored in children


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Methylphenidate, cont’d

  • Adverse Drug Reactions

    • Nervousness and insomnia; can be reduced by decreasing dose.

    • Cardiovascular – Hypertension, tachycardia, and arrhythmias.

    • CNS – Dizziness, euphoria, tremor, headache, precipitation of tics and Tourette’s syndrome, and rarely psychosis.

    • GI – Decreased appetite, weight loss.

    • Case reports of elevated liver enzymes and liver failure.

    • Hematological –Leukopenia and anemia have been reported

    • Growth Inhibition


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Basic Elements of Dextroamphetamine

  • Known as: Adderall, Adderall XR

  • Pharmacology:causes the release of norepinepherine from neurons. At higher doses, it will also cause dopamine and serotonin release

  • Preparations – Adderall 5-, 7.5-, 10-, 12.5-, 15-, 20-, 30-mg tablets; Adderall XR 5-, 10-, 15-, 20-, 25-, 30-mg capsules.


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Dextroamphetamine, cont’d

  • Half-Life – 10-25 hours

  • It’s a schedule II controlled substance, requiring a triplicate prescription

  • Pre-Drug Work-Up

    • Blood pressure and general cardiac status should be evaluated prior to initiating dextroamphetamine.

    • Can precipitate tics

    • Contraindicated in in patients with hypertension, hyperthyroidism, cardiac disease or glaucoma. It is not recommended for psychotic patients ot patients with a history of substance abuse.

    • Weight and growth should be monitored in all children.


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Dextroamphetamine, cont’d

  • Adverse Drug Reactions

    • Side effects – most common side effects are psychomotor agitation, insomnia, loss of appetite, and dry mouth. Tolerance to loss of appetite tends to develop. Effect on sleep can be reduced by making sure no drug is given after 12 pm.

    • Cardiovascular – Palpitations, tachycardia, increased blood pressure.

    • CNS – Dizziness, euphoria, tremor, precipitation of tics, Tourette’s syndrome, and rarely, psychosis.

    • GI – Anorexia and weight loss, diarrhea, constipation.

    • Growth inhibition


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Basic Elements of Atomoxetene

  • Known as: Strattera

  • Pharmacology:works via presynaptic norepinepherine transporter inhibition

  • Preparations – 10, 18, 25, 40, and 60 mg capsules .


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Atomoxetene, cont’d

  • Half-Life – approximately 4 hours

  • Not a schedule II controlled substance

  • Clinical Guidelines –

    • Dividing the dose may reduce some side effects

    • Dose reductions are necessary in presence of moderate hepatic insufficiency

    • Atomoxetine should not be used within 2 weeks of discontinuation of a MAO inhibitor.

    • Atomoxetine should be avoided inpatients with narrow angle glaucoma and, it should be used with caution in patients with tachycardia, hypertension, or cardiovascular disease.

    • It can be discontinued without taper.

    • Pregnancy C category.


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Atomoxetene, cont’d

  • Adverse Drug Reactions

    • Cardiovascular – increased blood pressure and heart rate (similar to those seen with conventional psychostimulant).

    • BI – Anorexia, weight loss, nausea, abdominal pain.

    • Miscellaneous – Fatigue, dry mouth, constipation, urinary hesitancy and erectile dysfunction.


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Basic Elements of Dexmethylphenidate

  • Known as: Focalin, Focalin XR

  • Pharmacology:causes the release of dopamine from neurons. Is an isomer of Ritalin.

  • Preparations – Focalin 2.5, 5 ,10-mg tablets; Focalin XR 5-, 10-, 20-mg capsules.


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Dexmethylphenidate, cont’d

  • Half-Life – 2.2 hours

  • It’s a schedule II controlled substance, requiring a triplicate prescription

  • Pre-Drug Work-Up

    • Blood pressure and general cardiac status should be evaluated prior to initiating Dexmethylphenidate.

    • Can precipitate tics

    • Contraindicated in in patients with hypertension, hyperthyroidism, cardiac disease or glaucoma. It is not recommended for psychotic patients or patients with a history of substance abuse.

    • Weight and growth should be monitored in all children.


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Dexmethylphenidate, cont’d

  • Adverse Drug Reactions

    • Side effects – most common side effects are psychomotor agitation, insomnia, loss of appetite, and dry mouth. Tolerance to loss of appetite tends to develop. Effect on sleep can be reduced by making sure no drug is given after 12 pm.

    • Cardiovascular – Palpitations, tachycardia, increased blood pressure.

    • CNS – Dizziness, euphoria, tremor, precipitation of tics, Tourette’s syndrome, and rarely, psychosis.

    • GI – Anorexia and weight loss, diarrhea, constipation.

    • Growth inhibition



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Other Medications

  • Dexadrine

  • Cylert

    • Since marketing in 1975, 13 cases of acute hepatic failure have been reported to the FDA. 11 resulted in death or transplant.

  • Attenade

  • Paxil

  • Wellbutrin

  • Zoloft

  • Trileptal

  • Celexa/Lexapro

  • Effexor


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When to use, when to change

  • Side effects

  • Past history

  • Substance abuse

  • Efficacy

  • Onset time

  • Stimulant first line, Strattera second

  • Follow MD


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Closing Thoughts

  • Stimulants still first line defense

  • Look at choice of drug based upon time of release

  • Be aware of study sponsor

  • Addictive nature

  • Subscribe to Medscape


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Tools/Resources

  • ADD/ADHD Behavior-Change Resource Kit

  • Teenagers with ADD: A Parents’ Guide

  • www.myadhd.com

  • www.adhdhelp.com

  • www.amenclinic.com

  • ADDitude Magazine


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References

  • American Academy of Pediatrics. Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105:1158-1170.

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:92-93.

  • National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder. Available at: http://www.nimh.nih.gov/publicat/helpchild.cfm. Accessed April 19, 2002.

  • U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Available at: http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec4.html. Accessed April 19, 2002.

  • Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1997;369(suppl):855-1215.

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:92-93.

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:92-93.

  • National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder—questions and answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.cfm. Accessed April 19, 2002.

  • National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder—questions and answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.cfm. Accessed April 19, 2002.

  • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

  • Fauman, M. A. (2002). Study Guide to DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.



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