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Lisa Benton Hardy, M.D. Private Practice San Ramon

ADHD: Is it AS Common as Everyone says it is? And if so, What’s the best way to help my Child Succeed?. Lisa Benton Hardy, M.D. Private Practice San Ramon Former Director of Psychiatry, Childrens Hospital Oakland. Objectives. Recognize common characteristics for ADHD: Diagnosis

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Lisa Benton Hardy, M.D. Private Practice San Ramon

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  1. ADHD: Is it AS Common as Everyone says it is? And if so, What’s the best way to help my Child Succeed? • Lisa Benton Hardy, M.D. • Private Practice San Ramon • Former Director of Psychiatry, Childrens Hospital Oakland

  2. Objectives • Recognize common characteristics for ADHD: Diagnosis • How to Support the Child with ADHD- at home and at school • Be familiar with non pharmacological supportive treatments options (Stimulant and Non-Stimulant) • Be familiar with medication treatments (Stimulant and Non-Stimulant)

  3. Erikson’s Developmental Theory • Adolescence (12-19 yr): Identity vs. Role Confusion • Young Adults (20-30 yr): Intimacy vs. Isolation • Mid Adults (30-60 yr): Generativity vs. Stagnation • Mature Adults (60+ yr): Ego-integrity vs. Despair • Infancy (birth – 1 yr): Trust vs. Mistrust • Toddler (1-3 yr): Autonomy vs. Shame • Preschool (3-5 yr): Initiative vs. Guilt • School Age (5-12 yr): Industry vs. Inferiority

  4. Development: the Milestones • Emotional/Social • Language/Cognition • Motoric/Physical/Physiological

  5. Development: Infancy • Prenatal Factors – the beginning of attachment • Period of rapid reorganization and enormous growth – when else do you double your height and triple your weight?? • Major Milestone: Emotional and Social Development

  6. Infancy: Milestones • Emotional- social smiling and selective attachments ; the beginning of a sense of self as connected to another; the affects of temperament/personality • Language/Cognition: Nonverbal more than Verbal (Receptive Skills > Expressive Skills); establishing basic patterns – trial and error • Physical : one word: MOBILE (fine motor too)

  7. Development: Toddlers • Walking and Talking opens up a new world --- personal independence and autonomy (remember : “I CAN DO IT MYSELF!!!!”) • Major Milestone: Emotional and Social Development

  8. Toddlers: Milestones • Emotional/Social: ambivalence…solid limits to develop self control; separations & siblings; body image development • Language/Cognition: 200 words by 2 years; trial and error in thought rather than physical action; egocentric; FEARS (a little knowledge can be dangerous) • Motoric/Physical/Physiological: solid physical skills; handedness; simple activities/chores

  9. Development: Preschoolers • Increasingly independent • Preparing for school – increasing sophistication to think beyond themselves • Major Milestone: Cognitive Development

  10. Preschoolers: Milestones • Emotional/Social: the importance of friends and others outside of the family; gender differences • Language/Cognition: the written word as well as the spoken; moving beyond egocentricity; basic concepts – space, time, causality; rigidity?? • Motoric/Physical/Physiological: riding a bike and drawing real people; strong self care skills; gender identity

  11. Development: School Age • The impact of school – entering the “real” world – where things really count • Major Milestone: Cognitive Development

  12. School Age: Milestones • Emotional/Social: feelings/thoughts are important and relevant; self identity; control of feelings (dramatic exceptions); rules and rituals; the peer group and imaginary friends • Language/Cognition: moving from concrete to more abstract thinking; logic and reason; judgment and conscience • Motoric/Physical/Physiological: normally quite active (the need for speed)

  13. Development: Preteens and Teens • Integration of previous stages and solidification of identity • Major Milestone: Physical

  14. Preteens & Teens: Milestones • Emotional/Social: the peer group; consolidation of identity • Language/Cognition: abstract/future thinking (in theory) • Motoric/Physical/Physiological: one word: PUBERTY

  15. Development: When to worry • Delay of normal milestones without cause • A child seems “held up” at a particular stage and is no longer progressing • Red flags: marked withdrawal or social isolation, excessive fears/anxiety, disorganized communication; inappropriate impulsive or aggressive behavior • ANY CHANGE FROM YOUR CHILD’S NORM: YOU KNOW YOUR KID BETTER THAN ANYONE ELSE EVER WILL (Trust in the Force)

  16. ADHD: Common Characteristics • Common disorder, especially in males (prevalence 3-10%) • Accounts for most child mental health referrals- 6-10% of school age children • Initially children believed to “outgrow it”- 65-85% persists to adolescence • Approach teen differently than young child – new issues as decreased hyperactivity and increased impulsivity, inattentiveness continues and is more symptomatic • Genetic aspect to etiology- multiple genes involved, multiple brain regions involved • Environmental aspect to etiology- prenatal injury, low birth weight, prematurity, maternal smoking in pregnancy, cocaine use in pregnancy

  17. DSM 5 : ADHD • Pattern of inattention and/or hyperactivity-impulsivity for 6 months or more • Inattentive sx incl: failure to complete projects, poor organization, easily distracted • hyperactivity-impulsivity sx incl: fidgeting, excessive talking, difficulty waiting turn • Present before age 12, impairment in 2 settings • Presentations: predominantly inattentive, predominantly hyperactive-impulsive, combined • Rule out: PDD, psychotic ds, mood ds, anxiety ds, dissoc ds, personality ds

  18. ADHD: Potential Areas of Impairment • Academic Issues • Work/vocational issues • Injuries and legal issues • Social Setbacks and effects on self esteem • MVA and substance abuse 18

  19. Diagnostic Assessment • Child/Adolescent • Hx/MSE • PE (*neurological) • *Neuropsychological Testing • Labs, Dx studies, Rating Scales • Family/School • HX • Rating Scales (Vanderbilt, Conner, Child Behavior Checklist, Achenbach scales) • School records (behavioral and academic)

  20. DDx of Hyperactivity-Impulsivity • Anxiety Ds (incl phobias and OCD) • Mood Ds (esp mania in BPD) • Medication effects • Drug abuse/Toxin exposure (Pb) • Seizure disorder • Thyroid/Endocrine disorder • Tourette’s Syndrome • ADHD • ODD • CD • Ineffective discipline • Family and social disruption

  21. ADHD: Common Comorbidities • Other Psychiatric Disorders - Mood Disorders, Anxiety Disorders, other Disruptive Behavior Disorders • Learning Disorders and Language Disorders • Associated conditions: Tourette’s, OCD, Autistic Spectrum Disorders, FAS, Sleep Disorders, PSA, PTSD 21

  22. Bipolar Disorder • It is not rare: 0.7-1.0% incidence in teens • It can present early: peek onset between age 15-20 • Its course is usually episodic

  23. Manic Episode • abnormally and persistently elevated, or irritable mood for 7 days or more • additional symptoms include: more talkative, distractibility, psychomotor agitation • clinically significant impairment • rule out substance abuse, general medical condition; rule out mixed episode

  24. Differentiating ADHD and Mania • irritability in mania is more severe, often associated with violence -“affective storms” • previous history of depressive episode • family history of mood disorders • onset: ADHD before age 7, BPD usually after age 12 • course: ADHD is continuous, BPD episodic

  25. Treatment: How to Support the child with ADHD at Home • Parent training- a different approach to parenting • Family Organization/ Structure • Study Skills • Balance Between Academic Development, Athletic Development, Artistic Development and Social Development

  26. Treatment: How to Support the child with ADHD at School • Teacher consultation/paraprofessional or aide • Structure within the classroom- behaviorally based interventions with daily report cards • SST/ IEP/504/AB3632 and other acronyms- task and instructional modification, homework assistance, peer tutoring, computer-assisted instruction • Teamwork and collaboration

  27. Treatment: Supportive Treatments for ADHD • Cognitive behavior therapy- modify distorted cognitions, attention regulation • Target study skills (planning and organizing), social skills, sport skills/OT • Psychotherapy – individual/family/group - developing personal goals, decision making, problem solving, resiliency, affect regulation

  28. Treatment: Supportive Treatments for ADHD • Behavioral Interventions- time management, organization (environmental engineering), communication skills, assertiveness, frequent reinforcement, refocusing reminders • Life Skills training • Summer camp programs • Biofeedback, Mindfulness Training, Cognitive Mediation (CogMed)

  29. Treatment: Supportive Treatments for ADHD- Resources • CHADD - www.chadd.org • ADDA- www.add.org • AAP - www. aap.org • AACAP - www.aacap.org

  30. Treatment: Medications - Stimulants • Stimulants are mainstay- initially introduced in the 1960s; most extensively studied psychotropic medication • Methylphenidate – Ritalin, Ritalin LA, Ritalin SR; Concerta (18-72mg) ; Metadate CD, Metadate ER; Focalin; Focalin XR max 40-60mg q d • Dextroamphetamine – Dexedrine, Dexedrine Sp; Adderall, Adderall XR; Vyvanse max 40 mg q d • Side effects (common): anorexia, insomnia, irritability, tics

  31. Treatment: Nonstimulants • Atomoxetine (Strattera) • SNRI • Start 0.5 mg/kg/dy q am or bid • Target 1.2 mg/kg/dy q am or bid; max 1.4 mg/kg/dy or 100mg per day • Lower dose with SSRI • Side effects (common): headache, GI, somnolence, anorexia, dizziness

  32. Treatment: Nonstimulants • Buproprion (Wellbutrin, Wellbutrin SR, Wellbutrin XL); max 450mg q d – no single dose to exceed 150mg (IR) or 200mg (SR/XL) • Side effects: anorexia, insomnia, dry mouth, rash, night sweats, dizziness • Cautions/contraindications: h/o sz ds or eating disorders or head injury

  33. Treatment: Nonstimulants • Tricyclic Antidepressants – Imipramine – 20-100 mg daily • Sedation, weight gain, anticholinergic side effects, monitor cardiac functions • Clonidine – 0.05 – 0.3 (divided) mg daily; Tenex - .5 - 3.0 (divided) mg daily • Sedation, weight gain, monitor blood pressure • Kapvay – 0.1 – 0.3 mg (divided) daily; Intuniv - 1- 3 (divided) mg daily • Sedation, weight gain, monitor blood pressure

  34. Course/Prognosis • 2/3 will continue with signif problems, 1/3 with full syndrome as adults • Overactivity tends to decrease with time • Compensatory behaviors • Excellent response to medication and behavioral rx possible

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