Housekeeping

2. Housekeeping • Bathrooms! • Questions • I can’t answer “my child…” questions. • The answer is “discuss with your pediatrician, psychologist, child psychiatrist.” • Evaluation forms

3. The Disorder(s)

4. What is ADHD/ADD? • Common disorder (3-7%) • Neurobiological, not “psychological” • Well-researched with broad agreement • Highly treatable, but serious chronic illness. • Poor outcome common without treatment.

5. What is ADHD/ADD? Problems with • Focus & attention (almost always) • Impulse control (usually) • Hyperactivity (sometimes) • Other associated problems

6. ADHD/ADD: Developmental • Measurement: Always have to compare child to peers. • Starts in early childhood. Most do NOT “grow out of it.” • Persists into adulthood but can become less disabling, especially with treatment.

7. Three types (DSM) • Attention Deficit Hyperactivity Disorder, Primarily Inattentive Type • Attention Deficit Hyperactivity Disorder, Primarily Hyperactive-Impulsive Type • Attention Deficit Hyperactivity Disorder, Combined Type

8. Three types & symptomsADHD, Primarily Inattentive Type (“ADD”) • Fails to give close attention to details; careless errors. • Difficulty sustaining attention. • Doesn’t appear to listen. • Trouble following instructions. • Disorganized/forgetful/loses things • Avoids/dislikes tasks • Spacey, slower paced, daydreamy

9. (A note about paying attention) • Attention span often fine in activities child finds interesting & fun. • Can child pay attention to not-so-interesting & fun stuff? • Good days/bad days.

10. Three types & symptomsADHD, Primarily Hyperactive-Impulsive Type (“ADHD”) • Fidgets, squirms • Difficulty staying seated • Runs/Climbs excessively • Difficultly being quiet when expected • Blurts out • Difficulty with “patience” • Interrupts/intrudes Note: Uncommonly seen with symptoms of inattention.

11. Three types & symptomsADHD, Combined Type (“ADHD”) • Has both sets (Inattention AND Hyperactivity/Impulsivity. Probably the most common type and certainly the most commonly diagnosed.

12. More common features • 2-4 year delay in overall maturity common. • Prone to other conditions (2 out of 3): Depression, anxiety, and especially learning disabilities. • Problems with sense of time. • Academic problems common. • Impulsivity a major source of problems & complications.

13. Causes? • Neurobiological basis • Precise nature unknown • Strong genetic connection • Genetic contribution to ADHD is almost as strong as the genetic contribution to height. • Sometimes related to nervous system damage • Birth, accidents, severe illnesses

14. Complications of untreated ADHD • School underachievement/failure • Depression • Poor relationships, including marriages • Substance abuse • Job problems • Social problems • Financial problems (underemployment & mismanagement • ACCIDENTS

15. Why is ADHD a disorder? • Accumulated scientific evidence that those with ADHD have a serious deficits/dysfunctions, compared to those without it. • Evidence that these deficits cause harm to the individual. • See: “International Consensus Statement on ADHD”, 2002.

16. Treatment

17. Treatment • Parent education about disorder • Parent training in managing it • Appropriate school interventions for child • Individual and family counseling • Medication

18. MTA Study: What works: Medicine vs. Behavior therapy

19. MTA: Medication treatment in study vs. Community • Subjects who received medication only in the study, did better than subjects who received medication in the “community care” group. • Better prescribing? Doses were higher and Rx more consistent and longer in duration.

20. Medications • Stimulants • Most common • Short acting vs. Long acting • Could say short, medium, long • In and out • Side effects • Addiction? • Recent safety concerns

21. Medications Stimulants • methylphenidate & variants (Ritalin, Ritalin LA, Concerta, Metadate, Metadate CD, Focalin, Focalin XR, Methylin). • DaytranaTM skin patch of methylphenidate • Adderall (now generic “mixed amphetamine salts”), Adderall XR • Dexedrine, Dexedrine Spansules • Vyvanse (lisdexamfetamine) • LiquADD (dextroamphetamine sulfate liquid)

22. Stimulant controversies Do stimulants cause substance abuse? • No. Accumulating evidence ADHD puts people at risk for substance abuse. • Most recent study: “Female adolescents with ADHD who receive stimulants had about a quarter of the risk for substance abuse and smoking as those not receiving stimulants.” (Wilens, Adamson, et al. Archives of Ped. & Adol. Med 2008;162(Oct.)

23. MTA: Growth suppression • Greatest in first year of treatment. • Decreased in 2nd year of treatment. • Absent in 3rd year. • Total growth suppression on average was less than 1 inch in the first two years, none after that. Awaiting longer-term follow-up.

24. Medication Strattera (atomoxetine HCl) • Non-stimulant • 2-4 weeks to get going & stays in system • Low side effects • Used in addition to stimulants in some. • Not used that much as only drug, but when it works, it works.

25. Controversies • Is it overdiagnosed? • Is medication overused? • Do “alternative” treatments work?

26. Overdiagnosis • A hypothetical cluster of human mental abilities: • Ability to focus attention appropriately • Ability to control one’s impulses • Ability to plan and organize • Etc.

34. Controversies • Is it overdiagnosed? • Is medication overused? • Do “alternative” treatments work?

35. Medication controversy • Based largely on myths and lack of knowledge. • Very little controversy among scientists and professionals. • Scientology campaigns aggressively against these medications. • The meds are largely safe and largely effective and are the most researched medications on the planet.

36. A common misunderstanding about diagnosis and treatment • “I don’t think Jason has it because ADHD is being overdiagnosed. I don’t think Jason should take medicine because these medicines are being overprescribed.” • EVEN IF OVERDIAGNOSIS AND OVERTREATMENT IS A PROBLEM, IT DOESN’T FOLLOW THAT JASON DOESN’T HAVE THE DISORDER OR NEED THE TREATMENT.

37. Controversies • Is it overdiagnosed? • Is medication overused? • Do “alternative” treatments work?

38. Alternative treatments with little or no scientific support • Diet or nutrition treatments (eliminations or additions) • Diet supplements • Homeopathy • Sensory integration therapy • Chiropractic treatment • EEG biofeedback • Cognitive or cognitive-behavioral therapy • Visual exercises • Psychotherapy to get at the “root of the problem”

39. Parenting

41. Parenting • There are no shortcuts or easy answers. • It can be hard.

42. Russell Barkley’s Principles (modified) • Give child more feedback & consequences, more frequently. • Use larger and more powerful consequences. • Use incentives before punishment. • Help with keeping up with time.

43. Russell Barkley’s Principles (modified) • Strive for consistency. • Act, don’t yak. • Plan ahead for problem situations. • Don’t personalize your child’s problems. • Practice forgiveness. • Take care of yourselves. • Use a solid discipline program

44. Best discipline program • Appropriate use of time-out • Acknowledging good behavior • Avoid corporal punishment • Parental control of parental anger

45. A solid discipline program • Breaking out of the “how many times have a I told you…” trap. • Basic strategy: • Give a clear command. • Give one warning for noncompliance. • Apply a consequence, like time-out.

46. Questions and maybe some answers

48. Teaching

49. Challenges in the classroom • Demand attention, talking out of turn, moving around • Trouble following instructions, especially when presented in a list. • Forget to write down homework assignments, do them, or bring completed work to school.

50. Trouble with operations w/ ordered steps (long division, solving equations.) • Problems with long-term projects. • Don’t pull their weight during group work and may keep group from accomplishing task.