ADHD and ASD: Everything you want to know about the A’s in School

1. ADHD and ASD: Everything you want to know about the A’s in School Judith Aronson-Ramos, M.D. www.draronsonramos.com

2. Overview • 5 -10 % of school age children will have a developmental or mental health concern affecting their functioning at school • ADHD and ASD of growing concern to teachers and parents • Recently published article from CA study 24 % of children 6-14 yrs with ADHD (includes a spike in minority children) • ASD now 1/88 up from prior estimates

3. Prevalence Statistics • Mental health problems affect 1/5 young people at any given time. (Department of Health & Human Services) • An estimated 2/3 of all young people with mental health problems are not getting the help they need. (Department of Health & Human Services) • Studies indicate that 1 in 5 children and adolescents (20 percent) may have a diagnosable disorder. • Estimates of the number of children who have mental disorders range from 7.7 million to 12.8 million. (Department of Health & Human Services)

4. Common Disorders • ADHD • Autism Spectrum Disorders – Autism, PDD-NOS, Aspergers Syndrome • Mood Disorders: Anxiety, Depression, OCD, Bipolar Disorder • Other problems of learning and behavior: LD, Tourettes, Selective Mutism, ODD and CDD

5. Joseph Biederman, M.D. - Harvard University

6. Medical Perspective • Training dictates treatment • Evidenced Based Medicine • Disciplines have different approaches: • Psychiatry • Developmental & Behavioral Pediatrics • Pediatrics • Neurology

7. The Principals of Medical Treatment – Developmental & Behavioral Pediatrics • Evidence based • Target symptom focused • Developmental Framework – stages of development, changes over time • Interdisciplinary collaboration • Family focused • Whole Child

9. I was trying to daydream, but my mind kept wandering I stopped to think, and forgot to start again

10. ADHD • DSM IV criteria – 6 Inattentive, 6 Hyperactive Impulsive, or Combined • Importance of impairment in more than one setting. • Consistency of observations between home and school. • Variability with age – young hyperactive and impulsive, older more inattentive and disorganized

11. Inattentive Symptoms - 6 • CARELESS • INATTENTIVE • DOES NOT LISTEN • NO FOLLOW THROUGH • DISORGANIZED • AVOIDS • LOSES THINGS • DISTRACTED • FORGETFUL

12. Hyperactive Symptoms Hyperactivity • FIDGETS • UP • RUNNING • NOISY • MOTOR • CHATTY

13. Impulsive Symptoms Impulsivity • BLURTS • CAN’T WAIT • INTERRUPTS

14. Additional Criteria • Some symptoms that cause impairment were present before age 13 years (new). Can begin as young as 4 years • Some impairment from the symptoms is present in two or more settings (e.g. at school and home). • There must be clear evidence of clinically significant impairment in social, school, or work functioning. • The symptoms are not due to a Pervasive Developmental Disorder, or other Mental or Neurologic disorder.

15. ADHD Trends • According to Medicaid data, the prevalence of attention-deficit/hyperactivity disorder (ADHD) diagnosis in adolescents ages 15 to 19 years increased from 0.45% in 1995-1996 to 2.47% in 2003-2004, a far larger increase than that observed for younger children. • The number of prescriptions for ADHD increased substantially, about 11.8% per year for the population overall. Between 2000 and 2005, prescriptions for pediatric boys increased 8.2% on average; the rate for pediatric girls increased 13.3%. • Among adults, prescriptions for ADHD treatment increased 18.1% among women and 12.6% among men. While more boys overall are treated than girls (a ratio of 2.96:1), the rates for girls are increasing faster. Among adults, men and women are treated at an equal rate, 0.8%.[1,2]

16. ADHD continued • Bias against girls • Bias for boys • Rule out confounding disorders vs co morbid disorders – LD, Anxiety, ASD, Neglect/Abuse, Family Dysfunction, BPD, and Low Cognitive Ability, ASD

17. Neurobiology • Neurobiological differences in children with ADHD leading to executive functioning deficits (organizing, planning, reasoning, attention) • Anatomic & Physiologic Differences in the Brain: Pre-frontal cortex – volume and perfusion; smaller right frontal lobe; connections between basal ganglia (movement) and other areas; overall decreased blood flow to certain brain regions • Dopamine and Catecholamine (NE) Transporter Genes • Research supports familial transmission

18. Treatment • Medication • Behavioral Intervention • Classroom Accommodations and Modifications • Psycho-education – teacher, family, peers • Maybe – Diet, Exercise, Neurofeedback, Working Memory Deficit Training

19. Medication Options - Stimulants • Stimulants – amphetamine or methylphenidate based • Methylphenidate – Concerta, Ritalin, Ritalin LA, Methylin, Methylin ER, Metadate CD or ER, Ritalin SR, Daytrana, Quillivant • Dexmethylphenidate – Focalin, Focalin XR • Amphetamine – Adderall, Adderall XR • Lisdexamphetamine – Vyvanse • Dexedrine – Spansules, Dextrostat

20. How do stimulants differ? • Delivery- sprinkle, patch, pump, liquid • Duration – 2, 4, 6, 8, 10, 12 hours • FDA Approval • Side effects • Unique pharmacokinetics

21. Non-Stimulants • Atomoxetine – Strattera • Alpha Agonists – Tenex/Intuniv/Guanfacince vs Clonidine/Kapvay • Why use a non-stimulant? Tics, anxiety, side effects, combination therapy, duration of action, age

22. Negative Effects • Tired • Hungry • Irritable • Wear off • Socially withdrawn • Tics • Aggressive

23. Positive Effects • Attentive • Calm, regulated, and compliant • Decrease in disruptive behaviors • Improved social functioning • Readiness to learn • Compliance

24. Unrealistic Expectations • Child • Parents • Teachers • Stimulants improve focus, not cognition • The Cure All for students with problems – academic, behavioral, social • 100% symptom resolution • New baseline has pitfalls

25. Other Factors in ADHD Treatment • Teens feel a loss of creativity and personality • Compliance with medication regimen • Need for boosters • Loss of efficacy • Overreliance on the medication vs. classroom interventions

27. THERE'S JUST A ONE-LETTER DIFFERENCE BETWEEN ARTISTIC AND AUTISTIC ASD - A Spectrum of Possibilities • THERE'S JUST A ONE-LETTER DIFFERENCE BETWEEN ARTISTIC AND AUTISTIC • "What would happen if the autism gene was eliminated from the gene pool? You would have a bunch of people standing around in a cave, chatting and socializing and not getting anything done.“ – Temple Grandin

28. Autism Spectrum Disorders • DSM IV Criteria • Pervasive Developmental Disorders – Autism, PDD-NOS, Aspergers, Retts, CDD • DSM V Criteria – social and communication problems combined need all symptoms plus rrbi • New terminology ASD – no more pdd-nos, aspergers or autism

29. Why so much ASD? • Diagnostic Substitution • Broadened Criteria • Broader Autistic Phenotype

31. Autism • 6 total from 1-3 at least 2 from 1 and 1 each from 2 and 3 • 1. Qualitative Impairment in Social Interaction (at least 2) • Nonverbal skills – eye contact, body posture, facial expressions • Peer Relationships – not developmentally appropriate • No Spontaneous joint attention • No social or emotional reciprocity 2.Qualitative Impairment in Communication • Delay or lack of language • Poor conversational skills • Idiosyncratic language • No make believe or imitation 3.Restricted and Repetitive Behaviors, Interests, or Activities: Preoccupations, Inflexible routines, Motor Mannerisms, Parts not the whole

32. Autism Spectrum Disorder Criteria

33. Additional Criteria for Autism • Onset prior to age 3 • Do not meet criteria for Retts or Childhood Disintegrative Disorder • PDD-NOS – sub threshold symptoms or atypical • Aspergers – no language delay and 2 symptoms from social domain and 1 from RRBI

35. PDD-NOS • Sub-threshold clinical symptoms per DSM criteria • Not necessarily less severe than autism cognitive abilities can range from high to low • Prognosis similarly varies dependent more on cognition, language, and behavior than diagnosis

36. Aspergers Syndrome • No language impairment • High cognitive ability - IQ from average to gifted • Must have a narrow area of interest or preoccupation can change over time • Despite intellectual advancement gaps in learning • Behaviors include: rigidity, black and white thinking, perseverating, anxiety, preference for sameness, poor social skills • Difficulty working in groups • Eccentric and quirky • Eye Contact may be atypical • Problems with transitions

37. DSM–IV criteria for the diagnosis of Asperger disorder • 1. Qualitative impairment in social interaction, as manifested by at least two of the following: • Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction • Failure to develop peer relationships appropriate to developmental level • Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people) • Lack of social or emotional reciprocity

38. 2. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: • An encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus • Apparently inflexible adherence to specific, nonfunctional routines or rituals • Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) • persistent preoccupation with parts of objects • This disturbance must be clinically significant, but without clinically significant language delay or delay in cognitive development or other skills

39. Final Criteria • This disturbance must be clinically significant, but without clinically significant language delay or delay in cognitive development or other skills • Every quirky eccentric person does not have AS

40. New Diagnostic Formulations • Autism Spectrum Disorder –DSM V

41. Rationale for ASD in DSM V • Differentiation of autism spectrum disorder from typical development and other "nonspectrum" disorders is done reliably and with validity • Distinctions among disorders have been found to be inconsistent over time, variable across sites and often associated with severity, language level or intelligence rather than features of the disorder.

42. Because autism is defined by a common set of behaviors, it is best represented as a single diagnostic category that is adapted to the individual’s clinical presentation by inclusion of clinical specifiers (e.g., severity, verbal abilities and others) and associated features (e.g., known genetic disorders, epilepsy, intellectual disability and others.) A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation; previously, the criteria were equivalent to trying to “cleave meatloaf at the joints”.

43. Autism Spectrum Disorder Aspergers Syndrome Autism PDD-NOS

44. From 3 domains to 2 Three domains of impairment will now become two: 1)     Social/communication deficits 2)     Fixated interests and repetitive behaviors Instead of 1.) Social 2.) Communication 3.) Restricted Interests Repetitive Behaviors

45. Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the symptoms of ASD, rather than defining the ASD diagnosis . Requiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivity Providing examples for sub domains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domains

46. The necessity for multiple sources of information including skilled clinical observation and reports from parents/caregivers/teachers is highlighted by the need to meet a higher proportion of criteria. RRBI- The presence, via clinical observation and caregiver report, of a history of fixated interests, routines or rituals and repetitive behaviors considerably increases the stability of autism spectrum diagnoses over time and the differentiation between ASD and other disorders.

47. MORE SPECIFIC EXAMPLES -Unusual sensory behaviors are explicitly included within a sudomain of stereotyped motor and verbal behaviors, expanding the specification of different behaviors that can be coded within this domain, with examples particularly relevant for younger children AG OF ONSET -Autism spectrum disorder is a neurodevelopmental disorder and must be present from infancy or early childhood, but may not be detected until later because of minimal social demands and support from parents or caregivers in early years.

49. For more information • www.dsmv.org • Publication in May 2013

50. Medical Treatment • Medications – ssri, stimulants, alpha agonists, atypical anti-psychotics • Therapies: ST, OT, BT, Education • Diet and Vitamins – antioxidants, probiotics, omega three fatty acids (published 2007), glutathione (in clinical trial) • Others with insufficient evidence: HBOT, Chelation, Stem Cells, Biofeedback, Neurofeedback, listening programs, hippotherapy, etc