Housekeeping

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Housekeeping

• Bathrooms!
• Questions
• I cant answer my child questions.
• The answer is discuss with your pediatrician,
  psychologist, child psychiatrist.
• Evaluation forms

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The Disorder(s)
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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.

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What is ADHD/ADD?

• Problems with
• Focus attention (almost always)
• Impulse control (usually)
• Hyperactivity (sometimes)
• Other associated problems

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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.

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DSM

• Disorders Usually First Diagnosed in Infancy,
  Childhood, or Adolescence
• Attention-Deficit and Disruptive Behavior
  Disorders
• Attention-Deficit/Hyperactivity Disorder
• Conduct Disorder
• Oppositional Defiant Disorder
• Disruptive Behavior Disorders, NOS

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Three types (DSM)

• Attention Deficit Hyperactivity Disorder,
  Primarily Inattentive Type
• Attention Deficit Hyperactivity Disorder,
  Primarily Hyperactive-Impulsive Type
• Attention Deficit Hyperactivity Disorder,
  Combined Type

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Three types symptoms ADHD, Primarily
Inattentive Type (ADD)

• Fails to give close attention to details
  careless errors.
• Difficulty sustaining attention.
• Doesnt appear to listen.
• Trouble following instructions.
• Disorganized/forgetful/loses things
• Avoids/dislikes tasks
• Spacey, slower paced, daydreamy

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(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.

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Three types symptoms ADHD, 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.

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Three types symptoms ADHD, Combined Type
(ADHD)

• Has both sets (Inattention AND Hyperactivity/Impul
  sivity. Probably the most common type and
  certainly the most commonly diagnosed.

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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.

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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

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Complications of untreated ADHD

• School underachievement/failure
• Depression
• Poor relationships, including marriages
• Substance abuse
• Job problems
• Social problems
• Financial problems (underemployment
  mismanagement
• ACCIDENTS

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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.

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Treatment
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Treatment

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

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Multimodal Treatment Study of Children with ADHD
(MTA)

• Huge multi-site study of ADHD treatment for
  combined (mixed) type.
• Follow-up data is available now at 2 years and 3
  years and now on year 12. 6- and 8-year data due
  soon.

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MTA Study What works Medicine vs. Behavior
therapy
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MTA Follow up

• After 2 years, combined treatment and med
  management still better than other treatments
  (but size of the difference was reduced.)
• After 3 years, all were still doing better than
  baseline, but differences among the groups were
  gone.

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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.

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Medications

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

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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)

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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 2008162(Oct.)

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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.

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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.

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Controversies

• Is it overdiagnosed?
• Is medication overused?
• Do alternative treatments work?

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Overdiagnosis

• A hypothetical cluster of human mental abilities
• Ability to focus attention appropriately
• Ability to control ones impulses
• Ability to plan and organize
• Etc.

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Controversies

• Is it overdiagnosed?
• Is medication overused?
• Do alternative treatments work?

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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.

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A common misunderstanding about diagnosis and
treatment

• I dont think Jason has it because ADHD is being
  overdiagnosed. I dont think Jason should take
  medicine because these medicines are being
  overprescribed.
• EVEN IF OVERDIAGNOSIS AND OVERTREATMENT IS A
  PROBLEM, IT DOESNT FOLLOW THAT JASON DOESNT
  HAVE THE DISORDER OR NEED THE TREATMENT.

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Controversies

• Is it overdiagnosed?
• Is medication overused?
• Do alternative treatments work?

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Alternative treatments with little or no
scientific support

• EEG biofeedback
• Cognitive or cognitive-behavioral therapy
• Visual exercises
• Psychotherapy to get at the root of the problem

• Diet or nutrition treatments (eliminations or
  additions)
• Diet supplements
• Homeopathy
• Sensory integration therapy
• Chiropractic treatment

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Parenting
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Parenting

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

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Russell Barkleys 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.

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Russell Barkleys Principles (modified)

• Strive for consistency.
• Act, dont yak.
• Plan ahead for problem situations.
• Dont personalize your childs problems.
• Practice forgiveness.
• Take care of yourselves.
• Use a solid discipline program

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Best discipline program

• Appropriate use of time-out
• Acknowledging good behavior
• Avoid corporal punishment
• Parental control of parental anger

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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.

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Questions and maybe some answers
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Teaching
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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.

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• Trouble with operations w/ ordered steps (long
  division, solving equations.)
• Problems with long-term projects.
• Dont pull their weight during group work and may
  keep group from accomplishing task.

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• Accommodations
• Instruction
• Behavioral Interventions
• Attitude/Relational

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Accommodations
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Seating

• Away from windows / door.
• In front of your desk unless that would be a
  distraction for the student.
• Watch for sources of distraction and move away.
• Sensory deprivation does not work!

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Delivery

• Instructions one at a time / repeat as necessary.
  Break down multi-part instructions.
• Mornings tend to be better.
• Use visuals charts, pictures, color coding.
• Assist with note-taking.

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Student Work

• Quiet area to work.
• Shorter packets of work. Divide long-term
  projects into segments / assign a completion goal
  for each segment.
• Reduce the number of timed tests/consider extra
  time.

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Student work

• Consider testing orally or filling in blanks.
• Show how to use a pointer or bookmark to track
  written words on a page.
• Let do as much work as possible on computer.
• Accept late work / give partial credit.

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Organization

• Make sure the student with ADD/ADHD has a system
  for writing down assignments and important dates
  and uses it.
• Master notebook, a three-ring binder with a
  separate section for each subject, and make sure
  everything that goes into the notebook has holes
  punched and is put on the rings in the correct
  section.
• Provide a three-pocket notebook insert for
  homework assignments, completed homework, and
  mail to parents (permission slips, PTA flyers).
  
• Color-code materials for each subject.
• Allow time for student to organize materials and
  assignments for home. Post steps for getting
  ready to go home.

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Time management

• Think of ADHD students as time-blind
• Not (necessarily) procrastinators

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Instruction

• Handouts

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Tips on behavioral intervention

• The more you call them out in class, the less
  they hear.
• Behavioral interventions as private as possible.
  Use nonverbal signals.
• Keep a disability perspective.