ADHD in the Home: Interventions and Strategies

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ADHD in the HomeInterventions 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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Todays Schedule

• Diagnosis and Identification
• Comorbid disorders
• Treatment
• Behavioral Modification
• Medication
• Tools and Resources
• Questions

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What wont 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, contd

• 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 cont

• 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 cont

• 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/distortio
  ns of people and situations.

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Types cont

• 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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Amens 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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Amens 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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Amens 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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Amens 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
• Conners
• 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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Consequences
Reward Punishment
Positive ? behavior by something ? behavior by something
Negative ? behavior by - something ? behavior by - something
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Consequences examples
Reward Punishment
Positive Add TV time when no hitting Add chores when there is hitting
Negative Take away chore when there is no hitting Take away toy when there is hitting
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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 dont 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
• SSRIs
• 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, contd

• Half-Life 3-4 hours 6-8 hours for sustained
  release
• Its 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, contd

• 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 Tourettes 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
• Pharmacologycauses 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, contd

• Half-Life 10-25 hours
• Its 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, contd

• 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, Tourettes syndrome, and rarely,
  psychosis.
• GI Anorexia and weight loss, diarrhea,
  constipation.
• Growth inhibition

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Basic Elements of Atomoxetene

• Known as Strattera
• Pharmacologyworks via presynaptic
  norepinepherine transporter inhibition
• Preparations 10, 18, 25, 40, and 60 mg capsules
  .

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Atomoxetene, contd

• 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, contd

• 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
• Pharmacologycauses 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, contd

• Half-Life 2.2 hours
• Its 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, contd

• 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, Tourettes syndrome, and rarely,
  psychosis.
• GI Anorexia and weight loss, diarrhea,
  constipation.
• Growth inhibition

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Release Characteristics
Concerta Metadate CD Ritalin LA
Immediate Release 22 30 50
Delayed Release 78 70 50
Technology Oros Eurand SODAS
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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/hyp
  eractivity disorder. Pediatrics.
  20001051158-1170.
• 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 199492-93.
• 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/librar
  y/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.
  1997369(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 199492-93.
• 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 199492-93.
• National Institute of Mental Health. National
  Institutes of Health. Attention deficit
  hyperactivity disorderquestions and answers.
  Available at http//www.nimh.nih.gov/publicat/adh
  dqa.cfm. Accessed April 19, 2002.
• National Institute of Mental Health. National
  Institutes of Health. Attention deficit
  hyperactivity disorderquestions and answers.
  Available at http//www.nimh.nih.gov/publicat/adh
  dqa.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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• www.pembertoncounseling.com