Transcript ADHD: Is it AS Common as Everyone says it is? And if so

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
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)
Erikson’s Developmental Theory
Infancy (birth – 1 yr): Trust Adolescence (12-19 yr):
vs. Mistrust
Identity vs. Role Confusion
Toddler (1-3 yr): Autonomy Young Adults (20-30 yr):
vs. Shame
Intimacy vs. Isolation
Preschool (3-5 yr): Initiative Mid Adults (30-60 yr):
vs. Guilt
Generativity vs. Stagnation
School Age (5-12 yr):
Mature Adults (60+ yr):
Industry vs. Inferiority
Ego-integrity vs. Despair
Development: the Milestones
Emotional/Social
Language/Cognition
Motoric/Physical/Physiological
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
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)
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
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
Development: Preschoolers
Increasingly independent
Preparing for school – increasing
sophistication to think beyond themselves
 Major Milestone: Cognitive Development
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
Development: School Age
The impact of school – entering the “real”
world – where things really count
Major Milestone: Cognitive Development
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)
Development: Preteens and Teens
Integration of previous stages and
solidification of identity
Major Milestone: Physical
Preteens & Teens: Milestones
Emotional/Social: the peer group;
consolidation of identity
Language/Cognition: abstract/future
thinking (in theory)
Motoric/Physical/Physiological: one word:
PUBERTY
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)
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
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
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
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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)
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
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
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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
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
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
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
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 acronymstask and instructional modification,
homework assistance, peer tutoring,
computer-assisted instruction
Teamwork and collaboration
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
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)
Treatment: Supportive Treatments for
ADHD- Resources
CHADD - www.chadd.org
ADDA- www.add.org
AAP - www. aap.org
AACAP - www.aacap.org
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
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
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
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
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