Children and Adolescent ADHD

2 Child & Adolescent Attention Deficit Hyper Activity Disorder (ADHD) dreamstimefree_

3  Receives much media attention and controversy  Neuro-developmental psychiatric disorder  Impairs social, academic, family, and occupational functioning  In Canada: 5 – 10 % in youth; 3 – 5 % in adults  Associated with serious mental disorders: ›Learning Disability ›Conduct Disorder ›Oppositional Defiant Disorder ›Anxiety Disorders ›Major Depressive Disorder ›Disruptive Mood Dysregulation Disorder ›Intermittent Explosive Disorder Fast Facts: Child & Adolescent ADHD

4  Greater risk for: ›Poorer academic achievement ›Fewer friends ›Lower self-esteem ›Teen pregnancies ›Substance misuse/abuse ›Interpersonal difficulties  More prone to: ›Physical injury ›Accidental poisoning ›Traffic accidents Fast Facts: Child & Adolescent ADHD Upsidedown Vehicle by Bill Longshaw

5  More likely to: ›Score lower on achievement tests ›Repeat grades ›Suffer suspensions ›Have problems with school  Early treatment & effective therapies can help: ›Medications ›Psycho-education, and/or ›Behavioral Intervention Fast Facts: Child & Adolescent ADHD

6  Stan [Kutcher] is disruptive in class, he is always talking and has great difficulty sitting still  Stanley cannot settle down to do desk work – he is always fidgeting  Stanley is not getting his homework done, he forgets to take his work home or to bring his homework to school  Stanley’s grades do not reflect what he is capable of doing  Stanley is so disorganized that he will never be successful at anything Typical School Report Card Notes

7 3.Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? ›If YES – consider ADHD ›Apply the SNAP-IV 18 item scale ›Proceed to the Identification, Diagnosis and Treatment of the Child and Adolescent ADHD Module ADHD Screening Question Schoolboy Does Exam Papers

8 ADHD Screening Tool – Parent Version Does your teenager usually not finish things that he or she starts? Is your teenager not able to pay attention to things for as long as other teenagers? Does your teenager fidget or move around much of the time, even when he/she knows she should not? Is your teenager impulsive or does he/she act without thinking much of the time? Is your teenager’s behaviour causing him/her problems at home and at school? Have these difficulties been there for a long time (six months or longer)? Family by Master isolated images 8

9 ADHD Screening Tool – Youth Version Are you able to finish most things that you start within the time others expect? Do you have trouble paying attention to things that are not that interesting to you? Do you fidget or feel you have to move around much of the time? Do you often do things without thinking? Are you having problems at home or school related to your behaviour or because of trouble paying attention? Have these difficulties been there for a long time (six months or longer)? Question Or Doubt by Jeroen van Oostrom 9

10 1.Identification of child/youth at risk for ADHD 2.Methods for screening & diagnosis 3.Treatment template 4.Suicide assessment (for adolescents only) 5.Safety and contingency planning 6.Referral flags Key Steps for Treatment of ADHD to Children & Adolescents

11 Step 1: Identification of Risk for ADHD 11 Well established and significant risk effect Less well established risk effect Possible “group” identifiers (these are not causal for ADHD but may identify factors related to adolescent onset ADHD) 1.A previous diagnosis of ADHD 2.Family history of ADHD 3.Family history of mental disorders (affective, anxiety, tics or conduct disorder) 4.Psychiatric Disorder: Oppositional Defiant Disorder, Conduct Disorder or a Learning Disorder 1. Exposure to severe environmental factors (i.e., lead contamination, prenatal exposure of alcohol and cigarette, birth trauma, low birth weight, head injuries). 2. Psychosocial adversity such as maternal depression, paternal criminality, chaotic home environment, and poverty 3. Substance misuse/abuse (early onset of use including cigarettes and alcohol) 4. Head injury (concussion) 1.School failure or learning difficulties 2.Socially isolated from peers or behavioural problems at home and at school (including gang activity & legal problems) – accident prone. 3.Bullying (victim and/or perpetrator)

12  Check for patterns of: › Declining grades › Frequent lates/absences › Discipline concerns › Homework not completed › Concentration problems › Over-activity or inattentiveness  Confidentiality & informed consent › Speak with both child and parents › Easier for child to access care › Easier for parents to know what to expect Decreasing Bar Chart by jscreationzs If Child is High Risk…

13  Part of general health visits › Screen at regular visits › Screen teens during visits for contraception/sexual health issues › Presentation of ADHD symptoms may change over time  Younger children are more impulsive and hyperactive  Adolescents are less hyper, but have inner restlessness, impulsivity and inattention  Co-morbidity of ADHD › Anxiety, Opposition Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Learning Disorder › Consider possibility of one or more of these disorders Step 2: Useful Methods for Screening & Diagnosis of ADHD in the Clinical Setting

14  Child/Adolescent may show : › Inattention › Distractibility › Impulsivity › Hyperactivity  Requires health provider intervention › Differentiate between normal responses to circumstances or developmental changes in normal children › Use the “Distress versus Disorder” model Screening & Diagnosis of ADHD Freedigitalphotos Africa 31513qkoh8f72ro Approx. 65% of children with ADHD still meet diagnostic criteria during adolescence

15 3 Sub-categories Predominantly Inattentive 1. Predominantly Inattentive › 20 – 30% of children and adolescents with ADHD › Daydreaming, distractibility and difficulty focusing on a single task for a prolonged period Predominantly Hyperactive-Impulsive 2. Predominantly Hyperactive-Impulsive › 5 – 10% of children and adolescents with ADHD › Manifesting as a situational inappropriate and excessive motor activity such as fidgeting, excessive talking, impulsive actions and restlessness Combined Inattentive/Hyperactive 3. Combined Inattentive/Hyperactive › 60 – 70% of children and adolescents with ADHD › Manifesting as a combination of the above two subtypes Screening & Diagnosis of ADHD

16  No biological diagnostic tests for ADHD › Clinical assessments of:  Signs  Symptoms  Clinical History › Carry out evaluations over more than one visit  2 to 3 visits are often needed  No hurry for a diagnosis; Take Your Time Screening & Diagnosis of ADHD freedigitalphotos ID 33138y9acpx7jy3

17  Difficulty attending › Reading a storybook with parent, or coloring/drawing  “ Squirmy”  Difficulties “settling”  Very active, always on the go › Bumping into things/getting hurt  Parents refer to child as: › “Not listening” › “Zippy” › “Always running around” Clinical Findings for ADHD Early Childhood 3 – 5 years of age dreamstimefree_113773

18  Child may not persist long with most tasks › Particularly what they do not want to do  Parents report child: › Does not pay attention or listen › Is very forgetful or disorganized  Described as: › “Overactive”, “always on the go” & “cannot sit still”, › Acting out of turn › Blurting out in class › More evident in situations where attention is expected Clinical Findings for ADHD Middle Childhood 6-12 years of age Girl With Bunny by Teeratas

19  School reports, “…not living up to academic potential”  Difficulty with peers  Impulsivity & intrusiveness An active child does not mean ADHD Girls with ADHD may demonstrate inattentiveness, not hyperactive symptoms Clinical Findings for ADHD Middle Childhood 6-12 years of age

20  Easily distracted from tasks  Feelings of inner restlessness  Stopping short on tasks  Forgetful; fail to complete tasks  Fidgety  Difficulty with relationships › Many “breakups”  Impaired temper control  Impulsive decision making Clinical Findings for ADHD Adolescence 13 – 19 years of age Glamour by federico stevanin

21  Engage in “risky” behavior › At higher risk for traffic accidents  Considered “lacking maturity” for their age  Without treatment, exhibit signs of demoralization › Due to negative comments › “Nagging” from parents, teachers, adults and peers › Do not confuse demoralization with depression  May get involved in drug use and criminal behavior  School drop outs, especially with unidentified learning disability Clinical Findings for ADHD Adolescence 13 – 19 years of age

22  Not likely ADHD if : › Symptoms only in one setting › Not functionally impairing  ADHD type symptoms may be › Post Traumatic Stress Disorder (PTSD) › Consider PTSD as a diagnostic possibility in youth who exhibit ADHD symptoms for whom a significant traumatic event has recently occurred. Remember: ADHD prior to age 12. Screening & Diagnosis of ADHD Stressful by Danilo Rizzuti

23 Inquire about substance misuse/abuse - Including marijuana - Youth with ADHD may be more likely to use a variety of substances Specialist consultation for substance abuse & ADHD Youth ADHD Screening Q’s stockxchng ID