Attention Deficit / Hyperactivity Disorder (ADHD) Common Symptoms, Differential Diagnoses, and Treatment Options Dr. Rachel Andaloro Metrowest Neuropsychology ASHPAC meeting 3/17

ADHD One of the most common childhood disorders ADHD affects about 9% of American children from and about 4.1% of adults Average age of onset is 7 years of age Boys are four times more likely to be diagnosed than girls The number of kids being diagnosed with ADHD is increasing

DSM-V ADHD Criteria Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development ◦ Inattention: (≥6 of following symptoms have persisted for at least 6 months; for >17 years ≥ 5 are required)  Fails to give close attention to details  Difficulty sustaining attention in tasks or play activities  Does not seem to listen when spoken to directly  Often does not follow through

DSM-V Criteria cont. (Inattention) Difficulty organizing tasks and activities Often avoids/dislikes/reluctant to engage in tasks that require sustained mental effort Often loses things necessary for tasks and activities Often distracted by extraneous stimuli Often forgetful in daily activities

DSM ADHD Criteria cont. 2) Hyperactivity/Impulsivity: (≥ 6, for >17 at least 5) ◦ Often fidgets, squirms in seat ◦ Often leaves seat ◦ Often runs about or climbs ◦ Often unable to engage in leisure activities quietly ◦ Often on the go ◦ Often talks excessively ◦ Often blurts out an answer ◦ Often has difficulty waiting his or her turn ◦ Often interrupts or intrudes on others

ADHD Criteria cont. Several symptoms were present < age of 12 Symptoms are present in two or more settings Symptoms interfere with social, academic, or occupational functioning Symptoms are not better explained by another mental disorder (*mood disorder, anxiety, personality disorder, psychotic disorder, substance intoxication or withdrawal) Can be combined presentation if both domains are met or predominantly inattentive presentation if criterion 2 are not met or vice versa

Neuropsychological Assessment ADHD is diagnosed based on these criteria But, it can be difficult to tease out other possible etiologies without a thorough evaluation. Neuropsychological evaluation provides a thorough assessment of history as well as a broad measurement of overall cognitive functioning

ADHD and cognition ADHD is associated with deficits in executive functioning Executive functions affect many aspects of behavior Determine our development of strategies to approach, plan, or carry out cognitive tasks, monitor or regulate behavior Measure a broad range of cognitive functions, with emphasis on measures of executive skills

Other Possible Etiologies… NP eval is important in ruling in or out other disorders Depression and anxiety - associated with deficits in executive functioning, and can present with similar symptoms Underlying mood disorder? Other health issues? ◦ Lyme Disease Obtaining a thorough history is key in teasing these apart.

Comorbidities ADHD is often comorbid with other mental health disorders: ◦ Oppositional Defiant Disorder ◦ Conduct Disorder ◦ Autism Spectrum Disorders ◦ Learning Disabilities If co-morbid with LD, ADHD symptoms may be masking the LD (or LD may cause inattention)

Treatment Options for treatment: ◦ Behavioral interventions first ◦ Medication as a last resort

Medications 70% improve with use Amphetamines (Adderall, Dexedrin) Methylphenidate (Concerta, Metadate, Ritalin) Strattera (non-stimulant option) Clonidine and guanfacine (Intuniv): nonstimulant medicines approved to treat aggression and impulsivity not controlled by other ADHD medicines. Antidepressants (Vyvanse, Wellbutrin)

Medications cont. Stimulants may be related to slower growth in children. Most children seem to catch up in height and weight by the time they are adults. (medication holidays) Stimulants can be abused Can cause sleep disturbance Research has shown that these medicines, when taken correctly, don't cause dependence.

Behavior Modification for ADHD Preferential seating, additional time, separate room for quizzes and tests Be on time, sit in the front row (limits distractions) Work with ADHD coach, mentor / advisor to help establish a plan and organizational strategy Frequent, brief contact with mentor Audio record lectures- can be replayed in order to review missed information Continuous note-taking to increase attention to lectures Work closely with more organized students Attend after-class help sessions whenever possible

Behavior Modification cont. Provide simple instructions and repeat if necessary. Have child repeat information/ instructions back in their own words, to ensure understanding Gentle and repeated prompting/reminders to engage in tasks/remain on-task Coached to quietly talk himself though tasks, step-by-step, as a means to maintain focus and sequence tasks appropriately. Regular refresher breaks to help refresh and refocus (e.g., movement or water breaks), given before student becomes overwhelmed and starts to lose focus.

Behavior Modification cont. Consistent praise for periods of (for example) ten minutes or more, when child remains on-task. Consider other rewards at school and home for substantial periods of controlled and attentive behavior (including assignments successfully completed).

Organization ◦ Clean workspace ◦ Maintain planner and review notes with teachers to ensure that student has recorded each item and understands the purpose of each assignment. ◦ Checklist for materials ◦ Organized binder with sections devoted to each subject where hand-outs, notes, and assignments can be placed. ◦ Structure!

Oppositionality Time-out (approximately 5 – 10 minutes) in a quiet, supervised area (should not be able to use behavior as manipulation to avoid work) Student should be given one calm, but firm warning when becoming disorderly. ◦ If student does not heed warnings, there should be a consistent system in place for applying sanctions. The use of time-outs and/or taking privileges away for unruly behavior may be beneficial. Oppositional students tend to respond best to both high structure and high warmth. Consistent disciplinary procedures be followed at both school and home.

Positive Behavior Support Proactive rather than reactive approach Set basic and clear expectations for behavior ◦ Be safe ◦ Be respectful of others ◦ Be responsible for students own well-being Clear examples of what it means to meet these expectations in various contexts should be given. PBIS.org

PBS cont. Student should receive the most attention (and also praise) when meeting expectations. Respond to any negative behaviors with brief redirection in a calm but firm manner, by stating and optimally demonstrating the type of behavior you want to see instead.

PBS cont. Error corrections should be provided. ◦ Set expectations and pre-correct as much as possible. Monitor his response to the pre- corrections and provide reinforcement accordingly. ◦ Reward positive behaviors rather than punish negative ones (5:1 ratio) ◦ Praise and error corrections should follow a NORMS format (Neutral, Observation-based, Reliable, Measurable, and Supportive).

PBS cont. PBS approach should be extended into the home If significant externalizing behaviors persist despite consistent behavioral intervention, a therapeutic school setting may be of benefit. ◦ Provide emotional and behavioral support ◦ Individualized attention, smaller class sizes

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