1. ADHD – What helps Linda S. Grossman, MD Bureau Director, Child, Adolescent and Reproductive Health Baltimore Co. Dept. of Health

2. ADHD – Diagnostic Criteria Sufficient behaviors in either inattentive category and/or hyperactive/impulsive category Symptoms for at least six months and beginning prior to age 7 years Symptoms in multiple settings by different observers Symptoms not better explained by another disorder

3. 6 of 9 inattentive behaviors Fails to give close attention to details or makes careless mistakes Difficulty sustaining attention in tasks or play Does not seem to listen Fails to finish school work or other tasks Difficulty organizing tasks Avoids tasks requiring sustained effort Loses things Easily distracted by external stimuli Forgetful in daily activities

4. 6 of 9 hyperactive/impulsive behaviors Fidgets with hands or feet or squirms Leaves seat often Runs about or climbs excessively Difficulty playing quietly “Always on the go” or acts like “driven by a motor” Talks excessively Blurts out answers Difficulty awaiting turn Interrupts or intrudes on others

5. Other things with similar symptoms Specific learning disabilities Mental retardation Anxiety disorders Mood disorders Oppositional defiant disorder Autism spectrum disorders Schizophrenia

6. More things with similar symptoms Unreasonable expectations for age Bright but bored Sleep deprivation Worry about situational things Domestic violence (witness or victim) Endocrine disorders Chronic medical conditions Side effects of some medications

7. School Interventions for ADHD Educate regarding disorder Identify specific problems youngster has and design supports to address those needs Make use of behavior plans Point out successes and help figure out why successful Encourage problem solving

8. Educate regarding disorder Helps to know what child can control and what he can’t Child still needs to follow rules, but modify punishment if impulsivity or distractibility was part of problem Planned misbehavior still should be punished as for any youngster

9. Identify specific problems – Attention span or easy distractibility – Organization problems – Getting started on work and/or finishing assignments – Handwriting problems – Difficulty with assignments requiring longer answers – Problems with projects or longer term assignments

10. Identify specific problems – Difficulty sitting still –squirmy – Often out of seat – Keeping hands to self – Oppositional or aggressive behaviors

11. Specific supports Match to the child’s specific problems Examples of supports – Preferential seating – Individual review of directions – Modification of assignments – Extra opportunities for breaks or movement – Extra organizational help – Assistive technology

12. Behavior plans Help provide extra structure Keep number of goals small (three or less) or highlight one goal of several to be the special focus for the week (perhaps with double points) For the plan to work, youngster must get reward at least 75% of the time – Modify interval at which assessed – Lower # points required to get reward or have different rewards for different # of points – Consider end of morning and end of afternoon rewards

13. Point out and build on successes Focus on successes – Gives child message that he can be successful – Easier to figure out what you did right than why you messed up Help youngster figure out why he was successful – – What did he do differently this time? – What did others do which helped him? Encourage him to try to use strategy again or to advocate for himself by asking others to provide identified helpful support

14. Encourage problem solving Everyone makes mistakes, key is how you go about making things right or fixing problem Steps in problem solving – Define the problem – Generate potential solutions (wild and inappropriate are OK here) – Evaluate potential solutions and select one to implement – Assess how solution is working – if not working, either figure out how to adjust it so it will work or go back and pick a different solution

15. Other interventions For specific learning disabilities – Carefully assess learning strengths and weaknesses – Take advantage of learning strengths – Address weaknesses with appropriate educational intervention and supports For depression and/or anxiety – Counseling Reframing Cognitive behavior interventions – Possible role for medication Depression meds do not work as well in children and teens

16. Interventions for oppositional behaviors Have a limited number of clear rules Enforce rules consistently and predictably Select consequences – Immediate or as close to infraction as possible – Time limited (and preferably of relatively short duration) – Consider using natural or logical consequences

17. Oppositional behaviors and conduct problems Avoid setting the youngster up – preventing misbehavior by preventing situation which often leads to misbehavior and/or redirecting early on is always better than letting a bad situation play itself out Provide a way out for youngster – give him a way to save face Give messages that you see the youngster having positive qualities – Adult messages about character (positive or negative) are very powerful! – Reframe into positives when possible (instead of “argumentative”, describe as “persuasive” or “a good debater”)

18. Organizational problems Use of routines – School materials in box by front door or in path to door – List posted near door of what special things need on what day (i.e. gym shoes, musical instrument, etc.) Visual reminders – Checklists – Cues Color coding Time lines – making sure to include time for the unexpected glitches

19. Organizational problems cont. Binder with a zipper Different color dividers (cover textbooks in matching colors by subject) Encourage re-organization of binder either daily or at least weekly Have a regular place to put papers taken out of binder (in case need later)

20. Role for medications to treat ADHD Stimulant medications – for school age and adolescents – Highly effective Any particular med works for approx. 75% One of the stimulants works for approx 90% – Good safety profile – Intermittent administration OK in terms of safety and effectiveness

21. Types of stimulants Methylphenidate family Ritalin Metadate Concerta Methylin Focalin Dextroamphetamine family Dexedrine Adderall Vyvanse

22. Other med options Atomoxetine (Strattera) – Norepinephrine re-uptake inhibitor – Not as effective as stimulants for most – Better choice for a few youngsters – Side effects similar to SSRI’s (depression meds) – Some risk of suicide ideation – Builds up in the system so must be taken daily but can be stopped abruptly

23. Other med options – not FDA approved for this use Need to be given on regular predictable schedule because of side effect issues Alpha agonists – Clonidine – Guanfacine (Tenex) Antidepressants – Welbutrin (not for those with seizures and bulimia) – Tricyclic antidepressants (safety margin is major problem)

24. Summary Environmental and behavioral interventions can be initiated without a diagnosis Tailor interventions to match specific problems Focus on positive strategies when possible Medication may help the child with ADHD be able to respond to the environmental and behavioral interventions