click to edit master title style 1 what is adhd? copyright © 2004 all rights reserved. prepared by...

Click to edit Master title style

1

What is ADHD?

What is ADHD?

Copyright © 2004 All rights reserved.

Prepared by Harvey C. Parker, Ph.D.www.myADHD.com


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Disclaimer

These slides and the accompanying presentation provide a general overview of strategies to manage attention-deficit/hyperactivity disorder (ADHD) and related conditions and do not constitute medical, psychological, educational, or legal advice. Please consult your own health care provider or other professional for specific advice.


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Finding Answers for ADHD

• What is ADHD?• How does ADHD affect daily living?• What causes ADHD?• What procedures are used to assess ADHD?• What treatments work best?• How can assessment tools, tracking tools, and

treatment tools from myADHD.com help families, practitioners, educators, and adults?

• How can teachers and parents help?


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What is ADHD?

• …A medical condition characterized by inattention and/or hyperactivity-impulsivity.

• …One of the most common mental disorders among children, affecting approximately 5 to 7 % of school-age children and about 2-5% of adults


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Prevalence in the United States

About 2 million children

About 5 million adults


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Prevalence World Wide

• Canada 3.8-9.4% kids • Australia 3.4% of kids • New Zealand 6.7% kids, 2-3% teens • Germany 4.2% children • India 5-29% children • China 6-9% children • Netherlands 1.3% teens • Puerto Rico 9.5% child & teens • Japan 7.7% children • Mexico approx. 5% children• Brazil 5.8% of 12-14 year olds


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Adult ADHD Remains Largely Undiagnosed*

85% Undiagnosed as an Adult

15% Diagnosed

*1999 analysis of a 1000 adult patient epidemiological database.Data on file, Lilly Research Laboratories.


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Three types of ADHD

1.ADHD, predominantly inattentive type

2.ADHD, predominantly hyperactive-impulsive type

3.ADHD, combined type

ADHD, NOS is a category for people who have some ADHD

symptoms, but not enough to meet full criteria for the condition.


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DSM-IV Criteria:6 of 9 Inattention Symptoms

• Fails to give close attention to details• Difficulty sustaining attention• Does not seem to listen• Does not follow through on instructions• Difficulty organizing tasks or activities• Avoids tasks requiring sustained mental effort• Loses things necessary for tasks• Easily distracted• Forgetful in daily activities


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DSM-IV Criteria:6 of 9 Hyperactive-Impulsive

• Fidgets with hands or feet or squirms in seat• Leaves seat in classroom inappropriately• Runs about or climbs excessively• Has difficulty playing quietly• Is “on the go” or “driven by a motor”• Talks excessively• Blurts out answers before questions are completed• Has difficulty awaiting turn• Interrupts or intrudes on others


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Other DSM-IV Criteria

• Developmentally Inappropriate Levels• Duration of 6 Months• Cross-setting Occurrence of Symptoms• Impairment in Major Life Activities• Onset of Symptoms/Impairment by 7• Exclusions: Severe MR, PDD, Psychosis• Subtyping into Inattentive, Hyperactive, or

Combined Types


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ADHD is Not a Problem of:

• Will power

• Inadequate parenting

• Lack of motivation

• Lack of intelligence

• Laziness


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ADHD is Not a Problem of:

• Will power

• Inadequate parenting

• Lack of motivation

• Lack of intelligence

• Laziness


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ADHD is a neurological disorder that impairs

• Regulation of attention• Regulation of motor activity• Regulation of impulsivity


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ADHD results in problems with

• Planning• Organizing• Starting and stopping activity• Managing behavior• Persisting on tasks• Problem solving• Working memory

These are called Executive Functions


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AAP Assessment Guidelines

• Diagnosis must meet DSM IV criteria• Evidence of symptoms and impairment must come

from parents or caregivers • Evidence of symptoms and impairment must come from

classroom teacher or other school professional• Assessment should include evaluation for co-morbid conditions• Rating scales designed specifically to assess ADHD symptoms

should be used in addition to narrative reports, observations, etc.

• Other diagnostic tests are not routinely used to establish presence of ADHD but may be used to discover other conditions


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Potential Areas of Impairment

Academic failure

Relationships

Legal difficulties

Smoking and SUD

Injuries

Motor vehicle accidents

Occupational/vocational


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• Dysfunction of dopaminergic and noradrenergic systems

• Dopamine and norepinephrine are important in drugs that treat ADHD

Arnsten AF. J Psychopharmacol 1997;11:151-62; Madras BK, et al. Behav Brain Res 2002;130:57-63; Russell VA. Behav Brain Res 2002;130:191-6; Solanto MV. Behav Brain Res 2002;130:65-71.

ADHD has a Neurobiological Basis


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How do you get ADHD?


20Faraone SV, et al. Child Adolesc Psychiatr Clin N Am 2001;10:299-316, viii-ix; Faraone SV, et al. Am J Psychiatry 2001;158:1052-7; MARK Web site.

Heritability estimate

0 0.2 0.4 0.6 0.8

Height

ADHD

Schizophrenia

IQ

Depression

Heritability Estimate

ADHD Is highly heritable


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Common Comorbid Diagnoses

0 10 20 30 40 50 60

Oppositionaldefiant disorder

Conductdisorder

Mood disorder

Anxietydisorder

Learningdisorder

Biederman et al. JAACAP 1996;35:343. Pliszka. J Clin Psychiatry 1998:59(suppl 7):50.Biederman et al. JAACAP 1999;38:966. Spencer et al. Pediatric Clin N Am 1999:46:915.


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How can we help people with ADHD?

Treatments for ADHD •Education•Medication•Behavior Modification•Classroom/Workplace Accommodations


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MTA Study—The Largest StudyComparing ADHD Treatments

Which ADHD treatments (or combination) work best?

1. Medication (MedMgt) vs. Behavioral Tx (Beh) vs. Combination (Comb) over the long term

2. State-of-art, intensive MTA treatments vs. standard care available in the community (CC), over the long term

See: http://www.myadhd.com/articles.html


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MTA Study—Treatment Groups

Four Treatment Groups (14 months)1. Medication alone (MPH dosed to last 12 hours)

2. Intensive behavioral treatment alone

a. over 30 sessions for parent training

b. 8 week summer program

c. behavior therapist for 12 wks in classroom

d. daily reports from school to home

3. Combined medication & behavioral treatment

4. Community-based care (control)

Source: MTA Study Group, Arch Gen Psych, 1999, 56, 1073-1086.


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MTA Study Results

All treatment arms found to be effective on an absolute basis

Medication + behavioral treatment

Medication alone

• Behavioral treatment alone • Community based treatment

Source: MTA Study Group, Arch Gen Psych, 1999, 56, 1073-1086.

Nearly equally effective and superior to:


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% “Normalized” at 14-Month Endpoint MTA Groups vs Classroom Controls

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100%

80%

60%

40%

20%

0%

Controls Comb Med Beh CC

Swanson, JM, et al. J. Amer Acad Child Adolesc Psychiatry , 2001; 40 (2); 168-179.

88%

68%

56%

34%

25%


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Commonly Used Stimulant Medications for ADHD

• Methylphenidate (MPH) Products• Ritalin short & mid-acting forms• Concerta long-acting • Metadate CD mid-acting • Ritalin LA mid-acting• Focalin mid-acting

• Amphetamine Products• Adderall mid-acting • Adderall XR long-acting• Dexedrine mid-acting spansule• Dextrostat mid-acting

Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+


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Commonly Used Non-Stimulant Medications for ADHD

• Nonstimulant Products• Strattera long-acting

• Other Nonstimulants Products• Wellbutrin long-acting• Tenex mid-acting• Clonidine mid-acting

Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+


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Efficacy of Medication for ADHD

• Improvements in core symptoms reduced hyperactivity reduced impulsivity improved attention

• Improvements in related symptoms reduced oppositional behavior Improved social relations improved academic performance


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Adverse Effects of Stimulants

insomnia decreased appetite weight loss headache irritability Stomachache rebound agitation or exaggeration of pre-medication symptoms as it

is wearing off

PrecautionsUse cautiously in patients with marked anxiety, motor tics or with family history of Tourette syndrome, or history of substance abuse. Don't use if glaucoma or on MAOI. Abuse potential particularly in tablet form.

Always consult your physician before using ADHD medications.


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Adverse Effects of Strattera

In children decreased appetite GI upset (can be reduced if medication taken with food) sedation (can be reduced by dosing in evening) lightheadedness

In adults insomnia sexual side effects increased blood pressure Precautions

Use cautiously in patients with hypertension, tachycardia, or cardiovascular or cerebrovascular disease because it can increase blood pressure and heart rate. Has some drug interactions. While extensively tested, short duration of population use.Always consult your physician before using ADHD medications.


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Using Medication Effectively

• American Academy of Pediatrics recommends that for treatment of ADHD physicians start with a low dose of medication and tritrate upward to find the optimal dose.

• Optimal dose is the best individualized response with minimal side effects.

• Have a system in place to monitor treatment outcomes to find the optimal dose and adverse effects.


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Your child’s educational rights

Students with ADHD are protected under three laws that serve disabled individuals:

•IDEA—Individuals with Disabilities in Education

•Section 504 of the Civil Rights Act

•ADA—Americans with Disabilities Act

Work with the child’s school to see if the child qualifies for special education or for an accommodation plan.


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How teachers can help

Teachers can provide accommodations in the classroom—for example:

Preferential seatingShorter assignmentsCloser supervisionClearer instructionsHelp in getting started on assignmentsCloser supervision of homeworkFrequent communication with parents/doctorsDaily report card programAllow time for movementExtra set of booksEnvironment with fewer distractions during tests


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How parents can help

Parents can help their child who has ADHD by doing the following:

Act, don’t yak when discipliningTake a disability perspectiveManage behavior at the point of performanceUse rewards and incentives more than punishments Work closely with the school Know what your child’s responsibilities are in schoolProvide close supervision for homeworkHelp your child stay organizedMonitor the child’s performance and let doctors knowFind the things your child does well and encourage themGet additional help for academic skill problems if neededLearn as much about ADHD as you canMaintain a good sense of humor


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Conclusions

• ADHD is a chronic condition that has significant affects on learning, behavior, socialization, and performance across the lifespan.

• Multimodal treatments work best and involve a combination of education about the condition, medication, counseling, behavior management, and school and workplace accommodations and interventions.

• Schools can provide special education or accommodations to students with ADHD who qualify for programs

• Teachers and parents can make adjustments to improve the performance and self-esteem of children with ADHD

• Enhanced communication among stakeholders (providers, parents, educators, adults with ADHD) can lead to maximum improvement.


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Resources

Children and Adults withAttention Deficit /HyperactivityDisorders (CHADD)www.chadd.org

Attention Deficit DisordersAssociation (ADDA)http://www.add.org/

Learning Disability Association ofAmericahttp://www.ldanatl.org/

American Academy of Child andAdolescent Psychiatry (AACAP)http://www.aacap.org/

American Academy of Pediatricswww.aap.org

A.D.D. WareHousewww.addwarehouse.com

myADHD.comwww.myadhd.com

http://www.myadhd.com/organizations.htmlSee:

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