Transcript Medication Management 2.0

ADHD: Co-occurring
conditions and non-stimulant
medication
Jack Levine, MD FAAP
Commercial Interests
Disclosure
Jack Levine, MD, FAAP
I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s) and/or
provider of commercial services discussed in this CME
activity.
I do not intend to discuss an unapproved or investigative
use of a commercial product/device in my presentation.
Learning Objective
• Develop a deeper understanding of medication
management for children with ADHD + comorbidities, non-stimulant medication management
and practical behavior management tips
References
• AAP ADHD Guidelines
• M. Augustyn, B. Zuckerman, E. Caronna.
Developmental and Behavioral Pediatrics for
Primary Care
• R. Voigt, M. Macias, S. Myers ed. Developmental
and Behavioral Pediatrics. American Academy of
Pediatrics
Primary Care Advantage
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A longitudinal, trusting relationship with patients and their families
Unique opportunities for prevention of mental health problems
through anticipatory guidance at routine health supervision visits
throughout childhood
Opportunities to screen for psychosocial problems in both the
child and family
To intervene early, as symptoms are just emerging
The opportunity to recognize the barriers that often keep families
from seeking help for their children’s problems—conflict within the
family, denial, stigma, for example—and to address those
barriers, facilitating the child’s and family’s readiness to engage
in mental health care
To provide diagnostic assessment and treatment within the
medical home
To refer for care, as needed, in the mental health specialty
system
To monitor and coordinate that care as is done for children and
youth with other special health care needs
“Moving Mental Health Forward” Barb Frankowski, MD, MPH, FAAP Future of
Pediatrics AAP 2011
Comorbidities
ODD (30-60%)
Conduct disorder (10-50%)
Anxiety disorder (10-30%)
Learning disability 30%
• Dyslexia
• NVLD
Tic disorder 5-30%
Comorbidities
Autism
Depression
Bipolar/Mood disorder
Developmental coordination disorder
Speech/language disorder
Auditory processing disorder
3/10 items
ODD/CD
Anxiety/Depression
3/7 Items
Learning Disability
ODD
4/8 items
CD
3/14 items
Anxiety
3/7 Items
Non-stimulant medications
are less effective
Non-Stimulant Medication
• Non stimulants – generic name
o Will only fill short acting – uh oh!!
• Atomoxetine – no generic
o 10MG, 18MG, 25MG, 40MG, 60MG
o Start .5mg/kg and titrate up to 1.2 mg/kg
o Max 100mg – over 70 kg
• Guanfacine ER – Intuniv
o 1mg, 2mg, 3mg, 4mg q day
• Clonidine ER – Kapvay
o 0.1mg, 0.2mg
o BID
o Max 0.2 mg bid
• Monitor blood pressure
• Taper
Non-stimulants
Clonidine/Kapvay and Guanfacine/Intuniv
• Alpha-2A postsynaptic adrenoreceptor in the prefrontal cortex.
• Blood pressure and arrhythmia
• Fatigue
Atomoxetine - selective norepinephrine-reuptake inhibitor
• Black box warning
• GI symptoms and sedation
• Liver injury
• Appetite suppression
• Start with half the treatment dose (0.5 mg/kg)
• Arrhythmias
Treatment Failure
• 80% respond to stimulant medications.
• Switch to another stimulant or formulation if
necessary
• Inadequate dosing
• Lack of adherence – unrealistic expectations, side
effects
• Incorrect diagnosis
• Comorbid conditions
• True nonresponse to stimulants
Side Effects - AAP
Combination therapy
ADHD and coexisting problems
• Tourette syndrome
• Autism or other disabilities
• Epilepsy
• Depression, anxiety, OCD
Alpha-2 agonists
Atomoxetine
Selective Serotonin Reuptake Inhibitors
• May interact with amphetamines.
• DO interact with Atomoxetine
Ryan
• 8 ½ year old boy in third grade – at the first teacher
conference grandmother is informed that he is not
listening, disrupting class and way behind in his
academics.
• You review his record and remember that he received ST
through EI because of language delay and was in an
integrated preschool class because of behavioral
problems and language delay.
• When he started Kindergarten, he was evaluated and
found to have no problems except he was a “real boy.”
• He struggled academically in first grade but was “really
trying.”
• He became a behavior problem in second grade but
the school decided that he might mature in third grade.
• You rule out any medical causes.
Jack Levine, MD
Next Step(s)?
• Get Vanderbilt from school and grandmother
• Discuss psychosocial circumstances with GM
• Tell GM to talk to school about the need for a
psychoeducational evaluation
• Start low dose stimulant for probable ADHD
• Reassure the grandmother that everything will be all
right
Psychosocial and
Vanderbilt
• GM and GF have been caring for Ryan since he
was a baby. Mother and father both had
academic issues, temper problems, substance
abuse and father had been in jail for a short time.
Psychosocial and
Vanderbilt
• Vanderbilt from school is positive for ADHD,
combined, some anxiety, all academic areas are
problems and all performance items are problems.
• GM Vanderbilt is positive for ADHD, IA and some
impulsivity.
Thank God for
Grandmas!!
Next?
• Diagnose ADHD and begin stimulant medication
• Start thinking this may be ADHD and LD and start
stimulant medication
• This is just LD and refer for tutoring
• Refer for psychoeducational evaluation through
school
• Refer for psychoeducational evaluation privately –
we don’t trust the schools
We’re getting there!
• Finally get psychoeducational evaluation which
among other results shows:
• WISC-V Full Scale IQ of 84
o Verbal Comprehension Index of 75
o Working Memory Index 80
o Perceptual Reasoning Index of 102.
• WIAT: Reading comprehension is 70. Math
computation is 90.
• This child has a language based learning disability
AND ADHD.
Finally?
• This child will need an IEP with academic support
(modifications) and accommodations for ADHD
• This child will need Section 504 accommodations
only
• Start stimulant medication and follow
• Speak with child and GM and explain LD and ADHD
• Refer for behavior therapy/counseling
Modern view of LD – Voigt and Zuckerman
• Discrepancy vs. Low Achievement
o Discrepancy – old school
o Low academic achievement with at least low average IQ
scores
o Reflected in Individual with Disabilities Education Act (IDEA)
• Neurological (Brain) problem – heavy genetic
implications
• Life disability
• One or more learning disorders
• All levels of intelligence and is a persistent problem
• Persistent and chronic condition with lifelong
implications – “Poor Readers”
NOT a Transient Developmental Lag!
Over time, good readers and poor readers without intervention tend to
maintain their relative positions along the spectrum of reading ability.
Children who get off to a poor start in reading rarely catch up on their
own.
IDEA – Types of LD
• Oral expression
• Listening comprehension
• Written expression
• Basic reading skills decoding
• Reading fluency skills
• Reading comprehension
• Mathematics calculation
• Mathematics problem solving
Reading Disorder – Natural History
Children with poor oral
language skills in kindergarten
often become poor readers
A poor reader in 1st grade - more
than 88% are poor readers at the
end of 4th grade
74% of poor readers in 3rd grade
are reading disabled in the 10th
grade
Untreated Dyslexia
Frustration,
low selfconfidence,
and poor
self-esteem
More attention,
concentration
and energy
Reading is
unpleasant,
tiring, difficult
Shame and
loss of
motivation
Read less
Decreased
information
from reading
Decreased
fluency and
vocabulary
Subtypes of LD
Most children have problems in multiple areas of academic
achievement
ADHD and
LD
Screen for both
Secondary attentional problems
Comorbidity
Language
based LD
Lower language scores
Trouble with reading and written expression
Most experience in school systems
NVLD
Lower non-verbal scores
Math computation
Organization
Higher level math and science concepts
Social perception and interaction
Free and
Appropriate
Education
Individualized
Education
Plan (IEP)
Least
Restrictive
Environment
IEP
• Educational modifications
o
o
o
o
•
•
•
•
Resource room
Collaborative – integrated
Self-contained
Separate schools – special programs
Remediation vs. Compensation
Extended school year – 12 month program
Transition planning – 14 yrs.
Related services
o OT, PT, ST, counseling, social services
o Mental health services vary
• Augmentative devices
• Testing accommodations
Section 504 Accommodations
• Medical disability
• Major impact on life
• Accommodations in educational program – NOT
modifications
• Special programs and services
o Food allergies
o ADHD
o Diabetes
•
Tutoring, preferential seating, separate exam site, extended time on
testing, oral exams, keyboarding, aide, modified workload.
Response to Intervention - RTI
 Classified with LD when response to
validated intervention is inferior to peers
Tier 1
Tier 2
Tier 3
•Routine educational program
•Secondary prevention – small group tutoring –
“extra help”
Is it LD or
teaching style or
testing or
intervention?
•Tertiary intervention – multidisciplinary
evaluation – intensive, individual programming
 Scientifically based treatment
 Considerable state attitude – wide variability even within
districts
Improve self-esteem!
o
o
o
o
School performance
Social settings
Sports
Hobbies, additional activities
Psychoeducational evaluation
Academic strengths and weaknesses
Cognitive ability
• Abstract reasoning, problem solving, and learning style
Perceptual strengths and weaknesses
Communicative ability
Social and emotional capabilities
Psychoeducational evaluation
School system
Test choice is
up to examiner
Testing
personnel
• State and federal mandates
• IQ tests
• General learning abilities
• Academic achievement tests
• Perceptual and motor function
• Informal techniques
• Psychologists
• Special educators/LD specialists
• ST
• Social workers
• OT, PT
WISC-IV
Verbal
Comprehension
Index
Perceptual
Reasoning
• Information
• Similarities
• Vocabulary
• Comprehension
• Block design
• Picture concepts
• Matrix reasoning – fluid reasoning
Working Memory
• Digit span
• Letter-number sequencing
Processing Speed
• Coding and symbol search
Woodcock-Johnson
Reading
• Decode familiar and nonsense words
• Comprehension
• Retain information
• Answer questions in writing
Writing
• Spelling, grammar, punctuation, capitalization
• Content, organization, language quality
Mathematics
General
knowledge
• Computation
• Concepts
Kathy
• “Medication is making her worse!”
• Kathy is an 8 year old girl in second grade who you
started on methylphenidate last year after
reviewing her Vanderbilts which were positive for
ADHD, IA and nothing else.
• Utilizing the results of follow up Vanderbilts she
started second grade on MPH 5mg in the AM and
at lunch. The major complaint is that she is refusing
to do her homework.
Jack Levine, MD
What’s next?
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Get follow-up Vanderbilts
Get full Vanderbilts
Discuss symptoms in more depth
Switch to long acting MPH
Change stimulants
Refer for behavior therapy/counseling
• You ask for full Vanderbilts?
• While waiting for them to be filled out you find out
from the parents that she also bothers her siblings at
home and is having frequent temper tantrums over
the littlest things in the evenings and all day
Saturday and Sunday.
• No threats or any amount of discipline seem to be
working
Next?
Increase medication immediately – sounds bad
Let’s wait and see what the Vanderbilts look like
Refer for behavioral therapy – might be ODD
Give some behavioral techniques and schedule a
revisit
• Add non-stimulant
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•
•
•
• Vanderbilts are back – doing well in school – low
scores on 1- 18. Everything else is good. Grades are
somewhat of a problem – not handing in
homework.
• Parent Vanderbilts – annoying, temper tantrums,
spiteful, angry, etc.
ODD?
• Looks like ODD and ADHD but can’t be – school is
ok
• Looks like ODD and ADHD – increase stimulant
• Looks like ODD and well controlled ADHD – refer for
behavioral therapy
• Looks like ADHD and a poorly behaved child – tell
parents they need to be stricter and more punitive
• Looks like ODD and ADHD – explain the disorder
and the importance of treatment for everyone’s
sake.
ODD – 2%-15% of
children!
Pattern of noncompliant (negative) and defiant (hostile) behavior toward
authority figures.
•More verbal than physical
•Reactive to limits or frustration
•Problems in community, school, home or all three.
Before the age of 8 years
•More boys than girls before puberty then equal!
•Start to see in late preschool and early elementary
•Younger children need more frequent symptoms – differentiate from normal
May progress to CD
50% of children with ADHD have ODD
ODD – 4 Symptoms for at least 6 Months
Angry/Irritable
Mood
Argumentative/
Defiant Behavior
Often loses
temper
Often argues with
authority figures
or with adults (if a
child or
adolescent)
Often touchy or
easily annoyed
Often actively
defies or refuses
to comply with
requests from
authority figures
Often angry and
resentful
Often deliberately
annoys others
Often blames
others for his or
her mistakes or
poor behavior
Vindictiveness
Has been spiteful
or vindictive at
least twice within
the past 6 months
Aggression toward people and
animals
Destruction of property without
aggression
•Sexual
•Bullying
•Cruelty
•Arson
•Vandalism
Conduct
Disorder
Deceitfulness, lying, and theft
Serious violations of rules
•Running away
•Truancy
•Promiscuity
Major concerns!
Untreated Childhood-onset CD
• Substance abuse
• Risky sexual behavior
• Accidents
• Antisocial personality disorder - callous disregard of other persons and societal rules
Adolescent-onset CD
• Better prognosis with intervention
• Address social and academic intervention
• Do well as adults – especially if without aggression (stealing)
Comorbidity – 60%
• ADHD - 50%.
• Anxiety and depression – 33%
• Academic failure and learning disabilities
Jimmy
• You are seeing Jimmy, age 8, in third grade, for a
follow-up for otitis media
• Mother mentions that he runs out of time on tests
and has trouble paying attention in school.
• Additionally, he has been saying that he doesn’t
like school, gets nervous before tests and has been
somewhat resistant to getting ready in the morning.
• And BTW – he has been having trouble going to
sleep at night.
Jack Levine, MD
Next?
• Schedule an appointment to discuss the issues in more
depth
• Get Vanderbilts
• Refer to neurology and/or psychiatry or DPEDS
• Tell mother to ask teacher to give Jimmy more time on
tests
• Explain that it is normal for an 8 year old not to like
school
What’s Going On?
• Here are the Vanderbilts that you so intelligently
obtained before the next appointment
• They show criteria for ADHD, IA
• Anxiety with some low self-esteem,
• Problems in organization, peer relationships,
assignment completion.
• How are you going to figure out what is going on?
And?
Get detailed family history and school history
Refer to psychologist
Start stimulant medication
Administer the parent and child SCARED or another
screen for anxiety
• Tell the parents that the child has ADHD and that
explains all his symptoms
•
•
•
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Family History
• Heritability is 30-40%
• Environment
• Temperament – Behavioral inhibition
SCARED
• Child SCARED: 40 (anything over 25 is positive)
o Generalized anxiety disorder
• Parent SCARED: 34
• You now diagnose ADHD, IA and anxiety disorder.
• You explain each diagnosis and hand out parent
education material. What is your next step?
Anxiety and ADHD
• Prescribe stimulant medication and schedule
follow-up with Vanderbilts
• Refer to psychologist for behavioral counselling and
CBT for anxiety
• Prescribe Atomoxetine (stimulants can make
anxiety worse)
• Refer to DPEDS or psychiatry
• Advise parents to get section 504 accommodations
Anxiety Disorder - Zuckerman
• Generalized anxiety disorder
o Chronic and excessive worry in number of areas
o Difficult to control
• Separation anxiety disorder
• Social phobia
• Obsessive-Compulsive Disorder
o Intrusive thoughts that produce uneasiness, apprehension, fear, or
worry (obsessions)
o Repetitive behaviors aimed at reducing the associated anxiety
(compulsions)
• Panic attacks – any anxiety disorder
ADHD NON STIMULANT CASES
• Billy is an 8 year old who has moved into your area. He was
previously diagnosed as having ADHD with mild anxiety. His
Vanderbilt’s have shown 8/9 inattentive symptoms and 2/9
hyperactive/ impulsive symptoms in the past.
• He was followed closely by his previous pediatrician and were
receiving behavior management counseling. Billy had been
on Metadate CD with initially good results. As he got older, the
dose had to be adjusted and he began having anorexia,
stomach aches and trouble sleeping.
• His pediatrician switched him to Vyvanse in the smallest dose
which he could not tolerate because it worsened his anxiety
and sleep.
• Parents’ are at their wits end. They want Billy to make a good
impression at his new school and are concerned about his
now untreated ADHD.
• They come to you, their new physician for advice.
Alan G. Weintraub, MD
So….
• Try him on another Methylphenidate with a different
release pattern like Daytrana.
• Try him on Atomoxetine (Strattera) as this is a class
that has not been tried as of yet.
• Try him on another amphetamine like Adderall XR.
• Send him for CBT since medication doesn’t seem to
be working
ANSWER
• B. After two different stimulants have been used
with significant side effects, it is recommended to try
a non-psychostimulant.
• Atomoxetine is effective for ADHD primarily
inattentive subtype and will not cause the typical
stimulant side effects. However, you must counsel
the family that this will take longer to take effect
and titrate up slowly to avoid the common side
effects of nausea and potentially sedation.
• The effect size for stimulants is 70-90% and that of
Atomoxetine is 50-70%.
Charlie
• Charles is a 16 year old who just started his junior
year in high school. He has had a long history of
ADHD combined type and refuses to take his
psychostimulants any more.
• He is on first string for the football team and
although he was fine on his Vyvanse for years in
elementary and middle school, now that he is
playing varsity football, he doesn’t feel as
competitive on his psychostimulant as he does off.
He acknowledges that when he is off the Vyvanse,
his teammates think he is great fun, but he
constantly gets intro trouble.
Alan G. Weintraub, MD
You tell him:
• “Grow up” and take your Vyvanse before he gets
thrown off the team
• You discuss options like an alpha adrenergic ER
product such as Clonidine ER (Kapvay) or
Guanfacine ER (Intuniv)
• You discuss a Methylphenidate with him because
he hasn’t been on one since early elementary
school.
• You tell him he doesn't need medication anymore
because he is almost an adult, and he is
outgrowing the ADHD anyway.
Options
• Decrease Lysdexamfetamine (Vyvanse) dose
• Start Guanfacine ER or Clonidine ER – address
hyperactivity and impulsivity with 24 hour coverage
• Try another stimulant.
• Add long acting alpha adrenergic to lower
Vyvanse dose
• Role for atomoxetine?
• Engage Charlie as an active partner in his
treatment!
Matt
• Matt is a 12 year who has been diagnosed as having
Asperger’s syndrome. (by DSM IV!). He knows more about
dinosaurs than anyone else in the school.
• He has social communication issues because that’s all he talks
about.
• He can remember every genus and species of amphibians
but he can’t remember his homework assignment and cannot
concentrate long enough to write it down.
• He is very anxious with thunderstorms, loud noises and bugs.
He refuses to go outside in the spring and summer.
• His parents and teachers have filled out Vanderbilt reports
and he shows 7/9 inattentive criteria and 6/9 hyperactive /
impulsive criteria. You are deciding how to treat him.
• .
Alan G. Weintraub, MD
Decision?
• You put him on a long acting alpha adrenergic
because of his anxiety and OCD symptoms
• You start him on a small dose of stimulant and
repeat Vanderbilt follow-up forms in two weeks.
• You start him on Atomoxetine (Strattera) because of
his anxiety
• You start him on an SSRI for his anxiety at the same
time you start the stimulant so the anxiety “Won’t
get out of control”.
ANSWER
• NOT D!
• Stimulants are the first line of ADHD treatment even in
individuals with autism.
• Stimulants can sometimes exacerbate OCD behaviors,
rigidity and anxiety in those with autism. So none of the
first three choices are wrong. Follow closely.
• Try another stimulant.
• If that does not work then switch to a non-stimulant. You
can think of starting with a non-stimulant.
• If anxiety is overwhelming, then START with the SSRI and
treat the anxiety BEFORE you introduce a
psychostimulant. SSRIs DO NOT treat perseverative and
repetitive behaviors of autism.
• If you are comfortable with using two medications,
titrate ONE first to optimal response before you introduce
a second.
Chaim
• Chaim is now 9 years old. He is in 4th grade at a
local private school that has very limited support
services. He has been doing well on MPH ER 20 mg
for the past 2 years but now is having problems. His
grades are going down, he has been getting in
trouble and f/u Vanderbilts reveal increasing IA
and HA/Impulsivity
Jack Levine, MD
What to do?
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•
•
•
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Increase to MPH ER 30 mg
Switch to amphetamine
Switch to atomoxetine
Switch to guanfacine ER
Switch to clonidine ER
Uh Oh!
• Increase to MPH ER 30 and Chaim complains of
headaches, stomachaches, weight loss and
dizziness. He is too quiet in class and mother thinks
he may be depressed.
If a first….
• Go back to MPH ER 20 and try to get services in
school
• Switch to amphetamine
• Add atomoxetine
• Switch to atomoxetine
• Switch to guanfacine ER
Mother knows best!
• Amphetamines cause side effects and are not well
tolerated. Mother and child like MPH better – isn’t
there something that you can do?
What now?
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•
•
•
•
Try another MPH preparation
Switch to atomoxetine
Switch to guanfacine ER
Add guanfacine ER
Add atomoxetine
Two medicines!
• You add guanfacine ER 1mg to the MPH ER 20 and
titrate to 2mg. All is well but Chaim is tired during
the day and wants to stop all medication.
Solution?
Stop all meds and see how he is doing
Switch to atomoxetine
Give the guanfacine ER at night
Tell him to take naps when he comes home from
school
• Refer to psychiatry or DPEDS
•
•
•
•
Behavior
Therapy
Source:
Dr. Kelly Wesolowski
ADHD Expert, Ohio AAP Chapter
AAP CQN ADHD Project
Psychologist/Clinical Lead Supervisor
Nationwide Children’s Hospital Community
Behavioral Health
Practical Behavior Therapy
Tips
• Today you will learn about…
o How you can prepare families to participate in behavior
therapy
o Simple strategies you can teach a family in the context of a
visit
o Resources to provide to families
Before we begin, let’s
acknowledge…
• Finding good behavior therapists is challenging and
there is no great way to search for them
o However, there are a few options (note these are not exhaustive
lists)
• CHADD
(http://www.chadd.org/Support/Directory.aspx?state=111111
1)
o CAP-PC can help find resources
o Call therapists in your area
o Parent experiences
Before we begin, let’s
acknowledge…
• Access to care is a problem in most communities
and wait times for services are long (and by the
time families are in your office problems have
reached an unmanageable level and they want
help NOW)
• You can provide education to your families to help
them become good consumers of services (i.e., Ask
the provider what they know about ADHD and how
they treat it and make sure that it fits with an
evidence based model)
Why is Behavior Therapy
Important?
•
Treatment Sequencing for Childhood ADHD: A MultipleRandomization Study of Adaptive Medication and Behavioral
Interventions, Pelham et al, Journal of Child & Adolescent
Psychology, 2016
• Outcomes included:
o Beginning treatment with a low dose of behavior modification (8
group parent training sessions plus implementation of a daily
report card at school) resulted in significantly lower rates of
observed classroom rule violations relative to beginning with a
low dose of medication
o Adding medication secondary to initial behavior modification
resulted in better outcomes on parent/teacher ratings of
oppositional behavior than adding behavior modification to initial
medication
o Families’ rate of completing behavior therapy was higher if
prescribed initially (approx. 70% completed 6 of 8 sessions if
behavior therapy prescribed first as opposed to approx. 10%
when meds prescribed first)
• Plus, the AAP Guidelines say it is!
Behavior Therapy
Is…
• Action oriented
• Goal is to increase
desirable behaviors and
decrease undesirable
behaviors
• Uses principles of classical
and operant conditioning
• Rooted in social learning
theory – we learn from
our environment and
which behaviors were
reinforced/ignored in the
past
Is Not…
• Individual therapy for a
child
• Play therapy
• Teaching a kid how to
pay attention or be less
hyperactive
• Diving into the past to
explain current problems
(except when examining
antecedents and
establishing patterns of
reinforcement)
Behavior Therapy
Expectations
• Physicians can help families prepare for entering
therapy – Tell the therapist what you want!
• Families need to know:
o Most, if not all, of the work will be done with parents and
the therapist may ask that your child does not come to
session
o Discussion and problem solving will occur in session, but the
real work occurs outside of session. So do your homework!
o Consistency and regular attendance is important – most
behavior therapy can be completed with success in 8-12
sessions
Behavior Therapy and
ADHD
• Changing/modifying environmental demands and
structure at home and school
• Providing external reinforcement for completion of
tasks
• Incorporating parents and teachers as models of
skills and coaches
• Remember – ADHD is a “point-of-performance”
disorder. Kids have the skills, but they have trouble
executing them in the moment.
Changing/Structuring
Environment
• Work to eliminate distractions (i.e.,
during homework) and provide more
supervision
• Consistent and predictable home
routines
• Turn verbal information into visual
information by writing information
down – making notes, using checklists,
picture schedules
• Break tasks into small components –
single step directions
Providing External
Motivators/Incentives
• Kids with ADHD are not intrinsically
motivated…externalize it for them
• Set up home reward system (i.e., sticker chart,
tickets, tokens) to reward/reinforce specific
behaviors
• Classroom incentives including daily report card
(school/home note) to track specific behavior(s)
Daily Report Card
• What is a DRC?
o simple method of tracking specific target behaviors in the
classroom and communicating success to parents
o typically some sort of incentive is offered either through
school or home for a specific percentage of positive
ratings
o Pediatricians can help support families in establishing a
DRC and there are plenty of resources on the web
DRC Examples
Daily Report Card
Resources
• http://ccf.buffalo.edu/pdf/school_daily_report_car
d.pdf
• http://www.cincinnatichildrens.org/assets/0/78/106
7/2709/2807/2829/2835/2837/2839/7c419ba8-cb5c40ab-9285-e361ddd29c68.pdf
• Check out Pinterest for creative ideas
Additional Resources for
Pediatricians to Provide to Families
Barkley’s 14 Guiding Principles for Raising a Child with ADHD
https://dyslexia.wordpress.com/2007/07/03/14-guiding-principles-for-raising-achild-with-adhd/
CHADD Handouts for Parents
http://www.chadd.org/Portals/0/Content/CHADD/NRC/Factsheets/parenting201
5.pdf
http://www.chadd.org/Portals/0/Content/CHADD/NRC/Factsheets/Psychosocial
%20Treatments%20for%20Children%20with%20ADHD.pdf
Dr. Russell Barkley’s You Tube Presentation – 30 Essential Things Parents Need to
Know About ADHD
https://www.youtube.com/playlist?list=PLzBixSjmbc8eFl6UX5_wWGP8i0mAs-cvY
CHADD Online Parent to Parent Training
http://www.chadd.org/Training-Events/Parent-to-Parent-Program.aspx
**Note: This is not an evidence based intervention, but may be beneficial for
families where behavior therapy services are not available. Families are
encouraged to seek out evidence based behavioral intervention with a licensed
mental health provider as a first line treatment.
Questions?