ADHD: We know it when we see it*or do we?
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Transcript ADHD: We know it when we see it*or do we?
ADHD: We know it when we
see it—or do we?
Constance J. Fournier, Ph.D.
Clinical Professor
Texas A & M University
Goal
The purpose of this workshop is to
provide school nurses information about
ADHD and related diagnosis and the
opportunity to consider how to develop
or modify interactions with school faculty
or medical personnel in order to better
serve students with these diagnoses.
Objectives
1. The learner will be able to list the key types of
ADHD on a Venn diagram.
2. The learner will be able to list basic
interventions used in treating ADHD in lecture
notes.
3. The learner will be able to show overlaps
between ADHD and other DSM IV diagnosis on
Venn diagrams.
4. The learner will be able to discuss action plan
ideas to take back to their school to improve
mental health intervention within the school nurse
role.
Overview
ADHD and types of ADHD
Basic interventions with ADHD
ADHD and the typical comorbidity
ADHD and depression
ADHD and anxiety
Action plan
ADHD and types
Inattentive symptoms
Often fails to give close attention to details,
or makes careless mistakes
Difficulty sustaining attention in tasks or play
(rule governed behavior)
Does not seem to listen when spoken to
directly
ADHD and types
Inattentive symptoms continued
Does not follow through on instructions, fails
to finish tasks (not due to oppositional
behavior or inability to understand)
Difficulty organizing tasks or activities
Avoid, dislikes, reluctant to engage in
mental effort tasks
Often loses necessary things
ADHD and types
Inattention symptoms continued
Often distracted by extraneous stimuli
Often forgetful in daily activities
ADHD and types
Hyperactivity symptoms
Fidgets with hands, feet, squirms in seat
Leaves seat when remaining seated is
expected
Runs or climbs excessively; adolescents
report restlessness
On the go, driven by a motor
Talks excessively
ADHD and types
Impulsivity symptoms
Blurts out answers before the question is
completed
Difficult awaiting turn
Interrupts or intrudes on others (butting into
conversations or games)
ADHD and types
Inattentive type
Hyperactive-Impulsive type
Combined type
Helps to put on the tri Venn diagram
Diagnosed before age 7
ADHD types
inattentive
hyperactive
inattentive
ADHD interventions
Behavioral Interventions
Parent training
Reinforcing positive behavior
Positive interactions
Parent time outs
ADHD Interventions
Behavioral interventions
School interventions
Reinforcing positive behavior
Positive interactions
Self-monitoring
ADHD Interventions
Behavioral interventions
Student interventions
Self monitoring
Direct instruction in organization
Direct instruction in studying
Pre-corrections
Visual and verbal direction
Reinforcement of behaviors you want to see
ADHD interventions
Medications
Stimulants
70 years of study showing positive results with
minimal side effects
Note for school nurses: medication gaps
Non-stimulants
Appropriate for particular circumstances
ADHD interventions
Typical side effects
Reduced appetite
Sleep problems
Headaches
Stomach pain
Irritability
ADHD interventions
Atypical side effects (rare to very rare)
Health related problems—usually related to
undiagnosed issues such as heart defects
Hallucination and agitation-FDA indicates a
slightly increased risk
Non stimulants—verbalizing suidical
thoughts; liver problems
Extreme caution with pre-existing psychosis
or bipolar disorder; still can use if needed
ADHD interventions: Which is better?
Medication or no medication
research generally suggests medication
Behavioral intervention alone
Always the first step; however, research
suggests that behavioral intervention alone is
not sufficient
ADHD interventions: Which is better?
Behavioral and medication
Most suggest medication alone is most effective
Medication with behavioral intervention about
the same as medication alone
Behavioral intervention alone less effective
Issues with sampling, assessment tools, length
of time studied
Jury still out, but medication does seem to hold
up as effect alone or with behavioral intervention
ADHD interventions: Which is better?
What does not work
Special diets
Herbal supplements
Homeopathic treatment
Bio-feedback
Chiropractic adjustments
Auditory treatments
However, don’t negate placebo effects
ADHD and comorbidity
The big 3
ADHD and Learning Disabilities
ADHD and Oppositional Defiant disorder
20% to 40% or higher
20% to 40% or higher
ADHD and both LD and ODD
20% to 40% or higher
Big 3
ADHD
LD
ODD
Learning Disability
Significant discrepancy between
cognitive ability and academic
achievement
In Texas, greater than one standard
deviation (16 or more points)
Method two—preponderance of the
evidence
Oppositional Defiant Disorder
Actively refuses to comply requests
Deliberately annoys others
Angry and resentful of others
Argues often
Blames others for own mistakes
Oppositional defiant disorder
Few friends, loses friends
Constantly in trouble in rule governed
situations
Spiteful or revengeful
Touchy or easily annoyed
ADHD and depression
One out four adults with ADHD also has
symptoms of depression
Children with ADHD are three times
more likely to have depression as
compared with other children
ADHD and depression
Symptoms of depression
depressed, irritable mood
marked diminished interest or pleasure in
activities
significant weight loss/gain; failure to make
expected gains
insomnia or hypersomnia
psychomotor agitation or retardation
ADHD and depression
Symptoms of Depression continued
fatigue or loss of energy
feelings of worthlessness or excessive or
inappropriate guilt
diminished ability to think or concentrate or
indecisiveness
recurrent thoughts of death, suicidal ideation,
suicide attempt
ADHD and depression
Using the Venn diagram, put in the
symptoms of depression along with the
symptoms of ADHD
What is overlapping?
What is separate?
ADHD
Both
Depression
ADHD and depression
General types of depression
major depression (more than 2 weeks)
Dysthymia
symptoms of depression more often than
not
in children, symptoms for one year
Bipolar disorder
ADHD and depression
Bipolar disorder
Depression (typically) & mania
inflated self-esteem
decreased need for sleep
more talkative, pressured talk
flight of ideas
distractible with irrelevant stimuli
increased behaviors
excessive activities that are potentially dangerous
ADHD and depression
General Intervention for Depressive
disorders
affective information
activity scheduling
social skills training
problem-solving training
ADHD and depression
General Intervention for Depressive
disorders
self-instructional training: monitoring,
evaluating, rewarding
relaxation training
cognitive structuring/cognitive modeling
ADHD and Anxiety
About 30% of children with ADHD also
have symptoms of anxiety
Up to 40% in adults with ADHD also
have symptoms of anxiety
ADHD and Anxiety
Symptoms of Anxiety
excessive anxiety and worry more often
than not for 6 months
difficult to control the worry
ADHD and Anxiety
Symptoms of anxiety continued
restlessness or keyed up or on edge
easily fatigued
difficulty concentrating, mind goes blank
irritability
muscle tension
sleep disturbance (falling asleep or
staying asleep)
ADHD and Anxiety
Using the Venn diagram, put in the
symptoms of Anxiety along with the
symptoms of ADHD
What is overlapping?
What is separate?
ADHD and Anxiety
Types of Anxiety disorders
Separation anxiety disorder
Specific phobias
Social
Animal
Natural environment
Blood-injection-injury
Situational
Other (clowns or mascots)
ADHD and Anxiety
Anxiety disorders
Somatoform--multiple physical complaints
with no medical explanation
Obsessive-compulsive disorder
obsessions—thoughts, impulses, images that are
intrusive and excessive; person tries to ignore or
suppress with other thoughts or actions; selfknowledge that this is own thoughts
compulsions—repetitive behaviors driven to perform
to try to deal with obsessive thinking, but does not
work
ADHD and Anxiety
General Interventions for anxiety
disorders
Systematic desensitization
modeling
social skills training
problem-solving training
ADHD and Anxiety
General interventions for anxiety
disorders
self-instructional training: monitoring,
evaluating, rewarding
relaxation training
cognitive structuring/cognitive modeling
ADHD and Action Plans for Nurses
Role of the school nurse
Medication dispensing
Health monitoring
Liaison with medical professionals
Liaison with school faculty
Liaison with family
ADHD and Action Plans for Nurses
General actions
Need for Release of Information forms
Need for clear lines of communication
How is communication with medical
personal maintained?
How is communication with family
maintained?
How is communication with faculty
maintained?
We learn from others
Share with elbow neighbor what is done
in your school
Consider what you do
What works well
What needs to change
We will have chance to share with each
other
We learn from others
Sharing with each other
What works!
ADHD and Action Plans for Nurses
Making your own plan
Prioritize what you would like to do
Consider what resources you have
Consider what barriers you have
Time is ALWAYS a barrier
Money is rarely a barrier
Set up a timeline for yourself
Resources
www.chadd.org
www.help4adhd.org
Combined resources
www.nasponline.org
Children and adults with Attention Deficit Disorders
National Association of School Psychologists
www.ed.gov
Department of Education
Resources
www.nichcy.org
www.aap.org
American Academy of Pediatrics
www.apa.org
National information center for children and youth
with disabilities
American Psychological Assocition
www.aacap.org
American Academy of Child and Adolescent
Psychiatry
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