Transcript Understanding ADHD

ADHD – What helps
Linda S. Grossman, MD
Bureau Director,
Child, Adolescent and
Reproductive Health
Baltimore Co. Dept. of Health
ADHD – Diagnostic Criteria
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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
6 of 9 inattentive behaviors
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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
6 of 9 hyperactive/impulsive
behaviors
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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
Other things with similar symptoms
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Specific learning disabilities
Mental retardation
Anxiety disorders
Mood disorders
Oppositional defiant disorder
Autism spectrum disorders
Schizophrenia
More things with similar symptoms
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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
School Interventions for ADHD
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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
Educate regarding disorder
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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
Identify specific problems
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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
Identify specific problems
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Difficulty sitting still –squirmy
Often out of seat
Keeping hands to self
Oppositional or aggressive behaviors
Specific supports
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Match to the child’s specific problems
Examples of supports
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Preferential seating
Individual review of directions
Modification of assignments
Extra opportunities for breaks or movement
Extra organizational help
Assistive technology
Behavior plans
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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
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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
Point out and build on successes
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Focus on successes
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Help youngster figure out why he was successful –
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Gives child message that he can be successful
Easier to figure out what you did right than why you messed up
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
Encourage problem solving
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Everyone makes mistakes, key is how you go about
making things right or fixing problem
Steps in problem solving
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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
Other interventions
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For specific learning disabilities
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Carefully assess learning strengths and weaknesses
Take advantage of learning strengths
Address weaknesses with appropriate educational intervention
and supports
For depression and/or anxiety
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Counseling
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Reframing
Cognitive behavior interventions
Possible role for medication
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Depression meds do not work as well in children and teens
Interventions for oppositional
behaviors
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Have a limited number of clear rules
Enforce rules consistently and predictably
Select consequences
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Immediate or as close to infraction as possible
Time limited (and preferably of relatively short
duration)
Consider using natural or logical consequences
Oppositional behaviors and
conduct problems
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Avoid setting the youngster up
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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
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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”)
Organizational problems
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Use of routines
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Visual reminders
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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.)
Checklists
Cues
Color coding
Time lines – making sure to include time for the
unexpected glitches
Organizational problems cont.
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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)
Role for medications to treat ADHD
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Stimulant medications – for school age and
adolescents
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Highly effective
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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
Types of stimulants
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Methylphenidate family
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Ritalin
Metadate
Concerta
Methylin
Focalin
Dextroamphetamine family
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Dexedrine
Adderall
Vyvanse
Other med options
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Atomoxetine (Strattera)
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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
Other med options – not FDA
approved for this use
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Need to be given on regular predictable schedule
because of side effect issues
Alpha agonists
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Clonidine
Guanfacine (Tenex)
Antidepressants
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Welbutrin (not for those with seizures and bulimia)
Tricyclic antidepressants (safety margin is major problem)
Summary
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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