Transcript Screening for Developmental and Behavioral Problems in Children

Screening for Developmental,
Behavioural, and Learning Problems
in Children
Roger Thomas, MD, Ph.D., CCFP, FCFP, MRCGP
Professor, Department of Family Medicine, University of
Calgary
Cochrane Collaboration Coordinator U of Calgary
Shirley Leew PhD, R. SLP, SLP(C) (for slides on language
impairments)
Goals: Using screening tools
1. Identify the prevalence of developmental, emotional and
behavioural problems in children.
2. Which screening tools have acceptable sensitivity and
specificity.
 Parental Evaluation of Developmental Status (PEDS)
 PEDS Developmental Milestones (PEDS:DM)
 Ages and Stages (ASQ)
[The Rourke Baby Record has no validity, reliability,
sensitivity or specificity data]
3. When children are identified as developmentally delayed,
what % is referred for expert help.
4. Is surveillance an acceptable screening tool.
Goals: Screening for specific problems
6. Motor Milestones
7. Adverse events of childhood
8. Positive parenting practices
9. Speech and language problems
10. ADHD
11. Adolescent depression
12. Tourette syndrome
What is the prevalence of parents’ concerns about their
child’s development? (n = 210,242 children)
37 studies: using the Parents Evaluation of
Developmental Status (PEDS)
12 countries: USA 18, Canada 4, Australia 4,
Philippines 3; UK, Malaysia, Indonesia,
Singapore, Tanzania, India, Spain, Thailand one
each
Parents’ concern
%
95%CI
High developmental risk
13.8
10.9, 16.8
Moderate developmental risk
19.8
16.7, 22.9
Parental Evaluation of Developmental Status (PEDS)
1.Please list any concerns about your child’s learning, development, and
behavior.
2.Do you have any concerns about how your child talks and makes speech
sounds?
3.Do you have any concerns about how your child understands what you say?
4.Do you have any concerns about how your child uses his or her hands and
fingers to do things?
5.Do you have any concerns about how your child uses his or her arms and
legs?
6.Do you have any concerns about how your child behaves?
7.Do you have any concerns about how your child gets along with others?
8.Do you have any concerns about how your child is learning to do things for
himself/herself?
9.Do you have any concerns about how your child is learning preschool or
school skills?
10.Please list any other concerns.
(Online version of these questions can be found at www.forepath.org)
Use the PEDS to ask about the child’s
skill repertoire
• As you ask about the negatives (parental concerns) on the PEDS,
then for each question ask positively for all the skills the child has:
This should provide a complete picture.
• Q2. Tell me all the words and sounds your child makes of any kind
• Q3. Tell me all the ways your child understands what you say
• Q4 Tell me all the ways your child uses his hands and fingers to do
things
• Q5. Tell me all the ways your child uses his arms and legs
• Q6. Tell me all the ways your child behaves that you like or concern
you
• Q7. Tell me all the ways how your child gets on with others
• Q8. Tell me all the ways your child has learned to do things for
her/himself
• Q9. Tell me what preschool skills your child has learned.
Parental Evaluation of Developmental
Status (PEDS)
• Sensitivity: 70-94% by age group (older age
groups high sensitivities)
• Specificity: 77-93% by age group
• 36 languages
• PEDStest.com From left hand margin choose:
1. Tools online: choose Trial of PEDS online then
choose CLICK HERE (30 days free or 10 trials)
2. The Book. Choose: Chapter 4. Measuring
Development and Behavior Including Tools (or
download free pdf)
PEDS Developmental Milestones
(PEDS:DM)
• Age range: birth to 8 years
• Domains: Fine motor, gross motor, social-emotional,
self-help, expressive language, receptive language,
reading and math (for older children)
• 6-8 items per age-range
• 5 minutes to complete
Based on:
• Brigance Inventory of Early Development – II (IED-II)
• Brigance Comprehensive Inventory of Basic SkillsRevised (CIBS-R)
PEDS Developmental Milestones (PEDS:DM)
• Normed on: 49,150 families in 38 US states
nationally representative of US population
census (ethnicity, High school education (e.g.
16% parents did not complete HS), language
spoken at home, gender, poverty
• Sensitivity: 75-87% by age group
• Specificity: 71-88 % by age group
PEDS Developmental Milestones
(PEDS:DM)
• Validity: sensitivity 85%, specificity 77%
compared to gold standard screens
• Test-retest reliability: 96%
• Interrater reliability: (by professionals) 81%
ACTIVITY with PEDS: Discuss with a
colleague
• the cases of 9 month old Robert Someone and
18 month old Ottilie Green
• Discuss the cases you submitted to PEDS
• Or go on line PEDStest.com and enter a case if
you haven’t already
ASQ: Ages and Stages Questionnaire (3rd ed)
• Sensitivity: 82-89% by age group
• Specificity: 77-92% by age group
• 30 questions: about developmental skills +
overall concerns (whereas PEDS asks about
parent concerns and PEDS:DM asks about
milestones)
• 30 items (5-8 pages for each age group)
ASQ: Ages and Stages Questionnaire (3rd ed)
• The complete questionnaire with Video shows
how to redefine items to reflect family’s
culture, create opportunities for child learning
and development, and promote positive
parent-child interaction
• Home visitor or video shows parents how to
complete
• $US 295 for kit so OK if you refer to a
psychologist who has this tool
ASQ: Ages and Stages Socio-Emotional (2nd ed)
• Sensitivity: 71-85% by 9 age groups
• Specificity: 90-98% by 9 age groups
• Domains: Self-regulation, compliance, communication,
adaptive functioning, autonomy, affect, interaction with
people
• www.agesandstages.com
• I checked costs on website 10 Dec 2016 : ASQ-3 complete
package US$1219.75, plus quarterly screening charges.
(ASQ-3 Questionnaires ($225); ASQ-3 User’s Guide ($50);
ASQ-3 Quick Start Guides (FREE); ASQ-3 Scoring and
Referral DVD ($49.95); Ages & Stages Questionnaires® on a
Home Visit DVD ($49.95); ASQ-3 Learning
Activities ($49.95); ASQ-3 Materials Kit ($295); ASQ Pro (1
year) ($149.95); ASQ Family Access (1 year) ($349.95)
ACTIVITY with Ages and Stages:
Discuss with a colleague
• Case for 30 month old you entered on the
Ages and Stages form (available on the
resident website)
• Use the same data with the Rourke (I have
abstracted the items testing 4 domains in the
attachment for the session)
Brigance Early Childhood Screens III
• Alfred Brigance spent 30 years developing these
screens and the PEDS is based on the most sensitive
items
• 8 forms for each 12 month age range
• Domains: Speech-language, motor, readiness and
general knowledge at younger ages, reading and math
at older ages, self-help, socio-emotional
• Sensitivity: 91%, specificity: 86%
• OK if the psychologist you refer to has paid the US$867
for the kit
• CONCLUSION: PEDS is the only nearly free EBM tool
Children tested with both PEDS and ASQ (334 children
12-60 months, 80 primary care providers, North Bay and Sudbury,
Ontario)
Test
Screening result
No
Developmental Sensitivity,
developmental delay
specificity
delay
PEDS ≥ predictive
concern
106
25
No concern
191
9
≥ failed domain
66
No concern
231
ASQ
95%CI
Sens 0.74
Spec 0.64
0.56, 0.87
0.59, 0.70
28
0.82
0.65, 0.93
6
Sens 0.82
Spec 0.78
0.65, 0.93
0.73, 0.83
Children tested with both PEDS and ASQ (334
children 12-60 months, 80 primary care providers, North Bay and
Sudbury, Ontario)
Children were tested on these detailed criteria
for developmental delay:
• Bayley Scales of Infant Development III
(children < 30 months)
• or Wechsler Preschool and Primary Scale of
Intelligence, 3rd ed., (children ≥ 30 months)
• Vineland Adaptive Behavior Scales, 2nd ed.
• Preschool Language Scale, 4th ed.
World Health Organisation Motor
Development Study
• Six gross motor milestones children 4 to 24
months Ghana, India, Norway, Oman, USA
• 90% achieved milestones in same sequence
• 4.3% no recorded hand-knee crawling (instead
bottom shuffling or tummy crawling)
Screening for motor development: World Health
Organisation Motor Development Study
Milestone
Average (months)
1st percentile (95%
CI)
99th percentile
(95%CI)
Sitting without
support
6
3.8 (3.7 to 3.9)
9.2 ( 8.9 to 9.4)
Standing with
assistance
7.6
4.8 (4.7 to 5.0)
11.4 (11.1 to 11.7)
Hands and knees
crawling
8.5
5.2 (5.0 to 5.3)
13.5 (13.0 to 13.9)
Walking with
assistance
9.2
5.9 (5.8 to 6.1)
13.7 (13.4 to 14.1)
Standing alone
11.0
6.9 (6.7 to 7.1)
16.9 (16.4 to 17.4)
Walking alone
12.1
8.3 (8.2 to 8.4)
17.6 (17.1 to 18.0)
Under-referral after screening (2083 mostly
African-American children, RCT by the US CDC of
developmental screening, 4 urban practices)
Screened
Identified
developmental
concern
With concern,
referred for early
intervention
With concern,
received
multidisciplinary
evaluation
(n=2083)
434 (21%)
253 (12%)
129 (6%)
Characteristic affecting referral to early intervention
Adj OR 95%CI
≥ 2 developmental concerns
3.15
1.89, 5.24
Special health care needs
3.16
1.24, 8.06
Developmental screening without staff support
0.44
0.27, 0.72
Usual care
0.45
0.25, 0.81
Can we over refer?
• 70% of children identified on PEDS with delay
but not confirmed on criterion screen were
found to have multiple psychosocial risk
factors.
• False positives are not the same as true
negatives: those who screen positive on initial
screens but developmental problems are not
initially confirmed, later are often found to
have multiple psychosocial/familial problems
Does surveillance miss problems? (95
children, Ohio primary care clinic)
• Surveillance: Nurse asks yes/no developmental questions,
enters in EMR
• Questions at 18 months:
• If ball is rolled to child, child rolls it back, not hands it back
• Walks up steps
• Drinks from regular cup (not one with spout)
• Vocalises and gestures
• Speaks 6-10 words
• Laughs in response to others
• Follows simple instructions
• Can point to ≥ body part when asked, without prompting
Does surveillance miss problems? (95
children, Ohio primary care clinic)
ASQ fail
ASQ monitor
ASQ Pass
Surveillance
concern
5
5
0
Surveillance no
concern
10
23
51
Screen for adverse events of childhood
(Chapman. Adverse childhood experiences…J Affective Disorders 2004;82:217-225)
Health Maintenance organisation, San Diego (n
= 9460 adults)
• Lifetime depressive disorder (28.9% females,
19.4% males)
• Lifetime depressive disorder: 18.5% if 0 ACEs,
61% if ≥ 5 ACEs)
• Mentally ill household member when growing
up (reported by 20% females, 15% males)
Adverse events of childhood
Adverse event
% females reporting
% males reporting
Emotional abuse
14
7
Physical abuse
29
32
Sexual abuse
24
15
Battered mother
13
11
Household substance abuse
28
22
Parental separation or
divorce
23
21
Criminal household
member
3.5
3.2
Positive parenting practices (US National
Survey of Children’s Health 2011/2012)
• 847,881 households contacted, 187,422 with
age-eligible children, 95,677 phone interviews
• Estimates 26% children 4 months to 5 years in
US at risk of developmental, social or
behavioral delays
Screen for positive parenting practices (US
National Survey of Children’s Health 2011/2012)
N (%)
% no/low risk of
delay
% moderate/high
risk of delay
Read to child 0 days/week
3.4
58.2
41.8
Read to child 7 days/week
52.6
76.8
23.1
Story telling/singing with
child 0 days/week
3.7
64.2
35.8
Story telling/singing with
child 7 days/week
55.9
75.7
24.3
Parent family meal with child
0 days/week
2.4
64.8
35.2
Parent family meal with child
7 days/week
60.1
74.2
25.8
Positive parenting practices
Score 0-5
20.9
62.4
37.6
Score 8-9
45.9
77.7
22.3
Screen for reading with child: Canadian Pediatric Society
Position Statement: Reach Out and Read (ROR)
• Parents want information from physicians about
learning
• 50% of parents who do not read daily would like to
discuss literacy with their physician
• Parents receiving Reach Out and Read are 4 - 10 times
more likely to read frequently (at least 3 days/week) to
their children. Effect greatest among poorest families
• Parents place more importance on reading to their
children when book is given by physician
• Preschoolers in ROR higher receptive and
expressive language scores on standardized tests
Canadian Pediatric Society Position Statement:
Development milestones of early literacy
Age
Motor function
Cognitive/social
ability
Interaction with
parents
6 to 12 months
Reaches for book.
Brings book to
mouth.
Sits in lap.
Holds head up
steadily.
Looks at pictures,
vocalizes, pats
picture.
Prefers
photographs of
faces.
Parents holds child
comfortably, faceto-face gaze.
Parent follows
baby’s cues for
‘more’ and ‘stop’.
13 to 18 months
No longer mouths
Holds book with
right away.
help.
Points at pictures
Turns pages, several
with one finger.
at a time.
May label a
Sits without
particular picture
support.
with a specific
Able to carry book.
sound.
Child gets upset if
parent won’t give
up control of book.
Child may bring
book to read.
If parent insists that
the child listen,
child may
insistently refuse.
Canadian Pediatric Society Position Statement:
Development milestones of early literacy
Age
18-36 months
3 years and older
Motor function
Turns one page at a
time.
Carries book around
house.
Holds book without
help.
Turns normal thickness
pages one at a time.
Cognitive/social
ability
Interaction with
parents
Names familiar
pictures.
Attention varies highly.
Asks for the same story
over and over.
‘Reads’ books to dolls.
Parent asks “What’s
that?” and gives the
child time to answer.
Parent relates book to
child’s experience.
Parent should be
comfortable with
fluctuating attention of
toddler.
Describes simple
actions.
Can retell familiar story.
Plays at reading,
moving finger from left
to right, top to bottom.
‘Writes’ name (linear
scribble).
Parents asks questions
like “What’s
happening?”
Parent validates child’s
response and
elaborates on them.
Parent does not drill
child, but shows
pleasure when child
supplies word.
Activity with a colleague
• Ask the colleague about parenting practices
used with a child they have observed; make
suggestions
• Maker suggestions to a hypothetical parent
about parenting and what reading a child
should be able achieve at different ages; make
suggestions
Screening for behavioural problems: Conner’s Parent
Rating Scale Revised (1998)
• Sample: 2200 students 3-17 years (average age 10
years), 200 schools throughout US and Canada
• Internal reliability: 0.85 to 0.92 (except psychosomatic
scale 0.75 to 0.83
7 scales:
 Oppositional
 cognitive problems
 hyperactivity-impulsivity
 anxious/shy
 perfectionism
 social problems
 psychosomatic
Activity with a colleague
• Imagine a child with a problem on one or
more of the 7 dimensions of Conner’s Parent
Rating Scale.
• Discuss what strategies the parent and you as
the family physician could use
Developmental Delay:
Developmental Domains
Neurological
Processes
Social
PPhysical/motorr
Language
Perception
Emotional
Cognitive
Identification of Speech and Language Concerns:
• Speech and Language delays are the most commonly
reported problems in early childhood
– Often 1st reported in complex delay and spectrum
disorders
– Gateway for early intervention
• Early intervention can ameliorate future disorders
and dysfunction
– Increase academic achievement
– Increase social success
• Strong association with life-long health outcomes
Normal language
• Semantics (understanding meanings of words)
• Morphology (capacity to change words
systematically – e.g. making plurals)
• Syntax (rules governing word order)
• Pragmatics (eye contact, interpreting nonverbal behaviours, interpreting
literal/nonliteral meanings of words, polite
requests, sustaining conversation topics)
Speech production
• Voice (respiratory support to vocal folds)
• Fluency (rhythm and rate)
• Speech intelligibility (coordinated articulation
of vowels and consonants) e.g. “b” uses lip
closure to stop and release flow through the
oral cavity, “m” is produced nasally
Normal Speech production in children
• 1 – 4 months; As laryngeal, oral and respiratory control develop, babies
produce pre-speech vowel-like sounds (cooing)
• 3 -8 months: definite vowel sounds, raspberries
• 5-10 months:
► sequential production of vowels and consonants (e.g. bababa);
► “m” “b” and ‘”p” may be produced as they are produced anteriorly in
the mouth and are easy to imitate
► may string together consonants and vowels in their own jargon
• By 8 months: language comprehension: Where is mummy? and infant will
turn to mummy
• 10-15 months : one true word
• 2 years: expressive vocabulary >>> 50 words, combine two words
Delays and Disorders of Speech and Language:
(1) Stuttering/speech dysfluency
• Prolongations in sounds in words, difficulty starting
(blocks), repetitions
Referral if
• dysfluency > 6 months
• tense pauses in speech
• blocks
• extraneous facial or body movements while talking or
trying to start speaking
• NOTE: In a typically developing child between 2-3 years of
age they begin to produce complex utterances & there may
be a period of “developmental dysfluency” with effortless
repetitions of syllables, words and phrases.
Delays and Disorders of Speech and
Language: (2) Childhood Apraxia of Speech
• Impaired volitional programming of speech
• Inconsistency in being able to produce speech
sounds from one moment to the next
• Speech may be limited to vowel sounds, difficulty
with consonants
• Lack of smooth transitions between sounds or
syllables
• Inappropriate inflection patterns
• Instead may point, grunt or hit
Childhood apraxia of speech: case
study (1)
• 8 year old has had 5 years of therapy with several speech
pathologists (>50 sessions) for childhood apraxia of speech
– parents assess as minimal progress
• FHx: Severe learning problems in children on one side of
the family
• Child has lots of programs: Lexia, Raz kids, Mathletics, IXL
math, spelling, with all of which he struggles +++
• I did a Medline search and found that many have very short
short-term memory (“I can’t remember”).
• The reason is he has Speech Apraxia because he has
minimal short-term memory. The solution is to switch to
activities that require minimal words to build confidence
Childhood apraxia of speech: case
study (2)
•
•
•
•
Whiteboard with activities (e.g. unload dishwasher)
Copy any instructions onto his tablet
Teachers dictate instructions/tasks onto his tablet
Buddy sits next to him in school and reminds him of
tasks/instructions
• Can’t remember what ice hockey coach says so have buddy
play next to him
• Can’t remember right from left so put bracelet on right
wrist)
• Prepare for a career using manual skills: woodwork,
construction toys, Fischer Technik (electrical trains and
constructions), www.artforkidshub.com ($2.99/week for
parent and child to paint together)
Delayed language without cognitive delay
(3) Specific Language Impairment (SLI)
•
•
•
•
•
•
•
•
•
In Kindergarten sample 5% of boys, 6% of girls
Limited expressive vocabulary development
Talking begins at about the same time as peers
May not understand age-appropriate commands
Smaller vocabulary, shorter utterances, omit grammatical endings, more
grammatical errors
Problems with inflection and word endings (morphology)
Difficulty with learning words incidentally (from context)
Difficulty generalizing word knowledge
29% of parents are aware of their child’s SLI
Difficulty with language, reading, and learning throughout school
• Not withdrawn
• Plays appropriately but at a level commensurate with language learning
• Normal age appropriate non-verbal problem solving skills and assembling of
age-appropriate puzzles.
• Risk for future emotional problems and for ‘acting out’
Cognitive delays and disorders in pre-schoolers
1. Limited receptive and expressive language
2. Poor problem-solving
atypical or delayed understanding of concepts such as object
permanence, means-end and recognition of functions of objects
3. Poor memory skills
reduced fast-mapping ability i.e., the ability to remember an event
after one instance of that event
4. Poor learning skills
reduced ability to acquire new skills or generalize old skills
compared to same age peers
5. Plays and interacts like a younger child
6. Atypical social skills
Poor ability to assess social cues and situations
Early identification of language, communication delays and
disorders
1. Low rate of babbling by 12 months
2. Low or no vocal imitating;
May seem to ignore people, doesn’t interact much
Inability to understand words that other babies understand
May ignore or seem to ignore instructions
3. Atypical production of speech sounds (abnormal vowels or
consonants)
Omits speech sounds
Produces unusual combinations of speech sounds
Unintelligible speech
A stranger should be able to understand approximately
>
>
>
>
25 % of what the child says by age one
50 % by age two,
75 % by age three, and
90 % or greater by age four.
Childhood milestones 0-5 years
(Oberklaid F. Is my child normal? Milestones and red flags for referral.
Australian Family Physician 2011)
Risk Factors
Biolgical: prematurity, low birth weight (< 1500 g),
birth injury, vision or hearing impairment, chronic
illness
Environmental: low parental education, parental
mental illness, social isolation, poverty
Community: poor quality services, lack of access to
services, poor housing
Multiple risk factors
Communication and language
Average age
Milestones
Social smile
6 weeks
Cooing
3 months
Turns to voice
4 months
Babbles
6–9 months
‘Mamma’/’Dadda’ (no meaning)
8–9 months
‘Mamma’/’Dadda’ (with meaning)
10–18 months
Understands several words
1 year
Speaks single words
12–15 months
Points to body parts
14–22 months
Able to name one body part
18 months
Combines two words
14–24 months
Speaks six or more words
12–20 months
Able to name five body parts
2 years
Has 50 word vocabulary
2 years
Uses pronouns (me, you, I)
2 years
Developmental milestones
(tasks)
Average age
Follows eyes past the midline
6 weeks
Smiles
6 weeks
Bears weight on legs with
support
3–7 months
Sits with support
4–6 months
Sits without support
5–8 months
Crawls
6–9 months
Puts everything into mouth
4–8 months
Pulls to standing position
6–10 months
First tooth
6–9 months
Walks holding on
7–13 months
Drinks from cup
10–15 months
Developmental milestones
(tasks)
Average age
Waves goodbye
8–12 months
Climb stairs
14–20 months
Turns pages
2 years
Scribbles
1–2 years
Uses a spoon
14–24 months
Puts on clothing
21–26 months
Buttons up
30–42 months
Jumps on spot
20–30 months
Rides a tricycle
21–36 months
Bowel control
18 months – 4 years
Bladder control (day)
8 months – 4 years
Clear hand preference
2–5 years
ADHD:
Worldwide prevalence:
3-17 years = 9.5%
12-17 years = 12%
>1/3 persist in adulthood (how many remain
undiagnosed in adulthood?)
Three types of symptoms
Inattentive type: at least 6/9 inattention behaviours
Hyperactive-Impulsive type: at least 6/9 of
hyperactive-impulsive behaviours
Hyperactive-inattentive type: at least 6/9
behaviours from both inattention and
hyperactive-impulsive lists
Should be present in at least two settings (home,
school)
ADHD symptoms: children
Symptom
Inattention
•Difficulty sustaining attention (except to video games)
•Does not listen
•Difficulty following multistep directions
•Loses things (e.g. school materials) messy locker, bookbag, or desk
•Easily distracted or forgetful
Hyperactiveimpulsive
•Squirms and fidgets
•Runs or climbs excessively
•Cannot play or work quietly
•Talks excessively
•On the go, driven by “a motor”
•Blurts out answers
•Cannot wait his/her turn
•Intrudes on or interrupts others
Dysfunction
at school
•Difficulty sitting still
•Easily overwhelmed
•Easily bored
•Speaks out in class
ADHD symptoms: Adolescents
Inattention
•Difficulty sustaining attention to reading or paperwork
•Poor concentration
•Difficulty finishing tasks
•Misplaces things (wallets, keys, mobile phones)
•Poor time management, works twice as hard for half as much
•Easily distracted or forgetful; scattered at home or work
Hyperactive •Inner restlessness
-impulsive •Fidgets when seated (drums fingers, taps foot, flips pens)
•Easily overwhelmed
•Talks excessively
•Self-selects active jobs or activities
•Impulsive decisions
•Drives too fast, impulsive risks
•Often irritable, quick to anger
Dysfunction •Teachers complain inattentive, lack of motivation, being overly social
at school
•Procrastination
•Missing assignments, poor grades
•Grades fall, avoids or cuts class or school
Does the child have other conditions associated
with hyperactivity?[Wolraich ML. ADHD among adolescents. Pediatrics
2005;115:1734-46.]
Summary based on 4 studies which followed
children into adulthood:
• Oppositional defiant*/conduct disorder**36%
• Anxiety disorder
36%
• Depressive/dysthmic disorder
48%
* Persistent negativistic, defiant, disobedient
hostile behaviours to authority figures
** Repetitive persistent pattern of violating basic
rights of others or major age-appropriate rules or
norms
How do parents rate the quality of life of the
child with ADHD?) [Dankaerts syst rev]
In 23 studies parents’ ratings were lower than
child’s self-rating:
• behaviour
• self-esteem
• role limitations
• mental health
• family activities, family cohesion
• impact on parental time
Activity with a colleague
• Invent ADHD symptoms for a 14 year old,
complete the SNAP and compute the
subscales.
Screen for effectiveness of treatment: Systematic
review of Rx for ADHD
(Chan Treatment of ADHD in adolescents: A systematic review. JAMA 2016;035(28):1997-2008.)
• Change in ADHD Rating Scale (administered by professionals (range 0-54)
Medication
Decrease in
Decrease in
p
scores (treatment scores (placebo
group)
group)
Methylphenidate
(Concerta)
-14.93
-9.58
0.001
Methylphenidate patch
(Daytrana)
-9.96
-6.53
<0.001
Mixed amphetamine salts
(Adderall XR)
-17.8
-9.4
<0.001
Lisdexamphetamine
(prodrug) (Vyvanse)
-18.3
-12.8
<0.006
Atomoxetine (nonstimulant)
-13.94
-5.95
<0.001
Screen for side-effects: Concerta
• Contraindications: anxiety, thyrotoxicosis,
hypertension, cardiomyopathy, structural cardiac
defects, epilepsy, bipolar, mania, drug abuse
• Safety not established in children < 6 years
• Adverse effects compared to placebo: headache,
insomnia, nausea, decreased appetite (also
insomnia, stomachache, irritability, dizziness,
weight loss, mild increase in pulse and Bp
• Dosage: (ages 6-18): start at 18mg, increase
through 27mg, 36mg, max 54 mg daily
Concerta (methylphenidate): Wilens (2006) RCT
(industry funded)
Measure
% Reduction on
Concerta
% Reduction on
Placebo
ADHD Rating
Scale
47
31
Clinician rating on
Child Conflict
Index: Very much
or much improved
51
33
Teen report
35
20
Screen for side-effects: Mixed amphetamine salts:
Adderall XR(d- and l- amphetamine in 3:1 ratio):
• Action: non-catecholamine sympathomimetic
amine. Action in ADHD unknown but thought to
block reuptake of norepinephrine and dopamine
in presynaptic neurons and increase release into
epineuronal space
• Contraindications: same as Concerta
• Side effects: same as Concerta
• Safety not established in children < 6 years
• Dosage: 5, 10, 15, 20, 25, 30 mg tablets. No
evidence better effect at > 20 mg/day (capsule
may be opened)
Amphetamines: Lisdexamfetamine
(Vyvanse)
Action: A prodrug which is converted to active
dextroamphetamine in bloodstream
Capsules: 20, 30, 40, 50, 60 or 70mg (capsule
may be opened)
Side effects: Same as Concerta
Screen for side effects: Strattera (atomoxetine); nonstimulant selective norepinephrine reuptake inhibitor
• CYP2D6: 7% Caucasians are poor metabolisers and will
have 10 fold higher area under curve and 5x higher
peak than extensive metabolisers. CYP2D6 inhibitors
such as paroxetine and fluoxetine will markedly
increase Strattera levels
• Contraindications: Same as Concerta.
• Side effects: Mania or psychotic symptoms in 0.2%
and suicidal ideation in 0.4% [FDA black box warning
for suicidal ideation]; headache, somnolence,
abdominal pain, nausea, decreased appetite, vomiting,
dizziness, rare hepatic failure
• Increased mydriasis so avoid in narrow angle glaucoma
Strattera dosage (max 100mg or 1.4mg/kg
whichever is less)
Weight (kg)
Step 1
(0.5mg/kg/day)
Step 2
(0.8mg/kg/day
Step 3
(1.2mg/kg/day
20-30
10mg/kg/day
18mg/kg/day
25mg/kg/day
30-44
18
25
40
45-64
25
40
60
65-70
40
60
80
Behavioral therapy for ADHD: focus on
adolescent daily functioning (Sibley MH. Child Psychol
Rev 2014)
• RCTs of group CBT: ADHD scale decreased by 9.11
points (Chan 2016)
• Web-based grade portals for daily grade entry
• Computerised car driving
• Motivational interviewing
• Daily checklists and behavioral contracts motored with
adult support (parents, teachers)
• Teen autonomy and self-efficacy by establishing
collaborative teen-parent relationships
• Teach teens ways to voice ways in which would like
more personal independence
ADHD in adolescents differs from
children
• Emotionally less mature, perform best with
younger children or adults who tolerate their
immature behaviours
• Easily frustrated, short fuse
• Cognitive problems of procrastination and
distraction, inability to complete projects may
present to parents and teachers as
behavioural problems
• Significant sleep disturbance
ADHD in adolescents
• Adolescents markedly under-report symptoms and
impairment
• Adolescents stop taking medications:
˃Pelham’s study reported of 87% who were medicated at
some time, 28% stopped by age 11, 68% by 15 years ˃
Thiruchelvam’s study found 48% stopped between 9 and 15
years
• Cessation linked to lack of explanation of ADHD and
medications by physician, fear of side-effects and persisting
symptoms
• ADHD have 2-5 fold risk of developing ≥1 additional
psychiatric disorder
• Enough information? Teachers provide in-class assessments
(1 hour/day contact) , but may be able to provide less
information about behaviour in hallways, cafeteria and
buses
Activity with a colleague
•
•
•
•
Advise the parent of a 14 year old with
impulsivity and hyperactivity about:
medication options
side effects
prescribe a starting dosage
Outline elements of focused behavioural
therapy you recommend
Screening for Adolescent Depression
(Lemstra M, et al. A Systematic Review of Depressed Mood and Anxiety by
SES in Youth Aged 10-15 Years. Can J Public Health March-April 2008: 125-129)
• Canadian national survey depression prevalence:
˃ 2.7% age 12-14
˃ 9.2% (95%CI 7.1 to 11.3) age 15-19
• 3 US population studies: depressive symptoms
may start at 12 and peak 15 to 17
• Ontario child health study:
˃ 16.1% of children with mental health disorders
receive mental health or social service attention
˃ 20% have one anxiety disorder
• Lower SES rate of depression 2 - 3 > higher SES
Preventing adolescent depression
(Merry SN, et al. Psychological and educational interventions for preventing
depression in children and adolescents. Cochrane Review 2011)
Time after
intervention
No of studies (n) Risk difference (95%CI)
Immediately after
intervention
15 (n = 3115)
– 0.09 (– 0.14 to -0.05)
p < 0.0003
3-9 months
14 (n = 1842)
– 0.11 (-0.16 to -0.06)
12 months
10 (n = 1750)
– 0.06 (-0.11 to -0.01)
24 months
8 (n = 1750)
-0.04 (–0.11 to 0.03)
Screening for Tourette Syndrome
•
•
•
•
•
Multiple motor tics with one or more vocal tics
Duration longer than 1 year
Onset is usually around 7 years
Tourette children have normal IQ range
Ask family and society to adjust to the child
rather than vice versa
• Screen for reactions of family members and
school: Calgary Tourette society provides free inservices in schools to teachers and pupils to
describe syndrome and best responses
Can Children Suppress Tics?
• Described as abnormal sensations in muscles
(like waiting for a sneeze you cannot suppress)
• May suppress tic for several minutes, with
great effort and some discomfort
• Suppression interferes with concentration on
schoolwork
• Tics wax and wane, affecting schoolwork from
day to day
Tourette Syndrome +
Most frequent additional syndromes in TS+:
• Attention Deficit Hyperactivity Disorder
• Obsessive Compulsive Disorder
• Social Skills Deficits
Neurological Storms in Tourette Syndrome (due to
dopamine surge)
• students with TS+ may have neurological
storms, which both parents and teachers find
very disturbing
• the student exhibits a loss of emotional
control often triggered by a minor event
• neurological storms are not temper tantrums.
They are involuntary and non- manipulative.
Often occur when students believe they are
alone and student is unaware of event
• Let child go to quiet room in school and wait
until neurological storm passes
Dr. Samuel Johnson 1709-1784
An individual with Tourettes Plus
Johnson’s literary achievements
• Wrote first major Dictionary 1746-1753 by
reading all the great works of literature after
Dryden, and identifying the best definitions in
literature
• wrote 58 Lives of the Poets (biographies and
critical appraisals of their poetry)
• His viewpoints are set out in brilliant essays in
The Vanity of Human Wishes, The Rambler (208
newspaper essays), The Adventurer, The Idler,
and Rasselas; wrote poetry in English, Greek and
Latin
Johnson’s tics
• Held his head towards his right shoulder and shook it
tremulously
• Rocked and seesawed his body, holding his head to the
right, and rubbing his left knee with his palm
• Boswell (his biographer) noted Dr. Johnson planned an
exact number of steps to enter doorways with the
correct foot. Then he:
 formed a triangle with his heels or toes
 held his hands up with fingers bent as if in cramp, or
against his chest like a jockey at full speed
 made a sudden and extensive stride across the

threshold
Johnson’s tics
• Mrs. Williams was a blind lady who lived with Dr.
Johnson and when he escorted on entering a
house he would whirl her about
• Made massive strides into rooms, smoothing the
carpet in the middle of the room
• Made massive straddles in the street
• Touched every post in street and then “he
hastened to rejoin waiting friends with an air of
great satisfaction” (fortunately he did not touch
people as is sometimes the case)
• When drinking tea, he stretched out his arm with
a full cup of tea in every direction, to the great
annoyance of neighbours and the imminent
danger of Ladies’ Court Dress
Conclusions
1. Screening with the evidence-based tools PEDS (or
ASQ ), PEDS-Milestones, Q-CHAT at regular intervals is
key for detection.
2. Nipissing and Rourke have no validity or reliability
data.
3. Surveillance finds few problems.
4. The key developmental domain is language skills.
Assessing language problems and providing prompt
therapy and reading help are very important.
5. Children’s gross motor skills develop worldwide with
the same median and 99%CI intervals.
Conclusions
6. The more adverse events of childhood a child has the greater the effect
on subsequent life career.
7. The more parenting skills parents learn the better the outcomes for
children
8. If the family physician provides books through the Canada Reads
program the parents are 4-10 x more likely to read to the child
9. ADHD causes major learning problems and is easily screened. Screen
for parent-child conflict and the child stopping medication
10. Adolescent depression is common, is multifactorial, causes in family
need treating, and needs sustained therapy.
11. There are no medications for the tics in Tourette syndrome. Comorbidities need treating. Free in-services at school can explain the
child’s behaviour to peers and teachers.
12. As a family physician you provide crucial assessment and support to
the child for the first 20 years of educational and life careers.