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Attention deficit hyperactivity disorder (ADHD) is:

a neurological condition that involves problems with inattention and hyperactivityimpulsivity that are developmentally inconsistent with the age of the child.

Three Sub Types


Predominantly inattentive Predominantly hyperactiveimpulsive Combined

Criteria for diagnosis of ADHD


Must exhibit several characteristics to be clinically dia gnosed:

SEVERITY Behaviors(s) must occur more frequently in child than in other children at the same developmental stage:has to be a pattern! EARLY ONSET Symptoms must have been present for at least six months prior to evaluation and are present usually prior to age seven: has to be recurring IMPACT - Symptoms must have a negative impact on childs academic or social life SETTINGS Symptoms must be present in multiple settings: home, school, church camp, Sunday school, etc.

Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association, 1994.

DIAGNOSTIC CRITERIA (cont)


DISTRACTIBILITY IMPULSIVITY HYPERACTIVITY EXCESSIVE, LONG TERM, PERVASIVE CONTINUE AT LEAST 6 MOS. APPEARS BEFORE THE AGE OF 7 HANDICAP IN AT LEAST 2 AREAS OF LIFE

GENERAL INFORMATION

FIRST NOTICED BY MEDICAL SCIENCE IN 1902 ALL SOCIOECONOMIC, CULTURAL, AND RACIAL BACKGROUNDS AFFECTED 80% SHOW NO SYMPTOMS IN DR. OFFICE: may not be the best place to assess them. Child psychologist will screen, send summary to md, who will prescribe medication MOST ABOVE OR AVERAGE INTELLIGENCE VERY INCONSISTENT IN PERFORMANCE AND BEHAVIOR

PREVALENCE (CDC Statistics)

35% of school-age children have ADHD


(1999 Report of U.S. Surgeon General on Mental Health)

1.398 million (3%) and 2.330 million (5%) of school-age children with ADHD
(January 2001 General Accounting Office)

Mayo Clinic studies use 7.5%


(March 2002 Archives of Pediatric and Adolescent Medicine)

Boys 3 x more likely to be diagnosed with ADHD.

GENERAL INFORMATION

MORE OFTEN IN BOYS THOUGH GIRLS OFTEN UNDER-IDENTIFIED COMMON WITH OTHER DISORDERS ABOUT 50% HAVE MOTOR PROBLEMS 1/3 TO HAVE BLADDER CONTROL PROBLEMS: rt the fact that they're distracted 40% CHILDREN WITH LD ALSO HAVE ADHD 20-25% WITH ADHD ALSO HAVE Learning Disabilities: dyslexia, etc MOST HAVE SYMPTOMS AS ADULTS

Co morbidity
65%
of children with ADHD will have a co morbid condition Asthma-we treat w
corticosteroids which makes it worse

20-30%
will also suffer depression

50%
of youth with Bipolar Disorder have ADHD

60%
of those with Tourettes Syndrome have ADHD

50%
Of those with Tourettes Syndrome have Obsessive Compulsive Disorder

Other Co morbid Difficulties


Conduct Disorders Obsessive Compulsive Disorder Tourettes Syndrome

Drug Abuse

Anxiety Disorders

Sleep Disorders

Oppositional Defiant Disorder

Learning Disabilities

Additional Statistics

30% never finish high school 43% of untreated ADHD aggressive boys are arrested 75% of those in prison have ADHD 75% will have interpersonal problems 2 - 4% of adult population have ADHD Medically untreated ADHD leads to an increase in substance abuse as adults

Research findings

Biological factors

Brain imaging research has shown differences exist in brains of children with and without ADHD

Genetic influences

Family History Identical Twin Studies: not all twins will both get ADHD

NEUROBIOLOGICAL DISABILITY

IMBALANCE OF CERTAIN CHEMICALS IN THE BRAIN:


DOPAMINE NOREPINEPHRINE SEROTONIN

DECREASED ACTIVITY IN CERTAIN AREAS OF THE BRAIN CHRONIC USUALLY LIFE LONG

Research does not support


that these factors lead to ADHD:

Food additives Sugar Yeast Poor child rearing methods Excessive television viewing

A comprehensive evaluation
Behavioral Componen t

include s
Education al Componen t Medical Componen t

Behavioral evaluation

Specific questionnaires and rating scales are used to distinguish between children with and without ADHD and quantify behavioral characteristics Completed by different sources such as teachers and parents Observations of the child done in various settings by a teacher, nurse, social worker, or psychologist as well as rating scales can assist in diagnosing a child

Medical Evaluation

Assesses whether a child is manifesting symptoms of ADHD regarding: Inattention Impulsivity Hyperactivity Assesses the severity of these problems Gathers information about other disabilities that may be contributing to the childs ADHD symptoms

Educational evaluation

Assesses the extent to which the symptoms of ADHD impact on the academic performance in school Includes:

direct observations of the child review of academic productivity


assessment of completion of class work and homework both percentage of work completed and accuracy of the work are considered

Treatment Options
Pharmacologic al Approach

include

Behavioral Approach

Multimoda l Approach

Pharmacological approach

Medical profession prescribes meds school staff need to monitor 80% of students respond to treatment with stimulant meds May need to try various meds for best results All meds have side effects

Not everyone experiences side effects Often are temporary and subside after few weeks of treatment Need to be reported to parents and doctors

Medications begin to work

Antidepressants

4 6 weeks 30 60 minutes

Stimulants
Stimulants cause appetite suppression: growth restriction

Neuroleptics

2 4 weeks may have some earlier effect on certain symptoms such as aggression or sleep 3 6 weeks or longer depending on dose (need to obtain

Mood stabilizers/anti-

Multimodal approach

Multimodal treatment is a combined approach that includes the use of


Medication Educational Interventions Behavioral Management Training and Counseling for both parents and children

Results of NIMH Multimodal Treatment Study

Compared four interventions medication, behavioral intervention, combination of medication and behavioral intervention, and no-interventioo community care Found that combined medication/behavior intervention and medication treatment were significantly better than behavioral therapy alone or community care alone in reducing the symptoms of ADHD.

Untreated ADHD Impact on School Performance


Core Features

Effects missing assignment details miss information during lectures assignment organization difficulty

Inattention

Hyperactivity Impulsivity

verbal disruptions physical disruptions

hurriedly respond to questions make careless errors

Studies have found: lower average marks more failed grades more expulsions and suspensions increased dropout rates lower rate of college undergraduate completion

ANTIDEPRESSANTS
Examples:

Side Effects:

Celexa Lexapro Prozac

Remeron

Tofranil (Imiprimine) Wellbutrin Zoloft (Paxil and Effexor are rarely used in children due to recent FDA warnings)

Dry mouth Nausea Vomiting Headache Excessive sweating Weight gain/loss Tremor Constipation Dizziness Sedation Nervousness Diarrhea

stimulants
Examples:

Side Effects:

Amphetamine/Dextroamp het-amine- (Adderall) Methylphenidate (Ritalin, Concerta-long acting) Dexmethylphenidate (Focalin) Metadate

Headache Decreased appetite Weight loss Sleeplessness/insomnia Motor tics Palpitations

Non-stimulants

Dont cause agitation or sleeplessness Are not controlled substances and dont pose the same risk of abuse or addiction Have a longer-lasting and smoother effect than many stimulants, which can take effect and wear off abruptly

Side effects

Atomoxetine HCl
(Stratterra)

Upset stomach Decreased appetite, which may cause weight loss Nausea Dizziness Fatigue Mood swings

Mood stabilizers/anti-seizure
Side Effects:

Examples:

Depakote* Lithium* Tegretol* Topomax Trileptal

* Need blood level monitoring

Nausea Vomiting Hair loss Weight gain Tremor Constipation Diarrhea Headache Sedation*sleepy in class Acne Rash Bruising Sleep problems Blurred vision Ringing in ears

Neuroleptics
psychotics)

(previously called anti-

Examples: helping to
restore the balance of certain natural substances in the brain (neurotransmitters).

Side Effects:

Aripiprazole (Abilify) Risperidone (Risperdal) Quetiapine (Seroquel) Zyprexa

Dry mouth Headache Weight gain Constipation Sedation Anxiety Agitation Rapid heartbeat Urination problems Very low blood pressure

ANTI-hypertensives
Examples: Clonidine (Catapres) may be
most beneficial in children with ADHD, who are easily emotionally overwhelmed, are anxious, and have a low frustration tolerance Guanfacine (Tenex or Intuniv) given .5mg BID. regulates levels of the neurotransmitter norepinephrine; in the prefrontal cortex of the brain, it decreases sensitivity to distracting stimuli, and it therefore may help with

Side Effects:

Anxiety Constipation Dizziness Drowsiness Dry eyes/mouth Fatigue Headache Decreased appetite Nausea Nervousness Rash

ANTI-anxiety
Examples:

Ativan Klonopin Valium Xanax Usually doctors (child/adolescent psychiatrists) will use anti-depressants to treat anxiety in children as there is an increased risk of addiction and abuse in using anti-anxiety medications (benzodiazepines).

We really have a lot more in common with some of these people than we think!

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