attention deficit / hyperactivity disorder (adhd) common symptoms, differential diagnoses, and...
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Attention Deficit / Hyperactivity Disorder (ADHD)
Common Symptoms, Differential Diagnoses, and Treatment Options
Dr. Rachel Andaloro
Metrowest Neuropsychology
ASHPAC meeting 3/17
ADHDOne of the most common childhood
disordersADHD affects about 9% of American
children from 13-18 and about 4.1% of adults
Average age of onset is 7 years of age Boys are four times more likely to be
diagnosed than girlsThe number of kids being diagnosed
with ADHD is increasing
DSM-V ADHD CriteriaPersistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with functioning or development◦Inattention: (≥6 of following symptoms have
persisted for at least 6 months; for >17 years ≥ 5 are required) Fails to give close attention to details Difficulty sustaining attention in tasks or play
activities Does not seem to listen when spoken to directly Often does not follow through
DSM-V Criteria cont.(Inattention)Difficulty organizing tasks and
activitiesOften avoids/dislikes/reluctant to
engage in tasks that require sustained mental effort
Often loses things necessary for tasks and activities
Often distracted by extraneous stimuliOften forgetful in daily activities
DSM ADHD Criteria cont.2) Hyperactivity/Impulsivity: (≥ 6, for
>17 at least 5)◦Often fidgets, squirms in seat◦Often leaves seat◦Often runs about or climbs◦Often unable to engage in leisure activities
quietly◦Often on the go◦Often talks excessively◦Often blurts out an answer◦Often has difficulty waiting his or her turn ◦Often interrupts or intrudes on others
ADHD Criteria cont.
Several symptoms were present < age of 12Symptoms are present in two or more settingsSymptoms interfere with social, academic, or
occupational functioningSymptoms are not better explained by another
mental disorder (*mood disorder, anxiety, personality disorder, psychotic disorder, substance intoxication or withdrawal)
Can be combined presentation if both domains are met or predominantly inattentive presentation if criterion 2 are not met or vice versa
Neuropsychological Assessment
ADHD is diagnosed based on these criteria
But, it can be difficult to tease out other possible etiologies without a thorough evaluation.
Neuropsychological evaluation provides a thorough assessment of history as well as a broad measurement of overall cognitive functioning
ADHD and cognitionADHD is associated with deficits in executive
functioning
Executive functions affect many aspects of behavior
Determine our development of strategies to approach, plan, or carry out cognitive tasks, monitor or regulate behavior
Measure a broad range of cognitive functions, with emphasis on measures of executive skills
Other Possible Etiologies…NP eval is important in ruling in or out
other disordersDepression and anxiety - associated
with deficits in executive functioning, and can present with similar symptoms
Underlying mood disorder?Other health issues?
◦Lyme DiseaseObtaining a thorough history is key in
teasing these apart.
ComorbiditiesADHD is often comorbid with other
mental health disorders:◦Oppositional Defiant Disorder◦Conduct Disorder◦Autism Spectrum Disorders◦Learning Disabilities
If co-morbid with LD, ADHD symptoms may be masking the LD (or LD may cause inattention)
TreatmentOptions for treatment:
◦Behavioral interventions first
◦Medication as a last resort
Medications70% improve with useAmphetamines (Adderall, Dexedrin)Methylphenidate (Concerta,
Metadate, Ritalin)Strattera (non-stimulant option)Clonidine and guanfacine (Intuniv):
nonstimulant medicines approved to treat aggression and impulsivity not controlled by other ADHD medicines.
Antidepressants (Vyvanse, Wellbutrin)
Medications cont.Stimulants may be related to slower
growth in children. Most children seem to catch up in height and weight by the time they are adults. (medication holidays)
Stimulants can be abused
Can cause sleep disturbance
Research has shown that these medicines, when taken correctly, don't cause dependence.
Behavior Modification for ADHDPreferential seating, additional time, separate
room for quizzes and testsBe on time, sit in the front row (limits
distractions)Work with ADHD coach, mentor / advisor to help
establish a plan and organizational strategyFrequent, brief contact with mentorAudio record lectures- can be replayed in order
to review missed informationContinuous note-taking to increase attention to
lecturesWork closely with more organized studentsAttend after-class help sessions whenever
possible
Behavior Modification cont.
Provide simple instructions and repeat if necessary.
Have child repeat information/ instructions back in their own words, to ensure understanding
Gentle and repeated prompting/reminders to engage in tasks/remain on-task
Coached to quietly talk himself though tasks, step-by-step, as a means to maintain focus and sequence tasks appropriately.
Regular refresher breaks to help refresh and refocus (e.g., movement or water breaks), given before student becomes overwhelmed and starts to lose focus.
Behavior Modification cont.
Consistent praise for periods of (for example) ten minutes or more, when child remains on-task.
Consider other rewards at school and home for substantial periods of controlled and attentive behavior (including assignments successfully completed).
Organization◦Clean workspace
◦Maintain planner and review notes with teachers to ensure that student has recorded each item and understands the purpose of each assignment.
◦Checklist for materials
◦Organized binder with sections devoted to each subject where hand-outs, notes, and assignments can be placed.
◦ Structure!
OppositionalityTime-out (approximately 5 – 10 minutes) in a quiet,
supervised area (should not be able to use behavior as manipulation to avoid work)
Student should be given one calm, but firm warning when becoming disorderly. ◦ If student does not heed warnings, there should be a
consistent system in place for applying sanctions. The use of time-outs and/or taking privileges away for unruly behavior may be beneficial.
Oppositional students tend to respond best to both high structure and high warmth.
Consistent disciplinary procedures be followed at both school and home.
Positive Behavior SupportProactive rather than reactive approach
Set basic and clear expectations for behavior ◦Be safe◦Be respectful of others◦Be responsible for students own well-being
Clear examples of what it means to meet these expectations in various contexts should be given.
PBIS.org
PBS cont.Student should receive the most
attention (and also praise) when meeting expectations.
Respond to any negative behaviors with brief redirection in a calm but firm manner, by stating and optimally demonstrating the type of behavior you want to see instead.
PBS cont.Error corrections should be provided.
◦Set expectations and pre-correct as much as possible. Monitor his response to the pre-corrections and provide reinforcement accordingly.
◦Reward positive behaviors rather than punish negative ones (5:1 ratio)
◦Praise and error corrections should follow a NORMS format (Neutral, Observation-based, Reliable, Measurable, and Supportive).
PBS cont.PBS approach should be
extended into the home
If significant externalizing behaviors persist despite consistent behavioral intervention, a therapeutic school setting may be of benefit. ◦ Provide emotional and behavioral support◦ Individualized attention, smaller class sizes
Thanks!
Contact info:[email protected] Neuropsychology1900 West Park Drive, Suite 280Westborough, MA 01581www.metrowestneuropsych.com