update - aap 2011 guidelines on adhd karen pierce md fapa, faacap northwestern university january...
TRANSCRIPT
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Update - AAP 2011 Guidelines on ADHD
Karen Pierce MD FAPA, FAACAPNorthwestern University
January 28, 2012
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Disclosure
• No conflict of interests• Off label use of medication will be indicated • Only Dexedrine is approved for children ages 3
to 4 years, all other stimulants are off-label
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Objectives
• To review the update of diagnosis and treatment of ADHD new AAP 2011 guidelines
• To review the importance of diagnosing comorbidity in a child with ADHD
• To talk about the importance of behavior treatment and learning skills for the pre-schooler that presents with behavior problems
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AAP ADHD 2011 Guidelines - Rational
• Updates and replaces two previous guidelines• Uses new information and evidence • Expanded age ranges from 4 to 18 years• Expanded scope-behavior interventions may
help families without full ADHD diagnosed• A process of care for diagnosis and treatment• Integration with Task Force on Mental Health
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AAP 2011 Guidelines 1
• Primary Care Clinicians should evaluate children 4 -18 years of age for ADHD who present with academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity
• Quality of the Evidence- B:strong recommendation
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Portrait of a child with ADHD
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Normal Development
A. Active: Characteristics of Active Baby Syndrome:
1. Highly active2. Poorly adaptive3. Intensely reactive4. Unpredictable with routines
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Normal Development
B. Short Attention Span: Preschoolers and Time on Task:
3 years old = 9 or 10 minutes4 years old = 13 minutes5 years old = 20 minutes
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Normal Development
C. Impulsive vs.. Normal Preschool
1. Excessive activity in structured situations2. Poor attention sustaining attention3. Trouble inhibiting behavior
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Clinical Picture
Attention deficit disorder is a developmentaldisorder characterized by defects in theregulation and maintenance of behavior.
ADHD has an onset before age seven, but determining how early to diagnose it is a challenge.
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ADHD and the Brain
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ADHD Facts
– ADHD not caused by poor parenting skills or a stressful family environment
– Environmental factors can exacerbate the symptoms
– Parenting techniques appropriately in tune with the ADHD child can improve symptoms and increase the child’s self-esteem
ADHD Practice Parameters. JAACAP 1997;36:85S.
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AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S.Barkley RA. J Am Acad Child Adolesc Psychiatry. 1991;30:752-761.
ADHD Affects Socialization• Children are stigmatized by their behavior
– Disruptive behavior• Troublemakers • Bad sportsmanship• Excessive talking • Cannot sit still• Unfocused, not responsive to others • Impulsive aggression
– Immaturity and impulsiveness• Center of attention • Breaks the rules• Blurting out answers • Peer rejection
• Adolescents continue to demonstrate social problems
- Poor participation in group activities– Few friends– Vulnerable to antisocial groups, drug abuse
• Adults– More marriages and divorces– Lower level of occupation/fewer advancements
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Peer Perception of ADHD Children
Those who: (%name)• Try to get other people in
trouble• Play the clown• Tell other children what to
do• Are usually chosen last• Start a fight over nothing
ADHD Boys Controls• 51 17
• 40 19• 41 16
• 27 13• 48 19
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Murphy D, Barkley B. Am J Orthopsychiatry. 1996;66:93-102.
How ADHD Affects Parents
• Increased stress– Worry — Anxiety– Frustration — Anger
• Lower self-esteem– Self-blame — Depression– Social isolation
• Increased employment disruption• Increased marital disruption• Increased alcohol/substance abuse
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Why is it important to identify & treat ADHD?
• Interferes with the child’s learning• Interferes with the learning of others• Disrupts social development• Reduces instructional time• Adds to stress for all involved• Drains resources• Not having an effective strategy can
maintain or exacerbate ADHD behaviors
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Why is it important to identify & treat ADHD?
• Less schooling & poorer grades• Higher expulsion rates• Fewer friends• Lower self-esteem• Higher arrest rates• Lower occupational rank• Higher job termination rates• Driving differences: 3x• Accident proneness
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Developmental Trendsof ADHD Symptoms
before 17 yo
Impa
irmen
t
Inattention
Hyper/Imp
Age
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AAP 2011 Guideline- 2
• To make a diagnosis of ADHD, determine that DSM-IV criteria have been met including impairment in more than one major setting with information obtained from parents, school or guardians. All alternative causes should be ruled out
• (Quality of the evidence: B/Strong Recommendation)
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Inattention Hyperactivity
Impulsivity
What Is ADHD?
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Hyperactive/Impulsive Symptoms
1. Fidgety & squirmy2. Often gets up out of seat3. Runs or climbs excessively4. Has trouble playing quietly5. “On the go” or “driven by a motor”6. Talks excessively7. Blurts out answers8. Has trouble waiting for a turn9. Interrupts or intrudes
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Inattentive Symptoms
1. Makes careless mistakes2. Has trouble paying attention to a task3. Does not seem to listen when spoken to directly4. Does not follow instructions5. Has trouble organizing6. Avoids or dislikes sustained effort7. Loses things8. Easily distracted9. Forgetful
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DSM IV Criteria (1)
• At least 6 of the 9 behaviors described in the inattentive domain occur often and to a degree inconsistent with child’s developmental age, and/or
• At least 6 of the 9 behaviors described in the hyperactive/impulsive domain occur often and to a degree inconsistent with child’s developmental age
• Presence of some impairment in two or more major settings (e.g., home and school) for at least six months
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DSM IV Criteria (2)
• Presence of some symptoms of ADHD that caused impairment (by history) prior to 7 years of age
• Symptoms have persisted for at least six months• Evidence for significant clinical impairment in
social, academic or occupational functioning due to the behaviors.
• Symptoms are not attributable to another physical, situational or mental health condition
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3 DSM IV Subtypes
• ADHD primarily of the inattentive type (ADHD/I, having the inappropriately often occurrence of at least 6 of 9 inattention behaviors and less than 6 hyperactive-impulsive behaviors)
• ADHD primarily of the hyperactive-impulsive type (ADHD/HI, having the inappropriately often occurrence of at least 6 of 9 hyperactive-impulsive behaviors and less than 6 inattention behaviors)
• ADHD combined type (ADHD/C, having the inappropriately often occurrence of at least 6 of 9 behaviors in both the inattention and hyperactive-impulsive dimensions) , most common
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Special Circumstances-Preschool
• Evidence for ADHD diagnosis in Preschool• Need a check list but only the Connors is
validated in preschool children• Need poor functioning in two or more setting,
so a valid rater outside the home is important to obtain
• Egger HL et al, The epidemiology and diagnostic issues in preschool ADHD, Infants and Young Children 2006;19(2);109-122
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Steps for Preschool pre-treatment
• Parents should consider completing a parent-training program prior to confirming an ADHD diagnosis
• Consider placement in a qualified preschool program such as Head Start
• Learn age-appropriate developmental expectations
• May qualify for Early Childhood Special Education through their local public school
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AAP 2011 Guideline-3
• In the Evaluation of a child for ADHD, an assessment for other conditions that might coexist with ADHD including emotional, behavioral (e.g. anxiety, depression, oppositional defiant, and conduct disorders), developmental (e.g. learning and language disorders, or other neurodevelopmental disorders) and physical(e.g. tics, sleep apnea)
• Quality of Evidence: B/Strong Recommendation
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ADHD—Childhood Common Comorbid Diagnoses
Biederman et al. JAACAP 1996;35:343. Pliszka. J Clin Psychiatry 1998:59(suppl 7):50.Biederman et al. JAACAP 1999;38:966. Spencer et al. Pediatric Clin N Am 1999:46:915.
Approximate Prevalence Rate in Children with ADHD (%)
0 10 20 30 40 50 60
Oppositional defiant disorder
Conduct disorder
Mood disorder
Anxiety disorder
Learning disorderMaleFemale
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Overlap of Symptoms and Diagnoses
ADHD Anxiety LD ODD
Attention Concentration Anxiety Sadness Opposition Fidgetiness Impulsivity Appetite Sleep
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Co-occurring Disorders
Oppositional defiant disorder…………….…………..40%Anxiety or mood disorder…………………...........25-30%Learning disability………………………………..…....20%Conduct disorder………………………………...….…10%Language disorder………………………..….…....10-60%Tics…………………..………………………………10-15%
½ of ADHD patients have two or more diagnoses
½ of ADHD patients have > 2 diagnoses
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Comorbidity
60% of children with ADHD have a learning disability
1. Language-Based Disorders2. Non-verbal Disorders
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Externalizing Disorders• Oppositional Defiant Disorder (ODD)
– Negativistic, hostile, and defiant behavior– Unwilling to conform to demands of others– Less severe than conduct disorder– Nationally: 30-40% of children with ADHD have ODD
• Conduct Disorder (CD)– Aggression toward people and/or animals– Destruction of property– Deceitfulness– Breaking the law– Lack of remorse– Nationally: 15-20% of children with ADHD have CD
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Oppositional Defiant Disorder IV
• A pattern lasting 6 months, need 4 Often loses temper Often argues with adults Often actively defies or refuses to comply Often deliberately annoys people Often blames others for his/her mistakes Often is touchy or easily annoyed by others Often is angry and resentful Often is spiteful and vindictive
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AAP 2011 Guideline-4
• ADHD is a chronic condition and therefore consider children and adolescents with ADHD as children with Special Health Care Needs (CYSHCN) and follow the principles of the chronic care model and the medical home
• Quality of evidence: B/Strong Recommendation
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AAP 2011 Guidelines-5
• Recommendations for treatment of children and youth with ADHD varies depending on age
• Preschool-(4-5) –evidence based parent and/or teacher administrated behavior therapy first
• Quality of Evidence: A/Strong Recommendation• May prescribe methylphenidate if behavior
treatment fails and there is moderate to severe impairment
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AAP 2011 Guidelines- 5 (cont)
• For Elementary school age children (6 to 11)Consider both FDA-approved mediations for
ADHD (quality of evidence A:/Strong) and/or evidence based parent and/or behavior treatment (quality of evidence B:/strong). The evidence is strong for stimulant medications and sufficient but less strong on Atomoxetine, extended release guanfacine and extended release clonidine
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Preschool Recommendations
• Studies of ADHD treatment in preschool was limited to children with moderate to severe dysfunction
• Research shows that up to 1/3 of young children (age 4-5) experience improvements in symptoms with behavior therapy alone
• There is limited information and experience about the effects of stimulant medication between ages 4 to 5- off label
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Management-1
– Set rules– Set clear expectations – Ignore mild inappropriate behaviors – Praise positive behavior– Utilize contingency management with positive
reinforcement (eg,stickers) and prudent negative consequences (eg, privilege loss)
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Contingency Management
• Explain clearly the behavior that is desired: ‘Sit quietly in the chair’ ‘ don’t bite my finger’
• Practice the behavior and reward immediately with a sticker, small point sheet to a larger ‘prize’
• Take breaks and reinforce with praise• Use visual charts to reinforce behavior
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Contingency Management
• Be consistent, • Be Predictable• Praise liberally• Have empathy• TALK TO THE CHILD DIRECTLY, not to the
parent
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Troubleshooting
• If rewards not working, examine the program and change the reward
• Ask the parent or get permission to call the PCP (children over 12 years need to sign mental health consent) for suggestions
• Ask what is reinforcing at home and use home rewards, too
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Components of Evidenced-Based
Child Intervention -Behavioral and developmental approach -Focus on teaching academic, recreational, and
social/behavioral competencies, decreasing aggression, increasing compliance, developing close friendships, improve adult relations,
-Paraprofessional or teacher-based -Summer treatment programs
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Components of Evidence-based Treatment for ADHD
School Intervention• Behavioral approach – teachers are trained and implement
treatment with the child, modifying interventions as necessary using ongoing functional analysis
• Focus on classroom behavior, academic performance, and peer relationships
• Widely available in schools• Teacher training: (1) Inservice training and follow-up or (2)
consultant model – initial weekly sessions as needed, then contact faded – Daily Report Card.
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Why Is It Important to Use Behavioral Interventions for ADHD in Schools?
(Kent et al, 2011; Loe & Feldman, 2007; Molina et al, 2009; Robb et al, 2011)
• 33% of ADHD have academic problems (special ed., academic probation, dropped out, or held back) every year, vs.. 2% of controls.
• 48% of ADHD children have at least one year of special education placement vs.. 3% of controls (bulk of cost).
• 12% of ADHD vs.. 5% of controls have been held back a grade.• 9% of ADHD adolescents drop out of school vs.. 1% of
controls.• ADHD adolescents score a full letter grade lower than
controls, with twice the rate of absences.• Medication does not improve these outcomes.
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Components of Evidence-based Treatment for ADHD
School Intervention• Don’t expect instant changes in child – improvement
(learning) often gradual• Continued support and contact for as long as necessary –
typically multiple school years and/or if deterioration• Program for maintenance and relapse prevention (e.g.,
school-wide programs, train all school staff, including administrators; train parent to implement and monitor).
• Reestablish contact for major developmental transitions (e.g., adolescence).
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Components of Evidence-based Treatment for ADHD
Parent Training• Behavioral approach • Focus on parenting skills, child’s behavior, and family
relationships• Parents learn skills and implement treatment with child,
modifying interventions as necessary using ongoing functional analysis
• Group-based or individual weekly sessions with therapist initially (8-16 sessions), then contact faded
• Don’t expect instant changes in child – improvement (learning) often gradual
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Why Is It Important to Include Behavioral Parent Training in ADHD Treatment?
• No one is taught how to be a parent.• Parents of ADHD children have significant stress,
psychopathology, and poor parenting skills.• ADHD children contribute greatly to parental stress and
disturbed parent-child relationships.• Parenting styles characteristic of ADHD parents predict and
mediate long-term negative outcomes for children.• Medication for the child has not been shown to improve these
domains.
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Daily Report Card (DRC)
• An integral part of all school interventions• Effective in changing ADHD children’s behavior• Cost little and takes little teacher time• Provide daily communication between
teachers and parents• Provide positive reinforcement for a child that
has been singled out by peers• Downloads free at http://ccf.flu.edu
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Daily Report Cards (2)
• Reduce the need for notes and phone calls • Once set up, reduce the time that a teacher
spends with a child• Provide a tool for ongoing monitoring of the
child’s progress• Can be used to titrate medications• Help give specific feedback and
rewards/consequences for behavior
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Daily Report Card
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Daily Report Card
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Pharmacology
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Swanson et al. Except Child 1993;60:154.
Symptoms Likely to Respond to Medication
• Inattention• Impulsivity• Hyperactivity
• Noncompliance• Impulsive aggression• Social interactions• Academic productivity and
accuracy
ANDCore Symptoms
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Preschool medication use
• Must assess severity with rating scales, interfering with function (expelled from multiple pre-schools etc), hospitalization, multiple home placements
• Symptoms have persisted for at least nine months
• Must asses development impairment, safety risk, or consequences for school or home
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Preschool Methylphenidate Study
• 165 children• Multi-site study• Increased risk of side effects at low doses• Doses start at methylphenidate 2.5 mg bid and
titrated in smaller increments.• Maximum doses have not been studied.
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ADHD Preschool Medication
• Dextro –amphetamine in the only FDA medication approved for children 4 to 6 but the approval was based on less stringent criteria when approved
• Most evidence about the safety and efficacy of treating preschool children with stimulant medication is limited to methylphenidate
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Stimulant Medications
• Medication choices depend on:– Targeted symptoms (ADHD symptoms, co-existing
conditions, areas of significant impairment)– Availability on formularies– Child’s individual response: efficacy vs.. side effects
• Research: McMaster report showed no differences comparing methylphenidate with dextroamphetamine or among different forms of each of these stimulants. Each stimulant improved core symptoms equally.
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ADHDStimulants
• Amphetamine mixed salts (Adderall®) (Adderall XR)– contains equal parts d-amphetamine sulfate, d,l-amphetamine sulfate,
d,l-amphetamine aspartate, and d-amphetamine saccharate. (Vyvanse)
• Dextroamphetamine (Dexedrine®; DextroStat®)
• Methylphenidate (Ritalin®; Methylin®; Metadate®; Concerta®,
Ritalin LA, Metadate CD, Focalin, Focalin XR)
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Stimulant Effects
• Stimulants last from 3 to 12 hours, with the best concentration at peak dose
• Rank order of duration of effect- Ritalin < Focalin < Dexedrine < Adderall < Ritalin LA < Adderall XR < Concerta
• If a child is taking medication, ask what time was there last dose
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Stimulant Adverse Effects
• AEs are similar for all stimulants:– Decreased appetite– Insomnia– Headache– Stomachache– Irritability/rebound phenomena
• Rates of these AEs may be high prior to any medical intervention so baseline levels should always be obtained
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Medication Titration Part I• Dosage amount:
– Begin with average starting dose (counsel family to expect no response)
– Should see result with first dose if working; allow child to stay on that dose for q3-7 days to track side effects
– Increase dose q3-7 days until significant decrease in symptoms & side effects minimal
– Ideal dose likely to be several mgs higher than 1st dose that makes a noticeable change
– Dosing is NOT related to child’s weight– NO laboratory tests are available to monitor dosage– Goal: highest possible dose which increases performance
and minimizes side-effects
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Medication Titration Part II
• Dosage interval: – Interval should be based on the specific target outcomes– Goal is smooth control: give 2nd dose before 1st wears off– REMEMBER: Children vary in metabolism rate so will vary
in appropriate interval
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Rationale for Non-stimulant Treatment of ADHD
• Stimulants and extremely effective, but:– Poor response or tolerability in some patients– Suboptimal response is not uncommon– Relative or labeled contraindications for some
comorbid conditions (e.g., tics, anxiety, substance abuse)
– Some patients will not take stimulants– Risk for diversion or abuse of Schedule II drugs
• Predominance of noradrenergic mechanisms among non-stimulant treatments
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Unproved or untested treatmentsPlay therapy or talking psychotherapy
BiofeedbackDietary changes, elimination diets
Gingko biloba & other supplementsMeditation
ExerciseKarate/martial arts
CaffeineMetronome
Vision trainingSensory integration therapy
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Summary- Evidence Treatment
• Use DSM IV criteria with functional impairment in two settings
• Parent training- Use always• School Interventions- Use always• Child interventions-Use when indicated• Medication-Use when needed
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Where to find help
• AAP and pediatricians• AACAP• CHADD.ORG – a great website for
information and up to date research
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Thank you
Questions???