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:r.andaloro@metrowestneuropsych.comMetrowest Neuropsychology1900 West Park Drive, Suite 280Westborough, MA 01581www.metrowestneuropsych.com