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ADHD in the Classroom: Diagnosis and Treatment

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Title: ADHD in the Classroom: Diagnosis and Treatment


1
ADHD in the Classroom Diagnosis and Treatment
  • Dr. Charles Pemberton, Ed.D, LPCC

2
Introduction
  • Charles Pemberton
  • M.Ed. In Counseling Psychology
  • Ed.D. in Educational Counseling
  • 16 years in Counseling and Mental Health
  • Presented in England, South Africa, Central
    America, and US.
  • Professor UL and JCTCS
  • Private Practice 60 children and families
  • ADHD
  • Depression
  • Aggression
  • Anxiety

3
Todays Schedule
  • Diagnosis and Identification
  • Treatment
  • Medication
  • Behavioral Modification
  • Tools and Resources
  • Questions

4
What wont you get today
  • Complete picture of medications
  • A plan that will work everywhere with everyone

5
Causes of ADHD
  • Biological Disorder
  • Neurological dopamine/norepinephrine
  • Genetic
  • Toxins
  • Head injuries
  • No evidence
  • Sugar
  • Food additives
  • Allergies
  • Immunizations

6
Diagnosis Attention Deficit/Hyperactivity Disorder
  • Diagnostic and Statistical Manual IV- TR
  • DSM- IV-TR
  • Within the Disorders Usually First Diagnosed in
    Infancy, Childhood, or Adolescence grouping,
    then subgrouped by the category of disruptive or
    self injurious behavior

7
ADHD, Major Diagnostic Features
  • Often will not complete tasks
  • Easily distracted by minor stimuli
  • Work often messy and completed w/o thought
  • Forgetful in day-to-day activities
  • Impulsive (interrupting others, cannot wait turn,
    etc.)
  • Fidgetiness
  • Excessive talking

8
Subtypes of ADHD
  • 314.01 ADHD, Combined Type
  • Classical ADHD
  • 314.00 ADHD, Inattentive Type
  • Old ADD
  • Seen more in girls
  • 314.01 ADHD, Hyperactive-Impulsive Type
  • 314.9 ADHD NOS
  • Prominent symptoms but do not meet diagnostic
    criteria

9
Diagnostic Criteria for ADHD - inattention
  • A 1. Must exhibit 6 or more symptoms of
    inattention, persisting for minimum of 6 months
  • fails to give close attention to details
  • often has difficulty sustaining attention
  • often does not seem to listen when spoken to
    directly 
  • often has difficulty organizing tasks and
    activities 
  • often loses things necessary for tasks
  • often easily distracted by extraneous stimuli
  • often forgetful in daily activities 

10
Diagnostic Criteria - Hyperactive
  • A 2. Must exhibit 6 or more symptoms of
    hyperactivity-impulsivity, persisting for minimum
    of 6 months
  • often fidgets with hands or feet or squirms in
    seat 
  • often leaves seat in classroom
  • often runs about or climbs excessively
  • is often "on the go" or often acts as if "driven
    by a motor
  • often talks excessively
  • often blurts out answers
  • often has difficulty awaiting turn
  • often interrupts or intrudes on others

11
Diagnostic Criteria, contd
  • B. symptom onset PRIOR to age 7 years
  • C. impairment present in two or more environments
  • D. clear clinically significant impairment in
    functioning
  • E. cannot be accounted for by other mental
    disorder

12
Prevalence
  • What percentage of children should be diagnosed
    with a form of ADHD?

13
Prevalence of ADHD
  • Estimated at 3-7 of school age children
  • More common in males than females
  • Often diagnosed during elementary school years.

14
Differential Diagnosis of ADHD
  • Must distinguish from age-appropriate behaviors
  • Mental Retardation or Learning Disability
  • Oppositional behavior (ODD, Conduct D/O)
  • Stereotypic Movement D/O
  • Behavior due to medications
  • Mood or Anxiety D/O

15
Co morbidity
  • Oppositional Defiance Disorder
  • Conduct disorder
  • Mood Disorder
  • Anxiety Disorder
  • Learning Disorder
  • Tourettes
  • Hx abuse or neglect, multiple foster homes, lead
    poisoning, Mental Retardation

16
Types according to Dr. Amen
  • Type 1 Classic ADD
  • Restlessness, hyperactivity, constant motion,
    troubles sitting still, talkative, impulsive
    behavior, lack of thinking ahead .
  • Type 2 Inattentive ADD
  • Short attention span (especially about routine
    matters), distractibility, disorganization,
    procrastination, poor follow-through/task
    completion.

17
Types cont
  • Type 3 Overfocused ADD
  • Worrying, holds grudges, stuck on thoughts, stuck
    on behaviors, addictive behaviors,
    oppositional/argumentative.
  • Type 4 Limbic ADD
  • Sad, moody, irritable, negative thoughts, low
    motivation, sleep/appetite problems, social
    isolation, finds little pleasure.

18
Types cont
  • Type 5 Temporal Lobe ADD
  • Inattentive/spacey/confused, emotional
    instability, memory problems, periodic intense
    anxiety, periodic outbursts of aggressive
    behavior seemingly triggered by small events or
    intense angry criticisms directed at himself for
    failures and frustrations, overly sensitive to
    criticism and slights by others, frequent
    headaches and/or stomachaches, learning
    difficulties, and serious misperceptions/distortio
    ns of people and situations.

19
Types cont
  • Type 6 Ring of Fire ADD
  • A ring of overactivity in the brain scan image
    which surrounds most of the brain is the source
    of the name for this type of ADD.
  • too many thoughts, very hyper behavior, very
    hyper verbal expressiveness, a hypersensitivity
    to light, sound, taste, or touch.

20
Amens interventions
  • Type 1 Classic ADD
  • Stimulant medication (Ritalin, Adderall, etc.), a
    diet with more protein and less carbohydrates,
    intense aerobic exercise.
  • Type 2 Inattentive ADD
  • Stimulant medication, perhaps stimulating
    antidepressants (Welbutrin, for example), a diet
    with more protein and less carbohydrates, intense
    aerobic exercise.

21
Amens interventions
  • Type 3 Overfocused ADD
  • An antidepressant that has a dual focus on two
    brain transmitters (seratonin and dopamine)
    (Effexor, for example), and/or an antidepressant
    that enhances seratonin (Prozac, Zoloft, Paxil,
    or others, for example). A stimulant medication
    may need to be added. A diet with less protein
    and increased complex carbohydrates will help,
    along with intense aerobic exercise.
  • Type 4 Limbic ADD
  • An antidepressant that is also stimulating
    (Effexor or Welbutrin, for example), with a
    stimulant medication could be added a balanced
    diet, and intense exercise.

22
Amens interventions
  • Type 5 Temporal Lobe ADD
  • Anticonvulsant medication (Neurontin, Depakote
    for example), a stimulant could be added a diet
    with more protein and less simple carbohydrates.
  • Type 6 Ring of Fire ADD
  • Anticonvulsant medication (Neurontin, Depakote
    for example, a stimulant medication could be
    added sometimes some of the newer, different
    anti-psychotic medications may help (Risperdal,
    or Zyprexa) a diet with more protein and less
    simple carbohydrates.

23
Assessment Am. Acad. Of Pediatrics
  • Evaluate any child 6 to 12 years of age who shows
    signs of school difficulties, academic
    underachievement, troublesome relationships with
    teachers, family members, peers, and other
    behavioral problems.
  • Use DSM-IV criteria these require that ADHD
    symptoms be present in 2 or more of a child's
    settings, and that the symptoms adversely affect
    the child's academic or social functioning for at
    least 6 months.
  • Requires information from parents or caregivers
    and a teacher or other school professional
    regarding core symptoms of ADHD in various
    settings, age of onset, duration of symptoms, and
    degree of impairment.
  • Assessment for co-existing conditions learning
    and language problems, aggression, disruptive
    behavior, depression or anxiety.

24
Assessment Tools
  • No test available
  • Dx by
  • Observation
  • Rating Scales
  • Vanderbilt
  • Conners
  • SNAP

25
How do we treat ADHD?
  • Medication
  • Differences
  • Dosages
  • Timing
  • Side-effects
  • Efficacy
  • Behavior Modification

26
Types of Medications
  • Methylphenidate
  • Dextroamphetamine
  • Atomoxetene
  • Dexmethylphenidate
  • Antidepressants
  • SSRIs
  • Tricyclics

27
Basic Elements of Methylphenidate
  • Known as Ritalin, Ritalin SR, Ritalin LA,
    Concerta, Metadate ER, Metadate CD, Focalin
  • Pharmacology It is a CNS stimulant, which is
    chemically related to amphetamine
  • Preparations 5, 10, 20 mg tabs sustained
    release 20 mg tabs LA 20, 30, and 40 mg
    capsules. The SR tablet should be swallowed and
    not crushed or chewed. Concerta comes in 18 and
    36 mg extended release tablets. Metadate CD 20 mg
    capsules Metadate ER 10 and 20 mg tabs.
    Focalin 2.5, - 5-, 10 - mg tabs.

28
Methylphenidate, contd
  • Half-Life 3-4 hours 6-8 hours for sustained
    release
  • Its a schedule II controlled substance,
    requiring a triplicate prescription
  • Pre-Drug Work-Up
  • Blood pressure and general cardiac status
  • baseline and periodic blood counts and liver
    function tests
  • Weight and growth should be monitored in children

29
Methylphenidate, contd
  • Adverse Drug Reactions
  • Nervousness and insomnia can be reduced by
    decreasing dose.
  • Cardiovascular Hypertension, tachycardia, and
    arrhythmias.
  • CNS Dizziness, euphoria, tremor, headache,
    precipitation of tics and Tourettes syndrome,
    and rarely psychosis.
  • GI Decreased appetite, weight loss.
  • Case reports of elevated liver enzymes and liver
    failure.
  • Hematological Leukopenia and anemia have been
    reported
  • Growth Inhibition

30
Basic Elements of Dextroamphetamine
  • Known as Adderall, Adderall XR
  • Pharmacologycauses the release of
    norepinepherine from neurons. At higher doses, it
    will also cause dopamine and serotonin release
  • Preparations Adderall 5-, 7.5-, 10-, 12.5-,
    15-, 20-, 30-mg tablets Adderall XR 5-, 10-,
    15-, 20-, 25-, 30-mg capsules.

31
Dextroamphetamine, contd
  • Half-Life 10-25 hours
  • Its a schedule II controlled substance,
    requiring a triplicate prescription
  • Pre-Drug Work-Up
  • Blood pressure and general cardiac status should
    be evaluated prior to initiating
    dextroamphetamine.
  • Can precipitate tics
  • Contraindicated in in patients with hypertension,
    hyperthyroidism, cardiac disease or glaucoma. It
    is not recommended for psychotic patients ot
    patients with a history of substance abuse.
  • Weight and growth should be monitored in all
    children.

32
Dextroamphetamine, contd
  • Adverse Drug Reactions
  • Side effects most common side effects are
    psychomotor agitation, insomnia, loss of
    appetite, and dry mouth. Tolerance to loss of
    appetite tends to develop. Effect on sleep can be
    reduced by making sure no drug is given after 12
    pm.
  • Cardiovascular Palpitations, tachycardia,
    increased blood pressure.
  • CNS Dizziness, euphoria, tremor, precipitation
    of tics, Tourettes syndrome, and rarely,
    psychosis.
  • GI Anorexia and weight loss, diarrhea,
    constipation.
  • Growth inhibition

33
Basic Elements of Atomoxetene
  • Known as Strattera
  • Pharmacologyworks via presynaptic
    norepinepherine transporter inhibition
  • Preparations 10, 18, 25, 40, and 60 mg capsules
    .

34
Atomoxetene, contd
  • Half-Life approximately 4 hours
  • Not a schedule II controlled substance
  • Clinical Guidelines
  • Dividing the dose may reduce some side effects
  • Dose reductions are necessary in presence of
    moderate hepatic insufficiency
  • Atomoxetine should not be used within 2 weeks of
    discontinuation of a MAO inhibitor.
  • Atomoxetine should be avoided inpatients with
    narrow angle glaucoma and, it should be used with
    caution in patients with tachycardia,
    hypertension, or cardiovascular disease.
  • It can be discontinued without taper.
  • Pregnancy C category.

35
Atomoxetene, contd
  • Adverse Drug Reactions
  • Cardiovascular increased blood pressure and
    heart rate (similar to those seen with
    conventional psychostimulant).
  • BI Anorexia, weight loss, nausea, abdominal
    pain.
  • Miscellaneous Fatigue, dry mouth, constipation,
    urinary hesitancy and erectile dysfunction.

36
Basic Elements of Dexmethylphenidate
  • Known as Focalin, Focalin XR
  • Pharmacologycauses the release of dopamine from
    neurons. Is an isomer of Ritalin.
  • Preparations Focalin 2.5, 5 ,10-mg tablets
    Focalin XR 5-, 10-, 20-mg capsules.

37
Dexmethylphenidate, contd
  • Half-Life 2.2 hours
  • Its a schedule II controlled substance,
    requiring a triplicate prescription
  • Pre-Drug Work-Up
  • Blood pressure and general cardiac status should
    be evaluated prior to initiating
    Dexmethylphenidate.
  • Can precipitate tics
  • Contraindicated in in patients with hypertension,
    hyperthyroidism, cardiac disease or glaucoma. It
    is not recommended for psychotic patients or
    patients with a history of substance abuse.
  • Weight and growth should be monitored in all
    children.

38
Dexmethylphenidate, contd
  • Adverse Drug Reactions
  • Side effects most common side effects are
    psychomotor agitation, insomnia, loss of
    appetite, and dry mouth. Tolerance to loss of
    appetite tends to develop. Effect on sleep can be
    reduced by making sure no drug is given after 12
    pm.
  • Cardiovascular Palpitations, tachycardia,
    increased blood pressure.
  • CNS Dizziness, euphoria, tremor, precipitation
    of tics, Tourettes syndrome, and rarely,
    psychosis.
  • GI Anorexia and weight loss, diarrhea,
    constipation.
  • Growth inhibition

39
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42
Release Characteristics
Concerta Metadate CD Ritalin LA
Immediate Release 22 30 50
Delayed Release 78 70 50
Technology Oros Eurand SODAS
43
Other Medications
  • Dexadrine
  • Cylert
  • Since marketing in 1975, 13 cases of acute
    hepatic failure have been reported to the FDA. 11
    resulted in death or transplant.
  • Attenade
  • Paxil
  • Wellbutrin
  • Zoloft
  • Trileptal
  • Celexa/Lexapro
  • Effexor

44
When to use, when to change
  • Side effects
  • Past history
  • Substance abuse
  • Efficacy
  • Onset time
  • Stimulant first line, Strattera second
  • Follow MD

45
Closing Thoughts
  • Stimulants still first line defense
  • Look at choice of drug based upon time of release
  • Be aware of study sponsor
  • Addictive nature
  • Subscribe to Medscape

46
Behavior Modification
  • Classroom
  • Home
  • Basics of Behaviorism

47
Steps in Behavior Modification
  • Identify behavior
  • Chart behavior for baseline
  • Identify motivators
  • Establish realistic goals
  • Match motivators with behavior changes
  • Short term
  • Long term
  • Implement Plan
  • Evaluate Plan
  • Modify and repeat

48
Measurable/Realistic Goal
  • Measurable Long term and Short Term Goals
  • Who will measure?
  • What is the goal?
  • Where is the behavior now?
  • When will we measure?
  • How will we measure?

49
Consequences
Reward Punishment
Positive ? behavior by something ? behavior by something
Negative ? behavior by - something ? behavior by - something
50
Consequences examples
Reward Punishment
Positive Add TV time when no hitting Add chores when there is hitting
Negative Take away chore when there is no hitting Take away toy when there is hitting
51
Other Behavior Therapy techniques
  • Token Economy
  • Time outs

52
Classroom Rewards
  • Homework reductions
  • Physical Contact
  • Computer Access
  • Additional recess
  • Free time in class
  • Tickets/stickers
  • Time to finish homework in class
  • Special pen or paper

53
Helping a child control his behavior
  • Daily Schedule
  • Cut down distractions
  • Organize your house
  • Set small, reachable goals
  • Limit choices
  • Use calm discipline - distraction

54
Tools/Resources
  • ADD/ADHD Behavior-Change Resource Kit
  • Teenagers with ADD A Parents Guide
  • www.myadhd.com
  • www.adhdhelp.com
  • www.amenclinic.com
  • ADDitude Magazine

55
References
  • American Academy of Pediatrics. Diagnosis and
    evaluation of the child with attention-deficit/hyp
    eractivity disorder. Pediatrics.
    20001051158-1170.
  • American Psychiatric Association. Diagnostic and
    Statistical Manual of Mental Disorders.
    DSM-IV-TR. In Disorders Usually First Diagnosed
    in Infancy, Childhood, or Adolescence Diagnostic
    Criteria for Attention-Deficit/Hyperactivity
    Disorder. Washington, DC American Psychiatric
    Association 199492-93.
  • National Institute of Mental Health. National
    Institutes of Health. Attention deficit
    hyperactivity disorder. Available at
    http//www.nimh.nih.gov/publicat/helpchild.cfm.
    Accessed April 19, 2002.
  • U.S. Department of Health and Human Services.
    Mental Health A Report of the Surgeon General.
    Available at http//www.surgeongeneral.gov/librar
    y/mentalhealth/chapter3/sec4.html. Accessed April
    19, 2002.
  • Dulcan M. Practice parameters for the assessment
    and treatment of children, adolescents, and
    adults with attention-deficit/hyperactivity
    disorder. J Am Acad Child Adolesc Psychiatry.
    1997369(suppl)855-1215.
  • American Psychiatric Association. Diagnostic and
    Statistical Manual of Mental Disorders.
    DSM-IV-TR. In Disorders Usually First Diagnosed
    in Infancy, Childhood, or Adolescence Diagnostic
    Criteria for Attention-Deficit/Hyperactivity
    Disorder. Washington, DC American Psychiatric
    Association 199492-93.
  • American Psychiatric Association. Diagnostic and
    Statistical Manual of Mental Disorders.
    DSM-IV-TR. In Disorders Usually First Diagnosed
    in Infancy, Childhood, or Adolescence Diagnostic
    Criteria for Attention-Deficit/Hyperactivity
    Disorder. Washington, DC American Psychiatric
    Association 199492-93.
  • National Institute of Mental Health. National
    Institutes of Health. Attention deficit
    hyperactivity disorderquestions and answers.
    Available at http//www.nimh.nih.gov/publicat/adh
    dqa.cfm. Accessed April 19, 2002.
  • National Institute of Mental Health. National
    Institutes of Health. Attention deficit
    hyperactivity disorderquestions and answers.
    Available at http//www.nimh.nih.gov/publicat/adh
    dqa.cfm. Accessed April 19, 2002.
  • American Psychiatric Association Diagnostic and
    Statistical Manual of Mental Disorders, Fourth
    Edition, Text Revision. Washington, DC, American
    Psychiatric Association, 2000.
  • Fauman, M. A. (2002). Study Guide to DSM-IV-TR.
    Washington, DC American Psychiatric Publishing,
    Inc.
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