ADHD in the Classroom:Diagnosis and TreatmentDr. Charles Pemberton, Ed.D, LPCC

IntroductionCharles PembertonM.Ed. In Counseling PsychologyEd.D. in Educational Counseling16 years in Counseling and Mental HealthPresented in England, South Africa, Central America, and US.Professor UL and JCTCSPrivate Practice 60% children and familiesADHDDepressionAggressionAnxiety

Todays ScheduleDiagnosis and IdentificationTreatmentMedicationBehavioral ModificationTools and ResourcesQuestions

What wont you get todayComplete picture of medicationsA plan that will work everywhere with everyone

Causes of ADHDBiological DisorderNeurological dopamine/norepinephrineGeneticToxinsHead injuriesNo evidence:SugarFood additivesAllergiesImmunizations

Diagnosis Attention Deficit/Hyperactivity DisorderDiagnostic and Statistical Manual IV- TRDSM- 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

ADHD, Major Diagnostic FeaturesOften will not complete tasksEasily distracted by minor stimuliWork often messy and completed w/o thoughtForgetful in day-to-day activitiesImpulsive (interrupting others, cannot wait turn, etc.)FidgetinessExcessive talking

Subtypes of ADHD314.01 ADHD, Combined TypeClassical ADHD314.00 ADHD, Inattentive TypeOld ADDSeen more in girls314.01 ADHD, Hyperactive-Impulsive Type314.9 ADHD NOSProminent symptoms but do not meet diagnostic criteria

Diagnostic Criteria for ADHD - inattentionA 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 attentionoften 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 stimulioften forgetful in daily activities

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

Diagnostic Criteria, contd:B. symptom onset PRIOR to age 7 yearsC. impairment present in two or more environmentsD. clear clinically significant impairment in functioningE. cannot be accounted for by other mental disorder

PrevalenceWhat percentage of children should be diagnosed with a form of ADHD?

Prevalence of ADHD

Estimated at 3-7% of school age childrenMore common in males than femalesOften diagnosed during elementary school years.

Differential Diagnosis of ADHDMust distinguish from age-appropriate behaviorsMental Retardation or Learning DisabilityOppositional behavior (ODD, Conduct D/O)Stereotypic Movement D/OBehavior due to medicationsMood or Anxiety D/O

Co morbidityOppositional Defiance DisorderConduct disorderMood DisorderAnxiety DisorderLearning DisorderTourettesHx abuse or neglect, multiple foster homes, lead poisoning, Mental Retardation

Types according to Dr. AmenType 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.

Types contType 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.

Types contType 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/distortions of people and situations.

Types contType 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.

Amens interventionsType 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.

Amens interventionsType 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.

Amens interventionsType 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.

Assessment Am. Acad. Of PediatricsEvaluate 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.

Assessment ToolsNo test availableDx by:ObservationRating ScalesVanderbiltConnersSNAP

How do we treat ADHD?MedicationDifferencesDosagesTimingSide-effectsEfficacyBehavior Modification

Types of MedicationsMethylphenidateDextroamphetamineAtomoxeteneDexmethylphenidateAntidepressantsSSRIsTricyclics

Basic Elements of MethylphenidateKnown 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.

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

Methylphenidate, contdAdverse 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 reportedGrowth Inhibition

Basic Elements of Dextroamphetamine

Known as: Adderall, Adderall XR Pharmacology:causes 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.

Dextroamphetamine, contdHalf-Life 10-25 hours Its a schedule II controlled substance, requiring a triplicate prescription Pre-Drug Work-UpBlood 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.

Dextroamphetamine, contdAdverse 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

Basic Elements of AtomoxeteneKnown as: Strattera Pharmacology:works via presynaptic norepinepherine transporter inhibitionPreparations 10, 18, 25, 40, and 60 mg capsules .

Atomoxetene, contdHalf-Life approximately 4 hours Not a schedule II controlled substanceClinical Guidelines Dividing the dose may reduce some side effectsDose reductions are necessary in presence of moderate hepatic insufficiencyAtomoxetine 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.

Atomoxetene, contdAdverse 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.

Basic Elements of Dexmethylphenidate

Known as: Focalin, Focalin XR Pharmacology:causes 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.

Dexmethylphenidate, contdHalf-Life 2.2 hours Its a schedule II controlled substance, requiring a triplicate prescription Pre-Drug Work-UpBlood 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.

Dexmethylphenidate, contdAdverse 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

Release Characteristics

Other MedicationsDexadrineCylertSince marketing in 1975, 13 cases of acute hepatic failure have been reported to the FDA. 11 resulted in death or transplant.Attenade PaxilWellbutrinZoloftTrileptal Celexa/LexaproEffexor

When to use, when to changeSide effectsPast historySubstance abuseEfficacyOnset timeStimulant first line, Strattera secondFollow MD

Closing ThoughtsStimulants still first line defenseLook at choice of drug based upon time of releaseBe aware of study sponsorAddictive natureSubscribe to Medscape

Behavior ModificationClassroomHomeBasics of Behaviorism

Steps in Behavior ModificationIdentify behaviorChart behavior for baselineIdentify motivatorsEstablish realistic goalsMatch motivators with behavior changesShort termLong termImplement PlanEvaluate PlanModify and repeat

Measurable/Realistic GoalMeasurable Long term and Short Term GoalsWho will measure?What is the goal?Where is the behavior now?When will we measure?How will we measure?

Consequences

Consequences examples

Other Behavior Therapy techniquesToken EconomyTime outs

Classroom RewardsHomework reductionsPhysical ContactComputer AccessAdditional recessFree time in classTickets/stickersTime to finish homework in classSpecial pen or paper

Helping a child control his behaviorDaily ScheduleCut down distractionsOrganize your houseSet small, reachable goalsLimit choicesUse calm discipline - distraction

Tools/ResourcesADD/ADHD Behavior-Change Resource KitTeenagers with ADD: A Parents Guidewww.myadhd.comwww.adhdhelp.comwww.amenclinic.comADDitude Magazine

ReferencesAmerican Academy of Pediatrics. Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105:1158-1170. 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; 1994:92-93. 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/library/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. 1997;369(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; 1994:92-93. 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; 1994:92-93. National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorderquestions and answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.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/adhdqa.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.

This is important so you can talk to other professionalsHyperactivity may manifest as internal feeling of restlessness for older individuals, versus fidgeting.Hyperactivity may manifest as internal feeling of restlessness for older individuals, versus fidgeting.Hyperactivity may manifest as internal feeling of restlessness for older individuals, versus fidgeting.Hyperactivity may manifest as an internal feeling of restlessness for older individuals verses fidgetingAnxiety or DepressionIs a child not completing tasks because he is unable, or because he truly has attention deficits?Stereotypic movement d/o will generally be very specific, recognizable behaviors as opposed to general hyperactivity. ODD or CD50% with tourettesThis is the kind of child who worries about things turning out exactly as he anticipates or wishes, gets extremely upset when his wishes are not satisfied, and then may argue intensely and without end to "get his way". He may engage in ritualistic behaviors that must be followed, or else intense upset occurs. This child lacks flexibility in his thinking, has great difficulty shifting his attention away from whatever is his current focus, and is often unable to see options, to go with the flow, or to cooperate with others in situations. There are often other family members with similar characteristics of being overfocused. This can also be thought of as Obsessive-Compulsive ADD.

Someone with "Over-Focused ADHD" is like Rabbit, in that he: May worry a LOT, even over things that don't really matter much Can be very oppositional to parents May like to argue May be somewhat compulsive about the way things ought to be done Will have a very hard time shifting from one activity to another Always wants to have his way The cause of this type of ADHD is an over-active Anterior Cingulate Gyrus. This part of the brain is over-active all of the time. And, to make things worse, when a "work load" is put on the brain, such as school work or a chore to be completed, there is the common ADHD symptom of decreased activity level in the Pre-Frontal Cortex.

The limbic system is the part of the brain responsible for emotions, basic drives for food, sleep, comfort, and sex, and for motivation to work and perform. Difficulties in this area often develop into depressive symptoms, which for children may manifest as irritability/anger more than the sadness/low energy seen in adults. This might be thought of as Depressive ADD. This type of ADHD is called "Limbic System ADHD" by Daniel Amen. And for good reason. SPECT scans show that when the brain is at rest, there is increased activity deep in the limbic system, in parts of the brain called the thalamus and hypothalamus. There is also a decreased level of activity in the underside of the pre-frontal cortex. When the brain is placed under a work load, as during a homework assignment, nothing changes. The over-active limbic system remains over-active, and the under-active pre-frontal cortex remains under-active. Those with this type, or style of ADHD are often: Inattentive; Have a chronic sadness or low-grade depression; The seem to be negative, or apathetic; They have low energy levels; They just do not seem to care. They often feel worthless, or helpless, or hopeless.

This kind of child struggles greatly to read social cues, understand facial expressions, and appreciate tone of voice. He may not "get the message" in social situations unless it is spelled out clearly, in bold letters, repeatedly, and then may make the same mistake the next time in the same or similar situation. His misperceptions may be very dramatic, such that typical teasing/joking/"messing with each other" that kids engage in may be felt to be severe personal attacks, which prompt intense retaliations. He may also not appreciate the impact of his own behavior, failing to see how he may be provoking/irritating to others. Learning difficulties may involve auditory and/or visual processing deficits - the kind of learning disabilities that can be assessed with standard testing instruments. This kind of ADD may be thought of as Explosive ADD.

Temporal Lobe ADHD is characterized by: Inattention, just like in other kinds of ADHD because during concentration there is a decrease in activity in the pre-frontal cortex; Being easily irritated or frustrated; Aggressive behaviors; Dark moods, big mood swings; Impulsivity; Breaking rules, in trouble a lot, in fights a lot; Defiant toward authority, disobedient toward parents and others; Can't get along with others, can be anti-social or just in trouble a lot; Often has terrible handwriting and problems learning; You expect him to be arrested at any time...

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. It is characterized by too many thoughts, very hyper behavior, very hyper verbal expressiveness, a hypersensitivity to light, sound, taste, or touch. This child is often easily distracted, aggressive, oppositional, and moody. His thoughts may "race" with overly grand ideas and expectations. The changes in behavior observed in this child may occur on a cyclical basis. This is ADD with Bipolar features, often a manic quality that is difficult to manage.