ADHD in the Classroom:Diagnosis and Treatment

Dr. Charles Pemberton, Ed.D, LPCC

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

Today’s Schedule

Diagnosis and Identification Treatment

Medication Behavioral Modification

Tools and Resources Questions

What won’t you get today

Complete picture of medications A plan that will work everywhere with

everyone

Causes of ADHD

Biological Disorder Neurological – dopamine/norepinephrine Genetic Toxins Head injuries No evidence:

Sugar Food additives Allergies Immunizations

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”

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

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

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 

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

Diagnostic Criteria, cont’d:

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

Prevalence

What percentage of children “should” be diagnosed with a form of ADHD?

Prevalence of ADHD

Estimated at 3-7% of school age children More common in males than females Often diagnosed during elementary school

years.

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

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

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.

Types con’t

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.

Types con’t

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/distortions of people and situations.

Types con’t

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.

Amen’s 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.

Amen’s 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.

Amen’s 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.

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.

Assessment Tools

No test available Dx by:

Observation Rating Scales

Vanderbilt Conner’s SNAP

How do we treat ADHD?

Medication Differences Dosages Timing Side-effects Efficacy

Behavior Modification

Types of Medications

Methylphenidate Dextroamphetamine Atomoxetene Dexmethylphenidate Antidepressants

SSRI’s Tricyclics

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.

Methylphenidate, cont’d

Half-Life – 3-4 hours; 6-8 hours for sustained release

It’s 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

Methylphenidate, cont’d

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 Tourette’s 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

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, cont’d

Half-Life – 10-25 hours It’s 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.

Dextroamphetamine, cont’d

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, Tourette’s syndrome, and rarely, psychosis.

GI – Anorexia and weight loss, diarrhea, constipation. Growth inhibition

Basic Elements of Atomoxetene Known as: Strattera Pharmacology:works via presynaptic

norepinepherine transporter inhibition Preparations – 10, 18, 25, 40, and 60 mg

capsules .

Atomoxetene, cont’d

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.

Atomoxetene, cont’d

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.

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, cont’d

Half-Life – 2.2 hours It’s 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.

Dexmethylphenidate, cont’d

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, Tourette’s syndrome, and rarely, psychosis.

GI – Anorexia and weight loss, diarrhea, constipation. Growth inhibition

Release Characteristics

Concerta Metadate CD

Ritalin LA

Immediate Release

22% 30% 50%

Delayed Release

78% 70% 50%

Technology Oros Eurand SODAS

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

When to use, when to change

Side effects Past history Substance abuse Efficacy Onset time Stimulant first line, Strattera second Follow MD

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

Behavior Modification

Classroom Home Basics of Behaviorism

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

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?

Consequences

Reward Punishment

Positive ↑ behavior by ‘+‘ something

↓ behavior by ‘+‘ something

Negative ↑ behavior by ‘-‘ something

↓ behavior by ‘-‘ something

Consequences examples

Reward Punishment

Positive Add TV time when no hitting

Add chores when there is hitting

NegativeTake away chore when there is no

hitting

Take away toy when there is

hitting

Other Behavior Therapy techniques Token Economy Time outs

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

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

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

References

American 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 disorder—questions 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 disorder—questions 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.