ADHD – What helps

Linda S. Grossman, MD

Bureau Director,

Child, Adolescent and Reproductive Health

Baltimore Co. Dept. of Health

ADHD – Diagnostic Criteria

Sufficient behaviors in either inattentive category and/or hyperactive/impulsive category

Symptoms for at least six months and beginning prior to age 7 years

Symptoms in multiple settings by different observers

Symptoms not better explained by another disorder

6 of 9 inattentive behaviors

Fails to give close attention to details or makes careless mistakes

Difficulty sustaining attention in tasks or play Does not seem to listen Fails to finish school work or other tasks Difficulty organizing tasks Avoids tasks requiring sustained effort Loses things Easily distracted by external stimuli Forgetful in daily activities

6 of 9 hyperactive/impulsive behaviors

Fidgets with hands or feet or squirms Leaves seat often Runs about or climbs excessively Difficulty playing quietly “Always on the go” or acts like “driven by a motor” Talks excessively Blurts out answers Difficulty awaiting turn Interrupts or intrudes on others

Other things with similar symptoms

Specific learning disabilities Mental retardation Anxiety disorders Mood disorders Oppositional defiant disorder Autism spectrum disorders Schizophrenia

More things with similar symptoms

Unreasonable expectations for age Bright but bored Sleep deprivation Worry about situational things Domestic violence (witness or victim) Endocrine disorders Chronic medical conditions Side effects of some medications

School Interventions for ADHD

Educate regarding disorder Identify specific problems youngster has and

design supports to address those needs Make use of behavior plans Point out successes and help figure out why

successful Encourage problem solving

Educate regarding disorder

Helps to know what child can control and what he can’t

Child still needs to follow rules, but modify punishment if impulsivity or distractibility was part of problem

Planned misbehavior still should be punished as for any youngster

Identify specific problems

– Attention span or easy distractibility– Organization problems– Getting started on work and/or finishing

assignments– Handwriting problems– Difficulty with assignments requiring longer answers– Problems with projects or longer term assignments

Identify specific problems

– Difficulty sitting still –squirmy– Often out of seat– Keeping hands to self– Oppositional or aggressive behaviors

Specific supports

Match to the child’s specific problems Examples of supports

– Preferential seating– Individual review of directions– Modification of assignments– Extra opportunities for breaks or movement– Extra organizational help– Assistive technology

Behavior plans

Help provide extra structure Keep number of goals small (three or less) or highlight

one goal of several to be the special focus for the week (perhaps with double points)

For the plan to work, youngster must get reward at least 75% of the time

– Modify interval at which assessed– Lower # points required to get reward or have different

rewards for different # of points– Consider end of morning and end of afternoon rewards

Point out and build on successes

Focus on successes – Gives child message that he can be successful– Easier to figure out what you did right than why you messed

up

Help youngster figure out why he was successful –– What did he do differently this time? – What did others do which helped him?

Encourage him to try to use strategy again or to advocate for himself by asking others to provide identified helpful support

Encourage problem solving

Everyone makes mistakes, key is how you go about making things right or fixing problem

Steps in problem solving– Define the problem– Generate potential solutions (wild and inappropriate are OK

here)– Evaluate potential solutions and select one to implement– Assess how solution is working – if not working, either figure

out how to adjust it so it will work or go back and pick a different solution

Other interventions

For specific learning disabilities – Carefully assess learning strengths and weaknesses– Take advantage of learning strengths– Address weaknesses with appropriate educational intervention

and supports For depression and/or anxiety

– Counseling Reframing Cognitive behavior interventions

– Possible role for medication Depression meds do not work as well in children and teens

Interventions for oppositional behaviors

Have a limited number of clear rules Enforce rules consistently and predictably Select consequences

– Immediate or as close to infraction as possible– Time limited (and preferably of relatively short

duration)– Consider using natural or logical consequences

Oppositional behaviors and conduct problems

Avoid setting the youngster up – preventing misbehavior by preventing situation which often leads

to misbehavior and/or redirecting early on is always better than letting a bad situation play itself out

Provide a way out for youngster – give him a way to save face

Give messages that you see the youngster having positive qualities

– Adult messages about character (positive or negative) are very powerful!

– Reframe into positives when possible (instead of “argumentative”, describe as “persuasive” or “a good debater”)

Organizational problems

Use of routines– School materials in box by front door or in path to door– List posted near door of what special things need on what day

(i.e. gym shoes, musical instrument, etc.) Visual reminders

– Checklists– Cues

Color coding Time lines – making sure to include time for the

unexpected glitches

Organizational problems cont.

Binder with a zipper Different color dividers (cover textbooks in

matching colors by subject) Encourage re-organization of binder either

daily or at least weekly Have a regular place to put papers taken out of

binder (in case need later)

Role for medications to treat ADHD

Stimulant medications – for school age and adolescents– Highly effective

Any particular med works for approx. 75% One of the stimulants works for approx 90%

– Good safety profile– Intermittent administration OK in terms of safety and

effectiveness

Types of stimulants

Methylphenidate family Ritalin Metadate Concerta Methylin Focalin

Dextroamphetamine family Dexedrine Adderall Vyvanse

Other med options

Atomoxetine (Strattera)– Norepinephrine re-uptake inhibitor– Not as effective as stimulants for most– Better choice for a few youngsters– Side effects similar to SSRI’s (depression meds)– Some risk of suicide ideation– Builds up in the system so must be taken daily but

can be stopped abruptly

Other med options – not FDA approved for this use

Need to be given on regular predictable schedule because of side effect issues

Alpha agonists– Clonidine– Guanfacine (Tenex)

Antidepressants– Welbutrin (not for those with seizures and bulimia)– Tricyclic antidepressants (safety margin is major problem)

Summary

Environmental and behavioral interventions can be initiated without a diagnosis

Tailor interventions to match specific problems Focus on positive strategies when possible Medication may help the child with ADHD be

able to respond to the environmental and behavioral interventions