Click to edit Master title style 1 ADHD Teleconference A free teleconference brought to you by...

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ADHD Teleconference

A free teleconference brought to you by ADDvisor.com and myADHD.com

See: http://www.myadhd.com/teleconferences.html

Part 1: ADHD Strategies at Your Fingertipsby Harvey C. Parker, Ph.D.

Part 2: Summer Management Tipsby Bill Benninger, Ph.D. and Alan Graham, Ph.D.

Copyright © 2004 All rights reserved.


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Disclaimer

These slides and the accompanying presentation provide a general overview of strategies to manage attention-deficit/hyperactivity disorder (ADHD) and related conditions and do not constitute medical, psychological, educational, or legal advice. Please consult your own health care provider or other professional for specific advice.


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Finding Answers for ADHD

• What is ADHD?• How does ADHD affect daily living?• What causes ADHD?• What procedures are used to assess ADHD?• What treatments work best?• How can assessment tools, tracking tools, and

treatment tools from myADHD.com help families, practitioners, educators, and adults?

• Management Tips


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What is ADHD?

• …A medical condition characterized by inattention and/or hyperactivity-impulsivity.

• …One of the most common mental disorders among children, affecting approximately 5 to 7 % of school-age children and about 2-5% of adults


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Prevalence in the United States

About 2 million children

About 5 million adults


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Prevalence World Wide

• Canada 3.8-9.4% kids • Australia 3.4% of kids • New Zealand 6.7% kids, 2-3% teens • Germany 4.2% children • India 5-29% children • China 6-9% children • Netherlands 1.3% teens • Puerto Rico 9.5% child & teens • Japan 7.7% children • Mexico approx. 5% children• Brazil 5.8% of 12-14 year olds


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Adult ADHD Remains Largely Undiagnosed*

85% Undiagnosed as an Adult

15% Diagnosed

*1999 analysis of a 1000 adult patient epidemiological database.Data on file, Lilly Research Laboratories.


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ADHD is Not a Problem of:

• Will power

• Inadequate parenting

• Lack of motivation

• Lack of intelligence

• Laziness


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ADHD is a neurological disorder that impairs

• Regulation of attention• Regulation of motor activity• Regulation of impulsivity


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ADHD results in problems with

• Planning• Organizing• Starting and stopping activity• Managing behavior• Persisting on tasks• Problem solving• Working memory

These are called Executive Functions


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DSM-IV Criteria:6 of 9 Inattention Symptoms

• Fails to give close attention to details• Difficulty sustaining attention• Does not seem to listen• Does not follow through on instructions• Difficulty organizing tasks or activities• Avoids tasks requiring sustained mental effort• Loses things necessary for tasks• Easily distracted• Forgetful in daily activities


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DSM-IV Criteria:6 of 9 Hyperactive-Impulsive

• Fidgets with hands or feet or squirms in seat• Leaves seat in classroom inappropriately• Runs about or climbs excessively• Has difficulty playing quietly• Is “on the go” or “driven by a motor”• Talks excessively• Blurts out answers before questions are completed• Has difficulty awaiting turn• Interrupts or intrudes on others


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Other DSM-IV Criteria

• Developmentally Inappropriate Levels• Duration of 6 Months• Cross-setting Occurrence of Symptoms• Impairment in Major Life Activities• Onset of Symptoms/Impairment by 7• Exclusions: Severe MR, PDD, Psychosis• Subtyping into Inattentive, Hyperactive, or

Combined Types


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AAP Assessment Guidelines

• Diagnosis must meet DSM IV criteria• Evidence of symptoms and impairment must come

from parents or caregivers • Evidence of symptoms and impairment must come from

classroom teacher or other school professional• Assessment should include evaluation for co-morbid conditions• Rating scales designed specifically to assess ADHD symptoms

should be used in addition to narrative reports, observations, etc.

• Other diagnostic tests are not routinely used to establish presence of ADHD but may be used to discover other conditions


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Potential Areas of Impairment

Academic failure

Relationships

Legal difficulties

Smoking and SUD

Injuries

Motor vehicle accidents

Occupational/vocational


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• Dysfunction of dopaminergic and noradrenergic systems

• Dopamine and norepinephrine are important in drugs that treat ADHD

Arnsten AF. J Psychopharmacol 1997;11:151-62; Madras BK, et al. Behav Brain Res 2002;130:57-63; Russell VA. Behav Brain Res 2002;130:191-6; Solanto MV. Behav Brain Res 2002;130:65-71.

ADHD has a Neurobiological Basis


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How do you get ADHD?


18Faraone SV, et al. Child Adolesc Psychiatr Clin N Am 2001;10:299-316, viii-ix; Faraone SV, et al. Am J Psychiatry 2001;158:1052-7; MARK Web site.

Heritability estimate

0 0.2 0.4 0.6 0.8

Height

ADHD

Schizophrenia

IQ

Depression

Heritability Estimate

ADHD Is highly heritable


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Causes of ADHD

• Heredity/Genetics• 25-30% siblings 55-92% identical twins

• 15-20% mothers 25-30% fathers

• Neurological Development

• Complications of pregnancy, fetal exposure to alcohol or tobacco, premature birth with minor brain hemorrhages (10-15%)

• Head trauma, brain hypoxia, infection, lead poisoning during early childhood (3-5%)


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Common Comorbid Diagnoses

0 10 20 30 40 50 60

Oppositionaldefiant disorder

Conductdisorder

Mood disorder

Anxietydisorder

Learningdisorder

Biederman et al. JAACAP 1996;35:343. Pliszka. J Clin Psychiatry 1998:59(suppl 7):50.Biederman et al. JAACAP 1999;38:966. Spencer et al. Pediatric Clin N Am 1999:46:915.


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AAP Treatment Guidelines

• Primary care physicians should establish treatment programs for ADHD

• Clinicians, parents, teachers, and children should collaborate to target outcomes

• Medication and/or behavior therapy are appropriate treatments

• Periodic, systematic follow-ups for the child should be done with monitoring for targeted symptoms. Information should be gathered from parents, teachers, and the child.


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How can we help people with ADHD?

Treatments for ADHD •Education•Medication•Behavior Modification•Classroom/Workplace Accommodations


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MTA Study—The Largest StudyComparing ADHD Treatments

Which ADHD treatments (or combination) work best?

1. Medication (MedMgt) vs. Behavioral Tx (Beh) vs. Combination (Comb) over the long term

2. State-of-art, intensive MTA treatments vs. standard care available in the community (CC), over the long term

See: http://www.myadhd.com/articles.html


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Co-Occurring Disorders in MTA Children (n=579)

OppositionalOppositionalDefiant DisorderDefiant Disorder

ADHD aloneADHD alone

TicTicDisDis..

ConductConductDisorderDisorder

AnxietyAnxietyDisorderDisorder

MoodMoodDisDis..

31%

40%11%

4%

34%14%


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MTA Study—Treatment Groups

Four Treatment Groups (14 months)1. Medication alone (MPH dosed to last 12 hours)

2. Intensive behavioral treatment alone

a. over 30 sessions for parent training

b. 8 week summer program

c. behavior therapist for 12 wks in classroom

d. daily reports from school to home

3. Combined medication & behavioral treatment

4. Community-based care (control)

Source: MTA Study Group, Arch Gen Psych, 1999, 56, 1073-1086.


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MTA Study Results

All treatment arms found to be effective on an absolute basis

Medication + behavioral treatment

Medication alone

• Behavioral treatment alone • Community based treatment

Source: MTA Study Group, Arch Gen Psych, 1999, 56, 1073-1086.

Nearly equally effective and superior to:


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% “Normalized” at 14-Month Endpoint MTA Groups vs Classroom Controls

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100%

80%

60%

40%

20%

0%

Controls Comb Med Beh CC

Swanson, JM, et al. J. Amer Acad Child Adolesc Psychiatry , 2001; 40 (2); 168-179.

88%

68%

56%

34%

25%


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Commonly Used Stimulant Medications for ADHD

• Methylphenidate (MPH) Products• Ritalin short & mid-acting forms• Concerta long-acting • Metadate CD mid-acting • Ritalin LA mid-acting• Focalin mid-acting

• Amphetamine Products• Adderall mid-acting • Adderall XR long-acting• Dexedrine mid-acting spansule• Dextrostat mid-acting

Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+


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Commonly Used Non-Stimulant Medications for ADHD

• Nonstimulant Products• Strattera long-acting

• Other Nonstimulants Products• Wellbutrin long-acting• Tenex mid-acting• Clonidine mid-acting



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Efficacy of Medication for ADHD

• Improvements in core symptomsreduced hyperactivityreduced impulsivityimproved attention

• Improvements in related symptomsreduced oppositional behaviorImproved social relationsimproved academic performance



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Adverse Effects of Stimulants

insomniadecreased appetiteweight lossheadache irritabilityStomachacherebound agitation or exaggeration of pre-medication symptoms as it

is wearing off

PrecautionsUse cautiously in patients with marked anxiety, motor tics or with family history of Tourette syndrome, or history of substance abuse. Don't use if glaucoma or on MAOI. Abuse potential particularly in tablet form.

Always consult your physician before using ADHD medications.


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Adverse Effects of Strattera

In childrendecreased appetite GI upset (can be reduced if medication taken with food)sedation (can be reduced by dosing in evening) lightheadedness

In adults insomniasexual side effects increased blood pressure Precautions

Use cautiously in patients with hypertension, tachycardia, or cardiovascular or cerebrovascular disease because it can increase blood pressure and heart rate. Has some drug interactions. While extensively tested, short duration of population use.Always consult your physician before using ADHD medications.


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Using Medication Effectively

• American Academy of Pediatrics recommends that for treatment of ADHD physicians start with a low dose of medication and tritrate upward to find the optimal dose.

• Optimal dose is the best individualized response with minimal side effects.

• Have a system in place to monitor treatment outcomes to find the optimal dose and adverse effects.



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Treatment for ADHD can beimproved by: • Empowering parents and providers with accurate information

about best practices– creating connections between stakeholders and

encourage greater communication– using an “educate the community” model

• Developing communication tools– web-based assessment tools– “checklists” for parents, teachers and doctors to guide

each one’s role in assessment and treatment

• Forming a coalition of parents, professionals, and policy makers


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MyADHD.com Tools

• Assessment Tools rating scales, checklists, and child/adult history forms

• Tracking Tools rating scales

• Treatment Tools worksheets for skill improvement

• Library Tools learning resources (articles, books, newsletters,

announcements, etc.)

Tools to Empower Providers, Parents, and Adults


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Assessment Tools

• Vanderbilt Assessment Scale (Parent and Teacher Informant Versions) (Wolraich, et al.)

• SNAP-IV (18 items) (Swanson, et al.)

• SNAP-IV-C (80 Items) (Swanson, et al.)

• ADHD Symptom Checklist (child and adolescent version) in English and Spanish

• ADHD Symptom Checklist (adult self-report and adult observer-report versions) in English and Spanish

• Childhood Disorders Checklist• Child and Adolescent History Form• Adult Psychosocial History Form• Novotni Social Skills Checklists (self and observer versions)

See: http://www.myadhd.com/assessmenttools.html


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Tracking Tools

• SNAP-IV (Swanson, et al.)

• ADHD Symptom Checklist (child and adolescent version)

• ADHD Symptom Checklist (adult self-report and adult observer report versions)

• ADHD Monitoring System (Rabiner, 1999)

See: http://www.myadhd.com/trackingtools.html


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How Assessment and Tracking Tools Can Be Completed and Sent?

• View form on screen then print and complete and send by mail or fax.

• Download form as PDF file then print and complete and send by mail or fax.

• Transmit form electronically using the Subscriber Administration Page.

– Select from over a dozen forms (Eng/Span) that you would like to send for completion.– Send form easily to multiple teachers (e.g., middle/high school) using myADHD.com

address book feature.– Once received, forms can be archived in your private account. Received forms can be

easily transmitted to others for review.


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Using Your myADHD.com Subscriber Administration Page

QuickTime™ and aTIFF (LZW) decompressor

are needed to see this picture.

See:http://www.myadhd.com/sampleadminpage1.html


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Treatment Tools

See:http://www.myadhd.com/treatmenttools.html

Worksheets to improve skillsfor children,adolescents,and adults.


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Types of Treatment Tools

Children Adolescents Adults

Behavior Management Behavior Management Organizational Strategies

Study Strategies Study Strategies Career Planning

Social Skills Social Skills Medication Management

Anger Management Anger Management Stress Management


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MyADHD.com Medication Chart

See:http://www.myadhd.com/treatment_tools/medicationchart.html


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Daily Report Cart

See: http://www.myadhd.com/treatment_tools/sample3003dailyreportcard.html


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Writing Behavior Contracts


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Home Token Economy Systems

See: http://www.myadhd.com/treatment_tools/sample3004hometokeneconomy.html


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Anger Management Worksheet


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Changing Angry Thoughts


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Don’t Call Out! Raise Your Hand

See: http://www.myadhd.com/treatment_tools/sample3009raiseyourhand.html


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Homework Self-Check


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Overcoming Roadblocks to Family Communication

See: http://www.myadhd.com/treatment_tools/sample7001familycommunication.html


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Problem Solving Worksheet


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Types of Resumes

See: http://www.myadhd.com/treatment_tools/sample9007typesofresumes.html


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Writing an Effective Cover Letter


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Keeping a Personal Budget

See: http://www.myadhd.com/treatment_tools/sample1201personalbudget.html


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Tackling Housecleaning


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Conclusions

• ADHD is a chronic condition that has significant affects on learning, behavior, socialization, and performance across the lifespan.

• ADHD is prevalent in every country where it has been studied.

• ADHD can persist into adulthood.

• ADHD treatments have been well studied.

• Multimodal treatments work best and involve a combination of education about the condition, medication, counseling, behavior management, and school and workplace accommodations and interventions.

• Enhanced communication among stakeholders (providers, parents, educators, adults with ADHD) can lead to maximum improvement.


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Summer Management TipsBill Benninger, Ph.D. and Alan Graham, Ph.D.

•Medication

•Structure

•Accountability

•Social skills

See: http://www.ADDvisor.com


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Summer Management Tips

• Camp• Sports• Vacations• Summer school• Jobs• Family projects• Tutoring

Summer Activities to Consider


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Contact Information

• MyADHD.com– Email: [email protected]– Harvey C. Parker, Ph.D.

Phone: (954) 792-8100

• ADDVisor1-866-ADDvisor

– Bill Benninger• Email: [email protected]• Phone: 1-614-251-0400

– Alan Graham• Email: [email protected]• Phone: 1-847-824-1235

See: http://www.myadhd.com See: http://www.ADDvisor.com


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Other Resources

Children and Adults withAttention Deficit /HyperactivityDisorders (CHADD)www.chadd.org

Attention Deficit DisordersAssociation (ADDA)http://www.add.org/

Learning Disability Association ofAmericahttp://www.ldanatl.org/

American Academy of Child andAdolescent Psychiatry (AACAP)http://www.aacap.org/

American Academy of Pediatricswww.aap.org

A.D.D. WareHousewww.addwarehouse.com

http://www.myadhd.com/organizations.htmlSee:

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