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Attention Deficit Disorder and Learning Disorders
David Johnson, M.D.
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Attention Deficit Hyperactivity Disorder
A persistent (more than 6 months) cluster of behaviors character-
ized by inattention, hyperactivity, and impulsivity with the follow-
ing features:
Behaviors are more frequent and more severe than occurs
in most children at a comparable developmental level
Behaviors began before 7 years of age
Behaviors are manifested in two or more settings (eg, school
and at home)
Behaviors cause clinically significant dysfunction in social,
academic, occupational, or family function
Attention and learning disorders in children are very common
problems. Primary care pediatricians should be the ones to make the
diagnosis and do the treatment in the majority of children. You do not
need a specialist in developmental/behavioral pediatrics to treat most
kids or diagnose most kids with ADHD.
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Attention Deficit Hyperactivity Disorder:
DSM IV Criteria
1. Inattention:Six or more of the following.
often flails to give close attention to details or makes care-
less mistakes in schoolwork, work, or other activities.
often has difficulty sustaining attention in tasks or playactivities.
often does not seem to listen when spoken to directly.
often does not follow through on instructions and fails to
finish schoolwork, chores, or duties in the workplace (not
because of oppositional behavior or inability to understand
directions).
often has difficulties organizing tasks and activities.
often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (such as schoolwork or
homework). often loses things necessary for tasks and activities (eg,
school assignments, pencils, books, tools).
is often distracted by extraneous stimuli.
is often forgetful in daily activities.
ADHD and the new DSM IV criteria. ADHD is defined as a persistent,
that is more than 6 month cluster of behaviors. It's a behavioral cluster
that has to have been going on for awhile - it can't just have started last
week or last month. The behaviors are more frequent and more severe
than most children at a comparable developmental level. This is very
subjective, and part of the whole problem with diagnosing ADHD is
there is no one way to make the diagnosis. There is no specific test. It
is defined as behavior that is just more frequent and more severe than
most children at a comparable level. It has to begin before seven years
of age. It is not something that begins later on.
Most importantly, it has to be manifested in two or more settings:
school or work and home. If you just have these behaviors occurring
in one setting only, that is not ADHD. If it is only at home and not at
school, it is not ADHD. If it is only at school and not at home, that is
not ADHD. You should be thinking of other parts of your differential
diagnosis. So, ADHD has to occur in at least two or more settings.
Finally to make the diagnosis, it has to cause clinically significant
dysfunction in the social, academic, occupational, or family setting.
There are some kids you'll see, that you will say to yourself, "this kid
has ADHD. He's wild." But, he's doing great. He has friends. He's
doing well in school. The school has adapted to him. The family has
adapted to him. You might not make the diagnosis in that child
because there is not a clinically significant dysfunction. With the same
child in another setting who has a lot of problems in school and at
home, you might make the diagnosis. So the diagnosis of ADHD is
tough because there are these subjective features. And even among
experts, so-called experts, people will disagree with the diagnosis.
The DSM IV criteria. For inattention, you have to have six or more of
the following. One fails to give close attention to details or makes
careless mistakes in school work, work outside the home, or in other
activities. They often have difficulty sustaining attention in tasks or
play activities. What is important is sustaining attention when it is not
easy to sustain attention, when it takes a little more effort, that is when
ADHD shows up. The parents say, "He can play Nintendo for two
hours." and therefore he doesn't have ADHD. But that is not true.
Because think of the kind of attention that it takes to play Nintendo.
Whereas you have to pay attention to what's going on it is always
changing. You are not sitting laboriously studying one thing or looking
at a number of things as you do in school. Does not seem to listen
when spoken to directly.
Often does not follow through on instructions and fails to finish
schoolwork, chores or duties in the workplace (not because of
oppositional behavior or inability to understand directions). He just
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2. Hyperactivity - Impulsivity: 6 or more of the following.
Hyperactivity
often fidgets with hands or feet or squirms in seat.
often leaves seat in classroom (or in other situations where
remaining in seat is expected).
often runs about or climbs excessively in situations where it
is inappropriate (in adolescents or adults, feature may be
limited to subjective feelings of restlessness).
often has difficulties playing or engaging in leisure activities
quietly.
is often on the go or often acts as is driven by a motor.
often talks excessively.
Impulsivity
often blurts out answers before questions have been
completed.
often has difficulty awaiting turn.
often interrupts or intrudes on others (eg, butts into conver-
sations or games).
can't get things done. Keeps trying a million projects, none of which
get completed on time, if they get completed at all. Often has difficul-
ties organizing tasks and activities. And often avoids, dislikes or is
reluctant to engage in tasks that require sustained mental effort, such
as schoolwork, homework.
Again inattention, six or more of these. Often loses things necessary for
tasks and activities, like school assignments, pencils, or books. Is often
distracted by extraneous stimuli. These are the kind of kids who are in
your office and they hear someone crying next door and they are
already over there looking to see what is happening. Something is
going on in the waiting room and they are looking over there. They are
extremely distractible. Their attention cannot stay focused unless it is
a quiet environment with very little else going on. And finally, is often
forgetful in daily activities. Many people are diagnosing themselves
with ADHD. Because it's on a continuum and all of us have, to a
greater or lesser degree, some of these issues. The question is, is it
causing dysfunction in our lives, and that is really a key question in
making a diagnosis.
The second aspect of ADHD, after inattention, is hyperactivity. As you
know, you can have inattention without hyperactivity. So, six or more
of the following.
Often fidgets with hands or feet or squirms in seat. ADHD kids didn't
move more than non-ADHD kids. It was that it was non-directional,
non-purposeful movements that happened more--squirming, fidgeting
all the time. When sitting in their seats, their foot is always racing.
They are always squirming, fidgeting around. When watching
television, they are in one position, then another position, then they're
on the floor and so on.
Often leaves seat in classroom or in other situations where remaining
in seat is expected. Often runs about or climbs excessively in situations
where it is inappropriate. Sometimes they have no sense of fear. They
are fearless at climbing and running around. In adolescents or adults
this may be manifested in more subjective feelings of restlessness. The
child feel restless and squirmy. The hyperactivity may go away, and
often usually does go away in older children and adults, but the
internal sensation of feeling restlessness persists. Often has difficulties
playing or engaging in leisure activities quietly. These are boisterous
kids. They are often "on the go" or act as if "driven by a motor". They
are talkative kids who talk excessively all the time. That is the second
part of the triad of ADHD, inattention and hyperactivity.
Thirdly, there is impulsivity. Often blurts out answers before questions
have been completed. Often has difficulty awaiting turn. Often
interrupts or intrudes on others, like butting into conversations or
games. It's almost as if there is no inhibition. There is no sensor
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DSM IV: Types of ADHD Patients
1. ADHD, Combined type (if criteria for both inattention and
hyperactivity are met)
2. ADHD, predominantly inattentive type
3. ADHD, predominately hyperactive impulsive type
between the thought and the action. Most of us have thoughts. We
want to do things, but we have the ability to pull in or rein in the
impulses. But for some kids, the thought is the action--there is nothing
in between. It is a disinhibition that causes them their impulsivity.
Some people view ADHD as a disorder of disinhibition, inability to
inhibit action in activity, inability to inhibit wandering attention and
inability to inhibit impulsivity.
The DSM IV then describes three types of ADHD. The combined
type, if the criteria for inattention as well as hyperactivity or
impulsivity are met. ADHD, predominantly inattentive type. These
are kids who are usually not diagnosed until they are school-age
because they are not hyperactive, but have a very difficult time in
school paying attention and achieving their potential in school
because of attentional problems. Some people feel that the incidence
of males and females for the inattentive type is about the same,
although it is much higher for the hyperactive type in males than
females. And then primarily hyperactive-impulsive type, which is
much less common.
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Differential Diagnosis of ADHD
Active, normal child
Acute or chronic stress
Post-traumatic Stress Disorder
Anxiety disorder
Depression
Under stimulation
Oppositional behavior or conduct disorder
Learning Disorder
Early mood disorder
Differential diagnosis. The first part of any differential diagnosis is
always, "This is an active, normal child. This is a very active child
but not a hyperactive child. And that is a very difficult decision to
make. I would stress that it is probably based more on the issue of
dysfunction in the child's life than an absolute level of activity or
inattention. The child is able to do well, has friends and so on - you
may just say this is a very active child. The same child though who
is not doing well in school or socially, you might say has ADHD.
Acute or chronic stress. Some kids will respond in a way that is very
ADHD-like to stress in their lives. Stress of any sort. Again as
primary care physicians, you are in the best position to know if it is
stress that is engendering these behaviors in kids. Post traumatic
stress disorder (PTSD) occurs in children who witness a lot of
violence. Children who have been traumatized themselves can look
very much like ADHD. And again, you need to know what the
environmental context of these behaviors are before you reach the
conclusion that this is an endogenous problem in the child that has
ADHD. Anxiety disorders, depression, the child is understimulated,
oppositional behaviors, conduct disorders, learning disabilities, and
early mood disorders. It is very interesting when people go back and
look at adults who have bipolar disorder, manic depressive disorder,
serious depression, they were often diagnosed in childhood as
having ADHD. Again, this is one of the things that is going to be
hard to know unless there is a positive family history. But it looks
like some children, who will eventually have significant psychiatric
mood disorders as young adults or adults, will for look like they had
ADHD when they were young children.
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Important Coexisting Features of ADHD,
Not in DSM Criteria
emotional lability / immaturity
resistance to reinforcement
aggressiveness
academic problems poor social skills
poor peer relations
- Poor Self-esteem
Kids with ADHD tend to have emotional lability and immaturity.
Other kids see them as babies. They cry a lot, they laugh a lot.
They're up, they're down. They seem to be really immature. It's
almost as if their emotions are as labile and hyperactive as every-
thing else about them. They seem to be resistant to reinforcement.
When we talk to parents, and say, "Try this. Try 'time out'." They
say, "I tried it. I tried it and nothing works." In fact, that is one of the
hardest parts of dealing with hyperactive kids is that they are more
relatively resistant to reinforcement than other children, positive or
negative reinforcement. They just can't seem to inhibit themselves
no matter much how reinforcement you use.
They may be aggressive. If there is one red flag about long term
outcome in children with ADHD, it is the aggressive child of
ADHD. When we look at long term studies, it is the ones who were
really aggressive in early childhood who are the most worrisome for
a bad long term outcome. And that should be a major red flag. If it is
a very aggressive child with ADHD, then that child definitely needs
counseling among the other modalities that you will use for the
child. So, aggressiveness is very important to ask about in terms of
long term prognosis. Academic problems clearly go along with
ADHD, as well as learning disabilities. Poor social skills and poor
peer relations should be sought.
One way to differentiate the very active child from an ADHD child
is that generally the very active child is accepted by his peers, and I
say "his" because males outnumber females 6:1. Very active chil-
dren are accepted by the peers, full of energy, very active, and other
kids like him. ADHD kids are not so much fun. They butt in, they
are babies, they can't inhibit themselves, they don't play the games
correctly, they may miss social cues. Often, other kids don't like
them. After treating their ADHD, these children may for the first
time be asked to play by other children. Social dysfunction as part of
ADHD. Other kids don't like them.
The bottom line, and I think in some ways the most pernicious
aspect of ADHD in the long run, is poor self-esteem. You put all
these things together, the child is having trouble with his parents,
not doing well in school, none of the kids like him. He really gets a
sense of himself that he's just not worth very much, and that sense of
himself may dog him all his days, long after perhaps he learns to
cope with his ADHD symptoms. One of the most important things
that you can do is emphasize to parents the importance of self-
esteem. Try to help the child to find islands of confidence in feeling
good about himself because in the long run that may be the most
important therapy of all.
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Prevalence of ADHD
4-6% of elementary school children
Male to female ratio is 6:1
? on the rise or more diagnostic sensitivity or overdiagnosed?
much higher incidence in first and second degree relatives
The prevalence of ADHD is up to 25%, and these kids are on
Ritalin. In other communities 0%. I think it is the most
overdiagnosed and most underdiagnosed condition in childhood. So,
it kind of depends on where you live and who you see.
The best estimates I would say are 4-6% of elementary school
children may have ADHD. So if you see a lot higher, you know
something is up. There is a higher incidence in first and second
degree relatives. So, family history is helpful in this.
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Etiology of ADHD
The etiology is unknown
believed to have a neurological basis (underactivity of frontal
lobes on PET scan; decreased dopamine metabolites in CSF)
We believe that ADHD is endogenous, not environmentally medi-
ated in any way. It is believed to have a neurological basis. There
have been studies showing the underactivity of frontal and
prefrontal lobes on PET scans. Decreased dopamine metabolites in
CSF. It's been associated with maternal smoking, prematurity. At
this point we really don't know.
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Clinical Diagnosis of ADHD
Corroboration. A questionnaire or interview of most or all of the
child's significant caregivers should assess the presence and
severity of symptoms. Clinical judgment is essential.
History
Symptoms are evaluated.
Complicating home or social stressors is assessed.
Cognitive and academic performance is documented.
The impact of symptoms on the rest of the family, including
the parent, is evaluated.
Child and sibling relationships are evaluated.
Treatments tried in the past are sought.
Physical exam
Most useful to assess child's response to a structured
situation
Neurological exam (e.g., clumsiness, "soft signs" not helpful;
hearing, tics)
Minor congenital or anomalies
Skin for neurocutaneous stigmata
Laboratory evaluation should include lead levels, anemia,
?hyperthyroidism.
In making the diagnosis, you have to seek corroboration, via ques-
tionnaires or interview, of the symptoms from most or all of the
child's significant caregivers. You never should make the diagnosis
just because you think it's true and the parent thinks it's true. That is
not enough because some kids can keep it together in the office very
well in a short visit. I have the luxury now of sometimes hour and
half evaluations in an academic setting and it isn't until an hour into
the evaluation the kid is beginning to show his true colors. The
clinicians perception of ADHD in the office does not necessarily
correlate. The child may be very anxious in the office and look like
he has ADHD when he doesn't, or conversely, be very quiet in the
office but if he stuck with it longer you'd see the symptoms.
In making the diagnosis it has to be in more than one setting. If the
parents give you a good history that's great. But you have to seek
corroboration in other important aspects of the child's life. If it's
daycare, if it's school, if it's Head Start, if it's grandparents, if it's the
babysitter. You need to hear from them too because to make the
diagnosis they have to have the symptoms across settings. If the
babysitter says, "No, he's great. I have no problems at all." then you
really need to question whether this is ADHD or not.
Aside from history of symptoms, which you'll ask about, you'll
certainly want to know about complicating home and social stress-
ors. Looking at the environmental context. How the child is doing
cognitively and academically.
Physical exam I think is generally not that helpful. You need to do
it, but there are almost no medical problems that you are going to be
ruling out. I think the physical exam is most useful to assess the
child's response to a structured situation and whether the child acts
like a kid with ADHD when you are examining him or her, as
opposed to looking for any special physical finding or medical
finding.
Minor congenital anomalies. There is increased ADHD in children
with minor congenital anomalies. But again it is not going to help
you so much with diagnosis. Looking for neurocutaneous stigmata,
just to make sure you're not missing something like
neurofibromatosis or tubular sclerosis. Lead, anemia,
hyperthyroidism should also be excluded.
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Diagnostic testing in ADHD
Testing is indicated only as indicated by the history and physical
examination.
Computer vigilance tests are not clinically useful.
The value of educational/neuropsychological testing is question-
able because of the 40% co-occurrence of learning disabilities.
The use of the diagnostic test will be basically based on a history
and physical exam. Computer vigilance tests are not that helpful
currently. There are too many false positives and false negatives for
it to be useful. If the child is doing well in school, I hold off on the
learning disabilities evaluation, if I think it is purely ADHD. On the
other hand, if the child is doing poorly at school, you may want to
try medication. If the medication works and the child continues to
do poorly in school, you should get a learning disabilities evalua-
tion, or you may want to do the learning disabilities evaluation
initially.
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Learning Disorders
Learning disorder is a generic term referring to a heterogeneous
group of disorders manifested by significant difficulties in the acquisi-
tion and use of reading (dyslexia), writing (dysgraphia) and/or
mathematical abilities (dyscalculia).
These disorders are intrinsic to the individual and presumed tooccur secondary to central nervous system dysfunction.
Learning disabilities. Learning disabilities are characterized by a
substantial discrepancy between ability as measured in an IQ test, as
much as that measures ability, and academic performance. The kind
of kid who is smart, but is just not doing well in school--should be
doing a lot better but isn't. You need that discrepancy. Difficulties
with neurodevelopmental functions such as language, memory,
visual-spatial ordering, temporal-sequential ordering. Different
kinds of ways of processing information seem to have problems.
These will come out best with neurodevelopmental testing. These
children also have difficulties with what people are now calling
executive functions. These are higher order mental processes, such
as concept acquisition, reasoning, problem-solving skills, critical
thinking and social cognition.
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Learning Disorder
characterized by a substantial discrepancy between ability (as
measured on IQ tests) and actual academic performance.
difficulties with neurodevelopmental functions such as language,
memory, visual-spatial ordering, temporal-sequential ordering.
difficulties with executive functions such as concept acquisition,
reasoning, problem-solving skills, critical thinking, social cogni-
tion
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Prevalence of Learning Disorder
5% of American schoolchildren are identified as having a
learning disorder. Some estimates as high as 15%.
male to female ratio is 4:1.
About 5% of American schoolchildren are identified as having
learning disabilities. Some people think it is a lot more, again. The
gradation between a learning disability and non-learning disability is
tough. All of us have strengths and weaknesses in our functioning.
Some estimates are as high as 15%. Again, males get the short end
of the stick, 4:1 as usual.
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Etiology of Learning Disorder
The etiology is unknown
There is often a strong family history
Dyslexia is now believed to be caused by dysfunction in phone-
mic awareness.
20 % of all boys and girls may be dyslexic.
The belief that letter reversal is indicative of dyslexia is a
Myth.
The etiology is unclear. There is often a strong family history.
Dyslexia. People used to talk about dyslexia as reading letters
backwards, writing letters backwards. It is now felt that dyslexia has
nothing to do with that. It doesn't matter if you write your letters
backwards or not. It is that dyslexia is a dysfunction in phonemic
awareness. That the children cannot process phonemes, the funda-
mental building block sounds, of language. They can't differentiate
"da" from "pa" very well. And because they can't differentiate these
phonemes they can't then begin to understand the words. They can't
differentiate one from the other when it comes to reading. They are
unable to do that. So, if they take the word "cat", they cannot decode
the word "cat" and therefore can't identify the word. In effect, their
ability to read specifically those words, even though they know what
a cat is.
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Consequences of Learning Disorder
The school drop-out rate is 40%.
Trouble keeping a job and problems with peer relations are
frequent.
10-25% coexist with conduct disorder, oppositional defiant
disorder, depression, or ADHD
Concomitants to learning disabilities. The high school drop-out rate
is 40%. Many kids who drop out of school have learning disabilities,
trouble keeping a job, problems with peer relations, and again, the
co-occurrence with conduct disorders, oppositional defiant disorder,
depression or ADHD.
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Office assessment of Learning Disorder
Physical examination and laboratory tests are rarely useful.
Clinical Evaluation of Learning Disorder:
academic achievement
classroom behavior
attendance
previous special testing and services at school
medical/perinatal history
developmental/behavioral history
family / social history
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Assessment of Learning Disorder
Initial assessment should start with the school (a mandate under
Public Law 94-142).
Parents have the right to an independent, second opinion.
A multi-disciplinary is recommended, but an assessment by a
psychologist is best if only one professional is allowed.
If you want an assessment done too, you can start with the school
and mandate under Public Law 94-142 that the school do an evalua-
tion for learning disabilities. The parents then have a right for an
independent second opinion if they don't agree with what the school
has said. Multidisciplinary evaluations are usually best, but I would
say if you were going to pick one, pick a psychologist or a
neuropsychologist to do the evaluation.
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Treatment of Learning Disorder
bypass strategies (e.g., decrease rate, volume, complexity of
task, go to auditory or visual mode, play to interests, use a
computer) skill remediation
developmental therapies (OT, speech, physical therapy)
curriculum modification
enhance strengths
Treatment of learning disabilities. Bypass strategies are used, so that
decreasing the rate or volume or complexity of the task, even in
small chunks, to work on at a time going in just the auditory or
visual mode. If you have trouble with auditory processing, you have
to learn visually. If you can hear things and remember things well
aurally but not visually, then you need to hear things and not so
much see them to do better in school. Computers seem to be very
helpful in teaching learning disabled kids. I think there is wonderful
potential in that area to learn at their own rate in the modality that
works best for them, whether it is visual or auditory.
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Management of ADHD
Goals
Enhance social functioning
Enhance academic functioning
Improve self-esteem
ADHD is really is a family problem. Kids with ADHD aren't fun.
But I think our role in the management of ADHD is critical in trying
to help the children. Especially by looking at enhancing social
functioning, academic functioning and emphasizing the importance
of self-esteem. The second thing we can do though is use medica-
tions. There is no question that the best treatment for a child who
truly has ADHD are medications. They are effective in about 70% of
the cases but they are not a cure. They improve symptomatology,
but the symptoms, although they will change over time, will proba-
bly last a lifetime. The long term efficacy of medications is still not
entirely clear. It's clear in the short term, it works, but in the long
run, we think it works, but the studies are not there to confirm it.
Ritalin is not a diagnostic test. If the child pays attention better it
doesn't matter. You would pay attention better if you took Ritalin. In
fact, I remember that people at school used it to study for finals
sometimes, illicitly. Ritalin improves attention for everybody, in all
kids. So the fact that a child does have a positive response doesn't
mean that they have ADHD.
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Medical Management of ADHD
Medications are effective in 70% of cases
medications are not a cure-all; long term efficacy data remains
inconclusive
not a diagnostic test!
I think that you should be very comfortable in using at least Ritalin
and Dexedrine. We usually mention pemoline, or Cylert. You may
have read the cautions about liver disease in Cylert, so I would
relegate it to a second line, although I still think you should be
comfortable with it. I use psychostimulants first. There are a few
rules to remember. One is that in the clinical trial, the decisions are
reversible. Just because you start it doesn't mean you can't stop it.
And you should present it to the parents as such. "We don't know if
it is going to work. Maybe it will work. If you like the idea, we can
try it. If you don't like it, we'll stop it. You need to do frequent
follow-up, at least until the child stabilizes. It is not the only treat-
ment. It is best used as part of a multi-modal treatment, including
educational, behavioral and counseling, if needed.
Ritalin is great and it helps, but the children may need help at
school. They may need counseling. The long term studies show that
the kids who do best are the ones who get multi-modal treatment.
You need to obtain ongoing efficacy and feedback from the same
caretakers who provided the history. If you asked the daycare pro-
vider if the child had ADHD through questionnaires or calling them
on the phone. If one medication doesn't work, try another. It is pretty
clear that some kids respond better to Dexedrine than they do to
Ritalin or to Ritalin than to Dexedrine or to pemoline or any of the
others. So, that it is worth it to go through all three. You might think
about whether they want to try some of the second line drugs, like
clonidine or tricyclic antidepressants.
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Drug Therapy of ADHD
Rule 1: Drug use is a clinical trial and decisions should be reversible.
Rule 2: Frequent follow-up is necessary until stabilized.
Rule 3: Drug therapy is best used as a part of multi-modal treatment,
including education, behavioral therapy, and counseling.
Rule 4: Obtain ongoing efficacy feedback from the caretakers who
provided the initial history. Adjust medications accordingly.Rule 5: If one medication doesn't work, try another.
Stimulants are the drug of choice. The good news is there is very
high efficacy and low morbidity to Ritalin and Dexedrine in chil-
dren. They have been extensively studied and they are very safe
when used correctly and you should feel comfortable about using
those. Many people start with Ritalin or Dexedrine.
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Stimulants Are Drugs of Choice
High eff icacy/low morbidity
Stimulants may increase the number of adrenergic receptors in
brain that stimulate attention and inhibitory centers.
Physicians should pick one or two agents and become comfort-
able with their use.
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Methylphenidate and Dextroamphetamine
Start with about 0.3 mg/kg/dose of methylphenidate (MPD) or
0.15 mg/kg/dose of dextroamphetamine (DA).
Increase every few days up to maximum of 1.0 mg/kg/dose (80
mg/day max) for MPD (1/2 dose to DA).
Onset 30 minutes; peak 2 hours; quite variable.
Frequency depends on target symptoms and setting.
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Short or Long-acting Stimulant?
Calculate daily dose of short-acting and convert to long-acting
Balance convenience vs erratic absorption
Consider effects on appetite
Short-acting or long-acting. Remember the problem with long-
acting is erratic absorption, so that the sustained release may last
longer but you never know when you are going to get the effect. It is
perfectly legitimate to titrate short-acting and long-acting.
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Side Effects of Stimulants
Appetite suppression
Sleep disturbance
Rebound hyperactivity vs. paradoxical effect
Emotional dysphoria ("zombie")
Questionable growth retardation
Tics
Side effects include appetite suppression, sleep disturbances, re-
bound hyperactivity, paradoxical effects., emotional dysphoria or
"zombie"-like kids is really something to watch for especially in
younger kids. Growth retardation, which probably doesn't exist and
if it does, it is no more than 2%, the studies have shown. It is gener-
ally not a real concern. And finally, tics. Tics will occur frequently
and nobody really feels that stimulants caused the tics, but we may
uncover tics in the child who has a pre-existing tic disorder, like
Tourette's, which may not show up beforehand. On the other hand,
in any child who has tics, I probably would not use any of the
stimulants, and clonidine is probably the drug of choice.
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Second line drugs
Clonidine
Desipramine
?SSRIs (Prozac)
There is a second line now, you may or may not use. I am getting
comfortable now using clonidine. I still am not comfortable using
the tricyclics, desipramine, and I refer those out if the child is also
depressed, especially if he has ADHD. People are now beginning to
use the serotonin, reuptake inhibitors, like Prozac. It is not clear how
well they will work.
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Parent Counseling
Provide information; demystify; take onus off child
Explain there is no cure, only coping
Emphasize importance of enhancing self-esteem
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Parent Training
Positive reinforcement; minimize punishment; differential
attention ("time-in")
Make positive prophecies; avoid negative character attributions
Discriminate necessary versus unnecessary limit-setting
Provide environments that are free of restraint
Finding something positive for that child to do that plays into their
strengths and not their weaknesses helps with self-esteem. Looking
at the environments. These kids need to be able to run and have a
good time and not be fenced in. Looking at the environment and the
quality of the environment. In letting the child have opportunities to
run and play and be free because that's what his nature tells him he
needs to do. Talk to parents about positive reinforcement, differen-
tial attention ("time-out") and so on. Making positive prophecies for
the child. "It's going to be good." as opposed to "It's going to be
bad." Discriminating necessary and unnecessary limits. These are all
common behavioral interventions you'll use in other areas.
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Classroom Therapy
Consistent with home program
Immediate and frequent consequences for misbehavior
Concrete rules
Hierarchy of rewards and punishments
Extra supervision and training
Allow time for uninhibited play
The classroom should be involved too and this needs to be consis-
tent with the home program with immediate and frequent conse-
quences for misbehavior and positive behavior. Concrete rules. A
hierarchy of rewards and punishments and some time for uninhibited
play are important interventions.
And then for the kids counseling and psychotherapy. If the child's
self-esteem is really low, if they are aggressive, if they are having a
really hard time, I think that counseling is helpful. Not to stop him
from having ADHD, but in dealing with the emotional consequences
of ADHD and/or a learning disability. Find successful activities and
awareness.
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Prognosis of ADHD
Symptoms persist in the majority, but change in nature (eg,
hyperactivity replaced by feelings of restlessness).
Most studies show a higher incidence of problems: Anti-social
behavior, violating the law (20-25%), substance abuse (16%),
other DSM diagnosis (33%)
Some have poorer work performance; adaptive problems; poor
interpersonal skills.
On the other hand, the majority become normal (especially if not
aggressive, high IQ, high socioeconomic scale, multi-modal
treatment)
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References
Dworkin P. School failure. in: Parker S and Zuckerman B: Behavioral
and developmental Pediatrics: A handbook for primary care. Boston,
MA:Little, Brown and Co. 1995, pp 256-260.
Levine M. Neurodevelopmental variation and dysfunction among
school-aged children. In Levine M, Carey W, Crocker A:
Developmental-behavioral pediatrics. Philadelphia: Saunders, 1992,
pp 477-494.
Sprague R, Sleator E. Methylphenidate in hyperkinetic children:
Differences in dose-effects on learning and social behavior. Science
198:1274, 1977.
Manhuzza S, et al. Adult outcome of hyperactive boys. Arch Gen
Psychiatry 50:565,1993.
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