Benard P Dreyer MD Director DevelopmentalBehavioral Pediatrics NYU

Benard P. Dreyer, MD Director, Developmental-Behavioral Pediatrics NYU Langone Medical Center ADHD IN CHILDREN…. . WHAT EVERY PARENT SHOULD KNOW 1

This evening, we will discuss the following questions…. . � Overview �What is ADHD? �Are there different types of ADHD? �How do I know if my child has ADHD? �What are the so-called “co-morbidities”? �Are there differences between boys and girls? � How do I parent my child with ADHD? � What are effective treatments? � How do I advocate for my child at my child’s school? 2

What is Attention-Deficit/ Hyperactivity Disorder (ADHD)? � Problems with attention and focus � Problems with hyperactivity � Problems with impulsivity � 3 types: �Primarily inattentive: used to be called ADD �Primarily hyperactive-impulsive: usually younger �Combined � Genetic: runs in families 3

Attentional Problems Doesn’t pay attention to details; makes careless mistakes in homework � Difficulty attending to what needs to be done � Doesn’t seem to listen when spoken to � Fails to finish activities or follow-through (not on purpose) � Disorganized � Avoids tasks that require a lot of mental effort � Is forgetful � Loses things � Easily distracted � 4

Hyperactive-Impulsive Problems � Hyperactivity �Fidgets �Leaves seat when expected to remain seated �Runs about when expected to stay still �Has difficulty in quiet play activities �Is always on the go �Talks too much � Impulsivity �Blurts out answers before questions completed �Difficulty waiting turn �Interrupts or intrudes in others’ conversations or play 5

How is ADHD diagnosed � Rating scales (0 -3; never, sometimes, often, very often) �“often” or “very often” for majority of items � Problems in at least 2 different environments �Usually home and school; �after school; Sunday school; Hebrew school; sports � Affects functioning causing impairment: �Academic: School performance �Participation in organized activities �Social: Relationships with peers and families More than 6 months duration � Some symptoms started before age 7 � 6

Can other problems be confused with ADHD… Adjustment reactions to divorce, death in family Obstructive sleep apnea Tourette’s (Tics, ADHD, and OCD) Bipolar disorder Act silly, trouble sleeping, trouble staying focused Talk really fast, mood swings Have little energy, feel sad Short temper, irritable 7

Co-Morbidities � Learning problems 25 -75% �Language and Reading, including phonemic awareness and auditory processing �Math �Executive functioning �Working memory �Processing speed � ODD: Oppositional Defiant Disorder 30% � Conduct Disorder 10% (lies, steals, truant) � Anxiety and/or Depression 25% 8

ODD Argues Loses temper Refuses to go along with adult requests or defies Deliberately annoys people Blames others for his or her mistakes Angry and resentful Spiteful and wants to get even 9

Anxiety and Depression � Anxiety � Separation anxiety � Panic � OCD (obsessive-compulsive disorder): repeated upsetting thoughts and ritual behaviors � Phobias: specific fears of animals, heights, injections � Social phobia: painfully shy, fear of public speaking or performance � Generalized anxiety: excessively worried about a lot of things, bodily complaints � Depression � Sad, feels worthless � No energy or interest in anything � Bad temper, irritable � Problems with eating and sleep 10

Evaluation � ADHD rating scales for parents and teachers � Assessment of impairment � Make sure not obstructive sleep problems � Assess for co-morbidities �Especially look at learning differences and problems �Neuropsychological evaluation �Screen for ODD, anxiety, depression � If tics, consider Tourette’s 11

Differences between boys and girls Boys: girls 3: 1 (although girls under-diagnosed and diagnosed later than boys) Girls more likely to have inattentive form only Girls more likely to have anxiety, especially in adolescence Girls less likely to be disruptive in the classroom If they are hyperactive-impulsive, tend to be more “motor-mouths” than running around 12

Parenting Effective Parenting General principles and specific examples Behavior Management Structure the Home 13

Effective Parenting of the Child with ADHD 1 � Use a Positive Approach �Try to reward positive behavior as much as possible rather than only focusing on what is being done wrong �Praise child when he is being nice to sister as opposed to only focusing on behavior when he is hitting his sister �Catch your child being good �Try to re-frame what you want from child by describing positive behavior rather than only saying what you don’t want to see �Focus on strengths and provide him with opportunities to succeed to build self esteem 14

Effective Parenting of the Child with ADHD 2 � View as a challenge rather than a burden �You are your child’s most important teacher and teaching about behavior is just part of that job. �Assume that your child is really trying and just can’t do it, not being purposely “bad” �Stay Calm: Take anger or emotional upset out of your response �Fight bad behavior, but love the child �Help your child when he needs help: children naturally mess-up �Reward effort 15

Effective Parenting of the Child with ADHD 3 � Clearly state what you expect from your child �Say exactly what behavior you want �Under what circumstances that behavior should occur �What your child can expect if he or she does what you ask �Give clear and simple feedback �Try to make it positive even if child is not perfect �Use checklists or, for younger children, star charts � Ignore some behaviors 16

Effective Parenting of the Child with ADHD 4 � Practice when you know when and where problems are likely, for example � Arrange a short trip to the store. � Explain in detail what you expect your child to do and be specific about the behaviors you expect from him. � Promise a treat after shopping if he is successful. � If the child grabs items, wanders away or has a fit because you will not buy what he wants, he needs more practice. � Drop everything, tell the child that you are sorry he forgot the rules and say, "I think we need more practice at this, honey. " � Then take the child back out to the car, and when he calms down, begin again. � Make it a short trip so that he is likely to succeed; and remember, it's practice. If he goofs up several times, end the practice and begin again another day. 17

Effective Parenting of the Child with ADHD 5 Be consistent over time: the worst thing to do is to respond differently at different times; this is likely to increase the unwanted behavior Be consistent as a “team” Work out differences between parents and other caretakers 18

Behavior Management 1 � Identify Target Behaviors � First pick one or at most two behaviors � Examples: � keep hands to self � wait your turn � play quietly � follow directions the first time asked � stay in your seat � complete homework � Talk to your child about the behaviors � Sometimes you have trouble staying in your seat when you are supposed to so we are going to work on sitting in your seat appropriately. It is important to sit still and keep all four chair legs on the floor. � Negotiate rewards and consequences up front 19

Behavior Management 2 � Identify effective rewards and consequences � Rewards � Material � Stickers � Edible treats � Earning points or tokens towards purchase of small toy � Privileges � Extra time on the playground or video game � Trip to movies or zoo � Social � Pat on back or hug � Praise � Consequences � Loss of privileges � Loss of tokens or points � Time out (don’t overuse) 20

Behavior Management 3 � Enforce the plan �Give rewards and consequences as quickly as possible �Natural, logical consequences are best; if the consequences are too “painful”, you may not be able to follow through �Be consistent � Provide frequent monitoring and feedback � Implementation across settings most powerful �Daily school-home report card 21

Structure the Home � Set up clear house rules � Organize your home �Get rid of clutter �Identify specific places for things to go �Make it clear that things have to be returned to their place and enforce � Set up a daily schedule �Routines are vital �Predictability is important 22

Treatments Medication Behavior Management at home Behavior Management at school Accommodations in school Special education in school 23

Medication 1: Stimulants � Type �Methylphenidate (Ritalin, Concerta, Focalin, Metadate, Daytrana) �Amphetamines (Adderall, Vyvance) � Long acting vs. Short acting �Ritalin LA, Metadate CD, Focalin XR �Concerta �Adderall XR �Vyvanse: longer acting than others �Daytrana patch (methylphenidate): � Can use for different amounts of time � Good for children who don’t like to take meds orally 24

Medication 1: Stimulants � Side Effects �Decreased appetite �Irritability �Social withdrawal �Emotional sensitivity �Stomachaches and headaches: usually self-limited �Tics? ? ? �Fear of cardiac problems (sudden death): � Get an EKG? ? � Don’t give to children with pre-existing cardiac problems �Decreased growth: probably small but real decrease �Abuse: perhaps in teenagers? But decreased illicit drug use when treated 25

Medication 2: other meds Atomoxetine (Strattera) Less effective Fewer side effects Gradual increase in dose and effect over weeks May be especially helpful if co-morbid anxiety Guanfacine and Intuniv (Guanfacine XR) May be helpful for those with aggressive or disruptive behavior and ADHD 26

Working with Your Child’s School Effectively: The Law � Section 504 of the Rehabilitation Act of 1973 and the ADA (Americans with Disabilities Act of 1990): � ADHD is considered to be a disability � Children entitled to free appropriate (not ideal) public education whether or not their ADHD makes them eligible for special education under IDEA � These include accommodations and supports in regular classrooms such has help in note-taking, changes in assignments and testing procedures � IDEA: Individuals with Disabilities Education Act Part B � Must evaluate child � Must be found to be impaired, not just ADHD diagnosis � May be eligible for special education under “other health impairment”, “learning disability”, or “emotional disturbance” � IEP process is used 27

Working with Your Child’s School Effectively: Issues � Evaluation: �School? �Private? Will it be accepted by the school? � Advocacy �Local parent groups �State parent training centers and protection and advocacy agencies �Professionals � Least restrictive � Keep in classroom with help vs. pullout � Is child learning? Does child have good self-esteem? 28

Working with Your Child’s School Effectively: What to ask The Teacher should � � Be warm and positive and encouraging Provide appropriate classroom management � Screen out distractions � Visual timetable � Chunking: reduce length of assignment, break down into achievable goals, short breaks between tasks � Extra time for slow processing � Assist with organization � Clear classroom rules � Behavior management principles similar to home � � Collaborate/ communicate with parents Focus on social skill building 29

Working with Your Child’s School Effectively: Summary Develop personal relationships with school staff Make the staff feel good about themselves Be a presence in the school Negotiate Learn when to fight and when not to fight Learn when to go to the “top” 30

QUESTIONS? COMMENTS? 31