how to diagnose and treat ADHD

1. ADHD (ATTENTION DEFICIT
HYPERACTIVITY DISORDER)
97.
pix45

2. ADHD, AD/HD, ADD
A neurobehavioral D: affects children, teens, adults.
>15 million Americans are affected. x 3 in males
3 features:
• Inattention
• Hyperactivity
• Impulsivity
–more frequent-severe than seen in ones peers

3. 3 subtypes
• Inattentive type (formerly ADD): not hyperactive;
usually don't disrupt the class
• Hyperactive/Impulsive type: fidgety and can't
control their impulses
• Combined type (commonest)
Usually starts not before 7

4. … fidgety; can't control their impulses

5. Who are those children
• Are restless, disobedient, untidy
• Have poor schooling, - performance
• Are embarrassing for parents
• Have few friends, poor social relation
• Not intellectually retarded. Not violent
• Struggle with low self-esteem, failed career, broken
marriage, etc

6. Cause is unknown
Genetics
• ADHD tends to run in families
Neurotransmitters
• Imbalance of NTs
Environment
• Smoking in or complications from pregnancy,
delivery, or infancy

7. 5-9.% of U.S. SCHOOL children have ADHD

8. Inattention
• No sustained attention, careless mistakes, losing
things, forgetfulness, poor listening, easy boredom
• Can't follow tasks/instructions. Poor organization
• Avoids tasks requiring sustained mental effort
• Easily distracted
Symptoms typically interfere with his/her functioning
in social and academic setting
Symptoms may persist into adulthood

9. Often fails to give attention to details; careless mistakes

10. Often has difficulty sustaining attention in tasks or play

11. No sustained attention

12. has trouble listening, following directions

13. Often does not seem to listen

14. Typically Dx at 5 or 6y, but SS start much earlier

15. Often not follows through on instructions, though understands

16. Often has difficulty organizing tasks and activities

17. Often avoids, or is reluctant to engage in schoolwork/HW)

18. Often loses necessary things

19. Often easily distracted by extraneous stimuli

20. Often forgetful in daily activities

21. Hyperactivity
• Fidgeting/squirming, difficulty seating still,
inappropriate running/climbing
• Difficulty with quiet activities, “on the go”, talkative
• Dash around, touching or playing with anything and
everything in sight
Symptoms may persist into adulthood

22. Often fidgets with hands or feet or squirms in their seat

23. Often runs or climbs excessively which it is inappropriate

24. Often has difficulty playing or engaging in leisure activities quietly

25. Often talks excessively

26. Symptoms of Impulsivity
• Blurting out answers, can’t wait for turn: very
impatient
• Intrusive: often interrupts others
• Inappropriate comments, show emotions without
restraint, act without regard for consequences

27. Often blurts out answers before the question is completed

28. Often experiences difficulty awaiting his/her or her turn

29. Often interrupts/intrudes on others (butts into conversations/games)

30. How Do I Know If My Child Has ADHD?
• Many ADHD symptoms are normal in childhood; majority
typically outgrown. Other conditions may have these. So,
very detailed evaluation is needed. But don't delay! Early
Dx can improve social and academic success
Symptoms must be
– ≥6 for 6 mo in >1 settings (home, school, community)
– started <7 y of age
– inconsistent with the age and severe enough to
interfere with social or academic functioning

31. … severe enough to interfere with social or academic functioning

32. Diagnosis
• Clinical. Varies P2P
• No single test
• Dx criteria: must have ≥6 symptoms x 6 mo in at
least 2 settings: home, school, society
– must cause significant impairment in functioning
– Cannot be better explained for another disorder
Dx by exclusion

33. Early Dx can improve social and academic success

34. DD
• Depression, anxiety disorders, mania
• Others: epilepsy, lead toxicity, deafness, liver
D, OSA, drugs, head injury

35. What Should I Do if …?
• Talk to pediatrician for evaluation and involve
various disciplines for
– comprehensive medical,
developmental, educational and
psychosocial Rx
• Early recognition is key to Rx
Treatment

36. Medications
• Relieve SS of ADHD, but don't cure! may not be
right for all, may be a part of a total Rx
• Stimulants: methylphenidate, dextroamphetamine,
lisdexamfetamine
• Non-stimulant: atomoxetine
• Antidepressants: bupropion, desipramine,
clonidine, guanfacine
• may take several weeks for full effect
No antipsychotic!

37. Parenting a ADHD child is a
special challenge!

38. Set Clear Rules and Expectations
• These are essential in both school and at home
• Post the rules for the home
• Provide fair and consistent rewards and
consequences for these rules
• The aim is behaviour modification

39. .. fair and rewards and consequences for these rules

40. Give Clear Instructions
• Not vague! "clean up your mess" or "play nicely“.
Say: "please put dirty clothes in the bowl," “put
toys back on shelves,“ "let's allow your friend to
have a turn for the toy"
• Let your child repeat the instructions back to you
• Use calm and clear voice and kind eye contact
• Break down larger tasks into simple steps

41. “put all toys back on shelves“

42. Discipline, Rewards, and Consequences
• They respond better to rewards and consequences
• Reward good behaviors with praise or special time
with you or outing or favorite activity. Offering
foods or toys not ideal
• It's best to reward and praise than negative
comments: smile and say, "I liked your HW" or "you
did a great job clearing the table”

43. "I liked your HW"

44. Consequences (contd.)
• These can include time-outs. It is essential that
these occur immediately for a negative behavior
• are to be fair, fit, consistent, predictable
• ideally should be explained in advance
• But events like holidays or BD should never be
withdrawn

45. It is essential that these occur immediately after negative behavior

46. time-outs.

47. Use Time-Outs Effectively
• Particularly for children, time-outs can be effective
• Time-outs not last longer in minutes than the
child's age in years (5-min for a 5-y-old)
• Longer time-out is too difficult (defiance)

48. A time-out is an immediate consequence

49. Ignore Within Reason
• Ignoring a negative behavior may be an effective
behavior-modification technique
• Don’t ignore risky or injurious behavior, but ignore
whining, nagging, arguing until these stop
• S/he can crave attention with these. Ignoring can
be effective if done consistently. If he is increasingly
loud if ignored, tell him gently that talk can resume
when he is calm

50. Ignoring an negative behavior may be an effective

51. Define Schedules and Routines
• Not-inflexible enjoyable daily routine: wake-up,
getting ready, breakfast, preparing school lunch,
playing, HW, sleep: s/he knows your expectations.
Post it to remind him/her what to do at a time
• Clocks can be used as cues
• Allow him/her check off completed items
• S/he becomes more structured and stays on task

52. "morning checklist“: making bed, brushing, preparing school lunch.

54. Education
• Most can be educated in standard classrooms
• Some do better in a more structured environment
• Special education is tailored to meet the specific
needs of children

55. Some do better in a more structured environment

56. Develop Organizational Aids
• They have poor skills: trouble organizing tasks.
Provide color-coded notebooks for each subject,
and a HW sheet on top for each day
• A 2nd set of books for home is useful if he forgets to
bring them back
• Help him develop a system for his/her room and
belongings and stick to it

57. Develop a system for his room and belongings and stick to it

58. Eliminate Distractions
• Home environments may be chaotic and full of
distractions
• Ensure plenty of quiet time and space for him to
complete HW and chores
• Room should be free of distractions like TV and
video games, not where most people gather

59. Let your child have plenty of quiet time and space for tasks

60. Set Small Attainable Goals
• You cant go for Marathon (26miles) from never
running! So is unrealistic on your child to change 5
behaviors immediately. This causes unbearable
stress for you and child leading to failure
• No overnight changes! Ask him not interrupting a
conversation for 5 min, remaining seated for 10
min, etc. Praise and reward for these small goals
Focus on 1 or 2 Challenging Behaviors/Time

61. Plenty of praise and rewards when small goals are met

62. … can create unbearable stress for both and leads to failure

63. Find Areas the Child Succeeds in
• No one enjoys constant criticism: it causes more
negative behaviors to get attention
• Everyone needs to feel good at something, find an
area of his/her success: sport, music, lesson, art,
etc. that can greatly improve his/her self-esteem
• Let his/her interests and enthusiasm be your guide

64. Let his/her interests and enthusiasm be your guide

65. Promote a Healthy Lifestyle - Nutrition
• Also for the whole family. Avoid junk foods or
"empty" calories on >1 occasions
• Sugary foods are not a c/of ADHD, but lots of these
may worsen ADHD. He/she may skip meals or eat
irregularly. Small frequent meals are effective
• Teach him/her good food choices by modeling these
upon yourself

66. Teach him make good food choices by modeling these choices yourself

67. Promote a Healthy Lifestyle - Exercise
• Exercise, sports can help excitable children "burn
off" extra energy. It promotes well-being and sleep
• Constant-activity or motion sports are better
• Many children with ADHD do well in martial arts or
yoga that affect mental as well as physical health

68. Regular exercise promotes well-being and sleep

69. Promote a Healthy Lifestyle – Sleep
• Sleep is essential! Not well-rested, he/she will have
more difficulty paying attention
• Set bedtime routine. Use a checklist
• No caffeine. Provide a calming ritual (cuddling or
sharing a story)
• Turn off computer; remove cell phones and others
out of room for the night

70. If not slept, s/he will have more difficulty paying attention

71. Show Your Unconditional Love
• Be sure s/he is aware of your unconditional love,
no matter how s/he behaves
• Withdrawal of affection is never appropriate
• It's OK to let him/her know you are unhappy with
his/her behavior, but remember to say "I love you"
every day. S/he will know that he/she is a valued
member of the family

72. "I love you”

73. Take Care of Yourself!
• Never forget to take care of the caregiver!
• It is a joy of accomplishment, though can bring on
frustration, anger, guilty-feeling, anxiety, worry!
• Remember! his/her behaviors are due to a
disorder not under his/her full control
• Take a break: accept help from friends. Take
pastime to recharge yourself!

74. Take pastime to recharge yourself

75. Prevention
• No surefire way
• Steps to reduce the risk
– avoiding alcohol, drugs, tobacco in pregnancy
– balanced food
Children whose mothers smokes during pregnancy
are twice as likely to develop ADHD

76. Balanced food

77. Outlook
• With Rx, majority of ADHD improve
• Many grow out of the disorder
• But >50% continue having it into adulthood

78. Many grow out of the disorder

79. QUIZES
ADHD denotes commonly
• A Attention Deficit Hypersensitivity Disorder
• B Affliction Diffusion Hyperactivity Disorder
• C Attention Deficit Hyperactivity Disorder
• D Affection Deficit Hypersensitivity Disorder

80. Which is NOT a symptom of ADHD?
• A inattention
• B impulsivity
• C fidgeting
• D Stuttering

81. ADHD symptoms must be present for
• A Three weeks total
• B Six consecutive weeks
• C Three months total
• D At least 6 mo

82. 1. You have to be stricter with ADHD kids
• True
• False
2. Kids with ADHD have discipline problems
because they can’t focus
• True
• False
• It depends

83. To help your child concentrate, make sure
her breakfast is rich in
• Protein
• Unrefined sugars
• Gluten

84. 1. Using a chart can help with discipline; you
should
• Add points for good behavior
• Remove points for bad behavior
• Both
2. Use short-term goals to motivate kids with
ADHD
• True
• False

85. 1. Bad parenting can cause ADHD
• True
• False
2. Cutting out sugar from diet can reduce
disruptive ADHD behavior by
• Up to 30%
• 10%
• 0 -- it doesn't help

86. Which is more likely to lessen disruptive ADHD
behavior?
• Controlling allergic triggers
• Getting more sleep
• Neither

87. ADHD can be an inherited condition
• True
• False

88. Which class of drugs is NOT used to Rx ADHD?
• A Psychostimulant medications
• B Antidepressant medications
• C Antipsychotic medications
• D B and C

89. Which supplements have no benefit for ADHD?
• A Zinc
• B St. John's wort
• C Fish oil
• D Multivitamins

90. ADHD usually resolves itself by adulthood
• True
• False

91. There are no differences in stimulant use for
Rx ADHD across racial and ethnic groups
• True
• False

92. What conditions are closely associated with
ADHD?
• A Cigarette smoking
• B Drug and alcohol abuse
• C Heart disease
• D A and B only

93. The best definition for "diversion“ related to
ADHD Rx is
• A Giving, trading, or selling prescribed medications
• B An ADHD patient's continued inability to concentrate
• C The federal government's method of managing
ADHD in schools
• D Parental denial of childhood ADHD despite diagnosis

94. What % of children with ADHD will have
persistent symptoms into adulthood?
• A At least 10%
• B At least 25%
• C At least 50%
• D At least 75%

95. In teens with ADHD, a major area of concern is
• A Overeating
• B Driving
• C Antisocial behavior
• D Acts of violence

96. ADHD has also been named
• A Superkinesis
• B Hyperkinesis
• C Hyperreality
• D Behavioral extremism

97. Which problems are common in adult ADHD?
• A Poorer educational performance
• B A lower socioeconomic status
• C Multiple marriages and divorces
• D All of the above

98. Pregnant women who smoke or drink alcohol
have more risk of having a child with ADHD
• True
• False

99. MCQ: ADHD
• Stuttering is a symptom
• SS must be persistent for minimum 9mo
• Usually resolves by adulthood
• 50% childhood ADHD continue in adulthood
• Antipsychotic drugs are DoC
• Effective parenting is the most important thing in
Rx ADHD

101. How do I know my child has ADHD and not
something else?
• Only a trained health care professional can
accurately diagnose ADHD. Get the facts
about how ADHD is diagnosed.
How can I get help?
• Always talk to your child's doctor first. Check
out your local resources to meet other parents
and professionals with ADHD expertise. Your
child's school, your human resources
department at work, and neighborhood clinics
may also have lists of resources for managing

102. Working with Your Child's Doctor
• Sometimes my child's doctor's appointments
go by so quickly, I forget to ask the questions
I have. Any tips to help me remember them?
• Try writing down your questions ahead of
time. Then be sure to hand your questions to
the health care professional as soon as he/she
enters the room! If you’ve already left the
office, pick up the phone and call back. Don’t
let a moment of embarrassment keep you
from getting the important information you
need for your child.
Why is the doctor changing the dosage of my

103. What if my child is struggling in school?
• For children dealing with ADHD and school,
there can be additional challenges and
difficulties. Here are three steps you can take
to help your child.
• Step 1: Get a professional diagnosis in writing.
• Step 2: See below to learn about federal laws
that ensure students with disabilities receive
educational opportunities equal to those of
their peers.
• Step 3: Be patient. You may need to involve
your school, as well as teachers and

104. What accommodations may be available to my child in
school?
• If after weighing the benefits and risks of pursuing
learning accommodations for your child, you decide to
proceed, you have several options:
• Section 504 of the Rehabilitation Act provides for
accommodations such as providing students with ADHD
clear and simple directions for homework and in-class
assignments, a quiet place to work, or access to a
computer in school for written work.

105. The Individuals with Disabilities Education Act (IDEA) provides for an
individualized education program, also known as an IEP.
• is a written document with specific goals for the child based on their
current level of performance, and with a list of services that will be
granted as discussed by the parent and school.
What are some things to consider when seeking learning
accommodations for my child?
• Before pursuing special learning arrangements for your child, keep
these points in mind:
• Consider if your child with ADHD would be embarrassed when
accommodations are made in class. You may wish to keep any
agreements about changes between your child and his/her or her
teachers.
• Consider if your child with ADHD would be upset with
accommodations that may call them out from their peers. You may
want to avoid implementing major new strategies until absolutely
necessary.

106. How can I work with my child's school?
• Meet with teachers to share your concerns and
explore accommodation options
• Ask them for written assessment of your child
• Take an active role in educational plan
• FU each meeting with your child’s school
• Find a local support group

118. ADHD associated disorders
• In 2⁄3. Learning disabilities in 30%. ADHD, is not a
learning disability but can significantly impact
academic performance
• Tourette syndrome more common in ADHD
• Oppositional defiant disorder (ODD) and conduct
disorder (CD) in 50% and 20%. SS: stubbornness,
aggression, temper tantrums, deceitfulness, lying,
and stealing. 50% of those with hyperactivity and
ODD or CD develop antisocial personality
disorder in adulthood

119. • .[37] Brain imaging supports that conduct disorder
and ADHD are separate conditions.[38]
• Primary disorder of vigilance, which is
characterized by poor attention and concentration,
as well as difficulties staying awake. These children
tend to fidget, yawn and stretch and appear to be
hyperactive in order to remain alert and active.[36]
• Mood disorders (especially bipolar
disorder and major depressive disorder). Boys
diagnosed with the combined ADHD subtype are
more likely to have a mood disorder.[39] Adults with
ADHD sometimes also have bipolar disorder, which
requires careful assessment to accurately diagnose

120. Often leaves seat in places where remaining seated is expected