ADHD, Autism, Mood Disorders in
School Aged Children
Judith Aronson-Ramos, M.D.
www.draronsonramos.com
Overview
• 5 -10 % of school age children will have a
developmental or mental health concern effecting
their functioning at school.
• Minority and socio-economically disadvantaged
students may be under identified.
• School may be the only opportunity for assessment
and intervention for some families.
• Financial strain on families will increase the burden
on the school system for identification, assessment,
and treatment of common disorders.
Prevalence
• Mental health problems affect one in every five
young people at any given time. (Department of
Health & Human Services)
• An estimated two-thirds of all young people with
mental health problems are not getting the help they
need. (Department of Health & Human Services)
• Studies indicate that 1 in 5 children and adolescents
(20 percent) may have a diagnosable disorder.
Estimates of the number of children who have
mental disorders range from 7.7 million to 12.8
million. (Department of Health & Human Services)
Common Disorders
• ADHD
• Autism Spectrum Disorders – Autism, PDDNOS, Aspergers Syndrome
• Mood Disorders: Anxiety, Depression, OCD,
Bipolar Disorder
• Other problems of learning and behavior: LD,
Tourettes, Selective Mutism, ODD and CDD
Joseph Biederman, M.D. - Harvard University
Medical Perspective
• Training dictates treatment
• Evidenced Based Medicine
• Disciplines have different approaches:
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Psychiatry
Developmental & Behavioral Pediatrics
Pediatrics
Neurology
The Principals of Medical Treatment –
Developmental & Behavioral Pediatrics
• Evidence based
• Target symptom focused
• Developmental Framework – stages of
development, changes over time
• Interdisciplinary collaboration
• Family focused
• Whole Child
Evidence Based
• The conscientious, explicit, and judicious use of current best evidence in
making decisions about the care of individual patients. The practice of
evidence based medicine means integrating individual clinical expertise
with the best available external clinical evidence from systematic
research."(1)
More recently it has been described as the "integration of best research
evidence with clinical expertise and patient values."(2)
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New basis of medicine
Use data, studies, and research to form treatment plans
Integrate knowledge demonstrated through well constructed studies
Understand that the placebo effect is real and measurable
The physician’s role has become one of assisting families in evaluating the
cost vs. benefit of various treatments
I was trying to daydream, but my mind kept wandering
I stopped to think, and forgot to start again
ADHD
• DSM IV criteria – 6 Inattentive, 6 Hyperactive
Impulsive, or Combined
• Importance of impairment in more than one
setting.
• Consistency of observations between home and
school.
• Variability with age – young hyperactive and
impulsive, older more inattentive and
disorganized
Inattentive Symptoms - 6
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CARELESS
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INATTENTION
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DOES NOT LISTEN
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FOLLOW THROUGH
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DISORGANIZED
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AVOIDS
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LOSES THINGS
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DISTRACTED
FORGETFUL
Hyperactive Symptoms
Hyperactivity
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FIDGETS
UP
RUNNING
NOISY
MOTOR
CHATTY
Impulsive Symptoms
Impulsivity
▫ BLURTS
▫ CAN’T WAIT
▫ INTERRUPTS
Additional Criteria
• Some symptoms that cause impairment were
present before age 7 years.
• Some impairment from the symptoms is present in
two or more settings (e.g. at school and home).
• There must be clear evidence of clinically significant
impairment in social, school, or work functioning.
• The symptoms are not due to a Pervasive
Developmental Disorder, or other Mental or
Neurologic disorder.
ADHD continued
• Bias against girls
• Bias for boys
• Rule out confounding disorders vs co morbid
disorders – LD, Anxiety, ASD, Neglect/Abuse,
Family Dysfunction, BPD, and Low Cognitive
Ability, ASD
Neurobiology
• Neurobiological differences in children with ADHD
leading to executive functioning deficits (organizing,
planning, reasoning, attention)
• Anatomic & Physiologic Differences in the Brain:
Pre-frontal cortex – volume and perfusion; smaller
right frontal lobe; connections between basal
ganglia (movement) and other areas; overall
decreased blood flow to certain brain regions
• Dopamine and Catecholamine (NE) Transporter
Genes
• Size of different brain structures
• Research supports familial transmission
Treatment
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Medication
Behavioral Intervention
Classroom Accommodations and Modifications
Psycho-education – teacher, family, peers
Maybe – Diet, Exercise, Neurofeedback,
Working Memory Deficit Training
Medication Options - Stimulants
• Stimulants – amphetamine or methylphenidate
based
• Methylphenidate – Concerta, Ritalin, Ritalin LA,
Methylin, Metadate, Daytrana
• Dexmethylphenidate – Focalin, Focalin XR
• Amphetamine – Adderall, Adderall XR
• Dexamphetamine – Vyvanse
• Dexedrine
How do stimulants differ?
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Delivery- sprinkle, patch, pump
Duration – 2, 4, 6, 8, 10, 12 hours
FDA Approval
Side effects
Unique pharmacokinetics
Non-Stimulants
• Atomoxetine – Strattera
• Alpha Agonists – Tenex/Intuniv/Guanfacince vs
Clonidine/Kapvay
• Why use a non-stimulant? Tics, anxiety, side
effects, combination therapy, duration of action,
age
Negative Classroom Effects
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Tired
Hungry
Irritable
Wear off
Socially withdrawn
Tics
Aggressive
Positive Classroom Effects
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Attentive
Calm, regulated, and compliant
Decrease in disruptive behaviors
Improved social functioning
Readiness to learn
Compliance
Unrealistic Expectations
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Child
Parents
Teachers
Stimulants improve focus, not cognition
The Cure All for students with problems –
academic, behavioral, social
• 100% symptom resolution
• New baseline has pitfalls
Other Factors in ADHD Treatment
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Teens feel a loss of creativity and personality
Compliance with medication regimen
Need for boosters
Loss of efficacy
Overreliance on the medication vs. classroom
interventions
THERE'S JUST A ONE-LETTER DIFFERENCE BETWEEN ARTISTIC AND AUTISTIC
ASD - A Spectrum of Possibilities
• THERE'S JUST A ONE-LETTER DIFFERENCE
BETWEEN ARTISTIC AND AUTISTIC
• "What would happen if the autism gene was
eliminated from the gene pool? You would have
a bunch of people standing around in a cave,
chatting and socializing and not getting anything
done.“ – Temple Grandin
Autism Spectrum Disorders
• DSM IV Criteria
• Pervasive Developmental Disorders – Autism,
PDD-NOS, Aspergers
• Diagnostic Substitution
• Broadened Criteria
• Broader Autistic Phenotype
Autism
• 6 total from 1-3 at least 2 from 1 and 1 each from 2 and 3
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1. Qualitative Impairment in Social Interaction (at least 2)
Nonverbal skills – eye contact, body posture, facial expressions
Peer Relationships – not developmentally appropriate
No Spontaneous joint attention
No social or emotional reciprocity
2.Qualitative Impairment in Communication
Delay or lack of language
Poor conversational skills
Idiosyncratic language
No make believe or imitation
3.Restricted and Repetitive Behaviors, Interests, or Activities:
Preoccupations, Inflexible routines, Motor Mannerisms, Parts not
the whole
PDD-NOS
• Sub-threshold clinical symptoms per DSM
criteria
• Not necessarily less severe than autism cognitive
abilities can range from high to low
• Prognosis similarly varies dependent more on
cognition, language, and behavior than diagnosis
Aspergers Syndrome
• No language impairment
• High cognitive ability - IQ from average to gifted
• Must have a narrow area of interest or
preoccupation can change over time
• Despite intellectual advancement gaps in learning
• Behaviors include: rigidity, black and white
thinking, perseverating, anxiety, preference for
sameness, poor social skills
• Difficulty working in groups
• Eccentric and quirky
• Eye Contact may be atypical
• Problems with transitions
DSM–IV criteria for the diagnosis of
Asperger disorder
• 1. Qualitative impairment in social interaction, as
manifested by at least two of the following:
• Marked impairment in the use of multiple nonverbal behaviors such
as eye-to-eye gaze, facial expression, body postures, and gestures to
regulate social interaction
• Failure to develop peer relationships appropriate to developmental
level
• Lack of spontaneous seeking to share enjoyment, interests, or
achievements with other people (e.g., by a lack of showing, bringing,
or pointing out objects of interest to other people)
• Lack of social or emotional reciprocity
2. Restricted repetitive and stereotyped patterns of behavior,
interests, and activities, as manifested by at least one of the
following:
An encompassing preoccupation with one or more stereotyped and
restricted patterns of interest that is abnormal either in intensity or
focus
Apparently inflexible adherence to specific, nonfunctional routines or
rituals
Stereotyped and repetitive motor mannerisms (e.g., hand or finger
flapping or twisting, or complex whole-body movements)
persistent preoccupation with parts of objects
This disturbance must be clinically significant, but without clinically
significant language delay or delay in cognitive development or other
skills
Final Criteria
• This disturbance must be clinically significant,
but without clinically significant language delay
or delay in cognitive development or other skills
• Every quirky eccentric person does not have AS
New Diagnostic Formulations
• Autism Spectrum Disorder –DSM V
Rationale for ASD in DSM V
• Differentiation of autism spectrum disorder
from typical development and other
"nonspectrum" disorders is done reliably and
with validity; while distinctions among disorders
have been found to be inconsistent over time,
variable across sites and often associated with
severity, language level or intelligence rather
than features of the disorder.
Because autism is defined by a common set of behaviors, it is best
represented as a single diagnostic category that is adapted to the
individual’s clinical presentation by inclusion of clinical specifiers
(e.g., severity, verbal abilities and others) and associated features
(e.g., known genetic disorders, epilepsy, intellectual disability and
others.)
A single spectrum disorder is a better reflection of the state of
knowledge about pathology and clinical presentation; previously,
the criteria were equivalent to trying to “cleave meatloaf at the
joints”.
From 3 domains to 2
Three domains of impairment will now
become two:
1) Social/communication deficits
2) Fixated interests and repetitive
behaviors
Instead of
1.) Social
2.) Communication
3.) Restricted Interests Repetitive
Behaviors
Deficits in communication and social behaviors are
inseparable and more accurately considered as a single set
of symptoms
Delays in language are not unique nor universal in ASD
and are more accurately considered as a factor that
influences the clinical symptoms of ASD, rather than
defining the ASD diagnosis .
Requiring both criteria to be completely fulfilled improves
specificity of diagnosis without impairing sensitivity
Providing examples for sub domains for a range of
chronological ages and language levels increases
sensitivity across severity levels from mild to more severe,
while maintaining specificity with just two domains
Decision based on literature review, expert consultations,
and workgroup discussions; confirmed by the results of
secondary analyses of data from CPEA and STAART,
University of Michigan, Simons Simplex Collection
databases
Requiring two symptom manifestations for
repetitive behavior and fixated interests
improves specificity of the criterion
without significant decrements in
sensitivity.
The necessity for multiple sources of
information including skilled clinical
observation and reports from
parents/caregivers/teachers is highlighted
by the need to meet a higher proportion of
criteria.
The presence, via clinical observation and
caregiver report, of a history of fixated
interests, routines or rituals and repetitive
behaviors considerably increases the
stability of autism spectrum diagnoses over
time and the differentiation between ASD
and other disorders.
Reorganization of sub domains increases
clarity and continues to provide adequate
sensitivity while improving specificity
through provision of examples from
different age ranges and language levels.
Unusual sensory behaviors are explicitly
included within a sudomain of stereotyped
motor and verbal behaviors, expanding the
specification of different behaviors that can
be coded within this domain, with
examples particularly relevant for younger
children
Autism spectrum disorder is a
neurodevelopmental disorder and must be
present from infancy or early childhood,
but may not be detected until later because
of minimal social demands and support
from parents or caregivers in early years.
Severity Level for ASD
Social Communication
Restricted interests & repetitive
behaviors
Level 3
‘Requiring very substantial
support’
Severe deficits in verbal and
nonverbal social communication
skills cause severe impairments
in functioning; very limited
initiation of social interactions
and minimal response to social
overtures from others.
Preoccupations, fixated rituals
and/or repetitive behaviors
markedly interfere with
functioning in all
spheres. Marked distress when
rituals or routines are
interrupted; very difficult to
redirect from fixated interest or
returns to it quickly.
Level 2
‘Requiring substantial support’
Marked deficits in verbal and
nonverbal social communication
skills; social impairments
apparent even with supports in
place; limited initiation of social
interactions and reduced or
abnormal response to social
overtures from others.
RRBs and/or preoccupations or
fixated interests appear
frequently enough to be obvious
to the casual observer and
interfere with functioning in a
variety of contexts. Distress or
frustration is apparent when
RRB’s are interrupted; difficult to
redirect from fixated interest.
Level 1
‘Requiring support’
Without supports in place,
deficits in social communication
cause noticeable
impairments. Has difficulty
initiating social interactions and
demonstrates clear examples of
atypical or unsuccessful
responses to social overtures of
others. May appear to have
decreased interest in social
interactions.
Rituals and repetitive behaviors
(RRB’s) cause significant
interference with functioning in
one or more contexts. Resists
attempts by others to interrupt
RRB’s or to be redirected from
fixated interest.
For more information
• www.dsmv.org
Medical Treatment
• Medications – ssri, stimulants, alpha agonists,
atypical anti-psychotics
• Therapies: ST, OT, BT, Education
• Diet and Vitamins – antioxidants, probiotics,
omega three fatty acids, glutathione
• Others with insufficient evidence: HBOT,
Chelation, Stem Cells, Biofeedback,
Neurofeedback, listening programs,
hippotherapy, etc
New Medical Tests
• Imaging
• Laboratory – markers and genes
• Head Circumference
If you do not look for it you may not
find it
• HFA and Aspergers can be elusive
• If you see triad of ADHD, Anxiety, OCD you
need to specifically assess for the presence of a
spectrum disorder
• ADOS becoming the gold standard
• CARS – HF, SRS, GARS, and other specific
assessment tools
• Be careful ruling ASD in or out based only on a
rating scale completed by parents and teachers
Bouba or Kiki
Neurobiology and Language
Ramachandran and Hubbard[3] suggest
that the kiki/bouba effect has implications
for the evolution of language, because it
suggests that the naming of objects is not
completely arbitrary. The rounded shape
may most commonly be named "bouba"
because the mouth makes a more rounded
shape to produce that sound while a more
taut, angular mouth shape is needed to
make the sound "kiki". The sounds of a K
are harder and more forceful than those of
a B, as well. The presence of these
"synesthesia-like mappings" suggest that
this effect might be the neurological basis
for sound symbolism, in which sounds are
non-arbitrarily mapped to objects and
events in the world.
Mood Disorders
• Anxiety (1/10) –GAD, SAD, Social Phobia,
Selective Mutism
• Depression (1/33)–MDD, Dysthymia,
Adjustment reactions
• Bipolar Disorder – TDD with Dysphoria (40x
increase in BPD diagnoses in past 10 years);
need for continuity with adult criteria
• OCD – (1/200)
Mood Disorders and Learning
• Mood Disorders interfere with learning for
obvious reasons
• Unique characteristics of mood disorders can
result in specific behavior patterns – i.e.
anxious-fearful of mistakes, depressed –
assumes-the worst, OCD – constant erasing
• Support of teacher can be critical
• Stress of social interaction
• Fear of change
Mood Disorders in the Classroom:
Advice for teachers
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Flexibility
Patience
Conflict Management
Self-Esteem
Avoid Confrontation
Support what can be accomplished, offer
alternative assignments when possible
Other related disorders
• Conduct Disorders
• ODD
• Tourettes Syndrome – 3/1000 – vocal and
motor tics together more than 6 mo
• Sensory Integration Dysfunction, aka
Developmental Coordination Disorder
• Sensory Impairments: Visual, Auditory
• Fine Motor Skills and Visual Perceptual
Weaknesses
• Trichotillomania – related to anxiety and ocd
Symptom Relief, Not Cure
Psychotherapeutic
medications, at their
best, improve symptoms
so that quality of life
and functioning are
significantly improved.
This class of medications
often falls short of a
“cure”.
How does a Physician
decide??
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Target Symptoms
Diagnoses
Co-morbidities
Family and Medical History
Allergies
Mode of Administration
Baseline Behaviors + Side Effect
Profile
Pre/Post Test -True or False
• Stimulant medications may be used safely in all
ages
• Anti-depressant medications are addictive and
need to be used cautiously in children.
• Anti-psychotic medications are only used for
psychosis.
• You must know a child’s diagnosis before ever
using medication.
• Stimulant medications lose their effectiveness
over time.
STRESS RELIEF for School Psychologists
Every time someone asks you to do something, ask if
they want fries with that.
Put mosquito netting around your cubicle.
At lunch time, sit in your parked car and point a hair
dryer at passing cars to see if they slow down.
Page yourself over the intercom. Don't disguise your
voice.
Resources on
www.draronsonramos.com
• www.parentsmedguide.org - Practical
information about medications for parents.
• www.fda.gov - Food and Drug Administration
resource of the Federal Government includes
most up to date listing of new medications.
• www.epocrates.com - Online medication
encyclopedia.
• www.thereachinstitute.org
www.mentalhealth.samhsa.gov/publications
www.mentalhealthamerica.net
www.nlm.nih.gov/medlinepluswww.nimh.gov