ADHD: We know it when we
see it—or do we?
Constance J. Fournier, Ph.D.
Clinical Professor
Texas A & M University
Goal

The purpose of this workshop is to
provide school nurses information about
ADHD and related diagnosis and the
opportunity to consider how to develop
or modify interactions with school faculty
or medical personnel in order to better
serve students with these diagnoses.
Objectives


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1. The learner will be able to list the key types of
ADHD on a Venn diagram.
2. The learner will be able to list basic
interventions used in treating ADHD in lecture
notes.
3. The learner will be able to show overlaps
between ADHD and other DSM IV diagnosis on
Venn diagrams.
4. The learner will be able to discuss action plan
ideas to take back to their school to improve
mental health intervention within the school nurse
role.
Overview
ADHD and types of ADHD
 Basic interventions with ADHD
 ADHD and the typical comorbidity
 ADHD and depression
 ADHD and anxiety
 Action plan

ADHD and types
Inattentive symptoms
Often fails to give close attention to details,
or makes careless mistakes
 Difficulty sustaining attention in tasks or play
(rule governed behavior)
 Does not seem to listen when spoken to
directly

ADHD and types

Inattentive symptoms continued
Does not follow through on instructions, fails
to finish tasks (not due to oppositional
behavior or inability to understand)
 Difficulty organizing tasks or activities
 Avoid, dislikes, reluctant to engage in
mental effort tasks
 Often loses necessary things

ADHD and types

Inattention symptoms continued
Often distracted by extraneous stimuli
 Often forgetful in daily activities

ADHD and types

Hyperactivity symptoms
Fidgets with hands, feet, squirms in seat
 Leaves seat when remaining seated is
expected
 Runs or climbs excessively; adolescents
report restlessness
 On the go, driven by a motor
 Talks excessively

ADHD and types

Impulsivity symptoms
Blurts out answers before the question is
completed
 Difficult awaiting turn
 Interrupts or intrudes on others (butting into
conversations or games)

ADHD and types
Inattentive type
 Hyperactive-Impulsive type
 Combined type

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Helps to put on the tri Venn diagram
Diagnosed before age 7
ADHD types
inattentive
hyperactive
inattentive
ADHD interventions

Behavioral Interventions

Parent training
Reinforcing positive behavior
 Positive interactions
 Parent time outs

ADHD Interventions

Behavioral interventions

School interventions
Reinforcing positive behavior
 Positive interactions
 Self-monitoring

ADHD Interventions

Behavioral interventions

Student interventions
Self monitoring
 Direct instruction in organization
 Direct instruction in studying
 Pre-corrections
 Visual and verbal direction
 Reinforcement of behaviors you want to see

ADHD interventions

Medications

Stimulants
70 years of study showing positive results with
minimal side effects
 Note for school nurses: medication gaps


Non-stimulants
Appropriate for particular circumstances
ADHD interventions

Typical side effects
Reduced appetite
 Sleep problems
 Headaches
 Stomach pain
 Irritability

ADHD interventions

Atypical side effects (rare to very rare)
Health related problems—usually related to
undiagnosed issues such as heart defects
 Hallucination and agitation-FDA indicates a
slightly increased risk
 Non stimulants—verbalizing suidical
thoughts; liver problems
 Extreme caution with pre-existing psychosis
or bipolar disorder; still can use if needed

ADHD interventions: Which is better?
Medication or no medication

research generally suggests medication
Behavioral intervention alone

Always the first step; however, research
suggests that behavioral intervention alone is
not sufficient
ADHD interventions: Which is better?

Behavioral and medication
Most suggest medication alone is most effective
 Medication with behavioral intervention about
the same as medication alone
 Behavioral intervention alone less effective
 Issues with sampling, assessment tools, length
of time studied
 Jury still out, but medication does seem to hold
up as effect alone or with behavioral intervention

ADHD interventions: Which is better?

What does not work
Special diets
 Herbal supplements
 Homeopathic treatment
 Bio-feedback
 Chiropractic adjustments
 Auditory treatments
 However, don’t negate placebo effects

ADHD and comorbidity

The big 3

ADHD and Learning Disabilities


ADHD and Oppositional Defiant disorder


20% to 40% or higher
20% to 40% or higher
ADHD and both LD and ODD

20% to 40% or higher
Big 3
ADHD
LD
ODD
Learning Disability
Significant discrepancy between
cognitive ability and academic
achievement
 In Texas, greater than one standard
deviation (16 or more points)
 Method two—preponderance of the
evidence

Oppositional Defiant Disorder
Actively refuses to comply requests
 Deliberately annoys others
 Angry and resentful of others
 Argues often
 Blames others for own mistakes

Oppositional defiant disorder
Few friends, loses friends
 Constantly in trouble in rule governed
situations
 Spiteful or revengeful
 Touchy or easily annoyed

ADHD and depression
One out four adults with ADHD also has
symptoms of depression
 Children with ADHD are three times
more likely to have depression as
compared with other children

ADHD and depression

Symptoms of depression



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depressed, irritable mood
marked diminished interest or pleasure in
activities
significant weight loss/gain; failure to make
expected gains
insomnia or hypersomnia
psychomotor agitation or retardation
ADHD and depression

Symptoms of Depression continued
fatigue or loss of energy
 feelings of worthlessness or excessive or
inappropriate guilt
 diminished ability to think or concentrate or
indecisiveness
 recurrent thoughts of death, suicidal ideation,
suicide attempt

ADHD and depression

Using the Venn diagram, put in the
symptoms of depression along with the
symptoms of ADHD
What is overlapping?
 What is separate?


ADHD

Both

Depression
ADHD and depression

General types of depression

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major depression (more than 2 weeks)
Dysthymia
symptoms of depression more often than
not
 in children, symptoms for one year
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Bipolar disorder
ADHD and depression

Bipolar disorder
 Depression (typically) & mania

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inflated self-esteem
decreased need for sleep
more talkative, pressured talk
flight of ideas
distractible with irrelevant stimuli
increased behaviors
excessive activities that are potentially dangerous
ADHD and depression
General Intervention for Depressive
disorders

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


affective information
activity scheduling
social skills training
problem-solving training
ADHD and depression

General Intervention for Depressive
disorders
self-instructional training: monitoring,
evaluating, rewarding
 relaxation training
 cognitive structuring/cognitive modeling

ADHD and Anxiety
About 30% of children with ADHD also
have symptoms of anxiety
 Up to 40% in adults with ADHD also
have symptoms of anxiety

ADHD and Anxiety
Symptoms of Anxiety


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excessive anxiety and worry more often
than not for 6 months
difficult to control the worry
ADHD and Anxiety

Symptoms of anxiety continued
 restlessness or keyed up or on edge
 easily fatigued
 difficulty concentrating, mind goes blank
 irritability
 muscle tension
 sleep disturbance (falling asleep or
staying asleep)
ADHD and Anxiety

Using the Venn diagram, put in the
symptoms of Anxiety along with the
symptoms of ADHD
What is overlapping?
 What is separate?

ADHD and Anxiety

Types of Anxiety disorders
Separation anxiety disorder
 Specific phobias

Social
 Animal
 Natural environment
 Blood-injection-injury
 Situational
 Other (clowns or mascots)

ADHD and Anxiety

Anxiety disorders
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Somatoform--multiple physical complaints
with no medical explanation
Obsessive-compulsive disorder
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obsessions—thoughts, impulses, images that are
intrusive and excessive; person tries to ignore or
suppress with other thoughts or actions; selfknowledge that this is own thoughts
compulsions—repetitive behaviors driven to perform
to try to deal with obsessive thinking, but does not
work
ADHD and Anxiety

General Interventions for anxiety
disorders
Systematic desensitization
 modeling
 social skills training
 problem-solving training

ADHD and Anxiety

General interventions for anxiety
disorders
self-instructional training: monitoring,
evaluating, rewarding
 relaxation training
 cognitive structuring/cognitive modeling

ADHD and Action Plans for Nurses

Role of the school nurse
Medication dispensing
 Health monitoring
 Liaison with medical professionals
 Liaison with school faculty
 Liaison with family

ADHD and Action Plans for Nurses

General actions
Need for Release of Information forms
 Need for clear lines of communication
 How is communication with medical
personal maintained?
 How is communication with family
maintained?
 How is communication with faculty
maintained?

We learn from others
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Share with elbow neighbor what is done
in your school
Consider what you do
 What works well
 What needs to change
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We will have chance to share with each
other
We learn from others

Sharing with each other

What works!
ADHD and Action Plans for Nurses

Making your own plan
Prioritize what you would like to do
 Consider what resources you have
 Consider what barriers you have

Time is ALWAYS a barrier
 Money is rarely a barrier

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Set up a timeline for yourself
Resources
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www.chadd.org
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www.help4adhd.org
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Combined resources
www.nasponline.org
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Children and adults with Attention Deficit Disorders
National Association of School Psychologists
www.ed.gov

Department of Education
Resources
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www.nichcy.org
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www.aap.org
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American Academy of Pediatrics
www.apa.org
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National information center for children and youth
with disabilities
American Psychological Assocition
www.aacap.org

American Academy of Child and Adolescent
Psychiatry
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