Unlocking Attention Deficit
Hyperactivity (ADHD)
Diagnosis
Characteristics
Management
Children with ADHD
 Estimated 1.46-2.46
million children with
ADHD (U.S.)
 3-5 % of student
population
 More boys than girls
are diagnosed (4 to 9
times more)
 While symptoms of
the disorder may
change many do not
grow out of it.
Core Characteristics result in
unique differences
 Inattention: six of nine persistent symptoms
(lasting at least 6 mos.)
 Hyperactivity-Impulsivity: six of nine persistent
symptoms (lasting at least 6 mos.)
 At least some of the symptoms are present before
the age of seven
 Must impair the individual in 2 or more settings
 Significant impairment in social, academic or
occupational functioning.
Diagnostic Statistical Manual of
Mental Disorders (DSM-IV)
 Fidgeting with hands or





feet, squirming in their
seat, restless
Difficulty remaining
seated when required
Difficulty sustaining
attention, waiting turn
Blurting out answers
before questions are
stated.
Easily distracted
Wide ranges in mood
swings
 Difficulty following




through on instruction
and organizing
Shifting from one
unfinished activity to
another
Failing to give close
attention to details,
careless mistakes
Losing things necessary
for tasks or activities.
Difficulty delaying
gratification
Three subtypes
Predominantly inattentive
Predominantly hyperactive-
impulsive
Combined
Sometimes it is not just ADHD
 20 to 30 percent of Children also have learning





disabilities
30 to 50 percent (mostly boys) conduct or oppositional
defiant disorders
About 20 to 40 percent of ADHD children may
eventually develop conduct disorder (CD)
13 to 51 percent anxiety or mood disorders
A very small proportion of people with ADHD have a
neurological disorder called Tourette’s syndrome.
There are no accurate statistics on how many children
with ADHD also have bipolar disorder. Differentiating
between ADHD and bipolar disorder in childhood can
be difficult.
Things that affect Inattention
Time
Of day
Place
Setting
Length of time
Needed
Sustained
attention needed
Coming to
attention
Allow for
activity
Activity
Demands on
attention
Hands on tasks
Encourage
activity
Inhibit activity
Visual tasks
Punish activity
Mental tasks
Oral tasks
Things that affect Level of Activity
Time
Place
Activity
Time of Day
Encourages or
demands
activity
Discourages or
limits activity
Needs
movement for
success
Can tolerate
movement for
success
Movement
interferes with
success
Length of Task
Punishes
Activity
Impulsive behavior
Typically
not a knowledge deficit.
They know and can tell
you the rules.
Typically
not as influenced by
time, place or activity.
Typically
global and stable in its
manifestation.
Typically
spurred on if anxiety is
an issue.
Much more of the same.
Who statistics
Going in
Boys are more likely to be referred and
identified and are more likely to become part of
clinic statistics
Best practice suggests waiting until five years
old or later
Hyperactive and impulsive behavior results in
more frequent referrals
Where does it come from?
 "Why? What went wrong?" "Did I do something to
cause this?"
 Little compelling evidence at this time that ADHD
can arise purely from social factors or child-rearing
methods
– Environmental factors may influence the severity of the
disorder and suffering the child may experience, but do not
seem to cause the condition by themselves
– Most substantiated causes appear to fall in the realm of
brain organization and genetics
– There appears to be an acquired variety connected to some
childhood diseases such as strep throat
– Our focus should be on finding the best possible way to
help these children.
Where does it really come from?
 Growing evidence that ADHD does not come from the home
environment, but from biological causes.
 Studies have shown a possible correlation between the use of cigarettes
and alcohol during pregnancy and risk for ADHD in the offspring of
that pregnancy.
 High levels of lead in the bodies of young preschool children is not as
prevalent as it once was but appeared to be a possible cause of
behaviors.
Brain Injury
 One early theory was
that attention disorders
were caused by brain
injury. Some similar
behaviors seem to
exist, but only a small
percentage of children
with ADHD have been
found to have suffered
a traumatic brain
injury.
Food Additives and Sugar.
In 1982, NIH held a scientific
consensus conference to discuss this
issue.
 Diet restrictions helped about 5
percent of children with ADHD.
 Mostly young children who had food
allergies.
 This remains an important rule out if
allergies are present in child or
family.
Some Sugar Studies
Children whose mothers felt
they were sugar sensitive
were given aspartame as a
substitute for sugar.
 Half the mothers were told their
children were given sugar.
 Half that their children were
given aspartame.
 The mothers who thought their
children had received sugar
rated them as more hyperactive
than the other children and
were more critical of their
behavior.
Another Sugar Study
Using sugar one day
and a sugar substitute
on alternate days.
 Without parents, staff,
or children knowing
which substance was
being used.
 Showed no significant
effects of the sugar on
behavior or learning.
Genetic Factors
Attention disorders often run in families.
 Studies indicate that 25 percent of the close relatives in the families of
ADHD children also have ADHD, whereas the rate is about 5 percent
in the general population.
 Many studies of twins now show that a strong genetic influence exists
in the disorder.
 Researchers continue to study the genetic contribution, have identified
some markers and predict there may be as many as twelve. Possibly as
high as 80% of ADHD is genetic. The most inherited, more than IQ or
height of any characteristic.
Impact areas of the Brain
The search for a physical basis for attention
deficit hyperactivity disorder.
 frontal lobes of the cerebrum. The frontal
lobes allow us to solve problems, plan
ahead, understand the behavior of others,
and restrain our impulses. (The executive,
president or conductor)
Brain continued
 All of these parts of the brain have been
studied through the use of various methods
for seeing into or imaging the brain.
 The main or central psychological deficits
in those with ADHD have been linked
through these studies.
NIMH Study
 By 2002 the researchers
in the NIMH Child
Psychiatry Branch had
studied 152 boys and
girls with ADHD,
matched with 139 ageand gender-matched
controls without
ADHD.
A picture is worth….
 The children were scanned
at least twice, as many as
four times over a decade.
 As a group, the ADHD
children showed 3-4
percent smaller brain
volumes in all.
 Showed that the ADHD
children who were on
medication had a white
matter volume that did not
differ from that of
controls.
 Those never-medicated
patients had an
abnormally small volume
of white matter.
The Treatment of ADHD
To determine what treatment will be most
effective for a child.
 Needs to be answered by each family in
consultation with their health care
professional.
 National Institute of Mental Health (NIMH)
has funded many studies of treatments for
ADHD and has conducted the most
intensive study ever undertaken for
evaluating the treatment of this disorder.
 The NIMH is now conducting a clinical trial
for younger children ages 3 to 5.5 years
MTA Details
 One study is known as the Multimodal
Treatment Study of Children with
Attention Deficit Hyperactivity Disorder
(MTA).
 The MTA study included 579 (95-98 at
each of 6 treatment sites) elementary
school boys and girls with ADHD, who
were randomly assigned to one of four
treatment programs:
Study Groups
 (1) medication
management alone;
 (2) behavioral treatment
alone;
 (3) a combination of
both; or
 (4) routine community
care.
In each of the study sites,
three groups were treated
for the first 14 months in
a specified protocol and
the fourth group was
referred for community
treatment of the parents'
choosing.
Study Details
 All of the children were reassessed
regularly throughout the study period. An
essential part of the program was the
cooperation of the schools, including
principals and teachers.
 Both teachers and parents rated the children
on hyperactivity, impulsivity, and
inattention, and symptoms of anxiety and
depression, as well as social skills.
Study Groups
 In the combined therapy group
 Received both treatments, that is,
– All the same assistance that the medicationonly received, as well as
– All of the behavior therapy treatments.
Study Groups
 In routine community care
– children saw the community-treatment doctor
of their parents' choice one to two times per
year for short periods of time
– community-treatment doctor did not have any
interaction with the teachers
Study Results
 .The results of the study indicated that long-term
combination treatments and the medicationmanagement alone were superior to
– intensive behavioral treatment and
– routine community treatment.
 the combined treatment was usually superior when
– anxiety, academic performance, oppositionality, parentchild relations, and social skills issues were present and
– children could usually be successfully treated with
lower doses of medicine, compared with the
medication-only group.
(Treatment of ADHD in PreschoolAge Children)
 The NIMH is sponsoring an
ongoing multi-site study,
"Preschool ADHD Treatment
Study" (PATS)
 It is the first major effort to
examine the safety and efficacy
of a stimulant,
methylphenidate, for ADHD in
this age group.
– Enrollment in the study will total
165 children.
– Same kind of groups
Which Treatment Should My
Child Have?
 For children with ADHD, no single treatment is
the answer for every child.
 A child may sometimes have undesirable side
effects to a medication that would make that
particular treatment unacceptable.
 If a child with ADHD also has anxiety or
depression, a treatment combining medication and
behavioral therapy might be best.
 Each child's needs and personal history must be
carefully considered.
MEDICATION INFORMATION
 For decades, medications have been used to treat the
symptoms of ADHD. The medications that seem to be the
most effective are a class of drugs known as stimulants.
 Following is a list of the stimulants, their trade (or brand)
names, and their generic names. "Approved age" means
that the drug has been tested and found safe and effective
in children of that age.
Trade Name
Generic Name
Approved Age
Adderall
amphetamine
3 and older
Concerta
methylphenidate
(long acting)
6 and older
Cylert*
pemoline
6 and older
Dexedrine
dextroamphetamine
3 and older
Dextrostat
dextroamphetamine
3 and older
Focalin
dexmethylphenidate
6 and older
Metadate ER
methylphenidate
(extended release)
6 and older
Metadate CD
methylphenidate
(extended release)
6 and older
Ritalin
methylphenidate
6 and older
Ritalin SR
methylphenidate
(extended release)
6 and older
Ritalin LA
methylphenidate
(long acting)
6 and older
*Because of its potential for serious side effects affecting the liver, Cylert should not
ordinarily be considered as first-line drug therapy for ADHD.
Facts to Remember About
Medication for ADHD
 They treat symptoms but do not cure the
disorder.
 They will often assist the child to use
knowledge and skills they already possess.
 About 80 percent of children who need
medication for ADHD still need it as
teenagers.
 Over 50 percent need medication as adults.
You are your child's best advocate
 Learn as much as you can about ADHD
and how it affects your child at home, in
school, and in social situations.
 If you suspect the possibility of this
diagnosis, talk to the teacher and see if a
request for evaluation is appropriate.
 If you and the teacher disagree you can
initiate the process yourself through either
the director of Special Education or the
Child Study Team.
Special Education Process and
Procedures
 A child diagnosed with ADHD may qualify for
special education services, the school, working
with you, must assess the child's strengths and
weaknesses and design an Individualized
Educational Program (IEP).
 You should be able periodically to review and
approve your child's IEP.
 If special education is not needed a 504 plan may
provide the safeguards necessary for success.
Once Diagnosed
 Let his or her teachers
know. They will be better
prepared to help your
child be successful.
 Identify your child’s
unique strengths and
weaknesses.
 Offer to supply additional
information.
 Most likely impact is on
writing
Find support and resources
 Each state has a Parent
Training and
Information (PTI)
center as well as a
Protection and
Advocacy (P&A)
agency.
 Locally we have
PREP (Sarah) at 9759400
Plan for transition
 Transition, unstructured times can be quite
difficult for the child with ADHD.
 Do what works
 Recognize the skill lag problem
 Beware of the middle school and teen years
– It’s a good time to have a complete reevaluation of your child's health.
Behavior Strategies to consider
 Remember that inconsistency is a hallmark
 Recognize/Identify Unique Strengths and
weaknesses.
 Go for fewer, clearer, straightforward rules
 Use punishment sparingly
 Time out may work
 Model and support organization strategies.
 Duplicate, duplicate, duplicate
 Prepare, review, set expectations
 Practice being firm
 Charts may work (self monitor or reward)
Factors that affect success of selfmanagement
Characteristics of
Environment
 Gender of person in
charge
 Match between ability
and tasks demands
 Possibility of success
or failure
 Degree of structure
 Frequency of feedback
Characteristics of
person
 Ability and desire to
be compliant
 Intelligence
 Degree of impairment
 Internal vs External
Control
 Gender
Just some facts to consider…
 Children with ADHD are more likely to
have;
–
–
–
–
–
Poor peer relationships (75%)
Immature motor coordination (30-60%)
Increased sleep disturbances
Verifiable (MRI) brain differences
Higher levels of substance abuse and addiction
(25-35% as teens, 10-15 as adults)
– More police involvement (50%) Court 20%)
– More grade retentions (25-35%)
Just some facts to consider…
 Children with ADHD have
– higher than normal rates of injury
– at least one close relative who also has
ADHD
– High rates of school difficulty (90%)
– Low frustration tolerance
– Low self-esteem (65%)
– Misattribution of intent of others acts
Just some facts to consider…
 Youth with ADHD, in their first 2 to 5
years of driving,
– have nearly four times as many
automobile accidents
– are more likely to cause bodily injury in
accidents
– have three times as many citations for
speeding as the young drivers without
ADHD.
The good news
 The absolute level of symptoms declines
 60-70% have a satisfactory outcome
 Most are living on own and are self-
supporting
 Predictors of Adult Outcome
– Socio-economic status predicts work success
and academic outcome
– Degree of childhood conduct problems predicts
social, legal and academic outcomes
– Degree of peer relationship problems predicts
ongoing social problems
Reading, Dyslexia, Learning
Disabilities
Who
What
How
Statistics
 ¼ to 1/3 of Children diagnosed ADHD also have
learning disabilities
 3.5 % of children ages 6-21(slightly more than 2
million are receiving educational services for a
reading disability
 A probable underestimate of children with reading
difficulties
– Large scale surveys of reading proficiency finds 50 to
almost 70 % measured read below grade placement.
– Boys are 4 to 6 times more likely to be identified but
this may reflect referral bias and gender issues the
actual prevalence is not that dissimilar
What is a learning disability (from
the Greene County SE Handbook)
A disorder in one or more of the basic psychological
processes involved in understanding or using
language, spoke or written, that may manifest
itself in an imperfect ability to listen think, speak,
read, write, spell or do mathematical calculations.
The term includes such conditions as perceptual
disabilities, brain injury, minimal brain
dysfunction, dyslexia and developmental aphasia.
The term does not include learning problems that
are primarily the result of visual, hearing or motor
disabilities ; of mental retardation, of emotional
disturbance or of environmental, cultural, or
economic disadvantage.
Agreement on certain factors:
These various definitions suggest
 The learning disabled have difficulties with academic
achievement and progress. Discrepancies exist between a
person's potential for learning and what he actually learns.
 The learning disabled show an uneven pattern of
development (language development, physical
development, academic development and/or perceptual
development).
 Learning problems are not due to environmental
disadvantage.
 Learning problems are not due to mental retardation or
emotional disturbance.
AREAS of Disability
 Reading
– Decoding
– Comprehension
 Mathematics
– Computation
– Reasoning
 Writing
– Spelling
– Grammar
– Composition
– Handwriting
 Language
– Spoken (Expressive)
– Listening (Receptive)
What causes LD
 Little is currently known about the
causes of learning disabilities. However,
some general observations can be made:
 Some children develop and mature at a
slower rate than others in the same age
group. As a result, they may not be able
to do the expected school work. This kind
of learning disability is called
"maturational lag."
Where does it come from
 Some children with normal vision and hearing
may misinterpret everyday sights and sounds
because of some unexplained disorder of the
nervous system.
 Injuries before birth or in early childhood
probably account for some later learning
problems.
 Children born prematurely and children who
had medical problems soon after birth
sometimes have learning
 Learning disabilities tend to run in families, so
some learning disabilities may be inherited.
More Ideas about cause
 Learning disabilities are more common
in boys than girls, possibly because boys
tend to mature more slowly.
 Some learning disabilities appear to be
linked to the irregular spelling,
pronunciation, and structure of the
English language. The incidence of
learning disabilities is lower in Spanish
or Italian speaking countries
Learning to Read
What we now know
Developmental Sequence for
Reading
 Your Handout is complete
 3-to4 year olds
– Show an interest in the sounds of language
– Identify ten alphabet letters (mostly own name)
– Develop an awareness that words and sentences come
apart
 4-5
– Breaks words into syllables
– Breaks words into phonemes
– Recognizes more letters
Chart continued
 5-51/2
– Can compare to determine if words rhyme
– Can provide rhyming words
– Recognizes and names most of upper and
lowercase letters
– Can count the number of syllables in a word
– Can match first letter of words to pictures
Why early diagnosis and
intervention is important
90%
90%
80%
70%
60%
50%
50%
40%
30%
20%
10%
10%
0%
Reading Test Scores (Percentiles)
< 1 minute = 8,000
words
4.6 minutes = 282,000
words
20 minutes = 1.8
million words
Clues to Reading Disabilities
 Preschool– Trouble learning common nursery rhymes
– Persistent baby talk
– Difficulty learning letter names
 Kindergarten & First
– inability to learn letter names and sounds
– Inability to learn word families
– History of reading problems in family
See handout for complete list
Clues to Reading Disabilities
 Second grade on
– Mispronunciation of long, unfamiliar or
complicated words
– Hesitant speaking
– Slow progress in acquiring reading skills
– Lack of strategy to read new words
– Fear of reading out loud
– Avoidance of reading for pleasure
Diagnosing reading problems
 History
 Evaluations
 Evidence of
 Potential
phonologic weakness
(rhyming pronouncing
and deletion tasks)
 Relatively intact
overall language
abilities.
 Standardized measures
of reading, writing,
spelling
 Processing tasks
Those Phono things
 Phonologic sensitivity = the ability to focus
on the sounds of words.
 Phonologic awareness = all levels of
awareness of the sound structure of words,
parts of words etc.
 Phonemic awareness = ability to notice,
identiy and manipulate the smallest parts
that make up a word (called phonemes)
 Phonemic memory = the ability to store
bits of verbal information
Several types of Reading Problems
 Developmental Dyslexia =language skills in tact
weakness in phonologic skills
 Language based learning disability =difficulty
both with decoding and comprehension
 Hyperlexia=great decoding very poor
comprehension
 Acquired alexia = a loss or lessening of
previously mastered skills as a result of brain
trauma
Writing difficulties &
Executive function
What it takes
Attention demanding Task
 Difficulty
– Initiating: beginning
– Sustaining: persisting
– Inhibiting: stopping
– Shifting: switching
– Organizing: specific
– Planning: predicting
 Seen as
– Poor idea generation
– Loss of thoughts,
disjointed
– Additions to words or
ideas
– Stuck on an idea
– Frequent erasers
– Poor spacing
– Lack of cohesive ties
What happens when there is both
Underlying weakness requires more sustained
effort and focus = greater affect in that area.
Specific skill requires more focus (i.e. writing
and inferential comprehension)=greater
affect in that area.
Specific skill requires organization=greater
affect in that area (30% lag in skills,
lifelong need for external plan)
THANK YOU
QUESTIONS