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ADHD and ASD: Everything you want to know about the A’s in School
Judith Aronson-Ramos, M.D.www.draronsonramos.com
Overview
•5 -10 % of school age children will have a developmental or mental health concern affecting their functioning at school
•ADHD and ASD of growing concern to teachers and parents
•Recently published article from CA study 24 % of children 6-14 yrs with ADHD (includes a spike in minority children)
•ASD now 1/88 up from prior estimates
Prevalence Statistics• Mental health problems affect 1/5 young people at any
given time. (Department of Health & Human Services)
• An estimated 2/3 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,
PDD-NOS, 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:
▫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
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▫ CARELESS
▫ INATTENTIVE
▫ DOES NOT LISTEN
▫ NO FOLLOW THROUGH
▫ DISORGANIZED
▫ AVOIDS
▫ LOSES THINGS
▫ DISTRACTED▫
FORGETFUL
Hyperactive Symptoms Hyperactivity
▫ 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 13 years (new). Can begin as young as 4 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 Trends• According to Medicaid data, the prevalence of attention-
deficit/hyperactivity disorder (ADHD) diagnosis in adolescents ages 15 to 19 years increased from 0.45% in 1995-1996 to 2.47% in 2003-2004, a far larger increase than that observed for younger children.
• The number of prescriptions for ADHD increased substantially, about 11.8% per year for the population overall. Between 2000 and 2005, prescriptions for pediatric boys increased 8.2% on average; the rate for pediatric girls increased 13.3%.
• Among adults, prescriptions for ADHD treatment increased 18.1% among women and 12.6% among men. While more boys overall are treated than girls (a ratio of 2.96:1), the rates for girls are increasing faster. Among adults, men and women are treated at an equal rate, 0.8%.[1,2]
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
•Research supports familial transmission
Treatment
•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, Methylin ER, Metadate CD or ER, Ritalin SR, Daytrana, Quillivant
•Dexmethylphenidate – Focalin, Focalin XR•Amphetamine – Adderall, Adderall XR•Lisdexamphetamine – Vyvanse•Dexedrine – Spansules, Dextrostat
How do stimulants differ?
•Delivery- sprinkle, patch, pump, liquid•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 Effects•Tired•Hungry•Irritable•Wear off•Socially withdrawn•Tics•Aggressive
Positive Effects
•Attentive•Calm, regulated, and compliant•Decrease in disruptive behaviors•Improved social functioning•Readiness to learn•Compliance
Unrealistic Expectations
•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•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
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
THERE'S JUST A ONE-LETTER DIFFERENCE BETWEEN ARTISTIC AND AUTISTIC
Autism Spectrum Disorders
•DSM IV Criteria •Pervasive Developmental Disorders –
Autism, PDD-NOS, Aspergers, Retts, CDD•DSM V Criteria – social and
communication problems combined need all symptoms plus rrbi
•New terminology ASD – no more pdd-nos, aspergers or autism
Why so much ASD?
•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
• 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
Autism Spectrum Disorder Criteria
Additional Criteria for Autism
•Onset prior to age 3•Do not meet criteria for Retts or
Childhood Disintegrative Disorder•PDD-NOS – sub threshold symptoms or
atypical•Aspergers – no language delay and 2
symptoms from social domain and 1 from RRBI
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
•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”.
Autism Spectrum Disorder
AutismPDD-NOS
AspergersSyndrome
Three domains of impairment will now become two:1) Social/communication deficits2) Fixated interests and repetitive behaviors
Instead of1.) Social2.) Communication3.) Restricted Interests Repetitive Behaviors
From 3 domains to 2
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 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
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.
RRBI- 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.
MORE SPECIFIC EXAMPLES -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
AG OF ONSET -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 CommunicationRestricted 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.
Medical Treatment
•Medications – ssri, stimulants, alpha agonists, atypical anti-psychotics
•Therapies: ST, OT, BT, Education•Diet and Vitamins – antioxidants,
probiotics, omega three fatty acids (published 2007), glutathione (in clinical trial)
•Others with insufficient evidence: HBOT, Chelation, Stem Cells, Biofeedback, Neurofeedback, listening programs, hippotherapy, etc
Medical Tests•Imaging – MRI, CT•Laboratory – bio markers and genes;
chromosomal microarray•Head Circumference – large in first year•EEG •Hearing and Vision•Experimental: Lange Lainhart DTI MRI
(University of Utah), EEG in 6 mo babies (Boston Children's Hospital)
•Mitochondrial dysfunction, anti-oxidant dysfunction
If you do not look for it you may not find it•HF ASD 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
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.
Neurobiology and Language
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•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
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”.
Symptom Relief, Not Cure
How does a Physician decide??
•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.
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.
Mental Health
www.nlm.nih.gov/medlinepluswww.nimh.gov
www.thereachinstitute.org
www.mentalhealth.samhsa.gov/publications
www.mentalhealthamerica.net
Autism
• www.oar.org – The Organization for Autism Research dedicated to the
dissemination of applied research and evidence based information about autism.
• www.asatonline.org –The Association for Science in Autism Treatment a
website dedicated to sharing information about the evidence supporting different treatments for autism.
• www.rethinkautism.org – Web based portal to begin an individualized ABA
program.
• www.ianproject.org - Interactive autism research website for parents and clinicians.
• www.autism-society.org – Official website of the Autism Society of America
• www.firstsigns.org – Focus on early diagnosis and intervention for Autism
More Autism Sites • www.nichd.nih.gov/autism/ - National Institute of Health website. • www.aspergersyndrome.org – Information for individuals and
families with high functioning Autism, PDD-NOS and Aspergers Syndrome.
• www.umcard.org – Main website for The Center for Autism and
Related Disabilities (CARD) serving Dade and Broward counties. • www.coe.fau.edu/card/ - Website for the CARD Center serving
Palm Beach County. This is a state funded information, education and advocacy group for individuals and families with Autism Spectrum Disorders.
