Attention Deficit Disorder and Learning Disorders

8/13/2019 Attention Deficit Disorder and Learning Disorders

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Attention Deficit Disorder and Learning Disorders

David Johnson, M.D.


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Attention Deficit Hyperactivity Disorder

A persistent (more than 6 months) cluster of behaviors character-

ized by inattention, hyperactivity, and impulsivity with the follow-

ing features:

Behaviors are more frequent and more severe than occurs

in most children at a comparable developmental level

Behaviors began before 7 years of age

Behaviors are manifested in two or more settings (eg, school

and at home)

Behaviors cause clinically significant dysfunction in social,

academic, occupational, or family function

Attention and learning disorders in children are very common

problems. Primary care pediatricians should be the ones to make the

diagnosis and do the treatment in the majority of children. You do not

need a specialist in developmental/behavioral pediatrics to treat most

kids or diagnose most kids with ADHD.


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Attention Deficit Hyperactivity Disorder:

DSM IV Criteria

1. Inattention:Six or more of the following.

often flails to give close attention to details or makes care-

less mistakes in schoolwork, work, or other activities.

often has difficulty sustaining attention in tasks or playactivities.

often does not seem to listen when spoken to directly.

often does not follow through on instructions and fails to

finish schoolwork, chores, or duties in the workplace (not

because of oppositional behavior or inability to understand

directions).

often has difficulties organizing tasks and activities.

often avoids, dislikes, or is reluctant to engage in tasks that

require sustained mental effort (such as schoolwork or

homework). often loses things necessary for tasks and activities (eg,

school assignments, pencils, books, tools).

is often distracted by extraneous stimuli.

is often forgetful in daily activities.

ADHD and the new DSM IV criteria. ADHD is defined as a persistent,

that is more than 6 month cluster of behaviors. It's a behavioral cluster

that has to have been going on for awhile - it can't just have started last

week or last month. The behaviors are more frequent and more severe

than most children at a comparable developmental level. This is very

subjective, and part of the whole problem with diagnosing ADHD is

there is no one way to make the diagnosis. There is no specific test. It

is defined as behavior that is just more frequent and more severe than

most children at a comparable level. It has to begin before seven years

of age. It is not something that begins later on.

Most importantly, it has to be manifested in two or more settings:

school or work and home. If you just have these behaviors occurring

in one setting only, that is not ADHD. If it is only at home and not at

school, it is not ADHD. If it is only at school and not at home, that is

not ADHD. You should be thinking of other parts of your differential

diagnosis. So, ADHD has to occur in at least two or more settings.

Finally to make the diagnosis, it has to cause clinically significant

dysfunction in the social, academic, occupational, or family setting.

There are some kids you'll see, that you will say to yourself, "this kid

has ADHD. He's wild." But, he's doing great. He has friends. He's

doing well in school. The school has adapted to him. The family has

adapted to him. You might not make the diagnosis in that child

because there is not a clinically significant dysfunction. With the same

child in another setting who has a lot of problems in school and at

home, you might make the diagnosis. So the diagnosis of ADHD is

tough because there are these subjective features. And even among

experts, so-called experts, people will disagree with the diagnosis.

The DSM IV criteria. For inattention, you have to have six or more of

the following. One fails to give close attention to details or makes

careless mistakes in school work, work outside the home, or in other

activities. They often have difficulty sustaining attention in tasks or

play activities. What is important is sustaining attention when it is not

easy to sustain attention, when it takes a little more effort, that is when

ADHD shows up. The parents say, "He can play Nintendo for two

hours." and therefore he doesn't have ADHD. But that is not true.

Because think of the kind of attention that it takes to play Nintendo.

Whereas you have to pay attention to what's going on it is always

changing. You are not sitting laboriously studying one thing or looking

at a number of things as you do in school. Does not seem to listen

when spoken to directly.

Often does not follow through on instructions and fails to finish

schoolwork, chores or duties in the workplace (not because of

oppositional behavior or inability to understand directions). He just


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2. Hyperactivity - Impulsivity: 6 or more of the following.

Hyperactivity

often fidgets with hands or feet or squirms in seat.

often leaves seat in classroom (or in other situations where

remaining in seat is expected).

often runs about or climbs excessively in situations where it

is inappropriate (in adolescents or adults, feature may be

limited to subjective feelings of restlessness).

often has difficulties playing or engaging in leisure activities

quietly.

is often on the go or often acts as is driven by a motor.

often talks excessively.

Impulsivity

often blurts out answers before questions have been

completed.

often has difficulty awaiting turn.

often interrupts or intrudes on others (eg, butts into conver-

sations or games).

can't get things done. Keeps trying a million projects, none of which

get completed on time, if they get completed at all. Often has difficul-

ties organizing tasks and activities. And often avoids, dislikes or is

reluctant to engage in tasks that require sustained mental effort, such

as schoolwork, homework.

Again inattention, six or more of these. Often loses things necessary for

tasks and activities, like school assignments, pencils, or books. Is often

distracted by extraneous stimuli. These are the kind of kids who are in

your office and they hear someone crying next door and they are

already over there looking to see what is happening. Something is

going on in the waiting room and they are looking over there. They are

extremely distractible. Their attention cannot stay focused unless it is

a quiet environment with very little else going on. And finally, is often

forgetful in daily activities. Many people are diagnosing themselves

with ADHD. Because it's on a continuum and all of us have, to a

greater or lesser degree, some of these issues. The question is, is it

causing dysfunction in our lives, and that is really a key question in

making a diagnosis.

The second aspect of ADHD, after inattention, is hyperactivity. As you

know, you can have inattention without hyperactivity. So, six or more

of the following.

Often fidgets with hands or feet or squirms in seat. ADHD kids didn't

move more than non-ADHD kids. It was that it was non-directional,

non-purposeful movements that happened more--squirming, fidgeting

all the time. When sitting in their seats, their foot is always racing.

They are always squirming, fidgeting around. When watching

television, they are in one position, then another position, then they're

on the floor and so on.

Often leaves seat in classroom or in other situations where remaining

in seat is expected. Often runs about or climbs excessively in situations

where it is inappropriate. Sometimes they have no sense of fear. They

are fearless at climbing and running around. In adolescents or adults

this may be manifested in more subjective feelings of restlessness. The

child feel restless and squirmy. The hyperactivity may go away, and

often usually does go away in older children and adults, but the

internal sensation of feeling restlessness persists. Often has difficulties

playing or engaging in leisure activities quietly. These are boisterous

kids. They are often "on the go" or act as if "driven by a motor". They

are talkative kids who talk excessively all the time. That is the second

part of the triad of ADHD, inattention and hyperactivity.

Thirdly, there is impulsivity. Often blurts out answers before questions

have been completed. Often has difficulty awaiting turn. Often

interrupts or intrudes on others, like butting into conversations or

games. It's almost as if there is no inhibition. There is no sensor


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DSM IV: Types of ADHD Patients

1. ADHD, Combined type (if criteria for both inattention and

hyperactivity are met)

2. ADHD, predominantly inattentive type

3. ADHD, predominately hyperactive impulsive type

between the thought and the action. Most of us have thoughts. We

want to do things, but we have the ability to pull in or rein in the

impulses. But for some kids, the thought is the action--there is nothing

in between. It is a disinhibition that causes them their impulsivity.

Some people view ADHD as a disorder of disinhibition, inability to

inhibit action in activity, inability to inhibit wandering attention and

inability to inhibit impulsivity.

The DSM IV then describes three types of ADHD. The combined

type, if the criteria for inattention as well as hyperactivity or

impulsivity are met. ADHD, predominantly inattentive type. These

are kids who are usually not diagnosed until they are school-age

because they are not hyperactive, but have a very difficult time in

school paying attention and achieving their potential in school

because of attentional problems. Some people feel that the incidence

of males and females for the inattentive type is about the same,

although it is much higher for the hyperactive type in males than

females. And then primarily hyperactive-impulsive type, which is

much less common.


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Differential Diagnosis of ADHD

Active, normal child

Acute or chronic stress

Post-traumatic Stress Disorder

Anxiety disorder

Depression

Under stimulation

Oppositional behavior or conduct disorder

Learning Disorder

Early mood disorder

Differential diagnosis. The first part of any differential diagnosis is

always, "This is an active, normal child. This is a very active child

but not a hyperactive child. And that is a very difficult decision to

make. I would stress that it is probably based more on the issue of

dysfunction in the child's life than an absolute level of activity or

inattention. The child is able to do well, has friends and so on - you

may just say this is a very active child. The same child though who

is not doing well in school or socially, you might say has ADHD.

Acute or chronic stress. Some kids will respond in a way that is very

ADHD-like to stress in their lives. Stress of any sort. Again as

primary care physicians, you are in the best position to know if it is

stress that is engendering these behaviors in kids. Post traumatic

stress disorder (PTSD) occurs in children who witness a lot of

violence. Children who have been traumatized themselves can look

very much like ADHD. And again, you need to know what the

environmental context of these behaviors are before you reach the

conclusion that this is an endogenous problem in the child that has

ADHD. Anxiety disorders, depression, the child is understimulated,

oppositional behaviors, conduct disorders, learning disabilities, and

early mood disorders. It is very interesting when people go back and

look at adults who have bipolar disorder, manic depressive disorder,

serious depression, they were often diagnosed in childhood as

having ADHD. Again, this is one of the things that is going to be

hard to know unless there is a positive family history. But it looks

like some children, who will eventually have significant psychiatric

mood disorders as young adults or adults, will for look like they had

ADHD when they were young children.


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Important Coexisting Features of ADHD,

Not in DSM Criteria

emotional lability / immaturity

resistance to reinforcement

aggressiveness

academic problems poor social skills

poor peer relations

- Poor Self-esteem

Kids with ADHD tend to have emotional lability and immaturity.

Other kids see them as babies. They cry a lot, they laugh a lot.

They're up, they're down. They seem to be really immature. It's

almost as if their emotions are as labile and hyperactive as every-

thing else about them. They seem to be resistant to reinforcement.

When we talk to parents, and say, "Try this. Try 'time out'." They

say, "I tried it. I tried it and nothing works." In fact, that is one of the

hardest parts of dealing with hyperactive kids is that they are more

relatively resistant to reinforcement than other children, positive or

negative reinforcement. They just can't seem to inhibit themselves

no matter much how reinforcement you use.

They may be aggressive. If there is one red flag about long term

outcome in children with ADHD, it is the aggressive child of

ADHD. When we look at long term studies, it is the ones who were

really aggressive in early childhood who are the most worrisome for

a bad long term outcome. And that should be a major red flag. If it is

a very aggressive child with ADHD, then that child definitely needs

counseling among the other modalities that you will use for the

child. So, aggressiveness is very important to ask about in terms of

long term prognosis. Academic problems clearly go along with

ADHD, as well as learning disabilities. Poor social skills and poor

peer relations should be sought.

One way to differentiate the very active child from an ADHD child

is that generally the very active child is accepted by his peers, and I

say "his" because males outnumber females 6:1. Very active chil-

dren are accepted by the peers, full of energy, very active, and other

kids like him. ADHD kids are not so much fun. They butt in, they

are babies, they can't inhibit themselves, they don't play the games

correctly, they may miss social cues. Often, other kids don't like

them. After treating their ADHD, these children may for the first

time be asked to play by other children. Social dysfunction as part of

ADHD. Other kids don't like them.

The bottom line, and I think in some ways the most pernicious

aspect of ADHD in the long run, is poor self-esteem. You put all

these things together, the child is having trouble with his parents,

not doing well in school, none of the kids like him. He really gets a

sense of himself that he's just not worth very much, and that sense of

himself may dog him all his days, long after perhaps he learns to

cope with his ADHD symptoms. One of the most important things

that you can do is emphasize to parents the importance of self-

esteem. Try to help the child to find islands of confidence in feeling

good about himself because in the long run that may be the most

important therapy of all.


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Prevalence of ADHD

4-6% of elementary school children

Male to female ratio is 6:1

? on the rise or more diagnostic sensitivity or overdiagnosed?

much higher incidence in first and second degree relatives

The prevalence of ADHD is up to 25%, and these kids are on

Ritalin. In other communities 0%. I think it is the most

overdiagnosed and most underdiagnosed condition in childhood. So,

it kind of depends on where you live and who you see.

The best estimates I would say are 4-6% of elementary school

children may have ADHD. So if you see a lot higher, you know

something is up. There is a higher incidence in first and second

degree relatives. So, family history is helpful in this.


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Etiology of ADHD

The etiology is unknown

believed to have a neurological basis (underactivity of frontal

lobes on PET scan; decreased dopamine metabolites in CSF)

We believe that ADHD is endogenous, not environmentally medi-

ated in any way. It is believed to have a neurological basis. There

have been studies showing the underactivity of frontal and

prefrontal lobes on PET scans. Decreased dopamine metabolites in

CSF. It's been associated with maternal smoking, prematurity. At

this point we really don't know.


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Clinical Diagnosis of ADHD

Corroboration. A questionnaire or interview of most or all of the

child's significant caregivers should assess the presence and

severity of symptoms. Clinical judgment is essential.

History

Symptoms are evaluated.

Complicating home or social stressors is assessed.

Cognitive and academic performance is documented.

The impact of symptoms on the rest of the family, including

the parent, is evaluated.

Child and sibling relationships are evaluated.

Treatments tried in the past are sought.

Physical exam

Most useful to assess child's response to a structured

situation

Neurological exam (e.g., clumsiness, "soft signs" not helpful;

hearing, tics)

Minor congenital or anomalies

Skin for neurocutaneous stigmata

Laboratory evaluation should include lead levels, anemia,

?hyperthyroidism.

In making the diagnosis, you have to seek corroboration, via ques-

tionnaires or interview, of the symptoms from most or all of the

child's significant caregivers. You never should make the diagnosis

just because you think it's true and the parent thinks it's true. That is

not enough because some kids can keep it together in the office very

well in a short visit. I have the luxury now of sometimes hour and

half evaluations in an academic setting and it isn't until an hour into

the evaluation the kid is beginning to show his true colors. The

clinicians perception of ADHD in the office does not necessarily

correlate. The child may be very anxious in the office and look like

he has ADHD when he doesn't, or conversely, be very quiet in the

office but if he stuck with it longer you'd see the symptoms.

In making the diagnosis it has to be in more than one setting. If the

parents give you a good history that's great. But you have to seek

corroboration in other important aspects of the child's life. If it's

daycare, if it's school, if it's Head Start, if it's grandparents, if it's the

babysitter. You need to hear from them too because to make the

diagnosis they have to have the symptoms across settings. If the

babysitter says, "No, he's great. I have no problems at all." then you

really need to question whether this is ADHD or not.

Aside from history of symptoms, which you'll ask about, you'll

certainly want to know about complicating home and social stress-

ors. Looking at the environmental context. How the child is doing

cognitively and academically.

Physical exam I think is generally not that helpful. You need to do

it, but there are almost no medical problems that you are going to be

ruling out. I think the physical exam is most useful to assess the

child's response to a structured situation and whether the child acts

like a kid with ADHD when you are examining him or her, as

opposed to looking for any special physical finding or medical

finding.

Minor congenital anomalies. There is increased ADHD in children

with minor congenital anomalies. But again it is not going to help

you so much with diagnosis. Looking for neurocutaneous stigmata,

just to make sure you're not missing something like

neurofibromatosis or tubular sclerosis. Lead, anemia,

hyperthyroidism should also be excluded.


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Diagnostic testing in ADHD

Testing is indicated only as indicated by the history and physical

examination.

Computer vigilance tests are not clinically useful.

The value of educational/neuropsychological testing is question-

able because of the 40% co-occurrence of learning disabilities.

The use of the diagnostic test will be basically based on a history

and physical exam. Computer vigilance tests are not that helpful

currently. There are too many false positives and false negatives for

it to be useful. If the child is doing well in school, I hold off on the

learning disabilities evaluation, if I think it is purely ADHD. On the

other hand, if the child is doing poorly at school, you may want to

try medication. If the medication works and the child continues to

do poorly in school, you should get a learning disabilities evalua-

tion, or you may want to do the learning disabilities evaluation

initially.


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Learning Disorders

Learning disorder is a generic term referring to a heterogeneous

group of disorders manifested by significant difficulties in the acquisi-

tion and use of reading (dyslexia), writing (dysgraphia) and/or

mathematical abilities (dyscalculia).

These disorders are intrinsic to the individual and presumed tooccur secondary to central nervous system dysfunction.

Learning disabilities. Learning disabilities are characterized by a

substantial discrepancy between ability as measured in an IQ test, as

much as that measures ability, and academic performance. The kind

of kid who is smart, but is just not doing well in school--should be

doing a lot better but isn't. You need that discrepancy. Difficulties

with neurodevelopmental functions such as language, memory,

visual-spatial ordering, temporal-sequential ordering. Different

kinds of ways of processing information seem to have problems.

These will come out best with neurodevelopmental testing. These

children also have difficulties with what people are now calling

executive functions. These are higher order mental processes, such

as concept acquisition, reasoning, problem-solving skills, critical

thinking and social cognition.


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Learning Disorder

characterized by a substantial discrepancy between ability (as

measured on IQ tests) and actual academic performance.

difficulties with neurodevelopmental functions such as language,

memory, visual-spatial ordering, temporal-sequential ordering.

difficulties with executive functions such as concept acquisition,

reasoning, problem-solving skills, critical thinking, social cogni-

tion


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Prevalence of Learning Disorder

5% of American schoolchildren are identified as having a

learning disorder. Some estimates as high as 15%.

male to female ratio is 4:1.

About 5% of American schoolchildren are identified as having

learning disabilities. Some people think it is a lot more, again. The

gradation between a learning disability and non-learning disability is

tough. All of us have strengths and weaknesses in our functioning.

Some estimates are as high as 15%. Again, males get the short end

of the stick, 4:1 as usual.


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Etiology of Learning Disorder

The etiology is unknown

There is often a strong family history

Dyslexia is now believed to be caused by dysfunction in phone-

mic awareness.

20 % of all boys and girls may be dyslexic.

The belief that letter reversal is indicative of dyslexia is a

Myth.

The etiology is unclear. There is often a strong family history.

Dyslexia. People used to talk about dyslexia as reading letters

backwards, writing letters backwards. It is now felt that dyslexia has

nothing to do with that. It doesn't matter if you write your letters

backwards or not. It is that dyslexia is a dysfunction in phonemic

awareness. That the children cannot process phonemes, the funda-

mental building block sounds, of language. They can't differentiate

"da" from "pa" very well. And because they can't differentiate these

phonemes they can't then begin to understand the words. They can't

differentiate one from the other when it comes to reading. They are

unable to do that. So, if they take the word "cat", they cannot decode

the word "cat" and therefore can't identify the word. In effect, their

ability to read specifically those words, even though they know what

a cat is.


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Consequences of Learning Disorder

The school drop-out rate is 40%.

Trouble keeping a job and problems with peer relations are

frequent.

10-25% coexist with conduct disorder, oppositional defiant

disorder, depression, or ADHD

Concomitants to learning disabilities. The high school drop-out rate

is 40%. Many kids who drop out of school have learning disabilities,

trouble keeping a job, problems with peer relations, and again, the

co-occurrence with conduct disorders, oppositional defiant disorder,

depression or ADHD.


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Office assessment of Learning Disorder

Physical examination and laboratory tests are rarely useful.

Clinical Evaluation of Learning Disorder:

academic achievement

classroom behavior

attendance

previous special testing and services at school

medical/perinatal history

developmental/behavioral history

family / social history


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Assessment of Learning Disorder

Initial assessment should start with the school (a mandate under

Public Law 94-142).

Parents have the right to an independent, second opinion.

A multi-disciplinary is recommended, but an assessment by a

psychologist is best if only one professional is allowed.

If you want an assessment done too, you can start with the school

and mandate under Public Law 94-142 that the school do an evalua-

tion for learning disabilities. The parents then have a right for an

independent second opinion if they don't agree with what the school

has said. Multidisciplinary evaluations are usually best, but I would

say if you were going to pick one, pick a psychologist or a

neuropsychologist to do the evaluation.


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Treatment of Learning Disorder

bypass strategies (e.g., decrease rate, volume, complexity of

task, go to auditory or visual mode, play to interests, use a

computer) skill remediation

developmental therapies (OT, speech, physical therapy)

curriculum modification

enhance strengths

Treatment of learning disabilities. Bypass strategies are used, so that

decreasing the rate or volume or complexity of the task, even in

small chunks, to work on at a time going in just the auditory or

visual mode. If you have trouble with auditory processing, you have

to learn visually. If you can hear things and remember things well

aurally but not visually, then you need to hear things and not so

much see them to do better in school. Computers seem to be very

helpful in teaching learning disabled kids. I think there is wonderful

potential in that area to learn at their own rate in the modality that

works best for them, whether it is visual or auditory.


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Management of ADHD

Goals

Enhance social functioning

Enhance academic functioning

Improve self-esteem

ADHD is really is a family problem. Kids with ADHD aren't fun.

But I think our role in the management of ADHD is critical in trying

to help the children. Especially by looking at enhancing social

functioning, academic functioning and emphasizing the importance

of self-esteem. The second thing we can do though is use medica-

tions. There is no question that the best treatment for a child who

truly has ADHD are medications. They are effective in about 70% of

the cases but they are not a cure. They improve symptomatology,

but the symptoms, although they will change over time, will proba-

bly last a lifetime. The long term efficacy of medications is still not

entirely clear. It's clear in the short term, it works, but in the long

run, we think it works, but the studies are not there to confirm it.

Ritalin is not a diagnostic test. If the child pays attention better it

doesn't matter. You would pay attention better if you took Ritalin. In

fact, I remember that people at school used it to study for finals

sometimes, illicitly. Ritalin improves attention for everybody, in all

kids. So the fact that a child does have a positive response doesn't

mean that they have ADHD.


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Medical Management of ADHD

Medications are effective in 70% of cases

medications are not a cure-all; long term efficacy data remains

inconclusive

not a diagnostic test!

I think that you should be very comfortable in using at least Ritalin

and Dexedrine. We usually mention pemoline, or Cylert. You may

have read the cautions about liver disease in Cylert, so I would

relegate it to a second line, although I still think you should be

comfortable with it. I use psychostimulants first. There are a few

rules to remember. One is that in the clinical trial, the decisions are

reversible. Just because you start it doesn't mean you can't stop it.

And you should present it to the parents as such. "We don't know if

it is going to work. Maybe it will work. If you like the idea, we can

try it. If you don't like it, we'll stop it. You need to do frequent

follow-up, at least until the child stabilizes. It is not the only treat-

ment. It is best used as part of a multi-modal treatment, including

educational, behavioral and counseling, if needed.

Ritalin is great and it helps, but the children may need help at

school. They may need counseling. The long term studies show that

the kids who do best are the ones who get multi-modal treatment.

You need to obtain ongoing efficacy and feedback from the same

caretakers who provided the history. If you asked the daycare pro-

vider if the child had ADHD through questionnaires or calling them

on the phone. If one medication doesn't work, try another. It is pretty

clear that some kids respond better to Dexedrine than they do to

Ritalin or to Ritalin than to Dexedrine or to pemoline or any of the

others. So, that it is worth it to go through all three. You might think

about whether they want to try some of the second line drugs, like

clonidine or tricyclic antidepressants.


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Drug Therapy of ADHD

Rule 1: Drug use is a clinical trial and decisions should be reversible.

Rule 2: Frequent follow-up is necessary until stabilized.

Rule 3: Drug therapy is best used as a part of multi-modal treatment,

including education, behavioral therapy, and counseling.

Rule 4: Obtain ongoing efficacy feedback from the caretakers who

provided the initial history. Adjust medications accordingly.Rule 5: If one medication doesn't work, try another.

Stimulants are the drug of choice. The good news is there is very

high efficacy and low morbidity to Ritalin and Dexedrine in chil-

dren. They have been extensively studied and they are very safe

when used correctly and you should feel comfortable about using

those. Many people start with Ritalin or Dexedrine.


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Stimulants Are Drugs of Choice

High eff icacy/low morbidity

Stimulants may increase the number of adrenergic receptors in

brain that stimulate attention and inhibitory centers.

Physicians should pick one or two agents and become comfort-

able with their use.


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Methylphenidate and Dextroamphetamine

Start with about 0.3 mg/kg/dose of methylphenidate (MPD) or

0.15 mg/kg/dose of dextroamphetamine (DA).

Increase every few days up to maximum of 1.0 mg/kg/dose (80

mg/day max) for MPD (1/2 dose to DA).

Onset 30 minutes; peak 2 hours; quite variable.

Frequency depends on target symptoms and setting.


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Short or Long-acting Stimulant?

Calculate daily dose of short-acting and convert to long-acting

Balance convenience vs erratic absorption

Consider effects on appetite

Short-acting or long-acting. Remember the problem with long-

acting is erratic absorption, so that the sustained release may last

longer but you never know when you are going to get the effect. It is

perfectly legitimate to titrate short-acting and long-acting.


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Side Effects of Stimulants

Appetite suppression

Sleep disturbance

Rebound hyperactivity vs. paradoxical effect

Emotional dysphoria ("zombie")

Questionable growth retardation

Tics

Side effects include appetite suppression, sleep disturbances, re-

bound hyperactivity, paradoxical effects., emotional dysphoria or

"zombie"-like kids is really something to watch for especially in

younger kids. Growth retardation, which probably doesn't exist and

if it does, it is no more than 2%, the studies have shown. It is gener-

ally not a real concern. And finally, tics. Tics will occur frequently

and nobody really feels that stimulants caused the tics, but we may

uncover tics in the child who has a pre-existing tic disorder, like

Tourette's, which may not show up beforehand. On the other hand,

in any child who has tics, I probably would not use any of the

stimulants, and clonidine is probably the drug of choice.


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27

Second line drugs

Clonidine

Desipramine

?SSRIs (Prozac)

There is a second line now, you may or may not use. I am getting

comfortable now using clonidine. I still am not comfortable using

the tricyclics, desipramine, and I refer those out if the child is also

depressed, especially if he has ADHD. People are now beginning to

use the serotonin, reuptake inhibitors, like Prozac. It is not clear how

well they will work.


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Parent Counseling

Provide information; demystify; take onus off child

Explain there is no cure, only coping

Emphasize importance of enhancing self-esteem


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Parent Training

Positive reinforcement; minimize punishment; differential

attention ("time-in")

Make positive prophecies; avoid negative character attributions

Discriminate necessary versus unnecessary limit-setting

Provide environments that are free of restraint

Finding something positive for that child to do that plays into their

strengths and not their weaknesses helps with self-esteem. Looking

at the environments. These kids need to be able to run and have a

good time and not be fenced in. Looking at the environment and the

quality of the environment. In letting the child have opportunities to

run and play and be free because that's what his nature tells him he

needs to do. Talk to parents about positive reinforcement, differen-

tial attention ("time-out") and so on. Making positive prophecies for

the child. "It's going to be good." as opposed to "It's going to be

bad." Discriminating necessary and unnecessary limits. These are all

common behavioral interventions you'll use in other areas.


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Classroom Therapy

Consistent with home program

Immediate and frequent consequences for misbehavior

Concrete rules

Hierarchy of rewards and punishments

Extra supervision and training

Allow time for uninhibited play

The classroom should be involved too and this needs to be consis-

tent with the home program with immediate and frequent conse-

quences for misbehavior and positive behavior. Concrete rules. A

hierarchy of rewards and punishments and some time for uninhibited

play are important interventions.

And then for the kids counseling and psychotherapy. If the child's

self-esteem is really low, if they are aggressive, if they are having a

really hard time, I think that counseling is helpful. Not to stop him

from having ADHD, but in dealing with the emotional consequences

of ADHD and/or a learning disability. Find successful activities and

awareness.


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Prognosis of ADHD

Symptoms persist in the majority, but change in nature (eg,

hyperactivity replaced by feelings of restlessness).

Most studies show a higher incidence of problems: Anti-social

behavior, violating the law (20-25%), substance abuse (16%),

other DSM diagnosis (33%)

Some have poorer work performance; adaptive problems; poor

interpersonal skills.

On the other hand, the majority become normal (especially if not

aggressive, high IQ, high socioeconomic scale, multi-modal

treatment)


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References

Dworkin P. School failure. in: Parker S and Zuckerman B: Behavioral

and developmental Pediatrics: A handbook for primary care. Boston,

MA:Little, Brown and Co. 1995, pp 256-260.

Levine M. Neurodevelopmental variation and dysfunction among

school-aged children. In Levine M, Carey W, Crocker A:

Developmental-behavioral pediatrics. Philadelphia: Saunders, 1992,

pp 477-494.

Sprague R, Sleator E. Methylphenidate in hyperkinetic children:

Differences in dose-effects on learning and social behavior. Science

198:1274, 1977.

Manhuzza S, et al. Adult outcome of hyperactive boys. Arch Gen

Psychiatry 50:565,1993.

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Attention Deficit Disorder and Learning Disorders