www.pspbc.ca

Children and Adolescent ADHD

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Child & AdolescentAttention DeficitHyper Activity Disorder(ADHD)

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Receives much media attention and controversy Neuro-developmental psychiatric disorder Impairs social, academic, family, and occupational

functioning In Canada: 5 – 10 % in youth; 3 – 5 % in adults Associated with serious mental disorders:

› Learning Disability › Conduct Disorder › Oppositional Defiant Disorder› Anxiety Disorders› Major Depressive Disorder› Disruptive Mood Dysregulation Disorder› Intermittent Explosive Disorder

Fast Facts: Child & Adolescent ADHD

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Greater risk for:› Poorer academic achievement › Fewer friends › Lower self-esteem› Teen pregnancies› Substance misuse/abuse› Interpersonal difficulties

More prone to:› Physical injury› Accidental poisoning› Traffic accidents

Fast Facts:

Child & Adolescent ADHD

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More likely to:› Score lower on achievement tests› Repeat grades› Suffer suspensions› Have problems with school

Early treatment & effective therapies can help:

› Medications

› Psycho-education, and/or

› Behavioral Intervention

Fast Facts: Child & Adolescent ADHD

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Stan [Kutcher] is disruptive in class, he is always talking and has great difficulty sitting still

Stanley cannot settle down to do desk work – he is always fidgeting

Stanley is not getting his homework done, he forgets to take his work home or to bring his homework to school

Stanley’s grades do not reflect what he is capable of doing

Stanley is so disorganized that he will never be successful at anything

Typical School Report Card Notes

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3. Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)?

› If YES – consider ADHD› Apply the SNAP-IV 18 item

scale› Proceed to the Identification,

Diagnosis and Treatment of the Child and Adolescent ADHD Module

ADHD Screening Question

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ADHD Screening Tool – Parent Version

Does your teenager usually not finish things that he or she starts?

Is your teenager not able to pay attention to things for as long as other teenagers?

Does your teenager fidget or move around much of the time, even when he/she knows she should not?

Is your teenager impulsive or does he/she act without thinking much of the time?

Is your teenager’s behaviour causing him/her problems at home and at school?

Have these difficulties been there for a long time (six months or longer)?

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ADHD Screening Tool – Youth Version

Are you able to finish most things that you start within the time others expect?

Do you have trouble paying attention to things that are not that interesting to you?

Do you fidget or feel you have to move around much of the time?

Do you often do things without thinking?

Are you having problems at home or school related to your behaviour or because of trouble paying attention?

Have these difficulties been there for a long time (six months or longer)?

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1. Identification of child/youth at risk for ADHD

2. Methods for screening & diagnosis3. Treatment template4. Suicide assessment (for adolescents

only)5. Safety and contingency planning6. Referral flags

Key Steps for Treatment of ADHD to Children & Adolescents

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Step 1: Identification of Risk for ADHD

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Well established andsignificant risk effect

Less well establishedrisk effect

Possible “group”identifiers

(these are not causal for ADHD but may

identify factors related

to adolescent onset ADHD)

1. A previous diagnosis of ADHD

2. Family history of ADHD

3. Family history of mental disorders (affective, anxiety, tics or conduct disorder)

4. Psychiatric Disorder: Oppositional Defiant Disorder, Conduct Disorder or a Learning Disorder

1. Exposure to severe environmental factors (i.e., lead contamination, prenatal exposure of alcohol and cigarette, birth trauma, low birth weight, head injuries). 2. Psychosocial adversity such as maternal depression, paternal criminality, chaotic home environment, and poverty3. Substance misuse/abuse (early onset of use including cigarettes and alcohol)4. Head injury (concussion)

1. School failure or learning difficulties

2. Socially isolated from peers or behavioural problems at home and at school (including gang activity & legal problems) – accident prone.

3. Bullying (victim and/or perpetrator)

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Check for patterns of:› Declining grades

› Frequent lates/absences

› Discipline concerns

› Homework not completed

› Concentration problems

› Over-activity or inattentiveness Confidentiality & informed consent

› Speak with both child and parents

› Easier for child to access care

› Easier for parents to know what to expect

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If Child is High Risk…

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Part of general health visits› Screen at regular visits

› Screen teens during visits for contraception/sexual health issues

› Presentation of ADHD symptoms may change over time Younger children are more impulsive and hyperactive Adolescents are less hyper, but have inner restlessness,

impulsivity and inattention Co-morbidity of ADHD

› Anxiety, Opposition Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Learning Disorder

› Consider possibility of one or more of these disorders

Step 2:Useful Methods for Screening & Diagnosis of ADHD in the Clinical Setting

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Child/Adolescent may show:› Inattention

› Distractibility

› Impulsivity

› Hyperactivity Requires health provider

intervention› Differentiate between normal responses to

circumstances or developmental changes in normal children

› Use the “Distress versus Disorder” model

Screening & Diagnosis of ADHD

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Approx. 65% of children with ADHD still

meet diagnostic criteria during adolescence

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3 Sub-categories1. Predominantly Inattentive

› 20 – 30% of children and adolescents with ADHD

› Daydreaming, distractibility and difficulty focusing on a single task for a prolonged period

2. Predominantly Hyperactive-Impulsive› 5 – 10% of children and adolescents with ADHD

› Manifesting as a situational inappropriate and excessive motor activity such as fidgeting, excessive talking, impulsive actions and restlessness

3. Combined Inattentive/Hyperactive› 60 – 70% of children and adolescents with ADHD

› Manifesting as a combination of the above two subtypes

Screening & Diagnosis of ADHD

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No biological diagnostic tests for ADHD› Clinical assessments of:

Signs Symptoms Clinical History

› Carry out evaluations over more than one visit 2 to 3 visits are often needed No hurry for a diagnosis; Take Your Time

Screening & Diagnosis of ADHD

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Difficulty attending› Reading a storybook with parent, or coloring/drawing

“Squirmy” Difficulties “settling” Very active, always on the go

› Bumping into things/getting hurt Parents refer to child as:

› “Not listening”

› “Zippy”

› “Always running around”

Clinical Findings for ADHD

Early Childhood 3 – 5 years of age

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Child may not persist long with most tasks› Particularly what they do not want to do

Parents report child: › Does not pay attention or listen

› Is very forgetful or disorganized Described as:

› “Overactive”, “always on the go” & “cannot sit still”,

› Acting out of turn

› Blurting out in class

› More evident in situations where attention is expected

Clinical Findings for ADHD

Middle Childhood 6-12 years of age

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School reports, “…not living up to academic potential”

Difficulty with peers Impulsivity & intrusiveness

An active child does not mean ADHDGirls with ADHD may demonstrate

inattentiveness, not hyperactive symptoms

Clinical Findings for ADHD

Middle Childhood 6-12 years of age

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Easily distracted from tasks Feelings of inner restlessness Stopping short on tasks Forgetful; fail to complete tasks Fidgety Difficulty with relationships

› Many “breakups” Impaired temper control Impulsive decision making

Clinical Findings for ADHD

Adolescence 13 – 19 years of age

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Engage in “risky” behavior› At higher risk for traffic accidents

Considered “lacking maturity” for their age Without treatment, exhibit signs of demoralization

› Due to negative comments

› “Nagging” from parents, teachers, adults and peers

› Do not confuse demoralization with depression May get involved in drug use and criminal behavior School drop outs, especially with unidentified learning

disability

Clinical Findings for ADHD

Adolescence 13 – 19 years of age

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Not likely ADHD if: › Symptoms only in one setting

› Not functionally impairing

ADHD type symptoms may be › Post Traumatic Stress Disorder (PTSD)

› Consider PTSD as a diagnostic possibility in youth who exhibit ADHD symptoms for whom a significant traumatic event has recently occurred. Remember: ADHD prior to age 12.

Screening & Diagnosis of ADHD

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Inquire about substance

misuse/abuse

- Including marijuana -Youth with ADHD may be more

likely to use a variety of substances

Specialist consultationfor substance abuse & ADHD

Youth ADHD Screening Q’s

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