Key areas covered include: Please remember: Richard C. Goldsworthy, M.S. Jeff Epstein, Ph.D.

Transcription

1

2 This brochure is a supplement to the three-part video program Understanding ADHD. Its purpose is to review and reinforce the main points of the video program, and provide you with more detailed information about the various treatments for ADHD, especially treatment with medication. Key areas covered include: What is ADHD? How is ADHD assessed and what is your role as a parent? How is ADHD managed and how can you help? Richard C. Goldsworthy, M.S. The Academic Edge, Inc. Jeff Epstein, Ph.D. Duke University Child & Family Study Center 2003 The Academic Edge, Inc. Please remember: You are not alone. Many other parents are experiencing things similar to you because ADHD is the most commonly diagnosed behavioral disorder in North America. ADHD is also the most studied childhood psychiatric disorder and has been recognized for almost 50 years. There are a variety of successful treatments available for children with ADHD including behavioral therapy, counseling, and medication. Many children with ADHD overcome the disorder s challenges with appropriate treatment. This package is not a substitute for the vital services performed by professional medical practitioners. It serves only as a source of additional information. The content herein is based on generally accepted medical guidelines and may not always apply in specific instances. Only your doctor, along with other health care providers, can accurately diagnose and treat specific medical problems. The writer, editors, and publisher cannot accept any responsibility for diagnosis or treatment of individual cases. If you have any health concerns after reading this booklet, we strongly recommend that you immediately contact your doctor or health care provider. The term doctor is used throughout this brochure to refer to your doctor or other professional health care provider. We hope you will derive much benefit from this brochure. 2

3 A recognized disorder for 50 years, ADHD has had a series of names, including Minimal Brain Damage, Hyperkinetic Reaction, and Attention Deficit Disorder/ADD. Since the 1990s, however, medical professionals have preferred the term Attention-Deficit/Hyperactivity Disorder. ADHD is a complicated disorder whose symptoms sometimes include: Inattention Impulsivity While almost everyone exhibits some ADHD symptoms at some time, children with ADHD will exhibit many of the behaviors most of the time, and have done so from an early age. The cause of ADHD is still not completely known, but researchers now believe it has neurobiological origins. Research has shown that there may be a genetic link. There are three distinct subtypes of ADHD: Predominantly Inattentive Type Predominantly Hyperactive/Impulsive Type Combined Type (both inattentive and hyperactive) Diagnosis of ADHD is not easy because many things can produce behavior similar to ADHD. Physical illness, visual impairment, learning disabilities, behavioral disorders, depression, and anxiety can look like ADHD. Therefore, the best assessment gathers a variety of information from a range of sources including parents, teachers, and pediatricians, to confirm ADHD. The following steps are crucial in confirming whether your child has ADHD: A doctor conducts a physical examination. Parents complete rating scales that detail the child s developmental and academic history, and rate recent behavior patterns Teachers complete rating scales that detail the child s developmental and academic history, and rate recent behavior patterns Parents take part in an ADHD Diagnostic Interview with the doctor To be diagnosed with one of these ADHD subtypes, a child: Must have many of the symptoms most of the time Must have symptoms that are more severe and frequent than other children the same age Must have had the symptoms since an early age Must have the symptoms present in more than one setting (e.g. school and home) Must have other disorders or conditions that could be causing these symptoms ruled out. Your role is very important to the assessment process. Some of the key information about your child comes from the rating scales and the diagnostic interview. It is also very important that you help ensure that your child s teacher complete the teacher version of the rating scales. Asking your child s teacher if they understand the scales, asking them if they have had an opportunity to complete the scales, and maintaining an open, friendly, and frank relationship will help the process. If indeed your child is diagnosed with ADHD, the doctor will outline a course of treatment. 3 4

4 There are a number of things that can be done to help a child with ADHD be successful in home, school, and play. Research has shown that a combination of therapies often proves most successful in dealing with ADHD. The following is a brief description of several common strategies. Your doctor can provide further information and referrals about each, and additional information is available from many of the sources listed in the resources section. Management in the School strategies in order to meet your child s educational needs. An Individualized Education Plan (IEP) is a written version of these goals and strategies. The formal IEP helps ensure that important accommodations are fully implemented. Some strategies that are often used in an IEP include a special resource room, increased time on tests, and other adaptations. Section 504 is not as strict as IDEA but can result in similar accomodations. Section 504 outlines a list of educational therapies that school personnel should implement for a child with ADHD. Acquiring Section 504 accommodations is often faster and more flexible than IDEA, but IDEA has more safeguards for ensuring accommodations are actually implemented. Educational accommodations under Section 504 may include: Many children with ADHD have difficulties in the classroom. Working closely with the school is essential. Two federal laws (the Individuals with Disabilities Act (IDEA) and Section 504 of the Rehabilitation Act of 1973) provide support for children with ADHD and their parents. These acts provide for free and appropriate educational accommodations in a public school setting. In order for your child to receive these services, first there needs to be documentation of an ADHD diagnosis. Check with your child s school to see what is required. Additionally, a common strategy is to implement Daily Report Cards. IDEA requires that several times during the school year, a team of school personnel gather to set goals and discuss implementation Moving the child to front of class Writing directions on the board Breaking instructions into small steps Reminding the child to turn in homework Providing additional time for tests and written work Ignoring negative behavior Rewarding positive behavior The Daily Report Card (DRC) is one of the most common behavioral techniques for school settings. Daily report cards allow the teacher to select a few target behaviors and work with the child to modify those target behaviors using a behavioral reward system that is usually implemented at home. 5 6

5 Steps for setting up a DRC include the following: Meet with your child s teacher to select behaviors that your child is having difficulty with in the school setting. No more than five behaviors should be selected. Some behaviors that can be listed on the DRC are remaining seated appropriately, raising one s hand before talking in class, refraining from daydreaming. These behaviors are then listed on the DRC. The teacher establishes times when s/he can let the child know how he or she is doing. The general rule is the more often feedback is given the better. If, for example, a teacher agrees to give feedback to the child on an hourly basis, the teacher will check off the behaviors that the child accomplished during the course of the last hour for each hour of the day. Teachers can use stickers, such as stars, instead of checkmarks if this is more motivating to your child. The DRC system allows children to begin anew each day and attempt to earn privileges based upon their behavior at school. The DRC system can be effectively strengthened by adding in weekly rewards tied to the percentages earned throughout the week (e.g., earning an average of greater than 90% across the week earns a movie rental). A properly implemented DRC is an effective tool for improving your child s behavior. A DRC can, however, be difficult and you may want to consult with a behavioral psychologist for assistance in setting up such a program. Management at Home At the end of the day, the teacher or parent will help your child add up the checkmarks and compute a percentage of checkmarks earned for that day. When your child goes home, they will get privileges based on levels of success that you establish beforehand. One way to do this would be to have three privilege levels (green, yellow, and red) which corresponded to certain percentage levels (above 90%, 80-90%, and below 80%). Green level privileges would allow the child to have a later bed time, play a game with the family, etc. Yellow level privileges would decrease the overall level of privileges. Finally, the red level affords very little in the way of any privileges (e.g., early bed time, no TV or videogames, etc.). For more detailed information about setting up a DRC please vist: This is a pdf file and will require that you have the free Adobe Acrobat Reader plug-in installed. Parenting a child with ADHD can be a difficult and overwhelming experience. Fortunately, there are many proven methods for improving your childʼs behavior. These methods all take time and effort to implement but can be very effective when done correctly. Some basic behavioral strategies that can be adopted at home include: Give your child clear, consistent directions and limits, and stick to them. Remember: consistent and persistent! Make your child s environment predictable and structured. Establish a token or reward system for appropriate behavior. The premise behind these programs is to provide your child a reward token (e.g., poker chip, sticker) when they accomplish a specific goal and then to provide daily or weekly actual rewards (e.g., movie rental, bedtime) based on the number of reward tokens achieved, similar to the DRC described above. 7 8

6 Identify your child s strengths and try to cater to them. If your children are good at sports, try to encourage them to participate and succeed in sports. Whether art, reading, or other hobbies, encourage participation in areas that they enjoy and are successful. Having symptoms of ADHD often leads to decreased self-esteem. By engaging in activities where they can succeed, your children s selfesteem will be strengthened. Be positive with your child. While it is easy to get into a pattern of being negative with your child, it is important to identify those times when your child is behaving well and reward your child for those times. Catch your child being good and praise him or her rather than focusing primarily on correcting inappropriate behavior. These strategies may help improve a child s behavior at home. There are many excellent resources available to help you effectively help your child. Your child s doctor, a psychologist, behavioral therapists, and many other health professionals are available to help you. Management with Medication Medications are one of the most effective interventions for addressing ADHD-related behaviors. Psychostimulant medications change the levels of certain chemicals in the brain. By changing the amount of these chemicals available to some types of cells in the brain, different areas of the brain are stimulated. This stimulation causes behavioral changes. These changes include improved attention, less impulsivity, and less hyperactivity. In addition, the psychostimulants also improve compliance, aggression, and sometimes even handwriting. Research has shown that 70-80% of children respond to the psychostimulant medications. Most of the stimulant medications have similar effects, benefits, and side effects. The major differences between these medications involve how often and when a child should take them. Most of the medications work equally well. However, some work better for some children than for others. Therefore, it will be important for you, as a parent, to discuss medications with your doctor and decide which medication is best for your child. Side Effects. Psychostimulant medications do have some side effects. Most side effects are relatively minor and tend to go away over time. Side effects include loss of appetite, listlessness, irritability, and problems sleeping. Other side effects that may occur include motor tics or depression. There is no evidence that these medications lead to long-term ill effects such as stunted growth, reduced brain size, or an increased likelihood of substance use and addiction. However, other negatives do include the possible misuse of these medications, whether abused by the child or given/sold to kids without ADHD. How do we determine which dose is the correct dose? Not all children respond the same to the same amount of medication. Typical methods of determining an amount of medication include: using the weight of the child to determine the dose or beginning with a low dose and increasing the dose until the child begins to respond. *Brand names and product names used in these materials may be trademarks, registered trademarks, or tradenames of their respective holders. AEI is not associated with any product or vendor mentioned in these materials. 9 10

7 Unfortunately, there is very little evidence these methods result in an ideal level of medication. Some research suggests that a better method is to conduct a titration trial. In a triation trial: the amount of medication is varied from a placebo (no medication) to a high dose. each dose is tried for a week. at the end of each week, parents and teachers rate the child s behavior and side effects at the end of the trial, the effectiveness of each level of medication is assessed. the best level of medication is then selected based on the results of the trial. In case you were wondering, the reason for including a placebo dose in a titration trial is to determine whether your child responds better to the medication than they do to no medication. In effect, you are conducting an experiment to see if your child really needs the medication to perform better at home and school. To get the most accurate picture, medications must be given at the same time every day, 24 hour apart. Each trial must start on a Monday. At the end of each week (Friday for teachers; Sunday for parents), you and your child s teacher will rate your child s behavior and side effects on several rating scale forms. When you schedule your next visit with your doctor, he or she will have a full report of your child s titration trial in order in order to better decide the most appropriate medication level for your child. Medication Maintenance Once an appropriate level of medication has been prescribed, you and your doctor should follow your childʼs progress to make sure that the medication level remains appropriate. Ongoing maintenance ideally involves monthly completion of additional rating scales by both you and your child s teacher. It will be tempting, especially when your child s behavior improves, not to complete the monthly rating scales. If you only complete the rating scales when your child is doing poorly in school, your physician will not be able to determine how the prescribed treatments are deteriorating over time. Regular monthly completion of the rating scales ensures an accurate ongoing picture of your child s treatment. If your child s behavior or side effects appear to be changing, your child s physician will hopefully schedule an appointment to address whatever problem is present. As with titration trials for medication prescription, this maintenance routine is ideal, but it is not frequently used. The closer you, your child s teacher(s), and your physician come to frequent, regular monitoring of your child, regardless of apparent success, the better overall success you are likely to have. Unfortunately, titration trials are not used very often because of the increased time and effort involved on the part of the physician, parent, and teacher

8 Children with Attention Deficit Disorders (CHADD) 8181 Professional Place, #201, Landover, MD National Center for Learning Disabilities 381 Park Avenue South, Suite 1401, New York, NY Learning Disabilities Association of America 4156 Library Road, Pittsburgh, PA Having a child with ADHD may leave you feeling out of control, but it does not have to control your child and your family. There are many effective treatment and management steps you and your child can take to regain control. There is no simple quick fix. Medications can help, but often other support is needed. Remember you are not alone: your family, your child s school, your doctor, and your child are all members of this team. Together, you can help your family have a brighter tomorrow. Additional Resources If you have additional questions, your first source of information should be the professionals who are working with your child. Additional sources of credible information include Organizations National Institute of Mental Health NIMH Public Inquiries 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD U.S.A. Voice (301) publicat/adhdmenu.cfm National Attention Deficit Disorder Association (ADDA) 1788 Second Street, Suite 200, Highland Park, IL Books Barkley, R.A.: Taking Charge of ADHD. The Guilford Press, 1995 Ingersoll, B.: Your Hyperactive Child A Parent s Guide to Coping With Attention Defi cit Disorder. Doubleday, Goldstein, S. and Goldstein, M.: Managing Attention Disorders in Children. John Wiley & Sons, Goldstein, S.: The Facts about ADHD: An overview of Attention- Deficit Hyperactivity Disorder. CHADD 1999 Conference Book. Landover, MD, This publication was made possible by grant number R43MH62845 from the National Institute of Mental Health. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIMH The Academic Edge, Inc.

9 2003 The Academic Edge. No portion of this publication may be reproduced in any form or by any means, including electronic and photocopy, without written permission from The Academic Edge, Inc.