Learning objectives. Case. Chronic conditions of childhood (per 100) Positive screen for ADHD, etc. Case: 8 year-old Paul

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1 Learning objectives 1. Screen for ADHD and other school problems. 2. Differentiate ADHD from learning & emotional disorders. 3. Counsel families on academic & behavioral interventions. 4. Manage medical treatment of uncomplicated ADHD. Introduction to AAP s ADHD Guidelines American Academy of Pediatrics, Pediatrics online Oct 2011; DOI: /peds Case It is early November and the mother of one of your 8-year-old patients is on the telephone. Her son s 2nd-grade teacher just called to tell her that Paul is jumping out of his seat and disrupting class. Worse still, his grades are slipping. The teacher thinks that he needs to see a child neurologist, and the mother asks you what she should do. Chronic conditions of childhood (per 100) ADHD 8.1 Learning disability 6.8 Intellectual dis. (MR) 1.5 Autism 1.1 Hearing loss 0.4 Visual loss 0.4 Cerebral Palsy 0.3 Down Syndrome 0.1 Obesity 16 Allergies 9.6 Recurrent OM 8.3 Asthma 6.2 Diabetes 0.1 Sickle cell 0.1 Kidney transplant Screening: yearly check-ups (> 4 years) School should be a focus of the visit Bring report card to check-ups Be specific and careful about language Do you have any concerns about how your child is learning? Do you have any concerns about how your child is behaving? Hearing and vision screening American Academy of Pediatrics (AAP) Guidelines Positive screen for ADHD, etc. Parental or child concern Failed a course Mandatory summer school Frequent detention and/or suspension Significant difficulties with teacher/peers Missing school Grades dropping Case: 8 year-old Paul Jumping out of his seat and disrupting class In 2 nd grade and his grades are slipping Similar complaints in kindergarten and first grade, but not as serious No significant PMH Family history of poor school performance

2 Most likely diagnoses Below-average cognitive ability Learning disability ADHD (combined type) Emotional disorders (e.g. depression) Others to consider Hearing or vision disorders Autism Spectrum Disorder (E) Rare medical conditions Borderline cognitive ability Debate on the nature of intelligence Standard tests of cognitive ability (IQ) WISC, Stanford-Binet, etc. Correlates with school performance IQ relative to expections/school Child who is has difficulty learning can get frustrated and act out/withdraw Learning disability Reading disorders (80% of LD s) Phenomic processing delay Not related to vision, reversing letters, or poor hand-writing Child who wants to read, has sufficient IQ, and has a teacher, but still can t read RTI response to intervention ADHD Cannot pay attention to boring things May be impulsive/hyperactive (or not) May have high, low, or average IQ Symptoms at least 6 months in 2 settings Rule out epilepsy, encephalitis, brain injury, sleep disorders, thyroid dysfunction Cocaine, amphetamines, antihistamines, neuroleptics, thyroid meds, phenobarbital Emotional disorders Depression, anxiety ( internalizing ) Oppositional defiant, conduct disorder ( externalizing ) May not present the way adults do Boys with depression may externalize Often related to family issues May not be revealed at first visit Co-morbid with low IQ, ADHD, LD

3 Hearing or visual impairment Unilateral hearing loss Auditory processing disorders May not be apparent until classroom Visual disturbances Uncommon cause of school difficulty Every child needs a screening test for hearing and vision Miscellaneous Some children do not meet clinical criteria for any specific diagnosis but are borderline in a number of areas Most children have more than one cause If abrupt change in a child s personality or school performance, consider medical causes, family changes, and substance abuse Regression at any age cause for alarm Case: 8 year-old Paul Jumping out of his seat and disrupting class In 2 nd grade and his grades are slipping Similar complaints in kindergarten and first grade, but not as serious No significant PMH Family history of poor school performance Key history questions How is he reading? If doing well, LD or cognitive unlikely, and focus is on ADHD, emotional issues How is he doing at home? (church?) Problems focused on academic issues? Any obvious family issues? History is helpful, but typically insufficient to diagnosis ADHD, reading disorders, etc. What to say to the family?

4 Treatment for ADHD 1. Individual (diet, sleep, exercise, musical instrument, mindfulness/spirituality) 2. Family parents learn basics of behavior management; take a disability perspective 3. School teachers start positive behavior support plan 4. Medications (psychostimulants) starting at age 6 years Daily Report Card

5 Medical treatment of ADHD ADHD treatment Medications work well in about 50% of cases Work only when a child is taking them Children still need to learn skills and improve executive function (frontal & prefrontal lobes) Starting behavior therapy first can reduce or eliminate need for medication Pelham et al J. Child Adol Psych (2016) shows some children do better if behavior is first-line treatment The MTA Cooperative Group, Arch Gen Psychiatry 1999;56:

6 ADHD medical treatment Healthy child (no epilepsy, cardiac condition) No family history of cardiac/early deaths Start with long-acting psychostimulant one covered by family s insurance Start with lowest dose and increase (weekly) Establish clear behavior goals e.g. stays in seat, completes classwork ADHD medical treatment Increase dose until desired outcome or side effects Headaches and stomach usually go away Stop if zombie or irritable/emotionally reactive Mention seizures and sudden cardiac death Decreased appetite, weight gain, and growth Try another stimulant if first one doesn t work Follow-up monthly (weight, blood pressure) Bill by time counseling with family (25 min = 99214) When and where to refer Learning, peers, grown-ups (following rules) are common outcomes If concerns, (1) review four ADHD treatments Individual, family, school, medication (2) psychoeducational evaluation - diagnosis Local public school (Part B of IDEA) Private testing to avoid waiting Results provide road map for treatment Psychoeducational evaluation Developmental history; observations Formal test of cognitive ability (IQ) Formal test of achievement (reading, math) Teacher and parent rating scales ADHD, emotional or behavioral concerns Conner Rating Scales, BRIEF, etc. Specialized tests of speech/language Auditory processing, subtle visual issues IEP or Section 504 Schools are responsible for child education and behavior when they are in school. Two pathways that schools follow ( staffing ) Individualized Education Plan IEP required by law (Part B of IDEA) Write a Physician Statement to initiate a Section Medican do this! Refer families to parent support networks e.g. Parent to Parent Take-home points: AHDH WHO? You. WHEN? Now. HOW? Screen for school and behavioral problems Use AAP s ADHD toolkit (Vanderbilt forms) Counsel families about behavioral and academic interventions (IDEA, Section 504) Psychostimulants - first-line ADHD medicines

7 Resources American Academy of Pediatrics AAP Guidelines for Treatment of ADHD AAP ADHD Toolkit Family organizations Family Voices National Office The National Parent Network on Disabilities