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Attention Deficit Hyperactivity
Disorder
Judith Axelrod, M.D.
Developmental-Behavioral Pediatrician
Square One: Specialists in Child and Adolescent
Development
ADHD
Attention Deficit
Hyperactivity Disorder
(ADHD) is a chronic
neurodevelopmental
disorder
Attention Deficit Hyperactivity
Disorder
The diagnosis of Attention Deficit Hyperactivity
Disorder is given to individuals who have frequent
failure to comply in an age appropriate fashion
with situational demands for inhibition of
impulsive responses and resistance to distracting
influences. These behaviors interfere with the
individual’s performance in social and academic
settings.
ADHD: Current Working Theory
Symptoms of ADHD are caused by
abnormality in the Executive Function of the
brain.
ADHD and Inheritance
• Inherited 57-97% (mean 80%)
– If parent has ADHD—offspring risk 20-54%
– 25-30% of fathers
– 15-20% of mothers
– Identical twins 55-92%
• Child with ADHD
– male sibling 35%
– female sibling 15%
Core issues with ADHD
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Impulsivity
Poorly regulated activity—hyperactivity
Distractibility—poor sustained attention
Disorganization
Diminished rule governed behavior
Emotional over arousal
Poor/No generalization of information
Variability of task performance
Pathology
Pathology occurs when the core
symptoms of ADHD are pervasive,
prominent and impair functioning
in all aspects of life.
What is it like to have ADHD
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Behavioral disinhibition
Dysfunction of cognitive ability
Poor adaptive function
Difficulty with rule governed behavior
Delays in internalization of language
Other ADHD qualities
• Sometimes work harder at avoiding work
than actually doing it
• Academic progress is often a roller coaster –
up and down all year
• Moody
• Really do want to do well
• Frustration
Qualities: ADHD Inattentive Type
(“ADD”)
• Often not identified until 5th grade, middle school,
or even high school
• May see substantial drop in grades around middle
school
• Compensate for struggles (mask it)
• Often described as “lazy”, “doesn’t care”,
“unmotivated”, “doesn’t try”
• Slower processing speed is common
• Often very quiet and well behaved – so not on the
“radar screen”
Typical Vulnerabilities
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Low self esteem
Humiliation
Feeling “dumb”
Always “in trouble”
Quick to lie about behavior
Become defensive
Feel defeated
Differences in youth with ADHD:
coping-temperament-subtypes
• ADHD with:
– Anxiety
– Obsessive Compulsive
– Agitation
– Mania
– Defiance
– Aggression
– Mood reactivity
Strengths and “Gifts”
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Creative
Charming
Funny
Social
Sensitive and caring
Hyperfocus
Enthusiasm
Comorbid Conditions
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Learning Disabilities
Cognitive Deficits
Tics / Tourette’s Disorder
Drug or alcohol use
Comorbid Conditions
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Depression
Anxiety
Obsessive Compulsive Disorder
Behavioral Disorders:
 Oppositional Defiant disorder
 Conduct Disorder
The Core Symptoms of ADHD are
present as symptoms in a variety
of psychiatric diagnoses
Other diagnoses with shared
symptoms
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Depression
Anxiety
Bipolar Disorder
Thought Disorder
Autism
Substance abuse
• Children with Attention Deficit
Hyperactivity Disorder frequently have
social skill difficulties which are manifested
by intrusive behaviors and erratic or
variable behaviors. They can be demanding
and controlling. Maturity seems to lag and
these children are often perceived as two
years behind their aged peers in maturity.
• 30-40% of children with Attention Deficit
Hyperactivity Disorder have affective
disorders such as depression and anxiety
How is the Diagnosis of Attention
Deficit Hyperactivity Disorder
made?
To make the diagnosis of ADHD
 Psychological evaluation
 Medical evaluation
Treatment
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Education
Behavior Management/Family Counseling
Medication
Consultation with school personnel
Behavior Management/Family
Counseling
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Effective in teaching ways to be consistent
Teaching problem solving techniques
Support
Breaking cycles of learned behavior
Help in the Classroom
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Be sure you are dealing with ADHD
Seek assistance to clarify diagnosis
Communicate with teachers/parents
Include the child in making a plan
Ask the child what will help
Help the child to take ownership
Help in the Classroom
• Avoid being punitive
• Set positive goals
• Attempt to reinforce effort and not just
accomplishment of goals (sometimes these
children try their best and still don’t meet
basic goals for behavior)
• Remember all ADHD is NOT alike
Help in the Classroom
• Use a “firm-flexibility” approach with the
child – combination of support,
accommodations, clear limits, and
expectations
• Daily schedules may help - visual
• Use visuals when possible
• Be cognizant of “high risk” times (e.g.,
unstructured, less supervised times)
Help in the Classroom
• Keep in mind that many behaviors may
reflect coping with frustration/anxiety
• Structure and clear expectations are vital for
success
• Need for cues, reminders, and repetition
• Be aware of and avoid “helping” strategies
that may humiliate the child
Help in the Classroom:
• ANY approach one takes should strive to
minimize penalizing the student for
struggles that are a direct result of ADHD.
That is, attempt to differentiate behaviors
that are much harder for the child due to
ADHD versus those that may occur by
choice
Help in the Classroom
• Initiate communication with parents and
ask about:
– Homework time
– Student’s understanding of tasks
– Time and effort spent with routine homework
Help in the Classroom
• If the child is clearly falling behind, take the
initiative to notify parents
• Be careful not to assume that problem
behaviors are intentional
• Try to stay positive
• Work with the student to set goals (but not
too many at once)
Help in the Classroom: Distraction
• Remember a child may be “listening” to you
but not attending to what you are saying
• Provide extended time as needed
• Emphasize quality over quantity with
assignments and homework
Help in the Classroom: Distraction
• Have the student repeat directions and/or
demonstrate understanding
• Monitor student’s progress in completing
work so it doesn’t pile up
• Provide cues to help the child stay on task
(e.g., agree on “secret” cues)
Help in the Classroom: Disorganization
• Consider allowing the student to have a
second set of books at home
• Make sure the child has correctly recorded
homework assignments
• Specifically request their homework and/or
find a system that works
• Suggest simple ways to organize papers
• Work with the child to organize locker
Help in the Classroom:
Hyperactivity/Impulsivity
• Provide adequate breaks and opportunities
to move or “reset”
• Use visual cues to help the child remember
to “STOP & THINK”
• When entering into a “high risk” situation,
talk through successful behavior with the
student beforehand
Help in the Classroom:
Working Memory
• A skill learned today is not necessarily
remembered tomorrow
• Note taking is often harder – be sure they
have relatively complete notes
• Suggest strategies that help the child
compensate for this weakness
ADHD Treatment
 Multimodal Treatment Study of ADHD (n = 579)
 Investigated effects of various treatment modalities on children
with ADHD, combined type over 14 month period
 Results
 Medication alone most effective treatment of core symptoms of ADHD
 Medication with psychosocial treatments was superior to other
treatments for non-ADHD areas of functioning – i.e. aggressive
behaviors, parent-child relations, teacher-rated social skills
 Medication Classes
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Stimulants
Antidepressants
Antihypertensives
Wake-promoting agent used in narcolepsy
Stimulants
 First line medication treatment of ADHD
 Approximately 70% of children will respond to
the first stimulant prescribed
 Up to 90% respond to the first or second
stimulant attempted
 Mechanism of Action
 Increase dopaminergic and noradrenergic
activity in frontal cortex
Stimulants
 Three types of stimulant formulations
 Short-acting
 Duration of action 2-4 hours
 Must be given 2-4 times per day
 Intermediate-acting
 Duration of action 6-8 hours
 Long-acting
 Duration of action 10-12 hours
 Current accepted practice is to initiate treatment
with an intermediate or long-acting preparation
Methylphenidate Class
 Short-acting
 Methylphenidate (Ritalin, Methylin)
 Focalin
 Intermediate-acting
 Ritalin LA/Ritalin SR
 Metadate CD/Metadate ER
 Long-acting
 Focalin XR
 Concerta
 Daytrana patch
Amphetamine Class
 Short Acting
 Adderall
 Abused in adolescent population
 Dexedrine/Dextrostat
 Desoxyn (Methamphetamine HCl)
 Intermediate-acting
 Dexedrine spansules
 Long Acting
 Adderall XR
 Vyvanse
 Prodrug – cleaved by stomach enzyme (less abusable)
Support
• CHADD (Children and Adults with Attention
Deficit Disorders)
8181 Professional Place, Suite 201
Landover, MD 20785
http://www.chadd.org/.
800-233-4050
ADHD Parent Support Group
• LDA of Kentucky
–www.ldaofky.org
Educational Intervention
• www.ed.gov
ADHD Recommeded Reading
For Parents
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Barkley, Russell. Taking Charge of ADHD: The Complete Authoritative Guide for Parents,
Fowler, M.C. (1990). Maybe You Know My Kid: A Parent’s Guide to Identifying,
Understanding, and Helping Your Child with Attention-Deficit Hyperactivity Disorder.
New York: Carol.
Hallowell. Edward and Ratey, John, Driven to Distraction: Recognizing and Coping with
Attention Deficit Disorder From Childhood through Adulthood. Patheon Books.
Hallowell. Edward and Ratey, John, Delivered from Distraction: Getting the most out of
Life with Attention Deficit Disorder. Patheon Books.
Jensen, Peter. Making the System Work For Your Child with ADHD. Guilford Press.
Ingersoll, B. (1988). Your Hyperactive Child. New York: Doubleday.
Ingersoll, B. and Goldstein, S. (1993). Attention Deficit Disorder and Learning Disabilities,
New York: Doubleday.
Nadeau, K. A Survival Guide for High School and College Students with ADHD, New York:
Magination.
Honos-Webb, Lara. The Gift Of ADHD: How To Transform Your Child's Problems Into
Strengths. Oakland: New Harbinger.
Taylor, Blake. ADHD and Me: What I Learned from Lighting Fires and the Dinner Table.
New Harbinger: 2008.
ADHD Recommended Reading
For Adults
• Nadeau, K. A Survival Guide for High School and
College Students with ADHD, New York:
Magination.
• Kelly, K. and Ramundo, P. (1993), You Mean I'm
Not Lazy. Stupid. or Crazy?! Cincinnati: Tyrell and
Jerem Press.
• Murphy, K. and LeVert, S. (1995). Out of the Fog:
Treatment Options and Coping Strategies for Adult
Attention Deficit Disorder. New York: Hyperion.
• Quinn, P.O. (1994). ADD and the College Student: a
Guide for High School and College Students with
Attention Deficit Disorder. New York: Magination.
ADHD Recommended Reading
For Children
• Gehret, J. (1991). Eagle Eyes: a Child's Guide to Paying
Attention. Fairport, NY: Verbal Images Press.
• Gordon, M. (1992), My Brother's a World-Class Pain: A
Sibling's Guide to ADHD/Hyperactivity. DeWitt, NY: GSI
Publications.
• Nadeau, K.G. and Dixon, E.B. (1991), Learning to Slow
Down and Pay Attention.
• Chesapeake Psychological Services, 5041 A&B Backlick
Road, Annandale, Virginia 22003.
• Qujnn, P.O. and Stem, J.M. (1991). Putting on the Brakes:
Young People's Guide to Understanding ADHD. New York:
Magination Press.
Square One Specialists
in Child and Adolescent Development
• Developmental & Mental Health
Specialists
• Comprehensive Evaluations
• In-depth Collaborative Treatment
www.squareonemd.com
(502) 896-2606
Multidisciplinary Staff
Our team of doctors and specialists are experts in child & adolescent
development. More importantly, they are people who love to help children—
who want nothing more than to see them succeed in everything they do.
Regardless of what makes your child unique, you can trust that our staff has
the expertise to help them reach their maximum potential.
•
Judith Axelrod, M.D.
– Developmental Pediatrician
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David Causey, Ph.D.
– Licensed Clinical Psychologist
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Lisa Ruble, Ph.D.
– Licensed Psychologist
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Ann Hayes Ronald, M.Ed.
– Licensed Psychological Associate
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Sherri Stover, M.S. L.C.S.W.
– Licensed Clinical Social Worker
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Ashley Redenbaugh, M.S. CCC-SLP
– Speech Language Pathologist