6/3/2015 PREVALENCE OF ADHD ADHD IS NOT JUST FOR KIDS DISCLOSURE ATTENTION DEFICIT HYPERACTIVITY DISORDER ADHD OUTLINE OCCURS ACROSS THE LIFESPAN

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DISCLOSURE ATTENTION DEFICIT HYPERACTIVITY DISORDER PATHOPHYSIOLOGY DIAGNOSIS TREATMENT I have no financial relationships with any manufacture(s) of any

medications in this presentation ADHD OUTLINE PATHOPHYSIOLOGY Prevalence Genetics Neuroanatomy /Neurotransmitters Coexisting Conditions DIAGNOSIS DSM 5

THE LIFESPAN ADHD is one of the most common neurobehavioral disorders of childhood. It is usually first diagnosed in childhood. It may last into adulthood.

1 DISCLOSURE ATTENTION DEFICIT HYPERACTIVITY DISORDER PATHOPHYSIOLOGY DIAGNOSIS TREATMENT I have no financial relationships with any manufacture(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity I will not be discussing off label use of FDA approved medications in this presentation ADHD OUTLINE PATHOPHYSIOLOGY Prevalence Genetics Neuroanatomy /Neurotransmitters Coexisting Conditions DIAGNOSIS DSM 5 Criteria AAP Guidelines TREATMENT Medication and Behavioral Approaches Family Considerations School Accommodations ADHD IS NOT JUST FOR KIDS OCCURS ACROSS THE LIFESPAN ADHD is one of the most common neurobehavioral disorders of childhood. It is usually first diagnosed in childhood. It may last into adulthood. [4%] Impulsivity until early teens Hyperactivity until mid-late teens Inattention: F-early 20 s; M-late 20 s PREVALENCE OF ADHD PREVALENCE OF ADHD Centers for Disease Control,

CDC DATA: US AND TN Does your child currently have ADHD or ADD? Is your child currently taking medication for ADHD or ADD?

8% of US children and 11.1% of children in Tennessee [parent report]. Tennessee ranked 11th highest. 2007: 4.8% of US children 6.

5% of children in Tennessee were taking medication for ADHD. Tennessee ranked 7th highest in US Kessler RC, Chiu WT, Demler O, Walters EE.

Archives of General Psychiatry, 2005 Jun;62(6):617-27.

2 CDC DATA: US AND TN Does your child currently have ADHD or ADD? Is your child currently taking medication for ADHD or ADD? ADHD: ADULT PREVALENCE 2007: 7.2% of US children and 8.7% of children in Tennessee [parent report]. Tennessee ranked 14th highest. 2011: 8.8% of US children and 11.1% of children in Tennessee [parent report]. Tennessee ranked 11th highest. 2007: 4.8% of US children 6.2% of children in Tennessee were taking medication for ADHD. Tennessee: 12th highest in US. 2011: 6.1% of US children and 8.5% of children in Tennessee were taking medication for ADHD. Tennessee ranked 7th highest in US Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6): PARENTS REPORT CHILD HAS BEEN DIAGNOSED WITH ADHD NATIONAL SURVEY OF CHILDREN S HEALTH, 2011 ADHD: GENETICS-NIH ADHD has> than 80% concordance in Twins Strong family histories ADHD is a polygenetic disorder with various candidate genes Candidate genes (DRD4, DAT, DRD5, DBH, 5HTT, HTR1B and SNAP25) brought relatively consistent results confirming the heredity of ADHD syndromes 2

ADHD: NEURO-CONNECTION EMOTIONAL FUNCTION REQUIRES BRAIN INHIBITION ADHD has a developmental lag in neuro-maturation Differences in Hippocampus [memory] Amygdala [emotion] Prefontal Cortex [impulse

A normally functioning limbic system has: normal emotional changes normal levels of energy normal sleep routines normal levels of coping with stress.

When the limbic system is over-activated: mood swings quick temper outbursts over-aroused quick to startle touching everything around hyper-vigilant.

3 ADHD: NEURO-CONNECTION EMOTIONAL FUNCTION REQUIRES BRAIN INHIBITION ADHD has a developmental lag in neuro-maturation Differences in Hippocampus [memory] Amygdala [emotion] Prefontal Cortex [impulse control and goal-directed behaviors] Outer cortical layer is thinner [attention] 70% of the brain is there to inhibit the other 30% of the brain. A normally functioning limbic system has: normal emotional changes normal levels of energy normal sleep routines normal levels of coping with stress. Dis-inhibition disorders" such as impulsive behaviors, quick temper, poor decision making, hyperactivity, and so on. When the limbic system is over-activated: mood swings quick temper outbursts over-aroused quick to startle touching everything around hyper-vigilant. DOPAMINE IS A NEUROTRANSMITTER ADHD RELATED NEUROTRANSMITTERS associated with motivation, short-term memory, creativity and personality metabolized into epinephrine and norepinephrine to increase alertness and attention must be properly balanced and metabolized for optimal benefit. Too much dopamine can result in manic states Too little can cause depression and lack of motivation Pleasure Reward ANXIETY Obsession Compulsion THE BALANCE OF DOPAMINE The ability to control behaviors, impulses, and urges is influenced by dopamine, and both reduced and increased dopamine levels have a detrimental effect on inhibitory control. Current evidence suggests that ADHD is a hypodopaminergic disorder, while OCD, TTM, and TS are considered hyperdopaminergic disorders. Pharmacotherapeutics used to treat the symptoms of these disorders are thought to normalize dopamine levels and thereby ameliorate response inhibition. 3

BRAIN MATURES A FEW YEARS LATE IN ADHD BUT FOLLOWS NORMAL PATTERN SOURCE: NIMH CHILD PSYCHIATRY BRANCH NOVEMBER 12, 2007 INTERCONNECTING NETWORK OF SENSORY AND MOTOR SIGNALS MODULATE FUNCTION There

EXECUTIVE FUNCTIONS [IMPAIRMENTS] Response Inhibition: [answers question before asked, begins task before instructions] Working Memory: [needs information/directions repeated, loss of

4 BRAIN MATURES A FEW YEARS LATE IN ADHD BUT FOLLOWS NORMAL PATTERN SOURCE: NIMH CHILD PSYCHIATRY BRANCH NOVEMBER 12, 2007 INTERCONNECTING NETWORK OF SENSORY AND MOTOR SIGNALS MODULATE FUNCTION There is a 3-5 year lag in maturation in children with ADHD compared to typical peers. EXECUTIVE FUNCTIONS [IMPAIRMENTS] Response Inhibition: [answers question before asked, begins task before instructions] Working Memory: [needs information/directions repeated, loss of direction/answer during task, forgets assignments, forgets to bring materials/books home needed to complete assignment] Emotional Control: [visibly upset/easily frustrated if item is challenging, makes negative statements while working, will not initiate if does not think task will be successful] Sustained Attention: [rushes through or gives up on tedious tasks, easily distracted, stops working if task is difficult, asks when task will be over, difficulty listening to others] Task Initiation:[difficulty starting assignments, needs cues to begin learned routines] Planning: [lack of strategy to complete long term project] Analysis: [Cannot make or follow a timeline or pattern] Prioritization: [Cannot determine what step to do first] Organization: [Cannot find belongings, messy desk/backpack/notebook, writing without plan] Time management: [misses deadlines for assignments, difficulty estimating time it takes to complete a task] Goal Directed Persistence: [stops work if becomes too difficult, forgets to return to task if interrupted] Flexibility: [difficulty following new approach or doing task if instructions change, upset if disruption in plans or routine, excessively rule bound; struggles with open ended tasks; does not try multiple approaches to solve a problem] Metacognition: [does not think through a problem, does not realize that directions for task were not understood, does not check work to ensure correct, does not notice how others react to their behavior, does not like tasks or games with significant problem solving] ADHD Diagnositic Assessment FROM TODDLER DEVELOPMENT TO SELF REGULATION CHILD DEV 2013MAY;84(30: Toddler [12-24 months] emotional dysregulation Quick, intense, sustained anger reactions [tantrums] Preschool [36-48months]emotional development Self regulation increases as child improves cognitive comprehension and language skills to regulate emotions Language development: Comprehension/Expression Increases child s ability to express needs with words Ability to think before they act Follow the rules and wait Ability to shift attention and sustain attention Rate of language growth contributes to better anger regulation By 48 months: Child relies less on parental support - is able to use prefrontal cortex to sustain attention, suppress impulses, control behavior in challenging situations with reasoning and decision making MOST EARLY TODDLERS HAVE EMOTIONAL DYSFUNCTION THAT RESOLVES BY MONTHS R. TREMBLAY, CANADA Frustration 50 Impulsivity 40 Language High ADHD Risk 4-6% 0 24 months 36 months 48 months 6 years 4

ADHD SUBTYPE CRITERIA DSM 5 DIAGNOSTIC CRITERIA Primarily Inattentive Type: Fails to give close attention to details or makes careless mistakes. Has difficulty sustaining attention.

5 ADHD SUBTYPE CRITERIA DSM 5 DIAGNOSTIC CRITERIA Primarily Inattentive Type: Fails to give close attention to details or makes careless mistakes. Has difficulty sustaining attention. Does not appear to listen. Struggles to follow through on instructions. Has difficulty with organization. Avoids or dislikes tasks requiring a lot of thinking. Loses things. Is easily distracted. Is forgetful in daily activities. Primarily Hyperactive-Impulsive Type: ADHD Subtypes : Combined Primarily Inattentive Primarily Hyperactive-Impulsive Fidgets with hands or feet or squirms in chair. Has difficulty remaining seated. Runs about or climbs excessively in children; extreme restlessness in adults. Difficulty engaging in activities quietly. Acts as if driven by a motor; adults will often feel inside like they were driven by a motor. Talks excessively. Blurts out answers before questions have been completed. Difficulty waiting or taking turns. Interrupts or intrudes on others Combined Type: Has symptoms of both types in the same person. Reference: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5) ADHD DIAGNOSTIC CRITERIA Children: 6 symptoms of inattention and/or 6 symptoms of hyperactivity-impulsivity, for 6 months prior to assessment Adults: 5 symptoms of inattention and/or 5 symptoms of hyperactivity-impulsivity, for 6 months prior to assessment Symptoms prior to 12 years of age Impairment present in 2 settings Clinically significant impairment in social, academic or occupational environments Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder, or are not better accounted for by another mental disorder ADHD DIAGNOSTIC EVALUATION: AAP In addition to clinical observation, interview of child, physical exam and neurological exam: FAMILY Reporting Chief Concerns History of symptoms [age of onset, duration, triggers] Family History Past Medical History Psychosocial History Review of Symptoms Validated ADHD Instrument from caregiver Evaluation of coexisting conditions Report of function: strengths and weaknesses SCHOOL Reporting Concerns Validated ADHD instrument Evaluation of coexisting conditions Report of students function in academic/work and social setting Academic records [standardized testing, report cards Administrative report [disciplinary actions] AAP ADHD CLINICAL PRACTICE GUIDELINES PEDIATRICS 2011;128[11]: Evaluate any child 4y-18y presenting with academic or behavioral problems or symptoms of inattention, hyperactivity or impulsivity Clinical assessment to document DSM [5] criteria are met; evaluate reports from family and school; evaluate alternative causes Assessment for other conditions: emotional/behavioral/learning/language/ neurodevelopmental and physical [sleep/nutrition] Recognize that ADHD is a chronic condition COMORBID DISORDERS AND ADHD 20-60% 3-10% 30-40% 30-60% 10-50% 5-35% 10-15% 5-30% 10-30% 5-30% Developmental Disorder Mild Cognitive Impairment Autism Spectrum Disorder Oppositional Defiant Disorder Conduct Disorder Anxiety Disorder Depressive Disorder Bipolar Disorder Neurologic Disorder Tic Disorder The hallmark symptoms of ADHD are commonly found in children with neurological, genetic or developmental disorders Strategies and treatments used for children with ADHD are often beneficial 5

BEHAVIOR CHALLENGES IN ADHD BOTH INTERNALIZING AND EXTERNALINZING BEHAVIORS ARE FOUND Disruptive Demanding Excitable Moodiness Noncompliant Oppositional Distractibility Forgetful Talkative Aggressive

6 BEHAVIOR CHALLENGES IN ADHD BOTH INTERNALIZING AND EXTERNALINZING BEHAVIORS ARE FOUND Disruptive Demanding Excitable Moodiness Noncompliant Oppositional Distractibility Forgetful Talkative Aggressive Difficulty with peers Difficulty with task completion Difficulty following rules Lack of attention to details Poor control of emotions Inhibited self control Can not wait turn Cannot sustain attention; modulate behavior or voice volume Cannot play quietly Immaturity ADHD: OTHER BEHAVIORS Emotional liability Resistance to environmental reinforcement Accident prone Oppositional stance to the world Poor social skills Low self esteem Little sense of personal safety Aggressive behaviors MEDICAL TREATMENTS Medication Behavior Therapy Reframing Management AAP ADHD CLINICAL PRACTICE GUIDELINES [STRONG RECOMMENDATIONS] PEDIATRICS 2011;128[11]: [EVIDENCE QUALITY] Treatment is age dependent 4-5 years old: Behavioral therapy as first line of treatment [A] 6-11yo: FDA approved medication for ADHD Stimulants had strongest evidence [A] Less strong for Atomoxetine or extended release guanfacine or clonidine [B] Parent/Teacher administered behavior therapy [A] years: FDA approved medication for ADHD Stimulants had strongest evidence [A] Parent/Teacher administered behavior therapy [C] Medication should be titrated to achieve maximal benefit with minimum adverse side effects FDA APPROVED MEDICATIONS FOR ADHD Psychostimulants: Methylphenidates LONG Acting Concerta [ mg] OROS Focalin XR [ mg]** Ritalin LA [ mg] Metadate CD [ mg]** Daytrana [ mg]patch Quillivant [25mg/5ml]Liquid SHORT Acting Ritalin [ mg] Focalin [ mg] Methylin chew [ mg] Psychostimulants: Amphetamines LONG Acting Adderall XR [ mg]** Vyvanse [ mg]**Prodrug Short Acting Adderall [ mg] Procentra [5mg/5ml]Liquid ** Capsule can be opened and put into applesauce 6

7 FDA APPROVED MEDICATIONS FOR ADHD CONSIDERATIONS WHEN PRESCRIBING ADHD MEDICATIONS Nonstimulants: Alpha Agonists Nonstimulants: Atomoxetine Psychostimulants Strattera Intuniv [ mg] Kapvay [ 0.1 mg] Strattera [ mg] Monitor Nutritional intake /growth Establish good bedtime routine Controlled Substance Prescribing/abuse Understand titrations/switching medication Black Box Warning Must take with fat in meal Nausea/ Vomiting Titrate dose up/down History of Familial Liver /Biliary Disorders FDA APPROVED MEDICATIONS FOR ADHD: MG CONVERSION EQUIVALENTS Adderall XR Vyvanse Concerta 5 mg 20 mg 27mg STIMULANT MEDICATION AND GROWTH Pediatrics 2014;134:e944 Harstad,etal 10mg 30 mg 36 mg 15mg 40 mg 54mg 20mg 50 mg 72mg 25mg 60 mg ADHD treatment with Stimulant medication is not associated with differences in adult height or significant changes in growth 30mg 70 mg Daytrana Patch vs Concerta 10 mg 27mg 15 mg 41 mg 20 mg 82 mg ADHD cases N=340 Controls N=680 from a birth cohort N=5718 MEDICATION REMINDERS Methylphenidates block reuptake site on delivering inhibitory nerve. Hallucinations are possible with stimulants hydrate well Amphetamine also block reuptake site on delivering inhibitory nerve but also increase volume of dopamine made. May see aggression and emotionality if dopamine increase is too much Strattera has a black box warning as an SNRI for suicidality in teenagers MEDICATION REMINDERS Sleep disturbance Rebound emotionality Appetite suppression Weight loss Medications may improve grades and school performance in children without learning disability or cognitive deficits Primary learning disabilities and intellectual disabilities will need support beyond medication Medication may help with social challenges although many children will benefit from social skills training and anger management 7

ADHD: MORE THAN A DIAGNOSIS ADHD Treatment is more than

AFFAIR Parents need HELP UNDERSTANDING AND INSIGHTS to promote

ADHD CHILDREN ARE BULLIES/VICTIMS OF BULLYING FUNCTIONAL PEERS

friendships with other children Often functioning1-3 years

Seek good peer models Will often fall in with the challenged

appropriate social interactions Boy Scouts/Girl Scouts Church

8 ADHD: MORE THAN A DIAGNOSIS ADHD Treatment is more than medication ADHD Family training and support ADHD: A FAMILY AFFAIR Parents need HELP UNDERSTANDING AND INSIGHTS to promote optimal outcome UNLOCKING THE HIDDEN CLUES OF SOCIAL SKILLS ADHD CHILDREN ARE BULLIES/VICTIMS OF BULLYING FUNCTIONAL PEERS Need to align maturity levels of ADHD child to build friendships with other children Often functioning1-3 years below actual age They only need a few friends to work on skills Seek good peer models Will often fall in with the challenged behavioral children Bully Issues Difficulty initiating appropriate social interactions Boy Scouts/Girl Scouts Church youth groups Individual interest groups [art, theater, swimming, track team, music, tae kwon do, etc] 8

ADHD IS AN EQUAL OPPORTUNITY DISORDER ADHD crosses all socioeconomic levels and all cognitive abilities Untreated ADHD often results in unacceptable behavior from

ADHD Parenting Resource 1. Everybody does not have a little bit of ADHD 2. It s GENETIC: Parenting does not cause ADHD-Genes do 3.

Kids need a reason to learn 7. You will get lost without a lesson plan: Organization is critical 8. Temperament may be inherited but emotional control is learned 9.

Parents are people too and must take care of themselves Finally: It don t come easy ADHD: LIFE SKILL CHALLENGES REFRAMING VIEW OF ADHD GIFT RATHER THAN LIABILITY A

Relationships Parents and Teachers can have the greatest impact by addressing these areas across childhood Parent to Child Foster creativity Promote exercise See

Cross off completed tasks and praise work done Parent to Parent/Teacher Open Communication You are a better parent than you feel Do something good for yourself

9 ADHD IS AN EQUAL OPPORTUNITY DISORDER ADHD crosses all socioeconomic levels and all cognitive abilities Untreated ADHD often results in unacceptable behavior from child who acts first before thinking about consequences ADHD child often has a focus on FUN Hyperfocus on areas of interest Challenged to complete multistep tasks ADHD Parenting Resource 1. Everybody does not have a little bit of ADHD 2. It s GENETIC: Parenting does not cause ADHD-Genes do 3. Medicines do not Cure ADHD but they sure can help 4. Nutrition does matter / Sleep does matters 5. Students with ADHD are entitled to help at school 6. Kids need a reason to learn 7. You will get lost without a lesson plan: Organization is critical 8. Temperament may be inherited but emotional control is learned 9. Yelling rarely solves anything 10. Parents are people too and must take care of themselves Finally: It don t come easy ADHD: LIFE SKILL CHALLENGES REFRAMING VIEW OF ADHD GIFT RATHER THAN LIABILITY A SENSE OF HUMOR AND A SMILE GO A LONG WAY Learning Skills Organizational Skills Visual-Motor Skills Friendship Skills Communication Skills Coping Skills Family Relationships Parents and Teachers can have the greatest impact by addressing these areas across childhood Parent to Child Foster creativity Promote exercise See traits as a gift in the positive Organize /Structure/Routines Daily review of schedule Give memory cues Clear Expectations for behavior Work together with child Cross off completed tasks and praise work done Parent to Parent/Teacher Open Communication You are a better parent than you feel Do something good for yourself Reframe your thoughts Plan-Organize-Evaluate-Adjust-Modify Work with the energy Exercise for all A CHILD WITH ADHD NEEDS YOU TO BE THEIR ADVOCATE Stand up and Cheer See the good SOCIAL ENGAGEMENT TRAINING ADHD children need a guide as well as opportunity and experience to develop effective relationships Support the strengths Scaffold the challenges Spend time 9

SCHOOL STRATEGIES Classroom and 504 Modification BE the CHILD in your Classroom ADHD: ORGANIZATIONAL SKILLS ARE SIGNIFICANTLY IMPACTED When Instructed to begin Follow Your Group Directions- Red

independently Rotating class rooms Time awareness Time management Homework Timing Low self esteem Anger management CHALLENGES IN CLASSROOM Fine motor handwriting Comprehension spelling reading

10 SCHOOL STRATEGIES Classroom and 504 Modification BE the CHILD in your Classroom ADHD: ORGANIZATIONAL SKILLS ARE SIGNIFICANTLY IMPACTED When Instructed to begin Follow Your Group Directions- Red Group: Blue Group: Yellow Group: Green Group: Top Left Right Every Other CHALLENGES IN SCHOOL Completion of class work Listening Following directions Engaging in class activities Working independently Rotating class rooms Time awareness Time management Homework Timing Low self esteem Anger management CHALLENGES IN CLASSROOM Fine motor handwriting Comprehension spelling reading Proofing work Note Taking Test Taking Turning assignments in Math Computation Memory Problem solving Conflict Resolution READING DIFFICULTIES IN CHILDREN WITH ADHD THE ADHD BOOK OF LISTS BY SANDRA RIEF Limited range of strategies Failure to use internal language and self talk Poor working memory Every child is different Paula Kluth: [You re going to love this kid: Teaching students with autism in the inclusive classroom] Difficulty with silent reading Poor phonemic awareness Inattention Often it is not the student that fails to learn, but the teacher that fails to understand how the child learns 10

WRITTEN LANGUAGE DISORDER [WLD] IN CHILDREN WITH AND WITHOUT ADHD PEDIATRICS 2011; 128 [3]: E605-612 ADHD is strongly associated with an increased risk of WLD Girls are at a higher risk of having WLD

Psycho-educational evaluation is strongly recommended to include cognitive, academic and adaptive assessments as well as visual motor and language evaluations.

FOR INATTENTIVE STUDENTS Use preferential seating Seat near good peer models Reduce environmental noises and distraction Allow ear plugs Use visual cues Make eye contact Gently put hand on shoulder

11 WRITTEN LANGUAGE DISORDER [WLD] IN CHILDREN WITH AND WITHOUT ADHD PEDIATRICS 2011; 128 [3]: E ADHD is strongly associated with an increased risk of WLD Girls are at a higher risk of having WLD with reading disorder Girls and boys are at the same risk for having WLD without reading disorder PSYCHOMETRIC ASSESSMENT: ESSENTIAL FOR CHILDREN WITH ADHD TO DEFINE ABILITIES Language Psycho-educational evaluation is strongly recommended to include cognitive, academic and adaptive assessments as well as visual motor and language evaluations. TEACHERS DO MAKE THE DIFFERENCE Create a Learning Environment Mutual Respect Acceptance Organization Flexibility High Expectations within the scope of ability Be Positive * Praise Efforts STRATEGIES FOR INATTENTIVE STUDENTS Use preferential seating Seat near good peer models Reduce environmental noises and distraction Allow ear plugs Use visual cues Make eye contact Gently put hand on shoulder Stand near-by Brief direct instructions Highlight key words Provide a study guide Allow gum chewing or fidgets Consider using a timer STRATEGIES FOR ENGAGING ATTENTION STRATEGIES FOR ENGAGING ATTENTION Be playful Use props Storytelling Auditory Signals Verbal Signals [1,2,3 Eyes on Me ] Visual cues Illustrate /Demonstrate Manipulatives High response opportunities [class/buddy] Have student become class helper Maximize strengths of child Use enthusiasm Prepare study guides Duplicate set of books Position to see board Less lecturing / share ideas 11

MODIFICATIONS OF ASSIGNMENTS Reduce paper and pencil tasks Shorten assignments Allow different ways to answer

assignments to parents MODIFICATIONS OF ASSIGNMENTS Give oral and written instructions Break assignments into

pages Peer tutors ADHD: YOU RE GOING TO LOVE THESE KIDS Share you re thoughts!

12 MODIFICATIONS OF ASSIGNMENTS Reduce paper and pencil tasks Shorten assignments Allow different ways to answer Reduce copying Allow varied testing approaches Simplify directions Duplicate set of text at home assignments to parents MODIFICATIONS OF ASSIGNMENTS Give oral and written instructions Break assignments into small segments Use taped textbooks Use large print Textbooks Reduce information on page Handouts with fewer pages Peer tutors ADHD: YOU RE GOING TO LOVE THESE KIDS Share you re thoughts! School Success for Kids with ADHD 101 School success tools for students with ADHD Stephan Silverman- Sue Jeweler -Jacqueline Iseman Any questions? 12

Attention Deficit Hyperactivity Disorder State of the Art. Christopher Okiishi, MD

Attention Deficit Hyperactivity Disorder State of the Art Christopher Okiishi, MD What is ADHD? Three subtypes: Inattentive (under diagnosed, esp. in girls) Hyperactive Impulsive Combined Impairments must