Case Studies in the Diagnosis and Treatment of ADD/ADHD in children 10/7/2013

Transcription

1 Case Studies in the Diagnosis and Treatment of ADD/ADHD in children 1. Understand and apply the diagnositc tools for ADD/ADHD (15 min) 2. Review the current pharmacological treatments for ADD/ADHD (20 min) 3. Recognize the variables in the treatment of children with ADD/ADHD (25 min) 4. Discuss co-morbidities associated with ADD/ADHD and their treatment in relation to the ADD/ADHD (15 minutes) ADD and disruptive behavior disorders more common in boys than girls by 5:1 Associated with low socioeconomic status, urban living, single parenthood, family dysfunction, learning disabilities, language delay, family history of disruptive behavior Characterized by inattention, impulsive behavior, over activity Children are restless, overactive, distractable, reckless, disruptive 1

2 Relatively common disorder in school age children around 2-11 per cent ADD/ADHD regarded as a chronic condition that continues into adulthood Hard to diagnose before the age of 4 must have really extreme behaviors to diagnose Usually diagnosed at 7 yoa, symptoms usually persist for 6 months before diagnosis Behaviors usually become more frequent and increase in severity eventually interfering with functioning at home and at school Careless mistakes, failure to pay attention to details. Easily distracted, difficulty concentrating on tasks long enough to complete, difficulty following instructions and organizing tasks and activities Poor impulse control: cannot wait one's turn, frequently blurting out answers, interupting or intruding on others Hyperactivity: fidgeting, cannot remain seated or cannot play quietly, feeling of restlessness in adolescent 2

3 Giftedness, language disorder, migraines, lead poisoning, hearing loss, thyroid dysfunction, visual disturbance, genetic disorder such as fragile x syndrome, seizure disorder, tourettes psychological disorders such as anxiety, oppositional defiant disorder, post-traumatic stress disorder, depression, substance abuse, pervasive developmental disorder environmental disorders such as child abuse, family stress, divorce, parenting disruptions, parental psychopathology, inappropriate eduational setting Subtle dysfunction in frontal lobe and functionality related subcortical structures play role in core symptoms. Frontal lobe important for planning, attention, regulation of motor activity. Frontal lobe slightly smaller in boys with ADHD on MRI. PET scans of adults with ADHD have ecreased metabolic activity in frontal lobe. Billy-5 yoa, arrives in office with mother. Has been sent home from school each day this week with a note from teacher. Teacher states child is disruptive during class, sharpens pencil multiple times during class, cannot finish tasks. Mother states child is not like this at home. HX: Third child, two older sisters (10 and 14), normal pregnancy and vaginal delivery. Both parents live at home, both work. Mom works nights at bakery. Dad works manufacturing days. Billy has had all school vaccinations. NKDA. Fam HX: non-contributory ROS: no other health issues 3

4 Recommended blood work: Cbc to rule out anemia, lead level, tsh. Testing for add/adhd: Various scales Refer out? Advantage: Psych can diagnose and start medication. Advantage: Various scales done in office can be charged. Advantage: Treatment can be initiated sooner. Disadvantage: Parents and teacher already frustrated, child flunking out. Not a lot of time before end of school term. Disadvantage: Grading scales can be time consuming. Disadvantage: Sometimes medications can be hard to get just right --provider frustration. Billy's parents do not have behavioral health coverage on insurance. Have been told that school can do the testing but it will be six months from now so they opt to have NP evaluate their son. Options discussed with parents. Medical Management Medical management with behavior modification Behavior modification alone Community treatment In studies: MM and MM with Beh. Mod. Did significantly better on ratings from parents and teachers. No difference between the last two. In follow up studies: Children on meds had slightly slower growth rates but had the least amount of deterioration in school and on rating scales. Stimulants Methyphenedate (Ritalin) Dextraamphetamine (Dexedrine) Mixed amphetamine salts (Adderall) Magnesium pemoline (Cylert) Non-Stimulant nonadrenergic Atomoxetine (Straterra) Others Antidepressants Clonidine, Guanfacine (Tenex), Intuit 4

5 Ritalin is used by 3 per cent of all school age kids 70-80% respond positively to stimulants Stimulants increase attention span, gross and fine motor coordination and compliance. Decreased impulsiveness, hyperactivity, and aggression. Non-stimulants may help non-responders. Not all non-responders are FDA approved for ADD/ADHD. Ex: TCA's, buspar, clonidine, quanfacine. Appear to normalize biochemistry in the parts of the brain involved in ADHD. They enhance nerve to nerve communication by making more neurotransmitters available to boost the signal between neurons. They work by blocking the recycle mechanism of the sending nerve cell, leading to an accumulation of the neurotransmitter, which is then available to pass on the signal. The neurotransmitters involved are dopamine and norepinephrine. Come in variety of options: pills, syrups, patches Each class of stimulants work slightly different from each other so one might work better than another and one form may work better than another. There are immediate release as well as extended release for each product. These can be combined for better symptom controlled such as extended release in the morning to get thru school and immediate release after lunch or after school for getting thru home work. 5

6 Watch over the counter meds Monitor height and weight, blood pressure and heart rate. EKG optional. Social and emotional maturation may decrease or eliminate the need for meds. Assess needs to adjust dosage at the beginning of the school year and with changes within family dynamics (moving, divorce, death). Include cognitive and behavioral strategies along with changes in meds. Billy's parents decided on the Daytranna patch. They likes the fact that they could remove the patch after home work was completed. The patch worked well for five months. Eventually the insurance company decided to remove the patch from their formulary and Billy was placed on Concerta which he did not tolerate and then Adderall with similar SE's. After failing both of these, his parents decided they would take him off of his meds for the summer. His next year he went without meds and did better with his new teacher who was older and less tolerant. Billy was seen in office prior to school year starting. Playing soccer and going to karate classes. Looking forward to school. Grades last year were good. Billy probably was too immature for school and has matured into a good student. Immaturity signs and symptoms overlap with ADHD/ADD symptoms. Tend to go away as child ages. 6

7 Joey 9 yoa white male. Only child. Lives with step mom and dad. Birth Mother died of breast cancer when he was 4. Two years ago, Joey was evaluated for ADD after parents received multiple notes from school. He was placed on Adderall. After one dose of Adderall Joey became very irritable, refused to eat or drink, did not sleep for 24 hours. Parents then tried a herbal remedy that was recommended by a friend which worked for his next year of school. Joey is here today with mom as his behavior is disrupting the class. He calls out answers, talks to his neighbors and fidgets. ROS negative. Family hx.: non-contributory. Dad denies any family hx of heart disease. Joey's physical exam was normal. Joey could not remain still in room. Mom had to time out him three or four times during the 20 minute visit. Options discussed with mom. Parents did not want stimulants but realized the need for therapy. Other options: Strattera, SSRI's, TCA, clonidine, tenex, Intuit. First nonstimulant. Studied extensively. Mechanistically similar to TCA's. Is a highly specific presynaptic (sending neuron) noradrenergic reuptake inhibitor. Makes more NE and dopamine available for nerve to nerve communication. Has no abuse potential. Not a scheduled medication. Works well for kids who are non-responders to stimulants, who had SE from stimulants and as an add on medication with stimulants. 7

8 Dosage based on weight 1.2 mg/kg per day, up to 1.8 mg/kg. Start low and increase slowly. May be sedating initially so it might be good to start it at night. Can be dosed daily or twice a day depending upon tolerability. SE: sedation, insomnia, stomach aches, headaches, nausea, vomiting, weight loss, anorexia Joey was placed on 10 mg of Strattera. He did well on this dose with no SE. At three months, Joey's weight increased 5 pounds and the dose was increased to 18. Parents are happy with the results. Joey developed stomach pain on Straterra at 25 mg. He was decreased back to 18 mg but the stomach pains did not go away. Joey is back to receiving teacher notes. Disruptive in class, sharpening pencils thru out day, calling out answers to questions. Joey is developing symptoms of OCD, tics. Parents decide they wish to have Joey evaluated by Developmental Pediatrics. 8

9 Started on Zoloft. Stopped Straterra. OCD symptoms resolved. Tics got better but not gone completely. Started family councelling. Did better in school. Joey went on Concerta last year as he started having ADHD symptoms. Did better on Concerta with the Zoloft. No increase in tics. Appitite remained up and continues to gain weight slowly. Still underweight for age and height. Has started playing flute at school and participates in church activities. April is 14 yoa. Here today with mom. Parents divorced. Little interaction with father who has a new wife and other children. Only child but has good family support grandmother, aunts and cousins. Behavior at home and at school initially attributed to normal teenage behavior but has worsen with hostility, irritability, overeating. Grades are now slipping and April might not pass this year of school. Grandfather died of CHF at 80. No other heart disease in family. 9

10 Normal VS Normal examination Cooperative with exam but hostile to mother, talks back, has angry outbursts. Diagnosed with ADHD 2 years ago. Concerned about weight BMI 26 Was on stimulants a few years ago and lost weight. Initially started on Adderall XR 20. Seen back in one month and was not doing well with home work. Mom requested a second dose. It was decided at this time to add Adderall XR 5 at lunch. Mom could not afford second Adderall script and requested immediate release. While on Adderall 5, patient was able to complete homework but developed tics. 10

11 Increase dose Change timing of administration Change preparation Substitute different stimulant Consider alternative treatment Assess if side effect is drug induced Determine when side effect is occurring (peak versus wear off) Consider changing Time of dose Preparation Type of stimulant Manufacturer (generic to brand) Use adjunctive medication Caused by the wearing off of medication Change preparation to an extended release Change timing of administration Add another small does 30 minutes to rebound symptoms Consider alternative treatment Consider adjunctive Strattera or TCA or clonidine in afternoon 11

12 Assess continuation of tics off stimulant If tics stop, try stimulant again If tics continue, discontinue stimulant Use alternative med If ADHD symptoms continue, cautiously reintroduce stimulant Consider use of adjunctive treatment such as Strattera, clonidine, despramine, Risperdal, Geodon, Haldol Assess timing of toxicity (at peak 1-2 hours after taking med) or withdrawal (during rebound wear, off phase hours later) Reduce or change dose Evaluate the return of ADHD symptoms Evaluate for another psychiatric disorder Change preparation or substitute type Discontinue stimulant Consider alternative treatment April's afternoon dose was dropped. Tic resolved. April resumed previous behavior of being unable to concentrate for home work, hostile to mother. It was decided to start Straterra with her morning dose of Adderall. April did two weeks of 10 mg, then 2 weeks of 18 and is now on 24 mg of Strattera a day. Mood improved. Self esteem and weight issues resolved. No further tics. 12

13 Now 16. On Adderall XR 20 BID. Still with impulsive behaviors. No tics. Complains of weight with each office visit. BMI 30. Does not exercise. Grades poor does not like to study. Mom struggling with bills and job. Feels stressed. Trying to find low cost counseling for daughter with hopes this will decrease her disruptive behavior and improve her selfesteem. Learning disabilities 35% Psychological disorders 25% Depression 25% ODD or Conducts disorder 50% Children untreated grow into adults with an increased incidence of anxiety, low selfesteem, antisocial behavior, alcohol/drug use, interpersonal difficulties, job changes. Co-mobities with ADD/ADHD lead to self medication such as alcohol and drug abuse. 13

14 Special accommodations at school provided by the reauthorization of the Individuals with Disabilities Act. Plans include academic learning objectives as well as behavior modification objectives Plans should be written in a form understandable by the teachers, parents and child Objectives also should list who is responsible for that objective (teacher, speech pathologist, parent) Mid-term monitoring of objectives is advised when child is not doing well in school. Vandebilt Scales: can be found online. Easy to score. Has both patient and teacher scales. Brown Scales: Must purchase. Maybe able to find scale from Shire rep. Adult ADHD Self Report Scale Need formal evaluation! Overlap of other psychiatric illnesses with ADD/ADHD which don t develop until adolescence such as bipolar disorder, borderline personality disorders, schizophrenia Waiting room screening tools not very conclusive 14

15 Requests medication by name Has tried someone else s meds and it worked Needs to start right now cannot wait for a formal evaluation due to possible job loss, flunking out of college etc etc etc Had been on a stimulant as a young child but was able to get out of college without meds Only wants immeadiate release drug Needs other controlled substances to control other side effects of the medication 18 year old male. Beginning college. Had trouble with concentration in high school but was able to pass as he found his courses easy. Now having trouble with college. Studies nightly. Reads the same page over and over again but does not retain material. No past history of depression. No family history of heart disease. Only child but has cousins with ADD. Wants to be a high school math teacher. Came alone to appointment. Did request medication by name but has not tried any. 15

16 Completed Connor scale High score of inattentiveness and ADD Passed urine drug screen Vyvanse 30 mg daily. Report side effects. Did not have problems with medication but could not afford $60 co-pay. Changed to Adderall XR 15. Maintained grades. Found concentration better. Has yearly drug screens. 32 year old female. Previous MD retired. Wanting to remain on current medications. Currently on: Adderall 30 md TID Alprazolam 1 mg TID Ambien 10 mg Q HS Reviewed SC Scripts wedsite and found patient had been filling medications earlier and earlier each month. Refused urine drug screening stating she has been out of medication for a while 16

17 Referred to psych. For formal evaluation. Patient states she needs medications Scripts data discussed with patient. No scripts given to patient today. On call MD received call from patient stating that she lost her scripts. He told her to return tomorrow for appointment as we did not call medications in after hours. Patient did not call for appointment. Treat co-morbidities aggressively Smoking cessation Hypertension EKG s on patients with stimulants and hypertensive Urine drug screens Watch for side effects Cut doses down to lowest dose possible Use long acting or time release formulations 17

18 Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Instructions The questions on the back page are designed to stimulate dialogue between you and your patients and to help confirm if they may be suffering from the symptoms of attention-deficit/hyperactivity disorder (ADHD). Description: The Symptom Checklist is an instrument consisting of the eighteen DSM-IV-TR criteria. Six of the eighteen questions were found to be the most predictive of symptoms consistent with ADHD. These six questions are the basis for the ASRS v1.1 Screener and are also Part A of the Symptom Checklist. Part B of the Symptom Checklist contains the remaining twelve questions. Instructions: Symptoms 1. Ask the patient to complete both Part A and Part B of the Symptom Checklist by marking an X in the box that most closely represents the frequency of occurrence of each of the symptoms. 2. Score Part A. If four or more marks appear in the darkly shaded boxes within Part A then the patient has symptoms highly consistent with ADHD in adults and further investigation is warranted. 3. The frequency scores on Part B provide additional cues and can serve as further probes into the patient s symptoms. Pay particular attention to marks appearing in the dark shaded boxes. The frequency-based response is more sensitive with certain questions. No total score or diagnostic likelihood is utilized for the twelve questions. It has been found that the six questions in Part A are the most predictive of the disorder and are best for use as a screening instrument. Impairments 1. Review the entire Symptom Checklist with your patients and evaluate the level of impairment associated with the symptom. 2. Consider work/school, social and family settings. 3. Symptom frequency is often associated with symptom severity, therefore the Symptom Checklist may also aid in the assessment of impairments. If your patients have frequent symptoms, you may want to ask them to describe how these problems have affected the ability to work, take care of things at home, or get along with other people such as their spouse/significant other. History 1. Assess the presence of these symptoms or similar symptoms in childhood. Adults who have ADHD need not have been formally diagnosed in childhood. In evaluating a patient s history, look for evidence of early-appearing and long-standing problems with attention or self-control. Some significant symptoms should have been present in childhood, but full symptomology is not necessary.

19 Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Patient Name Today s Date Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today s appointment. Never Rarely Sometimes Often Very Often 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? Part A 7. How often do you make careless mistakes when you have to work on a boring or difficult project? 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 10. How often do you misplace or have difficulty finding things at home or at work? 11. How often are you distracted by activity or noise around you? 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 13. How often do you feel restless or fidgety? 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? 15. How often do you find yourself talking too much when you are in social situations? 16. When you re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17. How often do you have difficulty waiting your turn in situations when turn taking is required? 18. How often do you interrupt others when they are busy? Part B

20 The Value of Screening for Adults With ADHD Research suggests that the symptoms of ADHD can persist into adulthood, having a significant impact on the relationships, careers, and even the personal safety of your patients who may suffer from it. 1-4 Because this disorder is often misunderstood, many people who have it do not receive appropriate treatment and, as a result, may never reach their full potential. Part of the problem is that it can be difficult to diagnose, particularly in adults. The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist was developed in conjunction with the World Health Organization (WHO), and the Workgroup on Adult ADHD that included the following team of psychiatrists and researchers: Lenard Adler, MD Associate Professor of Psychiatry and Neurology New York University Medical School Ronald C. Kessler, PhD Professor, Department of Health Care Policy Harvard Medical School Thomas Spencer, MD Associate Professor of Psychiatry Harvard Medical School As a healthcare professional, you can use the ASRS v1.1 as a tool to help screen for ADHD in adult patients. Insights gained through this screening may suggest the need for a more in-depth clinician interview. The questions in the ASRS v1.1 are consistent with DSM-IV criteria and address the manifestations of ADHD symptoms in adults. Content of the questionnaire also reflects the importance that DSM-IV places on symptoms, impairments, and history for a correct diagnosis. 4 The checklist takes about 5 minutes to complete and can provide information that is critical to supplement the diagnostic process. References: 1. Schweitzer JB, et al. Med Clin North Am. 2001;85(3):10-11, Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed Biederman J, et al. Am J Psychiatry.1993;150: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association. 2000:

21 Vanderbilt ADHD Diagnostic Parent Rating Scale Page 1 of 3 VANDERBILT ADHD DIAGNOSTIC PARENT RATING SCALE Child s Name: Today s Date: Date of Birth: Age: Grade: Each rating should be considered in the context of what is appropriate for the age of your child. Frequency Code: 0 = Never 1 = Occasionally 2 = Often 3 = Very Often 1. Does not pay attention to details or makes careless mistakes, for example homework Has difficulty sustaining attention to tasks or activities Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand) Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities (school assignments, pencils or books) Is easily distracted by extraneous stimuli Is forgetful in daily activities Fidgets with hands or feet or squirms in seat Leaves seat when remaining seated is expected Runs about or climbs excessively in situations when remaining seated is expected Has difficulty playing or engaging in leisure/play activities quietly Is on the go or often acts as if drive by a motor Talks too much Blurts out answers before questions have been completed Has difficulty waiting his/her turn Interrupts or intrudes on others (e.g., butts into conversations or games) Argues with adults Loses temper Actively defies or refuses to comply with adults requests or rules Deliberately annoys people Blames others for his or her mistakes or misbehaviors Is touchy or easily annoyed by others

22 Vanderbilt ADHD Diagnostic Parent Rating Scale Page 2 of Is angry or resentful Is spiteful and vindictive Bullies, threatens, or intimidates others Initiates physical fights Lies to obtain goods for favors or to avoid obligations (i.e., cons others) Is truant from school (skips school) without permission Is physically cruel to people Has stolen items of nontrivial value Deliberately destroys others property Has used a weapon that can cause serious harm (bat, knife, brick, gun) Is physically cruel to animals Has deliberately set fires to cause damage Has broken into someone else s home, business, or car Has stayed out at night without permission Has run away from home overnight Has forced someone into sexual activity Is fearful, anxious, or worried Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems, feels guilty Feels lonely, unwanted, or unloved: complains that no one loves him/her Is sad, unhappy, or depressed Is self-conscious or easily embarrassed

23 Vanderbilt ADHD Diagnostic Parent Rating Scale Page 3 of 3 PERFORMANCE Problematic Average Above Average 1. Overall Academic Performance a. Reading b. Mathematics c. Written Expression PERFORMANCE Problematic Average Above Average 2. Overall Classroom Behavior a. Relationship with peers b. Following Directions/Rules c. Disrupting Class d. Assignment Completion e. Organizational Skills Scoring Instructions for the ADTRS *Predominately inattentive subtype requires 6 or 9 behaviors, (scores of 2 or 3 are positive) on items 1 through 9, and a performance problem (scores of 1 or 2) in any of the items on the performance section. *Predominately hyperactive/impulsive subtype requires 6 or 9 behaviors (scores of 2 or 3 are positive) on items 10 through 18 and a problem (scores of 1 or 2) in any of the items on the performance section. *The Combined Subtype requires the above criteria on both inattention and hyperactivity/impulsivity. *Oppositional-defiant disorder is screened by 4 of 8 behaviors, (scores of 2 or 3 are positive) (19 through 26). *Conduct disorder is screened by 3 of 15 behaviors, (scores of 2 or 3 are positive) (27 through 40). *Anxiety or depression are screened by behaviors 41 through 47, scores of 3 of 7 are required, (scores of 2 or 3 are positive).

24 BRIGHT FUTURES TOOL FOR PROFESSIONALS I N S T R U C T I O N S F O R U S E Vanderbilt ADHD Diagnostic Teacher Rating Scale INSTRUCTIONS AND SCORING Behaviors are counted if they are scored 2 (often) or 3 (very often). Inattention Requires six or more counted behaviors from questions 1 9 for indication of the predominantly inattentive subtype. Hyperactivity/ Requires six or more counted behaviors from questions impulsivity for indication of the predominantly hyperactive/impulsive subtype. Combined subtype Requires six or more counted behaviors each on both the inattention and hyperactivity/impulsivity dimensions. Oppositional Requires three or more counted behaviors from questions defiant and conduct disorders Anxiety or Requires three or more counted behaviors from questions depression symptoms The performance section is scored as indicating some impairment if a child scores 1 or 2 on at least one item. FOR MORE INFORMATION CONTACT Mark Wolraich, M.D. Shaun Walters Endowed Professor of Developmental and Behavioral Pediatrics Oklahoma University Health Sciences Center 1100 Northeast 13th Street Oklahoma City, OK Phone: (405) , ext mark-wolraich@ouhsc.edu REFERENCE FOR THE SCALE S PSYCHOMETRIC PROPERTIES Wolraich ML, Feurer ID, Hannah JN, et al Obtaining systematic teacher reports of disruptive behavior disorders utilizing DSM-IV. Journal of Abnormal Child Psychology 26(2): The scale is available at vanderbilt.edu/vchweb_1/rating~1.html. 54

25 BRIGHT FUTURES TOOL FOR PROFESSIONALS Vanderbilt ADHD Diagnostic Teacher Rating Scale Name: Grade: Date of Birth: Teacher: School: Each rating should be considered in the context of what is appropriate for the age of the children you are rating. Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often 1. Fails to give attention to details or makes careless mistakes in schoolwork Has difficulty sustaining attention to tasks or activities Does not seem to listen when spoken to directly Does not follow through on instruction and fails to finish schoolwork (not due to oppositional behavior or failure to understand) 5. Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustaining mental effort 7. Loses things necessary for tasks or activities (school assignments, pencils, or books) 8. Is easily distracted by extraneous stimuli Is forgetful in daily activities Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected 12. Runs about or climbs excessively in situations in which remaining seated is expected 13. Has difficulty playing or engaging in leisure activities quietly Is on the go or often acts as if driven by a motor Talks excessively Blurts out answers before questions have been completed Has difficulty waiting in line Interrupts or intrudes on others (e.g., butts into conversations or games) Loses temper (continued on next page) 55

26 Vanderbilt ADHD Diagnostic Teacher Rating Scale (continued) Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often 20. Actively defies or refuses to comply with adults requests or rules Is angry or resentful Is spiteful and vindictive Bullies, threatens, or intimidates others Initiates physical fights Lies to obtain goods for favors or to avoid obligations (i.e., cons others) Is physically cruel to people Has stolen items of nontrivial value Deliberately destroys others property Is fearful, anxious, or worried Is self-conscious or easily embarrassed Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems, feels guilty Feels lonely, unwanted, or unloved; complains that no one loves him/her Is sad, unhappy, or depressed PERFORMANCE Problematic Average Above Average Academic Performance 1. Reading Mathematics Written expression Classroom Behavioral Performance 1. Relationships with peers Following directions/rules Disrupting class Assignment completion Organizational skills

27 Abnormal Psychology Dr. Brian Burke The multi-axial system of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 1994) is the way in which the DSM-IV tries to address "the whole person." It grows out of the professional conviction that, in order to intervene successfully in an emotional or psychiatric disorder, we need to consider the affected person from a variety of perspectives. In DSM-IV, clinical disorders are listed on 3 separate axes as described below (NOTE that, in DSM-5, all of these will be listed on a single axis). Axis I refers broadly to the principal disorder that needs immediate attention; e.g., a major depressive episode, an exacerbation of schizophrenia, or a flare-up of panic disorder. It is usually (though not always) the Axis I disorder that brings the person "through the office door." Axis II lists any personality disorder that may be shaping the current response to the Axis I problem. Axis II also indicates any developmental disorders, such as mental retardation or a learning disability, which may be predisposing the person to the Axis I problem. For example, someone with severe mental retardation or a paranoid personality disorder may be more likely to be "bowled over" by a major life stressor, and succumb to a major depressive episode. Axis III lists any medical or neurological problems that may be relevant to the individual's current or past psychiatric problems; for example, someone with severe asthma may experience respiratory symptoms that are easily confused with a panic attack, or indeed, which may precipitate a panic attack. Axis IV codes the major psychosocial stressors the individual has faced recently; e.g., recent divorce, death of spouse, job loss, etc. Axis V codes the "level of function" the individual has attained at the time of assessment, and, in some cases, is used to indicate the highest level of function in the past year. This is coded on a scale, with 100 being nearly "perfect" functioning (none of us would score that high!). Global Assessment of Functioning (GAF) Scale (DSM IV, Axis V) Note: This version of the GAF scale is intended for academic use only. Although it is based on the clinical scale presented in the DSM - IV, this summary lacks the detail and specificity of the original document. The complete GAF scale on page 32 of the DSM - IV should be consulted for clinical use.

28 Code Description of Functioning Person has no problems OR has superior functioning in several areas OR is admired and sought after by others due to positive qualities Person has few or no symptoms. Good functioning in several areas. No more than "everyday" problems or concerns Person has symptoms/problems, but they are temporary, expectable reactions to stressors. There is no more than slight impairment in any area of psychological functioning Mild symptoms in one area OR difficulty in one of the following: social, occupational, or school functioning. BUT, the person is generally functioning pretty well and has some meaningful interpersonal relationships Moderate symptoms OR moderate difficulty in one of the following: social, occupational, or school functioning Serious symptoms OR serious impairment in one of the following: social, occupational, or school functioning Some impairment in reality testing OR impairment in speech and communication OR serious impairment in several of the following: occupational or school functioning, interpersonal relationships, judgment, thinking, or mood Presence of hallucinations or delusions which influence behavior OR serious impairment in ability to communicate with others OR serious impairment in judgment OR inability to function in almost all areas There is some danger of harm to self or others OR occasional failure to maintain personal hygiene OR the person is virtually unable to communicate with others due to being incoherent or mute Persistent danger of harming self or others OR persistent inability to maintain personal hygiene OR person has made a serious attempt at suicide. SIhttp://faculty.fortlewis.edu/burke_b/Abnormal/Abnormalmultiaxial.htmTE: