Empathy, Compassion. Identification with and understanding of another s situation, feelings and motives. www,cdc.gov

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2 Empathy, Compassion. Identification with and understanding of another s situation, feelings and motives. www,cdc.gov

3 Accessibility to care. Psychosocial obstacles. Financial. Communication. Mobility and stability. Treatment planning. Medical status. Continuity of care. Preventive care.

Accessible. Family centered. Continuous. Comprehensive. Co-coordinated. Companionate. Culturally competent. Preventive orientated. Individualized recall. Emergency care. Dr.

4 Accessible. Family centered. Continuous. Comprehensive. Co-coordinated. Companionate. Culturally competent. Preventive orientated. Individualized recall. Emergency care. Dr. Heinrich Hoffman Let me see if Philip can be a little gentleman; let me see if he is able to sit still for once at table. Thus spoke, in earnest tone, the father to his son; and the mother looked very grave to see Philip so misbehave. But Philip he did not mind; his father who was so kind See the naughty, restless child, growing still more rude and wild, till his chair falls over quite. Philip screams with all his might, catches at the cloth, but then, that makes matters worse again. Down upon the ground they fall, glasses, bread, knives forks and all Poor Papa and poor Mamma look quite cross, and wonder how they shall make their dinner now.

dysfunction with the central nervous system and not related to gender, level of intelligence, or cultural environment.

5 Most extensively studied childhood disorder. the disorders known as the attention deficit hyperactive disorders are the chronic neurological condition resulting from persistent dysfunction with the central nervous system and not related to gender, level of intelligence, or cultural environment. Proper assessment and diagnosis are essential for proper intervention. Not simply a problem of hyperactivity & impulsivity, but the ability to monitor activity in appropriate settings. Poor ability to relate to time and chronology. Cognitive / behavioral.

6 AAP: ADHD Assessment Guidelines AAP CLINICAL GUIDELINES, 2000

7 Netherlands 1.3% teens Canada % of children. China 6-9% children. Australia 3.4% of children. India 5-29% children. Germany 4.2% children. New Zealand 6.7% children, 2-3% teens.

Individuals must display 6 of 9 inattention symptoms or 6 of 9 hyperactivity -impulsivity features for at least

8 Dysmorphic features. Hearing. PE usually normal. Increased incidence of soft neurologic signs. Careful developmental analysis. 18 criteria. Individuals must display 6 of 9 inattention symptoms or 6 of 9 hyperactivity -impulsivity features for at least 6 months. 9 inattention symptoms. Two distinct settings global diagnosis. 9 hyperactivity / impulsivity symptoms. Symptoms present on a regular basis for more than 6 months. Vision. 3 subtypes.

9 Inattention 1. Inattention to details. 2. Difficulty sustaining attention. 3. Seems not to listen. 4. Fails to finish tasks. 5. Avoids tasks that requires attention. 6. Loses items. 7. Easily distracted. 8. Forgetful in daily activities. 9. Organizing. Hyperactivity 1. Fidgets / squirms. 2. Unable to remain seated. 3. Cannot play quietly. 4. Talks excessively. 5. On the Go motor driven. 6. Runs and climbs excessively. Impulsivity 1. Blurts out answers. 2. Difficulty waiting turn. 3. Often interrupts or intrudes. Inattentive 6 of 9 Hyperactive Impulse 6 of 9 Combined 6 of 9 in both Inattentive Hyperactive Impulsive Male / Female 1 : : 1 Accidents Less Common Common Peer Relations Unpopular Rejected Co-Morbidities Anxiety / Depression Outcomes Less symptom decline than hyperactivity ODD / CD ODD/CD poorer Hyperactivity declines with puberty

Difficult Peer Relationships ADHD can have many effects on a child's development. It can make childhood friendships, or peer relationships, very difficult.

10 Difficult Peer Relationships ADHD can have many effects on a child's development. It can make childhood friendships, or peer relationships, very difficult. Children with peer problems may also be at higher risk for anxiety, behavioral and mood disorders, substance abuse and delinquency as teenagers. Parents report that children with a history of ADHD are almost 10 times as likely to have difficulties that interfere with friendships (20.6% vs. 2.0%). 1 ADHD alone = 31% Conduct = 7% Anxiety = 10% ODD = 21% Anxiety plus ODD = 21% Tics = 14% ADHD Alone Tic Mood Conduct Anxiety ODD Cognitive Flexibility Time Manage. Initiation Response Inhibition Interference Control Goals Planning Organization Failure to notice errors

Genetic factors. Genetic susceptibility.

11 Genetic factors. Genetic susceptibility. Lack of a single identifiable etiology. Biochemical / neurotransmitter. Heritable estimates Monozygotic twins (Faraone, 2000). Polycausality. Environmental. Hyper / Impulsive breeds true. Social. Inattentive, Combined do not (Faraone,2000).

Severe hyperkinetic with fetal distress.

Maternal bleeding, smoking, illicit drug use.

Kotimaa 2003, Thapar 2003. LES. Peterson 2001.

12 Severe hyperkinetic with fetal distress. Taylor Chronic infancy sleep problems. Thunstrum Pre-term birth. Breslau 1996, Whitaker Maternal bleeding, smoking, illicit drug use. Sprinch- Burkminster LBW. Kotimaa 2003, Thapar LES. Peterson Parental mental health. Russo Marital discord. Milberger 1997, Edwards No evidence of food dyes. Mattes 1981.

Children Adults Child Adult Forgetful Losing things Lack of focus Easily distracted Procrastination Indecision Poor time management Squirms On the go Cannot sit quietly Talks excessively Highly

13 Children Adults Child Adult Forgetful Losing things Lack of focus Easily distracted Procrastination Indecision Poor time management Squirms On the go Cannot sit quietly Talks excessively Highly active job Long hours Constant activity Easily bored Poor org. Follow through complex tasks Difficulty comp tasks No multitasking Shifting attention Cannot wait turn Blurts Intrudes Interrupts Impatient Low frustration levels Snap decisions Loses temper easily

14 Children Adults 1. Poor grades. 2. Repeating grades. 3. Fewer friends. 4. Disruptive in school. 5. School suspensions. 6. Increased drop out rates. 7. Delinquency / conduct problems. 8. Disruption of family function. 1. Poor employment hx. 2. Poor driving record. 3. Academic underachievement. 4. Multiple marriages. 5. Legal problems. 6. Accidents / injuries. 7. Teenage pregnancy. 8. STD. 9. Smoking. Home Classroom Education ADHD Medication Barkley RA et al. J Am Acad Child Adol Psych; 2006

Read books. Not web pages (AAP). Support groups.

Individual psychotherapy ineffective. 3.

In general, parents are irrelevant to their child's

is one of fthe strongest t factors in allowing them to

Understand where the behavior is coming from.

15 Read books. Not web pages (AAP). Support groups. Counseling 1. Play therapy ineffective. 2. Individual psychotherapy ineffective. 3. Behavior modification limited positive effect. In general, parents are irrelevant to their child's misbehavior. is one of fthe strongest t factors in allowing them to cope with their child s challenging behavior. Understand where the behavior is coming from. Formal IEP, 504 plan. Class size. Teacher / Aides. Teacher experience. Structured class room. Preferential seating. Extra time. Homework peer tutor. Accountability check books go home.

The Classroom Tests accommodations. Technique Description Example Positive Reinforcement Privileges contingent on Play on X-box. performance. Homework. Use peaks rather than average.

Bottom line ADHD don't need all accommodations, but only those that address specific difficulties and you don t want the child to hate school : fail and destroy selfconfidence.

16 The Classroom Tests accommodations. Technique Description Example Positive Reinforcement Privileges contingent on Play on X-box. performance. Homework. Use peaks rather than average. Time-out Removing access to positive reinforcement due to problem behavior. Hits sib impulsively goes to room. Time out applies to dental team. Classroom situation. Bottom line ADHD don't need all accommodations, but only those that address specific difficulties and you don t want the child to hate school : fail and destroy selfconfidence. Response cost Token economy Withdrawing rewards contingent on problem or unwanted behavior. Combines positive reinforcement and response cost. Child loses free time for not doing homework. Earns stars for doing homework, loses stars for misbehavior. Used for dental treatment.

17 65 75 % of 5899 children assigned to stimulant medication vs. 4-30% to placebo improved (161 RCT by Greenhill, 1998). Review of 78 studies by Jadad et al. (1999) consistently supported the superiority of stimulant over non-drug treatment. ADHD Multimodal Treatment Analysis (MTA) conducted by AAP large randomized controlled study in children 7 to 10 years of age showed stimulant along with behavior therapy showed greatest improvement in academic performance and measures of conduct.

18 Medication alone (MPH dosed to last 12 hours). Intensive behavioral treatment t t alone. Over 30 sessions for parent training. 8 week summer program. Behavior therapist for 12 wks in classroom. Daily reports from school to home Combined medication & behavioral treatment. Community- based care (control). ADHD is a disorder of polysynaptic dopaminergic circuits between prefrontal and striatal centers. Noradrenergic pathways are also involved. Source: MTA Study Group, Arch Gen Psych, 1999, 56,

Dopamine. Norepinephrine. Reward seeking behavior. Central psychomotor neurotransmitter.

1979, Shen, 1984, Zametkin 1984. Psychostimulants increase arousal, alertness, reduce fatigue.

AMPH and MPH blocks uptake Into vesicle MPH and AMPH Inhibit transporter uptake NEURON ( presynaptic )

19 Dopamine. Norepinephrine. Reward seeking behavior. Central psychomotor neurotransmitter. Bowden 1988, Cook 1995, Doughtery 1999 LaHoste 1996, Malone 1994, Rappaport 1999 Heilman 1991, Shekim 1979, Shen, 1984, Zametkin Psychostimulants increase arousal, alertness, reduce fatigue. Methylphenidate. Dextroamphetamine. Amphetamine salts. Atomoxetine. Non Stimulant. AMPH and MPH blocks uptake Into vesicle MPH and AMPH Inhibit transporter uptake NEURON ( presynaptic ) Storage vesicle DA Transporter AMPH/MPH diffuses into vesicle Releasing DA into cytoplasm AMPH is taken into cell Causing DA release into synapse

Going to school nurse is stigmatizing. Public hysteria about side effects. Market competition $$$$$. Newer drug delivery systems.

20 Why Newer Medications? Stimulants are short acting 3 / 5 hours. Multiple doses cause peaks & valleys giving rise to roller coaster effect through the day. Smooth effect through day is desirable. Going to school nurse is stigmatizing. Public hysteria about side effects. Market competition $$$$$. Newer drug delivery systems. Slow smooth release. Transdermal patch. Enantiomers and isomers. Dextro / levo. Combination. Prodrug. Newer classes of drugs. Noradrenergic / nonstimulant. Osmotic Release Oral System (OROS) Pulsated Delivery Beads Transdermal system Adderall XR. Ritalin LA Daytrana

Generic Class Daily Dosage Duration Stimulants MPH Short Acting (Ritalin, Metadate) BID / TID 3-5 hrs

Acting (Dexedrine) BID / TID 4-6 hrs Intermediate (Adderall) QD / BID 6-8 hrs LA (Adderall XR) QD 8-12

Reduced appetite Jitteriness Stomachache More effect on above avj. children.

21 Generic Class Daily Dosage Duration Stimulants MPH Short Acting (Ritalin, Metadate) BID / TID 3-5 hrs Intermediate (Ritalin SR, Metadate ER) QD / BID 3-8 hrs LA (Concerta) QD 8-12 hrs Amphetamine Short Acting (Dexedrine) BID / TID 4-6 hrs Intermediate (Adderall) QD / BID 6-8 hrs LA (Adderall XR) QD 8-12 hrs Headache Delayed sleep RCT report 4-10%. Most dose related. Reduced appetite Jitteriness Stomachache More effect on above avj. children. Most in year one, less in year 2, levels off in 3yd year. Effect on wt and ht is dose dependent 2 cm ht and 2.7 kgs wt. in 3 years No rebound after stimulant discontinued.

22 School Family therapy

23 Structure TSD. N2O, Sedation, OR Avoid treatment during drug holidays Child abuse Trauma Prevention

the oral and demographic characteristics of

disorder (ADHD) to those of a control group of

A sample of 25 dental records of children

The children with ADHD had a statistically

bleeding gums, and oral trauma histories than

24 If this were my kid!!!!! The purpose of this study was to compare the oral and demographic characteristics of children with attention-deficit hyperactivity disorder (ADHD) to those of a control group of children. A sample of 25 dental records of children medicated for ADHD was compared to 127 records of healthy children not receiving any medication. The children with ADHD had a statistically higher prevalence of toothache, bruxism, bleeding gums, and oral trauma histories than the control group (chi square, p < 0.05). Life-long condition. Biological disorder exacerbated by social factors. At the extreme of normal behavior variation. Treated because of associated distress and disability. Bimstein E, Primoch R. Spec Care Dentist May-Jun;28(3):

25 Concept Know your drugs. Be cool. Concept Early short appointments. Positive reinforcement. Concept Avoid drug holidays. Concept Keep disorder in mind.

Update on the Treatment of ADHD 2019

Update on the Treatment of ADHD 2019 James H. Beard, Jr., M.D, FAAP Developmental-Behavioral Pediatrician Division of Developmental Pediatrics The Rights of ADHD The right diagnosis of ADHD and co morbidities