ADHD: We know it when we see it—or do we? Constance J. Fournier, Ph.D. Clinical Professor Texas A & M University Goal The purpose of this workshop is to provide school nurses information about ADHD and related diagnosis and the opportunity to consider how to develop or modify interactions with school faculty or medical personnel in order to better serve students with these diagnoses. Objectives 1. The learner will be able to list the key types of ADHD on a Venn diagram. 2. The learner will be able to list basic interventions used in treating ADHD in lecture notes. 3. The learner will be able to show overlaps between ADHD and other DSM IV diagnosis on Venn diagrams. 4. The learner will be able to discuss action plan ideas to take back to their school to improve mental health intervention within the school nurse role. Overview ADHD and types of ADHD Basic interventions with ADHD ADHD and the typical comorbidity ADHD and depression ADHD and anxiety Action plan ADHD and types Inattentive symptoms Often fails to give close attention to details, or makes careless mistakes Difficulty sustaining attention in tasks or play (rule governed behavior) Does not seem to listen when spoken to directly ADHD and types Inattentive symptoms continued Does not follow through on instructions, fails to finish tasks (not due to oppositional behavior or inability to understand) Difficulty organizing tasks or activities Avoid, dislikes, reluctant to engage in mental effort tasks Often loses necessary things ADHD and types Inattention symptoms continued Often distracted by extraneous stimuli Often forgetful in daily activities ADHD and types Hyperactivity symptoms Fidgets with hands, feet, squirms in seat Leaves seat when remaining seated is expected Runs or climbs excessively; adolescents report restlessness On the go, driven by a motor Talks excessively ADHD and types Impulsivity symptoms Blurts out answers before the question is completed Difficult awaiting turn Interrupts or intrudes on others (butting into conversations or games) ADHD and types Inattentive type Hyperactive-Impulsive type Combined type Helps to put on the tri Venn diagram Diagnosed before age 7 ADHD types inattentive hyperactive inattentive ADHD interventions Behavioral Interventions Parent training Reinforcing positive behavior Positive interactions Parent time outs ADHD Interventions Behavioral interventions School interventions Reinforcing positive behavior Positive interactions Self-monitoring ADHD Interventions Behavioral interventions Student interventions Self monitoring Direct instruction in organization Direct instruction in studying Pre-corrections Visual and verbal direction Reinforcement of behaviors you want to see ADHD interventions Medications Stimulants 70 years of study showing positive results with minimal side effects Note for school nurses: medication gaps Non-stimulants Appropriate for particular circumstances ADHD interventions Typical side effects Reduced appetite Sleep problems Headaches Stomach pain Irritability ADHD interventions Atypical side effects (rare to very rare) Health related problems—usually related to undiagnosed issues such as heart defects Hallucination and agitation-FDA indicates a slightly increased risk Non stimulants—verbalizing suidical thoughts; liver problems Extreme caution with pre-existing psychosis or bipolar disorder; still can use if needed ADHD interventions: Which is better? Medication or no medication research generally suggests medication Behavioral intervention alone Always the first step; however, research suggests that behavioral intervention alone is not sufficient ADHD interventions: Which is better? Behavioral and medication Most suggest medication alone is most effective Medication with behavioral intervention about the same as medication alone Behavioral intervention alone less effective Issues with sampling, assessment tools, length of time studied Jury still out, but medication does seem to hold up as effect alone or with behavioral intervention ADHD interventions: Which is better? What does not work Special diets Herbal supplements Homeopathic treatment Bio-feedback Chiropractic adjustments Auditory treatments However, don’t negate placebo effects ADHD and comorbidity The big 3 ADHD and Learning Disabilities ADHD and Oppositional Defiant disorder 20% to 40% or higher 20% to 40% or higher ADHD and both LD and ODD 20% to 40% or higher Big 3 ADHD LD ODD Learning Disability Significant discrepancy between cognitive ability and academic achievement In Texas, greater than one standard deviation (16 or more points) Method two—preponderance of the evidence Oppositional Defiant Disorder Actively refuses to comply requests Deliberately annoys others Angry and resentful of others Argues often Blames others for own mistakes Oppositional defiant disorder Few friends, loses friends Constantly in trouble in rule governed situations Spiteful or revengeful Touchy or easily annoyed ADHD and depression One out four adults with ADHD also has symptoms of depression Children with ADHD are three times more likely to have depression as compared with other children ADHD and depression Symptoms of depression depressed, irritable mood marked diminished interest or pleasure in activities significant weight loss/gain; failure to make expected gains insomnia or hypersomnia psychomotor agitation or retardation ADHD and depression Symptoms of Depression continued fatigue or loss of energy feelings of worthlessness or excessive or inappropriate guilt diminished ability to think or concentrate or indecisiveness recurrent thoughts of death, suicidal ideation, suicide attempt ADHD and depression Using the Venn diagram, put in the symptoms of depression along with the symptoms of ADHD What is overlapping? What is separate? ADHD Both Depression ADHD and depression General types of depression major depression (more than 2 weeks) Dysthymia symptoms of depression more often than not in children, symptoms for one year Bipolar disorder ADHD and depression Bipolar disorder Depression (typically) & mania inflated self-esteem decreased need for sleep more talkative, pressured talk flight of ideas distractible with irrelevant stimuli increased behaviors excessive activities that are potentially dangerous ADHD and depression General Intervention for Depressive disorders affective information activity scheduling social skills training problem-solving training ADHD and depression General Intervention for Depressive disorders self-instructional training: monitoring, evaluating, rewarding relaxation training cognitive structuring/cognitive modeling ADHD and Anxiety About 30% of children with ADHD also have symptoms of anxiety Up to 40% in adults with ADHD also have symptoms of anxiety ADHD and Anxiety Symptoms of Anxiety excessive anxiety and worry more often than not for 6 months difficult to control the worry ADHD and Anxiety Symptoms of anxiety continued restlessness or keyed up or on edge easily fatigued difficulty concentrating, mind goes blank irritability muscle tension sleep disturbance (falling asleep or staying asleep) ADHD and Anxiety Using the Venn diagram, put in the symptoms of Anxiety along with the symptoms of ADHD What is overlapping? What is separate? ADHD and Anxiety Types of Anxiety disorders Separation anxiety disorder Specific phobias Social Animal Natural environment Blood-injection-injury Situational Other (clowns or mascots) ADHD and Anxiety Anxiety disorders Somatoform--multiple physical complaints with no medical explanation Obsessive-compulsive disorder obsessions—thoughts, impulses, images that are intrusive and excessive; person tries to ignore or suppress with other thoughts or actions; selfknowledge that this is own thoughts compulsions—repetitive behaviors driven to perform to try to deal with obsessive thinking, but does not work ADHD and Anxiety General Interventions for anxiety disorders Systematic desensitization modeling social skills training problem-solving training ADHD and Anxiety General interventions for anxiety disorders self-instructional training: monitoring, evaluating, rewarding relaxation training cognitive structuring/cognitive modeling ADHD and Action Plans for Nurses Role of the school nurse Medication dispensing Health monitoring Liaison with medical professionals Liaison with school faculty Liaison with family ADHD and Action Plans for Nurses General actions Need for Release of Information forms Need for clear lines of communication How is communication with medical personal maintained? How is communication with family maintained? How is communication with faculty maintained? We learn from others Share with elbow neighbor what is done in your school Consider what you do What works well What needs to change We will have chance to share with each other We learn from others Sharing with each other What works! ADHD and Action Plans for Nurses Making your own plan Prioritize what you would like to do Consider what resources you have Consider what barriers you have Time is ALWAYS a barrier Money is rarely a barrier Set up a timeline for yourself Resources www.chadd.org www.help4adhd.org Combined resources www.nasponline.org Children and adults with Attention Deficit Disorders National Association of School Psychologists www.ed.gov Department of Education Resources www.nichcy.org www.aap.org American Academy of Pediatrics www.apa.org National information center for children and youth with disabilities American Psychological Assocition www.aacap.org American Academy of Child and Adolescent Psychiatry "Copyright Disclaimer Under Section 107 of the Copyright Act 1976, allowance is made for "fair use" for purposes such as criticism, comment, news reporting, teaching, scholarship, and research. Fair use is a use permitted by copyright statute that might otherwise be infringing. 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