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ADHD WORKSHOP FOR PAEDIATRICIANS UCT Paediatric Refresher Course Feb 2010.

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Presentation on theme: "ADHD WORKSHOP FOR PAEDIATRICIANS UCT Paediatric Refresher Course Feb 2010."— Presentation transcript:

1 ADHD WORKSHOP FOR PAEDIATRICIANS UCT Paediatric Refresher Course Feb 2010

2 The role of the Paediatrician in the treatment of ADHD Diagnosis and management Diagnosis and management Increase in presentation Increase in presentation More presentations to Paediatricians and reluctance to visit a Psychiatrist More presentations to Paediatricians and reluctance to visit a Psychiatrist Families need from Paediatrician Families need from Paediatrician Awareness of differential diagnosis Awareness of differential diagnosis Awareness of co-morbidity Awareness of co-morbidity Medication cornerstone of treatment but holistic approach very NB Medication cornerstone of treatment but holistic approach very NB Paediatrician may be first professional to notice ADHD Paediatrician may be first professional to notice ADHD

3 General concepts of ADHD Aetiological and symptomatic understanding Aetiological and symptomatic understanding

4 Predominantly a neurobiological condition Predominantly a neurobiological condition Strong family history Strong family history Constellation of symptoms (vs. signs) Constellation of symptoms (vs. signs) Core symptoms: Inattention Core symptoms: Inattention Hyperactivity/Impulsivity Hyperactivity/Impulsivity DSM IV criteria DSM IV criteria

5 criteria INATTENTION INATTENTION Failure to give close attention to detail Failure to give close attention to detail Difficulty sustaining attention Difficulty sustaining attention Not listening when spoken to directly Not listening when spoken to directly Inability to finish work / follow through instructions Inability to finish work / follow through instructions Difficulty organizing tasks or activities Difficulty organizing tasks or activities Avoidance of tasks requiring sustained mental effort Avoidance of tasks requiring sustained mental effort

6 Often looses things required for tasks Often looses things required for tasks Easily distracted Easily distracted Forgetful in daily activities Forgetful in daily activities 6 symptoms required 6 symptoms required HYPERACTIVITY HYPERACTIVITY Fidgety Fidgety Difficulty remaining in seat Difficulty remaining in seat Excessive running about / subjective feeling of restlessness Excessive running about / subjective feeling of restlessness Difficulty engaging in leisure activity quietly Difficulty engaging in leisure activity quietly On the go / “driven by motor” On the go / “driven by motor” Excessive talking Excessive talking

7 IMPULSIVITY IMPULSIVITY Blurting out of answers Blurting out of answers Difficulty waiting turn Difficulty waiting turn Often interrupts or intrudes on others Often interrupts or intrudes on others 6 criteria required 6 criteria required

8 ALSO ALSO Symptoms present before age 7 years Symptoms present before age 7 years Impairment in 2 or more settings Impairment in 2 or more settings Impaired functioning Impaired functioning Symptoms not due to other causes Symptoms not due to other causes

9 Spectrum of presentation i.e.. Below threshold presentation vs. mild/moderate presentation vs. severe and complicated presentation with several comorbid conditions Spectrum of presentation i.e.. Below threshold presentation vs. mild/moderate presentation vs. severe and complicated presentation with several comorbid conditions Up to 50% of children have co morbid disorder(s) Up to 50% of children have co morbid disorder(s)

10 Impairment in social, family and academic functioning Impairment in social, family and academic functioning Occurrence in at least 2 settings Occurrence in at least 2 settings Onset during childhood Onset during childhood Longitudinal course - 2/3 of patients progress into adulthood Longitudinal course - 2/3 of patients progress into adulthood

11 Why are more children presenting now? Why are more children presenting now? “Evolutionary” concept of ADHD “Evolutionary” concept of ADHD How/why do most patients/families present? How/why do most patients/families present? Disruption (in class) probably most common reason for referral Disruption (in class) probably most common reason for referral

12 Has modern society created a disorder from a previous strength? Genetic and adaptive factors in ADHD Genetic and adaptive factors in ADHD Information overload Information overload Stimulation overload Stimulation overload Academic overload Academic overload Outsourcing of care Outsourcing of care Is it normal for a child to sit still at a desk for 6 – 8 hours Is it normal for a child to sit still at a desk for 6 – 8 hours Societal issues vs mental health issues Societal issues vs mental health issues

13 Why NB to treat Academic potential Academic potential Disruption Disruption Self esteem Self esteem Impaired functioning (academic, social, family ) Impaired functioning (academic, social, family ) co morbidity co morbidity

14 Evaluation of/Clinical approach to the child presenting with ADHD May depend on referral source e.g.. Psychologist, school, parents etc May depend on referral source e.g.. Psychologist, school, parents etc N.B. to take ones time, i.e. extended consult, 2-3 consultations N.B. to take ones time, i.e. extended consult, 2-3 consultations Differential diagnosis and co morbidity always need to be born in mind Differential diagnosis and co morbidity always need to be born in mind

15 Interview with parents (may need to start off without the child) Interview with parents (may need to start off without the child) Child interview Child interview Family observation Family observation Physical information/evaluation of the child Physical information/evaluation of the child Additional information/investigation Additional information/investigation

16 Interview with parents May initially be necessary to exclude the child May initially be necessary to exclude the child Presenting complaint Presenting complaint History of presenting complaint History of presenting complaint DSM IV checklist DSM IV checklist Context of symptoms Context of symptoms Resulting impairments Resulting impairments

17 Differential diagnosis i.e. may the child’s symptoms be due to another cause other than ADHD Differential diagnosis i.e. may the child’s symptoms be due to another cause other than ADHD Co morbidity i.e. are there additional emotional symptoms that the child is displaying e.g.. Mood, anxiety, conduct, defiance, intellectual impairment etc. Co morbidity i.e. are there additional emotional symptoms that the child is displaying e.g.. Mood, anxiety, conduct, defiance, intellectual impairment etc.

18 Past psychiatric history including ADHD and treatment, past alternative treatments Past psychiatric history including ADHD and treatment, past alternative treatments Developmental history Developmental history Areas of strength Areas of strength Medical history including medications Medical history including medications

19 Family history History of ADHD or co morbid disorder History of ADHD or co morbid disorder Learning difficulty Learning difficulty Family coping style, level of organisation and resources Family coping style, level of organisation and resources Family stressors Family stressors Signs of abuse and neglect (especially in younger children) Signs of abuse and neglect (especially in younger children)

20 Child Interview Note symptoms of ADHD (may however be absent during one on one consultation) Note symptoms of ADHD (may however be absent during one on one consultation) Note and explore: Note and explore: Defiance Defiance Aggression Aggression Anxiety Anxiety Obsessions and compulsions Obsessions and compulsions

21 Form, content and logic of thinking and perception Form, content and logic of thinking and perception Fine and gross motor coordination Fine and gross motor coordination Tics and movement disorders Tics and movement disorders Speech and language ability Speech and language ability Clinical estimate of intellect Clinical estimate of intellect

22 Family observation Patients behaviour with siblings and parents Patients behaviour with siblings and parents Parental responses to child’s behaviour Parental responses to child’s behaviour Parental level of agreement around child rearing principles and discipline Parental level of agreement around child rearing principles and discipline

23 Physical evaluation Past medical history and medication Past medical history and medication Medical record over past 12 months Medical record over past 12 months Stability of any illnesses e.g. asthma, allergies etc (may tip the balance) Stability of any illnesses e.g. asthma, allergies etc (may tip the balance) Visual acuity Visual acuity Hearing Hearing Height, weight and growth chart Height, weight and growth chart Other evaluation as indicated e.g. neurological, cardiology, developmental assessment Other evaluation as indicated e.g. neurological, cardiology, developmental assessment

24 Additional information/investigations Forms/rating scales completed by parents, teachers and significant others Forms/rating scales completed by parents, teachers and significant others Conner’s forms: basic and extended, also important to complete once patient being treated Conner’s forms: basic and extended, also important to complete once patient being treated School reports (especially the comments) School reports (especially the comments)

25 Collateral information from teacher and others (aftercare, other carers) Collateral information from teacher and others (aftercare, other carers) Depending on presentation child may need: Depending on presentation child may need: Psychometric assessment Psychometric assessment Speech and language assessment Speech and language assessment OT assessment OT assessment No “special tests” available No “special tests” available

26 Differential and co morbid scan Differential and co morbid scan Diagnostic formulation Diagnostic formulation Treatment plan Treatment plan

27 The younger and older child Young child: rule out neglect, abuse and other environmental factors, mother/parent: child relationship difficulties may be important contributor Young child: rule out neglect, abuse and other environmental factors, mother/parent: child relationship difficulties may be important contributor Older child: NB. To make patient an active participant in treatment Older child: NB. To make patient an active participant in treatment

28 Treatment/Intervention Non pharmacological Non pharmacological Pharmacological (cornerstone of treatment) Pharmacological (cornerstone of treatment)

29 Non pharmacological interventions Psycho education: parents, child, others Psycho education: parents, child, others Collaboration with/ interventions at school Collaboration with/ interventions at school Additional school/ remedial resources Additional school/ remedial resources Support group for parents Support group for parents Books and other materials Books and other materials Behavioural interventions Behavioural interventions

30 Behavioural interventions Should be part of overall intervention Should be part of overall intervention May be used on own if symptoms mild or parents refusing meds May be used on own if symptoms mild or parents refusing meds Attend to child’s misbehaviours and complaints (target symptoms) Attend to child’s misbehaviours and complaints (target symptoms) Token systems (target symptoms) Token systems (target symptoms) Time out Time out Manage non compliant behaviour in public places PTO Manage non compliant behaviour in public places PTO

31 Daily school report and other school interventions Daily school report and other school interventions Anticipate future misconduct Anticipate future misconduct Structure, routine, boundaries, predictability Structure, routine, boundaries, predictability *** may all be impossible if family stressors or if parent(s) have ADHD *** may all be impossible if family stressors or if parent(s) have ADHD

32 Play therapy, CBT and social skills training not helpful in children who only have ADHD/ADD Play therapy, CBT and social skills training not helpful in children who only have ADHD/ADD May be useful for co morbid disorders May be useful for co morbid disorders No empirical evidence for dietary intervention unless proven food intolerance No empirical evidence for dietary intervention unless proven food intolerance ? Food colorants in the very young ? Food colorants in the very young

33 Pharmacological interventions Methylphenidate: Ritalin IR Methylphenidate: Ritalin IR Ritalin LA Ritalin LA Concerta Concerta Atomoxetine: Strattera Atomoxetine: Strattera Other: Imipramine Other: Imipramine Clonidine Clonidine

34 Side effects and their management:Methylphenida te Loss of appetite (daily quantity N.B.) Loss of appetite (daily quantity N.B.) Weight loss (monitor) Weight loss (monitor) Headache, abdominal pain Headache, abdominal pain Rebound phenomena Rebound phenomena Anxiety Anxiety Tics Tics Depression Depression Affective blunting/ emotional lability Affective blunting/ emotional lability insomnia insomnia

35 Management of stimulant S/E loa loa loss of wt loss of wt early insomnia early insomnia blunted affect blunted affect tic tic stereotypic movement stereotypic movement growth delay growth delay

36 if symptoms severe -- change to 2nd line meds if symptoms severe -- change to 2nd line meds l o a l o a decrease dosage decrease dosage increase breakfast + supper increase breakfast + supper if early - dev of tolerance if early - dev of tolerance monitor wt and ht monitor wt and ht

37 loss of wt loss of wt decrease dose decrease dose increase caloric intake (breakfast and supper) increase caloric intake (breakfast and supper) no meds over w/e and holidays no meds over w/e and holidays monitor wt, growth curve monitor wt, growth curve hope for tolerance hope for tolerance

38 early insomnia early insomnia if IR - no meds after 3pm if IR - no meds after 3pm if LA - lower dosage, if LA - lower dosage, give dose earlier, give before breakfast for faster absorption ensure bedtime routine eg reading ensure bedtime routine eg reading Clonidine, anntihisamine,melat onin Clonidine, anntihisamine,melat onin

39 blunted affect blunted affect decrease dosage decrease dosage change preparation change preparation

40 tic tic discontinue, if tic disappears restart discontinue, if tic disappears restart if tic recurs - change meds if tic recurs - change meds

41 stereotypic movement stereotypic movement decrease dosage decrease dosage growth delay growth delay decrease dosage decrease dosage drug holidays drug holidays bone age monitoring on radiograph bone age monitoring on radiograph

42 Atomoxetine Gastrointestinal disturbances Gastrointestinal disturbances Sedation Sedation Decreased appetite Decreased appetite Hepatic disorder Hepatic disorder Black box warning: suicidality Black box warning: suicidality “feeling ill” but unable to verbalize “feeling ill” but unable to verbalize Severe acting out behaviour Severe acting out behaviour

43 N.B. to discuss side effects before commencing treatment N.B. to discuss side effects before commencing treatment Monitor for side effects Monitor for side effects

44 Use of different methylphenidate preparations i.e. which one to use Use of different methylphenidate preparations i.e. which one to use Advantages and disadvantage Advantages and disadvantage

45 Ritalin vs. Strattera Ritalin vs. Strattera Ritalin generally considered 1 st line Ritalin generally considered 1 st line Consider Strattera if: tics, anxiety, Ritalin intolerance, patient preference Consider Strattera if: tics, anxiety, Ritalin intolerance, patient preference

46 Introducing medication Dosage Dosage Start over weekend (parents feel in control) Start over weekend (parents feel in control) Warn re side effects Warn re side effects Ritalin : fast onset Ritalin : fast onset Strattera : 4-6 weeks onset (may start in holidays) Strattera : 4-6 weeks onset (may start in holidays) Drug holidays ; depends on side effects and level of functioning off meds Drug holidays ; depends on side effects and level of functioning off meds Follow up regularly including Connors form and collateral (see later) Follow up regularly including Connors form and collateral (see later)

47 A 9 year old girl is on Concerta 36mg daily. Reports from school indicate that her concentration remains poor until 1st break. What would your approach be? A 9 year old girl is on Concerta 36mg daily. Reports from school indicate that her concentration remains poor until 1st break. What would your approach be?

48 Establish at what time meds are taken Establish at what time meds are taken Consider adding mg Ritalin mane Consider adding mg Ritalin mane

49 An 8 year old girl refuses to take Ritalin LA 20mg as she feels she cannot swallow it. What would you advise? An 8 year old girl refuses to take Ritalin LA 20mg as she feels she cannot swallow it. What would you advise?

50 An 8 year old boy commenced on Strattera complains of persistent midday nausea. How would you manage him? An 8 year old boy commenced on Strattera complains of persistent midday nausea. How would you manage him?

51 A single mother presents with her four year old son who presents with symptoms of ADHD. What would your approach to management be? A single mother presents with her four year old son who presents with symptoms of ADHD. What would your approach to management be?

52 An 11 year old boy with ADHD and co morbid oppositional disorder stops responding to Ritalin LA 20 mg. you increase the dosage to 30mg without much success. How would you approach this presentation An 11 year old boy with ADHD and co morbid oppositional disorder stops responding to Ritalin LA 20 mg. you increase the dosage to 30mg without much success. How would you approach this presentation

53 A matriculant presents to you whom you had last seen 4 years ago and treated for ADD. He decided to stop meds then but now realises he requires them to get a decent matric result. How would you approach this problem? A matriculant presents to you whom you had last seen 4 years ago and treated for ADD. He decided to stop meds then but now realises he requires them to get a decent matric result. How would you approach this problem?

54 Role play : the difficult parents

55 Meds around for over 30 years- no major lawsuits in USA Meds around for over 30 years- no major lawsuits in USA “drug” dependency issues – the opposite is true, never come across a child addicted to Ritalin, drug dealers don’t stock Ritalin…Why not “drug” dependency issues – the opposite is true, never come across a child addicted to Ritalin, drug dealers don’t stock Ritalin…Why not Self esteem issues and marginalisation Self esteem issues and marginalisation Co morbidity Co morbidity Sitting on the other side Sitting on the other side Why withhold something that works e.g. other meds (asthma), spectacles Why withhold something that works e.g. other meds (asthma), spectacles Consideration of trial of meds Consideration of trial of meds In and out of system….like coffee In and out of system….like coffee If side effects… at least you can say you tried If side effects… at least you can say you tried

56 Empirical evidence of other interventions lacking, i.e. diet, multivitamin loading, specialized programmes etc Empirical evidence of other interventions lacking, i.e. diet, multivitamin loading, specialized programmes etc If there were a proven intervention programme say over sessions I would certainly administer it. It would be far more remunerative for me If there were a proven intervention programme say over sessions I would certainly administer it. It would be far more remunerative for me If you know of a programme show me the evidence If you know of a programme show me the evidence Internet myths--- you can find anything on the internet Internet myths--- you can find anything on the internet

57 Patient follow up What would your follow up strategy and protocol be for a patient that you have commenced on medication? What would your follow up strategy and protocol be for a patient that you have commenced on medication? What specific features would you be looking out for? What specific features would you be looking out for?

58 Frequency of follow up (scripts may act as a good gatekeeper) Frequency of follow up (scripts may act as a good gatekeeper) Weight, height, pulse and blood pressure Weight, height, pulse and blood pressure Co morbidity check, other disorders may creep in over time Co morbidity check, other disorders may creep in over time Assess level of functioning in all spheres Assess level of functioning in all spheres Repeat Connor’s form Repeat Connor’s form Side effects Side effects Dosage Dosage When to discontinue? When to discontinue?

59 Differential diagnosis of ADHD/ADD and co morbidity ADD may often go undetected until later. Why? ADD may often go undetected until later. Why? Symptoms of ADHD may often mimic other psychiatric conditions Symptoms of ADHD may often mimic other psychiatric conditions In addition about 50% of individuals with ADHD meet criteria for one or more other psychiatric disorder(s) In addition about 50% of individuals with ADHD meet criteria for one or more other psychiatric disorder(s) The list is long and the treatment may be complex The list is long and the treatment may be complex

60 Differential diagnosis and Co morbid conditions Oppositional Defiant Disorder Oppositional Defiant Disorder Anxiety Disorders (incl OCD) Anxiety Disorders (incl OCD) Mood Disorders (incl BMD) Mood Disorders (incl BMD) Conduct Disorder Conduct Disorder Learning Disorder Learning Disorder Tourette’s Disorder, Motor Tic Disorder Tourette’s Disorder, Motor Tic Disorder Substance Abuse Disorder Substance Abuse Disorder

61 Pervasive Developmental Disorder Pervasive Developmental Disorder Sleep Difficulties/Disorders Sleep Difficulties/Disorders Accidental Injuries Accidental Injuries “Personality Difficulties”, Cluster B traits “Personality Difficulties”, Cluster B traits Family dysfunction Family dysfunction Medical illnesses/ medication Medical illnesses/ medication Actively exclude co morbidity Actively exclude co morbidity Consider when ADHD “refractory” Consider when ADHD “refractory”

62 , Joseph Biederman and Stephen Faraone 1996

63 Differential diagnosis How would you differentiate a child suffering from ADHD/ADD from the following condition(s):Note that these patients may be referred to you with a request to treat their “ADHD/ADD” How would you differentiate a child suffering from ADHD/ADD from the following condition(s):Note that these patients may be referred to you with a request to treat their “ADHD/ADD” Anxiety disorder( all types) Anxiety disorder( all types) Depression Depression Bipolar mood disorder Bipolar mood disorder Learning disorder Learning disorder Oppositional defiant disorder Oppositional defiant disorder Substance use disorder Substance use disorder Pervasive developmental disorder Pervasive developmental disorder

64 Similarities in presentation Similarities in presentation vs vs Differences in presentation Differences in presentation See flip chart See flip chart

65 Co morbidity and ADHD/ADD More complex than establishing whether another diagnosis/disorder may be responsible for an “ADHD/ADD” presentation is when one or more disorders are indeed present in addition to ADHD/ADD More complex than establishing whether another diagnosis/disorder may be responsible for an “ADHD/ADD” presentation is when one or more disorders are indeed present in addition to ADHD/ADD Furthermore when these disorders present during treatment of ADHD we need to ask ourselves whether these symptoms could be as a result of medication Furthermore when these disorders present during treatment of ADHD we need to ask ourselves whether these symptoms could be as a result of medication

66 If co morbid condition(s) is mild, treatment of ADHD may significantly improve co morbid presentation If co morbid condition(s) is mild, treatment of ADHD may significantly improve co morbid presentation Caution in : Caution in : Anxiety disorders and stimulants (academic performance anxiety may however be improved) Anxiety disorders and stimulants (academic performance anxiety may however be improved) Tourrette’s disorder Tourrette’s disorder Bipolar mood disorder Bipolar mood disorder

67 Psychological intervention often necessary when co morbid conditions present Psychological intervention often necessary when co morbid conditions present Polypharmacy may be unavoidable Polypharmacy may be unavoidable Second opinions often useful Second opinions often useful

68 How would you treat a child with ADHD and the following comorbidities given the fact that the child/family is receiving psychological intervention? How would you treat a child with ADHD and the following comorbidities given the fact that the child/family is receiving psychological intervention? Tourette’s syndrome Tourette’s syndrome PDD PDD BMD BMD Substance abuse Substance abuse Anxiety disorder Anxiety disorder Depressive disorder Depressive disorder

69 Tourette’s Syndrome clonidine clonidine atomoxetine atomoxetine stimulants (not as problematic as initially thought) stimulants (not as problematic as initially thought)

70 Pervasive Development Disorder meds not as effective 50% vs 70% meds not as effective 50% vs 70% S/E less well tolerated S/E less well tolerated can be used but monitor can be used but monitor ? other agents eg Risperidone ? other agents eg Risperidone

71 B M D OK to use once stable on mood stabilizer OK to use once stable on mood stabilizer Substance abuse avoid stimulants (however) avoid stimulants (however) NB preventative role NB preventative role

72 Anxiety Disorder Second line agents Second line agents add SSRI add SSRI

73 Depressive disorder Consider adding a SSRI (Fluoxetine) Consider adding a SSRI (Fluoxetine) Imipramine of limited value Imipramine of limited value

74 Challenging cases over time Imaad, 5 yrs old at end 2007 Imaad, 5 yrs old at end 2007 Met parents at ADHD Support Group Met parents at ADHD Support Group Recently diagnosed with ADHD and had been commenced on Ritalin 5mg mane Recently diagnosed with ADHD and had been commenced on Ritalin 5mg mane Now presents with mood swings and irritability in afternoons Now presents with mood swings and irritability in afternoons Changed to Concerta 18mg with good effect Changed to Concerta 18mg with good effect Mid 2009 – Psychometric assessment reveals some learning difficulties and significant ADHD “break through” symptoms Mid 2009 – Psychometric assessment reveals some learning difficulties and significant ADHD “break through” symptoms

75 Increased dose to 36mg, initially symptoms controlled Increased dose to 36mg, initially symptoms controlled Oct 2009 emergence of vocal tic (parents concerned +++) Oct 2009 emergence of vocal tic (parents concerned +++) changed to Atomoxetine, Clonidine and Risperidone (monotherapy)….. Mild reduction of tics but ADHD out of control changed to Atomoxetine, Clonidine and Risperidone (monotherapy)….. Mild reduction of tics but ADHD out of control Recommenced on Concerta 18mg in Jan 2010, ADHD symptoms controlled, still minor vocal tics Recommenced on Concerta 18mg in Jan 2010, ADHD symptoms controlled, still minor vocal tics

76 Lara, grade 1, 2009, Referred with diagnosis of ADHD/anxiety…Aggression on Strattera, mood swings on Ritalin, dysinhibited on Fluoxetine Lara, grade 1, 2009, Referred with diagnosis of ADHD/anxiety…Aggression on Strattera, mood swings on Ritalin, dysinhibited on Fluoxetine Found to have additional ODD when seen Found to have additional ODD when seen Predominant symptom ADHD Predominant symptom ADHD Commenced on Concerta 18mg Commenced on Concerta 18mg Developed severe insomnia Developed severe insomnia

77 Commenced on Risperidone 0, mg nocte, Concerta stopped Commenced on Risperidone 0, mg nocte, Concerta stopped Manageable Manageable severe anxiety, not coping at school, psychometric assessment – discrepencies, weight gain severe anxiety, not coping at school, psychometric assessment – discrepencies, weight gain Commenced on 12.5mg Sertraline recently….. Awaiting response Commenced on 12.5mg Sertraline recently….. Awaiting response

78 Tristan, aged 8, 2009, ADHD, tics and temper outbursts. Started on Strattera…. Tristan, aged 8, 2009, ADHD, tics and temper outbursts. Started on Strattera…. Major “meltdown” requiring hospitalisation Major “meltdown” requiring hospitalisation Sensitive and hyperreactive Sensitive and hyperreactive Co morbid ODD, anxiety and ? Depression Co morbid ODD, anxiety and ? Depression Strattera stopped Strattera stopped Commenced on Risperidone 0,5mg and Fluoxetine 10 mg Commenced on Risperidone 0,5mg and Fluoxetine 10 mg

79 Reasonable response Reasonable response Concentration difficulties at school Sept2009 Concentration difficulties at school Sept2009 Addition of Concerta 18mg Addition of Concerta 18mg Good response Good response RSA karate champ end 2009 RSA karate champ end 2009 Mini “meltdown” beginning school year 2010 Mini “meltdown” beginning school year 2010 Parental tension Parental tension Couple counselling Couple counselling Keeping fingers crossd…… Keeping fingers crossd……

80 Recent referral Recent referral Learning disorder and ADHD Learning disorder and ADHD PTO PTO

81 Comment of the year 2009 Comment of the year 2009 A 17 year old boy diagnosed with ADHD in Grade 11 and commenced on Methylphenidate: A 17 year old boy diagnosed with ADHD in Grade 11 and commenced on Methylphenidate: Marks initially improved by 20% Marks initially improved by 20% “For the first time in my life I realized that I am not STUPID!” “For the first time in my life I realized that I am not STUPID!”


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