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ADHD, Autism, Mood Disorders in School Aged Children

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Presentation on theme: "ADHD, Autism, Mood Disorders in School Aged Children"— Presentation transcript:

1 ADHD, Autism, Mood Disorders in School Aged Children
Judith Aronson-Ramos, M.D.

2 Overview 5 -10 % of school age children will have a developmental or mental health concern effecting their functioning at school. Minority and socio-economically disadvantaged students may be under identified. School may be the only opportunity for assessment and intervention for some families. Financial strain on families will increase the burden on the school system for identification, assessment, and treatment of common disorders.

3 Prevalence Mental health problems affect one in every five young people at any given time. (Department of Health & Human Services) An estimated two-thirds of all young people with mental health problems are not getting the help they need. (Department of Health & Human Services) Studies indicate that 1 in 5 children and adolescents (20 percent) may have a diagnosable disorder. Estimates of the number of children who have mental disorders range from 7.7 million to million. (Department of Health & Human Services)

4 Common Disorders ADHD Autism Spectrum Disorders – Autism, PDD- NOS, Aspergers Syndrome Mood Disorders: Anxiety, Depression, OCD, Bipolar Disorder Other problems of learning and behavior: LD, Tourettes, Selective Mutism, ODD and CDD

5 Joseph Biederman, M.D. - Harvard University

6 Medical Perspective Training dictates treatment
Evidenced Based Medicine Disciplines have different approaches: Psychiatry Developmental & Behavioral Pediatrics Pediatrics Neurology

7 The Principals of Medical Treatment – Developmental & Behavioral Pediatrics
Evidence based Target symptom focused Developmental Framework – stages of development, changes over time Interdisciplinary collaboration Family focused Whole Child


9 Evidence Based The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."(1) More recently it has been described as the "integration of best research evidence with clinical expertise and patient values."(2) New basis of medicine Use data, studies, and research to form treatment plans Integrate knowledge demonstrated through well constructed studies Understand that the placebo effect is real and measurable The physician’s role has become one of assisting families in evaluating the cost vs. benefit of various treatments

10 I was trying to daydream, but my mind kept wandering
I stopped to think, and forgot to start again

11 ADHD DSM IV criteria – 6 Inattentive, 6 Hyperactive Impulsive, or Combined Importance of impairment in more than one setting. Consistency of observations between home and school. Variability with age – young hyperactive and impulsive, older more inattentive and disorganized

12 Inattentive Symptoms - 6

13 Hyperactive Symptoms Hyperactivity FIDGETS UP RUNNING NOISY MOTOR

14 Impulsive Symptoms Impulsivity BLURTS CAN’T WAIT INTERRUPTS

15 Additional Criteria Some symptoms that cause impairment were present before age 7 years. Some impairment from the symptoms is present in two or more settings (e.g. at school and home). There must be clear evidence of clinically significant impairment in social, school, or work functioning. The symptoms are not due to a Pervasive Developmental Disorder, or other Mental or Neurologic disorder.

16 ADHD continued Bias against girls Bias for boys
Rule out confounding disorders vs co morbid disorders – LD, Anxiety, ASD, Neglect/Abuse, Family Dysfunction, BPD, and Low Cognitive Ability, ASD

17 Neurobiology Neurobiological differences in children with ADHD leading to executive functioning deficits (organizing, planning, reasoning, attention) Anatomic & Physiologic Differences in the Brain: Pre-frontal cortex – volume and perfusion; smaller right frontal lobe; connections between basal ganglia (movement) and other areas; overall decreased blood flow to certain brain regions Dopamine and Catecholamine (NE) Transporter Genes Size of different brain structures Research supports familial transmission

18 Treatment Medication Behavioral Intervention
Classroom Accommodations and Modifications Psycho-education – teacher, family, peers Maybe – Diet, Exercise, Neurofeedback, Working Memory Deficit Training

19 Medication Options - Stimulants
Stimulants – amphetamine or methylphenidate based Methylphenidate – Concerta, Ritalin, Ritalin LA, Methylin, Metadate, Daytrana Dexmethylphenidate – Focalin, Focalin XR Amphetamine – Adderall, Adderall XR Dexamphetamine – Vyvanse Dexedrine

20 How do stimulants differ?
Delivery- sprinkle, patch, pump Duration – 2, 4, 6, 8, 10, 12 hours FDA Approval Side effects Unique pharmacokinetics

21 Non-Stimulants Atomoxetine – Strattera
Alpha Agonists – Tenex/Intuniv/Guanfacince vs Clonidine/Kapvay Why use a non-stimulant? Tics, anxiety, side effects, combination therapy, duration of action, age

22 Negative Classroom Effects
Tired Hungry Irritable Wear off Socially withdrawn Tics Aggressive

23 Positive Classroom Effects
Attentive Calm, regulated, and compliant Decrease in disruptive behaviors Improved social functioning Readiness to learn Compliance

24 Unrealistic Expectations
Child Parents Teachers Stimulants improve focus, not cognition The Cure All for students with problems – academic, behavioral, social 100% symptom resolution New baseline has pitfalls

25 Other Factors in ADHD Treatment
Teens feel a loss of creativity and personality Compliance with medication regimen Need for boosters Loss of efficacy Overreliance on the medication vs. classroom interventions


27 ASD - A Spectrum of Possibilities
THERE'S JUST A ONE-LETTER DIFFERENCE BETWEEN ARTISTIC AND AUTISTIC ASD - A Spectrum of Possibilities THERE'S JUST A ONE-LETTER DIFFERENCE BETWEEN ARTISTIC AND AUTISTIC "What would happen if the autism gene was eliminated from the gene pool? You would have a bunch of people standing around in a cave, chatting and socializing and not getting anything done.“ – Temple Grandin

28 Autism Spectrum Disorders
DSM IV Criteria Pervasive Developmental Disorders – Autism, PDD-NOS, Aspergers Diagnostic Substitution Broadened Criteria Broader Autistic Phenotype


30 Autism 6 total from 1-3 at least 2 from 1 and 1 each from 2 and 3
1. Qualitative Impairment in Social Interaction (at least 2) Nonverbal skills – eye contact, body posture, facial expressions Peer Relationships – not developmentally appropriate No Spontaneous joint attention No social or emotional reciprocity 2.Qualitative Impairment in Communication Delay or lack of language Poor conversational skills Idiosyncratic language No make believe or imitation 3.Restricted and Repetitive Behaviors, Interests, or Activities: Preoccupations, Inflexible routines, Motor Mannerisms, Parts not the whole


32 PDD-NOS Sub-threshold clinical symptoms per DSM criteria
Not necessarily less severe than autism cognitive abilities can range from high to low Prognosis similarly varies dependent more on cognition, language, and behavior than diagnosis

33 Aspergers Syndrome No language impairment
High cognitive ability - IQ from average to gifted Must have a narrow area of interest or preoccupation can change over time Despite intellectual advancement gaps in learning Behaviors include: rigidity, black and white thinking, perseverating, anxiety, preference for sameness, poor social skills Difficulty working in groups Eccentric and quirky Eye Contact may be atypical Problems with transitions

34 DSM–IV criteria for the diagnosis of Asperger disorder
1. Qualitative impairment in social interaction, as manifested by at least two of the following: Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction Failure to develop peer relationships appropriate to developmental level Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people) Lack of social or emotional reciprocity

35 2. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: An encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus Apparently inflexible adherence to specific, nonfunctional routines or rituals Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) persistent preoccupation with parts of objects This disturbance must be clinically significant, but without clinically significant language delay or delay in cognitive development or other skills

36 Final Criteria This disturbance must be clinically significant, but without clinically significant language delay or delay in cognitive development or other skills Every quirky eccentric person does not have AS

37 New Diagnostic Formulations
Autism Spectrum Disorder –DSM V

38 Rationale for ASD in DSM V
Differentiation of autism spectrum disorder from typical development and other "nonspectrum" disorders is done reliably and with validity; while distinctions among disorders have been found to be inconsistent over time, variable across sites and often associated with severity, language level or intelligence rather than features of the disorder.

39 Because autism is defined by a common set of behaviors, it is best represented as a single diagnostic category that is adapted to the individual’s clinical presentation by inclusion of clinical specifiers (e.g., severity, verbal abilities and others) and associated features (e.g., known genetic disorders, epilepsy, intellectual disability and others.) A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation; previously, the criteria were equivalent to trying to “cleave meatloaf at the joints”.

40 From 3 domains to 2 Three domains of impairment will now become two: 1)     Social/communication deficits 2)     Fixated interests and repetitive behaviors Instead of 1.) Social 2.) Communication 3.) Restricted Interests Repetitive Behaviors

41 Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis . Requiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivity Providing examples for sub domains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domains Decision based on literature review, expert consultations, and workgroup discussions; confirmed by the results of secondary analyses of data from CPEA and STAART, University of Michigan, Simons Simplex Collection databases

42 Requiring two symptom manifestations for repetitive behavior and fixated interests improves specificity of the criterion without significant decrements in sensitivity. The necessity for multiple sources of information including skilled clinical observation and reports from parents/caregivers/teachers is highlighted by the need to meet a higher proportion of criteria. The presence, via clinical observation and caregiver report, of a history of fixated interests, routines or rituals and repetitive behaviors considerably increases the stability of autism spectrum diagnoses over time and the differentiation between ASD and other disorders.

43 Reorganization of sub domains increases clarity and continues to provide adequate sensitivity while improving specificity through provision of examples from different age ranges and language levels. Unusual sensory behaviors are explicitly included within a sudomain of stereotyped motor and verbal behaviors, expanding the specification of different behaviors that can be coded within this domain, with examples particularly relevant for younger children Autism spectrum disorder is a neurodevelopmental disorder and must be present from infancy or early childhood, but may not be detected until later because of minimal social demands and support from parents or caregivers in early years.

44 Severity Level for ASD Social Communication Restricted interests & repetitive behaviors Level 3  ‘Requiring very substantial support’ Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.    Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres.  Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly. Level 2  ‘Requiring substantial support’ Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others. RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts.  Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interest. Level 1 ‘Requiring support’ Without supports in place, deficits in social communication cause noticeable impairments.  Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others.  May appear to have decreased interest in social interactions.  Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts.  Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.

45 For more information

46 Medical Treatment Medications – ssri, stimulants, alpha agonists, atypical anti-psychotics Therapies: ST, OT, BT, Education Diet and Vitamins – antioxidants, probiotics, omega three fatty acids, glutathione Others with insufficient evidence: HBOT, Chelation, Stem Cells, Biofeedback, Neurofeedback, listening programs, hippotherapy, etc

47 New Medical Tests Imaging Laboratory – markers and genes
Head Circumference

48 If you do not look for it you may not find it
HFA and Aspergers can be elusive If you see triad of ADHD, Anxiety, OCD you need to specifically assess for the presence of a spectrum disorder ADOS becoming the gold standard CARS – HF, SRS, GARS, and other specific assessment tools Be careful ruling ASD in or out based only on a rating scale completed by parents and teachers

49 Bouba or Kiki

50 Neurobiology and Language
Ramachandran and Hubbard[3] suggest that the kiki/bouba effect has implications for the evolution of language, because it suggests that the naming of objects is not completely arbitrary. The rounded shape may most commonly be named "bouba" because the mouth makes a more rounded shape to produce that sound while a more taut, angular mouth shape is needed to make the sound "kiki". The sounds of a K are harder and more forceful than those of a B, as well. The presence of these "synesthesia-like mappings" suggest that this effect might be the neurological basis for sound symbolism, in which sounds are non-arbitrarily mapped to objects and events in the world.

51 Mood Disorders Anxiety (1/10) –GAD, SAD, Social Phobia, Selective Mutism Depression (1/33)–MDD, Dysthymia, Adjustment reactions Bipolar Disorder – TDD with Dysphoria (40x increase in BPD diagnoses in past 10 years); need for continuity with adult criteria OCD – (1/200)

52 Mood Disorders and Learning
Mood Disorders interfere with learning for obvious reasons Unique characteristics of mood disorders can result in specific behavior patterns – i.e. anxious-fearful of mistakes, depressed – assumes-the worst, OCD – constant erasing Support of teacher can be critical Stress of social interaction Fear of change

53 Mood Disorders in the Classroom: Advice for teachers
Flexibility Patience Conflict Management Self-Esteem Avoid Confrontation Support what can be accomplished, offer alternative assignments when possible

54 Other related disorders
Conduct Disorders ODD Tourettes Syndrome – 3/1000 – vocal and motor tics together more than 6 mo Sensory Integration Dysfunction, aka Developmental Coordination Disorder Sensory Impairments: Visual, Auditory Fine Motor Skills and Visual Perceptual Weaknesses Trichotillomania – related to anxiety and ocd

55 Symptom Relief, Not Cure
Psychotherapeutic medications, at their best, improve symptoms so that quality of life and functioning are significantly improved. This class of medications often falls short of a “cure”.

56 How does a Physician decide??
Target Symptoms Diagnoses Co-morbidities Family and Medical History Allergies Mode of Administration Baseline Behaviors + Side Effect Profile


58 Pre/Post Test -True or False
Stimulant medications may be used safely in all ages Anti-depressant medications are addictive and need to be used cautiously in children. Anti-psychotic medications are only used for psychosis. You must know a child’s diagnosis before ever using medication. Stimulant medications lose their effectiveness over time.

59 STRESS RELIEF for School Psychologists
Every time someone asks you to do something, ask if they want fries with that. Put mosquito netting around your cubicle. At lunch time, sit in your parked car and point a hair dryer at passing cars to see if they slow down. Page yourself over the intercom. Don't disguise your voice.

60 Resources on
- Practical information about medications for parents. - Food and Drug Administration resource of the Federal Government includes most up to date listing of new medications. - Online medication encyclopedia.

61 www. thereachinstitute. org www. mentalhealth. samhsa

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