Escolar Documentos
Profissional Documentos
Cultura Documentos
ADHD:
Medication and Treatment Considerations
November 19, 2013
Presenters
COMMUNITYCAREOFNORTHCAROLINA
TheodorePikoulas,PharmD
AssociateDirectorofBehavioralHealthPharmacyPrograms
CHAPELHILLPEDIATRICPSYCHOLOGY
AbbyPressel,PhD
Psychologist
AndrewS.Preston,PhD
Psychologist
Produced by
FamilyandChildrensResourceProgram,partofthe
JordanInstituteforFamilies
UNCChapelHillSchoolofSocialWork
Sponsored by
NCDivisionofSocialServices
Contents
PresenterInformation..................................................................................................................2
DiagnosticCriteriaforADHD........................................................................................................3
Q&AaboutObtainingInformedConsent...................................................................................4
MedicationsCommonlyUsedtoTreatADHD.............................................................................6
UsingaTokenSystem...................................................................................................................7
CaseScenarios..............................................................................................................................8
Caringforachildwhotakespsychotropicmedication...............................................................9
ResourcesforFamilies................................................................................................................10
References..................................................................................................................................11
WebinarSlides............................................................................................................................12
November19,2013Webinar
JordanInstituteforFamilies,UNCCHSchoolofSocialWork
PRESENTER INFORMATION
THEODOREPIKOULAS,PHARMD.Dr.Pikoulasreceivedhis
DoctorofPharmacydegreefromtheMylanSchoolofPharmacy
atDuquesneUniversityinPittsburgh,PA.Hewentonto
completeaPharmacyPracticeResidencyattheUniversityof
PittsburghMedicalCenterMercyHospitalinPittsburgh,PA,and
aPsychiatricPharmacyResidencyattheLouisStokesCleveland
VAMedicalCenterinCleveland,OH.Dr.Pikoulasispsychiatric
pharmacyspecialistandiscurrentlytheAssociateDirectorof
BehavioralHealthPharmacyProgramsforCommunityCareof
NorthCarolina(CCNC).Inhisrole,heworkswithboththe
pharmacyteamandthebehavioralhealthteam,andservesasa
bridgebetweenthetwo.
ABIGAILS.PRESSEL,PH.D.Dr.Presselisalicensed
psychologistwhopracticesatChapelHillPediatricPsychology.
SheearnedherBachelorsdegreefromYaleUniversityand
receivedherdoctorateinclinicalpsychologyfromtheUniversity
ofNorthCarolinaatChapelHill.
ANDREWS.PRESTON,PH.D.Dr.Prestonisalicensed
psychologistspecializinginpediatricneuropsychologyatChapel
HillPediatricPsychology.HeearnedhisBachelorsdegreefrom
DavidsonCollegeandreceivedhisdoctorateinclinical
psychologyfromtheUniversityofFlorida.Hecompletedhis
internshipandpostdoctoralfellowshipatBrownUniversity
MedicalSchool.
November19,2013Webinar
JordanInstituteforFamilies,UNCCHSchoolofSocialWork
Herearethecriteriainshortenedform.Pleasenotethattheyarepresentedjustforyourinformation.
OnlytrainedhealthcareproviderscandiagnoseortreatADHD.
PeoplewithADHDshowapersistentpatternofinattentionand/orhyperactivityimpulsivitythatinterfereswith
functioningordevelopment:
1. Inattention:Sixormoresymptomsofinattentionforchildrenuptoage16,orfiveormoreforadolescents17
andolderandadults;symptomsofinattentionhavebeenpresentforatleast6months,andtheyare
inappropriatefordevelopmentallevel:
o Oftenfailstogivecloseattentiontodetailsormakescarelessmistakesinschoolwork,atwork,orwith
otheractivities.
o Oftenhastroubleholdingattentionontasksorplayactivities.
o Oftendoesnotseemtolistenwhenspokentodirectly.
o Oftendoesnotfollowthroughoninstructionsandfailstofinishschoolwork,chores,ordutiesinthe
workplace(e.g.,losesfocus,sidetracked).
o Oftenhastroubleorganizingtasksandactivities.
o Oftenavoids,dislikes,orisreluctanttodotasksthatrequirementaleffortoveralongperiodoftime
(suchasschoolworkorhomework).
o Oftenlosesthingsnecessaryfortasksandactivities(e.g.schoolmaterials,pencils,books,tools,wallets,
keys,paperwork,eyeglasses,mobiletelephones).
o Isofteneasilydistracted
o Isoftenforgetfulindailyactivities.
2. HyperactivityandImpulsivity:Sixormoresymptomsofhyperactivityimpulsivityforchildrenuptoage16,or
fiveormoreforadolescents17andolderandadults;symptomsofhyperactivityimpulsivityhavebeenpresent
foratleast6monthstoanextentthatisdisruptiveandinappropriateforthepersonsdevelopmentallevel:
o Oftenfidgetswithortapshandsorfeet,orsquirmsinseat.
o Oftenleavesseatinsituationswhenremainingseatedisexpected.
o Oftenrunsaboutorclimbsinsituationswhereitisnotappropriate(adolescentsoradultsmaybelimited
tofeelingrestless).
o Oftenunabletoplayortakepartinleisureactivitiesquietly.
o Isoften"onthego"actingasif"drivenbyamotor."
o Oftentalksexcessively.
o Oftenblurtsoutananswerbeforeaquestionhasbeencompleted.
o Oftenhastroublewaitinghis/herturn.
o Ofteninterruptsorintrudesonothers(e.g.,buttsintoconversationsorgames)
Inaddition,thefollowingconditionsmustbemet:
Severalinattentiveorhyperactiveimpulsivesymptomswerepresentbeforeage12years.
Severalsymptomsarepresentintwoormoresetting,(e.g.,athome,schoolorwork;withfriendsor
relatives;inotheractivities).
Thereisclearevidencethatthesymptomsinterferewith,orreducethequalityof,social,school,orwork
functioning.
Thesymptomsdonothappenonlyduringthecourseofschizophreniaoranotherpsychoticdisorder.The
symptomsarenotbetterexplainedbyanothermentaldisorder(e.g.MoodDisorder,AnxietyDisorder,
DissociativeDisorder,oraPersonalityDisorder).
November19,2013Webinar
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What forms should county DSS agencies use to obtain this consent?
TheNorthCarolinaDivisionofSocialServicesdoesnothavearequiredformfordocumentingtheparentinformed
consentformedication.
Does the need to obtain parental consent only apply to psychotropic meds or to routine medical
treatment?
Parentalconsentisnotrequiredforroutinemedicalcare.Source:NCG.S.7B903(a)(2)(c).Itisrequiredfor
medicalcarethatisnotroutineoremergency.
November19,2013Webinar
JordanInstituteforFamilies,UNCCHSchoolofSocialWork
November19,2013Webinar
JordanInstituteforFamilies,UNCCHSchoolofSocialWork
BRANDNAME
DOSINGFREQUENCY
Methylphenidate (MPH)
MPHIR
Ritalin,Methylin)
23Xdaily
DexMPHIR
Focalin
2Xdaily
MPHSR,MPHER
RitalinSR,MetadateER
12Xdaily
MPHLA,MPHCD,MPHOROS,
DexMPHXR
RitalinLA,MetadateCD,
Concerta,FocalinXR
1Xdaily
MPHtransdermal
Daytrana
1Xdaily
MPHoralsuspension
QuillivantXR)
1Xdaily
Dextroamphetamine
Dexedrine,DexedrineSpansules
12Xdaily
Amphetaminemixedsalts
Adderall
13Xdaily
AmphetaminemixedsaltsXR
AdderallXR
1Xdaily
Lisdexamfetamine
Vyvanse
1Xdaily
Atomoxetine
Straterra
GuanfacineER
Intuniv
ClonidineER
Kapvay
Amphetamine
Non-stimulant Medication
2ndlinetreatmentoption
Contraindicationsseizuredisorder,anorexia/bulimia,ETOH&BZDabuse
Modafinil
3rdlinetreatmentoption
Safetyconcerns
TCAs
3rdlinetreatmentoption
November19,2013Webinar
JordanInstituteforFamilies,UNCCHSchoolofSocialWork
Focusonasinglechallengeatatime(e.g.,completinghomework,gettingreadyinthemorningorready
forbed,completingchores,etc.).
Limitthenumberoftaskstocomplete.
Maketherewardssimpleandrealisticforthechildandparent.Itsgenerallyeasiertosetupasystem
wherethechildearnsordoesntearnchecksandrewards,ratherthangettingintoargumentsabout
partialcredit.(Ireadfor5minuteseachnight,canIplayforhalfanhour?)
Expectationsandrewardscangoupasthechildprogresses.
Remindparentstogivelotsofspecificpraiseandpositiveinteractionforeachpositivebehavior,andto
limitinteraction/discussion/arguing/pesteringwhenchildshowsnegativebehaviors.
Donotremovepointsorstickersfromthechartforunrelatedmisbehavior.
SallysBedtimeChart
Saturday
Brushteeth
Shower
Readfor15mins.
Settledinbedby
8:00
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
WhenSallyhasgottenall4checksforatleast5daysintheweek,shewillearntwohoursof
videogametimeontheweekend.Ifshedoesnotgetherchecks,shehasnovideogametime
thatweekend.
November19,2013Webinar
JordanInstituteforFamilies,UNCCHSchoolofSocialWork
CASE SCENARIOS
1. Andrew
YouareaCPSinhomesocialworker.Oneofyourfamiliesincludesa6yearoldboynamedAndrew.Hisparents
reportthattheschoolwantsAndrewtobestartedonmedicationforADHD.TheteachersaysAndrewcantstayin
hisseat,doesntgethisworkdone,andisalwaysdisruptingtheclass.Thefamilydoesntwanthimmedicated,
andtheydonteventhinkhehasADHD.Theyreportthathehasneverlikedschool,buthecanplayvideogames
orplaywithhisStarWarsactionfiguresforalongtimewithoutwantingtostop.Andrewliveswithhismotherand
twoyoungersisters.Hisfatherstaysatthehousesometimes,andothertimesstaysathismothers.Thefamily
wasreferredtoDSSforinappropriatedisciplinewhenhecametoschoolonedaywithbruisescausedbyhis
motherhittinghimwithabelt.Theparentshavebeenprettyreceptivetoyourhelp,sayingtheydontreallylike
tohitbutcantgetAndrewtolistentothem.
1a. WhatquestionswouldyouaskAndrewsparents?
1b. Whatquestionswouldyouaskschoolstaff?
1c. Aspartofyourworkwiththefamily,youarrangeforthechildtobeevaluatedathismedicalhome.What
questionswouldyouwantansweredduringthisevaluation?
1d. Whatinformationfromthispresentationwouldyouwanttobesurethefamilyhas?
2. Ariana
Youareafostercaresocialworker.Arianaisa13yeaoldgirldiagnosedwithADHDwhotakesRitalinbut
continuestohaveproblemsathomeandschool.Sheisdoingpoorlyacademicallyandisgettingintofightswith
peersatschool.Herfosterparentsareconcernedaboutherbehaviorinschool,andalsoarefrustratedthatat
homeshedoesntlistenorcompletehomework,chores,orotherthingsshessupposedtodo.Youandyour
supervisordecidetotrycognitivebehavioralproblemsolvingwithAriana.
2a. Whichproblemwouldyoustartwith,andhowwouldyouidentifyitwithAriana?
2b. HowwouldyouencourageArianatobrainstormandthenevaluatepossiblechoiceswithyou?
2c. Howwouldyouhelpherevaluatehowherdecisionworkedsinceyouwontbeseeingherforanotherfew
weeks?
2d. Howcouldyouinvolveandcoachthefosterparentonthistechnique?
2e. Whatinformationfromthispresentationwouldyouwanttobesurethefamilyhas?
November19,2013Webinar
JordanInstituteforFamilies,UNCCHSchoolofSocialWork
Childreninfostercareespeciallythosewhohaveexperiencedtraumaoftenrequirementalhealthtreatment.
Formany,thattreatmentinvolvesprescriptionsforpsychotropicmedications.
Psychotropic(pronouncedsikeohtropeick)medicationsaffectapersonsmind,emotions,moods,and
behaviors.ExamplesincludepsychostimulantssuchasAdderallandRitalin,antipsychoticssuchasSeroquel,
andantidepressantssuchasPaxilandZoloft.
Whenitcomestomanagingchildrensmedications,fosterparentsandkincaregivershaveanimportantrole
toplay.Afterall,youretheonewhospendsthemosttimewiththechild.Youknowwhetherthatchildistaking
themedicationappropriatelyandhowthatmedicationaffectsthatchildsbehavior.
Sowhatcanfosterparentsandcaregiversdotomakesurethatchildrentakingpsychotropicmedicationsget
thecareandtheoversighttheyneed?Herearesomesuggestions:
1.Seethisasateameffort.Managingchildrenscareisasharedresponsibility.Importantpartnersinthistask
includeyoursupervisingagency,thebirthfamily,andtheDSSthathascustodyofthechild.Whenitcomesto
managingmedications,itisveryimportantthattheteamworkwithsomeonewithspecialexpertiseinthisarea
usuallythiswillbethechildsmentalhealthclinicianorphysician.
Itcanbeintimidatingtoworkwithdoctorsandmentalhealthclinicians,butyoubringsomethingessentialto
thetableinformationaboutthechildandhowtheyaredoing.Withoutthis,itshardtomakegooddecisionsor
recommendationsabouttreatmentandmedications.
2.Besureyouhavetheinformationyouneed.Communicateregularlywiththechildssocialworker,mental
healthprovider,andphysiciantomakesureyouhaveacurrentlistofallchildrensprescriptionsanddosages.
3.Watchforsideeffects.Themajorityofchildrenwillnotexperienceanysideeffectsfromtheirmedications;
however,sideeffectsarepossible.Differentpsychotropicmedicationcancausedifferentsideeffectssoits
importantthatyouarefamiliarwiththepossiblesideeffects.
Ifachildinyourcareistakingmedications,besuretoasktheprescriberaboutpossiblesideeffectsandwhat
todoiftheyoccur.Ifyouseeanythingthatconcernsyou,besuretolettheprescriberknow.
4.Bewareofovermedicationorinappropriatemedication.Thesamedoseofmedicationcanhavedifferent
effectsintwodifferentpeoplebecausenotallpeoplereacttomedicationsthesame.Justbecauseadosage
doesntcausedrowsinessinonechild,doesntmeanitwontcauseanotherchildtobedrowsy.Thisissimilarto
beingawareofsideeffects.Ifthemedicationseemstobehavinganegativeimpactonthechildforanyreason,let
thechildssocialworkerandprescriberknowrightaway.
5.Documentandcommunicate.Trackandloganychangesyouseeinyourchildsbehavior,wellness,or
functioning,especiallywhenamedicationhasjustbeenintroducedoranadjustmenthasbeenmade.Sharethis
informationwithothermembersoftheteamcaringforthechild.
6.Rememberthatmedscansometimesworkbestwhenusedincombinationwiththerapy.Whenitcomes
totreatinganxiety,depression,orothermentalhealthneeds,medicationaloneissometimesnotaseffectiveas
medicationincombinationwiththerapy.Ifachildinyourcareistakingpsychotropicmedication,butisnot
receivingtherapy,askthechildssocialworkerandothermembersofthechildsteamiftherapywouldbe
appropriate.
November19,2013Webinar
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7.Listentothechild.Childrenandyouthareagreatsourceofinformationabouttheirmedicationsandhow
welltheyareworking.Olderyouthcanuseajournaltonoteanychangesintheirexperienceonamedication,
concernstheyhave,orresponsestotreatment.SharingthesewrittennoteswithphysiciansandDSSstaffduring
orbetweenappointmentscanhelpprovidersgaugetheeffectivenessofatreatmentandalertsthemto
unintendedeffectsofthemedication.
8.Knowyourlimits.Ifyouareafosterparent,therapeuticfosterparent,orkincaregiver,understandthat
youdonothavethepowertogiveconsentfortreatmentortomakedecisionsabouttreatmentormedicationfor
childreninfostercare.Ifadecisionneedstobemadeaboutthesethings,involveothermembersofthechilds
team,inparticularthechildssocialworker.
9.Askforhelpifyouneedit.Ifyoudontfeelcomfortablewithyourresponsibilitiesrelatedtoachilds
medication,reachouttoyoursupervisingagencytheywillbegladtoansweryourquestions,clarifyyourrole
andwhatisexpectedofyou,andprovideyouwiththetrainingandsupportyouneedtolookafterthechildrenin
yourcare.
1. Knowwhythechildistakingaparticularmedication.
2. Knowsideeffectstowatchforandwhattodoifthey
occur.
3. Knowwhatyouragencyexpectsofyou.
ADHDRESOURCESFORFAMILIES
ChildrenandAdultswithAttentionDeficit/HyperactivityDisorder(CHADD)www.chadd.org
AttentionDeficitDisorderAssociation(ADDA)www.add.org
NationalInstitutesofMentalHealthADHDOverview
www.nimh.nih.gov/health/publications/adhd/completepublication.shtml
Books
TakingChargeofADHDbyRussellBarkley
UnderstandingGirlswithAD/HDbyPatriciaQuinn
DriventoDistractionbyHallowellandRatey
DeliveredfromDistractionbyHallowellandRatey
IEPand504Information
ExceptionalChildrensAssistanceCenter(ECAC)www.ecacparentcenter.org
www.wrightslaw.com
November19,2013Webinar
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10
REFERENCES
AmericanAcademyofChildandAdolescentPsychiatry.(2007).Practiceparameterforthe
assessmentandtreatmentofchildrenandadolescentswithattentiondeficit/hyperactivity
disorder.JAmAcadChildAdolescPsychiatry,46(7),894921.
AmericanAcademyofPediatrics.(2011).ADHD:Clinicalpracticeguidelinesforthediagnosis,
evaluation,andtreatmentofattentiondeficit/hyperactivitydisorderinchildrenandadolescents.
Pediatrics,128(5),116.
AmericanPsychiatricAssociation.(2013).Diagnosticandstatisticalmanualofmentaldisorders(5th
ed.).Arlington,VA:AmericanPsychiatricPublishing.
Barkley,R.(2005).TakingchargeofADHD.NewYork:GuilfordPress.
CentersforDiseaseControlandPrevention.(2013).Attentiondeficit/hyperactivitydisorder(ADHD):
Data&statistics.RetrievedOctober29,2013from
http://www.cdc.gov/ncbddd/adhd/data.html.
CentersforDiseaseControlandPrevention.(2013).Attentiondeficit/hyperactivitydisorder(ADHD):
StatebasedprevalencedataofADHDdiagnosis.RetrievedOctober29,2013from
http://www.cdc.gov/ncbddd/adhd/prevalence.html.
TherapeuticResearchCenter.(2013,Feb.).ComparisonofADHDmedications(PLDetailDocument
#290204).PharmacistsLetter.RetrievedOctober29,2013from
http://pharmacistsletter.therapeuticresearch.com.
Cooper,SoxCM,etal.(2011).ADHDdrugsandseriouscardiovasculareventsinchildrenandyoung
adults.NEnglJMed.365,1896904.
MurrayDW,ArnoldLE,SwansonJ,et.al.(2008).Aclinicalreviewofoutcomesofthemultimodal
treatmentstudyofchildrenwithattentiondeficit/hyperactivitydisorder(MTA).CurrPsychiatry
Rep.,10(5),42431.
Nadeau,K.G.,Littman,E.B.,&Quinn,P.O.(1999).UnderstandinggirlswithADHD.SilverSpring,MD:
AdvantageBooks.
NewcornJH,etal.(2008).Atomoxetineandosmoticallyreleasedmethylphenidateforthe
treatmentofattentiondeficithyperactivitydisorder:Acutecomparisonanddifferential
response.AmJPsychiatry,165,721730.
SchellemanH,BilkerWB,StromBL,etal.(2011).Cardiovasculareventsanddeathinchildrenexposed
andunexposedtoADHDagents.Pediatrics,127,11201100.
Solanto,M.V.(2001).AttentionDeficit/HyperactivityDisorder:ClinicalFeatures.InM.V.Solanto,A.F.T.
Arnstein,&F.X.Castellanos(Eds.)StimulantDrugsandADHD,BasicandClinicalNeuroscience,3
30.
SwansonJ,ArnoldLE,Kraemer.(2008).Evidence,interpretation,andqualificationfrommultiplereports
oflongtermoutcomesinthemultimodaltreatmentstudyofchildrenwithADHD(MTA):PartI:
executivesummary.JAttenDisord,12:414.
TexasDept.ofFamilyandProtectiveServices&UniversityofTexasatAustinCollegeofPharmacy.
(2013,September).Psychotropicmedicationutilizationparametersforfosterchildren.
AccessedNovember11,2013from
http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters
September2013.pdf
November19,2013Webinar
JordanInstituteforFamilies,UNCCHSchoolofSocialWork
11
Understand
common
medication options and
challenges for children with
ADHD
Welcome!
Agenda
Brief Orientation
Introductions
Family
Behavioral
Educational
Panelists
Theodore Pikoulas, PharmD
Abby Pressel, PhD
Andrew S. Preston, PhD
Moderator
Mellicent Blythe
Tech Support
Phillip Armfield
John McMahon
Case Scenarios
November 19, 2013 Webinar UNC-CH School of Social Work
ADHD
1.
Medication for
ADHD: Overview
(APA, 2013)
12
Prevalence
Before Medication
Comprehensive evaluation
prior to treatment
Non-pharmacological interventions
should be considered along with
psychotropic medication
Alternative treatments
Diagnosis
2.
Atomoxetine (Straterra)***
Alpha-2 Adrenergic Agonists***
Bupropion (Wellbutrin)
Modafinil (Provigil)
Tricyclic Antidepressants (amitriptyline,
notriptyline, doxepin, etc.)
*** = FDA-approved
November 19, 2013 Webinar UNC-CH School of Social Work
2 Types:
Methylphenidate (MPH)
Amphetamine
Adderall, Dexedrine, Vyvanse
1010
Stimulant Agents
Stimulant agents***
Non-Stimulant agents
UNC-CH
School
of SocialSchool
Work of Social Work
November 19, 2013
Webinar
UNC-CH
ADHD Medications
1.
Mechanism of Action:
Dosing varies
DA, NE
12
13
Adverse Effects
Stimulant Agents
Side Effect
Stimulant Agents
Other Considerations
Possible Solution
Decreased
appetite (probably
the most common)
Insomnia
Increased anxiety
GI distress
Irritability
Growth
Results mixed:
Reduce dose
Switch to non-stimulant agent
Place in therapy:
GI discomfort
Insomnia
Dizziness
15
Place in therapy:
Adverse Effects:
Sedation
Hypotension
Dizziness
16
Cost of FDA-approved
ADHD Medications
Lower (~ $20 - $100)
Generic IR stimulants (Adderall, Focalin, Ritalin)
Generic methylphenidate ER (Ritalin SR)
factors:
Available evidence
Expert opinion
Their own clinical experience
Clinical judgment
US
Multiple
Off-label
14
Recent evidence: no
significant differences in
rate of sudden death,
ventricular arrhythmia, or
death from any cause
Non-Stimulant Agents
NE
Atomoxetine (Straterra)
Mechanism of Action:
Murray, et al., 2008; Texas DFPS, 2013; Swanson, et al., 2007; Cooper, et al., 2011; Schelleman, et al., 2011
Non-Stimulant Agents
Reduce dose
Switch to non-stimulant agent
Tachycardia/
Hypertension
Cardiovascular
17
18
14
AAP Recommendations
Preschool-aged
AACAP Recommendations
Behavior therapy
May prescribe methylphenidate
Elementary
FDA-approved medications
AND/OR behavior therapy
Preferably both
AAP, 2011
November 19, 2013 Webinar UNC-CH School of Social Work
19
AACAP, 2007
20
Take-Home Points
1.
2.
3.
4.
Other Key
Interventions for
ADHD
21
22
Therapeutic Interventions
Why
consider approaches
beyond medication
management?
and behavioral
interventions
Family
Educational
interventions
23
24
15
Psych-education
Attend
Increase
Reward
2.
3.
4.
Make a decision
5.
rules consistent
Keep
How
27
28
For Parents
Increase
26
For Parents
Keep
25
Cognitive-Behavioral
Problem-Solving Training
1.
29
30
16
Mother-daughter issues
31
32
ADHD
Considerations
for Working with
Schools
33
34
School/Educational Interventions
with ADHD often qualify for 504Plan or Individualized Education Plan (IEP).
Children
Both
This
IEP.
Parents
504-Plan.
35
36
17
Classroom Accommodations
37
Interventions
Pull
Modify
Provide
Use
Social
39
Interventions (2)
40
Homework Strategies
Curriculum Assistance
behavior interventions
Time
for testing
skills group
Classroom
Accommodations
38
41
42
18
Scenario 1: Andrew
Use your chat box
Case Scenarios
43
Scenario 2: Ariana
a)
b)
c)
d)
b)
c)
d)
45
44
46
19
CHAPELHILLPEDIATRICPSYCHOLOGY
AbbyPressel,PhD
Psychologist
AndrewS.Preston,PhD
Psychologist
Produced by
FamilyandChildrensResourceProgram,partofthe
JordanInstituteforFamilies
UNCChapelHillSchoolofSocialWork
Sponsored by
NCDivisionofSocialServices
Handouts.Besuretoconsultthehandoutsforthiswebinar:
https://www.ncswlearn.org/ncsts/webinar/handouts/30_Webinar_Handouts_111913.pdf
Recording.Ifyoumissedthewebinarorwanttoviewitagain,youcanaccessarecordingofthisevent
bygoingto:http://fcrp.unc.edu/videos.asp
GeneralQuestionsaboutADHD............................................................................2
2.
MedicationQuestions............................................................................................2
3.
CoOccurringDisorders/Issues...............................................................................3
4.
NonPharmacologicalInterventionsforADHD.......................................................4
5.
SchoolIssues..........................................................................................................5
6.
ResourcesforParents............................................................................................6
NCDivisionofSocialServices:FollowuptoNovember19,2013Webinar
2. Medication Questions
I understand that Welbutrin is used for ADHD. It is also used for depression. Are there
any main differences in the doses?
Generally,higherdoses(i.e.,450mg)willbeusedforadultswithdepression,whilelowerdoses(i.e.,3
mg/kg/day)willbeusedforchildrenwithADHDordepression.
Should children on stimulants have regular EKGs?
EKGsdonotneedtobedoneroutinelyforeverysinglechildtakingstimulantmedicationforADHD.The
decisiontodoanEKGshouldbemadeonachildbychildbasisbythechildsmedicalprovider.Ifthe
NCDivisionofSocialServices:FollowuptoNovember19,2013Webinar
childhasafamilyhistoryofcardiacproblemsorthechildalreadyhascardiacproblems,itmaybe
warranted.
Isnt Clonidine more for anxiety?
ImmediatereleaseclonidineisFDAapprovedtotreathypertension.Theextendedreleaseversion,
Kapvay,isFDAapprovedtotreatADHDinchildren,whichistypicallygivenatlowerdoses(i.e.,0.05
0.4mgperday).Whileclonidinecanbeusedasanofflabelmedicationtotreatanxiety,physicianswill
typicallytryseveralotherclassesofmedications(SSRIs,SNRIs,benzodiazepines,buspirone)before
tryingamedicationlikeclonidine.
If a person takes medication for ADHD or ADD as a child, will he or she need to continue
on medication as an adult as well?
Itdepends.Asindividualsmature,somefeeltheyareabletomanagetheirsymptomswithbehavioral
strategiesalone.Somemayonlyutilizemedicationforcertainsituations,suchasaroundmidtermsand
finalexams.Othersfindbenefitfromcontinuingmedicationonadailybasis.
Is it really true that at least half of meds our kids use are not FDA approved? Should we be
concerned about this?
Itistruethatmanymedicationsusedwithpreschoolagedchildrenareadministeredofflabel.Itis
estimatedthatmorethan75%oftheprescriptionswrittenforpsychiatricillnessinchildrenand
adolescentsareofflabelinusage(Nauert,R.PsychotropicMedicationsOverusedAmongFoster
Children.PsychCentral,2008.Therearemedicallyappropriatereasonstoprescribeoneofthecommon
offlabelprescriptionsforADHD,includingdifficultywithsideeffectsfromFDAapprovedmedication
types.Aswithanypsychotropicmedication,itisgoodpracticetoasktheprescriberwhythemedication
wasselected,howitistobegiven,whatsideeffectstowatchfor,andhowlongitshouldtaketoseea
benefit.
When asked about ADHD medication side effects they have seen or are concerned about,
participants responded:
Headaches
Lossofappetite
Drowsiness
Stomachpain
Chestpain
Insomnia
Increasedheartrate
Parentssellingchild'smedication
Irritability/moodiness
Childrenactlikezombies
GIdistress
3. Co-Occurring Disorders/Issues
What percentage of children has a dual diagnosis of ADHD and Autism Spectrum
Disorder?
Generallyspeaking,adiagnosisontheAutismspectrumwouldprecludeadiagnosisofADHDinother
words,technicallyyoucannothaveboth.Thus,achildwithanASDdiagnosismighthavebehaviors
commontosomeonewithADHD,butthosewouldbeattributedtotheASD.
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Thatsaid,somechildrenmayhavebeendiagnosedwithbothASDandADHD.Forexample,earlyon
theymayhavebeendiagnosedwithADHD,buttheyhavesincebeenseenashavingASD.
Is it common for children with ADHD to have issues with hygiene?
Thisdoesoccur.ProblemswithhygieneinchildrenwithADHDcanhavedifferentcauses.Itmaybedue
toasensoryissueforsomechildrenshoweringorbathingmaybeexperiencedasaversive/negativeat
asensorylevel.Butproblemswithhygienecanjustaseasilybeduetodifficultieswithtime
managementorinattentiontodetail.Forthesechildren,havingacheckofflistofselfcareactivitiesyou
needtodoeverymorningwhengettingreadyforschooloreachnightbeforebedisveryhelpful.
How often does sensory integration disorder coexist with ADHD?
Sensoryprocessingdisorderisnotrecognizedasamentaldisorderinanyofthemedicalmanuals,such
theDSM5.Thatterm,sensoryintegration,isusedmoreofteninthecontextofOccupationalTherapy
(OT).Thatsaid,inourexperiencechildrenwithADHDoftenhavechallengesrelatedtosensory
integration.Inourpracticeweapproachitasdifficultyregulatingreactionstostimuli.
ThoughwedoseekidswhohavethesensorypiecewithoutADHD,usuallytheyarecooccurring.OT
solutions(wiggleseats,bumpyseats,a"fidget"iftheycanholditintheirhandswithoutdistracting
others,etc.)canbeveryhelpfulintheschoolsetting).
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5. School Issues
In my experience classroom accommodations are tougher to put in place for older
children (i.e., those in middle or high school). Is this true in your experience as well?
Definitely.Weencourageparentstotrytogetaccommodationsputinplaceformallyinwritingaspart
ofanIEPor504Plan.Thisistrueevenifyouhaveaverysupportive/accommodatingteacherrightnow;
nextyearthechildmayhaveateacherwhoisntsosupportiveandwithoutawrittenplanitmaybe
hardertogetthechildsneedsmet.Onceyouhavea504orIEP,dontdropitifyoucanavoidititcan
behardtorecreate/restore.
I have a child that the school said they could no longer link his ADHD to a school deficit.
They say his behaviors are not a reason for continuing his IEP, so they have dropped it.
Can they do that?
Yes.SchoolsareabletodropachildsIEPiftherearenoperceiveddeficitsatschool.Ifyouareworking
withparentsandchildreninthissituation,wesuggestexploringthebehaviorsthataregoingonand
whatevidenceyouhaveforsayingtheIEPshouldcontinue.Forexample,theschoolmaybepersuaded
tomaintaintheIEPifyoucanshowthatthechildisexperiencingstress/difficultyrelatedtohomework.
SourcesofinformationtodrawonwhenmakingyourcaseforkeepinganIEPincludeobservationsfrom
parentsandteacherswhoareontheparents'side.
IftheschoolendstheIEPandyoucan'tgetitbackyoumayimprovethesituationbyworkingharder
athome.YoualsocanbringrepresentativesfromtheExceptionalChildrensAssistanceCenter(ECAC,
http://www.ecacparentcenter.org/)orotheradvocatestomeetingswiththeschool.A504Planmaybe
ahelpfulsecondavenuetoexploreifyourchildsIEPcomestoanendandthechildstillseemstoneed
accommodationswithintheclassroom.
Can you add writing assistance on the IEP for a child that has extreme handwriting issues?
Oftenitdependsontheageofthechild.Ifthechildisveryyoung,youmaygethelp.Ifchildisolder,the
bestapproachmightbetoseekaccommodations(typing,dictatingtoadultswhocanwritethingsdown
forthem,etc.).
Some parents do not understand the tests and/or test results. Any advice for practitioners
about working with these families?
Partofthejobofanevaluatoristoexplainresultsinawaythatparentsunderstand.Encourageparents
toaskforthisforthemselves,orifnecessaryyoucanaskonaparentsbehalfforadditionalexplanation
inafollowupmeetingorphonecall.Youcanalsohelpparentspreparealistofquestionsaheadoftime,
andencouragethemtotakenotesifitwouldbehelpfultorememberkeypointsorwordingthatmaybe
newtothem.Remindparentstheyhavetherighttoaskasmanyquestionsastheyneed.Ifyoucanbe
presentforthemeetingwhenresultsareshared,youmaybeabletostoptheconversationandcheckin
withtheparentifyousensethatheorsheisnotunderstanding.
Particpant responses when asked if the families they work with are more likely to have
IEPs or 504 plans:
MostlyIEPs
Ithinkfamiliesarenotawareofthe540
Parentsarealsonotawaretheycanrequesttestingfromtheschoolsiftheyputthatrequestin
writing
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TakingChargeofADHD(GuilfordPress,2005)
YourDefiantTeen:10StepstoResolveConflictandRebuildYourRelationship(GuilfordPress,
2008)
ExecutiveFunctions:WhatTheyAre,HowTheyWork,andWhyTheyEvolved(GuilfordPress,
2012)
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