ADHD, Autism, Mood Disorders in School Aged ChildrenJudith Aronson-Ramos, M.D.www.draronsonramos.com

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.

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 12.8 million. (Department of Health & Human Services)

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

Joseph Biederman, M.D. - Harvard University

Medical Perspective

•Training dictates treatment •Evidenced Based Medicine•Disciplines have different approaches:

▫Psychiatry▫Developmental & Behavioral Pediatrics▫Pediatrics▫Neurology

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

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

I was trying to daydream, but my mind kept wandering

I stopped to think, and forgot to start again

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

Inattentive Symptoms - 6▫ CARELESS

▫ INATTENTION

▫ DOES NOT LISTEN

▫ FOLLOW THROUGH

▫ DISORGANIZED

▫ AVOIDS

▫ LOSES THINGS

▫ DISTRACTED▫

FORGETFUL

Hyperactive Symptoms Hyperactivity

▫ FIDGETS▫ UP ▫ RUNNING▫ NOISY▫ MOTOR▫ CHATTY

 

Impulsive Symptoms

Impulsivity▫BLURTS ▫CAN’T WAIT▫INTERRUPTS

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.

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

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

Treatment

•Medication•Behavioral Intervention•Classroom Accommodations and

Modifications•Psycho-education – teacher, family, peers•Maybe – Diet, Exercise, Neurofeedback,

Working Memory Deficit Training

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

How do stimulants differ?

•Delivery- sprinkle, patch, pump•Duration – 2, 4, 6, 8, 10, 12 hours•FDA Approval•Side effects•Unique pharmacokinetics

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

Negative Classroom Effects•Tired•Hungry•Irritable•Wear off•Socially withdrawn•Tics•Aggressive

Positive Classroom Effects

•Attentive•Calm, regulated, and compliant•Decrease in disruptive behaviors•Improved social functioning•Readiness to learn•Compliance

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

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

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

THERE'S JUST A ONE-LETTER DIFFERENCE BETWEEN ARTISTIC AND AUTISTIC

Autism Spectrum Disorders

•DSM IV Criteria •Pervasive Developmental Disorders –

Autism, PDD-NOS, Aspergers•Diagnostic Substitution•Broadened Criteria•Broader Autistic Phenotype

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

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

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

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

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

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

New Diagnostic Formulations

•Autism Spectrum Disorder –DSM V

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.

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”.

Three domains of impairment will now become two:1)     Social/communication deficits2)     Fixated interests and repetitive behaviors

Instead of1.) Social2.) Communication3.) Restricted Interests Repetitive Behaviors

From 3 domains to 2

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

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.

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.

Severity Level for ASD Social CommunicationRestricted 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.

For more information

•www.dsmv.org

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

New Medical Tests

•Imaging•Laboratory – markers and genes•Head Circumference

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

Bouba or Kiki

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.

Neurobiology and Language

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)

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

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

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

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”.

Symptom Relief, Not Cure

How does a Physician decide??

•Target Symptoms•Diagnoses•Co-morbidities •Family and Medical History•Allergies•Mode of Administration•Baseline Behaviors + Side Effect

Profile

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.

STRESS RELIEF for School PsychologistsEvery 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.

Resources on www.draronsonramos.com•www.parentsmedguide.org - Practical

information about medications for parents.

•www.fda.gov - Food and Drug Administration resource of the Federal Government includes most up to date listing of new medications.

•www.epocrates.com - Online medication encyclopedia.

•www.thereachinstitute.org www.mentalhealth.samhsa.gov/publicationswww.mentalhealthamerica.netwww.nlm.nih.gov/medlinepluswww.nimh.gov