ADHD in School

7/27/2019 ADHD in School

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EQ071: March 2004

ADHD in school age children

Immediate problems with long-

term consequences


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What is ADHD?


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Attention Deficit/Hyperactivity

Disorder (DSM-IV) A persistent pattern of inattention

and/or hyperactivity-impulsivity that is

more frequent and severe than is

typically observed in individuals at a

comparable level of development

Must cause significant impairment in

social or academic (occupational for

adults) functioning or marked distress

American Psychiatric Association. Diagnostic and

Statistical Manual of Mental disorders, Fourth Edition.

Washington, DC. American Psychiatric Association;

1994:7885.


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Hyperactivity disorders (ICD-10)

In ICD-101, the term

hyperkinetic disorder is

roughly equivalent to ADHD

(combined type) asdiagnosed by DSM-IV

Narrower criteria and more

stringent than DSM-IV2

1 World Health Organization. International Classification of Diseases (ICD-10). Geneva: WHO; 1992;

2 Taylor E et al. Eur Child Adolesc Psychiatry 1998;7:184200.


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How common is ADHD?


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Worldwide prevalence in school

age children and adolescents

Prevalence estimates depend on the choice of

diagnostic tool and the age of the children (older children

show a lower prevalence)1

1.914.4% (DSM-III or DSM-III-R)1,2

1.717.8% (11.417.8% DSM-IV)3,4

Estimates for the school age population range from: 312%1,5,6

1 Reviewed in Scahill L & Schwab-Stone M. Child Adolesc Psychiatr Clinics N Am 2000;9(3):541

555; 2 Landgren M et al. Eur Child Adolesc Psychiatr 2003;12:162171; 3 Reviewed in Elia J et

al. N Engl J Med 1999;340(10):780788; 4 Taylor E et al. Eur Child Adolesc Psychiatry

1998;7:184200; 5 Reviewed in Brown RT et al. Pediatrics 2001;107(3):E43; 6 Reviewed in

Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am 2000;9(3):711726.


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What effect does ADHD have on

a childs school performance and

achievement?


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ADHD usually becomes apparent

in primary school

Diagnosis often only confirmed once child starts

school Symptoms may only appear in a structured

setting demanding task completion

Depends on teachers observations in theclassroom

Teacher can compare patterns of

compliance, on-task behaviour and

disruptiveness with other children pursuing

similar tasks

Diagnosis currently made in primary school

setting: 79 years old

Greenhill LL. J Clin Psychiatry 1998;59(Suppl 7):3141.


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Indications of ADHD in primary

school children

Inattention Trouble following instructions

Tasks not completed

Disorganised (messy desk or cluttered book bag)

Careless, messy, work full of mistakes Teacher may feel that the child is not listening/has not heard

Hyperactivity-impulsivity Difficulty remaining seated and excessive fidgetiness (squirming in the

seat, noisily manipulating objects on the desk)

Answers to questions blurted out before the teacher has a chance tofinish

Comments made out of turn

Interrupts the teacher during lessons and other pupils during quiet study

Greenhill LL. J Clin Psychiatry 1998;59(Suppl 7):3141.


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Impaired learning in primary school

Impaired academic adjustment

Impairments in fundamental skills: Reading

Spelling

Arithmetic

Placed in special education groups

ADHD children are poor academically1,2

1 Barkley RA et al. J Consult Clin Psychol 1990;58(6):775789.

2 Landgren M et al. Eur Child Adolesc Psychiatr 2003;12:162171.


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ADHD persists into adolescence

7080% of adolescents who had ADHD in childhood continue tohave social, academic and emotional difficulties16

Poorer performances in verbal learning, vigilance and maths task

Greater off-task behaviour

More fidgeting and out-of-seat behaviour

More suspensions More failures to complete full time education

Some present with ADHD for the first time as adolescents showing:1 Chronic academic underachievement and irritability

Disorganised school work with poor follow-through

Failure to complete independent academic work

1 Greenhill LL. J Clin Psychiatry 1998;59(Suppl 7):3141; 2 Barkley RA et al. J Am Acad Child Adolesc Psychiatry

1990;29:546557; 3 Barkley RA et al. J Am Acad Child Adolesc Psychiatry 1991;30(5):752761; 4 Evans SW et al.

Exp Clin Psychopharmacol 2001;9(2):163175; 5 Mannuzza S et al. Arch Gen Psychiatry 1993;50:565576; 6

Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am 2000;9(3):711726.


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What are the clinical treatment

objectives for children with

ADHD?


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Key ADHD treatment objectives for clinicians (spontaneous)

0% 10% 20% 30% 40% 50% 60% 70%

Improve school functioning

General symptom improvement

Improve family relationships

Improve inattention

Improve social functioning

Reduce hyperactivity

Improve self-esteem

Reduce impulsiveness

Minimise side effects

Ensure compliance

Minimise dosage

Reduce violence/aggression

Maximise convenience

Other

Proportion of respondents

Improving functioning during the school day:

an important clinical objective

Quantitative interviews with 42 UK paediatric/child & adolescent psychiatrists

and 8 UK paediatricians. Data on file, Celltech Pharmaceuticals, 2003.


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What times of day are most

important for control of ADHD

symptoms?


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What are the pros and cons of

current treatments for ADHD for

children in school?


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Many children require treatment for

ADHD during the school day

22.5% of all school age children in North

America receive drug treatment for hyperactivity1

This equates to about 2 million children1

90% of these children receive methylphenidate

(MPH)1,2

1 Reviewed in Greenhill LL. J Clin Psychiatry 1998;59(Suppl 7):314.

2 Greenhill L. Child and Adolescent Psychiatric Clinics of North America 1995;4:123168.


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Methylphenidate: benefits for primary

school children and adolescents Children with ADHD methylphenidate treatment improves:13

Classroom behaviour

Classwork and academic learning

Peer and parent interactions

Adolescents with ADHD methylphenidate treatment improves: Classroom behaviour and academic performance4,5

Note taking

Quiz performance

Written language

Study assignments

Likely to translate into long-term gains in academic achievement5

1 Pelham WE et al. J Consult Clin Psychol 2002;70(2):320335; 2 Reviewed in Carlson CL & Bunner MR.

J School Psychol Rev 1993;22:184198; 3 Yang P et al. Psychiatry Clin Neurosci 2004;58:3741; 4

Evans SW & Pelham WE. J Abnormal Child Psychol 1991;19:537552; 5 Evans SW et al. Exp Clin

Psychopharmacol 2001;9(2):163175.


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Problems with taking a drug for

ADHD during the school day1,2

Supervision requires the school nurse or equivalentpersonnel

Bureaucracy of using a classified drug in the school

Inadequate supervision of those taking short-actingstimulant medication can lead to noncompliance Missed doses lead to worsening of attention and behaviour

Education policy may prevent the involvement of school

personnel, leaving individuals responsible for their owntreatment

1 Greenhill L. Child and Adolescent Psychiatric Clinics of North America 1995;4:123168.

2 Swanson J. CNS Drugs 2003;17(2):117131.


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The stigma of taking medication at

school

Of 77 parents of children with ADHD attending

the 1999 US Children and Adults with ADHD

conference

59% considered that their childs self esteem hadsuffered as a result of taking medication at school and

thought their child was embarrassed by taking their

medication

Swanson J. CNS Drugs 2003;17(2):117131.


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Advantages of drug treatments that

do not require a midday dose

Avoids stigma of having to take medication during schoolor at college or in the workplace

Improves supervision of treatment

Parent can administer the dose before the child leaves for school Supervision problems and noncompliance during the day are

avoided

Less bureaucracy for the school

Swanson J. CNS Drugs 2003;17(2):117131.


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What are the long-term

consequences of childhood

ADHD?


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ADHD in childhood: consequences

for adult academic achievement16

Poorer educational achievement Attended special schools Failed to finish school Failed to go on to college More academic problems when in school

Lower class marks

More failed courses

Poor occupational attainment by 25 years old7 Poorer occupational rankings Poorer work adequacy, independent working and task completion (employer

rating) More likely to be laid-off

1 Seidman LJ et al. Biol Psychiatry 1998;44:260268; 2 Biederman J et al. Am J Psychiatry 1993;150:1792

1798; 3 Weiss G et al. J Am Acad Child Psychiatry 1985;24(2):211220; 4 Elia J et al. N Engl J Med

1999;340(10):780788; 5 Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am

2000;9(3):711726. 6 Barkley RA. J Clin Psychiatry 2002;63(Suppl 12):1015. 7 Mannuzza S et al. Arch Gen

Psychiatry 1993;50(7):56576.


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Early poor academic achievement

has long-term consequences

In adults whose ADHD symptoms decreased during

adolescence and are not present in adulthood,

achievement is similar to that of normal subjects for:1,2

Occupational achievement

Social functioning

Substance use

Academic achievement remains poor1,2

1 Mannuzza S et al. Arch Gen Psychiatry 1988;45(1):1318.

2 Manuzza et al. Arch Gen Psychiatry 1993;50:565576.


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ADHD in young adults

ADHD can persist from childhood

into adult life1,2

Up to 50% of children with ADHD

become adults with ADHD36

ADHD can present for the first time

in adulthood6

1 Seidman LJ et al. Biol Psychiatry 1998;44:260268; 2 Biederman J et al. Am J Psychiatry 1993;150:1792

1798; 3 Gittelman R et al. Arch Gen Psychiatry 1985;42:937947; 4 Weiss G et al. J Am Acad Child Psychiatry.

1985;24(2):211220; 5 Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am

2000;9(3):711726; 6 Barkley RA. J Clin Psychiatry 2002;63(Suppl 12):1015.


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ADHD in childhood: outcomes as

adults

Many adults who had ADHD in childhood continue tohave:16 Stuttering, speech and language disorders Anxiety disorders Restlessness

High impulsivity (e.g. more car accidents, move house more often) Interpersonal problems and sexual problems (many divorced or

separated) Higher rates of antisocial personality disorders (e.g. conduct disorder) Substance abuse (particularly with co-existing conduct and antisocial

disorders)

1 Seidman LJ et al. Biol Psychiatry 1998;44:260268; 2 Biederman J et al. Am J Psychiatry

1993;150:17921798; 3 Gittelman R et al. Arch Gen Psychiatry 1985;42:937947; 4 Weiss G et al. J Am

Acad Child Psychiatry 1985;24(2):211220; 5 Elia J et al. N Engl J Med 1999;340(10):780788; 6

Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am 2000;9(3):711726.


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Towards optimal outcomes for

children with ADHD Drug treatment should be tailored to maximise attention

during the school day Short-term benefits during the school day

Long-term benefits for academic achievement and job prospects

Ideal drug treatment regimens do not require a lunchtimedose

To minimise stigma

To improve compliance

To reduce the burden on the school and on teachers

Drug treatment should be used in conjunction withappropriate behavioural and psychosocial interventions

ADHD in School

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