Expert Tips for NCE Exam Preparation: Treating ADD & ADHD

Hey there, everybody, and welcome to this presentation on Attention Deficit Hyperactivity Disorder. This is part of the NCMHCE and NCE exam review. I'm your host, Dr. Donnellice Snipes. In today's presentation, we're going to briefly review the DSM criteria for Attention Deficit and Attention Deficit Hyperactivity Disorder. We'll explore differential diagnosis and identify some current best practices that you might select for using with people who have ADD or ADHD. According to the DSM, five people who are up to age 16 need to have six or more of the following symptoms, and if they are 17 or older, they need to have five or more of the following symptoms for at least six months, and those symptoms need to be inappropriate for developmental level. So, for example, somebody who is four is going to have very different developmental expectations than somebody who's 14. In terms of inattention, the person often fails to pay attention to directions or details or makes careless mistakes. And we will see this a lot in homework. We will see this a lot in even things like cleaning their room or following instructions at home. They often have trouble holding attention on tasks or play activities. So they may start something and then get distracted really easily. They may not seem to listen when spoken to directly. If you're speaking to them, they may be looking other places. They may have difficulty focusing their attention and. Or you may say something to them and it's like it goes one ear in one ear and out the other and they go off and don't do what you ask them to do. They often do not follow instructions and fail to finish tasks. They often have trouble organizing tasks and activities. Organization takes attention and concentration. For somebody who has difficulty with attention, organization is difficult. I remember sitting with my son and helping him organize his syllabi for the semester. So he knew, you know, he had all of these different tasks from all of these different classes. How was he going to get every single one of them done? And so we would sit down at the beginning of the semester and plot it out on a calendar, but it was very difficult and it still is very difficult for him to plot those things out. They often avoid, dislike, or are reluctant to do tasks that require extended mental effort. This is very difficult, if not sometimes impossible for people with add, adhd, and as a result, they avoided because they know it's going to cause stress and distress and it may result in failure criticism. You know, you avoid things that are unpleasant and potentially hurtful. They often lose things necessary for tasks and activities. When you're not paying attention, it's easy to lose things. It's not that they're trying to lose things. It is just they're not paying attention where they set their keys down. They're not paying attention where they set their phone down. They are often easily distracted and forgetful in daily activities. They may forget things like even general activities of daily living, like remembering to take a shower or if remembering to eat lunch, they get distracted by other things and they may forget if they have hyperactivity. Six or more of the symptoms, again, up to age 16 and five or more, 17 and older. This includes adults. They have to be present for at least six months and disruptive and inappropriate for the developmental level. Have to continue to emphasize that. And you know, while I'm on this just a little aside. If the person has fetal alcohol spectrum disorders, important to remember that they can often talk and communicate to others at a much higher level than they can receive communication. I always, you know, consider when somebody presents with potential ADHD or oppositional defiant disorder. I always consider whether there might be some fetal alcohol stuff. Stuff, because when somebody can talk at a level of a 16 year old, but they're only receiving information at the level of a six year old, then you know, obviously there's going to be a disconnect between what we expect them to do and what they can actually do. So I digress back to ADHD. Six symptoms up to age 16, five symptoms 17 and older. They often fidget with or tap their hands or feet or they squirm. Now, this can also be a symptom of anxiety, but it can be a symptom of hyperactivity. They often get up in situations when remaining seated is expected. Very often this is hyperactivity. But it can also be a sign if they're getting up to go to the bathroom, they could have urinary tract infection. You know, we want to look at that and remember it has to be present for at least six months. They often run or climb in inappropriate situations for adolescents and adults. They may feel restless. They may be able to force themselves to stay seated, but they feel very restless and agitated and they squirm in their seat a lot. They're often unable to play or take part in leisure activities quietly. They're often on the go as if driven by a motor. And people with hyperactivity just, they're constantly on the go. They're constantly doing something and you know, little hint, jumping ahead to interventions. Some of these behaviors can be harnessed and embraced instead, instead of looking at them as a detriment, you know how can you use that energy productively? But I digress. The person often talks excessively. They may blurt out answers before people finish asking questions. They often have trouble waiting their turn in line in games in life and they may interrupt or intrude on others. They may have difficulty knowing how to enter a conversation effectively. Or they may interrupt and blurt out. Now a lot of these communication skills can be taught. People can learn how to hold their tongue and not blurt. They can learn to be more effective listeners. But it is important to be aware and take into account if these if these symptoms are present, how they impact the individual's ability to function at school, at work, in relationships, etc. In addition to the hyperactivity symptoms and or the attention symptoms, the following conditions must be met. Several symptoms were present before age 12. Several symptoms are present in two or more settings. There is clear evidence that the symptoms interfere with or reduce the quality of social, school or work functioning and the symptoms do not happen only during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder like anxiety dissociative disorder or a personality disorder. You know the DSM always has that clause at the end. It's not better explained by non diagnostic Features that may be a focus of clinical attention include mild delays in motor, language or social development as a result of having difficulty focusing and playing and interacting with others as a child. They may not have developed childhood relationships, so they may not have gone out and interacted with others in the same way. So there may be delays in motor it's not uncommon for people with ADHD to also have difficulty with penmanship and language and social development also can be hindered as a result of their symptoms. They may have a low frustration tolerance if somebody is impulsive and hyperactive. You know that's kind of built in having a low frustration tolerance, which is why they blurt why they have difficulty waiting. They may have irritability and mood lability. A lot of times, especially as they get older, people recognize that the symptoms they have are causing them difficulty and they may feel frustrated angry about it. They may be irritable that other people don't seem to understand them. They may have episodes of anxiety because they know it's going to be difficult to do something or depression because they feel hopeless and helpless to control their behaviors. They may have impaired educational performance. A lot of people with ADD and ADHD are extremely bright, however, because they have difficulty following directions, because they make careless mistakes like on math tests. You can't make careless mistakes or you get the problem wrong. And so they may be demonstrating a much lower level of educational attainment than they actually have. And it's important to identify these so we can help the child, help the person build their self awareness and be able to figure out how to demonstrate what they actually know. And they may have relationship difficulties because others perceive them as lazy or uncooperative, because they don't finish tasks, because they don't follow directions, because they make silly mistakes, because they blurt or don't wait their turn. Those are all symptoms of ADD adhd. They're not trying to be lazy or uncooperative. They just, they have these symptoms that need to be addressed. Differential diagnosis now for a lot of disorders there are only a few things to look at for add. There are a lot of things to potentially consider. Oppositional defiant disorder, you want to rule that out. Conduct disorder apparently is commonly co diagnosed with ADHD about 25% of the time. So one out of every four people with ADHD may also meet the criteria for conduct disorder. Autism spectrum disorder is also frequently co occurring with ADD adhd. And there is a wonderful video by the University of Wisconsin Medical School. It's called something like Asperger's, ADHD and Giftedness. And the gentleman talks a lot about how those diagnoses often are co occurring and how they may present and how sometimes they are misdiagnosed. One for the other reactive attachment disorder, anxiety disorder, ptsd, disruptive mood dysregulation disorder, personality disorders, specifically borderline antisocial or narcissistic and medication or substance induced reasons for the behaviors, including the use of bronchodilators, stimulants and this can be illicit stimulants as well or neuroleptics for late adolescents and adults. We also want to consider ruling out early onset dementia. I don't know of any situations where early onset dementia occurs in children. So that would be something more for an adult or an older adolescent that you're seeing. Best practices for ADHD it's almost always recommended that the person explore the use of medication. And there are a variety of medications to treat adhd. Not all of them are the stimulant medications. There are some theories that norepinephrine imbalances may contribute to adhd. There are some theories that it could be dopamine and it's going to be a matter of working with the person's multidisciplinary team. They've also found and nutritional interventions is lower on this list. But They've also found that people with ADD and ADHD may also experience worsening of their symptoms based on certain foods and based on the balance of the gut microbiome. Behavior modification is another one that is almost always helpful and implemented for ADD ADHD because it can help people learn how to sit still, how to wait their turn, how to listen, how to work within their capabilities to focus their attention. Interpersonal skills training is used both in family, group and individual where, where the person learns how to interact with others, how to enter conversations, how to not blurt. It can be something that's done between the individual and the therapist through role playing. It can also be a part of family therapy where the family learns how to coach the person on communicating and effectively interacting with other people. And it can also be a part of group therapy where multiple people with ADHD are in a group and they are learning from each other how to most effectively communicate and interact. Distress tolerance skills are super helpful because when somebody is having to wait before they speak so they don't blurt, when they're having to wait their turn, when they're having to listen or sit still, it can be very anxiety provoking, very frustrating. Learning skills to tolerate that distress so they don't feel like they're going to crawl out of their own skin can be extremely helpful. They can learn that they can tolerate that feeling without having to act on it. Mindfulness is also super helpful because people will start identifying things that can make their symptoms worse or better, for example, if they drink caffeine or if they don't get enough sleep or if they, you know, whatever. But developing mindfulness of their physical health, their affect, their cognitions, their environment and their relationships and how all of those things may enhance or inhibit their progress in treatment can be super helpful. And when they're mindful, they can intervene early. They can prevent or mitigate those vulnerabilities that exist. As I said, nutritional interventions have been found to be helpful. And you can go online and search for PubMed and it'll come come up. It's PubMed, something something, national Library of Medicine. It's a huge long URL. But when you go to pubmed, you can find those peer reviewed, double blind, placebo controlled studies that we've heard so much about on different interventions with ADD and adhd. Environmental modifications are also important for the individual. What do they need in order to be able to focus on my son, for example, when he was younger, he needed to be in an environment that was pretty, what I call sterile, you know, we had the blinds drawn and there wasn't a lot of stuff on the walls. There wasn't a lot of stuff to distract him and we had a white noise machine on. He was homeschooled so it was easier to control the environment. But that allowed him to focus more effectively during his, during his lesson times when the blinds were open, for example, he would be distracted every time a butterfly flew by or a bird landed on the windowsill. Knowing what environmental modifications are helpful can help the person feel more empowered. They can develop a toolkit that they bring with them as well. If they know that they need to have earplugs and in order to filter out all of the extraneous sounds, that can be helpful and it can be noise canceling headphones or earplugs. But knowing that is really important in terms of family and group. Parent mediated family is when the therapist teaches. The family teaches the caregivers the techniques that are being used in treatment so they can continue to apply those techniques at home. Data journaling Best thing I could think of to call it keeping daily information or baseline data, whatever you want to call it, on the person's behaviors throughout the week can help the therapist really get an idea about, you know, if things are going in the right direction and if they start going, going off track, you can get a better idea of, okay, what happened, what changed that all of a sudden, you know, little Tommy is starting to decompensate again. Skills training, as I mentioned, can be really helpful in individual with role play, but also in group and teaching the family how to help the person. And they can all practice skills training. Most of us are really not good listeners in general, so learning how to effectively listen and not blurt and sit still are actually effective tools that a lot of people could benefit from even without ADD or adhd. Support groups can be very helpful for the individual with ADD as well as for the family members who may feel frustrated and dealing with the ADHD ADD symptoms. And finally, another almost universal intervention are school based interventions. Because we know these symptoms have such a significant impact on the person's school or work life. Interventions in that setting are really important to help the person be able to succeed. For people who have significant impairment because of their ADD ADHD as adults, they may even benefit from some job coaching to help them create an environment that is conducive and supportive of their abilities. You can also go to askjan.org which is the job Accommodation network, and you can even look for ADD ADHD and identify things that the federal government has already determined are reasonable accommodations for people with ADD. ADHD impacts up to 5% of youth and often persists into adulthood. ADHD symptoms overlap with many different issues, including anxiety and PTSD as well as fetal alcohol spectrum disorder, so it's imperative to examine the course of the disorder. The goal for people with ADHD is to help them learn to manage their symptoms so they can have a rich and meaningful life as they define it. It's not to say, well, some of their symptoms can be embraced as strengths and seen instead of seen as deficits. If they are able to to have a lot of energy, for example, that can be a strength. Identifying any of their symptoms that might be able to be used as a strength can also help them feel more empowered. Remember, on the NCMHCE when identifying interventions, you're generally identifying all possible interventions that could be used because of like developing a menu that would be chosen from. You're not assuming that, okay, I have these 11 things that the person could do and they're going to do all of them. That's not realistic. However, it is important to identify potential interventions that could be used. And then theoretically in real life, you would look at that menu of options and work with the family and the patient to identify the things that would be useful and that they are willing and able to do. I hope that helps you a little bit. Review for and prepare for the NCE or NCMHCE.