"ADD/ADHD Task Force Meeting"
Formatted: Different first page header ADD/ADHD Task Force Meeting Wednesday, Nov. 3, 2004 Minutes Members Present: Dave Dryden, Co-Chair, Office of Narcotics and Dangerous Drugs Linda Wolfe, Co-Chair, appointed by the Secretary of Department of Education Kathleen Allen, appointed by the Speaker of the House of Representatives Genevieve Tighe, appointed by CHADD Andrea Rubinoff, appointed by the Secretary of DSCYF W. Douglas Tynan, appointed by A.I. duPont Hospital and the Delaware Psychological Association Anthony Policastro, M.D., appointed by Medical Society of Delaware Debbie Puzzo, Task Force Administrator for the House Majority Caucus Formatted: Font: 10 pt Attendees: Susan Keene Haberstroh, Executive Assistant to Secretary Woodruff, DOE Lori Duerr, DOE Dennis Rozumalski, DOE Michael Morton, Controller General’s Office Martha Toomey, DOE Martha Brooks, DOE Formatted: Font: 8 pt Co-chair Dave Dryden called the meeting to order at 1:05 pm. He thanked everyone for attending the meeting. Co-chair Linda Wolfe stated that it was agreed at the previous meeting to have experts address questions generated by the Task Force. The following is a summary of those presentations and information elicited through discussion and questions between the Task Force and the experts. Positive Behavior Support (PBS) Initiative - Department of Education – Lori Duerr and Dennis Rozumalski, “PBS is a broad range of systematic and individualized strategies for achieving important social and learning results while preventing problem behavior” (Center on Positive Behavioral Interventions and Support, 2001). PBS is a collaborative project with the Delaware Department of Education, the University of Delaware Center for Disabilities Studies, and Delaware's Public Schools. It is in its 6 th year in Delaware. Fifty two schools are currently involved in the program. (25 new schools were added this year). These schools include public, charter and alternative schools. When PBS strategies are implemented school-wide, students benefit by having an environment that is conducive to learning. All individuals (students, staff, teachers, parents) learn more about their own behavior, learn to work together, and support each other as a community of learners. The following are some key elements that characterize PBS schools in Delaware. They: Embrace both “systems” and “individualized” perspectives in adopting a broad range of evidenced-based strategies, programs, and supports. Establish a positive and safe school climate that promotes academic, social and emotional development. Place great emphasis on the importance of preventing behavior problems. They are proactive and positive rather than reactive and punitive. Recognize that ALL students can benefit from proactive positive behavioral supports. Adopt a team process for planning, development, implementation, and evaluation. 2 Formatted: Right: 0.25" Implement, with demonstrated fidelity, a variety of positive techniques, strategies, programs, and supports at three levels of prevention and intervention: universal (for all students), secondary (target “at-risk” students), and tertiary (targeting students with serious and/or chronic behavior problems). Develop individualized behavioral support plans, linked to functional behavioral assessments, when supporting a student with challenging problem behavior. Recognize that many students with serious and chronic behaviors require coordinated and integrated “wrap around” services. A discussion and step by step analysis of a sample student’s behavior was provided to illustrate successful PBS intervention. The Task Force asked the experts specific questions regarding PBS support plan. If a child has an IEP, the support plan is incorporated into the IEP. The development of a support plans takes many meetings between a school wide team that includes a representative from each grade level, the nurse, parents and the counselor. Sometimes students participate in the meetings. A support plan can be created for regardless of whether a student receives services. The PBS process is school wide for all students. It addresses the school system and delivery of education in a comprehensive manner that yields changes that impact individual students. Definition, Diagnosis and Treatment of ADD/ADHD - Dr. Tynan (A complete copy of Dr. Tynan’s comments can be found at the end of this document.) The terminology of and reference to ADHD has changed over the years. The National Institutes of Health Consensus Conference November 1998 found that there is validity in the diagnosis of ADHD as a disorder with broadly accepted symptoms and behavioral characteristics that define the disorder. There are two factors that should be considered with ADHD – inattention and hyperactivity/impulsiveness. There can be a combination of both factors. Each factor has list of nine symptoms. For a diagnosis the individual needs to have 6 of the nine symptoms listed in each category and onset before age seven, behaviors that occur in two settings, and significant social, academic or occupational impairment. Guidelines for standards of care for assessment & treatment were outlined by the American Academy Child & Adolescent Psychiatry (October 1997); American Medical Association Council Report (April 1998; and the American Academy of Pediatrics (May 2000). According to the American Academy of Pediatrics, psychological testing is not required to make a diagnosis. ADD/ADHD can be co-morbid with other disorders, for example a learning disability. Treatment of ADD/ADHD - Dr. Tynan Treatments with documented effectiveness: Behavior modification Stimulant medicine Role of Primary Care Gather information from home and school Use AAP guidelines for evaluation Discuss treatment options with parents Treat / refer as needed. Role of the School in Evaluation Gather information on child’s school performance and behavior 3 Formatted: Right: 0.25" Discuss with parent Inform parent of evaluation procedures, distinguishing between educational evaluation and medical diagnostic determination Evaluate for suspected learning disability - most health insurance will not cover this Role of the School in Treatment Provide accommodations, including behavior programs Under Section 504, items such as preferential seating, use of classroom behavior programs. Provide special education services if problem is severe Provide feedback on treatment to parent and physician Role of Mental Health Providers Provide parenting skills therapy Provide individual therapy and support as needed Dave asked whether there are any effects of long term stimulant use and are there any adverse affects to the heart. Dr. Policastro stated that there is no evidence of any long term affects on the heart. Usage may affect height, weight, growth and appetite. In 1975 Congress passed legislation recognizing learning disorders and ADHD. The diagnosis of ADHD has been used regularly since the late 1960’s. Alternative Treatments – Dr. Tynan Treatments that have no scientific basis to date include: Individual psychotherapy including play therapy. Diet manipulation including the Feingold diet EEG biofeedback Sensory Integration Therapy Visual Therapy. Task Force members noted (and the doctors confirmed) that other alternative treatments such as brushing, spectrogram, massage have not been scientifically confirmed as effective. Dave reported to the group that Dr. Alton Williams had requested to come before the Task Force group to make a presentation regarding a vision therapy program he founded. The members of the Task Force stated that they did not feel that a presentation was necessary as it is not directly related to the charge. The doctors on the Task Force agreed that they would be willing to review any documented research submitted by Dr. Williams, however, that review would be done outside this Task Force. A letter will be sent to Dr. Williams relaying the above information. Laws/Regulations/Procedures for school personnel – Martha Toomey, Martha Brooks, DOE A copy of the Regulations was distributed. New Regulations will be presented to the State Board in November. They will redefine and separate disabilities and clarify some procedures. For a child to be identified as ADHD impaired, there must be a doctor’s diagnosis. Federal statute requires schools to identify children with educational needs. The specific process for identification and referral is determined by state regulations and district policies. The issue may not be whether it is the role of the school or not but rather how the process/referral is handled by the teacher/school. 4 Formatted: Right: 0.25" No child can be evaluated by the school without the parents’ consent. No special services can be made available to a child without the parents’ consent. The following describes what happens when a parent or teacher recommends that a child be evaluated. Prior to making a referral for evaluation steps are taken to make sure that the child’s problem is not a failure of instruction The formal evaluation process includes: - parental permission - team evaluation (school psychologist, teacher, nurse, parent) - observation of behavior in classroom - education assessment - medical information (to rule out such conditions as hearing loss, vision problem, etc.) Dr. Policastro stated that he works with two districts and each district handles the evaluation process differently. This was confirmed by Martha Toomey. Martha Brooks stated that every district has instructional support team guidelines and a process for evaluation. Martha Toomey will make copies of random district instructional support team guidelines for the Task Force to review at the next meeting. Martha Brooks stated that there a broad range of testing. A.I. duPont offers very comprehensive testing. The checklist from the school must be given to the doctor by the parent. Schools cannot contact the doctor directly. Kathy expressed her concerns regarding studies done in North Carolina and Virginia regarding the number of children receiving medication and the possible implications for Delaware. She stated that the reason that this Task Force is meeting is “because Delaware’s numbers are so high” and she brought this to the Representative Smith’s attention. The Task Force discussed “Johnny can’t sit still in the classroom” and evaluation guidelines for both schools and physicians. Kathy suggested that doctors are over diagnosing ADHD/ADD. She also believes that perhaps this diagnosis is a cultural phenomenon. Martha Brooks referred to the “designer disability phenomenon”. In the 1960’s schools saw increasing numbers of children with learning disabilities; currently there are increased number of children with asperger’s syndrome. The question for the Task Force continues to be if ADHD is over-diagnosed or if doctors are overdosing. Kathy stated that there is no way this group can determine whether doctors are overdosing or not. She asked whether there is something we need to do with these high numbers to address children at risk? Dr. Policastro referred to a survey he remembered being done a few years ago by school nurses. The Task Force would like to see the survey. Kathy stated that she believes that medication is the first treatment people turn to and that is why we are here. Kathy suggested that even if there is a misdiagnosis, everyone would benefit from the effects of the medication. Dr. Policastro stated that although every child would improve on the medication, in a child with ADHD/ADD there would be a marked difference. Dr. Tynan stated that he believes that teachers play an important role in the diagnosis. The best thing teachers can do is gather information for the doctors about the child’s behavior and learning in the school setting. 5 Formatted: Right: 0.25" Role of the school psychologist – Martha Toomey, Martha Brooks, DOE The school psychologist is involved in all areas of working with children with ADHD. The school psychologist is not a medical doctor and CANNOT prescribe medication or diagnose. The psychologist’s role is identification and assessment. Debbie Puzzo excused herself as a staff person for the Task Force and spoke as a member of the public. She stated that as a parent of a child with ADD she would have welcomed a suggestion by a teacher when her child was in 2nd, 3rd, 4th or even 5th grade that perhaps her child had ADD. She asked this Task Force not to focus on medication as being a bad thing. “Do not tie the teachers’ hands so they cannot make that referral.” Kathy stated that parents may be being pressured into placing their child on medication. Linda stated that she is not convinced that Delaware’s high numbers are because schools are pressuring parents. She wondered what percentage of adults are using medication, what the dosage levels are, etc.. She stated that based upon all the information we have to date she is not convinced that the schools are over referring and thus causing Delaware numbers to appear so high. She suggested that perhaps Delaware’s numbers are higher than other states because Delaware does a better job of reporting. Dr. Rubinoff suggested that the public needs to be good consumers. Parents need to be educated about ADHD. CHADD has a big role in the teacher/parent relationship. HR 1170 - Overview of findings; status in Washington – Debbie Puzzo No response from Congressman Castle’s office. Insurance coverage for children in Delaware - Dr. Policastro While not confined to the State of Delaware, there is a problem with Managed Care Organizations reimbursement for ADHD evaluations. Their tendency is to expect to pay for a 15 minute evaluation for this diagnosis. The result is a situation where the physician must decide with inadequate data whether to give the patient a trial of stimulant medication or not. This creates a leaning toward a trial of medication. “When I was a general pediatrician, AI DuPont used to get reimbursed about 25% of billed charges for my services in this area. Now that I am a Board Certified Developmental and Behavioral Pediatrician, the reimbursement has risen to 47% of charges" Debbie distributed information from the Delaware Health Care Commission and KIDS COUNT 2004 regarding the number of children without insurance. From the Delaware Health Care Commission (10/27-04): 9.6% of persons aged 0-4 are uninsured and 8% of persons aged 5-17 are uninsured. The report also states that an estimated 17,897 persons aged 18 and under are uninsured, but of that, only 2499 are officially classified as being under the poverty line and over 51% are above 2 times the poverty line. This suggests that Medicaid and CHIP enrollments are having their desired effect. This does not get at issues of those who have private coverage, but may not have a prescription plan, or a comprehensive one. We have struggled with the "under-insured" for several years, but measuring it is tough, and arriving at a common definition of exactly what under-insured means 6 Formatted: Right: 0.25" From KIDS COUNT 2004 – Annie E. Casey Foundation: State National Children without health insurance (2001) 8% 12% Prescription Drug Monitoring Program - Dave Dryden Prescription Monitoring Programs (PMPs) provide a highly efficient means of collecting the prescribing and dispensing information that has been routinely collected as part of investigations into prescription drug diversion. Currently 22 states have PMPs and these states have found that PMPs are an effective tool for enforcement, education and prevention that does not interfere with legitimate prescribing and dispensing of pharmaceuticals. The Federal DEA has funding available for the first 2 years of a program. The funding is approximately $300,000. Delaware/national numbers (Number of children taking medication/children’s dosages) – Dave Dryden This information is not available. Although pharmacies can be requested to voluntarily provide this information it would be a labor intensive undertaking and the information collected would not necessarily be complete. Minutes from the September 30, 2004 meeting were approved and accepted. ACTION ITEMS Requested information: 1. Copy of survey from school nurses – Dr. Policastro, Martha Brooks 2. Status of HR 1170 – from Congressman Castle’s office – Debbie 3. Copies of random district instructional support team guidelines – Martha Toomey 4. Task Force members were asked to jot down any remaining questions for the experts 5. Task Force members were asked to compile a list of possible recommendations. Issues for upcoming meeting: 1. The Role of School Personnel SUGGESTED RECOMMENDATIONS (to be considered at a later date) 1. This Task Force might want to recommend that Delaware establishes a prescription monitoring program. 2. This Task Force may recommend that school personnel should make suggestions/comments (regarding behavior/evaluation etc.) to the parent in writing. 3. The public need to be educated about ADD/ADHD so they can become good consumers. NEXT MEETING Monday, November 22, 2004 2:00 – 4:00, House Hearing Room, 2nd Floor Legislative Hall, Dover Formatted: Font: 7 pt The meeting was adjourned at 4:00 pm Respectfully Submitted by: Debbie Puzzo November 17, 2004 7 Formatted: Right: 0.25" ADHD: Definition, Diagnosis and Treatment W. D. Tynan, Ph.D. Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. ADHD is also among the most prevalent chronic health conditions affecting school-aged children and thus has an impact on education, health and mental health systems. For appropriate effective care of ADHD, it is essential do define the role of health and mental health care providers and educational professionals in the initial screening, assessment and treatment. Compounding the difficulty is the fact that other conditions that are not ADHD can result in similar symptoms. The core symptoms of ADHD include inattention, hyperactivity, and impulsivity that exist without any apparent external causes. But these same behaviors may also be symptoms of learning difficulties, affective disorders or environmental conditions. Children diagnosed with ADHD experience an inability to sit still and pay attention in class and the negative consequences of such behavior. They experience peer rejection and engage in a broad array of disruptive behaviors. Their academic and social difficulties have far-reaching and long-term consequences. These children have higher injury rates. As they grow older, children with untreated ADHD in combination with conduct disorders experience drug abuse, antisocial behavior, and injuries of all sorts. For many individuals, the impact of ADHD continues into adulthood. Families who have children with ADHD, as with other behavioral disorders and chronic diseases, experience increased levels of parental frustration, marital discord, and divorce. In addition, the direct costs of medical and mental health care for children and youth with ADHD are substantial. These costs represent a serious burden for many families because they frequently are not covered by health insurance. Children with ADHD also can increase costs for schools. In the larger world, these individuals consume a disproportionate share of resources and attention from the health care system, criminal justice system, schools, and other social service agencies. Methodological problems preclude precise estimates of the cost of ADHD to society. However, these costs are large. For example, additional national public school expenditures on behalf of students with ADHD may have exceeded $3 billion in 1995. Moreover, ADHD, often in conjunction with coexisting conduct disorders, contributes to societal problems such as violent crime and teenage pregnancy. If a mental disorder is defined as a disorder that causes in major life activities, then ADHD qualifies because of its disruption in school, family and other social relationships. Diagnostic Criteria & Prevalence Clinicians who diagnose this disorder have been criticized for merely taking a percentage of the normal population who have the most evidence of inattention and high levels of activity and labeling them as having a disease. In fact, it is unclear whether the signs of ADHD represent a discreet categorical disorder in the population, or one end of a continuum of characteristics. Most of the data at this time point to ADHD symptoms as being on the end of a continuum and not a discrete categorical entity. This is not unique to ADHD as other medical diagnoses, such as essential hypertension are continuous in the general population, yet the utility of diagnosis and treatment have been proven. Nevertheless, related problems of diagnosis include differentiating this entity from other behavioral problems and determining the appropriate boundary between the normal population and those with ADHD. ADHD, in the majority of cases, does not present as an isolated disorder, and comorbidities (coexisting conditions) complicates research studies, which may account for some of the inconsistencies in research findings. While the disorder was first identified by Dr. George Still in 1902, classification of ADHD and diagnostic criteria have shifted over the past 100 years primarily because of the multiple characteristics of ADHD. In particular there have been significant changes in diagnostic criteria in the past 25 years, 8 Formatted: Right: 0.25" and the currently terminology is certainly cause for confusion. . However, research on the diagnostic criteria have helped to clarify the two primary dimensions of ADHD: inattention and hyperactivity, that are accepted by researchers and clinicians.. The Diagnostic and Statistical Manual of the American Psychiatric Association - Second Edition (DSM II) published in 1968 and emphasized a disorder of hyperactivity. By 1980, the DSM III swung in the direction of emphasizing attention problems, and acknowledged hyperactivity and yielded essentially two diagnostic categories, and discussed three dimensions including impulsivity, hyperactivity and inattention, and resulting diagnoses of Attention Deficit Disorder with or without hyperactivity. In 1987, the two factors were combined in the DSM III-R into a single list of 14 symptoms of both hyperactivity and inattention, of which eight were needed to meet criteria for the disorder (ADDH). However, there were concerns that this single factor model did not classify those children who had significant attention and focus problems and genuine impairment if they did not have signs of hyperactivity and also would not include children who simply had hyperactivity without signs of inattention. In the field trials to develop criteria for DSM IV, a number of researchers looked at a broad array of symptoms in large numbers of referred patients and did both exploratory factor analysis, to determine if certain symptoms reliably co-occurred, and confirmatory factor analyses to see if these factors held up in prospective evaluations of patients. These studies consistently indicate that the distinction between the two dimensions of inattention and hyperactivity / impulsivity provides a better explanation of the covariation of symptoms than either the three factor DSM III or the single dimension of the DSM III R. When these extensive studies are considered they provide substantial support for the internal validity of the two factors, even though the two factors are correlated and do co-occur quite frequently in individuals. While research looking at how each factor affects other symptoms and impairment is fairly new, it is apparent that the two factors of inattention and hyperactivity result in different outcomes. Hyperactivity / impulsivity is more highly correlated with oppositional and conduct problems, but not necessarily organization and academic problems. Oppositional behavior problems are highly likely to lead to referral for services. Hyperactivity is also associated with greater rates of non-intentional injuries and peer problems due to aggression. Hyperactivity problems do result in global ratings of impairment and are detected by broad global checklists (e.g. Achenbach CBCL) Inattention is correlated with anxiety, depression, homework problems, friendship problems, lack of assertiveness and teacher ratings of schoolwork problems, but is not related to global assessments of functioning, aggression or conduct problems. Thus broad global checklists (e.g. Achenbach CBCL) do not detect inattention problems even when they are significant. (Lahey et al. 2002). Developmentally, over time and growth into adolescence, there is a decline in hyperactivity and impulsivity, but the development course of attention problems is not clear. Although the prevalence of ADHD in the United States has been estimated at about 3 to 5 percent, a wider range of prevalence has been reported across studies. A recent Commonwealth Fund nationally representative survey found an overall rate of 3% in six year old children with 5% of boys and 2% of girls identified as having been formally diagnosed and treated for ADHD: 9 Formatted: Right: 0.25" The reported rate in some other countries is much lower, in others much higher. Recorded prevalence rates for ADHD vary substantially, partly because of changing diagnostic criteria over time,10–13 and partly because of variations in different settings and the frequent use of referred samples, rather than population samples to estimate rates. Studies using ICD criteria tend to be lower, and those using the DSM IV symptom criteria tend to be higher (see below). Cross culturally rates run from 1.7% to nearly 15%, with the highest rates reported in Hong Kong and Germany. Regardless of the base rates in given studies, the factor analyses of those data inevitably show that hyperactive and inattentive behaviors tend to cluster together, the two factors hold up in cross cultural studies. Practitioners of all types (primary care, subspecialty, psychiatry, and nonphysician mental health providers) vary greatly in the degree to which they actually use all of the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM-IV) criteria to diagnose ADHD. Researchers looking at base rates have used the DSM III, DSM III R, DSM IV, ICD-9 and ICD-10 criteria, and each of these yields differing results. Some of the confusion around DSM IV diagnostic rates comes from the use of what are termed "symptom criteria", whether or not a child has been identified as having 6 of 9 symptoms of inattention and/or hyperactivity, versus "full diagnostic criteria". The full diagnostic criteria include documentation of symptoms in two or more settings, documentation of impairment in two or more settings, onset before age seven and verification that the symptoms are not due to any other events in the child's life or not better explained by other disorders. When symptom criteria only, rates can become quite high, in some cases over 15%, but when the much more clearly defined and restrictive full criteria are used, it usually results in rates of around 5%. All formal diagnostic criteria for ADHD were designed for diagnosing children (ages 6 to 12) and have not been adjusted for older children and adults. The criteria are not developmentally sensitive, and cross 10 Formatted: Right: 0.25" sectional data indicate that the symptoms, specifically those of hyperactivity, do decrease with age, and thus great care needs to be taken particularly when evaluating younger children. Despite these problems with criteria, the NIH Consensus conference on ADHD (1998) concluded "there is validity in the diagnosis of ADHD as a disorder with broadly accepted symptoms and behavioral characteristics that define the disorder." Diagnostic Procedures With a disorder that is on a continuum from a range of normal, typical behavior to one of severe impairment, accurate use of diagnostic criteria become critical so as to neither over diagnose or under diagnose. Even relatively minor changes in diagnostic criteria can result in large numbers of children being either excluded or included in the diagnostic categories. Within the past seven years, a number of professional organizations have developed guidelines for accurate diagnosis. In 1997, the American Academy of Child and Adolescent Psychiatry published the first set of diagnostic criteria. The recommendations were for a history and physical within the last twelve months, a detailed parent interview regarding current and past behaviors, the use of broad checklists to rule in or out other psychiatric problems, the use of ADHD specific checklists to rule in or out ADHD. In addition the AACAP recommended psychological or neuropsychological testing, as well as speech or occupational therapy evaluations if the initial interview suggested impairment in the areas of intellectual, academic, language or daily living skills areas. The American Medical Association (AMA) (1998) criteria were quite similar with essentially the same recommendations regarding history & physical, parent interview and ADHD specific checklists. They also recommended some review of intellectual and academic functioning, which could be done either through formal testing or review of school data. The most recent set of criteria were developed by the American Academy of Pediatrics (AAP),with an interdisciplinary committee, and corresponds most closely with the DSM IV, with the suggested use of checklists to document not only symptoms but also impairment across two situations, as well as the history and physical and detailed history from the parent. With regards to other testing and evaluation, AAP requires "evidence directly obtained from the classroom teacher regarding symptoms, functional impairment and co-existing conditions…review any reports from a school based multidisciplinary team" for the diagnosis. A further recommendation is that the evaluation of the child should include assessment of co-existing conditions, including anxiety, depression, oppositional or conduct problems, and learning disabilities, if there is evidence of problems in those areas. Table 1 Comorbid Disorder Estimated Prevalence Confidence Limits on Prevalence Oppositional Defiant D/O 35.2% 27.2-43.8% Conduct Disorder 25.7% 12.8-41.3% Anxiety Disorder 25.8% 17.6-35.3% Depressive Disorder 18.2% 11.1-26.6% Learning Disability 18% (Hinshaw 1992) 15-40% (AAP 2000) While the AACAP AMA & AAP criteria all agree on the importance of the history and physical, a detailed history of the behaviors from the parent, the use of ADHD specific checklists, and data from both home and school, the implication is that additional psychological and educational testing is dependent on the presence of a possible co-morbidity. But as can be seen from Table 1, co-morbidities are quite common. Thus a reasonable case could be made that the clinical assessment of individuals 11 Formatted: Right: 0.25" who meet criteria for ADHD, and who do not respond to initial interventions, should include standardized assessments of intelligence, academic achievement, co-morbid mental disorders, family circumstances, and adaptive behaviors. The assessment of intelligence provides information that can be used with other measures of development to determine whether the apparently symptomatic behaviors are more frequent and severe than is typical of individuals at a comparable developmental level. In addition, standardized measures of intelligence and achievement can be used to determine whether the child is achieving at a level that is substantially below the level expected for their intelligence and age. At a minimum, the AAP criteria should be met, including the use of detailed checklists and clear documentation of impairment across situations, a detailed family history and a history and physical by the primary care provider. Etiology Prematurity and prenatal injury have been implicated in 10-20% of cases, many small preterm infants do well medically and in general developmental skills and then have difficulty in the early grades in school. Post natal brain injury, including head trauma in abuse or non-intentional injury has also been implicated in ADHD. Anatomically, group studies comparing patients diagnosed with ADHD with matched controls show that there is less well developed and smaller orbital prefrontal cortex on the right side, decreased striatum and globus pallidus in the basal ganglia and decreased size of the cerebellum. However scanning cannot accurately be used to diagnose ADHD because of the variability in size of these structures in the population. The suspected neurochemical deficiencies are in dopamine dysregulation and norepinephrine dysregulation. Family studies have shown that about 30% of siblings have ADHD, 20% of mothers, 25% of fathers and close to 90% of identical twins. Heritability is over 80%, and environmental factors are not strongly linked to ADHD. There is no convincing evidence for glucose metabolism, sugar consumption, thyroid problems or parenting practices as causing ADHD. There may be a small percentage (less than 5%) of preschool children adversely affected by food additives. Treatment While there are many claims for effective treatment, there are relatively few scientific studies of treatment effectiveness. For this paper, a scientific study is one that uses an experiment in which patients are randomly assigned to a treatment condition, assessed at baseline, post treatment, and possible at follow up. Also in a scientific study the assessment of behaviors of interest should not be influenced by group assignment, that is assessment should be done by raters blind to the treatment conditions. Single subject experiments can be done in which the subject is evaluated at baseline, during a treatment conditions and then back again at baseline. Typically a treatment is deemed effective if two independent research groups test the treatment in a group design which yields the same results. For single subject designs the standard is typically 8 to 10 well controlled individual cases. A true scientific study should be replicable, and the treatment variable(s) clearly identified. Testimonials about effectiveness, and uncontrolled case studies do not meet the criteria of a scientific study. Treatments that have no scientific basis to date include: Individual psychotherapy including play therapy. 12 Formatted: Right: 0.25" Diet manipulation including the Feingold diet EEG biofeedback Sensory Integration Therapy Visual Therapy. This is not to say that these therapies are effective or ineffective, this says that there is no convincing scientific proof of effectiveness. Only a single psychosocial intervention has been supported by research. Behavior Therapy/Management was found to be superior to pill placebo in a single study, and was found superior to no treatment control conditions in 6 small studies and has been found to be effective in the larger MTA study (described in detail below). The evidence has not established the efficacy of Social Skills Training, “Parents are Teachers,” Parent Effectiveness Training, or Self-Control Training. According to the research, Behavior Therapy and Management, both in the classroom and at home, were the best-supported non-drug treatments. Further, the combination of behavior therapy and low dose medication may be similar to high dose medication for symptoms of ADHD, and superior for other co-morbid difficulties. Behavior Therapy/Management is relatively short term, has been delivered by therapists ranging from teachers and teacher’s aides to doctoral level therapists, and showed large effects in those studies reporting degree of change. Effect size estimates from two studies suggested that the average child at post- test scored better than 89% of children’s pre-treatment scores. Classroom Behavior Management tended to be more frequent and shorter term within the studies reviewed (e.g., daily implementation of a classroom time out or reward program), as opposed to Parent Training in behavioral interventions, which generally involved a therapist meeting weekly with parents to review similar behavior management strategies for the home. Although the follow up evidence was not reviewed, it appears that behavior management programs for Attention Deficit and Hyperactivity behavior problems may not need to be ongoing. The MTA study shows good maintenance over two years, and studies of children identified with oppositional or disruptive behavior (similar but not quite ADHD) have shown 5 and 10 year positive outcome. In contrast one study showed that when a classroom behavior program was withdrawn, children’s problems returned. It would appear that treatment needs to be of sufficient duration both to change the child behavior, but more importantly to bring about meaningful and self reinforcing change in the adults. Psychostimulants The medications of this class have similar side effects and safety. All have been in use in the US for more than twenty years. This class includes: Methylphenidate, available as Ritalin® and numerous generic brand names, Dextro-amphetamine, available as Dexedrine®, and mixed salts of dextroamphetamine and inactive levo-amphetamine, available as Adderall® The literature of over 160 replicated randomized controlled trials demonstrate robust short-time efficacy and a good safety profile when used for the symptoms of Attention DeficitHyperactivity Disorder (ADHD). All of these studies focused on children meeting DSM III & III R criteria for ADHD with symptoms of both hyperactivity and inattention. Few studies lasting longer than 24 months have been conducted which demonstrate longer-term efficacy. Side effects are manageable with monitoring, dose and timing adjustment and matching medication to the needs of the patient. Generally, patients continue to respond to the same dose over time without a need to increase the dose; there is little evidence for the development of tolerance. As most of these medications have rapid absorption and rapid metabolism, they are short in duration with onset of effect within 30 minutes, peak within one to three hours, and 13 Formatted: Right: 0.25" rarely have an effect beyond five hours. Thus, most patients require multiple doses and demonstrate some “roller-coaster” effect; some have a “rebound” effect with short-term intense “wear off” effects. These effects are related to the short duration of effect and account for much of the reported poor compliance with use as prescribed on a multiple-dosing schedule. A multiple dosing of schedule II controlled medications also complicates management in schools, leading to further problems with compliance. Thus, compliance with the multiple doses that produce improved school and home behavior and performance is a concern with these short-acting medications. Stimulant-related adverse effects may occur early in intervention and are generally mild, short-lived, and responsive to dose and timing adjustments. Severe adverse effects, which necessitate discontinuation of medication, occur in less than 10% of patients. The most common adverse effects are delayed sleep onset, reduced appetite, stomachache, headache, and jitteriness. Rare side effects include perseverative behaviors, cognitive impairments, and motor and/or vocal tics, which usually respond to dose and timing adjustments. Hallucinosis, psychotic reactions, and mood disturbance have been reported only in overdoses and in patients receiving high doses of stimulants. Abuse is a concern, although emergency room reporting in the Drug Abuse Warning Network documents the prescription stimulant abuse rate at less than 1/40th of the rate for cocaine. Abusers generally prefer substances, which produce euphoria such as methamphetamine and cocaine. The majority of studies do not suggest that the use of prescribed stimulants for ADHD increases the risk of abuse. Methylphenidate has been released in a longer-acting product, Concerta®, and a longer acting Adderall XR has also been released. These may improve compliance with stimulant medication. In the NIMH Collaborative Multisite Multimodal Treatment Study (MTA) of children with ADHD, in the initial results of the first 14 months, compliance was highest in the study group receiving both monthly physician monitoring, as well as school and family behavioral management training. Compliance studies with a variety of medications demonstrate improved compliance with less frequent dosing; once a day dosing produces the greatest rate of compliance. Monitoring of stimulant medication includes observation and mental status monitoring as well as focused physical examinations with particular attention to movement disorders, tics, tremors, and a regular schedule of monitoring heart rate and blood pressure as well as stature and weight changes. The MTA indicates that after titration to an effective dose and timing schedule, monitoring can be reduced to less than five follow-ups per year, with parents and teachers aware of the medication and potential adverse effects. The regularity of schedule follow up is a factor in improving compliance. Parent and teacher completion of rating scales and school progress reports are important components of assessing the effects of stimulants and other interventions. The follow up studies of the MTA yields a picture of some potential side effects of continued stimulant use. There was evidence in the group that received medication for the entire 24 month period of some height and weight growth suppression that was not seen in either the children that never received medication or the groups that only received medication for part of the 24 month period, approximately 1.0 cm per year. Weight suppression was approximately 2.5 kg in the first year and 1.2 kg in the second year. Combined Behavioral & Stimulant Treatment A small number of well designed studies have demonstrated the additive effects of behavioral therapy with stimulant treatment for children with the hyperactive or combined types of ADHD. In general, these studies show that stimulant medicine helps with the core symptoms of ADHD from the DSM IV, but not with many of the co-morbid oppositional behavioral problems. Those conflicts both at home and school tend to respond to the behavioral treatments. 14 Formatted: Right: 0.25" The largest of these studies is the MTA study. This is a multisite study with nearly 600 patients (100 at each site) assigned to one of four treatment groups. The groups were: 1. Medication only – which included titrating doses up to effective levels and monthly visits with a Psychiatrist. 2. Behavioral – A positive classroom based behavior program, a parent group to teach behavioral management skills, the Pelham summer camp program and a classroom aide for 20 weeks to implement behavior program at school. 3. Combined – all elements of Medication and Behavioral 4. Community Treatment – monitor only, family is to obtain treatment available in their community. There were multiple measures in several domains that could best be summarized as: ADHD symptoms, Oppositional behavior symptoms, academic achievement and positive social behavior with peers and parents. The initial results at 14 months found that for ADHD and Oppositional Symptoms improved for both medication groups, there was no improvement initially in academic achievement or social skills. One of the most important findings of the MTA study was the impact of behavioral therapy on the amount of medication required to reach therapeutic level. In that study each patient’s dose was titrated up until rating scales fell out of the clinical range. Subjects receiving medication only tended to require doses approximately 24% higher than those subjects receiving medication and behavioral therapy. Thus combined treatment yields equivalent initial outcome, improved long term outcome and at a much lower dosage of medicine. Recent data on the two year follow up show that the deterioration of effectiveness during the follow up from 14 months to 24 months was greatest for the two medication groups (Medication only and Combined Behavior & Medication). A “surprising number” of these families have stopped medication during the second year of the study. The Behavior only group maintained and showed further improvement. In general the four groups converged. Behavior therapy only seemed to show some advantages at two years in terms of parent satisfaction, adherence to treatment and improvement. 15 Formatted: Right: 0.25" Analysis was made of medication use in the period from 14 to 24 months in the groups that self formed by their use of medication. Once again convergence was the rule, there seems to be no advantage to the 14 month period of intensive medication management. 16 Formatted: Right: 0.25" Alternative Treatments Recent studies (Chan 2004 Boston Children's) indicate that the majority of parents of children who have ADHD have sought and are using a number of alternative treatments. While these indeed are popular among parents, their efficacy is not well established at this time. These treatments utilize a number of approaches. The oldest alternative approaches are diet manipulation, either by elimination diets, that is excluding foods or additives that are thought to contribute to the behavioral problems, or nutritional supplements, giving additional vitamins or other supplements to improve an existing behavioral difficulty. Elimination diets, frequently referred to as Feingold diets, are supported by a number studies with significant improvement in children who have the suspect food additives withheld compared to a disguised full diet including the additives, or deterioration by a challenge with the particular substance. These findings are in young children (preschool) and the behaviors are the hyperactive/impulsive, and not the inattentive behaviors. Group effects appear to be due to a subset of a small number of subjects who respond to the elimination diet, while the majority of children do not respond. Studies evaluating the elimination of sugar only has not been shown to have a positive effect, even studies with a duration of three weeks. One concern of elimination diets is the restriction of breadth of nutrients. On the other elimination of certain snack (junk) foods may have an overall health benefit. Nutritional supplements including amino acid, essential fatty acid, glyco-nutritional have not shown consistent positive effects in studies. Other supplements, L-carnitine, dimethylaminoethanol (DMAE) have shown some mild positive effects which warrant further study. Vitamin supplements have shown mixed effects with one positive outcome study and one with no effect. The major concern here is possible toxicity with high doses. Mineral supplements including iron, zinc & magnesium have had little research. In general studies of children who are already deficient in these minerals show improvement, but there is no data suggesting improvement in children who essentially have normal levels before supplementation. Deleading only appears to be effective in children who have elevated lead levels. Herbal therapies are very popular. At this time, however, there are no systematic data to support the use of hypericum, ginko biloba, or pycnogenol. There is a body of data, but open trials, that suggest the use of Chinese herbals prescribed by appropriately trained practitioners, but double blind studies are yet to be done. Acupuncture has not yielded any data to support its use with ADHD. All herbal and homeopathic treatments have some risk that need to be evaluated. EEG biofeedback is currently very popular and there is one open trial that supports its use, but whether this is a placebo effect or not needs to be determined by appropriate double blind research that would include a sham treatment. It warrants further study. Relaxation using EMG feedback has been shown to be effective in single cases as has relaxation training (often incorporated in group treatments) and meditation, but again double blind studies have not been done. There have been random assignment studies comparing massage and relaxation training with improvement in both, and better scores with massage with adolescents with ADHD. The magnitude of change here is higher than with other alternative treatments with the advantage of no potentially damaging side effects. Various sensory stimulation/ sensory integration training including sensorimotor integration, optometric visual training, and interactive metronome have not controlled data to support their use. 17 Formatted: Right: 0.25" Antifungal treatment is usually done in conjunction with diet manipulation. This is based on the hypothesis that since most children with ADHD have a history of recurring otitis media, they have had treatment with antibiotics which has caused yeast overgrowth in the intestines. There has been systematic study to date. Thyroid disorders are found in a very small percentage of children with ADHD, and the AAP recommends evaluation for thyroid problems only if there are other indicators. Thyroid treatment for ADHD in children with normal thyroid functioning is not supported. In general of many of the alternative therapies, open trials of these methods yield treatment effects of 0.2-0.4, which is in the same range as placebo effects (source Treatment alternatives for ADHD. By L. Eugene Arnold, M.Ed. MD in Jensen, PS & Cooper, JR (2002) Attention Deficit Hyperactivity Disorder: State of the Science, Best Practices, Civic Research Institute) Informed Treatment Decisions. Because ADHD appears to be associated with significant functional impairment, the discussion of treatment options should weigh the potential risks and benefits of treatment against the potential risks of impairment in social, academic and occupational domains, and the risks of morbidity and mortality from accidents. While any form of treatment has risks, there are also risks inherent in not treating. Substantial evidence suggests that ADHD in children who have oppositional behavior are at risk for antisocial behavior in the adolescent years. Children with low academic achievement are at higher risk of school failure and drop out, and later occupational difficulties. Treatment Team Primary care clinicians cannot work alone in the treatment of school-aged children with ADHD. Ongoing communication with parents, teachers, and other school-based professionals is necessary to monitor the progress and effectiveness of specific interventions. Parents are key partners in the management plan as sources of information and as the child’s primary caregiver. Integration of services with psychologists, child psychiatrists, neurologists, educational specialists, developmental-behavioral pediatricians, and other mental health professionals may be appropriate for children with ADHD who have coexisting conditions and may continue to have problems in functioning despite treatment. Attention to the child’s social development in community settings other than school requires clinical knowledge of a variety of activities and services in the community. 1. Reiff MI, Banez GA, Culbert TP. Children who have attentional disorders: diagnosis and evaluation. Pediatr Rev. 1993;14:455–465 2. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: Guilford Press; 1996 3. Zentall SS. Research on the educational implications of attention deficit hyperactivity disorder. Exceptional Child. 1993;60:143–153 4. Schachar R, Taylor E, Wieselberg MB, Ghorley G, Rutter M. Changes in family functioning and relationships in children who respond to methylphenidate. J Am Acad Child Adolesc Psychiatry. 1987;26:728–732 5. Almond BW Jr, Tanner JL, Goffman HF. The Family Is the Patient: Using Family Interviews in Children’s Medical Care. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999:307–313 6. Biederman J, Faraone SV, Milberger S, et al. Predictors of persistence and remissions of ADHD into adolescence: results from a four-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry. 1996; 35:343–351 18 Formatted: Right: 0.25" 7. Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150: 1792–1798 8. Baumgaertel A, Copeland L, Wolraich ML. Attention deficithyperactivity disorder. In: Disorders of Development and Learning: A Practical Guide to Assessment and Management. 2nd ed. St Louis, MO: Mosby Yearbook, Inc; 1996:424–456 9. Cantwell DP. Attention deficit disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1996;35:978–987 10. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. 2nd ed. Washington, DC: American Psychiatric Association; 1967 11. American Psychiatric Association. Diagnostic and Statistical Manual forMental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980 12. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders-Revised. 3rd ed. Washington, DC: American Psychiatric Association; 1987 13. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994 14. Drug Enforcement Agency. Washington, DC (personal communication) 15. August GJ, Garfinkel BD. Behavioral and cognitive subtypes of ADHD. J Am Acad Child Adolesc Psychiatry. 1989;28:739–748 16. August GJ, Realmuto GM, MacDonald AW III, Nugent SM, Crosby R. Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior. J Abnorm Child Psychol. 1996; 24:571–595 17. Bird H, Canino G, Rubio-Stipec M, et al. Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico. Arch Gen Psychiatry. 1988;45:1120–1126 18. Cohen P, Cohen J, Kasen S, Velez CN. An epidemiological study of disorders in late childhood and adolescence I: age and gender-specific prevalence. J Child Psychol Psychiatry. 1993;34:851–867 19. King C, Young RD. Attentional deficits with and without hyperactivity: teacher and peer perceptions. J Abnorm Child Psychol. 1982;10:483–495 20. Kuperman S, Johnson B, Arndt S, Lingren S, Wolraich M. Quantitative EEG differences in a nonclinical sample of children with ADHD and undifferentiated ADD. J Am Acad Child Adolesc Psychiatry. 1996;35: 1009–1017 21. Newcorn J, Halperin JM, Schwartz S, et al. Parent and teacher ratings of attention-deficit hyperactivity disorder symptoms: implications for case identification. J Dev Behav Pediatr. 1994;15:86– 91 22. Shaffer D, Fisher P, Dulcan MK, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. J Am Acad Child Adolesc Psychiatry. 1996;35:865–877 23. Shekim WO, Kashani J, Beck N, et al. The prevalence of attention deficitdisorders in a rural midwestern community sample of nine-year-oldchildren. J Am Acad Child Adolesc Psychiatry. 1985;24:765–770 24. Green M, Wong M, Atkins D, et al. Diagnosis of Attention Deficit/Hyperactivity Disorder: Technical Review 3. Rockville, MD: US Department of Health and Human Services, Agency for Health Care Policy and Research; 1999. Agency for Health Care Policy and Research publication 99-0050 25. Wolraich ML, Hannah JN, Pinnock TY, Baumgaertel A, Brown J. Comparison of diagnostic criteria for attention deficit/hyperactivity disorder in a county-wide sample. J Am Acad Child Adolesc Psychiatry. 1996; 35:319–324 26. Wolraich M, Hannah JN, Baumgaertel A, Pinnock TY, Feurer I. Examination of DSM-IV criteria for attention deficit/hyperactivity disorder in a county-wide sample. J Dev Behav Pediatr. 1998;19:162–168 19 Formatted: Right: 0.25" 27. Gibbs N. Latest on Ritalin. Time. 1998;152:86–96 28. Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics. 1996;98:1084–1088 29. Rappley MD, Gardiner JC, Jetton JR, Houang RT. The use of methylphenidate in Michigan. Arch Pediatr Adolesc Med. 1995;149:675–679 30. Wolraich ML, Lindgren S, Stromquist A, et al. Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder. Pediatrics. 1990;86:95–101 Carlson, C.L., Pelham, W.E., Milich, R., & Dixon, J. (1992). Single and combined effects of methylphenidate and behavior therapy on the classroom performance of children with Attention- Deficit Hyperactivity Disorder. Journal of Abnormal Child Psychology, 20, 213-232. Dubey, D.R., O’Leary, S.G., & Kaufman, K.F. (1983). Training parents of hyperactive children in child management: A comparative outcome study. Journal of Abnormal Child Psychology, 11, 229-246. Horn, W.F., Ialongo, N.S., Pascoe, J.M., Greenberg, G., Packard, T., Lopez, M., Wagner, A., & Puttler, L. (1991). Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 233-240. TABLE 1. Diagnostic Criteria for ADHD A. Either 1 or 2 1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive andinconsistent with developmental level: Inattention a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities b) Often has difficulty sustaining attention in tasks or play activities c) Often does not seem to listen when spoken to directly d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) e) Often has difficulty organizing tasks and activities f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) g) Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools) h) Is often easily distracted by extraneous stimuli i) Is often forgetful in daily activities 2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity a) Often fidgets with hands or feet or squirms in seat b) Often leaves seat in classroom or in other situations in which remaining seated is expected c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) d) Often has difficulty playing or engaging in leisure activities quietly e) Is often “on the go” or often acts as if “driven by a motor” f) Often talks excessively Impulsivity g) Often blurts out answers before questions have been completed h) Often has difficulty awaiting turn 20 Formatted: Right: 0.25" i) Often interrupts or intrudes on others (eg, butts into conversations or games) B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age. C. Some impairment from the symptoms is present in 2 or more settings (eg, at school [or work] or at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, or personality disorder). Code based on type: 314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both criteria A1 and A2 are met for the past 6 months 314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if criterion A1 is met but criterion A2 is not met for the past 6 months 314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive, Impulsive Type: if criterion A2 is met but criterion A1 is not met for the past 6 months 314.9 Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified Pediatricians and other primary care clinicians frequently are asked by parents and teachers to evaluate a child for ADHD. RECOMMENDATION 1: Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition (strength of evidence: good; strength of recommendation: strong). RECOMMENDATION 2: The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management (strength of evidence: good; strength of recommendation: strong). RECOMMENDATION 3: The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong). RECOMMENDATION 4: When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions RECOMMENDATION 5: The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child (strength of evidence: fair; strength of recommendation: strong). 21 Formatted: Right: 0.25" K. Allen’s Corrections / Omissions to the minutes for the Nov. 3 meeting. 1. “Kathy expressed her concerns regarding studies done in North Carolina and Virginia regarding the number of children receiving medication and the possible implications for Delaware.” I believe I stated that submitted studies from North Carolina and Virginia concluded there was over diagnosis in those states and that Delaware gives more ADHD medications than both. 2. “Kathy suggested that even if there is a misdiagnosis, everyone would benefit from the effects of the medication” The implication is incorrect. I stated that studies have shown that stimulant medication improves focus and concentration in individuals without ADHD. This was as reported in the study by Vicki Snider in the context that response to medication cannot be used as the sole diagnostic criteria for ADHD. I in no way think children without a full work up and proper diagnosis should get medication. 3. “Dr. Policastro referred to a survey he remembered being done a few years ago by school nurses” Dr. Policastro remembered the study to have shown very high numbers in Northern Delaware. He mentioned 21% but said he could not be sure as it was a while ago. I then emphatically asked everyone if that was not over diagnosis? I don’t believe anyone answered. 4. “The school psychologist is not a medical doctor and cannot prescribe medication or diagnose. The psychologist’s role is in identification and assessment.” However, when I asked for clarification she stated that school specialists can make some sort of “educational assessment of ADHD” which although is not a diagnosis, can be given to the medical doctor for his use in making the diagnosis. She also agreed that a teacher may discuss problems with a parent, recommend the child see their doctor and then complete evaluation forms provided by a parent without notification to other school personnel. 5. After Debbie Puzzo stated her personal experience I stated that I in no way wanted to prevent a child who is on the medication from receiving it, nor did I want to get in the way of a parent and Doctor doing what is right for a child. I simply want to make sure parents will not have their children misdiagnosed and then be pressured to put them on stimulants they don’t feel are needed. Formatted: Don't adjust space between Latin and Asian text, Don't adjust space between Asian text and numbers