Share and Learn! CAPP Learning Collaborative
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Newsletter for California School and
School Based Health Center Partners
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What is this newsletter? The University of California San Francisco (UCSF) Benioff Children’s Hospital Child and Adolescent Psychiatry Portal (CAPP) Learning Collaborative is happy to share our first newsletter for a broad audience of California School and School Based Health Center (SBHC) Partners! This effort is supported by funding from a Health Resources and Services Administration (HRSA) American Rescue Plan award aimed at expanding pediatric mental health access.
Who is the intended audience of this newsletter series? We hope to distribute an ongoing series of newsletters with education and resources on mental health topics relevant to a wide array of professionals working in California schools and school based health centers.
How did you select the focus of this newsletter? Since 2021, we have been meeting with local San Francisco Bay Area School and SBCH partners to learn about pressing needs facing our school communities. Overwhelmingly, we have heard a concern about the collective impact of and high rates of trauma from the COVID-19 pandemic for families -and- staff, as well as struggles with attention and trauma exposure in our youth. We curated this newsletter in response and look forward to continuing our newsletter series with topics covering other identified needs in the future!
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In our issues:
- Resources in English & Spanish
Focus of
this issue: ADHD and trauma
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Case Example: 8-year old boy with ADHD and trauma |
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An 8-year-old child, the youngest of three in a newcomer Latinx family, is brought to a school-based health clinic by their mother after a school conference. The child's teacher had complained about their refusal to do schoolwork and inability to stay in their seat and recommended that the child be evaluated for ADHD. The child's mother states that the child is easily frustrated when doing homework sheets, often refuses to do age-appropriate chores at home, and is unable to sit through the family dinner. The mother states that a cousin was recently diagnosed with ADHD and did not react well to medication, so she is not sure about giving medication to her child if diagnosed with ADHD. The child has no allergies, no history of cardiovascular problems, no physical chronic conditions.
The clinician collects rating scales from the child’s mother and teacher, including the Vanderbilt (link) which indicate a combination of impulsive and inattentive ADHD symptoms and some anxious, irritable and defiant behaviors, but no bullying, lying or cruelty. The PEARLS (link) reveals a history of adverse-experiences and trauma during the family’s migration to the U.S.
Next, the provider gives the family psychoeducation about potential school accommodations and behavioral services which their child may qualify for (see IEP/504 and evaluation links) and assists with a formal evaluation request letter (see template), which the parent submits to the school. After the evaluation, the provider helps the family advocate for a reduced workload and daily report card in which the child earns points and privileges for on-task behavior and work completion (FUI link & ADDitude link). The provider also shares psychoeducation about the overlap in presentation between ADHD and trauma reactions (link); the teacher appreciated hearing that some of the child’s behaviors may be reflective of his trauma history and was open to learning about trauma-informed approaches to help promote his success (ACES aware link).
Finally, the provider reviews behavioral parenting treatments options, which are effective in improving difficulties related to ADHD and trauma. They discuss key strategies from these treatments, such as establishing and implementing routines, giving clear and specific instructions, as well as providing consistent positive rewards and effective discipline (CDC link & CLS link). The provider also shares that behavioral parent and classroom management services are often most effective when used with medication (AAP guidelines); the provider uses motivational interviewing strategies (link) to respectfully explore the family’s willingness to try medication in combination with behavioral strategies.
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Updates to the ADHD Diagnosis: DSM-V & American Academy of Pediatric Changes |
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- Inattentive, hyperactive/impulsive and combined ADHD are now considered "presentations"
- Rather than subtypes because the primary presentation may change throughout the lifespan
- Children can be diagnosed as young as 4 years of age
- If their behavior is out of range for age expectations and difficulties occur in at least two domains (of the three: school, peer, and family settings/contexts)
- For adolescents and young adults, symptoms must have appeared by age 12, rather than age 7
- This change accounts for internal symptoms, inattentive symptoms and organizational problems which may not appear until an individual is in middle/high school
- The change also accounts for difficulties with retrospective memory back to early childhood if the adolescent or young adult is being evaluated for the first time
- ADHD is still considered the purview of primary care to diagnose and treat, unless there are complex co-occurring neuropsychiatric symptoms
- All children being evaluated for ADHD should also be evaluated for depression, anxiety, trauma, and sleep problems given that comorbid problem are common
- Indeed, most children with ADHD have at least one co-occurring behavioral/psychiatric condition (such as depression, anxiety, sleep issues, oppositional behavior, trauma, or learning difficulties)
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Commonly used scales (in Spanish & English at capp.ucsf.edu) are:
- Vanderbilt parent and teacher questionnaires
- SNAP IV questionnaire (which may be better for adolescents)
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Early Treatment Considerations
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- Family education and positive parent involvement are essential components of behavioral treatments that work for both ADHD and Trauma
- Although less effective than medication for short-term symptom improvement, they are critical for improving long-term outcomes (including youth emotional regulation & self-esteem, as well as family functioning)
- It is important for families to understand that people with attention challenges (due to ADHD and/or trauma exposure) tend to become overwhelmed by new or tedious tasks and under-perceive positive & over-perceive negative feedback, so positive behavioral interventions (such as routines, praise, and reward systems) are necessary
- Psychoeducation for the child is also important, especially for adolescents and emerging adults
- These treatments appear to work equally well with families across languages and cultures!
- Educational interventions are accommodations also essential
- Most youth will not qualify for special education without additional diagnoses or learning problems
- Accommodations typically fall under ADA/504 Plans & classroom strategies (e.g., clear rules and rewards)
- ADHD medication may be indicated (for ages 6 and up) and new options are available in all categories
- Stimulants remain the first line option because they are most effective for most individuals
- Norephinephrine reuptake inhibitors also are used and two options are now available
- Alpha adrenergic agonists can be helpful as an add-on or for primarily impulsive behaviors
- Long acting medication may be used with teens to manage driving and impulsive behaviors; consider using the longest acting option for 7-days/week management
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Please see the AMERICAN ACADEMY OF PEDIATRICS (AACAP) Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents for more information |
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Resources in English & Spanish |
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ADHD Screening Tools:
ADHD Psychoeducation for families:
ADHD Guides for Teachers:
Tips for Low-Cost ADHD Service Referrals:
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General & Trauma Screening Tools:
Trauma Psychoeducation:
or
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CAPP ADHD webinar
Drs. Lauren Schumacher and Lauren Haack from the UCSF CAPP team gave a 45-minute
presentation on ADHD and common co-occurring conditions. Please visit the CAPP site to see a recording!
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ACEs Aware certified training
Participants who complete this
a-synchronous training are eligible for continuing education credits and to self-attest completion of the training required to receive Medi-Cal reimbursement for ACE screening with an approved tool.
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UCSF School-based ECHO Tele-Consultation Program |
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If you are interested in participating in a future tele-consultation cohort, contact us! |
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We'd love to get to know you! |
We are interested in your feedback about pressing needs and strengths in your school communities, as well as supports which might be helpful in addressing needs you identify. Please complete a brief, anonymous survey via this link or QR code.
Respondents will have the chance to enter a raffle to win a $100 gift card!
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Is the content of this newsletter relevant to you?
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