NR606 / NR 606 Week 5 Exam | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions

NR606 / NR 606 Week 5 Exam | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions What are the two possible states of neuronal networks in ADHD? Hyperactive or underactive. Is there a cure for ADHD? No, but medications can help improve focus. What are the signs and symptoms of ADHD? Inattention, disorganization, hyperactivity, impulsivity. What can untreated ADHD lead to? Academic disruptions, family stress, social difficulties, accidents. What are some associated conditions with ADHD? Depression and substance use disorder. What is selective attention? Ability to focus on specific details or tasks. What are some symptoms of lack of sustained attention? Poor problem solving, difficulty completing tasks, disorganization. What are some symptoms of impulsivity? Excessive talking, blurting things out, not waiting for turn, interrupting. What are some symptoms of hyperactivity? Fidgeting, leaving seat, running, climbing, trouble playing quietly. What are some delays in development that children with ADHD may experience? Speech, motor, and social development delays. What are some common characteristics of children with ADHD? Reduced behavioral inhibition, emotional dysregulation or impulsivity, and negative emotionality. What is a challenge that some children with ADHD face? Challenges with working memory. When does hyperactivity typically present in children with ADHD? Early childhood. When do inattentive features become more prominent in children with ADHD? Preschool and elementary school. When is ADHD most often diagnosed in children? Preschool and elementary school. What can happen to signs of hyperactivity in adolescence for individuals with ADHD? They become less common. What can some adolescents with ADHD experience as they develop? Worsening of the condition with development of antisocial behaviors. What are some challenges that teens with ADHD may face? Poor academic performance, problems with driving, difficulties with social situations, risky sexual behavior, and substance abuse. What percentage of children with ADHD experience symptoms in adulthood? More than 75%. What symptoms may still be present in adolescents and adults with ADHD? Struggles with executive function, attention, and working memory. What problems can struggles with executive function, attention, and working memory cause? Problems with day-to-day functioning, performance at work, and relationships. What can make it difficult to distinguish ADHD symptoms in children under the age of four? The usual inattentiveness, impulsivity, and activity seen in neurotypical children. What is the acronym for the organization that provides information on ADHD? CHADD. What are some challenges that young children with ADHD may face? Developmental delays and less mature behaviors compared to peers. What can adolescents with ADHD experience as hyperactive symptoms decline? Struggles with executive function, attention, and working memory. How long must symptoms persist for a diagnosis? Six months or longer. What areas of functioning can ADHD symptoms interfere with? Social, academic, and occupational functioning. In how many settings must symptoms be present for a diagnosis? Two or more settings ( for instance home and school). What are the symptoms of ADHD predominantly inattentive presentation? Lack of attention to detail, careless mistakes, difficulty listening, disorganization, distractibility, avoidance of tasks, forgetfulness. What are the symptoms of ADHD with a hyperactive-impulsive presentation? Fidgeting, excessive energy, difficulty engaging in quiet activities, speaking out of turn, excessive running, interrupting others. What are the symptoms of ADHD combined presentation? Fidgeting, speaking out of turn, excessive talking, interrupting, difficulty listening, paying attention, forgetfulness, difficulty with organization. Why is it important to gather data from multiple sources for an ADHD diagnosis? To make an informed diagnosis and gather information from different perspectives. Who should be involved in gathering data for an ADHD diagnosis? Client, parents, and teachers of children and adolescents. What instruments are available to assist in ADHD diagnosis? Several instruments, free or for a fee, to assist in diagnosis and monitor changes in symptoms during treatment. What are common co-occurring conditions with ADHD? Learning disabilities, conduct disorders, tics, anxiety, depression, and language disorders. What are adolescents with ADHD at increased risk of? Substance use disorders. What should be considered when making a diagnosis and treatment plan for ADHD? Whether the symptoms are attributed to ADHD, another disorder, or both. How are children with co-occurring conditions often treated? First for ADHD and then for comorbidities. What is the multimodal approach to ADHD treatment? Medical, educational, behavioral, and psychological intervention. What are the two categories of medication options for ADHD treatment? Stimulant and non-stimulant medications. What percentage of clients with ADHD do stimulant medications effectively treat? 70-80%. When are nonstimulant medications commonly used for ADHD treatment? When a client does not respond to stimulant medications or when stimulants are contraindicated. What benefits can nonstimulant medications provide for ADHD? Lower distractibility, improved attention, working memory, and impulsivity. When is a combination of stimulant and nonstimulant medications used for ADHD? When ADHD includes argumentative or oppositional symptoms. What factors should be considered before prescribing medication for ADHD? Thorough health history, personal or family history of cardiac disease, and the need for an electrocardiogram (ECG) if cardiac history is present in a first-degree relative. What should be monitored regularly during ADHD treatment? Blood pressure, height, and weight. What is the purpose of obtaining a thorough health history before initiating stimulant medication? To assess for a personal or family history of cardiac disease. When is an electrocardiogram (ECG) required before initiating stimulant medication? If cardiac history is present in a first-degree relative. What are the potential benefits of treating ADHD symptoms first in children with co occurring conditions? Reducing overall stress levels and providing a clearer picture of comorbid symptoms. What are the potential benefits of nonstimulant medications for ADHD? Lower distractibility and improved attention, working memory, and impulsivity. What is the purpose of educational intervention in ADHD treatment? To provide support and accommodations in the academic setting. What is the purpose of behavioral intervention in ADHD treatment? To address problematic behaviors and promote positive coping strategies. What should be assessed before treating clients? Bipolar disorder What can CNS stimulants cause in clients with no prior history? Psychotic or manic symptoms What can CNS stimulants exacerbate in clients with pre-existing psychosis? Behavior disturbance symptoms and thought disorders What can CNS stimulants exacerbate in clients with comorbid disorders? Anxiety and substance use disorders When will treatment efficacy be noted? Within the first week of treatment How can increased irritability and insomnia be treated? Low dose of nonstimulant medication What can abrupt withdrawal after prolonged use of stimulants result in? Irritability and rebound symptoms What can stimulants cause or worsen? Tics What can stimulants unmask? Presence of tics What should be done when switching stimulants? Discontinue current medication and start new medication at a starting dose the next day What are the available formulations of stimulant medications? Immediate-release or sustained-release What is the classification of several stimulant medications? Schedule II What should be monitored when prescribing short-acting stimulant medications? Risk for diversion and occasional urine drug screens What are common side effects of stimulant medications? Restlessness, irritability, anxiety, insomnia, stomachache, headaches, tics, and worsening aggression symptoms What may occur when the medication wears off? Worsening of symptoms or 'crash', especially with immediate-release medications When should the medication be taken to decrease anorexia or associated weight loss? With breakfast What is a booster dose of medication? A dose of short-acting medication to reduce rebound symptoms. What are the potential sleep disturbances caused by stimulant medications? Sleep disturbances, especially if taken later in the day. What is the duration of amphetamine/dextroamphetamine immediate release? 4-8 hours. What is the duration of amphetamine/dextroamphetamine extended-release? 8-12 hours. How can sleep disturbances be improved when taking stimulant medications? Switching to extended-release dosing or taking the second dose earlier in the day. What can help offset stimulant-related weight loss? Stimulant holidays combined with caloric supplementation and monitoring. When should switching to a non-stimulant medication be considered? If stimulant holidays do not provide the desired result of weight stabilization. What are some things parents learn in behavior therapy? Positive communication, positive reinforcement, structure and discipline. What are the benefits of behavior therapy for children with ADHD? Improved functioning at school, home, and in relationships. What is the recommended treatment for ADHD in younger children? Parent training in behavior management. What can a booster dose of short-acting stimulant medication reduce? Problems of rebound when the earlier dose wears off. What can help improve sleep when taking stimulant medications? Switching to extended-release dosing or taking the second dose earlier in the day. What nonpharmacologic options can benefit clients with ADHD? Educational support, behavioral interventions, and accommodations provided by schools. What is a recommended first-line intervention for children under the age of 6? Parent training in behavior management. What is cognitive-behavioral therapy (CBT)? A psychotherapeutic intervention that focuses on changing negative thoughts and behaviors. What is social and organizational skill training? A psychotherapeutic intervention that helps individuals develop social and organizational skills. What is family therapy? A psychotherapeutic intervention that involves the whole family in the treatment process. What is unique about disruptive behavioral disorders? Behaviors often violate others' rights and conflict with social norms. What are common diagnoses within disruptive behavioral disorders? Oppositional defiant disorder, conduct disorder, intermittent explosive disorder. What are the causes of emotional and behavioral dysregulation? Varies according to the disorder and among individuals. Are disruptive behavioral disorders more common in boys or girls? More common in boys. When does the first onset of disruptive behavioral disorders typically occur? Childhood or adolescence. What are the hallmark characteristics of oppositional defiant disorder (ODD)? Persistent angry and irritable mood, argumentative and defiant behavior, vindictiveness. Can the behavioral features of ODD present with or without negative mood? Yes, they can present with or without negative mood. In which setting do symptoms of ODD typically occur? Most commonly in the home, but can also occur in various settings. How does symptom expression of ODD impair social functioning? It impairs the social functioning of the individual, especially in interactions with peers or adults they know. When does ODD typically onset? Most often in early childhood. Does ODD frequently occur comorbidly with any other disorder? Yes, it frequently occurs comorbidly with attention deficit/hyperactivity disorder (ADHD). What disorder often follows the development of ODD? Conduct disorder. What are the co-occurrence rates of ODD with anxiety and major depressive disorders? High co-occurrence rates. Is ODD associated with an increased risk for suicide ideation? Yes, it has been associated with an increased risk for suicide ideation. What are the prevalence rates for ODD? Ranges from 1% to 11%. What is the persistence of ODD symptoms? Symptoms commonly persist into adulthood. What are the considerations for determining if a child's behavior meets diagnostic thresholds for ODD? Negative consequences, not associated with other disorders, not meeting criteria for DMDD What are the symptoms of Angry/Irritable Mood in ODD? Losing temper, easily annoyed, angry and resentful What are the symptoms of Argumentative/Defiant Behavior in ODD? Arguing with authority figures, defying rules, deliberately annoying others, blaming others How many symptoms of Angry/Irritable Mood must occur for a diagnosis of ODD? Four or more How many instances of vindictiveness must occur within the past 6 months for a diagnosis of ODD? At least twice What is the required persistence and frequency of symptoms for a diagnosis of ODD in children under age 5? Behaviors must occur on most days for at least six months What is the required persistence and frequency of symptoms for a diagnosis of ODD in people 5 and older? Behaviors must occur at least once per week for at least six months What is DMDD? Disruptive Mood Dysregulation Disorder Can a child be diagnosed with both ODD and DMDD? Yes, many individuals meet criteria for both disorders What should be diagnosed if criteria for both ODD and DMDD are met? DMDD What is the age range for ODD diagnosis? Children and adolescents What are the exclusions for a diagnosis of ODD? Psychotic, substance use, depressive, or bipolar disorders Why may a diagnosis of ODD lead to stigma? Reactive behavior and trauma responses are mischaracterized as self-control issues. What are some proposed changes to the DSM-5-TR ODD entry? Using neutral terminology and including a trauma specifier. What is the purpose of using neutral terminology in the ODD diagnosis? To describe behavior or state rather than a disposition. Why is the inclusion of a trauma specifier important for the ODD diagnosis? To acknowledge the role of trauma in the development of ODD. What is the developmental relationship between ODD and conduct disorder? Some children with ODD may later develop conduct disorder. When do behaviors associated with conduct disorder typically appear? Early as preschool, more serious symptoms later in childhood or adolescence. Where do behaviors associated with conduct disorder occur? Multiple settings, causing significant dysfunction. What are the potential outcomes for individuals with conduct disorder? Social and occupational adjustment, increased risk of criminal behaviors and substance related disorders. What are the comorbidities associated with conduct disorder? Mood and anxiety disorders, impulse-control disorders, psychotic disorders, posttraumatic stress disorder. What is the prevalence of conduct disorder in the U.S.? Between 1.5% and 3.4%, more frequent in males. What are the temperamental risk factors for conduct disorder? Difficult infant temperament, lower-than-average intelligence. What are the family-level risk factors for conduct disorder? Caregiver abuse and neglect, varying child-rearing practices, harsh discipline, family criminality, substance-related disorders. What are the community-level risk factors for conduct disorder? Rejection by peers, participation in delinquent peer group, poverty, exposure to violence. What are the genetic or physiological risk factors for conduct disorder? Family members with conduct disorder, depressive and bipolar disorders, schizophrenia, ADHD, substance use disorders. What are the diagnostic criteria for conduct disorder? Three or more symptoms in the past 12 months, with one symptom occurring within the last 6 months. What are the three subtypes of conduct disorder based on age at onset? Childhood-onset, adolescent-onset, and unspecified-onset. What is the requirement for behaviors to be considered conduct disorder? They must cause significant impairment and not fulfill the diagnostic criteria for antisocial personality disorder. What are the symptoms of aggression to people and animals in conduct disorder? Bullying, physical fights, using weapons, being physically cruel. What are the symptoms of destroying property in conduct disorder? Using arson or other methods to destroy property. What are the symptoms of deceitfulness or theft in conduct disorder? Vandalism, lying to obtain goods or favors, theft without confronting a victim. What are the symptoms of serious violations of rules in conduct disorder? Staying out at night before age 13, running away from home overnight at least twice, truancy from school before age 13. What is intermittent explosive disorder (IED)? Low tolerance for frustration and frequent impulsive or angry outbursts. What are the essential features of IED? Unplanned, rapid onset, out of proportion to trigger, lasts no longer than 30 minutes. How often do verbal outbursts occur in IED? Twice a week for three months. How often do behavioral outbursts or tantrums occur in IED? Within 12 months, involving destruction of property. What are the consequences of IED outbursts? Subjective distress, social or occupational dysfunction, poor life satisfaction. What is the diagnostic process for disruptive, impulse-control, and conduct disorders? Comprehensive psychiatric evaluation, family history, parenting styles, developmental history, academic records. What are the symptom-specific instruments for disruptive disorders? Child-rated, caregiver-rated, and clinician-rated tools. What is the Minnesota Impulse Disorders Interview (MIDI)? A diagnostically valuable tool for disruptive disorders. What is the focus of management for disruptive disorders? Reducing positive reinforcement for undesirable behaviors, encouraging prosocial behaviors, using nonviolent discipline, consistent parenting strategies. What are some interventions for treating disruptive disorders? Group parent-caregiver training programs. Who are group parent-caregiver training programs recommended for? Children aged 3-11 years and their families. What do group parent-caregiver training programs provide? Psychoeducation about the disorder and support for caregivers. What is the goal of group parent-caregiver training programs? To provide support and education for caregivers. What is the purpose of reducing positive reinforcement for undesirable behaviors? To discourage the occurrence of those behaviors. What is the importance of encouraging prosocial behaviors? To promote positive and socially acceptable behaviors. Why is nonviolent discipline recommended for disruptive disorders? To avoid escalating aggressive or impulsive behaviors. Why is consistency in parenting strategies important? To provide a stable and predictable environment for the individual. What is the overall aim of treatment for disruptive disorders? To address the unique needs of the individual and family. What is individual parent-caregiver training? Training for extreme or complex child behavior with individualized attention. Who are group child-focused programs recommended for? Children aged 9-14 to enhance social and problem-solving skills. What is cognitive problem-solving skills training? Training to help children see situations differently and respond appropriately. Who are school-based programs recommended for? Children and adolescents to improve peer relationships and school performance. What is the role of medication in treating disruptive disorders? Pharmacologic management can help reduce symptoms, especially in children with comorbid conditions like ADHD. What types of medications may be prescribed for non-amenable aggression? Mood stabilizers, antidepressants, or atypical antipsychotics may be prescribed. What is the purpose of individual parent-caregiver training? To address extreme or complex child behavior with personalized attention. Who can benefit from group child-focused programs? Children aged 9-14 who want to improve social and problem-solving skills. What does cognitive problem-solving skills training aim to achieve? Helping children develop a different perspective and respond appropriately to situations. Why are school-based programs recommended for children and adolescents? To improve peer relationships and enhance academic performance. What is the purpose of individual parent-caregiver training? To address extreme or complex child behavior with personalized attention. Who can benefit from group child-focused programs? Children aged 9-14 who want to improve social and problem-solving skills. What types of medications may be prescribed for non-amenable aggression? Mood stabilizers, antidepressants, or atypical antipsychotics may be prescribed. What is the purpose of individual parent-caregiver training? To address extreme or complex child behavior with personalized attention. Who can benefit from group child-focused programs? Children aged 9-14 who want to improve social and problem-solving skills. Are there FDA-approved medications for disruptive disorders? No, but pharmacologic management can still help reduce symptoms. What types of medications may be prescribed for non-amenable aggression? Mood stabilizers, antidepressants, or atypical antipsychotics may be prescribed. What are disruptive, impulse-control, and conduct disorders? Disorders characterized by difficulty controlling behavior and impulsivity. How do children with these disorders often face consequences? They are frequently penalized instead of receiving treatment. What is the Baker Act in Florida? Legislation allowing families to seek treatment for individuals with severe mental disorders against their wishes. How can the Baker Act be misused? It can be used to punish children who may need treatment. When can the Baker Act be invoked? When an individual's behavior is likely to cause harm to themselves or others. How have school personnel sometimes used the Baker Act? As a form of punishment for children with developmental disabilities and difficult behaviors. What actions can be taken under the Baker Act? Physically restraining, detaining, and removing children from school. Why do some schools struggle to work with children with disruptive behaviors? They lack training and resources. What are some concerns with the Baker Act? Misuse as a punitive measure and lack of appropriate support. Where can I read more about concerns with the Baker Act? External links provided in the notes. What is the impact of disruptive behaviors on children? They often face challenges in school and legal systems. What is Fetal Alcohol Spectrum Disorder (FASD)? Umbrella term for disabilities caused by prenatal alcohol exposure. What is Fetal Alcohol Syndrome (FAS)? Most severe diagnosis on the FASD spectrum with physical and developmental abnormalities. What does FASD encompass? Physical, mental, behavioral, and/or learning disabilities. Is FASD a lifelong disability? Yes, it requires support from various disciplines. How is the prevalence of FASD determined? Challenging, but estimated to impact 1-5 school children per 100 in the U.S. and Western Europe. What is the estimated annual cost of FAS in the U.S.? Over $4 billion. What does FASD result from? Prenatal exposure to alcohol. What are some cognitive problems associated with FASD? Memory and learning difficulties, especially in math, poor attention span, poor reasoning and limited executive function. What is a physical characteristic of FASD? Prenatal growth deficits, vision and hearing problems, poor motor skills and coordination, kidney problems, heart and bone problems, Short stature and low body weight, small head size What are some behavioral problems associated with FASD? Poor social skills, poor emotional control, impulsivity, and hyperactivity What are some functional difficulties associated with FASD? Difficulties with sleep and feeding in infancy, difficulties with self care What are the four diagnostic categories for FASD according to the IOM? Fetal alcohol syndrome (FAS), Partial FAS (pFAS), Alcohol-related neurodevelopmental disorder (ARND), Alcohol-related birth defects (ARBD). Why is diagnosing FASD complex? No specific test, symptoms overlap with other diagnoses, challenges with limited family history or poor historians. What professionals may be involved in an interdisciplinary evaluation for FASD diagnosis? Primary care provider, developmental pediatrician, geneticist, psychologist, social worker, speech-language pathologist, occupational therapist, educational specialist. What are the facial dysmorphia features associated with FASD? Skin folds at the corner of the eye, small head circumference, low nasal bridge, small eye opening, short nose, small midface, indistinct philtrum, thin upper lip. What percentage of children with FASD do not display facial dysmorphia? As many as 80.1%. What percentage of children with FASD are missed when diagnosed primarily based on physical markers? As many as 80.1%. What percentage of children with FASD are misdiagnosed when diagnosed primarily based on physical markers? 6.4%. What should providers consider when diagnosing FASD? The full scope of neurobehavioral deficits. What is the best prognosis for FASD? If children receive a diagnosis and begin treatment before the age of six. What skills can early intervention services help children develop? Walking, talking, and interacting with others. What are the two types of interventions used in FASD treatment? Pharmacological and nonpharmacological interventions. What are some examples of pharmacological interventions used in FASD treatment? SSRI antidepressants, alpha2 agonists, anticonvulsants, stimulants, and atypical antipsychotics. What are some examples of nonpharmacological interventions used in FASD treatment? Behavioral interventions, social skills training, problem-solving training, personal safety training, speech therapy, occupational therapy, behavioral supports, accommodations, family support groups, and parent education. What are some complementary and alternative therapies? Relaxation therapy, meditation, art therapy, yoga and exercise, acupuncture and acupressure, massage, Reiki, and energy work. What is the Individuals with Disabilities Education Act (IDEA)? Federal law ensuring free appropriate public education (FAPE) for children with disabilities. What does IDEA ensure? Individualized special education, preparation for employment and independent living, protection for children and families, support for educational agencies. What does Section 504 of the Rehabilitation Act of 1973 protect? Rights of individuals with disabilities in programs receiving federal financial assistance. How are rights protected under Section 504? Through the implementation of Individualized Education Plans (IEP) or 504 plans. What do IEP and 504 plans describe? Services and accommodations for students with qualifying disabilities. What is the role of schools in providing education and services for children with disabilities? Identifying and providing appropriate education and services. What is the variation in the degree of support provided by school districts? Wide variation in timely and accurate information and support. How can psychiatric mental health nurse practitioners (PMHNPs) assist in identifying diagnoses for children with disabilities? By identifying diagnoses that qualify children for services. What can PMHNPs do to support parents of children with disabilities? Provide education about their rights under the law. How can PMHNPs support the creation of IEPs or 504 plans? By providing documentation to support their creation. What role can PMHNPs play in advocating for services for children with disabilities? Advocating for services for children. How can PMHNPs collaborate with teachers and school personnel? By identifying strategies to help children function in the educational setting. Stimulant Medications: Methylphenidate -Low risk of adverse effects -Available formulations: • Ritalin - available in immediate release (IR) and extended release (XR) available in beads that may be sprinkled on food for children who cannot swallow pills • Concerta biphasic - combined immediate and delayed release in one medication • Daytrana - patch applied in AM and removed after 9 hour Stimulant Medications: Dexmethylphenidate (Focalin) -Available in IR and ER -More potent than Ritalin -High risk of adverse effects Stimulant Medications: Amphetamine (Adzenys) -available in orally disintegrating ER formula for children who cannot swallow pills -Avoid prescribing when an MAOI has been used within 14 days Stimulant Medications: Dextroamphetamine (Adderall) -Available in IR and extended-release formulations -Often dosed in morning (IR or XR) with an evening or evening prn (IR) dose if med effects diminish prior to end of school, study or the workday -Most abused & diverted prescription stimulant Stimulant Medications: Lisdexamfetamine (Vyvanse) -Biologically inactive until metabolized by the body (Prodrug) -Less abuse & diversion potential than other stimulants -Higher-cost medication Non-stimulant medication: Atomoxetine (Strattera) -Noradrenergic (NRI) -Initial drug of choice for adults with ADHD -no abuse potential -tolerated well when prescribed in BID dosing -appropriate choice for comorbid substance abuse -may augment the effects of antidepressants & antianxiety meds -can be dosed at bedtime if fatigue is noted -unlikely to worsen tics Non-stimulant medication: Clonidine -α 2 agonist • May be taken as monotherapy or with stimulant medications -enhances precortical function for better mental focus -appetite neutral -may help with sleep disturbances, administer at bedtime -adverse effects: • sedation, brain fog -monitor of BP closely during initial titration, risk of hypotension -tapered to avoid rebound hypertension post discontinuation Non-stimulant medication: guanfacine -α 2 agonist • May be taken as monotherapy or with stimulant medications -may also be used for children with tics, sleep disturbances, or aggression -tolerability & convenience enhanced by once-daily oral controlled-release formulation -adverse effects: • sedation, headache, decreased appetite -reduced side-effect profile comparable to clonidine -bedtime administration to avoid daytime sedation Non-stimulant medication: Bupropion (Wellbutrin) -Norepinephrine Dopamine Reuptake Inhibitor -off-label use for ADHD in adults -appropriate for clients with concurrent depression or tobacco abuse Attention-deficit/hyperactivity disorder (ADHD) -one of the most common neuropsychiatric disorders -approximately 9.4% of children in the U.S. -more frequently males than females, ratio 2:1 -symptom burden mild to severe -characterized by consistent pattern of inattention &/or hyperactivity & impulsivity that interferes with functioning & development • affect development of proper cognitive, behavioral, emotional, social, & academic function -hyperactivity and impulsivity ADHD subtype symptoms: excessive fidgeting or talking, feelings of restlessness and impatience, frequent interruption, and difficultly playing quietly -inattentive ADHD subtype symptoms: difficulty organizing tasks, maintaining a routine, and paying attention to detail • may not be distinguishable until eight or nine years of age -primarily disrupts neuronal connections within the frontal lobe & prefrontal cortex Without early identification and proper treatment, ADHD can cause disruptions in: academic performance family stress difficulties in social relationships accidental injuries ADHD is associated with: increased rates of depression & SUD Symptoms of ADHD -Selective Attention • Lack of attention to detail • Careless mistakes • Not listening • Losing things • Diverting attention • Forgetfulness -Lack of Sustained Attention • Poor problem solving • Difficulty completing tasks • Disorganization • Difficulty sustaining mental effort -Impulsivity • Excessive talking • Blurting things out • Not waiting for one's turn • Interrupting -Hyperactivity • Fidgeting • Leaving one's seat • Running, climbing • Trouble playing quietly When is ADHD most often diagnosed -preschool and elementary school • inattentive features become more prominent ADHD Lifespan Considerations: Symptoms Change with Age -Young children with ADHD • often have developmental delays • may engage in behaviors less mature than peers -Teens with ADHD at risk for: • poor academic performance • problems with driving • difficulties with social situations • risky sexual behavior • substance abuse -75% of children with ADHD experience symptoms in adulthood -Adolescents & Adults with ADHD • may struggle with executive function, attention, working memory • problems with day-to-day functioning, performance at work, relationships ADHD is a deficiency of neurotransmitters, mainly _________ & _________ dopamine and norepinephrine ADHD diagnostic criteria -A pattern of at least six symptoms of inattention and/or hyperactivity-impulsivity that interfere with functioning or development. -Symptoms persist for six months or longer. -Symptoms interfere with social, academic, or occupational functioning. -Symptoms are present in two or more settings • for instance, home & school Kelsey is a 7-year-old first-grader who is the youngest of four children. During parent teacher conferences, her teacher reported that she is polite, respectful, and gets along well with her peers. She has a hard time keeping her desk neat and she frequently misplaces her supplies and loses library books. She must often be told more than once to complete instructions. Her work is appropriate for her grade level, but she often makes careless mistakes on her assignments. She struggles with math and avoids doing arithmetic assignments. Her parents endorse that Kelsey's room is "sloppy" but do not notice any of the other concerns in the home environment. What is the most likely diagnosis for Kelsey? ADHD predominantly inattentive presentation ADHD predominantly hyperactive-impulsive ADHD combined presentation unlikely ADHD diagnosis ADHD predominantly inattentive presentation Rationale: Kelsey meets diagnostic criteria for ADHD with a predominantly inattentive presentation. Inattentive symptoms include lack of attention to detail, making careless mistakes, difficulty listening and following instructions, frequent disorganization and misplacing items, distractibility, avoiding tasks that require sustained mental effort, and forgetfulness. Although Kelsey's parents identify only one symptom in the home setting, she exhibits multiple symptoms in the school setting. Logan is a 6-year-old kindergartener who has a newborn sister. His parents are concerned that Logan seems to be unable to occupy himself quietly when his sister is napping. Logan interrupts both his parents and other adults in the home who come to visit his sister. He gets impatient when his questions are ignored by adults. His parents endorse that the behaviors began about the same time as his mom's pregnancy was announced. Logan's teacher does not endorse the same behaviors at school; his teacher states he is quiet, reserved, and plays well with others. What is the most likely diagnosis for Logan? ADHD predominantly inattentive presentation ADHD predominantly hyperactive-impulsive presentation ADHD combined presentation unlikely ADHD diagnosis unlikely ADHD diagnosis Rationale: Although Logan has some symptoms that are consistent with a diagnosis of ADHD, the symptom onset coincides with his mother's pregnancy. There are no concerns of symptoms at school; more information is needed to assign a diagnosis of ADHD. Xander is an 8-year-old second-grader who is the youngest of two children. His mother notes that he acts as if he has "non-stop energy." He pesters and interrupts his older sister to play when she is reading or doing homework, and he has little patience for completing his homework. Xander's mom endorses that his behavior has been consistent for the past few years. Xander's teacher notes that he fidgets during seat time, speaks out of turn in class, and runs or skips in the halls. What is the most likely diagnosis for Xander? ADHD predominantly inattentive presentation ADHD predominantly hyperactive-impulsive presentation ADHD combined presentation unlikely ADHD diagnosis ADHD predominantly hyperactive-impulsive presentation Rationale: Xander meets diagnostic criteria for ADHD with a hyperactive-impulsive presentation, including fidgeting, "non-stop" energy, difficulty in engaging in quiet activities, speaking out of turn, excessive running, and interrupting others. The behaviors occur in school and at home and have been present consistently for several years. Belle is a 10-year-old fourth-grader who is the oldest of two children. During parent teacher conferences, her teachers expressed concerns that she has difficulty listening and paying attention in class. She plays with her pencil and eraser constantly during lessons and, when she does pay attention, she blurts out answers to questions without waiting to be called upon. She talks to her peers during class and often interrupts the teacher to share with the class. Belle often forgets to bring her backpack or lunch to school and often leaves school without her jacket. Belle's mother notes that her daughter has always been talkative and energetic; she has difficulty keeping her things organized and must be reminded of daily chores, such as feeding her hamster. What is the most likely diagnosis for Belle? ADHD predominantly inattentive presentation ADHD predominantly hyperactive-impulsive presentation ADHD combined pres ADHD combined presentation Rationale: Belle meets diagnostic criteria for ADHD combined presentation. She has several symptoms of hyperactive-impulsive presentation, including fidgeting, speaking out of turn, excessive talking, and interrupting. She also has symptoms of inattentive presentation, including difficulty listening, paying attention, forgetfulness, and difficulty with organization. Although her symptoms at school differ from those seen at home, she has symptoms in both environments. Rating scales for ADHD -ADHD Rating Scales (ADHD-RS-IV and 5) -Swanson, Nolan and Pelham (SNAP) scale -Adult ADHD Self Report Scale (ASRS) -Vanderbilt scales -Conners' scales ADHD Comorbidities 2/3 of children dx'd with ADHD have at least one coexisting psychiatric condition -learning disabilities -conduct disorders -tics -anxiety -depression -language disorders -SUD's • adolescents at increased risk *often tx ADHD 1st then comorbidities, may reduce overall stress levels, provide clearer picture of comorbid symptoms Tenzing is a 15-year-old who presents with restlessness, distractability, impulsive behavior, and inattention at school. He sleeps very little most nights and is often irritable. His parents describe him as "moody" and state that the smallest changes cause his mood to shift. He has had these symptoms for a few years, but recently the symptoms have gotten worse. The PMHNP diagnoses Tenzing with ADHD. Which of the following is the most likely comorbid diagnosis for Tenzing? bipolar disorder (BPD) unipolar depression generalized anxiety disorder bipolar disorder (BPD) Rationale: After beginning medication for ADHD, Tenzing's remaining symptoms are consistent with bipolar disorder. Although mood dysregulation is common in clients with ADHD, mood changes are typically situational. Bipolar disorder presents with more random and cyclical mood changes. Both ADHD and BPD can present with irritability, sleep issues, restlessness, and impulsive behavior. Onyenna is a 12-year-old whose teacher has concerns related to her school performance. She makes careless mistakes with her work and has difficulty listening in class and following directions. She frequently forgets to bring homework assignments and misplaces her personal belongings. She appears fatigued most days and complains of being tired frequently. Onyenna's parents endorse that she always seems irritable and disorganized at home, and they often have to ask her to complete tasks more than once. Onyenna states that she has no interest in school or extracurricular activities and does not care that she is not doing well in her classes. The PMHNP diagnoses Onyenna with ADHD and prescribes atomoxetine 25 mg once daily. Which of the following is the most likely comorbid diagnosis for Onyenna? bipolar disorder (BPD) unipolar depression generalized anxiety disorder learning disability unipolar depression Rationale: After beginning medication for ADHD, Onyenna's remaining symptoms are consistent with unipolar depression. In children, depression often presents with irritability, fatigue, and a decreased interest in school or peer activities. Both ADHD and depression can cause diminished concentration and attention. Forgetfulness, carelessness, difficulty following directions and disorganization are common symptoms of ADHD with a predominantly inattentive presentation. Elijah is a 6-year-old whose teacher is concerned with his behavior at school. She reports that he is frequently irritable. He gets angry when he must wait his turn for an activity, and often speaks out of turn, interrupts, and talks "nonstop." He has difficulty sitting still. Elijah's custodial grandmother endorses that he has high energy at home. She also notes that he loses his temper often and appears to purposely antagonize his older sister. He often blames her for leaving messes around the house that are his. He argues with both his grandparents when asked to complete chores. The PMHNP diagnoses Elijah with ADHD and prescribes methylphenidate extended-release 20 mg daily. Which of the following is the most likely comorbid diagnosis for Elijah? bipolar disorder (BPD) oppositional defiant disorder conduct disorder generalized anxiety disorder learning disability oppositional defiant disorder Rationale: After beginning medication for ADHD, Elijah's remaining symptoms are consistent with oppositional defiant disorder (ODD), which presents with symptoms including anger, arguing with adults, refusing to follow rules, deliberately annoying others, and blaming others for their mistakes. Both ADHD and ODD can present with irritability. Interrupting, talkativeness and high energy are common symptoms of ADHD with hyperactive-impulsive presentation. ADHD tx -multimodal, often requiring medical, educational, behavioral, & psychological intervention -Pharmacologic • stimulants effective for 70-80% of clients meds of choice for children • non-stimulants used when client doen't respond to stimulant meds used when stimulants are contraindicated can help lower distractibility, improve attention, working memory, & impulsivity -combination sometimes used • when argumentative or oppositional symptoms ADHD tx clinical pearls • Stimulant - ECG req if cardiac hx present in a first-degree relative • Monitor BP, height, weight regularly during tx • Assess for bipolar disorder before tx. CNS stimulants may cause psychotic or manic symptoms or may exacerbate behavior disturbance symptoms and thought disorders in clients with pre-existing psychosis. • CNS stimulants may exacerbate comorbid anxiety and substance use disorders. • Tx efficacy noted within first week • Increased irritability & insomnia tx'd with low dose of nonstimulant med • stimulants may unmask the presence of tics • Switching stimulants, D/C current med & start new med at a starting dose the next day ADHD Prescribing Advisory -Several stimulant meds are Schedule II indicating high potential for abuse • short-acting meds are at higher risk for diversion -Occasional urine drug screens should be obtained • verify the presence of amphetamines and the absence of other substances of abuse Education for clients taking stimulant medications includes: -common side effects: • restlessness, irritability, anxiety, insomnia, stomachache, headaches, tics, worsening aggression symptoms -worsening of symptoms or "crash" may occur when med wears off • especially with IR meDs -take med with breakfast to decrease anorexia or associated weight loss Teddy is a 7-year-old who was diagnosed with ADHD with hyperactive-impulsive presentation. The PMHNP prescribed dexmethylphenidate extended-release 10 mg once daily. His mother has been giving him the medication before school. Teddy's teachers report that his symptoms are much improved, but his parents note that he has a significant rebound of symptoms in the late afternoon, and he struggles on days he has homework and after-school activities. Which of the following medication adjustments are appropriate for Teddy? prescribe a daily afternoon dose of dexmethylphenidate immediate release 2.5 mg in addition to the morning dose increase the daily dose of dexmethylphenidate extended-release to 20 mg recommend a PRN afternoon dose of dexmethylphenidate 5mg IR when Teddy has after school commitments switch to lisdexamfetamine dimesylate 10 mg daily add atomoxetine 0.5mg/kg/day prescribe a daily afternoon dose of dexmethylphenidate immediate release 2.5 mg in addition to the morning dose Rationale: Although long-acting medications typically act for 8-12 hours, some clients experience a shorter window of symptom control. A "booster" dose of short-acting stimulant medication can reduce problems of rebound when the earlier dose wears off. Josué is an 11-year-old who was diagnosed with ADHD combined presentation. He was prescribed amphetamine/dextroamphetamine immediate release 10mg twice daily. He takes the medication in the morning and after school. His symptoms have improved; however, he now complains of difficulty falling and staying asleep. Which of the following medication adjustments is appropriate for Josué? Select all that apply. switch to amphetamine/dextroamphetamine extended-release 20 mg daily decrease the dose of amphetamine/dextroamphetamine immediate release to 5 mg twice daily decrease the frequency of amphetamine/dextroamphetamine immediate release to once daily recommend sleep hygiene techniques prescribe zolpidem as needed switch to amphetamine/dextroamphetamine extended-release 20 mg daily recommend sleep hygiene techniques Rationale: Stimulant medications may cause sleep disturbances, especially if the doses are taken later in the day. Amphetamine/dextroamphetamine immediate release has a duration of 4-8 hours, while extended-release has a duration of 8-12 hours. Switching to extended-release dosing and improving sleep hygiene may help improve sleep. Alternatively, the second dose of amphetamine/dextroamphetamine immediate release can be taken earlier in the day. Addison is a 9-year-old who was diagnosed with ADHD predominantly combined presentation and was prescribed methylphenidate extended-release chewable tablets 20 mg once daily. Since she has started taking the medication, her appetite has decreased. She is 51 inches tall, and her initial weight was 58 lbs. She has lost 8 lbs. since beginning treatment. Which of the following medication adjustments is appropriate for Addison? implement stimulant holidays on weekends and non-school days decrease the dosage of methylphenidate extended-release to 10 mg daily switch to methylphenidate immediate-release 20 mg once daily switch to atomoxetine 25 mg once daily implement stimulant holidays on weekends and non-school days Rationale: Stimulant holidays combined with caloric supplementation and monitoring can help offset stimulant-related weight loss. Switching to a non-stimulant medication may be warranted if drug holidays do not provide the desired result of weight stabilization. ADHD nonpharmacologic tx -Schools • educational support, behavioral interventions in the classroom, and accommodations -Psychotherapy • CBT • social and organizational skill training • family therapy. • Under age 6 American Academy of Pediatrics (AAP) recommends parent training in behavior management as a first-line intervention ADHD parent training in behavior management -What parents learn: • Positive Communication • Positive Reinforcement • Structure and Discipline ADHD complementary and alternative medicine (CAM) interventions -dietary approaches -nutritional supplements -mind/body practices • exercise • yoga • meditation -brain training programs disruptive behavioral disorders -Disruptive, impulse-control, & conduct disorders -problems with emotional & behavioral regulation -often violate others' rights -bring ind. into conflict with social norms & authority figures -Behaviors often severe, frequent, occur in varied settings, can have serious consequences -more common in boys than girls -first onset in childhood or adolescence -Common diagnosis: • oppositional defiant disorder • conduct disorder • intermittent explosive disorder Oppositional Defiant Disorder (ODD) -hallmark: persistent angry & irritable mood, argumentative & defiant behavior, & vindictiveness -behavioral features may present with or without (-) mood -symptom expression in one setting • commonly the home • severe cases symptoms may present in various settings -symptom expression impairs social functioning of the ind. • more evident, interactions with peers or adults they know -Onset: early childhood • symptoms commonly persist into adulthood -frequently occurs comorbidly with ADHD & often precedes development of conduct disorder -high co-occurrence rates with anxiety & MDDs -associated with increased risk for suicide ideation -Prevalence rates: 1%-11%, more prevalent in boys than girls ODD diagnosis -behaviors must have (-) consequences & must not be associated exclusively with a psychotic, substance use, depressive, or bipolar disorder. • must also not meet diagnostic criteria for DMDD -First, 4 or more of the following symptoms must have occurred during an interaction with one or more individuals that are not siblings within the last 6 months: • Angry/Irritable Mood often loses temper is often easily annoyed is often angry and resentful • Argumentative/Defiant Behavior argues with authority figures or adults actively defies or refuses to follow rules or requests from authority figures deliberately annoys others blames others for their mistakes or misbehavior • Vindictiveness has been spiteful or vindictive at least twice within the past 6 months -Second, symptom persistence & frequency must exceed typical developmental behaviors r/t the child's age, gender, & culture. • For children under age 5, behaviors must occur on most days for at least six months. • For people 5 and older, the behaviors must occur at least once per week for at least six months. The severity of ODD is determined by: the number of settings in which the behaviors occurred. ODD and DMDD Diagnosis Considerations -DMDD shares many symptoms with ODD, many individuals meet diagnostic criteria for both disorders • ODD cannot be diagnosed if criteria are also met for DMDD. These circumstances, should receive a diagnosis of DMDD ODD stigma -reactive behavior & trauma responses are mischaracterized as self-control issues -Some mental health providers are calling for a revision of the DSM-5-TR ODD • use neutral terminology, behavior (reactive) or state (dysregulated) rather than a disposition (oppositional and defiant) Conduct disorder -severe behaviors that violate societal norms or the rights of others, may involve aggression towards others, animals, theft, &/or the destruction of property -developmental relationship between ODD & conduct disorder -Behaviors may present as early as pre-school, though more serious symptoms tend to appear later in childhood or adolescence before age 16 • occur in multiple settings, freq cause significant dysfunction -increased risk of: • criminal behaviors & substance-related disorders especially those with childhood-onset type • mood & anxiety disorders • impulse-control disorders • psychotic disorders • PTSD -prevalence: 1.5%-3.4% in the U.S., occurs more in males risk factors for conduct disorder -Temperamental • Difficult infant temperament • lower-than-average intelligence -Environmental: Family-Level • caregiver abuse and neglect • varying caregivers or child-rearing practices • harsh discipline • family criminality • substance-related disorders -Environmental: Community-Level • rejection by peers • participation in a delinquent peer group • poverty • exposure to violence -Genetic or Physiological • Family members with conduct disorder • depressive & bipolar disorders • schizophrenia • ADHD • substance use disorders Conduct Disorder DSM-5-TR Diagnosis 3 or more of the following symptoms in the past 12 months with one symptom occurring within the last 6 months: -Aggression to People and Animals • Bullies, threatens, or intimidates others • Initiates physical fights • Uses a weapon • Physically cruel to people or animals • Theft with confronting a victim • Forces another into sexual activity -Destroys Property • Uses arson to destroy property • Uses methods other than arson to destroy property -Deceitfulness or Theft • Vandalism • Lies to obtain goods or favors • Theft without confronting a victim -Serious Violations of Rules • Stays out at night, before aged 13 • Runs away from home overnight at least twice • Truant from school, before aged 13 *must cause significant impairment & not fulfill diagnostic criteria for antisocial personality disorder Conduct Disorder subtypes -based on the age at onset: • childhood-onset symptoms before age 10 • adolescent-onset symptoms after age 10 • unspecified-onset subtype when the age at onset is unknown. Conduct disorder pharmacologic tx -atypical antipsychotics -SSRIs -Mood stabilizers -Beta blockers *Main component of tx is psychotherapy Intermittent explosive disorder (IED) -low tolerance for frustration & adversity -essential features: freq impulsive or angry outbursts, often include temper tantrums, verbal assaults, or physical assaults towards others, animals, or property • unplanned • rapid onset • out of proportion to the trigger that elicited the response • lasts no longer than 30 minutes -Verbal outbursts: average of twice a week for three months -behavioral outbursts or tantrums that involve the destruction of property within 12 months -outbursts often lead to subjective distress or social or occupational dysfunction and poor life satisfaction and quality of life for the affected individuals. Seamus is a 13-year-old who was referred to the psychiatric mental health nurse practitioner (PMHNP) by a family court judge for evaluation. Seamus was arrested after breaking into several cars on his street overnight and stealing loose change and small electronics. Seamus's parents endorse that he has had problems since he was a young boy. Starting in kindergarten, he has had "anger management" issues and argues with his parents and with teachers. He has difficulty sitting still in the classroom and was frequently disciplined for interrupting teachers, talking constantly, and running in the halls. At home, he often exhibits vindictive behavior towards his siblings and blames them for his actions. His parents describe him as "driven by a motor." He is irritable most of the time. He has never liked school and has struggled academically since first grade. He was suspended twice in elementary school for bullyi Yes According to the DSM-5-TR, does Seamus meet the diagnostic criteria for conduct disorder? yes no unable to determine Yes According to the DSM-5-TR, does Seamus meet the diagnostic criteria for intermittent explosive disorder? yes no unable to determine No According to the DSM-5-TR, does Seamus meet the diagnostic criteria for ADHD? yes no unable to determine Yes Rationale: Seamus meets diagnostic criteria for ODD, conduct disorder, and ADHD. His symptoms consistent with ODD include anger and irritability, argumentative and vindictive behavior, and blaming others. Symptoms consistent with conduct disorder include a history of repetitive, persistent behavior that violates societal norms within the past twelve months, including bullying, fighting, vandalism, theft, and truancy. His symptoms consistent with ADHD include "non-stop" energy, speaking out of turn, talkativeness, excessive running, and interrupting others. The behaviors occur in school and at home and have been present consistently for several years. His behaviors have negatively impacted his academic performance to the extent that he has been expelled from school. disruptive, impulse-control, and conduct disorders assessment and screening -comprehensive psychiatric evaluation • family hx • parenting styles • developmental hx • academic records -child-rated, caregiver-rated, and clinician-rated tools • Minnesota Impulse Disorders Interview (MIDI) diagnostically valuable Tx of disruptive disorders -reducing (+) reinforcement for undesirable behaviors -encouraging prosocial behaviors -nonviolent forms of discipline -following consistent parenting strategies -interventions: • Group parent-caregiver training programs • Individual parent-caregiver training • Group child-focused programs • Cognitive problem-solving skills training • School-based programs • Medication Collaborative and Proactive Solutions (CPS) -Lives in the Balance is an organization promotes an evidence-based treatment model for children with disruptive behaviors -model focuses on identifying the underlying problems that may be causing concerning behaviors and working collaboratively with children to address the problems -organization provides educational materials and support for parents, educators, and healthcare providers -Lives in the BalanceLinks to an external site. is one resource PMHNPs can provide to help parents and educators navigate disruptive behaviors in the home and school settings. Fetal alcohol spectrum disorder (FASD) -umbrella term • describes the physical, mental, behavioral, &/or learning disabilities that can occur in an individual who was prenatally exposed to alcohol -Fetal alcohol syndrome (FAS) • most involved dx on the spectrum -lifelong disability -estimate 1-5 school children per 100 in U.S. & Western Europe - estimated annual cost, FAS in US $4 billion FASD Effects of Development and Behavior -Cognitive • Problems with memory & learning, especially math • Poor reasoning & limited executive function • Problems with attention • Intellectual disability -Physical • Prenatal growth deficits • Poor motor skills & coordination • Vision & hearing problems • Problems with heart, bones, kidneys • Short stature & low body weight • Small head size • Abnormal facial features -Behavioral problems • Poor social skills • Poor emotional control • Impulsivity • Hyperactivity -Functional • Difficulties with sleep & feeding in infancy • Difficulties with self-care Types of FASD -Fetal alcohol syndrome (FAS) -Partial FAS (pFAS) -Alcohol-related neurodevelopmental disorder (ARND) -Alcohol-related birth defects (ARBD) -Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) FASD interdisciplinary evaluation may include: collaboration with a primary care provider, developmental pediatrician, geneticist, psychologist, social worker, speech-language pathologist, occupational therapist, or educational specialist Facial Dysmorphia -Requirement for the dx of the most severe forms of FASD • FAS, and pFAS -requires presence of facial dysmorphia • including narrow eyes, a smooth philtrum between the nose & mouth, & a thin upper lip -most children with FASD do not display facial dysmorphia • 80.1% with FASD are missed • 6.4% misdiagnosed when diagnosed primarily based on presence of physical markers Facial features of FAS Skin folds at the corner of the eye Small head circumference Low nasal bridge Small eye opening Short nose Small midface Indistinct philtrum (groove between nose and upper lip) Thin upper lip FASD treatment -based on the severity of symptoms & developmental impact -Prognosis: best if children receive dx & begin tx before age 6 -combines pharmacological & nonpharmacological approaches -Pharmacologic • SSRIs, antidepressants, alpha2 agonists, anticonvulsants, stimulants, and atypical antipsychotics -Nonpharmacologic • Behavioral interventions & training in social skills, problem-solving, & personal safety • School-based interventions, such as speech & occupational therapy, behavioral supports, & accommodations • Family support groups & parent education FASD complementary and alternative therapies Relaxation therapy Meditation Art therapy Yoga and exercise Acupuncture and acupressure Massage, Reiki, and energy work Vitamins and herbal supplements Animal-assisted therapy Educational Support -critical for providing opportunities to children diagnosed with: • ADHD • disruptive, impulse-control, & conduct disorders • FASD - federal law designed to ensure that children who have disabilities receive free appropriate public education (FAPE) the Individuals with Disabilities Education Act (IDEA) -Initially passed in 1975 -IDEA ensures that: • Children with an identified disability receive individualized special education & services that address their needs. • Children with disabilities receive preparation for employment & independent living. • Children & families impacted by disability are protected under the law. • Federal agencies, states, localities, & educational service agencies that provide educational assistance to children with disabilities receive support. protects the rights of individuals with disabilities who are enrolled in programs receiving federal financial assistance through the U.S. Department of Education Section 504 of the Rehabilitation Act of 1973 -Support typically provided through implementation of Individualized Education Plans (IEP) or 504 plans • describe the services & accommodations that will be provided to students with qualifying disabilities