Attention Deficit/Hyperactive Disorder

1. David Lombard, Ph.D. Center for Applied Behavioral Studies www.DavidLombard.com Attention Deficit/Hyperactive Disorder

3. Overview • What Is AD/HD • What Causes AD/HD • How Common • Common Symptoms • Common Treatments • Comparison with Conduct Disorder

4. What has it been called • First called minimal brain damage • Afterwards called minimal brain dysfunction • Next called ADD • Finally called ADHD

5. What is AD/HD? …A medical condition characterized by inattention and/or hyperactivity-impulsivity. …One of the most common mental disorders among children, affecting approximately 5 to 7 % of school-age children and about 2-5% of adults

6. What is AD/HD? • Persistent inability to pay attention • May have additional characteristics of hyperactive motor movements and/or impulsivity • Usually begin before age 7 but may not be noticed until child is older

7. What is AD/HD • Symptoms of inattention and/or hyperactivity must be present in at least two environments • Symptoms must cause problems for the individual in their environment

8. What causes AD/HD? • Decreased amount of certain neurotransmitters • There may be a genetic association • Appears more often in children whose parents suffer from AD/HD, alcohol dependence and/or mood disorders

9. Pathophysiology • Delayed in frontal and temporal lobe • Accelerated maturity of the motor cortex • SPECT shows reduce circulation • Pet Scan shows a decrease glucose metabolism during activity

11. ADHD Throughout the Lifespan • Preschool- Disruptive behavior, aggression towards other children, hyperactivity, conduct problems, inattentive and overactive • Middle Childhood- Unfinished tasks (unfinished games, uncovered toothpaste), trouble with school work, criticism from parents/teachers/peers, low self esteem. Depression and conduct disorders can develop here.

12. ADHD throughout the Lifespan cont. • Adolescence- higher rates of anxiety, depression, oppositional behavior, social failure, substance abuse • Adulthood- trouble at work, relationships, difficulty following directions, remembering, and concentrating, emotional and social problems

13. Epidemiology • CDC estimates 4.4 million youth ages 4-17 have been diagnosed with ADHD • In 2003, 2.5 million youth ages 4-17 are currently receiving medication treatment for the disorder. http://www.cdc.gov/ncbddd/ADHD/

14. Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health http://www.cdc.gov/ncbddd/ADHD/adhdprevalence.htm

15. Percent of Youth 4-17 ever diagnosed and currently medicated for Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health http://www.cdc.gov/ncbddd/ADHD/adhdmedicated.htm

16. Prevalence in the US • About 2 million children • About 5 million adults

17. Prevalence World-Wide Australia 3.4% of kids New Zealand 6.7% kids, 2-3% teens Germany 4.2% children India 5-29% children China 6-9% children Netherlands 1.3% teens Puerto Rico 9.5% child & teens Japan 7.7% children Mexico approx. 5% childrenBrazil 5.8% of 12-14 year olds

18. How common is AD/HD? • More common in males than females with studies showing a ratio of between 3:1 and 4:1 • As many as 5 out of every 100 children may have AD/HD

19. What are the signs of AD/HD? • Three main symptoms (signs) • Problem paying attention (distractibility) • Being very active (hyperactivity) • Acting before thinking (impulsivity)

20. Based on the these criteria, three types of ADHD are identified: 1. ADHD, Combined Type: if both criteria A and B are met for the past 6 months. Tigger type-Hyperactive, restlessness, disorganized, inattention, impulsivity

21. 2. ADHD, Predominantly Inattentive Type: if criterion A is met but criterion B is not met for the past six months Pooh type- Inattentive, sluggish, slow-moving, unmotivated, daydreamer

22. 3. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion B is met but Criterion A is not met for the past six months. Rabbit Type- over focused, obsessive, argumentative

23. ADHD NOS ADHD, NOS is a category for people who have some ADHD symptoms, but not enough to meet full criteria for the condition.

24. DSM-IV Criteria • Inattentive type (6 of 9 needed) • Fails to give close attention to details • Difficulty sustaining attention • Does not seem to listen • Does not follow through on instructions • Difficulty organizing tasks or activities • Avoids tasks requiring sustained mental effort • Loses things necessary for tasks • Easily distracted • Forgetful in daily activities

25. DSM-IV Criteria • Hyperactive-impulsive type (6 of 9 needed) • Fidgets with hands or feet or squirms in seat • Leaves seat in classroom inappropriately • Runs about or climbs excessively • Has difficulty playing quietly • Is “on the go” or “driven by a motor” • Talks excessively • Blurts out answers before questions are completed • Has difficulty awaiting turn • Interrupts or intrudes on others

26. DSM-IV Criteria • Combined type • Symptoms of both types described • At times all children are inattentive, impulsive and too active • With children with AD/HD these behaviors are the rule not the exception

27. DSM-IV Criteria • Developmentally Inappropriate Levels • Duration of 6 Months • Cross-setting Occurrence of Symptoms • Impairment in Major Life Activities • Onset of Symptoms/Impairment by 7 • Exclusions: Severe MR, PDD, Psychosis • Subtyping into Inattentive, Hyperactive, or Combined Types

28. ADHD is Not… • Will power • Inadequate parenting • Lack of motivation • Lack of intelligence • Laziness

29. What are long-term effects? • Without effective treatment AD/HD can result in serious problems • Academic failure • Relationships • Legal difficulties • Smoking and SUD • Injuries • Motor vehicle accidents • Occupational/vocational

32. ADHD Treatments • Education • Medication • Behavior Modification • Classroom/Workplace Accommodations

33. Multidisciplinary Approach • Primary Provider • Psycho-educational Consultant • academic, aptitude, and psychometric testing • IQ measurement • (usually done through the school) • Social Services • Counseling Services • Individual and Family

34. Commonly Used Stimulant Medications for ADHD Methylphenidate (MPH) Products Ritalin short & mid-acting formsConcerta long-acting Metadate CD mid-acting Ritalin LA mid-actingFocalin mid-acting Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+

35. List of meds approved by FDA http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/medications.shtml

36. Commonly Used Stimulant Medications for ADHD Amphetamine Products Adderall mid-acting Adderall XR long-acting Dexedrine mid-acting Dextrostat mid-acting Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+

37. Commonly Used Non-Stimulant Medications for ADHD • Nonstimulant Products Strattera long-acting • Other Nonstimulant Products Wellbutrin long-acting Tenex mid-acting Clonidine mid-acting Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+

38. Pemoline (Cylert) Medication for ADHD • Secondary choice • Long-acting Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+

39. What are side effects of treatment? • Headache • Involuntary muscle movements • Loss of appetite • Mood changes as medication wears off • Sleep difficulty • Weight management problems

40. Questions?

41. Conduct Disorder

42. Not just for boys

43. Conduct Disorder • The term conduct disorder has traditionallybeen used to characterize children who display a broad range of behaviors that bring them into conflict with their environment. • These include behaviors that are probably best described as coercive or oppositional; • temper tantrums, • defiance, • noncompliance

44. Conduct Disorder • Also included under this general heading have been behaviors of a more serious nature (e.g., cruelty to people or animals, aggressiveness, stealing) . • These are more serious in that they • represent a greater threat to those the child interacts with and/or • have the potential of bringing the child into contact with the juvenile justice system

45. Types of Conduct Disorders • DSM IV features usually associated with the general label of conduct disorder are subdivided in order to provide for the diagnosis of two specific patterns of behavior; • Oppositional Defiant Disorder (ODD) • Conduct Disorder (CD)

46. Conduct Disorder • Symptoms • Bullies, threatens or intimidates others • Often initiates physical fights • Has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun)

47. Conduct Disorder • Symptoms • Is physically cruel to people or animals • Steals from a victim while confronting them (e.g. assault) • Forces someone into sexual activity

48. Conduct Disorder • Symptoms • Deliberately engaged in fire setting with the intention to cause damage • Deliberately destroys other's property

49. Conduct Disorder • Symptoms • Broken into someone else's building, house, or car • Lies to obtain goods, or favors or to avoid obligations • Steals items without confronting a victim (e.g. shoplifting, but without breaking and entering)

50. Conduct Disorder • Symptoms • Often stays out at night despite parental objections • Runs away from home • Often truant from school