ATTENTION DEFICIT HYPERACTIVITY DISORDER In Children & Adolescents

1. ATTENTION DEFICIT HYPERACTIVITY DISORDERIn Children & Adolescents

2. What is ADHD?The Current Clinical View • A disorder featuring age-inappropriate : • Inattention • Poor persistence of responding • Impaired resistance to distraction, • Deficient task re-engagement following disruption • Hyperactivity-Impulsivity (Disinhibition) • Impaired motor inhibition, • Poor sustained inhibition • Excessive and often task-irrelevant motor and verbal behavior • Restlessness decreases with age, becoming more internal, subjective by adulthood • Most cases are developmental and involve delays in the rate at which these two traits are maturing • Some cases are acquired (20%+; mainly males) • These may represent pathology and may differ in severity, recovery, & possibly treatment response

3. Essential Features • ADHD presents as impairment in: • Persistence • Resistance to distraction • Working memory

4. Persistence • ADHD Individuals do not have problems with such perceptual aspects of attention as: • arousal or alertness • focus or selective attention • span of apprehension or divided attention • Rather have an inability to sustain action toward a goal for an adequate period of time which is a motor problem • Persistence is on the motor side of attention, it is an output disorder. • Output is the problem • Most people think of attention as an input problem: how you perceive, select filter and process information

5. Resistance to Distraction • Related to persistence: opposite sides of the same coin. • If you can persist it is because you can resist distraction; If you can resist distraction you can persist: One requires the other • Not a perception problem, ADHD kids are not “overly perceptive” they do not perceive distractions any better the difference is that they respond to the distracting events • Most of us are able to inhibit our responses to distracting events, ignore them even though we detect them. • ADHD is not a problem of perception but inhibition

6. Working Memory • Once distracted ADHD individuals are far less likely to return to the original goal or task • “task” re-engagement is a major problem for this population • This is modulated by working memory: information held in mind that guides us toward a goal. • People with ADHD are likely to have serious difficulties with working memory. • Once distracted they are gone, off on another task

7. Inattention Symptoms (DSM-IV) • Failure 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 Symptoms must occur “Often” or more frequently

8. Hyperactive-Impulsive Symptoms • 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 Symptoms must occur “Often” or more frequently

9. DSM-IV Criteria for ADHD • Manifests 6+ symptoms of either inattention or hyperactive-impulsive behavior • Symptoms are developmentally inappropriate • Have existed for at least 6 months • Occur across settings (2 or more) • Result in impairment in major life activities • Developed by age 7 years • Are not better explained by another disorder, e.g. Severe MR, PDD, Psychosis • 3 Types: Inattentive, Hyperactive, or Combined

10. ADHD Varies by Setting Better Here: Worse Here: • Fun Boring • Immediate Delayed Consequences • Frequent Infrequent Feedback • High Low Salience • Early Late in the Day • Supervised Unsupervised • One-to-one Group Situations • Novelty Familiarity • Fathers Mothers • Strangers Parents • Clinic Exam Room Waiting Room

11. Prevalence (United States) • 7-8% of children (using DSM-IV) (~3-4 million) • Varies by sex, age, social class, & urban-rural • 3:1 Males to females in children (5:1 in clinical samples) • Somewhat more common in middle to lower-middle classes • More common in population dense areas • No evidence for ethnic differences to date that are independent of social class and urban-rural

12. Co-Occurring DSM-IV Disorders • More than 80% have one additional disorder • More than 60% have two additional disorders • Oppositional Defiant Disorder (Average of 55%) • Conduct Disorder (Average of 45%) • Anxiety Disorders (20-35%) • Major Depression (25-35%) • Bipolar Disorder (0-27%; likely 6-10% max.) • (97% of those Diagnosed w/ Bipolar also have ADHD)

13. Medical Risks • Sleep problems (39-56%); mainly delayed onset and greater night waking leading to shorter sleep time • Developmental Coordination Disorder (50+%) • Reduced Physical Fitness, Strength, & Stamina (using physical fitness tests) • Accident Proneness 57%+ • 1.5 to 4x risk of injuries (greater in ODD) • 3x risk for accidental poisonings • Due to Impulsivity, risk-taking, impaired coordination, oppositionality, and poor parental monitoring

14. Causes of ADHD • Disorder arises from multiple causes • All currently recognized causes fall in the realm of biology (neurology, genetics) • Causes may compound each other • Common neurological pathway for ADHD appears to be the areas of the brain controlling Executive Functions and Physical Activity (Smaller / Less Developed) • Social causes have poor evidence

15. Acquired Cases: Prenatal • Maternal smoking in pregnancy (odds 2.5) • Maternal alcohol drinking in pregnancy (same) • Prematurity of birth, especially if brain bleeds (45%+ have ADHD) • Total increased pregnancy complications • Maternal high phenylalanine levels in blood (?) • High maternal anxiety in second trimester (?) • Cocaine/crack exposure not a risk factor after controlling for the above factors

16. Acquired Cases: Post-Natal (7-10%) • Head trauma, brain hypoxia, tumors, or infection • Lead poisoning in preschool years (0-3 yrs.) • Survival from acute leukemia (ALL) • Treatments for ALL cause brain damage • Post-natal Streptococcal Bacterial Infection • triggers auto-immune antibody attack of basal ganglia • Post-natal elevated phenylalanine (dietary amino acid related to PKU) • Prenatal – hyperactivity • Post-natal – inattention

17. Heredity – Family Studies • Familial Expression of ADHD: - 25-35% of siblings - 78-92% of identical twins - 15-20% of mothers - 25-30% of fathers - If parent is ADHD, 20-54% of offspring (odds 8+)

18. Heredity – Twin Studies • Heritability (Genetic contribution) • 57-97% of individual differences (Mean 80%+) • (91-95%+ using DSM criteria) • Shared Environment (common to all siblings) • 0-6% (Not significant in any study to date) • Unique Environment (events that happen only to one person in a family) • 15-20% of individual differences • (but includes unreliability of measure used to assess ADHD)

19. Etiologies of ADHDFrom Joel Nigg (2006), What Causes ADHD? Other Perinatal Smoking Lead FASD LBW Heritable (Genetics)

20. ADHD Evaluation: Core Considerations • Are the symptoms of inattention, impulsiveness, and overactivity, present. MOST Importantly Is there clear evidence of an impulsive style? • Is there evidence that these symptoms significantly interfere with the child’s functioning both at school and at home? • Did these symptoms have a reasonably early onset? (If not, is there a good explanation?). • Have these symptoms been an enduring and consistent feature of the child’s behavior throughout their development and in the majority of contexts? • Is there evidence that the child wishes to perform well but cannot? • Are there better explanations for the underachievement? • Is there a pattern or specific triggers to the problem behaviors?

21. 6 Step Diagnostic Process • Review of Home Behavior • Review of School Bx and Collateral Information • Review of Developmental History • Review of Family/Marital Situation • School / Natural Environment Observation • Interview of Child

22. Psychodiagnostic Evaluation • A psychodiagnostic Evaluation may be necessary if the assessment produces mixed/inconsistent results or has uncovered possible evidence of any of the following: • Suicidality • Significant Developmental Delays • Intellectual limitations • Learning disabilities • Serious Psychiatric disturbance • Significant family problems • Other reasons to refer for testing: • Child was moderately to severely premature • Prenatal exposure to toxins especially ETOH & Nicotine • Low birth weight • Complicated pregnancy and/or birth • Reports that child had trouble grasping concepts/acquiring new skills • Reports that child has trouble with major academic subjects even when attentive.

23. Ruling out Depression • Later onset than ADHD • Usually preceded by excessive anxiety • Not uncommon to have both as a result of the negative outcomes due to ADHD behaviors. • Must treat both • When comorbid, associated with a 4x increase in suicidal ideation and 2x increase in attempts • Appears to be connected to same genes associated with ADHD. • Best differential: EARLY HISTORY

24. Ruling Out Anxiety • Onset later than ADHD • Associated with a particular event or in accordance with a time pattern (anniversary). • Restlessness is not a primary manifestation of Anxiety (usually a habit, style, or boredom) • Usually characterized by panic or dread along with worry. • Best measure for presence of anxiety is child’s report (parents and teachers under report).

25. Ruling Out PTSD • Must look closely at developmental and early school history. • PTSD will stem from a specific event • Children with ADHD are at greater risk for PTSD from abuse and risky behaviors.

26. Ruling Out Bipolar Disorder • Childhood BPD manifests as severe and chronic irritability (rather than episodic mania) • Also characterized by Disjointed thinking, capricious mood, destructiveness, and dysphoria. • BPD usually starts as ADHD in childhood • ADHD itself does not develop into BPD • One-way Comorbidity • 3-6% of ADHD have BPD • 80-97% of BPD have ADHD

27. Ruling Out ODD • In many cases ADHD is at the root of ODD • There is a high degree of co-occurrence • Early onset of ADHD symptoms is the differential

28. TreatingATTENTION DEFICIT HYPERACTIVITY DISORDERIn Children & Adolescents

29. Current Perspective • ADHD creates a kind of Myopia for future events or “Time Blindness”. • ADHD individuals live in the Moment • ADHD is a Disorder of: • Performance, not skill • Doing what is known, not knowing what to do • The when & where, not the how or what • Using representations of the past at the appropriate place & time (Point of Performance) • ADHD is better characterized as an Intention Deficit

30. ADHD & Executive Functioning • Executive Functioning is responsible for two types of sustained attention (SA): • Contingency-shaped (Externally maintained) • Video Games • Goal-directed (Internally guided & motivated) • Homework • Goal-directed (SA) is impaired in ADHD individuals which creates problems with: • Delayed responding & intrinsic motivation • Doing the opposite of what is suggested in sensory fields • Time, waiting, delays, and future orientation • Problem solving, strategy development, & flexibility • Increases in complexity with age & development

31. Treatment Implications • Teaching skills is ineffective (As is insight) • Treatment must occur at the point of performance. • Medications are likely to be essential for most but not all cases. • Diminished capacity does not excuse accountability (The problem is time and timing not consequences). • Behavioral treatment is essential but does generalize or endure after removal. • Treatment success depends on the compassion and willingness of others to make accommodations. • Maintaining a “Chronic Disability” perspective is most effective.

32. Unproven / Disproved Therapies • Elimination Diets: Sugar, Additives, etc. (Weak Evidence) • Megavitamins, Anti-oxidants, Minerals: (No strong evidence or disproved) • Sensory Integration Training (Disproved) • Chiropractic Skull Manipulation (No Evidence) • Play / Psychotherapy (Disproved) • Neurofeedback (Experimental) • Cognitive Self-Control Therapies (Effective in Clinic) • Social Skills Training (Effective in Clinic Setting) • Better for Inattentive (SCT) Type and anxious cases

33. Empirically Proven Treatments • Parent Education • Psychopharmacology • Parent Training in Child Management • 65-75% of Children under 11 respond • 25-30% of Adolescents show reliable changes • Family Therapy for Adolescents: • Problem-Solving and Communication Training • 30% show change (best combined with BMT) • Teacher Education • Train Teachers in Classroom Bx Management • Special Ed (IDEA, 504) • Regular Physical Exercise • Residential Treatment (5-8%) • Parent Family Services (25+%) • Parent/Patient Support Groups

34. Managing ADHD • Time is critical: reduce delays • Externalize a many processes as possible: • Time (Clocks, Timers, Calendars, PDAs etc.) • Important information (Lists, reminders, instruction cards, etc.) • Motivation (Token economy, tangible rewards) • Problem Solving (use paper and pencil or dry erase board) • Give immediate feedback • Increase frequency of consequences • Increase accountability to others • Use salient & artificial rewards

35. General Recommendations • Change rewards periodically • Minimize talking, maximize communicative touch • Corollary: “Act don’t Yak” • Maintain a sense of humor • Emphasize rewards over punishments (reward first) • Anticipate problem situations and make a plan • Keep a sense of priorities (pick your battles) • Hold to the perspective of ADHD as a Disability • Be forgiving (of child, self, and others)

36. Give Effective Commands • Initially give heavy praise to high compliance commands • Don’t use questions, use Imperatives • Use eye contact and touch • Have child recite request • Break complex tasks into simpler ones • Make chore cards for Multi-Step tasks • List all steps involved on a 3x5 card • Stipulate the time period on the card • Reduce time delays for consequences • Make use of Timers at the Point of Performance • Avoid assignment of multiple tasks all at once • Praise initiation of compliance • Provide rewards throughout the task • Have child evaluate their performance at the end

37. Time-Out • Target time-out to focus on one problem • Act quickly after infractions • Violations of household rules get instant time out • Immediate commands: • Give Command ( count backwards from 5) • Give Warning with raised voice (repeat count of 5) • Initiate time-out • Release from time-out contingent on: • Completion of minimum time period (1-2 minutes/year of age) • Becoming quiet • Consenting to command • Reward next good behavior • Best to use Bedroom for Time-out • Remove all major play activities (Sanitize)

38. Psychopharmacology

39. Stimulant Medications • These are the most well studied drugs in psychiatry • In use for over 40 years • Over 350 studies • Thousands of cases

40. Stimulants:Behavioral Effects • Increased concentration and persistence • Decreased Impulsivity & hyperactivity • Increased work productivity • Better emotional control • Decreased aggression and defiance • Improved compliance • Better working memory & internalized language • Improved handwriting and motor coordination • Improved self-esteem • Decreased punishment • Improved peer acceptance and interactions • Better awareness in sports • Improved driving performance

41. Stimulants: Side Effects • Most tolerate well • 5% discontinue due to negative effects • Side effects are dose dependent • Most common side effects: • Insomnia (50% +) • Loss of Appetite (50% +) • Headaches (20-40%) • Stomach Aches (20-40%) • Irritability, tearfulness (<10%) • Nervous Habits & Mannerisms (<10%) • Tics (<3%) and Tourette’s (Rare) • Mild Weight Loss (Average 1-4 pounds; transient) • Small effect on height during 1st year (Approx 1cm) Increased heart rate (3-10 bpm) • Increased blood pressure (1.5-14 mmHg) • Psychosis (<3%)

42. Stimulants:Common Myths • Addictive when used as prescribed • No, Must be inhaled or injected • Over Prescribed • 7.8% prevalence rate, only 4.3% on stimulants • Creates Aggressive, Assaultive Behavior • No, decreases aggression and antisocial actions • Increases the likelihood of Seizures • Only at very very high doses • Causes Tourette’s Syndrome • Can increase tics in 30%; decreases it in 35% • Increases risk of later substance abuse • No, 14 studies have found no such result, some found that it decreased risk if continued throughout teens

43. Strattera • Selective Norepinepherine reuptake inhibitor • Not Schedule II; no abuse potential • Effective for children, adolescents, and adults • Equal efficacy with Methylphenidate with previously unmedicated cases (75% positive response) • Slightly lower efficacy with those previously on stimulants (55% positive response) • Sustained response for up to 3 years • Increasing improvement over time • Can be given once daily (morning) or split (am/pm)

44. Benefits of Strattera • Reduces ADHD, ODD, & aggression • Reduces internalizing symptoms • Increases school productivity • Improved peer social behavior • Improved self-esteem • Improved parent-child relations • Improved dry nights among bed-wetters • Better “morning after” behavior • Less insomnia and faster onset of sleep than Methylphenidate • No emotional blunting

45. Academic and Occupational Interventions for the Treatment of ADHD

46. Classroom Management:Basic Considerations One of the major impairments of children with ADHD is functioning in the educational setting. More children with ADHD are receiving services in public schools now than at any other time in history. Despite the success of medication management and parent training, psychoeducational interventions are needed to ensure academic success and maintain positive behavior in children with ADHD.

47. Classroom Management:Basic Considerations The first goal of school-based interventions is to improve basic knowledge among educators about the nature, causes, course and treatment of ADHD. The second goal is to increase home and school collaboration to ensure that the treatment plan is consistent, and effective across settings. Third, effective interventions should include strategies to improve academic and social functioning in children and adolescents and occupational functioning in adults.

48. ADHD Basics:Training for Educators ADHD is biologically based and is treatable but not curable. Goal is to manage symptoms and reduce secondary harm (e.g., grade retention, peer rejection, disciplinary actions). ADHD is not due to a lack of skill or knowledge, but is a problem of sustaining attention, effort, and motivation and of inhibiting behavior. It is a disorder of performing what one knows, not of knowing what to do. Treatment is most effective when applied consistently at the place and time where a behavior is expected to be performed (e.g., at school).

49. ADHD Basics:Training for Educators It is harder for students with ADHD to do the same academic work and exhibit the social behavior expected of other students. Thus, these students need more structure, frequent positive consequences, consistent negative consequences, and accommodations to assigned work. To maximize behavior change: proactive interventions involve manipulating antecedent events to prevent challenging behaviors from occurring; reactive interventions involve implementing consequences following a target behavior.

50. Classroom Interventions :9 Key Principles Rules and instructions provided to children with ADHD must be clear, brief and often delivered through more visible and external modes of presentation than required for the management of their peers. Consequences used to manage the behavior of those with ADHD must be delivered more swiftly (ideally, immediately) than with their peers. Consequences must also be applied more frequently.