Introduction to ADHD Its Impact and Practical Strategies to Help

1. Introduction to ADHDIts Impact and Practical Strategies to Help Angel Adams, PhD Chartered Clinical Psychologist www.prosocial.co.uk

2. DEFINITIONA neurodevelopmentaldisorderthat is genetically transmitted and mediated bydecreased brain dopaminergic functioning. It’s main features are impairments inself-regulation and attention due to executive functioning deficits localized in the frontal lobes of the brain.It is a biopsychosocial condition that can be potentially life-threatening and least of all causes debilitating impairment in several areas of life. It usually comes with co-morbidity and persists into adulthood.

3. WHAT IS ADHD? • A disorder of age-inappropriate symptoms in: • 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 disorders: delays in the rate with 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

4. KNOW THE FACTS “Education and knowledge about the disorder is more powerful than anything else you do. Teaching people about their disorder is crucial. Our studies show it actually changes more behaviour than the active treatment. It gives people (teachers, family members, employers) knowledge from which they can reframe their understanding of sufferers. That's a very powerful act. So much change takes place just from giving people accurate information.” Russell A Barkley, PhD (Cape Cod Lecture Series, 2001)

5. Facts & Myths about ADHD

6. Facts & Myths about ADHD MYTH: ADHD is just a lack of willpower. Persons with ADHD focus well on things that interest them; therefore they could focus on any other tasks if they really wanted to. FACT: ADHD looks very much like a willpower problem, but it isn't. It's essentially a chemical problem in the management systems of thefrontal lobe of the brain.

7. Facts & Myths about ADHD MYTH: ADHD is just a lack of willpower. Persons with ADHD focus well on things that interest them; therefore they could focus on any other tasks if they really wanted to. FACT: ADHD looks very much like a willpower problem, but it isn't.It's essentially a chemical problem in the management systems of thefrontal lobe of the brain.

8. Facts & Myths about ADHD MYTH: ADHD is a simple problem of being hyperactive or not listeningwhen someone is talking to you. FACT: ADHD is a complex disorder that involves impairments in focus, organization, motivation, inhibition emotional modulation, memory, and otherfunctions of the brain's management system.

9. Facts & Myths about ADHD MYTH: ADHD is just a lack of willpower. Persons with ADHD focus well on things that interest them; therefore they could focus on any other tasks if they really wanted to. FACT: ADHD looks very much like a willpower problem, but it isn't. It's essentially a chemical problem in the management systems of thefrontal lobe of the brain.

10. Facts & Myths about ADHD MYTH: ADHD is a simple problem of being hyperactive or not listeningwhen someone is talking to you. FACT: ADHD is a complex disorder that involves impairments in focus,organization, motivation, inhibition emotional modulation, memory, and otherfunctions of the brain's management system.

11. Facts & Myths about ADHD MYTH: Brains of persons with ADHD are overactive and need medicationto calm down. FACT: Underactivity of the brain's management networks is typical of persons with ADHD. Effective medications improve communication in the brain's management system (e.g. increase alertness, decrease impulsivity)

12. Facts & Myths about ADHD MYTH: ADHD is simply a label for behavior problems such as defiance, and refusal to tow the line. FACT: Many with ADHD have few behaviour problems. Chronic inattention symptoms cause more severe and longer-lasting problems for learning and relationships for those with adult ADHD.

13. Facts & Myths about ADHD MYTH: Those who have ADHD as children usually outgrow it as they entertheir teens. • FACT: Often ADHD impairments are not noticeable until the teen years, when more self-management is required in school and elsewhere. ADHD may be subtle, but more disabling during adolescence than in childhood.Cognitive hyperactivity remains and is an ongoing challenge to manage

14. Facts & Myths about ADHD MYTH: Unless you have been diagnosed with ADHD as a child, you can'thave it as an adult. FACT: Many adults have struggled all their lives with unrecognized ADHD impairments. They haven't received help because they assumed that their chronic difficulties, like depression or anxiety, were caused by other impairments that did not respond to the usual treatments

15. Facts & Myths about ADHD MYTH: ADHD doesn't really cause much damage to a person's life. FACT: Untreated or inadequately treated ADHD syndrome often severely impairs learning, family life, education, work life, social interactions, and driving safely. Most of those with ADHD who receive adequate treatment, however, function quite well.

16. Facts & Myths about ADHD MYTH: They may appear to be irresponsible or downright lazy. FACT: People with ADHD often work harder than their colleagues to keep up

17. Facts & Myths about ADHD MYTH: Medications for ADHD are likely to cause longer-term problemswith substance abuse or other health concerns, especially when used bychildren. FACT: The risks of using appropriate medications to treat ADHD areminimal, whereas the risks of not using medication to treat ADHD aresignificant. The medications used for ADHD are among the bestresearched for any disorder.

18. Psychostimulants • Increased Concentration & Persistence • Decreased Impulsivity & Hyperactivity • Increased Work Productivity (~Accuracy) • Better Emotional Control • Decreased Aggression & Defiance/ODD/CD • Improved Compliance & Rule Following • Better Working Memory & Internalized Language • Improved Handwriting & Motor Coordination • Improved Self-esteem • Decreased Punishment from Others • Improved Peer Acceptance & Interactions • Better Awareness of Game in Sports • Improved Driving Performance

19. Prevalence 3-10% school aged 67%of children with ADHD have symptoms that persist into adulthood. Cognitive hyperactivity remains and is an ongoing challenge to manage Intelligence or ethnicity Males and females..6 to 1 Adults 1:1 Wender regards ADHD as the most undiagnosed disorder of adult life.

20. Prevalence 3-10% school aged 67%of children with ADHD have symptoms that persist into adulthood. Cognitive hyperactivity remains and is an ongoing challenge to manage Intelligence or ethnicity Males and females..6 to 1 Adults 1:1 Wender regards ADHD as the most undiagnosed disorder of adult life.

21. Its a Universal Disorder Germany Ireland Diagnostic criteria PuertoRico New Zealand DSM-IV Canada UK DSM-III-R Switzerland DSM-III Spain ICD-9 USA USA USA: Adults Brazil Netherlands 0% 5% 10% Prevalence

22. IMPACT OF ADHD Teens with ADHD are more likely to • experience teen pregnancy (40%) • contract sexually transmitted diseases(16%), • speed excessively • have multiple car accidents • experience depression (20–30%) • engage in antisocial activities (40–50%), • use tobacco or illicit drugs more (60-70%)

23. IMPACT OF ADHD Sufferers are far more likely than normals to: • Dropout of school (32–40%), • Low rates of college completion (5–10%) (Whitman, 2000) • When completing college, earn less money • More grade retention (25-45%; MKE: 42 vs. 13) • Pagani et al. (2001) showed that retention is harmful • More placed in special educational (25-50%) • More are suspended (40-60%; MKE: 60 vs. 19) • Reflects disciplinary action; more associated with CD • Greater expulsion rate (10-18%; MKE: 14 vs. 6) • Higher drop out rate (30-40%; MKE 32 vs 0) • Lower Class Ranking (MKE: 66% vs. 53%) • Lower GPA (MKE: 1.8 vs. 2.4) • Fewer enter college (MKE: 22 vs. 77%) • Lower college graduation rate (5-10 vs. 35%)

24. IMPACT OF ADHD • Lower rates of professional employment • Underperformers at work (70–80%) • More likely to be sacked • 55 vs. 23% had been sacked • 16% vs. 6% of jobs held • Have conflict with managers • Miss promotions • Have stalled careers • Mismanage and endanger their lives

25. EMPLOYMENT PROBLEMS • Enter workforce at unskilled/semi-skilled level • Greater unemployment at age 21+ (22 vs. 7%) • Change jobs more often • 2.6 vs. 1.4 over 2-8 years since leaving high school • More ADHD/ODD symptoms on the job • As rated by current supervisors • Lower work performance ratings • As reported by current supervisors • Greater use of sick days & health insurance claims • Lower social class status • By 30s, 35% self-employed (NY Study)

26. Inheritability Index .80 Genes aren't destiny. Genes play a substantial role, but they may be triggered Environmental stressors in the development of the disorder

27. GENETIC LOADING • The most common co-existing disorders in ADHD in adulthood: • depression • anxiety • substance abuse • specific learning difficulties -- also have a strong genetic component.

28. Need to bridge the gap Assessment and treatment of ADHD discontinue services for adults Not understood as a life span disorder

29. ADULT SYMPTOMATOLGY • Low tolerance to stress • Hot temper • Mood lability • Organisational deficits • Impulsive/inhibition

30. EXECUTIVE FUNCTIONING Neuroimaging studies show structural and functional abnormalities in the frontal lobe regions of the brain

31. EXECUTIVE FUNCTIONING This is the part of the brain that is in charge of self-control. The prefrontal lobe is chronically under-aroused, and so the ability to monitor behaviour is impaired.

32. THE CEO Planning Working memory Impulse control Inhibition Mental flexibility Initiation and monitoring of action Motivation Internalisation of speech

33. The Problem is not the skill • Performance, not skill • Doing what you know, not knowing what to do • The when and where, not the how or what • Using your past at the “point of performance”

34. Time Management Chronic Lateness Not prepared Procrastination Difficulty with Prioritising Poor work habits Poor follow through Trouble Meeting Deadlines

36. Disorganisation • Waste hours on a minor task • Get distracted by the slightest interruption • Papers may not get filed • Office is messy • Attention span fluctuates

37. INTERFERENCE CONTROL REISITANCE TO DISTRACTION Need to protect oneself from being disrupted by environment Tend to have distractions that hurt them when there requires thoughtful, planful future directed behaviour

38. MOTIVATION DEFICIT Impersistent Needs immediate rewards Get bored easily High need for stimulation Premack principle

39. Cognitive Obstacles • Difficulty setting priorities • (often take on more than they can handle), spend hours on the wrong things • It takes them longer to do tasks • Often don’t work to their potential

40. Problems at the Workplace • Mixed presentation (Sometimes do brilliant and amazing creative things, but other times they're just out to lunch) • Everything seems to come harder for them. • They're like ducks, appearing to swim effortlessly, but furiously paddling under the surface.

41. Strategies Adults with ADHD frequently excel in the workplace, once they adapt to their disability, use evidence based strategies and develop their coping skills Entrepreneurs, entertainers, athletes, politicians, and business leaders have ADHD (CEO of JetBlue, David Neeleman)

42. Strategies The importance of self-awareness, support systems, organized ideas and information, as well as identification of the characteristics of “ADHD-friendly occupations and work places” Tailor workplace environment (to advantage of strong points) while minimizing the negative impact of deficits. Knowing how to delegate is a valuable but often overlooked skill.

43. Strategies for Time Management • Arrive early to work, when it is quiet, can help focus and get work done. • May need to take work in an empty office or conference room, or quiet cubicle. • Don't answer phone, let voicemail take messages, and return calls later at a set time. • To discourage interruptions, hang a "Do Not Disturb" sign on door. • To minimize visual distractions, face desk toward a wall.

44. Strategies for Minimising Distraction • Deal with clutter • Use "white noise" earphones, classical music or other sounds to drown out office noises. • Jot down ideas in a notebook to avoid interruption of the current task. • Keep a list of ideas that come during meetings so communication is more effective. • Perform one task at a time.

45. Speeding Up Neurotransmitters

46. Strategies for Internal Distractions • "Ah-ha!" distractions • "Oh no!" distractions • "Ho-hum" distractions

47. Strategies toExternalise Time If tendency to day dream or hyper focus—then "cue" with externalizing time: • Post-it notes • A watch alarm • Pop-ups on computer screen, beepers, • Anything to make time external

48. Strategies toExternalise Time • All treatments are at the point-of-performance • Medications may be essential • Behavioral treatment is essential but does not generalize or endure after removal • Reverse engineer the EFs: • Externalize important information (make lists, posters, signs, etc.) • Externalize time periods related to tasks (use timers) • Break up future tasks into many small ones (do 1 daily) • Externalize sources of motivation (rewards) • Permit more external manipulation of task information (manualize it) • The compassion and willingness of others to make accommodations are vital to success • A disability perspective is most useful

49. Strategies for restlessness Take every appropriate opportunity to move around at work. Take a break every hour Calisthenics Stroll through the halls in garden Fidget to focus

50. Strategies for impulsivity Learn self-talk strategies to monitor impulsive actions. • Work with a coach to role-play appropriate responses to frustrating situations. • Ask for regular, constructive feedback as a way of becoming more aware of how impulsivity might manifest • Practice relaxation and meditation techniques • Anticipate the problems that regularly trigger impulsive reactions and develop routines for coping with these situations.