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ADHD Update 2012: Paying Attention to Inattention

ADHD Update 2012: Paying Attention to Inattention. Oren Mason MD oren@mason.md MASSW Fall Conference 2012 October 25, 26, 27. Electronic copies of presentation slides and notes available at: www.attention.md Please consider the environment before printing. Learning Objectives.

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ADHD Update 2012: Paying Attention to Inattention

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  1. ADHD Update 2012:Paying Attention to Inattention Oren Mason MD oren@mason.md MASSW Fall Conference 2012 October 25, 26, 27

  2. Electronic copies of presentation slides and notes available at:www.attention.mdPlease consider the environment before printing

  3. Learning Objectives Participants will: • Learn the neurobiological basis for ADHD • Gain skills in screening and diagnosis of ADHD • Coordinate school-based interventions for ADHD with medical management

  4. ADHD Neurobiology

  5. Abnormalities in ADHD Brain • The ADHD brain: • is smaller overall • grows more slowly • matures later • uses emotional processes more • uses cognitive processes less • Has less dopamine available

  6. Less Neurotransmitter Available For Cognitive Processing Pet scans, courtesy of National Institute of Mental Health

  7. Two Types of Attention • Cognitive Attention • Driven by anterior cingulate • Learned • Based on importance, timeliness, efficiency, learned values • Modulated, adjustable • Durable, enduring • High availability • Willfully engaged • Time sensitive • Socially aware • Emotional Attention • Driven by basal ganglia • Innate • Based on interest, emotional engagement, novelty, urgency • Powerful, not adjustable, 110% or absent • Hyper-focus or inattention • Intermittent availability • Passively engaged • Time blind • Socially blind

  8. Observer’s View of Attention Emotional intensity Blah-ness Time’s passage

  9. Interplay of TwoAttentions Emotional intensity Interest-based performance Importance-based performance Blah-ness Time’s passage

  10. Abnormal processing in ADHD Normal Adult ADHD Adult ADHD adults fail to utilize the most efficient pathway to process information in an attention-based task. MGH-NIMR Center & Harvard – MIT CITP, Bush G, et al. Biol Psychiatry 1999.

  11. ADHD: Deficit of Cognitive Attention Normal ADHD Emotional intensity Blah-ness Time’s passage Interest-based performance Importance-based performance

  12. ADHD concept • Disability of attention control • Hallmark—inconsistent attention • Normal interest-based attention • Deficient attention to important matters • Similar deficits in broad executive function: • Planning, scheduling, time management • Imagination, evaluation, selection of options • Organization • Motivational management • Maintenance and modulation of effort • Self-observation and evaluation • Emotional self-management

  13. ADHD concept • Children with ADHD learn to attend and function by artificially inducing emotional engagement • Interest-based production when possible • Anxiety and shame otherwise

  14. Prevalence of ADHD

  15. Risks of ADHD ANNUAL DEATHS due to ADHD (USA): 4,000 MVA deaths 1,200 suicides

  16. Risks of ADHD Calculated effect of ADHD on life expectancy: 7 year decrease in adults with AD/HD* 3 year decreasein adults with heart disease. *Calculation R. Barkley due to increased smoking, obesity, decreased medical compliance, exercise in adults with AD/HD.

  17. Risks increase for ADHD adults Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford.

  18. Success decreases for ADHD adults Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford.

  19. Hardships for ADHD families PF physical function RP role physical BP bodily pain GH general health REB role emotional-behavioral BE behavior MH mental health SE self-esteem PE parental impact-emotional PT parental impact-time FA family activities FC family cohesion Klassen A F et al. Pediatrics 2004;114:e541-e547

  20. Annual cost of ADHD (US) Billions of dollars in the USA

  21. Screening for ADHD

  22. ADHD screening All students Students with ADHD and disability Students with ADHD Students with academic disability

  23. Purpose of ADHD screening • To identify individuals with a high probability for ADHD who need a full psychological evaluation. • It is not necessary for schools to perform diagnosis in the absence of academic disability • It is ethically unacceptable to fail to perform screening and parental notification when ADHD symptoms are impacting academic or social performance

  24. Indicators for ADHD screening • Academic triggers: • Teacher observation of inattention, impulsivity or hyperactivity • Grades less than predicted (IQ test) • Inconsistent grades • Inconsistent performance in classwork vs tests • Behavioral triggers: • Truancy, disciplinary issues • Underage use of tobacco, alcohol • Marijuana, illicit drug use • Early, indiscriminate, unprotected sex

  25. Indicators for ADHD screening • Social triggers: • Class clown • Lack of friendships • Lack of long-term friendships • Toxic friendships • Bullying, being bullied or ostracized • Psychological triggers: • Depression • Anxiety • Oppositionality

  26. Screening tools • All ages: • Vanderbilt ADHD Teacher Form (18-item)* • Primary and middle school • Connors Teacher Report Short Form • High school • Connors Adolescent Self-Report • Connors Teacher Report Short Form • Adult Self-Report Scale v1.1* *Available without cost

  27. ASRS v1.1 • Scoring: • Never = 0, • Rarely = 1, • Sometimes = 2, • Often = 3, • Very Often = 4 • Total score 0-12, ADHD unlikely. • Total score 13-24, ADHD likely

  28. ADHD Treatment

  29. Medication Effects • Behavioral improvements often profound: • Control of attention • Control of activity • Self-esteem • Academic improvements • Standardized test scores improve • Self-esteem improves • Reduced absenteeism • Reduced grade retention • Efficient use of time improves • Strattera may improve dyslexia

  30. Medication Effects • Improvements in home and family life • Mothers reduce controlling behaviors • Family time and participation improves • Parent stress decreases • Overall quality of life improves • Driving Improvements • Stimulants and Strattera improve attention while driving • Daytrana decreases collisions • Driving improvements in simulator studies: • Concerta-15 hours • Adderall XR-9 hours • 3 doses methylphenidate-9 hours

  31. Problems when we don’ttreat ADHD medically Per cent of children whose score declined from 4th to 7th grade. Zoëga H, et al. A population-based study of stimulant drug treatment of ADHD and academic progress in children. Pediatrics. 2012 Jul;130(1):e53-62.

  32. Who Should Take ADHD Medication? Everyone with AD/HD should undergo trials of medication. Everyone who responds well should take the medications.

  33. Medication classifications Stimulants Long-acting Stimulants Non-stimulants

  34. Stimulant duration of effect 1Daytrana [package insert]. New York, NY: Noven Therapeutics; 2012; 2Vyvanse [package insert]. Wayne, PA: Shire Inc. 2012; 3Facts and Comparisons. Facts and Comparisons web site. http://www.factsandcomparisons.com/index.aspx. Accessed July 25, 2012; 4Adderrall [package insert]. Wayne, PA: Shire Inc. 2012; 5Focalin XR [package insert]. East Hanover, NJ: Novartis. 2012.

  35. Nonstimulants SR, sustained release; XL, extended release 1Strattera [package insert]. Indianapolis, IN: Eli Lilly & Co.; 2012; 2Facts and Comparisons. Facts and Comparisons web site. http://www.factsandcomparisons.com/index.aspx. Accessed July 25, 2012; 3Intuniv [package insert]. Wayne, PA: Shire, Inc.; 2012; 4Kapvay [package insert]. Florham Park, NJ: Shionogi Pharmaceuticals; 2012.

  36. Side effects diminish with constant use

  37. Treatment Strategies Improving efficacy and duration

  38. Evaluate symptoms frequently

  39. Optimize Efficacy • Increase dose until intolerable, then reduce • Repeat scales at every visit. • If one medication gives an inadequate response, try another • Consider combination therapy.

  40. Potential benefits of combination therapy

  41. Efficacy: combination therapy Symptom reduction with combination therapy Wilens, T An Open Study of Adjunct OROS-Methylphenidate. J Child AdolescPsychopharmacol. 2009 October; 19(5): 485–492.

  42. Meds, psychosocial support or both MultiModal Treatment Study in children with ADHD for 14 months in 579 children ages 7-10 Arch Gen Psychiatry. 1999 Dec;56(12):1073-86

  43. Effect of medication Medications for ADHD • normalize brain function • improve self-control • improve control of attention • improve decision-making ________________________ Medications allow the practice of self-control

  44. When function is restored, training begins • Marlon Shirley • Amputee age 5 • Paralympics Gold Medal winner for USA in 100m and 200m sprints • World record holder in men’s 100m sprint for single amputees – 10.97 sec

  45. Accommodations for ADHD students • Medication-optimized • Review and reinforce academic routines • Not optimized • Replace deficient self-controls with external controls • Monitor task completion • Coordinate with parents who must do the same in evening • Provide intermittent rewards • Provide frequent reminders to sustain attention, effort • Individualize motivational structure • Token behavioral reward systems • Workload reduction

  46. Teaching ADHD Students • General strategies: • Increase emotional engagement • Support executive function • Adopt “Disability Model” • 30% rule—ADHD students can maintain the executive function of a child 30% junior. • 6th grader—3rd grade function • 9th grader—5th grade function • Do not teach organizational/functional methods • You may require use of a method • Must follow up and reward use of the method • Do not expect to withdraw support

  47. Teaching ADHD Students • Increase emotional engagement. • Maintain rewarding environment • Reward every positive thing you can • 10:1 ratio of positive encouragement to correction. • Touch can be very effective • Polite, respectful, positive, low-key, appropriate • Hand on shoulder/back to signal “pay attention”

  48. Teaching ADHD Students • Increase emotional engagement. • Allow students to work in areas of interest whenever possible. • To create a rewarding environment, take a lesson from video games: • State objective clearly • Provide feedback on progress • Reward frequently • Reward immediately • Reward visibly • Small tokens are adequate

  49. Teaching ADHD Students • Increase emotional engagement. • Time outs should deprive a student of a rewarding environment. • Physically separate from rest of class • Involve assignment (worksheet) that must be complete to return to class • Time out can be proportionate: 2-sheet, 3-sheet • Return to class setting without comment • Threats of harm can be effective, are not desirable.

  50. Teaching ADHD Students • Increase emotional engagement. • Participatory events effective • Peer tutoring effective • Students teaching younger students highly effective • Work done should be rewarded • Cash awards are very effective. (Get over it.)

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