Presented at the KU Mini-College Monday, June 3, 2013 1001 Wescoe Hall 2:15-3:30PM

Paying attention to your Attention Deficits (or “everything you need to know about Adult ADD in 75 Minutes”) Presented at the KU Mini-College Monday, June 3, 2013 1001 Wescoe Hall 2:15-3:30PM

Welcome Back to KU!

PRESENTED BY • Robert G. Harrington, Ph.D. • Department of Psychology and Research In Education • KU School of Education • 630 J R Pearson Hall • University of Kansas • Lawrence, Kansas 66047 • rgharrin@ku.edu

My Background • I have been a Professor in the PRE Dept . of the SOE for the past 34 years. • I teach graduate and undergraduate courses in the program in Development and Learning. • Among the courses that I have taught are included, Theory and Research in Intelligence, Classroom Management, Diagnosis and Treatment of Oppositional Defiant Disorders, Attention Deficit Disorders in Children and Adults, Bullying Prevention and Intervention, Behavior Problems and Personality Assessment, Social Skills Development in Children and Adults, Human Development Across the Lifespan. • Currently, I am working on an online certification program to prevention and intervene in cases of bullying • I regularly provide inservice training to schools, mental health agencies, hospitals and professional groups on the topic of ADD/ADHD and related topics • Just completed keynote presentations at Irish International Conference on Education and at Nebraska Autism Disorders Conference

Description of my Presentation • It is conservatively estimated that 5 to 6 percent of school-age children will have attention deficits while in school but what happens to them when they graduate from school? Do their attention deficits just disappear and go away? We just don’t hear much about adults with attention deficits. Are they successful in their lives, in their work, in their relationships? How can someone tell if they have attention deficits as an adult? What can be done to manage and cope with attention deficits in adulthood? What could happen if you are in a relationship with someone with attention deficits? Are there happy endings? The purpose of this mini-course is to explore attention deficits and their effects in adult life.

Objectives of the Presentation • Two relevant cases of Adult ADD • Can you spot the myths? • What does ADD in Adulthood look like? • How is it diagnosed? • What are the effects of Adult ADD on personal/ emotional development? • What are the effects of Adult ADD on marital and social relationships ? • What are the effects of Adult ADD in the workplace? • What can be done to help? • Questions/Answers

Two ReleVant CASES OF Adult ADD • Grad Student in Learning Theory Course • Teacher attending a workshop on Childhood ADHD speaks up about her husband at the break

Can you spot the Facts vs. Myths? • ADD/ ADHD in Adults is just a lack of willpower. • Everyone has the symptoms of ADD/ADHD and anyone with adequate intelligence can overcome these difficulties on their own. • Someone cannot have ADD/ADHD and also have depression, anxiety, or other psychiatric problems • Unless you have been diagnosed with ADD/ADHD as a child, you cannot have it as an adult. • ADD/ADHD always requires medication. • It is not uncommon for individuals with adult ADD to seek out relationships with others with social skills strengths that complement their deficits • Disorganized physical environments tend to increase the ADD symptoms • Men have more ADD than women • In the West we diagnose more ADD/ADHD than anywhere else in the world • Kids mostly grow out of their ADD symptoms with age.

Adult Attention Deficit Disorder • Also referred to as: • Adult Attention Deficit Hyperactivity Disorder (Adult ADHD) • Adult ADD or AADD • NOTE: Adult Attention Deficit Disorder is the term used to describe the neuropsychiatric condition attention deficit hyperactivity disorder when it is present in adults. • Up to 60% of children diagnosed with ADHD in early childhood continue to demonstrate notable symptoms as adults. • It is estimated that 5% of the global population has ADHD (including cases not yet diagnosed).

What does adult ADD look like?: Identification and Classification • DSM-IV TR or the Diagnostic and Statistical Manual of Mental Disorders, 2000, ed. defines three types of disorder: • Inattentive type • Hyperactive/impulsive type • Combined type • To meet the formal diagnostic criteria, an individual must display • at least 6 inattentive symptoms for the inattentive type • at least 6 hyperactive symptoms for the hyperactive/impulsive type • all of the above to have the combined type • Note: DSM V is coming out soon! Symptoms are similar to these…..

Signs and symptoms-inattention • IN CHILDREN: • Forgetful during daily tasks • Easily distracted • Losing important items • Not listening and not responding to name being called out • Unable to focus on tasks at hand; cannot sustain attention • Avoids tasks requiring tasks sustained mental effort • Makes careless mistakes by failing to pay attention to details • Difficulty organizing tasks and activities • Fails to follow through on complex instructions and tasks

SIGNS AND SYMPTOMS-INATTENTION • IN ADULTS: • Procrastination • Indecision, difficulty recalling and organizing details required for a task • Poor time management; losing track of time • Avoiding tasks or jobs that require sustained attention • Difficulty initiating tasks • Difficulty completing and following through on tasks • Difficulty multitasking • Difficulty shifting attention from one task to another

Signs and Symptoms-hyperactivity/impulsivity • IN CHILDREN: • Squirms and fidgets (with hands and/or feet) • Cannot sit still • Cannot play quietly or engage in leisurely activities • Talks excessively • Runs and climbs excessively • Always on the go, as if “driven by a motor” • Cannot wait for their turn • Blurts out answers • Intrudes on others and interrupts conversations

Signs and symptoms-Hyperactivity/impulsivity • IN ADULTS: • Chooses highly active, stimulating jobs • Avoids situations with low physical activity or sedentary work • May choose to work long hours or two jobs • Seeks constant activity • Easily bored • Impatient • Intolerant to frustration; easily irritated • Impulsive, snap decisions and irresponsible behaviors • Loses temper easily, angers quickly

Clinical Evaluation of Adult ADD • Find out what prompted the individual to make an appointment at this time • Have the client complete some questionnaires before the initial visit • Discuss the medical background, work history, home history, family relationships with the client • Are the client’s conditions being worsened by some condition other than ADD? A medical problem? A Psychiatric problem? Stress? Sleep disorder? Alcoholism? • Asperger’s? Autism? Learning Disability, Dyslexia, Hearing Disorder? Developmental Disorder? • ADD is diagnosed if: • No other cause for the client’s symptoms can be found • The person has a long history of such symptoms • The symptoms are severe enough to cause significant in function or relationship

Adult ADD FACTS • Adults with ADD have a deficiency in executive cognitive functioning; resulting in deficiencies in self-regulation, self-motivation, distractibility, procrastination, organization and prioritization. • Adults with ADD are average to above average in intelligence • Adults with ADD experience a chronic condition that requires coping skills • Adults with ADD experience significant effects on education, employment and interpersonal relationships • Employers, spouses and friends often fail to see the signs of Adult ADD; symptoms change with maturity • Adults are far less likely to evidence traditional hyperactivity symptoms • Adults with ADD are more likely to have car accidents, less education, less professional development • Adults with ADD often compensate for the need for high stimulation by smoking, taking alcohol or illegal drugs • Adults with ADD often have comorbidities such as depression, anxiety, substance abuse, learning disabilities, dyslexia; up to 80% will have some comordbidity

Causes of adult add • Specific causes are unknown • Speculations: • Genetics – Twin studies show that Adult Add is highly inheritable; 75% of cases • Evolutionary Theory – (Hunter V. Farmer Theory) ADHD may have been adaptive • Environmental Theory – alcohol and tobacco exposure during pregnancy, exposure to lead, premature birth, low birth weight, maternal infections during pregnancy, exposure to pesticides • Diet – Food coloring such as red dye #40; no evidence for sugar or caffeine • Social – Disorganized family life or educational experience, attachment disorder and trauma, foster care, internationally adopted children, sensory integration dysfunction

Causes continued • Neurodiversity: Issue of emotional tolerance and behavioral tolerance • Social Construct theory of ADHD: Thomas Szasz, “ADD was invented and not discovered.” • Low Arousal Theory: Excessive activity is needed to compensate for low arousal; require environmental stimuli to pay attention; if not enough stimulation then the adult creates their own stimulation • Pathophysiology: Frontal lobe, left temporal lobe, cerebellum, dopamine neural transmission

Questionnaires to assess Adult ADD • Adult ADD History Questionnaire – Client’s personal and family psychological history • Adult ADD Medical History Questionnaire – Medical issues related to the diagnosis • Adult ADD Symptoms Questionnaire – Client symptoms related to ADD • Available at AdultADD.Info

Diagnostic and Behavioral Symptom Questionnaire • Scoring Key: Answer how well each statement describes you when you don’t use special aids or tricks you have developed to get around or compensate for difficulties you might have. Score each answer as follows: • 0. Doesn’t describe me at all • 1. Describes me somewhat or some of the time • 2. Describes me pretty well or most of the time • Describes me very well or almost all the time

Initiation • I have trouble getting started doing things. • Completion • I have trouble completing things • I dislike tasks that require a long series of steps • Execution • I don’t do tasks efficiently ( a good job in a short time) • It is hard for me to do two or three tasks in a row • I do not always do what needs to be done

Distraction • I am easily distracted by things I hear or see even when I am trying to concentrate • I get distracted by my own thoughts • Perseverance and Focus • I have trouble doing tasks that require keeping my attention on them for along period of time • I often switch from doing one thing to another even when I don’t have to. • I have trouble keeping my attention on one task. • Inattentiveness • I don’t pay attention when I should, make careless mistakes • I have trouble listening while others speak to me

Memory • I get so deeply into one thing that I forget others • I lose or misplace things • I have trouble being on time • I forget appointments • I am often late for appointments • Future Awareness and Planning • I have trouble making plans long in advance • I rarely get to trains at least 10 minutes early

Consider a diagnosis of Adult ADD if: • A person’s average score on these 34 questions is 2 or higher and • The symptoms significantly impair the person’s work, school, family, or personal activities and • The person experiences significant stress from the effects of the symptoms and; • There is no other medical or psychological explanation for them

Personal and family add history • Childhood History of ADD • Explain , if necessary • As a child, I …. • --- Had to repeat one or more grades_______________ • __Fidgeted a lot, couldn’t sit still__________________ • __Was distractible, had a short attention span________________ • __Had a lot of discipline problems________________ • __Never did as well as I should have in school________________ • __Was treated for ADD

Adult History Related to ADD • __I have been diagnosed as having ADD • __I have been treated for ADD • __I have been given one or more tickets for speeding • __I was driving a car when it was totaled • __I have been in one or more “fender benders” • __I think so much that I have trouble getting to sleep • __I have to change jobs often (been fired) • __I have had periods when I overspent • __I have had periods when I gambled too much

__I have had periods when I was overactive physically • __I have had periods when my mind raced • __I need a lot of caffeine to get going at the start of the day • __I have been hospitalized for a psychiatric disorder • Family History • __I believe that a blood relative had/has ADD • __A blood relative was given the diagnosis of ADD • __A blood relative has taken medication for ADD • __I have a blood relative who has manic-depressive (bipolar ) illness

ADULT ADD Related Medical History • Medical Issues • Thyroid problems (which)? • (Thyroid problems can mimic ADHD. Both thyroid meds and stimulants can cause weight loss) • Glaucoma? • (Stimulants can increase eye pressure in people with narrow angle glaucoma • Seizures? • (stimulants may cause seizures in people who have already had them • Been knocked unconscious • (Brain injury mimic ADD or make it worse)

Liver problems • (Many medications are metabolized in the kidneys. Some medications, like Strattera, may cause liver problems. • Reynaud’s • (Stimulants can make Raynaud’s worse or cause it (cold and white or blue fingers or toes) • Heart Problems • (Stimulants are contraindicated in people with heart problems, Very rare deaths from the use of stimulants have been associated with a history of structural heart disease or cardiac dysrhythmias) • Migraines, if so, what medication do you take from them, if any? • (Stimulants may increase blood pressure, An increase in blood pressure medication may be required by patients taking stimulants or Wellbutrin(buproprion)

What is your blood pressure? When was it last taken? • (Bring blood pressure down to normal before starting stimulants) • Is your pulse less than 50 per minute when resting? • (May need cardiac work-up unless low pulse is from good physical conditioning) • Is your pulse more than 95 per minute when resting? • Stimulants can further increase the pulse and are contraindicated in people with pulse this rapid • Did a blood relative die at an early age of heart problems? • (This may be a contraindication to taking stimulants since this fatal vulnerability may be genetic • Do you have twitches or tics • (Tics or twitches may be made better or worse by stimulants

Sleep • Do you have sleep apnea? • (Sleep apnea may cause ADD like symptoms or make ADD worse) • If so, what evaluation or treatment have you had for sleep apnea? • A sleep study may be indicated for t hose with major sleeping problems. If a person is using CPAP, are they using it regularly with good effect? • Do you have difficulty falling asleep? • (May be due to sleep apnea or depression) • Difficulty staying asleep? • (May be due to sleep apnea or depression)

Find yourself tired during the day, yawning a lot? • (These symptoms may be caused by sleep apnea, Overtiredness may make ADD symptoms worse or mimic ADD) • Do you nap at least a few times a week to stay alert? • (This may be a sign of sleep apnea) • Do you awaken during the night feeling frightened? • (This may be a sign of sleep apnea) • Do you snore? • Slightly suggestive of sleep apnea • Have you been observed to stop sleeping during sleep, and then awaken with a start? • This is a symptom very suggestive of sleep apnea

Medication Reactions • Are you allergic to a medication (Medication? Reaction?) • Do you take an MAOI antidepressant medication? • (Stimulants and SSRIs are contraindicated in persons taking MAOIs • Diet Supplements • Do you take fish oil? • (This may be mildly helpful to people with ADD but good research support for this is still lacking) • Vitamin C? • This decreases the absorption and increases the excretion of amphetamines and thereby reduces it effect

Do you take an herbal medicine? If so, which? • (There are some interactions with stimulants) • Do you take over the counter medications? (which)? • (Aspirin taken at the same time as stimulants can reduce the absorption of stimulants. OTC medications containing ephedrine or pseudoephedrine can make the cardiac side of stimulants worse) • Substance History • Have you been addicted to or abused drugs? • (Persons with such a history may require more careful oversight if stimulants are prescribed) • Have you used “speed” or uppers (Dexedrine or others)? • (People’s previous experience taking these medications can suggest how they will respond now)

Have you ever taken a stimulant? What effect did it have on you? • (A person’s reaction to stimulant medication taken in the past may predict his or her response to its therapeutic use) • Drugs/Alcohol • Do you smoke marijuana fairly regularly? • (Marijuana often interferes with the use of medications for ADD) • Do you smoke cigarettes or cigars? (How many per day?) • People with ADD find it harder to stop smoking. It is possible that successful treatment of the ADD may make it easier to stop. Buproprion, which of some help to some patients with ADD, is a fairly good smoking cessation aid) • Do you smoke caffeinated drinks (if so, how much per day?) • (Caffeine may worsen some of the side effects of stimulants like difficulty sleeping, headache, and atrial fibrillation)

Do you have at least one drink almost every day? (How many?) • (Alcohol can interfere with the effects of stimulants) • Have you sometimes had too much alcohol to drink? • People taking stimulants may be less likely to realize when their judgment and reflexes are impaired by alcohol. This may make driving more dangerous. • Is there someone in your home who has abused drugs or who might use drugs prescribed for you? • (If this is so, the patient, must be very careful to keep the stimulant medication in a secure place where it will not tempt the other person in the home to use it. • Females only • Are you pregnant or planning to get pregnant? • (Stimulants may adversely affect fetal development)

Are you using protection against getting pregnant? • (Such protection will reduce the concern about the need for stimulants during pregnancy) • Are you breast feeding or considering breast feeding? • Stimulants are carried in breast milk and may adversely affect the infant

Have you ever taken a stimulant? What effect did it have on you? • (An individual’s reaction to stimulant medication taken in the past may predict his or her response to its therapeutic use) • Drugs/ Alcohol • Do you smoke marijuana fairly regularly? • (Marijuana often interferes with the use of medications for ADD)’ • Do you smoke cigarettes or cigars (How many per day?) • (People with ADD find it harder to stop smoking. It is possible that successful treatment of the ADD may make it easier to stop. Buproprion, which of some help to some patients with ADD, is a fairly good smoking cessation aid) • Do you drink caffeinated drinks (if so, how much per day?)

Organization • I get disorganized • I have trouble organizing tasks • My personal work area is messy • I don’t prioritize or plan my day • I can’t work well without structure or direction • I waste a lot of time doing nothing • Physical Activity (Hyperactivity) • I need to keep walking, moving around • I have trouble sitting still, I fidget

Frustration/Impulsiveness • I am easily frustrated • I get impatient easily • I interrupt when other people are talking • Anxiety • I focus and concentrate better if I am somewhat anxious • Multi-Tasking • I often try to do more than one task at a time • I tend to make things more complicated than they need to be • Sleep • I have trouble getting to sleep because my mind is going

Diagnosis of Adult ADD • Entirely clinical and therefore controversial! • Were the symptoms present in childhood? • Get corroborating evidence from family members • Get corroborating evidence from school records • Get corroborating evidence from employment history • Get corroborating evidence from medical history/family tree • Neuropsychiatric evaluation to determine: • intelligence • general knowledge • self-reported ADD symptoms • tests to screen for co-morbid conditions

NOTE CAREFULLY • Every normal individual may exhibit ADD or ADHD like symptoms occasionally (e.g., when tired or stressed) but for the ADULT ADD diagnosis: • Symptoms should be present from childhood • Symptoms should persistently interfere with functioning in multiple spheres • Symptoms from childhood are manifested in adulthood but in perhaps a different manner

Treatment of Adult ADD • Self – Help • Exercise and eat right • Get plenty of sleep • Practice better time management • Work on your relationships • Create a supportive work environment

In General: Treatment and therapy for Adult Add • Talk Therapy • Marriage and Family Therapy • Cognitive Behavioral Therapy • Job Coaching • Social Skills building • Medical Treatment • Self-Management • Modification of the Physical Environment • Development of Support System • Positive Attitude; take advantage of personal skills

Support Groups for Adult Add • Purposes for support groups: • Reduces the isolation of struggling alone with the disorder • Gives you a place to express your feelings among others who may understand • Lets you share strategies for success

Behavioral Coaching • Goal: Practical solutions to problems in everyday life; not a substitute for therapy • Prioritizing • Motivation • Time Management • Procrastination • Organization • Impulse Control • Distraction Reduction

Interventions • SELF • Relationships • Workplace

Effects of Adult ADD on the Individual • Messages received by adults with ADD: • I am a fraud and others will find out • If only I would try harder • My way of doing things is wrong • I am lazy • Just do it like everyone else • I just can’t follow the conversation and I interrupt • I resent the criticism I get from others • I just don’t seem to know what is socially appropriate

What is an Adult with ADD to do? • Accept yourself • Be realistic about what you can do • Set goals and celebrate accomplishments • Understand your limitations and plan for them • Anticipate your needs • Get a schedule book • Allow for de-stressing time • Plan a meeting with your spouse to figure out you both are doing • Recognize that partners need respite too • Don’t overcommit • Know when to say, “NO” and do not overcommit • Rearrange your environment • Do things your way as long as it does it does not irritate or affect others • Get knowledge about Adult ADD and seek medical help if necessary

What does an ADD/ADHD MarriAGE Look Like? • Spouses report: My husband or wife constantly forgets, misses appointments. I feel like I am raising another child? I can never count on my spouse. It goes from feeling responsible for everything to chronic anger. I did not like the person I had become either. I have 100% of the family responsibility. • Symptoms: • “Do you hear what I am saying?” • “You never help me around the house” • “You are so unreliable” • “How could you forget to pick up our son from school again? • “You know we can’t afford that new computer you just bought” • “Help, my partner does not seem motivated to change”

Presented at the KU Mini-College Monday, June 3, 2013 1001 Wescoe Hall 2:15-3:30PM