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The ADHD Story

The ADHD Story. James J. Messina, Ph.D. Go to: www.coping.org for ADHD Articles & Links. ADHD a Neurobiological Condition is related to SLD. A ttention D eficit H yperactivity D isorder (ADHD) - with Inattention and/or Impulsivity

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The ADHD Story

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  1. The ADHD Story James J. Messina, Ph.D. Go to: www.coping.org for ADHD Articles & Links

  2. ADHD a Neurobiological Condition is related to SLD • Attention Deficit Hyperactivity Disorder (ADHD) - with Inattention and/or Impulsivity • Specific Learning Disability (SLD) - with Auditory, Visual or Kinesthetic Processing Problems including Dyslexia/Reading Disorder

  3. Other Neurobiological Conditions Related to ADHD: • Central Auditory Processing Disorder (CAPD) • Sensory Integration Disorder • Motor Planning Disorder • Self-Regulatory Disorder • Autistic Spectrum Disorder - PDD, MSD, Globally Delayed, Autistic • Neurological Conditions: Epilepsy, Tourette Syndrome

  4. What Research is Telling Us about ADHD • Genetically transmitted in 70-95% of cases • Results from chemical imbalance or deficiency in certain neurotransmitters-chemicals which help brain regulate behavior • Rate at which brain uses glucose, its main energy source, is lower in subjects with ADHD than those without (Zametkin et al, 1990) • Depressed release of Dopamine might have role in ADHD (Volkow et al, 2003)

  5. Research also tells us about ADHD that: • Central pathological deficits of ADHD are linked to several specific brain regions • Frontal Lobe • Its connections to Basal Ganglia • Their relationships to central aspect of Cerebellum • Less electrical activity in brain & show less reactivity to stimulation in one or more of above brain regions • Brains are 3-4% smaller-in more severe-frontal lobes, temporal gray matter, caudate nucleus & cerebellum were smaller

  6. PET Scan of Metabolism of Glucose Adult Brain with ADHD Positron Emission Tomography (PET) Pictures of Adult with ADHDNormal Adult

  7. ADHD & LD lead to Diminished Executive Functions • Deficient self-regulation of behavior, mood, response • Impaired ability to organize/plan behavior over time • Inability to direct behavior toward future • Diminished social effectiveness & adaptability

  8. What is the Impact of these Disorders? • Neurologically based behavioral issues can keep child from developing normally • Lack of full coordination of gross & fine motor skills • Lack of complete age appropriate speech, language & communications • Impaired self-esteem

  9. What is the Extent of ADHD? • About 3% of school-aged population have full ADHD symptoms & another 5-10% have partial ADHD • Another 15-20% of school-aged population show transient behaviors suggestive of ADHD • Boys are 3 times more likely than girls to have ADHD • Symptoms decrease with age but 50-65% of children still manifest symptoms into Adulthood (Korn & Weiss, 2003)

  10. What is the Extent of SLD? • 15% of Americans have learning disabilities with many going untreated due to lack of diagnosis • 10 million children or approximately 1 in 5 children in 1st through 9th grades (Cramer & Ellis, 1996) • 60% of adults with severe literacy problems have undetected/untreated LD (NALLDC, 1994)

  11. What is the Impact of ADHD on people? (Barkley, 2002) • 32-40% of students with ADHD drop out of school • Only 5-10% will complete college • 50-70% have few or no friends • 70-80% will under-perform at work • 40-50% will engage in antisocial activities • More likely to experience teen pregnancy & sexually transmitted diseases • Have more accidents & speed excessively • Experience depression & personality disorders

  12. What is the Impact of these Disorders? • 35% of students with learning disabilities drop out of school • 30% of adolescents with learning disabilities will be arrested 3 to 5 years out of High School (Wagner et al, 1993) • Previously undetected learning disabilities have been found in 50% of juvenile delinquents - Once treated their recidivism drops to just 2% (Lerner, 1997)

  13. Attention Deficit Hyperactivity Disorder • Inattention - Traditionally known as ADD • Impulsivity - Traditionally known as Hyperactivity

  14. ADHD Characteristics • Inattention • Impulsivity • Overactivity

  15. Inattention-Distractibility • Doesn’t seem to listen • Fails to finish assigned tasks • Often loses things • Can’t concentrate • Easily distracted • Daydreams • Requires frequent redirection • Can be very quiet & missed

  16. Impulsivity-Behavioral Disinhibition • Rushing into things • Careless errors • Risk taking • Taking dares • Accidents/injuries prone • Impatience • Interruptions

  17. Hyperactivity - Overarousal • Restlessness • Can’t sit still • Talks excessively • Fidgeting • Always on the go • Easy arousal • Lots of body movement

  18. Different Names for ADHD Through the years: • 1902 Defects in moral character • 1934 Organically driven • 1940 Minimal Brain Syndrome • 1957 Hyperkinetic Impulse Disorder • 1960 Minimal Brain Dysfunction (MBD) • 1968 Hyperkinetic Reaction of Childhood (DSM II) • 1980 Attention Deficit Disorder - ADD (DSM III) with-hyperactivity without-hyperactivity residual type

  19. Names for ADHD • 1987 Attention-Deficit Hyperactivity Disorder or Undifferentiated Attention Deficit Disorder (DSM III-R) • 1994 Attention-Deficit/Hyperactivity Disorder (DSM IV) 314.01: ADHD, Combined Type 314.00: ADHD, Predominantly Inattentive type 314.01: ADHD, Predominantly Hyperactive-Impulsive Type

  20. What is Learning Disability? Definition: • A learning disability is a disorder that affects a person’s ability to either interpret what is seen and heard or to link information from different parts of the brain. These limitations can show up in many ways - as specific difficulties with spoken and written language, coordination, self-control, or attention. Such difficulties extend to school work and can impede learning to read or write or do math.

  21. What are Learning Disabilities • Neurological in origin • Impede person’s ability to store, process or produce information • Affect ability to read • Affect ability to speak • Affect ability to compute math • Impair socialization

  22. LD Language Symptoms • Pronunciation problems • Slow vocabulary growth • Lack of interest in stories • Poor spelling • Delayed decoding • Poor reading comprehension • Trouble following directions • Lack of verbal participation in class

  23. LD Memory Symptoms • Trouble learning numbers, alphabet & days of the week • Slow acquisition of new skills • Poor memory for routines • Slow recall of facts • Organizational problems

  24. LD Attention Symptoms • Trouble sitting still • Extreme restlessness • Impersistence at tasks • Impulsivity • Inconsistency • Poor self-monitoring, insatiability • Great knowledge of trivia • Careless errors

  25. LD Fine Motor Skill Symptoms • Trouble learning self-help skills • Clumsiness • Reluctance to draw, trace or color • Poor pencil grasp • Poor letter formation • Fist-like or tight pencil grasp

  26. Rule outs for Diagnosis of ADHD

  27. GARLIC V.S. ONION-Rule out System in Diagnosing ADHD Rule of Thumb of Ruling out Garlic Issues: • Garlic’s odor outdoes Onion’s so treat Garlic first • Rule out Garlic issue or treat it prior to addressing Onion issue • Lack of success in treating Onion may be because Garlic was not identified & treated • Ongoing setbacks may be due to power of Garlic’s strength & incapability of de-powering it

  28. Garlic Rule Outs in Diagnosing ADHD: • Seizure Disorder or other neurological issue such as Tourette’s Syndrome • Specific Learning Disability • Vision acuity problem • Hearing problem • Metabolic problem • Genetic problem • Child Psychiatric Problem

  29. Electroencephalography • Rule out epileptiform activity and/or epilepsy especially petit mal seizures which cause attention lapses • Use sleep deprived prolonged overnight EEG study to obtain all four stages of sleep (Tuchman, 1994, 1997; Volkmar & Nelson, 1990; Tuchman et al 1998; & Chez et al, 1997) • Use MRI if neurologic examination & EEG or other clinical indicators suggest focal lesion (CAN 1998)

  30. Ophthalmologic Screening • Behavioral in focus • Pure formal visual screening • Rule out processing deficits • Rule out central nervous system abnormality

  31. AudiologicalScreening • Rule out middle ear infection that causes intermittent hearing problems • Behavioral in focus • Pure formal tone audiometry • Brainstem auditory evoked potential if necessary • Rule out processing deficits • Rule out central nervous system abnormality

  32. Metabolic Screening Tests • Rule out food allergies or nutritional problems • Metabolic Lab tests are indicated with signs of metabolic disease e.g. failure to thrive, small stature etc. • Quantitative amino acids • Urine organic acids • Uric acid & calcium in a 24 hr urine • Thyroid studies

  33. Cognitive, Speech & Language, Motor, Sensory & Motor Planning • Pediatric Psychologist • Speech & Language Pathologist • Occupational Therapist - sensory integration • Physical Therapist

  34. Medication Treatment of ADHD STIMULANTS • Ritalin-one dose lasts up to 4 hours • Metadate – Ritalin – once a day lasts up to 12 hrs • Focalin – New Ritalin derivative lasts up to 4 hours • Attenade-Newest Ritalin derivative-lasts 6 hours • Concerta- once a day lasts up to 12 hours • Dexedrine-last 4 hours-spansule lasts 10 hours • Adderall- New Dexedrine - once or twice a day lasts longer than Ritalin • Cylert-requires liver function testing due to history of hepatic failure with children who were on it

  35. Medication Treatment of ADHD Non-Stimulant Medication: • Strattera – acts as a stimulant with similar side affects – norepinephrine reuptake inhibitor – not to be used with Prozac, Paxil or albuterol Nutraceutical: • Attend - a natural product which combines amino acids, fatty acids, lipid complexes, homeopathic medicines, hormone precursors to specific neurotransmitters

  36. Plus these interventions: • Parent Team • Home Modifications • Parent-Teacher Team • 504 Plan with Educational • Consistency of parent-teacher-doctor team • Unconditional love from all adults

  37. Classroom Modifications for Students with ADHD & SLD

  38. 1. Classroom Modifications • Establish rules in classroom • Reinforce rules in classroom • Be consistent • Interact with student by: eye contact, call name, finger on desk, touching • Place student: in front, near positive peers, in low distracting areas

  39. 2. Classroom Modifications • Evaluate & structure environment • Reduce external visual & auditory stimuli • Repeat & have student paraphrase directions • Give short directions • Use predetermined signals • Multiple modalities

  40. 3. Classroom Modifications • Natural & logical consequences • Develop learning contracts with student • Use environmental clues: prompts, steps, written lists, schedules • Demonstrate acceptable ways to communicate displeasure, anger, frustration & pleasure

  41. 4. Classroom Modifications • Earphones & study carrels • Reduced rote assignments • Longer time for testing • Read test to student • Assignment books & organizers • Keep notebook for parent teacher communications after each class day

  42. 5. Classroom Modifications • Computer games & programs • Peer Buddy Tutors & Helpers • Classroom shadow, 1 on 1 Assistant • Progress notes to parents • Quarterly conferences with parents • Parents selection of teacher for next school year • Medications monitoring

  43. 6. Classroom Modifications • Unconditional love of child • Willingness to extend oneself • Openness to doing things differently • Working with parents as a team • Admitting when you are lost • Flexibility • Willingness to change

  44. 7. Classroom Modifications • Getting outside help • Openness to other’s input • Enthusiasm • Optimism - “We Can” Attitude • Determination to make it work • Commitment to process and to child

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