adhd

1. ADHD??!!!?!

2. Relationship between ADHD and EF EF ? ADHD All ADHD have some EFD but All EFD not ADHD

3. ADHD and EF The two are not the same; stem from different descriptive systems ADHD is a diagnosis based on cluster of observed behaviors EF is a neuropsychological construct Both describe a regulatory phenomenon

4. Provocative Question #1 ADHD is Undergoing a redefinition�.ADHD is Undergoing a redefinition�.

5. Provocative Question #2

6. Provocative Question #3 YES�absolutely�although hard b/c people were resisting in past but with new RTI�this will changeYES�absolutely�although hard b/c people were resisting in past but with new RTI�this will change

7. Attention-Deficit/Hyperactivity Disorder (ADHD): DSM-IV Diagnostic Criteria A. Either (1) or (2) (1) 6 or more symptoms of Inattention have persisted for at least 6 months: often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities often has difficulty sustaining attention in tasks or play activities often does not seem to listen when spoken to directly You guys know this�.You guys know this�.

8. often does not follow-through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand the instructions) often has difficulty organizing tasks and activities often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort often loses things necessary for tasks or activities (toys, school assignments) is often easily distracted by extraneous stimuli is often forgetful in daily activities

9. Attention-Deficit/Hyperactivity Disorder (ADHD): DSM-IV Diagnostic Criteria (2) 6 or more symptoms of hyperactivity-impulsivity Hyperactivity (6) often fidgets with hands or feet or squirms in seat often leaves seat in classroom or in other situations in which remaining seated is expected often runs about or climbs excessively in situations in which it is inappropriate often has difficulty playing or engaging in leisure activities quietly is often �on the go� or acts as if �driven by a motor� often talks excessively

10. Impulsivity (3) often blurts out answers before questions have been completed often has difficulty awaiting turn often interrupts or intrudes on

11. (Sub)types 1. ADHD, Combined Type: A1 and A2 met for past 6 months 2. ADHD, Predominantly Inattentive Type: A1 met but not A2 3. ADHD, Predominantly Hyperactive-Impulsive Type: A2 but not A1 Never met a hyper kid that wasn�t inattentive????have you? Kids who areimpulsive but not hyper�they are active but not hyper�they do rush thru work�Never met a hyper kid that wasn�t inattentive????have you? Kids who areimpulsive but not hyper�they are active but not hyper�they do rush thru work�

12. Rule Outs TBI Epilepsy Language processing disorders Anxiety disorders including PTSD Depression Chaotic environment Sleep disorders Need to rule out; hx brain injury�.lang processing disorders: they have behav regu px but theyare lang related sometimes�sendory issues too: they look imlulsive but are responding to all aspects of sensory material at all times. Chaotic home environment: divorse, alcohol, drugs; Sleep disourders: sleep onset, apnea, etc. 10 to 11 hours of sleep is need by adolescence accoding to research..that is when our body repairs itself or brain repairs itself�.staying up late and not getting enough sleep by gaming is not good. Sugar and candy etc..may cause momentary energy bursts but does not cause ADHDNeed to rule out; hx brain injury�.lang processing disorders: they have behav regu px but theyare lang related sometimes�sendory issues too: they look imlulsive but are responding to all aspects of sensory material at all times. Chaotic home environment: divorse, alcohol, drugs; Sleep disourders: sleep onset, apnea, etc. 10 to 11 hours of sleep is need by adolescence accoding to research..that is when our body repairs itself or brain repairs itself�.staying up late and not getting enough sleep by gaming is not good. Sugar and candy etc..may cause momentary energy bursts but does not cause ADHD

13. Clinical Symptoms of ADHD Beyond the traditional triad of �not paying attention�, �not thinking before he acts� and �running all over the house constantly�...

14. Clinical Symptoms of ADHDCore or not? � Reports of �Disorganization, can�t remember 3-step instructions, poor planning, not checking his/ her work, difficulty accepting other strategies, getting stuck, overemotional, locker/ notebook looks like a disaster...�

15. Clinical Symptoms of ADHDCore or not? Executive Function (EF) is largely implicit in the DSM-IV diagnosis of ADHD. Only Inhibit (Impulse Control) is explicit. Should EF be formally incorporated into theories and definitions of ADHD? Are formal assessment and treatment of these (core?) EF symptoms necessary?

16. Evolution of Diagnosis of ADHD 1st clinical description: British physician Still (1902) - �deficit in volitional inhibition�, �defect in moral control� Similarities to brain-injured child syndrome (Strauss & Lehtinen, 1947) but without evidence of brain injury resulted in �minimal brain damage� �Minimal brain dysfunction� �Hyperkinetic impulse disorder� �Hyperactive child syndrome� First descript of ADHD were in 1902. He is lazy, stubborn�. MBD used to be used for Minimal Brain DysfunctionFirst descript of ADHD were in 1902. He is lazy, stubborn�. MBD used to be used for Minimal Brain Dysfunction

17. Evolution of Diagnosis of ADHD �Hyperkinetic reaction of childhood� (DSM-II) first mention of inattention and distractibility �Attention-deficit disorder� (Douglas) (DSM-III) with and without hyperactivity �Attention-Deficit/ Hyperactivity Disorder� (DSM-III-R) (no with or without) �Attention-Deficit/ Hyperactivity Disorder� (DSM-IV) (�3� subtypes) ??? Like you are reacting to something your mother did�. Second one actually made sense�. Like you are reacting to something your mother did�. Second one actually made sense�.

18. Recent Conceptualizations With a better understanding of brain-behavior relationships, particularly the frontal lobes: ADHD is undergoing further redefinition in terms of a disorder of the executive functions (EF) (Barkley, 1997, 2000; Brown, 1999; Denckla, 1996; Pennington & Ozonoff, 1996) The primacy of �attention� is being questioned. Attention deficit is questioned so name may change.Attention deficit is questioned so name may change.

19. Models of executive function in ADHD Pennington & Ozonoff (1996) �frontal metaphor�: deficits in inhibition and working memory tasks Barkley (1997, 2000) Inhibition as core, executive function as model Bayliss & Roodenrys (2000) supervisory attentional system as executive function

20. That is Russell Barkely not Charles!That is Russell Barkely not Charles!

21. Barkley (Bronowski) EF Model Nonverbal working memory - visual imagery and private audition; internalized resensing. Verbal working memory - covert language that controls self; rule-governed behavior. Internalized emotion/ motivation - with working memory, emotional control and motivation can occur. Covert affective states. Source of intrinsic motivation that drives future behavior.

22. Barkley (Bronowski) EF Model Reconstitution - analysis combining with synthesis, allowing manipulation to synthesize new responses. Allows flexible, fluent, inventive goal-directed behaviors.

23. General Conclusions Relationship between EF and ADHD hypothesized by Barkley (1997, 2000) and Pennington & Ozonoff (1996) is given strong support by BRIEF findings Multidimensional construct of EF appears to define with greater specificity the symptoms of ADHD.

24. General Conclusions Multidimensionality of Executive Function provides a more comprehensive yet more specific model of ADHD, incorporating a more full set of relevant symptom behaviors. Looking at all self domains is the point of this slide.Looking at all self domains is the point of this slide.

26. Not just in prefrontal system �giving stimulants wakes up the conductor so he can calm the system down�meds leave more dopamine in the gap so keeps the system working rapidly. Meds�activates the fronal system so under more control of the regualrtroy syst.. We want more internal and hopefully more external control�learning t play the instrumets better�allows them to be more focused and less impulsive 30% off the social emotional curve for maturity ( Barkley) look up�.meds does not cause tics but bring it out in those that are predisposed to that anyway�there are side effects from both txing and not txing.Not just in prefrontal system �giving stimulants wakes up the conductor so he can calm the system down�meds leave more dopamine in the gap so keeps the system working rapidly. Meds�activates the fronal system so under more control of the regualrtroy syst.. We want more internal and hopefully more external control�learning t play the instrumets better�allows them to be more focused and less impulsive 30% off the social emotional curve for maturity ( Barkley) look up�.meds does not cause tics but bring it out in those that are predisposed to that anyway�there are side effects from both txing and not txing.

27. Proportional size of prefrontal region Human 29% Chimpanzee 17% Gibbon/Macaque 11.5% Lemur 8.5% Dog 7% Cat 3.5% Prefrontal helps us be more human�29% is a big chunk of the brain; now some cat people say the cat just didn�t want to do the test!Prefrontal helps us be more human�29% is a big chunk of the brain; now some cat people say the cat just didn�t want to do the test!

28. Neuroanatomic Organization Executive function & neurological development are parallel Development of prefrontal cortex is central Frontal lobe damage can result in dysfunction of various executive subdomains BUT - Executive functions do not simply reside in the frontal lobes Remember the �.Bi directional arrowsRemember the �.Bi directional arrows

29. 3 Neuroanatomic Axes andNeuropsychological Function Anterior-Posterior Axis Anterior Systems ?-----? Posterior Systems Anticipates behavior - Receives information Selects Goals - Encodes Organizes/ Plans - Stores Orchestrates - Structure/ organization Monitors of Knowledge Base Modulates <----> Complimentary Relationship

30. Lateral Axis Left Hemisphere Systems Preferentially involved with: Building blocks of language Parts of complex materials Temporal processing Processing unimodal codable information Executive of discrete motor Right Hemisphere Systems Preferentially involved with: Spatial information Relationship between parts Configuration of complex Processing multi-modal novel information Emotional tone in speech

31. Cortical-Subcortical Cortical (Thinking) Systems Frontal System Modulation Inhibition and selection Subcortical Systems Retic. Activ Syst Motor Control Emotions/Drive -Arousal - Impulses -Alertness - Emotional/Social Drives Cortex�there is so much of it that you can actually unfold it and lay it out on your bed like a blanket�.well most people�sCortex�there is so much of it that you can actually unfold it and lay it out on your bed like a blanket�.well most people�s

32. Neuroanatomic Organization: Frontal lobes are densely connected with other cortical and subcortical regions Prefrontal system is highly, reciprocally interconnected with the limbic (motivational) system, reticular activating (arousal) system posterior association cortex (perceptual/ cognitive processes and knowledge base) motor (action) regions of the frontal lobes

33. Central neuroanatomic position underlies regulatory control over: Perceptual coding in posterior/temporal isotypic regions Conceptual processes of the posterior association cortex Attentional functions supported by subcortex (reticular activating system) Emotional functions subserved by subcortex (limbic system)

34. Frontal system versus frontal lobe Frontal system acknowledges & incorporates interconnectedness A disorder within any component of the frontal system network can result in executive dysfunction

35. Conditions that render the frontal systems vulnerable include: Connectivity disorders such as cranial radiation and white matter development (migration errors) Lead poisoning affecting synaptogenesis Direct prefrontal trauma in traumatic brain injury Dysfunctional neurotransmitters (e.g., dopamine in TS & ADHD) Posterior cortex disorders including LD Arousal mechanism disorders in TBI (shearing), severe depression. Kids who have cranial rediation damage�those cells do not come back�lead poisoning does impact exc functioning�remember with tbi�can be hit in front of head but b/c of coup contra coup�damage can be in the back also as wel as tru out! Kids with tics but doesn�t dev into touretts ( RED FLAG)..be monitoring for anxious temperment and ADHD�Kids who have cranial rediation damage�those cells do not come back�lead poisoning does impact exc functioning�remember with tbi�can be hit in front of head but b/c of coup contra coup�damage can be in the back also as wel as tru out! Kids with tics but doesn�t dev into touretts ( RED FLAG)..be monitoring for anxious temperment and ADHD�

36. Executive dysfunction can arise from damage to the primary frontal regions as well as to the densely interconnected secondary posterior or subcortical areas. The associated cognitive �partners� and �slave� systems must be present in order for the executive regulatory functions to have any operational purpose.

37. �Executive Function is a convenient shorthand that captures the problems of a group of patients...The levels should be kept separate; Executive function should not be confounded with �prefrontal� except at a hypothesis-generating level.� (Denckla, 1996) Neuroanatomy The 2 are not synomynusThe 2 are not synomynus