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ADHD and the Brain Non-medication Treatments for ADHD

ADHD and the Brain Non-medication Treatments for ADHD. Sharon Mock, LPC-S, Ed.D . Sharon Mock, LPC-S, Ed.D . Author: Academic Success of emotionally disturbed students owner: Center for research and academic success Psychotherapist in private practice in Kerrville, Texas. Goals .

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ADHD and the Brain Non-medication Treatments for ADHD

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  1. ADHD and the BrainNon-medication Treatments for ADHD Sharon Mock, LPC-S, Ed.D.

  2. Sharon Mock, LPC-S, Ed.D. Author: Academic Success of emotionally disturbed students owner: Center for research and academic success Psychotherapist in private practice in Kerrville, Texas

  3. Goals Review of ADHD Symptoms and Impairment Brain Imaging Genetic Links Research Findings on ADHD Treatment Implications Traditional Treatments Non-medication Treatments

  4. What is ADHD • Frequent • Affects 4.4% of population • Kessler et al. 2005 • Lifetime Disorder • Debilitating • Under diagnosed • Treatable

  5. Diagnostic Criteria from DSM IV • Inattentive Type • Must meet at lest 6/9 symptoms • Daydreaming • Forgetfulness • Losses items frequently • Hyperactive/Impulsive Type • Must meet at least 6/9 symptoms • Driven by a motor • Interrupting • Excessive talking • If a patient meets at least 6/9 or more symptoms in both categories: Combined Type

  6. Continued • Impairment must be in 2 of the following: • School • Family • Peers • The onset is before the age of 7 • Note that DSM-IV-TR diagnostic criteria is written for pediatric ADHD

  7. Growing out of ADHD • At least 50% of children retain the symptoms into adulthood • Frontal lobes mature at a slower rate • Don’t reach the maturation of a non ADHD brain • Adult ADHD presents differently: • Feel restless rather an hyperactive • MckAlemanet.al. 2009: Wilens 2004

  8. Adult ADHD Significantly lower socioeconomic status Lower level of academic achievement Higher medical costs Increase of motor vehicle accidents Increase of unplanned pregnancy Increase rate of substance abuse Higher rate of unemployment

  9. Affect of ADHD on Prefrontal Lobes • Prefrontal lobes of the brain hold the executive functions of the brain • Help to inhibit and self-regulate: • Direct • Process • Manage • Disseminate information

  10. Frontal Lobe and Pre-Frontal Cortex

  11. What are the Executive Functions that are Affected? • Working memory • Time Management • Behavioral Inhibition • Regulation of Emotions • Planning • Forethought • Learning from Consequences • Organization • Reconstitution of Information • Brown 2009, Barkley 2005

  12. Genetic Link to ADHD? • Executive function impairment in ADHD is genetic • At a rate of 75% • Several genes have been identified with ADHD • Hundreds of gene variations are found in children with ADHD and not the control group Elia et al. 2010, Guan et al. 2009, Rietveld et al. 2004

  13. Brain Structure Difference in ADHD? • Children with ADHD exhibit a smaller volume of frontal and temporal gray matter and it is correlated significantly with parent- and clinician- rated severity measures • Castellanos et al. 2002 • The ADHD brain was found to have a thinner cerebral cortex compared to the non-ADHD brain • The non-ADHD brain showed not signs of cortical thinning • Klein, 2011

  14. Brain Function in ADHD • In children with ADHD, there is a disconnect between the frontal cortex of the brain, which regulates attention, and the visual processing areas of the brain • This difference does not occur in non-ADHD children • Therefore, the way the brain pays attention is biologically different in those with ADHD • Mazaheri et al, 2010

  15. Brain Function continued • Difficulty with reuptake of neurotransmitters • The ADD brain has a low amount of neurotransmitters called dopamine • VOLKOW ET AL, 2009 • Brain scans show a direction in dopamine synaptic markers associated with symptoms of inattention in the dopamine reward pathway of the ADD brain • VOLKOW ET AL, 2009

  16. ADHD: Disorder of Motivation or Inattention? • ADHD • Difficulty focusing on uninteresting tasks • Difficulty hyper focusing on interesting tasks The frontal lobes of the brain have difficulty getting motivated to start and stop tasks Executive Function Example: Person with ADHD surfing the Internet

  17. Difficulties in Focus and Concentration Sleep apnea (Youssef et al, 2011) Chronic otitis media Depression Anxiety The disorders can also be co morbid with ADHD

  18. Traditional Treatments

  19. Medications for ADHD Stimulants Non Stimulants ”FDA-approved for ADHD” means drugs have been found to be safe and efficacious in clinical trials Medications that are not FDA-approved for ADHD can be prescribed “off label”

  20. Stimulants • These medications • Increase attention • Decrease hyperactivity • Decrease impulsivity • Mechanisms of action • Increases dopamine

  21. Stimulant Medication for ADHD • Concerta (methylphenidate HCI extended-release) • Vyvanse (lisdexmfetamine) • Daytrana (methylphenidate) • Adderall XR (amphetamine of mixed salts) • Focalin XR 9dexmethylphenidate extended –release) • Side Effects • Dry mouth • Difficulty sleeping • Reduced appetite

  22. Is Substance Abuse increased because of Taking Stimulant Medication? • 10 year study of 140 children ages 6-17 • Assessed at baseline and 10years later • People with ADHD who took stimulant medication did not have a statistically significant increase in alcohol, drug, or nicotine use disorders • Biderman et al, 2008

  23. Non-Stimulant Medication for ADHD • Strattera (atomoxetine) • Side Effects • Headache • GI discomfort • Lightheadedness • Intuniv (guanfacineextended-release • Side Effects • Low blood pressure • drowsiness

  24. Medication • Impact on Executive Functions • Study on methylphenidate versus a placebo in adults with ADHD • Participants were given two MRI’s while completing an Executive function task • Before and after the 6 week study • Findings • After 6 weeks the MRIs in the methylphenidate group shower higher activation in the dorso-lateral prefrontal cortex and parietal center • Bush et al, 2008

  25. Time Released Effect

  26. Medication (Bush et.al. 2008)

  27. What do ADHD Medications Increase in the Brain? • Increases catecholamine levels in the brain • Methylphenidate • Dextroamphetamine • Atomoxetine • Improves pre-frontal cortex functioning • del Campo et al, 2011

  28. ADHD Young Adults and Stimulant Medications • Significantly improved driving performance on a simulator compared to the placebo group • ADHD rating scale scores were decreased by at least 35% in 80% of the stimulant medication group • Kay, et al. (2009)

  29. What Positives Come out of Medicating those with ADHD Gives the extra space to decide whether or not to interrupt Helps hold thoughts until a break in conversation Helps inhibit behavior Helps one to self-regulate behavior

  30. Psychotherapy • ADHD and couples therapy • Difficult planning ahead for important events • Birthdays • Anniversaries • Messages get garbled in translation • Difficulty remembering what upsets your partner • Impulsive spending and not saving up for retirement or emergencies • Partner may take ADHD related behavior personally

  31. Cognitive-Behavioral Psychotherapy for ADHD • Cognitive-Behavioral Approaches • Focused on changing attitudes and beliefs • Help research defined goals • Approaches • Changing Cognitions • ADHD can cause feelings of failure • Self-doubts and shame • Set goals and create concrete steps • Nadeau 2002

  32. Social Skills Training • Picking up on non-verbal cues • Appropriate person-to-person distance • Hula-hoop test • Standard distance during conversation • Basic social graces • The art of apology • Showing gratitude

  33. Effects of Coaching for ADHD • “Counseling lite” • Brief Interventions • Assistive support • Organization skills • Prioritizing skills • Goal-setting skills • Focus on the present and future • No addressing: • the family of origin • pathology

  34. Research on Coaching (Parker and Boutelle, 2009) • Study of 54 undergraduates with ADHD and /or LD • 7 in-depth interviews • Opinions after coaching • Provided a self-determination approach to attaining goals • Supported their autonomy • Assisted in the development and execution of functional skills • Promoted self-efficacy and confidence regarding future success

  35. Effective Movement Techniques Exercise Integrated movement systems Yoga Karate Tai Chi

  36. Exercise • Raises dopamine levels in the brain • Volkow et al. 2009 • If done first thing in morning, it can keep the dopamine at an increased level all day long • Exercising with a partner can increase the motivation to continue to exercise

  37. Study: Tai Chi and ADHD (Hernandez-Reif, et al. 2001) • 13 Teenagers with ADHD attended Tai Chi • Twice a week • 5 weeks • Teachers rated their behavior • before, • after, • two weeks after sessions were completed

  38. Continued • After all the sessions (10), the participants were rated with: • Less anxiety • Improved conduct • Less daydreaming • Less inappropriate emotions • Less hyperactivity • Improved scores were found after the 2 week follow up • (Hernandez-Reif, et al. 2001)

  39. Is it the Discipline? Yoga, karate and tai chi emphasize form and practice Is it the discipline or practice or both?

  40. Frontal Lobe/Working Memory Training Improving cognitive ability “Brain Gym” Integrative listening systems “Tomatis Method” Interactive Metronome

  41. Working Memory One of the executive functions (EF) in the frontal lobe of the brain ADHD produces an impairment Some treatments focus on improving working memory and overall cognitive function

  42. Working Memory (Cont) Temporary Storage Output of Information Manipulation of Information Processing Information

  43. Decreased Activation During a Working Memory Task

  44. Working Memory Training • Computer programs • Tasks that train verbal and visual spatial working memory • Difficulty level increased with progress • Client is monitored by a “coach” • Daily training sessions • 30-40- minutes 5 days a week for 5 weeks • Klingberg 2006

  45. Study Results • Multicenter, randomized, controlled, double-blind, follow –up study • 53 ADHD children 7-12 years old, without medication • Assigned to WMT group or control group • WMT group had significant improvements on measures of non trained visual spatial and verbal working memory • In areas of visual spatial and verbal working memory • Response inhibition • Complex Reasoning • Most effects were present 3 months after the study in a follow up • Klingberg et al. 2005, Starkis, 2012

  46. Attention Training • Trains the following Sustained Selective Alternating Divided Attention • Brain Train • Play Attention • 23 children participants • 16 sessions • Parents and clinicians rated fewer ADHD symptoms • Unable to define if it is sustained for a long term • Klingberg et al, 2005, Sarkis, 2012

  47. Attention Training Continued • Learning Prescriptions • Cognitive-Fun • 10 sessions • Parent/child Dyad • Assessment of Executive Function and occupational performance • Initial, post-intervention and 3 month follow up • Significant improvements with medium to large effects on measures after intervention and at follow up

  48. Tomatis Method • This addresses the “Central Auditory Processing Disorder” (CAPD) • Those with CAPD can hear in the sense there is no damage to the ear’s ability to receive and perceive sounds • But, they cannot fully process the information they hear due to the inability of the ear and brain to communicate properly. • Uses sound through an electronic device • Works to strengthen the auditory system and the central nervous system • The goal: Awaken the connections needed for the brain to process auditory information

  49. Tomatis Program • 30 hour program • 2 hours daily for 15 days (excluding weekends) • Follow with 2 sixteen hour programs • 4 weeks to 3 months between each session

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