Attention-Deficit/Hyperactivity Disorder (ADHD) and Gambling Disorders in Adults

1. Attention-Deficit/HyperactivityDisorder (ADHD) and Gambling Disorders in Adults • RORY C. REID, Ph.D., LCSWAssistant Professor, Research Psychologist / NeuropsychologyDepartment of PsychiatryUniversity of California, Los Angeles • UCLA Gambling Studies Program

2. Overview of Presentation • What is ADHD: Brief Summary? • The ADHD Brain • What Causes ADHD? • Why ADHD and Problem Gambling? • Assessing ADHD: DSM-5 Criteria • Treatments / Special Considerations

3. What is ADHD? A Brief Summary

4. ADHD and Gambling Disorders

5. What is ADHD: Brief Summary • Attention-deficit/hyperactivity (ADHD) is a neurodevelopmental disorder beginning in childhood with symptoms persisting into adulthood for a substantial number of individuals. • The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. • Population surveys suggest that ADHD occurs in most cultures in about 5% of children and about 2.5% of adults.

6. What is ADHD: Brief Summary cont… • Inattention manifests behaviorally in ADHD as wandering off task, lacking persistence, having difficulty sustaining focus, and being disorganized and is not due to defiance or lack of comprehension. • Hyperactivity refers to excessive motor activity and in adults, hyperactivity may manifest as extreme restlessness or wearing others out with their activity.

7. What is ADHD: Brief Summary cont… • Impulsivity refers to hasty actions that occur in the moment without forethought and that have high potential for harm to the individual (e.g., risky sexual behavior, reckless driving). Impulsivity may reflect a desire for immediate rewards or an inability to delay gratification. Impulsive behaviors may manifest as social intrusiveness (e.g., interrupting others excessively) and/or as making important decisions without consideration of long-term consequences (e.g., taking a job without adequate information).

8. The ADHD Brain

9. The ADHD Brain • Diminished arousal of the Nervous System • Decreased blood flow to prefrontal cortex and pathways connecting limbic system (caudate nucleus and striatum) • PET scans show decreased glucose metabolism throughout the brain. • Similarities of ADHD symptoms to thosefrom injuries and lesions of frontal lobeand prefrontal cortex.

10. The ADHD Brain cont… • MRI Scans in ADHD patients show: • Smaller anterior right frontal lob suggesting abnormal development in frontal and striatal regions • Significantly smaller splenium or corpus callosum potentially contributing to diminished communication and information processing between brain hemispheres. • Smaller caudate nucleus.

11. Attention Networks in the Brain • There are primary 3 different attentional networks • Alerting • Orienting • Executive Petersen, S. E. & Posner, M. I. (2012). The attention system of the human brain: 20 years after. Annual Review of Neuroscience, 35, 73-89.

12. What Causes ADHD?

13. What Causes ADHD? • Underlying cause or etiology is still unknown with conflicting data between studies. • Strong evidence of genetic component • Predominant theory: Catecholamine neurotransmitter dysfunction or imbalance that impacts decreased dopamine and/or norepinephrine uptake. • Premature birth (under developed brain) • Maternal alcohol and tobacco use • Exposure to high levels of led in early childhood • Brain injuries, especially involving prefrontal cortex

14. Why ADHDAND Problem Gambling?

15. Why ADHD and Problem Gambling? • Current studies suggest that the prevalence of adult ADHD in problem gamblers is ~ 10 – 20%. • Perhaps the more relevant question is why are individuals with ADHD at increased risk for a variety of addictive behaviors, in particular: Alcohol and DrugAddictions (19% - 33%) Hypersexual BehaviorSex Addiction (23% to 28%)

16. ADHD Vulnerability to Hypersexual Behavior Common ADHD challenges: • Social rejection • Loneliness • Academic underachievement • Emotional dysregulation • Difficulties with task-completion • Poor self-concept • Diminished identity-formation • Relationship difficulties • Attrition from college • Poor work performance Increased tendency to escape, disconnect, numb out, etc…

17. Attentional Model of Problem Gambling Inability to sustain attention and vigilanceon the target stimuli, and inhibit focused attention to the distractor stimuli. Target Stimuli Distractor Stimuli

18. Alternative Attentional Model of Problem Gambling Attentive Condition Inattentive Condition Work Gambling Gambling Work Signal Strength Target Distractor Target Distractor

19. Assessing ADHD:DSM-5 Criteria

20. Assessing Adult ADHD: DSM-5 Criteria • Typically Adult ADHD can be assessed using several approaches including: • Diagnostic interview for ADHD • Self-report questionnaires • Collateral information • Neuropsychological testing Note: No biological marker is diagnostic for ADHD. As a group, compared with peers, chil­dren with ADHD display increased slow wave electroencephalograms, reduced total brain volume on magnetic resonance imaging, and possibly a delay in posterior to anterior cortical maturation, but these findings are not diagnostic.

21. Assessing Adult ADHD: DSM-5 Criteria cont… • Meaningful changes to the DSM-5 criteria include: • Age of onset raised from age 7 to 12 • Fewer symptoms required for adults; 5 out of 9 • More examples of symptoms manifest in adults • Comorbidity with autistic spectrum disorders allowed

22. Assessing Adult ADHD: DSM-5 Criteria cont… • Omissions in DSM-5: • Behaviorally-focused emphasis that does not adequately reflect the underlying cognitive difficulties • Inadequate information on important role of emotions in ADHD. It does not pick up the impaired motivational aspect of emotions which makes it so difficult for many with ADHD to get started on or sustain effort for tasks not intrinsically interesting to them. And it does not include any symptoms that reflect characteristic problems of persons with ADHD in modulating their experience and expression of emotions.

23. Assessing Adult ADHD: DSM-5 Criteria cont… • Omissions in DSM-5: • DSM-5 does not recognize the importance of problems in regulating sleep and alertness which have been identified in research on ADHD in children and adults. Thomas E. Brown, Ph.D.Yale University

24. Assessing Adult ADHD: DSM-5 Criteria cont… • Review • Self-Report Questionnaires • ADHD Diagnostic Interview of DSM-5 Criteria • Neuropsychological Testing • Example of ADHD Diagnostic Protocol • Special Consideration with Gambling Disorders

25. Assessing Adult ADHD: DSM-5 Criteria cont… • Self-Report Questionnaires • Adult ADHD Self-Report Scale • Conners Adult ADHD Rating Scale • Behavior Rating Inventory of Executive Functions • Neuropsychological / Psychological Testing • Wechsler Adult Intelligence Scale • Delis–Kaplan Executive Function System

26. Inattention & Time Estimation: An Illustration An accurate estimation of how long something will take to complete requires several aspects of attention.

27. Associated Issues in Adults with ADHD Problems with Sleep Disorders Problems with Obesity

28. Treatment Issues &Special Considerations for Adult ADHD and Gambling Disorders

29. Treatment of ADHD and Gambling Disorders Handout on Treatment Recommendations Example of Referral Letter to Medical Provider

30. Mindfulness and Attention Using Mindfulness to Increase Focus and Attention

31. Mindfulness Applications • Outcome studies have provided evidence that mindfulness can be helpful for attenuating psychological distress associated with a number of mental health issues including: • Anxiety / Depression • Eating Disorders • Obsessive-Compulsive Disorders • Pathological Gambling • Substance-Related Disorders • Hypersexual Behavior

32. Mindfulness and Attention

33. Goodness of Fit for Mindfulness & Gambling

34. Mindfulness and Cravings Addictive cravings are powerful and can be intense Patients often get into a tug-of-war with cravings Patients often give special status to cravings Patients have an adversarial relationship with cravings Cravings Gambling Consequences Reorganize relationship with craving to co-exist Neither avoiding nor indulging, just being present in a non-judgmental, curious manner

35. Developing a New Relationship with Cravings Dr. HedyKober, Assistant Professor Yale University School of Medicine

36. Mindfulness, Emotions, Stress, Impulsivity, & Gambling Gambling Anxiety Depression Stress Impulsivity Mindfulness

37. Shame and Self-Compassion

38. Focus of Mindfulness in Gambling & ADHD • Using Mindfulness, we attempt to target: • Increased tolerance for cravings and urges • Increased tolerance for emotionally uncomfortable experiences • Increase stress tolerance • Increased ability to focus attention • Increased ability to be present with the self

39. THE END

40. Attention-Deficit/HyperactivityDisorder (ADHD) and Gambling Disorders in Adults • RORY C. REID, Ph.D., LCSWAssistant Professor, Research Psychologist / NeuropsychologyDepartment of PsychiatryUniversity of California, Los Angeles • UCLA Gambling Studies Program