Attention Deficit/Hyperactive Disorder

1. David Lombard, Ph.D. Center for Applied Behavioral Studies www.LegalShrink.com Attention Deficit/Hyperactive Disorder

2. Overview • What Is AD/HD • What Causes AD/HD • How Common • Common Symptoms • Common Treatments • Comparison with Conduct Disorder

3. What is AD/HD? …A medical condition characterized by inattention and/or hyperactivity-impulsivity. …One of the most common mental disorders among children, affecting approximately 5 to 7 % of school-age children and about 2-5% of adults

4. What is AD/HD? • Persistent inability to pay attention • May have additional characteristics of hyperactive motor movements and/or impulsivity • Usually begin before age 7 but may not be noticed until child is older

5. What is AD/HD • Symptoms of inattention and/or hyperactivity must be present in at least two environments • Symptoms must cause problems for the individual in their environment

6. What causes AD/HD? • Decreased amount of certain neurotransmitters • There may be a genetic association • Appears more often in children whose parents suffer from AD/HD, alcohol dependence and/or mood disorders

7. Prevalence in the US • About 2 million children • About 5 million adults

8. Prevalence World-Wide Australia 3.4% of kids New Zealand 6.7% kids, 2-3% teens Germany 4.2% children India 5-29% children China 6-9% children Netherlands 1.3% teens Puerto Rico 9.5% child & teens Japan 7.7% children Mexico approx. 5% childrenBrazil 5.8% of 12-14 year olds

9. How common is AD/HD? • More common in males than females with studies showing a ratio of between 3:1 and 4:1 • As many as 5 out of every 100 children may have AD/HD

10. What are the signs of AD/HD? • Three main symptoms (signs) • Problems paying attention • Being very active (hyperactivity) • Acting before thinking (impulsivity)

11. Three Types of ADHD 1. ADHD, predominantly inattentive type 2. ADHD, predominantly hyperactive-impulsive type 3. ADHD, combined type ADHD, NOS is a category for people who have some ADHD symptoms, but not enough to meet full criteria for the condition.

12. DSM-IV Criteria • Inattentive type (6 of 9 needed) • Fails to give close attention to details • Difficulty sustaining attention • Does not seem to listen • Does not follow through on instructions • Difficulty organizing tasks or activities • Avoids tasks requiring sustained mental effort • Loses things necessary for tasks • Easily distracted • Forgetful in daily activities

13. DSM-IV Criteria • Hyperactive-impulsive type (6 of 9 needed) • Fidgets with hands or feet or squirms in seat • Leaves seat in classroom inappropriately • Runs about or climbs excessively • Has difficulty playing quietly • Is “on the go” or “driven by a motor” • Talks excessively • Blurts out answers before questions are completed • Has difficulty awaiting turn • Interrupts or intrudes on others

14. DSM-IV Criteria • Combined type • Symptoms of both types described • At times all children are inattentive, impulsive and too active • With children with AD/HD these behaviors are the rule not the exception

15. DSM-IV Criteria • Developmentally Inappropriate Levels • Duration of 6 Months • Cross-setting Occurrence of Symptoms • Impairment in Major Life Activities • Onset of Symptoms/Impairment by 7 • Exclusions: Severe MR, PDD, Psychosis • Subtyping into Inattentive, Hyperactive, or Combined Types

16. ADHD is Not… • Will power • Inadequate parenting • Lack of motivation • Lack of intelligence • Laziness

17. What are long-term effects? • Without effective treatment AD/HD can result in serious problems • Academic failure • Relationships • Legal difficulties • Smoking and SUD • Injuries • Motor vehicle accidents • Occupational/vocational

18. ADHD Treatments • Education • Medication • Behavior Modification • Classroom/Workplace Accommodations

19. Commonly Used Stimulant Medications for ADHD Methylphenidate (MPH) Products Ritalin short & mid-acting formsConcerta long-acting Metadate CD mid-acting Ritalin LA mid-actingFocalin mid-acting Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+

20. Commonly Used Stimulant Medications for ADHD Amphetamine Products Adderall mid-acting Adderall XR long-acting Dexedrine mid-acting Dextrostat mid-acting Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+

21. Commonly Used Non-Stimulant Medications for ADHD • Nonstimulant Products Strattera long-acting • Other Nonstimulant Products Wellbutrin long-acting Tenex mid-acting Clonidine mid-acting Short acting = 3-5 hours; Mid-acting = 6-8 hours; Long acting = 12 hours+

22. What are side effects of treatment? • Headache • Involuntary muscle movements • Loss of appetite • Mood changes as medication wears off • Sleep difficulty • Weight management problems

23. Conduct Disorder

24. Conduct Disorder • The term conduct disorder has traditionallybeen used to characterize children who display a broad range of behaviors that bring them into conflict with their environment. • These include behaviors that are probably best described as coercive or oppositional; • temper tantrums, • defiance, • noncompliance

25. Conduct Disorder • Also included under this general heading have been behaviors of a more serious nature (e.g., cruelty to people or animals, aggressiveness, stealing) . • These are more serious in that they • represent a greater threat to those the child interacts with and/or • have the potential of bringing the child into contact with the juvenile justice system

26. Types of Conduct Disorders • DSM IV features usually associated with the general label of conduct disorder are subdivided in order to provide for the diagnosis of two specific patterns of behavior; • Oppositional Defiant Disorder (ODD) • Conduct Disorder (CD)

27. Conduct Disorder • Symptoms • Bullies, threatens or intimidates others • Often initiates physical fights • Has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun)

28. Conduct Disorder • Symptoms • Is physically cruel to people or animals • Steals from a victim while confronting them (e.g. assault) • Forces someone into sexual activity

29. Conduct Disorder • Symptoms • Deliberately engaged in fire setting with the intention to cause damage • Deliberately destroys other's property

30. Conduct Disorder • Symptoms • Broken into someone else's building, house, or car • Lies to obtain goods, or favors or to avoid obligations • Steals items without confronting a victim (e.g. shoplifting, but without breaking and entering)

31. Conduct Disorder • Symptoms • Often stays out at night despite parental objections • Runs away from home • Often truant from school

32. Co-Morbidity • As with ADHD, children with Conduct Disorders frequently display other types of problems • Between 34.7 and 48 % of children and adolescents with CD also show evidence of ADHD. • Co-morbidity estimates ranging from 12 to 17.6 % have been found for depressive disorders. • As many as 19% of children/adolescents with CD qualify for a diagnosis of anxiety disorder.

33. Break Time

34. David Lombard, Ph.D. Center for Applied Behavioral Studies www.LegalShrink.com Cutting and Self-Mutilation

35. Overview • What is Cutting and Self-Mutilation • Theories of Why People Cut • Is it Suicide, a Cry for Help, or Coping • How is it Treated • What to Ask to Assess Risk • What are Your Options for Intervention

36. What do they have in common? • Angelina Jolie • Christina Ricci • Courtney Love • Princess Diana

37. How Common? • 12% to 14% of adolescents reported self-injury behavior • 40% to 61% in adolescent inpatient settings • Higher proportion of females (64%) than males (36%) • 750 per 100,000- general population • Typical onset-puberty • Persist for five to ten years or longer

38. The Cutting Culture • Websites-“Blood Red” -“Razor Blade Kisses” -“The Cutting World” • Films- “Thirteen” • Genre of music- “emo”

39. Examples of Cutting

40. Examples of Cutting

41. Examples of Cutting

42. Examples of Cutting

43. What is Cutting • Purposeful use of Sharp Objects for Goal of Cutting Skin and Seeing Blood • Cutting Tools: • Knives, Razors, Needles, Cut Glass, Fingernail, Surgical Blades, Paper

44. What is Cutting • Most Commonly – Arms, Shoulders & Thighs • More Advanced – Hips Below Belt Line (hidden and felt more when walking), Top of Feet, Underarms, Lower Buttock • More Dangerous – Inside of Mouth, Private Areas, Pre-Existing Surgical Scars

45. What is Self-Mutilation • Often Seen the Same as Cutting • Much Worse in Severity/Scope of Damage • Destruction of Large Sections of Tissue Through Cutting, Tearing, Biting, or Repetitive Puncturing • Always Hospitalize

46. “I cut….” 'to run away from my feelings' 'to feel pain on the outside instead of the inside' 'to cope with my feelings' 'to express my anger toward myself' 'to feel like I'm real' 'to turn off emotions and hide from reality' 'to tell people that I need help' 'to get people's attention'

47. “I cut….” 'to tell people I need to be in hospital' 'to get people to care about me' 'to make other people feel guilty' 'to drive people away' 'to get away from stress and responsibility' 'to manipulate situations or people'

48. Theories of Why People Cut • To Feel • Due to Abuse, Neglect, or Other Significant Life Trauma the Person Cannot Feel • In Sad Situations, They Want to Feel Something…So Cut. • Allows Them to Feel Physical Pain When They Have No Emotional Pain

49. Theories of Why People Cut • Distraction • Due to Overwhelming Emotional Pain or Problems Dealing with Emotional Pain • Allows the Shift in Focus From Emotional Pain to Physical Pain • Easier to Understand and Deal With

50. Theories of Why People Cut • Punishment • Person Has Failed at Something, Hurt Someone, Or Displeased Themselves • A Way to Punish…Clearly Defined…Clearly Punitive • In These Cases, Severity of Cutting Increases to Mutilation Frequently