The Complete Picture

1. The Complete Picture

2. Like Drinking from a Fire Hydrant

3. Why the complete picture? • It’s not enough to know what to do, you should also know why • This is a complex neuro-genetic disorder • With a full understanding of the disorder, the strategies / accommodations make more sense • Is it a can’t or a won’t. Where to hold my child accountable • Knowledge is empowering • Allows you to problem solve when needed. • May not be the complete picture. Always learning more about ADHD

4. What is ADHD? • Most cases are a Developmental Disorder • Such disorders are delays in the rate with which human traits emerge over maturation • In ADHD the delays occur in two traits: • Inattention • Persistence, resistance to distraction, and task re-engagement following disruption • Hyperactivity-Impulsivity (Disinhibition) • Impaired motor inhibition, excessive and often task-irrelevant motor and verbal behavior • Disorder – a commonly seen cluster of symptoms • These get cataloged and placed in DSM

5. DSM-IV Criteria for ADHD • Manifests 6+ symptoms of either inattention or hyperactive-impulsive behavior • Symptoms are developmentally inappropriate • Existed for at least 6 months • Demonstrate cross-setting occurrence • Result in impairment in major life activities • Onset of symptoms producing impairment by 7 • Symptoms are not best explained by another disorder • 3 Types: Inattentive, Hyperactive, or Combined

6. DSM Inattention Symptoms • 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 Symptoms must occur “Often” or more frequently

7. Hyperactive-Impulsive Symptoms • 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 Symptoms must occur “Often” or more frequently

8. Difficulty with these symptom checklists given younger children? • What an assessment should include: • Current Concerns • history of the disorder / developmental progression • observations in multiple settings • info from multiple sources • severity of symptoms in comparison to same age peers • level of disruption • Differential diagnosis / comorbidity • Domains of impairment

9. Problems with DSM-IV Criteria • Symptoms are not appropriate to all ages • Need more items for adult stage of disorder • Symptom cutoffs are not age-referenced • Cutoffs are not sex-referenced • Duration may be too short for preschoolers: try 1 yr. • Age of onset of 7 has no validity

10. Problems with DSM-IV Criteria • Developmental deviance undefined • Implies need for parent-teacher agreement • No requirement for corroboration by others (adults) • Inattention list may miss or misname problems • Executive functioning, e.g. Working memory • Sluggish cognitive tempo

11. DSM 5 Criteria - Changes • Age of onset • Several noticeable symptoms present by age 12 • # of symptoms by age • minimum of 4 symptoms needed if a person is 17+ • 6 or more symptoms for under 17 years of age • Recommending teachers as sources of information • Information obtained from parentsand teachers • Pediatric office exam may or may not be informative • Confirmatory observations by third parties should be obtained whenever possible

12. DSM 5 Criteria - Changes • Added 4 new symptoms to the Hyperactivity / Impulsivity aspect • Tends to act without thinking • Starting tasks without adequate preparation • Avoiding reading or listening to instructions • Speak out without considering consequences • make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend • Is often impatient • Feeling restless when waiting for others • Wanting to move faster than others, • Wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others • Is uncomfortable doing things slowly and systematically / often rushes through activities or tasks • Finds it difficult to resist temptations or opportunities, even if it means taking risks. • Committing to a relationship after only a brief acquaintance • taking a job or entering a business without due diligence

13. ADHD Prevalence (United States) • 3-8% of children • Varies by sex, age, social class, & urban-rural • 12-15% of U.S. military dependents • No evidence for ethnic differences that are independent of social class • 5% of adults • 3:1 males:females • 5:1-9:1 in clinical population

14. Rising ADHD rates(CDC data June 2012) • Nearly 1 in 5 H.S. age boys • 11 percent of school age children • 15% of school aged boys • 7% of school aged girls • HS age only 14 – 17% (10% for girls / 19% for boys) • This is a marked rise over the last decade • 16% increase since 2007 • 41% rise in the past decade • Two thirds of those with a current diagnosis receive prescriptions for stimulants

16. Why? • Mild symptoms are being diagnosed readily • Behavior problems are being used as evidence for ADHD • Quick diagnosis without full evaluation • Performance enhancement – Can improve behavior and focus even in mild cases • Accommodation hunting for SAT / ACT • Powerful marketing by pharmaceutical companies to parents.

17. Potential negative outcomes • Overuse of medication • Predictable problems – Abuse, sharing, misuse. • Continued cost of Dr. visits and meds • Increased false positives • New DSM-V criteria will likely increase the diagnosis rates. • Symptoms before 12 rather than 7 • Older age examples (losing cell phone, losing focus during paperwork) • Symptoms merely impact daily activities rather than cause impairment.

18. Prevalence (Internationally) • Canada: 3.8-9.4% kids (DSM-III-R) • Australia: 3.4% of kids (DSM-III-R) • New Zealand: 6.7% kids, 2-3% teens (DSM-III-R) • Germany: 9.6% (DSM-III); 4.2% children (DSM-III-R) • India: 5-29% children (DSM-III) • China: 6-9% children (DSM-III-R) • Netherlands: 7.8% kids (DSM-IV) • Puerto Rico: 9.5% child & teens (DSM-III) • Spain: 8% (DSM-III-R) • Japan: 7.7% children (DSM-III-R ratings) • Colombia: 2-13% (DSM-IV ratings) • Brazil: 5.8% of 12-14 year olds (DSM-IV) ADHD is a universal disorder

19. ADHD Related Deficits Cognitively, Socially, Academically, Developmentally

20. Inattentive Subtype and Executive Functions Problems of Executive Functioning

21. Executive Functions • An umbrella construct that includes a collection of interrelated functions • These functions are responsible for purposeful, goal directed, problem solving behavior. • The ability to maintain a problem solving set for attainment of a future goal • Significant problems with these functions in ADHD children • (Codding, Lewandowski, Gordon, 2003)

22. Executive Functions • Inhibit – control impulses, appropriately stop own behavior at proper time • Shift – Move freely between tasks, transition, flexible in problem solving • Emotional Control – Modulate emotional responses appropriately • Initiate – Independently begin a task or activity, generate ideas • Working Memory – Hold info in mind for purpose of completing a task • Plan / Organize – Anticipate future events, set goals, carry out tasks in systematic manner • Org of Materials – Keep workspace / materials in orderly manner • Monitor – Keep track of own behavior and effect, assess performance during or after task to ensure goal attainment

23. Associated Cognitive Deficits • Slower, more variable reaction time • More impulsive errors and missed signals • Poor interference control (distractible) • Reduced sensitivity to errors • Greater attention to task-irrelevant information • Poor mental computation and memory for verbal sequences (digit span reversed) • Concrete, disorganized story recall

24. Associated cognitive deficits • Poor problem solving and strategy development • Deficient spatial memory • Delayed internalization of speech • Necessary for goal directed behavior • Steeper reward discounting • Diminishes the value of delayed rewards • Poor time reproduction (Impairment of time) • Can sense time but can’t use it to guide behavior • Time blindness – Temporal Myopia

25. Childhood Developmental Risks • Language Disorders • Expressive -10-54% • Pragmatic deficits in 60% • Developmental Coordination Disorder • Reduced Physical Fitness, Strength, & Stamina • Accident Proneness • 1.5 to 4 x risk of injuries • 3 x risk for accidental poisonings

26. Childhood Academic Impairments • Poor School Performance (90%+) • Reduced productivity is greatest problem • Low Academic Achievement (10-15 pt. deficit) • Low Average Intelligence (7-10 point deficit) • Failure to keep pace with peers • Poor executive functioning that can impact test performance • Learning Disabilities (24-70%) • Reading - 15-30% • Spelling - 26% • Math - 10-60% • Handwriting (60%; Mayes, Calhoun, Lane, 2002) • ADHD may contribute to later reading comprehensions deficits through its impact on working memory

27. Social-Emotional Impairments • Increased parent-child conflict & stress • Greater parental commands • Reduced responsiveness • More child noncompliance and negativity • Reduced duration of compliance • Reduce self-confidence in parental role • Greater maternal depression • Peer Relationship Problems • Less sharing, cooperation, turn-taking • More talking, commanding, intrusive, hostile • Most serious in ODD/CD subgroup • Poor Emotional Control • More anger, frustration, hostility (ODD/CD) • Less self-regulation of other emotional states

28. Etiology of ADHD What may be causing this disorder?

29. Etiologies: Food Allergies & Miscellaneous Factors • Sugar - Disproven • Hyper/hypoglycemia - No evidence • Food Allergies - Largely disproven • Possibly 5% of ADHD Preschoolers react adversely to high doses of food additives • Side Effects of Anticonvulsants (10-35%) • mainly to phenobarbital and dilantin • Thyroid abnormalities - Unlikely • Rare in children • Evidence is conflicting

30. Etiologies - Psychosocial • Excessive Television /Videogames • No evidence (Acevedo-Polakovich, Lorch, Milich, 2005) • Cultural Tempo/Fast-Paced Society • No evidence • Family Stressors - Linked to ODD/CD • Poor Child Management - Linked to ODD/CD • Low Self-Esteem - A late occurring consequence • Learning Disabilities - Comorbid not causal • Intolerant Teachers/Parents - No evidence

31. Etiologies – What we’re pretty sure of • Disorder arises from multiple causes • All currently recognized causes fall in the realm of biology (neurology, genetics) • Causes may compound each other • Neural location for disorder appears to be the fronto-striatal-cerebellar circuits in the brain • Social causes lack credibility • Pre and Perinatal risk factors can impact the development of this part of the brain

32. Cigarette Exposure Alcohol Exposure Drug Exposure Low Birth Weight Psychosocial Adversity SES Age at Birth Parental IQ Parental ADHD Parental CD 1 Pre- and Perinatal Risk Factors for ADHD (Biederman & Colleagues) Results from Logistic Regression Model 0 2 4 6 8 10 Odds Ratio (ADHD versus Control)

33. Neurology • Postnatal Brain Damage (3-5%) • Head trauma, brain hypoxia, tumors, or infection • Lead poisoning in preschool years (0-3 yrs.) • Survival from acute lymphoblastic leukemia (ALL) • Treatments for ALL cause brain damage • Post-natal Streptococcal Bacterial Infection • triggers auto-immune antibody attack of basal ganglia • Pre-and post-natal elevated exposure to phenylalanine (dietary amino acid related to PKU) • Prenatal – hyperactivity • Post-natal – inattention

34. Neuro-Imaging Findings • Smaller, Less Active, Less Developed Brain Regions • Orbital-Prefrontal Cortex (primarily right side) • Basal Ganglia (mainly striatum & globus pallidus) • Cerebellum (central vermis area, more on right side) • Size of this network is correlated with degree of ADHD symptoms, particularly inhibition

35. Activity = Neurochemicals • Neurotransmitters • Chemical substances that carry messages between neurons. • Sending neuron releases small amounts of a neurotransmitter, and this activates receptors on the receiving neuron. • Receptor activation then initiates a series of chemical changes in the receiving neuron, and if enough receptors are activated, the receiving neuron may itself become active and send the message along.

37. Neurochemical Deficits • Dopamine dysregulation – Too little • Norepinephrine dysregulation – Too little • Medication helps with distribution of neurotransmitters in id’d brain regions • Stimulants increase dopamine outside nerves • Methylphenidate - Slows re-uptake • Amphetamines - Increases production/release • Strattera decreases norepinephrine reuptake

38. Heredity – Family Studies • Family Aggregation of Disorder: - 25-35% of siblings - 78-92% of identical twins - 15-20% of mothers - 25-30% of fathers - If parent is ADHD, 20-54% of offspring (odds 8+)

39. ADHD group Control group ADHDFamily Studies ADHD in family members of ADHD children Biederman et al (1990) Cantwell (1972) Morrison & Stewart (1971) 0 5 10 15 20 25 30 Percent

40. How long does it last? • Developmental Disorder – Do symptoms develop?

41. Persistence of Disorder • Symptoms decrease somewhat with age • Adolescence: (Based on parent reports) • 50% persistence to adolescence (1970-80s) • 70-80% in modern DSM studies (1990s onward) • Young Adulthood (age 20-26) (Barkley et al. 2002) • 46% Full disorder • 66% Using 98th percentile (parent report) • 85-90% remain functionally impaired

42. Decline in ADHD Symptoms from Teens to Adulthood (DSM3R) Parent reports

43. Development of Inhibition and Self-RegulationHypothetical Growth Curve – 30% Delay

44. Children Difficulty paying attention No follow through Can’t organize Loses impt items Squirming/ Fidgety Can’t stay in seat Can’t wait turn Runs excessively Can’t play quietly Interrupts others Adult Difficulty paying attention Procrastination Poor time mgmt Disorganized Inefficiency at work Can’t sit through mtgs Can’t wait in line Drives too fast Selects active job Makes inappropriate comments Symptom Course

45. Treatments

46. Major Treatment Approaches • Evaluation / Diagnosis • Education / Counseling • Medication • Accommodations / Strategies / Interventions • at home • in school • in the community • Maturation (accounts for 3-4x more change)

47. Buyer Beware • Elimination Diets • Sodium benzoate (Can increase hyperactivity / distractibility, but does not cause ADHD; Shaw, 2008, NIMH) • Megavitamins, Anti-oxidants, Minerals • (No compelling proof or disproved) • Sensory Integration Training (further research needed – Vargas & Camilli, 1999) • Chiropractic Skull Manipulation (no proof) • Play Therapy, Psycho-therapy (disproved) • Self-Control (Cognitive) Therapies (in clinic) • Social Skills Therapies (in clinic)

48. Empirically Proven Treatments • Parent Education About ADHD • Psychopharmacology • Stimulants • Noradrenergic Medications • Tricyclic Anti-depressants • Anti-hypertensives • Parent Training in Child Management • Children (<11 yrs., 65-75% respond) • Adolescents (25-30% show reliable change) • Family Therapy for Teens • Problem-Solving, Communication Training (30% show change)

49. Empirically Proven Treatments • Teacher Education About ADHD • Teacher Training in Classroom Behavior Management • Special Education Services (IDEA, 504) • Physical Exercise • Residential Treatment (5-8%) • Parent/Family Services (25+%) • Parent/Client Support Groups (CHADD, ADDA, Independents) • Biofeedback (EEG) (experimental) • Difficulty with research design • AMA – “worthy of further research”

50. Treatments EEG Biofeedback