The ADHD Story James J. Messina, Ph.D.


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The ADHD Story James J. Messina, Ph.D.

  1. 1. The ADHD Story James J. Messina, Ph.D. Go to: for ADHD Articles & Links
  2. 2. ADHD a Neurobiological Condition is related to SLD <ul><li>A ttention D eficit H yperactivity D isorder (ADHD) - with Inattention and/or Impulsivity </li></ul><ul><li>S pecific L earning D isability (SLD) - with Auditory, Visual or Kinesthetic Processing Problems including Dyslexia/Reading Disorder </li></ul>
  3. 3. Other Neurobiological Conditions Related to ADHD: <ul><li>Central Auditory Processing Disorder (CAPD) </li></ul><ul><li>Sensory Integration Disorder </li></ul><ul><li>Motor Planning Disorder </li></ul><ul><li>Self-Regulatory Disorder </li></ul><ul><li>Autistic Spectrum Disorder - PDD, MSD, Globally Delayed, Autistic </li></ul><ul><li>Neurological Conditions: Epilepsy, Tourette Syndrome </li></ul>
  4. 4. What Research is Telling Us about ADHD <ul><li>Genetically transmitted in 70-95% of cases </li></ul><ul><li>Results from chemical imbalance or deficiency in certain neurotransmitters-chemicals which help brain regulate behavior </li></ul><ul><li>Rate at which brain uses glucose, its main energy source, is lower in subjects with ADHD than those without (Zametkin et al, 1990) </li></ul><ul><li>Depressed release of Dopamine might have role in ADHD (Volkow et al, 2003) </li></ul>
  5. 5. Research also tells us about ADHD that: <ul><li>Central pathological deficits of ADHD are linked to several specific brain regions </li></ul><ul><ul><li>Frontal Lobe </li></ul></ul><ul><ul><li>Its connections to Basal Ganglia </li></ul></ul><ul><ul><li>Their relationships to central aspect of Cerebellum </li></ul></ul><ul><li>Less electrical activity in brain & show less reactivity to stimulation in one or more of above brain regions </li></ul><ul><li>Brains are 3-4% smaller-in more severe-frontal lobes, temporal gray matter, caudate nucleus & cerebellum were smaller </li></ul>
  6. 8. PET Scan of Metabolism of Glucose Adult Brain with ADHD <ul><li>Positron Emission Tomography (PET) Pictures of </li></ul><ul><li>Adult with ADHD Normal Adult </li></ul>
  7. 9. ADHD & LD lead to Diminished Executive Functions <ul><li>Deficient self-regulation of behavior, mood, response </li></ul><ul><li>Impaired ability to organize/plan behavior over time </li></ul><ul><li>Inability to direct behavior toward future </li></ul><ul><li>Diminished social effectiveness & adaptability </li></ul>
  8. 10. What is the Impact of these Disorders? <ul><li>Neurologically based behavioral issues can keep child from developing normally </li></ul><ul><ul><li>Lack of full coordination of gross & fine motor skills </li></ul></ul><ul><ul><li>Lack of complete age appropriate speech, language & communications </li></ul></ul><ul><ul><li>Impaired self-esteem </li></ul></ul>
  9. 11. What is the Extent of ADHD? <ul><li>About 3% of school-aged population have full ADHD symptoms & another 5-10% have partial ADHD </li></ul><ul><li>Another 15-20% of school-aged population show transient behaviors suggestive of ADHD </li></ul><ul><li>Boys are 3 times more likely than girls to have ADHD </li></ul><ul><li>Symptoms decrease with age but 50-65% of children still manifest symptoms into Adulthood (Korn & Weiss, 2003) </li></ul>
  10. 12. What is the Extent of SLD? <ul><li>15% of Americans have learning disabilities with many going untreated due to lack of diagnosis </li></ul><ul><li>10 million children or approximately 1 in 5 children in 1st through 9th grades (Cramer & Ellis, 1996) </li></ul><ul><li>60% of adults with severe literacy problems have undetected/untreated LD (NALLDC, 1994) </li></ul>
  11. 13. What is the Impact of ADHD on people? (Barkley, 2002) <ul><li>32-40% of students with ADHD drop out of school </li></ul><ul><li>Only 5-10% will complete college </li></ul><ul><li>50-70% have few or no friends </li></ul><ul><li>70-80% will under-perform at work </li></ul><ul><li>40-50% will engage in antisocial activities </li></ul><ul><li>More likely to experience teen pregnancy & sexually transmitted diseases </li></ul><ul><li>Have more accidents & speed excessively </li></ul><ul><li>Experience depression & personality disorders </li></ul>
  12. 14. What is the Impact of these Disorders? <ul><li>35% of students with learning disabilities drop out of school </li></ul><ul><li>30% of adolescents with learning disabilities will be arrested 3 to 5 years out of High School (Wagner et al, 1993) </li></ul><ul><li>Previously undetected learning disabilities have been found in 50% of juvenile delinquents - Once treated their recidivism drops to just 2% (Lerner, 1997) </li></ul>
  13. 15. Attention Deficit Hyperactivity Disorder <ul><li>Inattention - Traditionally known as ADD </li></ul><ul><li>Impulsivity - Traditionally known as Hyperactivity </li></ul>
  14. 16. ADHD Characteristics <ul><li>Inattention </li></ul><ul><li>Impulsivity </li></ul><ul><li>Overactivity </li></ul>
  15. 17. Inattention-Distractibility <ul><li>Doesn’t seem to listen </li></ul><ul><li>Fails to finish assigned tasks </li></ul><ul><li>Often loses things </li></ul><ul><li>Can’t concentrate </li></ul><ul><li>Easily distracted </li></ul><ul><li>Daydreams </li></ul><ul><li>Requires frequent redirection </li></ul><ul><li>Can be very quiet & missed </li></ul>
  16. 18. Impulsivity-Behavioral Disinhibition <ul><li>Rushing into things </li></ul><ul><li>Careless errors </li></ul><ul><li>Risk taking </li></ul><ul><li>Taking dares </li></ul><ul><li>Accidents/injuries prone </li></ul><ul><li>Impatience </li></ul><ul><li>Interruptions </li></ul>
  17. 19. Hyperactivity - Overarousal <ul><li>Restlessness </li></ul><ul><li>Can’t sit still </li></ul><ul><li>Talks excessively </li></ul><ul><li>Fidgeting </li></ul><ul><li>Always on the go </li></ul><ul><li>Easy arousal </li></ul><ul><li>Lots of body movement </li></ul>
  18. 20. Different Names for ADHD Through the years: <ul><li>1902 Defects in moral character </li></ul><ul><li>1934 Organically driven </li></ul><ul><li>1940 Minimal Brain Syndrome </li></ul><ul><li>1957 Hyperkinetic Impulse Disorder </li></ul><ul><li>1960 Minimal Brain Dysfunction (MBD) </li></ul><ul><li>1968 Hyperkinetic Reaction of Childhood (DSM II) </li></ul><ul><li>1980 Attention Deficit Disorder - ADD (DSM III) with-hyperactivity without-hyperactivity residual type </li></ul>
  19. 21. Names for ADHD <ul><li>1987 Attention-Deficit Hyperactivity Disorder or Undifferentiated Attention Deficit Disorder (DSM III-R) </li></ul><ul><li>1994 Attention-Deficit/Hyperactivity Disorder (DSM IV) 314.01: ADHD, Combined Type 314.00: ADHD, Predominantly Inattentive type 314.01: ADHD, Predominantly Hyperactive-Impulsive Type </li></ul>
  20. 22. What is Learning Disability? <ul><li>Definition: </li></ul><ul><li>A learning disability is a disorder that affects a person’s ability to either interpret what is seen and heard or to link information from different parts of the brain. These limitations can show up in many ways - as specific difficulties with spoken and written language, coordination, self-control, or attention. Such difficulties extend to school work and can impede learning to read or write or do math. </li></ul>
  21. 23. What are Learning Disabilities <ul><li>Neurological in origin </li></ul><ul><li>Impede person’s ability to store, process or produce information </li></ul><ul><li>Affect ability to read </li></ul><ul><li>Affect ability to speak </li></ul><ul><li>Affect ability to compute math </li></ul><ul><li>Impair socialization </li></ul>
  22. 24. LD Language Symptoms <ul><li>Pronunciation problems </li></ul><ul><li>Slow vocabulary growth </li></ul><ul><li>Lack of interest in stories </li></ul><ul><li>Poor spelling </li></ul><ul><li>Delayed decoding </li></ul><ul><li>Poor reading comprehension </li></ul><ul><li>Trouble following directions </li></ul><ul><li>Lack of verbal participation in class </li></ul>
  23. 25. LD Memory Symptoms <ul><li>Trouble learning numbers, alphabet & days of the week </li></ul><ul><li>Slow acquisition of new skills </li></ul><ul><li>Poor memory for routines </li></ul><ul><li>Slow recall of facts </li></ul><ul><li>Organizational problems </li></ul>
  24. 26. LD Attention Symptoms <ul><li>Trouble sitting still </li></ul><ul><li>Extreme restlessness </li></ul><ul><li>Impersistence at tasks </li></ul><ul><li>Impulsivity </li></ul><ul><li>Inconsistency </li></ul><ul><li>Poor self-monitoring, insatiability </li></ul><ul><li>Great knowledge of trivia </li></ul><ul><li>Careless errors </li></ul>
  25. 27. LD Fine Motor Skill Symptoms <ul><li>Trouble learning self-help skills </li></ul><ul><li>Clumsiness </li></ul><ul><li>Reluctance to draw, trace or color </li></ul><ul><li>Poor pencil grasp </li></ul><ul><li>Poor letter formation </li></ul><ul><li>Fist-like or tight pencil grasp </li></ul>
  26. 28. Rule outs for Diagnosis of ADHD Psycho-Social History & Personality Testing Behavioral or Emotional Problem caused by anxiety & depression Pediatric Neurologist-EEG, 24 hr EEG, MRI etc Neurological Conditions: Seizures, Tourette’s etc. Academic/Perceptual Testing-Psychologist Learning Disability IQ Testing-Psychologist Gifted Evaluation by use of: Rule Out’s Diagnosis
  27. 29. GARLIC V.S. ONION-Rule out System in Diagnosing ADHD <ul><li>Rule of Thumb of Ruling out Garlic Issues: </li></ul><ul><li>Garlic’s odor outdoes Onion’s so treat Garlic first </li></ul><ul><li>Rule out Garlic issue or treat it prior to addressing Onion issue </li></ul><ul><li>Lack of success in treating Onion may be because Garlic was not identified & treated </li></ul><ul><li>Ongoing setbacks may be due to power of Garlic’s strength & incapability of de-powering it </li></ul>
  28. 30. Garlic Rule Outs in Diagnosing ADHD: <ul><li>Seizure Disorder or other neurological issue such as Tourette’s Syndrome </li></ul><ul><li>Specific Learning Disability </li></ul><ul><li>Vision acuity problem </li></ul><ul><li>Hearing problem </li></ul><ul><li>Metabolic problem </li></ul><ul><li>Genetic problem </li></ul><ul><li>Child Psychiatric Problem </li></ul>
  29. 31. Electroencephalography <ul><li>Rule out epileptiform activity and/or epilepsy especially petit mal seizures which cause attention lapses </li></ul><ul><li>Use sleep deprived prolonged overnight EEG study to obtain all four stages of sleep (Tuchman, 1994, 1997; Volkmar & Nelson, 1990; Tuchman et al 1998; & Chez et al, 1997) </li></ul><ul><li>Use MRI if neurologic examination & EEG or other clinical indicators suggest focal lesion (CAN 1998) </li></ul>
  30. 32. Ophthalmologic Screening <ul><li>Behavioral in focus </li></ul><ul><li>Pure formal visual screening </li></ul><ul><li>Rule out processing deficits </li></ul><ul><li>Rule out central nervous system abnormality </li></ul>
  31. 33. Audiological Screening <ul><li>Rule out middle ear infection that causes intermittent hearing problems </li></ul><ul><li>Behavioral in focus </li></ul><ul><li>Pure formal tone audiometry </li></ul><ul><li>Brainstem auditory evoked potential if necessary </li></ul><ul><li>Rule out processing deficits </li></ul><ul><li>Rule out central nervous system abnormality </li></ul>
  32. 34. Metabolic Screening Tests <ul><li>Rule out food allergies or nutritional problems </li></ul><ul><li>Metabolic Lab tests are indicated with signs of metabolic disease e.g. failure to thrive, small stature etc. </li></ul><ul><li>Quantitative amino acids </li></ul><ul><li>Urine organic acids </li></ul><ul><li>Uric acid & calcium in a 24 hr urine </li></ul><ul><li>Thyroid studies </li></ul>
  33. 35. Cognitive, Speech & Language, Motor, Sensory & Motor Planning <ul><li>Pediatric Psychologist </li></ul><ul><li>Speech & Language Pathologist </li></ul><ul><li>Occupational Therapist - sensory integration </li></ul><ul><li>Physical Therapist </li></ul>
  34. 36. Medication Treatment of ADHD <ul><li>STIMULANTS </li></ul><ul><li>Ritalin -one dose lasts up to 4 hours </li></ul><ul><li>Metadate – Ritalin – once a day lasts up to 12 hrs </li></ul><ul><li>Focalin – New Ritalin derivative lasts up to 4 hours </li></ul><ul><li>Attenade -Newest Ritalin derivative-lasts 6 hours </li></ul><ul><li>Concerta - once a day lasts up to 12 hours </li></ul><ul><li>Dexedrine -last 4 hours-spansule lasts 10 hours </li></ul><ul><li>Adderall - New Dexedrine - once or twice a day lasts longer than Ritalin </li></ul><ul><li>Cylert -requires liver function testing due to history of hepatic failure with children who were on it </li></ul>
  35. 37. Medication Treatment of ADHD <ul><li>Non-Stimulant Medication: </li></ul><ul><li>Strattera – acts as a stimulant with similar side affects – norepinephrine reuptake inhibitor – not to be used with Prozac, Paxil or albuterol </li></ul><ul><li>Nutraceutical: </li></ul><ul><li>Attend - a natural product which combines amino acids, fatty acids, lipid complexes, homeopathic medicines, hormone precursors to specific neurotransmitters </li></ul>
  36. 38. Plus these interventions: <ul><li>Parent Team </li></ul><ul><li>Home Modifications </li></ul><ul><li>Parent-Teacher Team </li></ul><ul><li>504 Plan with Educational </li></ul><ul><li>Consistency of parent-teacher-doctor team </li></ul><ul><li>Unconditional love from all adults </li></ul>
  37. 39. Classroom Modifications for Students with ADHD & SLD
  38. 40. 1. Classroom Modifications <ul><li>Establish rules in classroom </li></ul><ul><li>Reinforce rules in classroom </li></ul><ul><li>Be consistent </li></ul><ul><li>Interact with student by: eye contact, call name, finger on desk, touching </li></ul><ul><li>Place student: in front, near positive peers, in low distracting areas </li></ul>
  39. 41. 2. Classroom Modifications <ul><li>Evaluate & structure environment </li></ul><ul><li>Reduce external visual & auditory stimuli </li></ul><ul><li>Repeat & have student paraphrase directions </li></ul><ul><li>Give short directions </li></ul><ul><li>Use predetermined signals </li></ul><ul><li>Multiple modalities </li></ul>
  40. 42. 3. Classroom Modifications <ul><li>Natural & logical consequences </li></ul><ul><li>Develop learning contracts with student </li></ul><ul><li>Use environmental clues: prompts, steps, written lists, schedules </li></ul><ul><li>Demonstrate acceptable ways to communicate displeasure, anger, frustration & pleasure </li></ul>
  41. 43. 4. Classroom Modifications <ul><li>Earphones & study carrels </li></ul><ul><li>Reduced rote assignments </li></ul><ul><li>Longer time for testing </li></ul><ul><li>Read test to student </li></ul><ul><li>Assignment books & organizers </li></ul><ul><li>Keep notebook for parent teacher communications after each class day </li></ul>
  42. 44. 5. Classroom Modifications <ul><li>Computer games & programs </li></ul><ul><li>Peer Buddy Tutors & Helpers </li></ul><ul><li>Classroom shadow, 1 on 1 Assistant </li></ul><ul><li>Progress notes to parents </li></ul><ul><li>Quarterly conferences with parents </li></ul><ul><li>Parents selection of teacher for next school year </li></ul><ul><li>Medications monitoring </li></ul>
  43. 45. 6. Classroom Modifications <ul><li>Unconditional love of child </li></ul><ul><li>Willingness to extend oneself </li></ul><ul><li>Openness to doing things differently </li></ul><ul><li>Working with parents as a team </li></ul><ul><li>Admitting when you are lost </li></ul><ul><li>Flexibility </li></ul><ul><li>Willingness to change </li></ul>
  44. 46. 7. Classroom Modifications <ul><li>Getting outside help </li></ul><ul><li>Openness to other’s input </li></ul><ul><li>Enthusiasm </li></ul><ul><li>Optimism - “We Can” Attitude </li></ul><ul><li>Determination to make it work </li></ul><ul><li>Commitment to process and to child </li></ul>