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Week 1 Edcn633 Adhd


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    • 1. ECN 633 Spring 2009 Week 1 January 12 2009
      • ADHD – a Fascinating Disorder
      • Dr Jeff Bailey
      • UAA
    • 2. ADHD #10
      • All children with ADHD are
      • hyperactive
    • 3. Fact
      • 3%-5% school age children affected
      • 3:1 males to females
      • About 40% referrals to child mental health clinics
      • Current diagnoses recognise that hyperactivity does not need to be present
        • ADHD-PI or ADD are terms sometimes used
        • ADHD better thought of as a disorder of thought processes, rather than behaviour.
    • 4. ADHD #9
      • ADHD is easy to recognise
    • 5. Fact
      • Many children labeled ‘ADHD’ incorrectly
      • Diagnosis an informed clinical judgement by a skilled professional:
      • DSM-IV criteria usually used
      • Avoid labeling and making diagnoses unless qualified to do so
    • 6. ADHD #8
      • Children grow out of ADHD during adolescence
    • 7. Fact
      • 40%-50% of adolescents with ADHD continue to have symptoms in adulthood
      • Main effects
        • Difficulty organising personal affairs
        • Difficult personal relationships
        • Higher involvement in crime
        • Poor employment record
        • More likely to be involved in accidents
    • 8. ADHD #7
      • ADHD is caused
      • by poor
      • parenting
    • 9. Fact
      • No known cause of ADHD but perhaps
        • Biochemical abnormalities in neurotransmitters
        • Familial - hereditary transmission – 80% in a twin study
      • Not proven
        • Neurological immaturity
        • Parental/teacher management
        • Environmental toxins e.g., lead
        • Food additives, sugar, milk etc
    • 10. ADHD #6
      • Children with ADHD could behave “if they really tried”.
    • 11. Fact
      • When symptoms are related to a biochemical imbalance volitional control is disturbed - allow for the probability that ‘he just can’t help it’
      • Require clear, often simple directions
        • Use child’s name; make eye contact
        • Introduce material in small steps ad with a logical order
        • Diagrams, notes
        • Model, demonstrate
        • Check understanding
    • 12. ADHD #5
      • Medication
      • will cure
      • ADHD
    • 13. Fact
      • ADHD cannot be cured. Medications will help many, but not all, children manage their daily lives.
      • Commonly dexamphetamine (Dexadrine) and methylphenidate (Ritalin)
      • Short acting (3-4 hr). No cumulative, or deleterious effects recorded
      • Stimulant medications benefit
        • Emotional stability
        • Behavioural inhibition/ impulse control, and executive functioning
        • Selective attending, academic learning
        • Social relationships
    • 14. Fact
      • Side effects are usually mild, and managed with dose adjustment
        • Insomnia, loss of appetite, mood changes
        • Nausea, tics, headaches
        • Rebound effects in few cases
      • Concerns of parents and children
        • Growth retardation
        • Leads to drug dependency and abuse
          • Neither supported in follow up studies
        • Embarrassment at school
        • ‘ Psychological’ dependency
    • 15. ADHD #4
      • Parents and teachers welcome medications
    • 16. Fact
      • Decision to medicate is a major source of stress for many parents – but refer to my Brisbane study of medication acceptance
      • A moral issue for some
      • Concern about dependency, ‘holidays’, stopping
      • Medication only one aspect of a multimodal approach which must involve remedial tuition
    • 17. ADHD #3
      • Nonmedical management is
      • as effective
      • as medication
    • 18. Fact
      • Multimodal treatments - including medication - shown to be most effective
      • Management best when characterised by
        • Structure, predictability
        • Immediate, salient consequences
        • Action not just words
        • Anticipation of problems
        • Positive incentives wherever possible
      • If child takes medication use times when effect is greatest
      • Not supported by research: diet, megavitamin therapy, sensory integration programs, relaxation therapy, biofeedback.
    • 19. ADHD #2
      • Only the person with ADHD is affected
    • 20. Fact
      • Having a child with ADHD affects all family members
      • Family life may be disrupted in numerous ways
        • Arguments with siblings
        • Few family outings
        • Frequent contact with school
        • Stress on marriage
      • Professionals
        • Remember wider social context
        • Do not trivialise parental concerns
        • Recognise effects on all family members
        • Provide accurate information
        • Be positive, but avoid unrealistic expectations
    • 21. ADHD #1
      • ADHD
      • is a myth
    • 22. Now for some specifics
    • 23. New Insights into ADHD - Self-Regulation and Intention
    • 24. Some Early Explanations
      • Defect in moral control
      • Brain damage
      • Poor parenting
      • Allergies and diet
      • Too much TV and video games
      • A faster life style
      • Poor teaching, poor parenting, unresponsive schools
    • 25. Current descriptions of ADHD are based mainly on DSM-IV: three categories Hyperactive/Impulsive Combined Inattentive
    • 26. But the DSM-IV descriptions DO NOT:
      • Give a clear view of severity levels or of the diversity within the syndrome
      • recognise ‘normal’ behaviour – when is behaviour ‘abnormal?’
      • Help with class programming and management
      • explain underlying cognitive processes and styles
    • 27. Different Views of the Same Problem
      • In the Past: a disorder of behaviour premised on psychosocial theories
      • …… but now …..
      • a neurological basis with …
      • a disorder in inhibition, executive functioning, self-regulation and even an ‘intention deficit disorder’
    • 28. The Brain-Behaviour Link I want you to know that I have a different physiology - in the frontal-striatal-cerebellar network. The effect is that I have low inhibition control and poor executive functioning!
    • 29. Contemporary View of ADHD
      • Reduced vigilance (impersistence; disinhibition)
      • Poor response inhibition & motor planning
      • Poor interference control (distractibility)
      • Deficient working memory
      • Impaired fluency (verbal and nonverbal)
      • Perseverative errors
      • Reduced emotional self-regulation
      • Greater errors in handling time
    • 30. ADHD Causes: Family and Heredity
      • In families, the likelihood of ADHD is
      • - for sibs - 25 to 35%
      • - for identical twins - 55 to 92%
      • - for mothers - 15 to 20%
      • - for fathers 25-30%
      • - if parent is ADHD, 20-54% of offspring
      • Twin Studies of Heritability:
      • - Heritability = 57-97%
      • - Shared Environment = 0-6% (Not significant )
    • 31. Empirically Proven Treatments
      • Psychopharmacology
        • Stimulants
        • Tricyclic Anti-depressants
        • Anti-hypertensives
      • Parent Training in Child Management
        • Children (<11 yrs., 65-75% respond)
        • Adolescents (25% respond)
    • 32. Empirically Proven Treatments
      • Teacher education about ADHD
      • Classroom behaviour modification
      • Learning Support
      • Parent/family services
      • Parent support groups
    • 33. Outcomes for Children with ADHD
      • Educational Problems:
      • 25-35% repeat a grade
      • 60% are suspended from school
      • 14% are expelled from school
      • 30-40% drop out at high school
      • greater likelihood of social problems
    • 34. Outcomes for Adults with ADHD
      • Employment Problems:
        • More Likely to be Fired
        • Change Jobs 3x More Often
        • ADHD/ODD Symptoms Impair Job
        • Under-employed for IQ/Family Background
      • Driving:
        • More Accidents/Citations (Speeding)
        • Worse Accidents (2-3x $ & injuries)
        • More License Suspensions/Revocations
      • Social Relationship Problems (75%):
          • Fewer Close Friends
          • Shorter Dating Relationships
          • More Likely to Divorce
    • 35. ADHD is Often Complicated by Comorbidity
      • In 50%-70% of cases, ADHD is further complicated by one or more additional psychiatric or learning disorders
      • For those with ADHD it is up to 5 times more likely in lifetime to have another disorder
    • 36. Self-Regulation and Cognitive Processes - The Story of Aiden
      • Case study
      • 6 year old boy, only grand child, father Australian, mother Russian, appears to be of average intelligence, consistent problems in school as follows:
      • over active
      • inattentive
      • rarely completes work
      • does not seem to be able to keep anything in his working memory
      • forgets, loses place
      • cannot organise his desk, books or anything
      • drives the teacher to distraction.
    • 37. Assessing Self-regulation and Metacognition Case study on Aiden
    • 38. Second Case Study - Donnie
    • 39. Profiling 2 Boys with ADHD
    • 40. What are Executive Functions?
      • Several central control processes of the brain
      • Connect, prioritise, and integrate cognitive functions - moment by moment
      • Like a ring master, or conductor of a symphony orchestra
      • Brown, TE (AUG., 2002). New Understandings of ADHD and “executive functions”. Conference presentation, Sydney.
    • 41. EF Development and Demands
      • EF capacity develops through childhood into adolescence and beyond
      • Environmental demands for EF increase with age from preschool to adulthood
      • EF impairments often not noticeable by
      • age 7.
    • 42. Executive Functions Often Impaired in ADHD
    • 43. 1. Organise, Prioritise, and Activate
      • Difficulty organising tasks, materials
      • Difficulty estimating time, prioritising tasks
      • Trouble getting started on work
      • Brown, TE, .(2000) Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults.
    • 44. 2. Focus, Shift, and Sustain Attention
      • Loses focus when trying to listen or plan
      • Easily distracted - internal, external
      • Forgets what was read, needs to re-read
    • 45. 3. Regulating Alertness, Effort, and Processing Speed
      • Difficulty regulating speed and alertness
      • Quickly loses interest in task, especially longer projects; doesn’t sustain effort
      • Difficult to complete task on time, especially in writing - “slow modem”
    • 46. 4. Manage Frustration, Modulate Emotion
      • Emotions impact thoughts, actions too much
      • Frustration, irritations, hurts, desires, worries etc experienced “like a computer virus”
      • “ Can’t put it to the back of my mind”
    • 47. 5. Utilise Working Memory, Access Recall
      • Difficulty holding one or several things “on line” while attending to other tasks
      • Difficulty “remembering to remember”
      • Inadequate “search engine” for activating stored memories, integrating these with current information to guide current thoughts and actions
    • 48. 6. Monitor and Self-Regulate Action
      • Difficulty controlling actions, slowing self, and/or speeding up as needed for tasks
      • Doesn’t size up ongoing situations carefully
      • Hard to monitor and modify own actions to fit situation/aims
    • 49. What We Know of Attention Attention implies a relationship between an event (stimulus) and the response of the individual to that stimulus To ‘attend’ effectively requires one to:
      • Select the target and focus
      • Initiate attention (determine that the relationship will exist and that attention resources will be allocated; put ‘intention’ into effect)
      • Sustain attention (concentrate as we used to say)
      • Inhibit lapses in attention (self-regulation; response inhibition)
      • Shift attention (avoid perseveration; shift the target of our focus as required; shift from visual to auditory; divide attention as required)
    • 50. Some Learning Characteristics
      • Poor at Tasks Involving:
        • Delayed responding & intrinsic motivation
        • Time, waiting, delays, and a future-orientation
        • Problem-solving, strategy development, flexibility
      • ADHD Creates a “Time Blindness”
      • It is Not an Attention Deficit but an Intention Deficit Disorder
      • This means the ability to focus on a task, presume that you will complete the task successfully within a reasonable time period and that you will understand and manage your own behaviours in order to achieve a satisfactory outcome.
    • 51. What do we see in students?
      • Difficulties in
        • organising time
        • organising belongings
        • organising thoughts
        • initiating tasks (getting started)
        • maintaining tasks (keeping focussed)
        • switching tasks as needed
        • selecting important aspects of tasks
        • delaying responses
        • planning
        • problem solving
    • 52. Guidelines for Assessment
      • Allow sufficient time for thorough observation and assessment - in more than a clinical setting
      • Most tests do not provide the breadth and depth of information required and few measure cognitive processing style and skills
      • Interview people (parents and professionals, especially teachers) who have known the child for a sustained period of time and who know the child well
      • Rating scales can be useful if informed people complete them - but insufficient for intervention planning
      • Daily work observations, work logs etc are important
      • Functional assessments must be part of the assessment protocol, together with formal tests, rating scales and observations - but an ecological perspective (social skills, social perception and impact on the social group of the child) is essential
    • 53. Implications for Treatment
      • Teaching splinter skills (visual-memory etc) does not work
      • Teaching away from the natural setting (classroom etc) is not effective, eg., teaching social skills in a clinic
      • Interventions must be at the point of performance - this is usually the classroom
      • Support must be sustained over a long period of time
      • Only medication temporarily improves or normalizes the underlying inhibitory deficit thereby improving executive functioning
      • Other Important Tips
        • Externalize important information (make lists, post rules, use signs,)
        • Externalize time periods related to tasks (timers)
        • Break up future tasks into many small ones (do 1 daily)
        • Externalize sources of motivation (token systems)
    • 54. Some Good Management Ideas
      • Tips to Aid Cognitive Processing
      • Keep work periods short
      • Reduce delays, externalize time
      • Externalize important information
      • Externalize motivation (think win/win)
      • Externalize problem-solving (play)
      • Use timers at points of performance
      • Don’t assign multiple tasks at once
      • Help the student to evaluate performance at end
    • 55. Classroom Management: Externalizing Rules and Time
      • Posters of rules for each work period
      • 3-sided stop sign with class rules on it
      • Laminated colour-coded card sets on desks with rules for various class activities
      • Child restates rules at start of each activity
      • Child uses vocal self-instruction during work
      • Nag tapes - taped reminders from Dad
      • Use timers, watches, taped time signals, etc.
    • 56. Classroom Management: Moving to Self-Management
      • Child records work productivity on a daily chart or graph on public display
      • Child rates self on daily conduct card
      • Cue child to self-monitor (self-question)
      • Nonverbal cues for teens - paper clips
      • Placing a mirror in front of the child
      • Severe cases, use videotape feedback
    • 57. Some practical materials Let’s convert this information into practical ideas by reviewing the handouts.
    • 58. ADHD medication
    • 59. Typical medications
        • Dexamphetamine (DEX): 3 times daily
        • Methylphenidate (MPH): 3-times daily and sustained slow-release versions
        • Atomoxetine: non-stimulant alternative
    • 60. Evidence for ADHD – Magnetic Resonance Imaging
      • Smaller brain volume: ADHD brains
      • 3-4% smaller than non-ADHD brains
      • Volume of white matter is abnormally small in ADHD without medication; but medicated children had same white matter as non-ADHD children
      • Functional MRI indicates subnormal activation of the prefrontal cortex in adolescents with ADHD
    • 61. What does the medication do?
      • Methylphenidate improves response inhibition - reduces symptoms of ADHD
      • Methylphenidate improves alertness, focused and sustained attention
      • Methylphenidate increases prefrontal cortex activation
    • 62. Hypothesized effects of medication
      • The pathogenesis of ADHD is thought to be caused by a metabolic imbalance in the cerebral cortex, specifically between norepinephrine and dopamine systems
      • Role of stimulants – Methylphenidate and Dexamphetamine appear to improve dopamine-based neurotransmission
      • Both act on neurotransmission and improve response inhibition
    • 63.  
    • 64. Three-times-daily medication: DEX and MPH
      • Stimulant medication has been used for over 50 years in the treatment of ADHD
      • Stimulants are a safe form of treatment: a few children do not tolerate them and hence there are “first-line” and “second-line” forms of treatment.
    • 65. Three-times-daily medication: DEX and MPH
      • The major side effects are loss of appetite (DEX and MPH) and insomnia (DEX), often managed by adjusting the dosage
      • Adverse effects decline quickly when the drug is withdrawn
      • DEX and MPH do not accumulate in the system
      • As with all medications for children, it is essential to monitor children closely, comply with instructions and report immediately to the pediatrician if there are any adverse reactions.
    • 66. Problems with 3-times-daily MPH and DEX
      • Drugs have a short half-life so there is a need for multiple daily doses
      • Multiple daily doses produce problems with administration during school
      • If the children self-administer, raises problems of compliance and black-marketing
      • Also raises issues of privacy vs disclosure to school staff: what is in the best interests of the child?
    • 67. Development of once-a-day methylphenidate
      • Sustained release over 12 hours: early morning dosage lasts all day
      • Research shows that the long-acting formulation is equivalent to short-dosage formulations 19
      • Construction of tablets ensures release over the day
      • Tablets are non-crushable: reduces chances of abuse
    • 68. The vulnerability of parents of children with ADHD
      • Parenting a child with ADHD is exhausting
      • Families often have more than one member with ADHD
      • Genuine ADHD is NOT caused by parental or home conditions, although home management may ameliorate or exacerbate the symptoms
      • Medication is accepted as part of the appropriate management of asthma, juvenile diabetes etc – why not ADHD?