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Week 1 Edcn633 Adhd


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Week 1 Edcn633 Adhd

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