Attention Deficit/Hyperactivity Disorder

Jillian C. Schneider, Ph.D.Pediatric NeuropsychologistFairfax Neonatal Associates

February 11 2014

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Background and TrainingDoctoral Degree: Ph.D. in Clinical Psychology from Drexel

University

Pre-doctoral training: Kennedy Krieger Institute/The Johns Hopkins University School of Medicine

Post-doctoral training (two year fellowship): Children’s National Medical Center

Previous employment: independent pediatric neuropsychology practice, contractor with Department of Defense

Publications include book chapters and articles on infectious

disease and mild traumatic brain injury in peer reviewed journals

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Commonly Asked QuestionsWhat is attention?What is ADHD?How is ADHD diagnosed?How is ADHD treated?

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What is Attention?Process whereby individuals receive and

process incoming informationSubtypes:

SpanFocusedSelectiveSustained (vigilance/concentration)AlternatingDivided

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What is Executive FunctioningEnables individuals to engage in

independent, purposeful behaviorDomains:

Inhibitory control, Behavioral/emotional regulationMental flexibilityInitiationWorking memoryPlanning, Organization, Goal settingAbstract reasoning, Problem-solving, Hypothesis

generationSelf-monitoring

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What is ADHD?What are the symptoms?What’s the difference between ADHD and

ADD?Can a gifted child be diagnosed with it?Is it different in girls vs. boys?Do children grow out of it?How common is it?What causes it?

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What is ADHD?

Inattention Hyperactivity

Impulsivity

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InattentionInattention to detail, makes careless mistakesTrouble staying focused and on taskNot listeningNot following through with instructions or tasksDisorganizedAvoids and dislikes tasks that require sustained

effortLoses thingsEasily distractedForgetful

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HyperactivityFidgets or squirms in seatTrouble sitting stillRuns or climbs at inappropriate timesTrouble playing quietlyOften “on the go,” acts as if “driven by a

motor”Talks excessively

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ImpulsivityBlurts out answersDifficulty waiting his/her turnInterrupts or intrudes on others

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ADHD SubtypesPredominantly Inattentive Presentation

6 (5 in adults) or more symptoms of inattention

Predominantly Hyperactive/Impulsive Presentation6 (5 in adults) or more symptoms of hyperactivity or

impulsivity

Combined Presentationat least 6 (5 in adults) symptoms of inattention AND

6 (5 in adults) symptoms of hyperactivity or impulsivity

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ADHD Diagnostic CriteriaSeveral symptoms of inattention and/or

hyperactivity and impulsivity are present before age 12 years

Symptoms are present in two or more settings

Symptoms interfere with or reduce the quality of social, academic, or occupational functioning

Symptoms are not better accounted for by another disorder

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How Common is ADHD?

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ADHD: Boys vs. Girls

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ADHD: Boys vs. GirlsCompared to boys, girls:

Rated lower on scales in hyperactivity and impulsivity

Display fewer behavioral problemsHave more internalizing problems (e.g.,

depression, anxiety)Clinical presentation in girls:

Inattention –spacey, daydreamers, may appear shy

Hyperactivity –extremely talkative

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Can ADHD be Diagnosed in Gifted Children? Yes, ADHD and GT can co-exist.Like most children with ADHD, gifted

children with ADHD: may display problems with sustained attention

and hyperactivity in less stimulating or motivating environments

may display academic inconsistencies and/or underachievement

May exhibit a wider gap between intellectual functioning and social/emotional functioning

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Do Children Grow out of ADHD?• No, most children do not “grow out” of ADHD

• In general, ADHD increases the risk for academic and occupational underachievement, substance abuse, delinquent behavior, relationship problems, trouble managing stress, etc.

• However, many children learn various coping strategies for managing their difficulties.

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ADHD Across the LifespanPreschool

Poor sustained attention, easily distractedElevated gross motor activity

School AgePoor sustained attention, distractibility Inconsistent academic progressRestless, fidgety

Adolescence/AdulthoodProblems with sustained effort and concentrationExecutive functioning weaknesses Internal feelings of restlessnessParticipation in risky activitiesAcademic / occupational underachievement

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Comorbidity: Rule Not the Exception

ADHD

Learning Disability

46%

Speech Proble

ms12%

Anxiety18%Depressio

n14%

Conduct Disorder

27%

Tourette/Tics10%

Autism Spectrum Disorder

25%

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What Causes ADHD: NeurodevelopmentDifferences in brain maturation, structure,

and function

Prefrontal cortexBasal gangliaCerebellum

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What Causes ADHD: Genes and the EnvironmentFamilial and significantly heritable

30-35% of first-degree relatives of children with ADHD also have the disorder

Environmental Risk FactorsPremature birth and birth complicationsMaternal smoking and substance useLead exposure/toxicityTraumatic brain injury

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What Doesn’t Cause ADHD?Bad parentingSugarDietToo much televisionVideogames

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How is ADHD Diagnosed?What kind of psychological work-up should

be done to make a diagnosis?Is there a specific test used to diagnose

ADHD?Where should I go to get a diagnostic

evaluation?

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Diagnosing ADHDDiagnostic requirements:

At least 6 symptoms of inattention and/or 6 symptoms of hyperactivity/impulsivity

Symptoms must: have been present before age 12 have persisted for at least six months be present across two different settings be present to a degree that causes problems and is

inconsistent with developmental levelSymptoms are not better accounted for by

another disorder

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Assessing Symptoms of ADHDThere is NO test for ADHD

Diagnosis is made based on information gathered about presenting concerns/symptoms through: Review of development and clinical historyHistorical review of concerning behaviorsBehavioral observation

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Standardized Assessment of ADHDStandardized assessment may include:

Questionnaires/rating scales completed by parents and teachers

Cognitive testing

Assessment should be individualized to an individual child’s specific problems.

Considerations:Children may do well on standardized testsPerformance may be variable on measures

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Symptoms of ADHD are not better accounted for by another disorder

MedicalHearing/vision

problemsIntellectual disabilityLearning disabilityLanguage disorderSleep apneaSeizure disorderMetabolic disorderSubstance abuse

PsychologicalDepression or AnxietyBehavioral problems Stress or changes and

sudden changes in life

EnvironmentalFamily dynamicsAcademic environment

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Specialists who diagnose ADHDPediatrician/Developmental PediatricianPsychiatristBehavioral Neurologist Psychologist/Neuropsychologist

The person conducting the evaluation should be a professional trained in assessing children’s development, emotions, and behavior and in differential diagnosis

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Neuropsychological EvaluationAssess learning and behavior in relation to an

individual’s brain processes.Intellectual functioningAcademic achievementLanguageVisual processingAttention and concentrationExecutive functioningLearning and memorySensory and motor functioningAffective, behavioral, and social functioning

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Neuropsychological assessment is helpful when…There is suspicion of low cognitive abilitiesThere is low academic achievementIn order to differentiate among coexisting disordersIn order to describe an individual’s strengths and

weaknesses and to tailor recommendations and help with treatment and educational planning

In order to increase validity of diagnostic impressions

There are coexisting medical conditions (e.g., epilepsy)

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How is ADHD Treated?There is no cureThe focus of treatment should be on reducing

the symptoms of ADHD and improving functioning

Common treatment methods include:MedicationBehavioral/Cognitive Behavioral TherapyCombination of Treatment

Medication > Medication + Behavioral Intervention > No Treatment

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MedicationMedications Types:

Psychostimulants (e.g., Ritalin, Adderall, Concerta)Non-stimulants (e.g., Strattera, Tenex, Intuniv)Short vs. Long ActingPill/capsule, Liquid, Skin patch

Side Effects:Decreased appetite, sleep problems, anxiety,

irritability Not a one-size-fits-all approach –finding the right

medication requires careful and continuous fine-tuning

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Behavior / Cognitive Behavior TherapyBehavioral Parent /Teacher Training

Focuses on teaching the child more socially acceptable behavior by training caregivers and teachers in contingency management strategies.

Academic InterventionsEnvironmental modifications, curriculum changes,

testing accommodations, assistive technology Peer-related Interventions

Addresses difficulties that children have with initiating and maintaining appropriate peer relationships

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Alternative and Complementary TreatmentsTreatments that have not been scientifically

validated to improve symptoms of ADHDDietary changesHerbal supplementsChiropractic adjustmentsInteractive metronome trainingEye or vision training and special colored

glassesEEG biofeedback

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ResourcesBooks for Parents

Taking Charge of ADHD: The Complete Authoritative Guide for Parents by Russell Barkley

Parenting Children with ADHD: 10 Lessons that Medicine Can Not Teach by Vincent Monastra

How to Reach and Teach ADD/ADHD Children by Sandra ReifLiving with ADHD: A Practical Guide to Coping with ADHD

by Rebecca KajanderExecutive Skills in Children and Adolescents: A Practical

Guide to Assessment and Intervention by Peg Dawson and Richard Guare

Smart but Scattered: A Revolutionary “Executive Skills” Approach to Helping Kids Reach Their Potential by Peg Dawson and Richard Guare

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Resources Cont.Books for Kids

Clayton’s Path by Brett BishopJoey Pigza Swallowed the Key by Jack GantosHelp Is on the Way: A Child’s Book about ADD

by Marc Nemiroff, Margaret Scott, and Jane Annunziata

OrganizationsCHADD (Children and Adults with Attention

Deficit Hyperactivity Disorder) www.chadd.org

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Questions

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Jillian C. Schneider, Ph.D.Fairfax Neonatal Associates2720-D Prosperity Avenue

Fairfax, Virginia 22031(703) 752-2765

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