ADHD Web

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ATTENTION DEFICIT

HYPERACTIVITY DISORDERIn Chi ldren & Ado lescents

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What is ADHD?The Current Clinical View

A disorder featuring age-inappropriate : Inattention

Poor persistence of responding Impaired resistance to distraction, Deficient task re-engagement following disruption

Hyperactivity-Impulsivity(Disinhibition) Impaired motor inhibition, Poor sustained inhibition Excessive and often task-irrelevant motor and verbal behavior Restlessness decreases with age, becoming more internal, subjective by

adulthood

Most cases are developmental and involve delays in therate at which these two traits are maturing

Some cases are acquired (20%+; mainly males) These may represent pathology and may differ in severity, recovery, &

possibly treatment response

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Essential Features

ADHD presents as impairment in:

Persistence

Resistance to distraction Working memory

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Persistence

ADHD Individuals do not have problems withsuch perceptual aspects of attention as:

arousal or alertness

focus or selective attention

span of apprehension or divided attention

Rather have an inability to sustain actiontoward a goal for an adequate period of timewhich is a motor problem

Persistence is on the motor side of attention, itis an output disorder.

Output is the problem

Most people think of attention as an inputproblem: how you perceive, select filter andprocess information

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Resistance to Distraction Related to persistence: opposite sides of the

same coin.

If you can persist it is because you can resist

distraction; If you can resist distraction you

can persist: One requires the other

Not a perception problem, ADHD kids are notoverly perceptive they do not perceive

distractions any better the difference is that

they respond to the distracting events

Most of us are able to inhibit our responses todistracting events, ignore them even though

we detect them.

ADHD is not a problem of perception but

inhibition

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Working Memory

Once distracted ADHD individuals are far lesslikely to return to the original goal or task

task re-engagement is a major problem for

this population

This is modulated by working memory:information held in mind that guides us toward

a goal.

People with ADHD are likely to have serious

difficulties with working memory. Once distracted they are gone, off on another

task

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Inattention Symptoms (DSM-IV)Failure to give close attention to details

Difficulty sustaining attention

Does not seem to listen

Does not follow through on instructions

Difficulty organizing tasks or activitiesAvoids tasks requiring sustained mental effort

Loses things necessary for tasks

Easily distractedForgetful in daily activities

Symptoms must occur Often or more frequently

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Hyperactive-Impulsive SymptomsFidgets 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 motorTalks excessively

Blurts out answers before questions arecompleted

Has difficulty awaiting turn

Interrupts or intrudes on others

Symptoms must occur Often or more frequently

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DSM-IV Criteria for ADHD Manifests 6+ symptoms of either inattention or

hyperactive-impulsive behavior

Symptoms are developmentally inappropriate

Have existed for at least 6 months

Occur across settings (2 or more) Result in impairment in major life activities

Developed by age 7 years

Are not better explained by another disorder,e.g. Severe MR, PDD, Psychosis

3 Types: Inattentive, Hyperactive, or Combined

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ADHD Varies by SettingBetter Here: Worse Here:

Fun Boring

Immediate Delayed Consequences

Frequent Infrequent Feedback

High Low Salience

Early Late in the Day

Supervised Unsupervised

One-to-one Group Situations

Novelty Familiarity

Fathers Mothers

Strangers Parents

Clinic Exam Room Waiting Room

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Prevalence (United States) 7-8% of children (using DSM-IV) (~3-4 million) Varies by sex, age, social class, & urban-rural

3:1 Males to females in children (5:1 in clinical samples) Somewhat more common in middle to lower-middle classes More common in population dense areas

No evidence for ethnic differences to date that areindependent of social class and urban-rural

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Co-Occurring DSM-IV Disorders More than 80% have one additional disorder

More than 60% have two additional disorders Oppositional Defiant Disorder (Average of 55%) Conduct Disorder (Average of 45%) Anxiety Disorders (20-35%) Major Depression (25-35%) Bipolar Disorder (0-27%; likely 6-10% max.)

(97% of those Diagnosed w/ Bipolar also haveADHD)

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Medical Risks Sleep problems (39-56%); mainly delayed

onset and greater night waking leading toshorter sleep time Developmental Coordination Disorder (50+%) Reduced Physical Fitness, Strength, &

Stamina (using physical fitness tests) Accident Proneness 57%+

1.5 to 4x risk of injuries (greater in ODD) 3x risk for accidental poisonings

Due to Impulsivity, risk-taking, impaired coordination,

oppositionality, and poor parental monitoring

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Causes of ADHD

Disorder arises from multiple causes All currently recognized causes fall in the

realm of biology (neurology, genetics)

Causes may compound each other

Common neurological pathway for ADHDappears to be the areas of the braincontrolling Executive Functions and

Physical Activity (Smaller / LessDeveloped)

Social causes have poor evidence

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Acquired Cases: Prenatal

Maternal smoking in pregnancy (odds 2.5) Maternal alcohol drinking in pregnancy (same)

Prematurity of birth, especially if brain bleeds(45%+ have ADHD)

Total increased pregnancy complications

Maternal high phenylalanine levels in blood (?)

High maternal anxiety in second trimester (?)

Cocaine/crack exposure not a risk factor aftercontrolling for the above factors

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Acquired Cases: Post-Natal (7-10%)

Head trauma, brain hypoxia, tumors, or infection

Lead poisoning in preschool years (0-3 yrs.)

Survival from acute leukemia (ALL)

Treatments for ALL cause brain damage

Post-natal Streptococcal Bacterial Infection triggers auto-immune antibody attack of basal ganglia

Post-natal elevated phenylalanine (dietary amino

acid related to PKU) Prenatalhyperactivity

Post-natalinattention

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HeredityFamily Studies

Familial Expression of ADHD:

- 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+)

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HeredityTwin Studies Heritability (Genetic contribution)

57-97% of individual differences (Mean 80%+)

(91-95%+ using DSM criteria)

Shared Environment (common to all siblings)

0-6% (Not significant in any study to date)

Unique Environment (events that happenonly to one person in a family)

15-20% of individual differences

(but includes unreliability of measure used toassess ADHD)

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Etiologies of ADHDFrom Joel Nigg (2006), What Causes ADHD?

HeritableLBW

FASD

Lead (high)

Smoking

Perinatal

Other (Toxins)

LBW

FASDLead

Smoking

Perinatal

Other

Heritable (Genetics)

ADHD E l ti C

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ADHD Evaluation: CoreConsiderations

Are the symptoms of inattention, impulsiveness, and

overactivity, present. MOST Importantly Is there clearevidence of an impulsive style?

Is there evidence that these symptoms significantlyinterfere with the childs functioning both at school and athome?

Did these symptoms have a reasonably early onset? (Ifnot, is there a good explanation?).

Have these symptoms been an enduring and consistentfeature of the childs behavior throughout theirdevelopment and in the majority of contexts?

Is there evidence that the child wishes to perform well butcannot?

Are there better explanations for the underachievement?

Is there a pattern or specific triggers to the problembehaviors?

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Psychodiagnostic Evaluation A psychodiagnostic Evaluation may be necessary if the

assessment produces mixed/inconsistent results or hasuncovered possible evidence of any of the following:

Suicidality

Significant Developmental Delays

Intellectual limitations

Learning disabilities

Serious Psychiatric disturbance

Significant family problems

Other reasons to refer for testing:

Child was moderately to severely premature

Prenatal exposure to toxins especially ETOH & Nicotine

Low birth weight Complicated pregnancy and/or birth

Reports that child had trouble grasping concepts/acquiring newskills

Reports that child has trouble with major academic subjects evenwhen attentive.

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Ruling out Depression

Later onset than ADHD

Usually preceded by excessive anxiety

Not uncommon to have both as a result of thenegative outcomes due to ADHD behaviors.

Must treat both

When comorbid, associated with a 4x increasein suicidal ideation and 2x increase in attempts

Appears to be connected to same genesassociated with ADHD.

Best differential: EARLY HISTORY

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Ruling Out Anxiety

Onset later than ADHD

Associated with a particular event or inaccordance with a time pattern (anniversary).

Restlessness is not a primary manifestation ofAnxiety (usually a habit, style, or boredom)

Usually characterized by panic or dread alongwith worry.

Best measure for presence of anxiety is childsreport (parents and teachers under report).

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Ruling Out PTSD

Must look closely at developmental and earlyschool history.

PTSD will stem from a specific event

Children with ADHD are at greater risk forPTSD from abuse and risky behaviors.

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Ruling Out Bipolar Disorder

Childhood BPD manifests as severe andchronic irritability (rather than episodic mania)

Also characterized by Disjointed thinking,

capricious mood, destructiveness, anddysphoria.

BPD usually starts as ADHD in childhood

ADHD itself does not develop into BPD

One-way Comorbidity

3-6% of ADHD have BPD 80-97% of BPD have ADHD

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Ruling Out ODD

In many cases ADHD is at the root of ODD

There is a high degree of co-occurrence

Early onset of ADHD symptoms is thedifferential

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Treating

ATTENTION DEFICIT HYPERACTIVITYDISORDER

In Chi ldren & Ado lescents

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Current Perspective

ADHD creates a kind of Myopia for future eventsor Time Blindness.

ADHD individuals live in the Moment

ADHD is a Disorder of: Performance, not skill Doing what is known, not knowing what to do

The when & where, not the how or what

Using representations of the past at the appropriateplace & time (Point of Performance)

ADHD is better characterized as an IntentionDeficit

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ADHD & Executive Functioning

Executive Functioning is responsible for twotypes of sustained attention (SA): Contingency-shaped (Externally maintained)

Video Games

Goal-directed (Internally guided & motivated)

Homework Goal-directed (SA) is impaired in ADHD

individuals which creates problems with: Delayed responding & intrinsic motivation Doing the opposite of what is suggested in sensory

fields Time, waiting, delays, and future orientation Problem solving, strategy development, & flexibility

Increases in complexity with age & development

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Treatment Implications

Teaching skills is ineffective (As is insight) Treatment must occur at the point of performance.

Medications are likely to be essential for most butnot all cases.

Diminished capacity does not excuse accountability(The problem is time and timing not consequences).

Behavioral treatment is essential but doesgeneralize or endure after removal.

Treatment success depends on the compassion andwillingness of others to make accommodations.

Maintaining a Chronic Disability perspective ismost effective.

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Unproven / Disproved Therapies

Elimination Diets: Sugar, Additives, etc. (Weak

Evidence) Megavitamins, Anti-oxidants, Minerals: (No strong

evidence or disproved)

Sensory Integration Training (Disproved)

Chiropractic Skull Manipulation (No Evidence) Play / Psychotherapy (Disproved)

Neurofeedback (Experimental)

Cognitive Self-Control Therapies (Effective in Clinic)

Social Skills Training (Effective in Clinic Setting) Better for Inattentive (SCT) Type and anxious cases

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Empirically Proven Treatments Parent Education

Psychopharmacology Parent Training in Child Management

65-75% of Children under 11 respond

25-30% of Adolescents show reliable changes

Family Therapy for Adolescents:

Problem-Solving and Communication Training

30% show change (best combined with BMT)

Teacher Education

Train Teachers in Classroom Bx Management

Special Ed (IDEA, 504) Regular Physical Exercise

Residential Treatment (5-8%)

Parent Family Services (25+%)

Parent/Patient Support Groups

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Managing ADHD

Time is critical: reduce delays Externalize a many processes as possible:

Time (Clocks, Timers, Calendars, PDAs etc.)

Important information (Lists, reminders, instruction

cards, etc.) Motivation (Token economy, tangible rewards)

Problem Solving (use paper and pencil or dry eraseboard)

Give immediate feedback Increase frequency of consequences

Increase accountability to others

Use salient & artificial rewards

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General Recommendations

Change rewards periodically Minimize talking, maximize communicative

touch Corollary: Act dont Yak

Maintain a sense of humor Emphasize rewards over punishments (reward

first)

Anticipate problem situations and make a plan Keep a sense of priorities (pick your battles)

Hold to the perspective of ADHD as a Disability

Be forgiving (of child, self, and others)

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Give Effective Commands Initially give heavy praise to high compliance commands

Dont use questions, use Imperatives Use eye contact and touch

Have child recite request

Break complex tasks into simpler ones

Make chore cards for Multi-Step tasks List all steps involved on a 3x5 card

Stipulate the time period on the card

Reduce time delays for consequences

Make use of Timers at the Point of Performance

Avoid assignment of multiple tasks all at once

Praise initiation of compliance

Provide rewards throughout the task

Have child evaluate their performance at the end

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Time-Out Target time-out to focus on one problem

Act quickly after infractions Violations of household rules get instant time out

Immediate commands: Give Command ( count backwards from 5)

Give Warning with raised voice (repeat count of 5) Initiate time-out

Release from time-out contingent on: Completion of minimum time period (1-2 minutes/year of age)

Becoming quiet

Consenting to command

Reward next good behavior

Best to use Bedroom for Time-out Remove all major play activities (Sanitize)

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Psychopharmacology

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Stimulant Medications These are the most well studied drugs in psychiatry

In use for over 40 years Over 350 studies

Thousands of cases

Stimulant Response Rate

Ritalin (Methylphenidate) 77%

Adderall (Amphetamine) 74%

Dexedrine

(Dextroamphetamime)73%

Trying All 90%

Stimulants:

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Stimulants:Behavioral Effects

Increased concentration and persistence

Decreased Impulsivity & hyperactivity

Increased work productivity

Better emotional control

Decreased aggression and defiance

Improved compliance

Better working memory & internalized language

Improved handwriting and motor coordination

Improved self-esteem

Decreased punishment

Improved peer acceptance and interactions

Better awareness in sports

Improved driving performance

Sti l t Sid Eff t

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Stimulants: Side Effects Most tolerate well

5% discontinue due to negative effects

Side effects are dose dependent Most common side effects:

Insomnia (50% +) Loss of Appetite (50% +) Headaches (20-40%) Stomach Aches (20-40%)

Irritability, tearfulness (

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Stimulants:Common Myths

Addictive when used as prescribed No, Must be inhaled or injected

Over Prescribed 7.8% prevalence rate, only 4.3% on stimulants

Creates Aggressive, Assaultive Behavior

No, decreases aggression and antisocial actions

Increases the likelihood of Seizures Only at very very high doses

Causes Tourettes Syndrome

Can increase tics in 30%; decreases it in 35% Increases risk of later substance abuse

No, 14 studies have found no such result, some found that itdecreased risk if continued throughout teens

St tt

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Strattera

Selective Norepinepherine reuptake inhibitor Not Schedule II; no abuse potential

Effective for children, adolescents, and adults

Equal efficacy with Methylphenidate with

previously unmedicated cases (75% positiveresponse)

Slightly lower efficacy with those previously onstimulants (55% positive response)

Sustained response for up to 3 years Increasing improvement over time

Can be given once daily (morning) or split

(am/pm)

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Benefits of Strattera

Reduces ADHD, ODD, & aggression

Reduces internalizing symptoms

Increases school productivity

Improved peer social behavior

Improved self-esteem Improved parent-child relations

Improved dry nights among bed-wetters

Better morning after behavior Less insomnia and faster onset of sleep thanMethylphenidate

No emotional blunting

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Academ ic and Occupat ional

In tervent ions fo r theTreatment o f ADHD

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Classroom Management:Basic Considerations

One of the major impairments of children withADHD is functioning in the educational setting.

More children with ADHD are receiving services inpublic schools now than at any other time in

history. Despite the success of medication management

and parent training, psychoeducationalinterventions are needed to ensure academic

success and maintain positive behavior in childrenwith ADHD.

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Classroom Management:Basic Considerations

The first goal of school-based interventions is toimprove basic knowledgeamong educatorsabout the nature, causes, course and treatmentof ADHD.

The second goal is to increase home andschool col laborat ionto ensure that thetreatment plan is consistent, and effectiveacross settings.

Third, effective intervent ionsshould includestrategies to improve academic and socialfunctioning in children and adolescents and

occupational functioning in adults.

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ADHD Basics:Training for Educators

ADHD is biological lybased and is treatable butnot curable. Goal is to manage symptoms andreduce secondary harm (e.g., grade retention,peer rejection, disciplinary actions).

ADHD is not due to a lack of skill or knowledge,but is a problem of sustaining attention, effort,and motivation and of inhibiting behavior. It is adisorder of performing what one knows, not of

knowing what to do. Treatment is most effective when appliedconsis tent lyat the place and time where abehavior is expected to be performed (e.g., at

school).

ADHD B i

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ADHD Basics:Training for Educators

It is harder for students with ADHD to do thesame academic work and exhibit the socialbehavior expected of other students. Thus, thesestudents need more st ruc ture, frequent positive

consequences, consistent negativeconsequences, and accommodations to assignedwork.

To maximize behavior change: proact ive

interventions involve manipulating antecedentevents to prevent challenging behaviors fromoccurring; reactive interventions involveimplementing consequences following a target

behavior.

Cl I t ti

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Classroom Interventions :9 Key Principles

Rules and instructions provided to childrenwith ADHD must be c lear, b riefand oftendelivered through more vis ib leand externalmodes of presentation than required for themanagement of their peers.

Consequences used to manage the behaviorof those with ADHD must be delivered more

swi f t ly (ideally, immediately) than with theirpeers.

Consequences must also be applied moref requent ly.

Cl I t ti

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Consequencesmust often be of a highermagnitude, or more powerful, than thatneeded to manage the behavior of typicalchildren.

An appropriate degree of incent ivesmustbe provided within a setting or task toreinforce appropriate behavior before

punishment can be implemented. Reinforcers/rewards that are employed must

be changed or rotated more frequently thantypical to avoid habituation or satiation.

Cl I t ti

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Ant ic ipat ionis key. Thus, teachers mustplan ahead and ensure that children with

ADHD are cognizant of an upcomingtransition or change in rules or routine beforeit occurs. Think aloud, think ahead.

Children with ADHD must be held morepublicly accountable for their behavior and

goal attainment than typical children. Behavioral interventions only work while they

are being implemented and requiremodification over time for effectiveness.

Cl M t

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Classroom Management:Accommodations

10 core areas of intervention: Decrease workload to fit the childs attentional capacity

Alter teaching style and curriculum

Make rules external

Increase frequency of rewards and fines Increase immediacy of consequences

Increase the magnitude/power of rewards

Set time limits for work completion

Develop a hierarchy of classroom punishments Coordinate home and school consequences

Modifications for teens & adults

Cl M t

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Decreasing the workload Give smaller quotas of work

Allow frequent, shorter work periods

Target productivity and effort first; accuracy and

completion of assignments later Post work instructions on the board; provide a schedule

of assignments weekly and send home to parents.

Reduce the amount of homework to 10 mins. per gradelevel (e.g., 1st grade= 10 mins.)

Cl M t

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Modifying the classroom and curriculum Be animated, flexible and responsive

Reward incentive systems and clear

consequences for misbehavior are crucial Use participatory teaching strategies: have child

write on board, point, use counters

Sit child close to the teachers areaAllow for restlessness, short stretching and/or

exercise breaks

Intersperse low interest with high interest tasks

Cl M t

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Make rules external Post schedule and rules

Use color-coded materials for instructionsand organization

Have child re-state the instruction toensure understanding

Use verbal prompts such as stay in seat,keep on working, etc.

Cl M t

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Use a reward incentive system

Combine positive consequences (praise,

rewards, token economies) and negativeconsequences (response cost, time out),with positive consequences tending to

make the most impact Use strategic teacher attention: smiles,

nods, pats on the back, active ignoring

Cl M t

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Consequences must be immediateAvoid lengthy reasoning over misbehavior.

Simply state the misbehavior and theconsequence (should be posted as a rule)

Use a daily report card or sticker chart.

Variations of time out: go to the chill area ofclassroom; complete a given number of

worksheets (drills) depending on the severity ofthe misbehavior

Use mild, private, specific reprimands althoughpunishment should be used sparingly

Cl M t

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Rewards must be tangible and desirable

Vary rewards to keep interest high

A videogame (especially, educational type) orcomputer program can be used as an incentive

Have parents donate preferred toys and games

Try group rewards

Use a home-school based reward program (e.g.good behavior points from school transfer torewards at home)

Classroom Management

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Set time limits for work completion

Use timers or a bell to signify the end of a

work period; use a signal about fiveminutes before the end as well

Generally, extra time is not beneficial.

Focus on developing a distraction-freework setting and provide breaks after shortwork periods.

Classroom Management:

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Use a punishment hierarchy Head down on desk; quiet time

Response cost (loss of tokens) Time out in a corner/chill location

Time out at school office where childs

behavior can be monitored Suspension to the office (in school, not athome)--punishment is immediate and briefand does not include rewarding activities


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Coordinate home and schoolconsequences

Daily school behavior report card/ratingform and point system

Daily home-school journal to communicate

with parents and/or provide a reminder tochild when completing homework

Gradually, move to weekly monitoring


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Specifically, for teens with ADHD: Use a daily assignment notebook/planner with teacher

verification and cross-checking

Create a private, in-class cueing system for off-task

behavior and disruption Use a daily or weekly school report card; coordinate w/

home rewards (e.g. $ for grades)

Assign a daily case manager or organizational coach to

help monitor, organize and motivate Permit music during homework

Require note-taking to pay attention

Keep an extra set of books/materials at home


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More tips for teens: Learn SQ4R for reading comprehension:

Survey material, draft Questions, Read, Recite,

Write, Review

-- Study with buddy after school

-- Swap phone numbers and email addresses withclassmates to call in the event of lost or missing

assignment sheets and instructions-- Attend after school help/tutoring sessions

-- Schedule parent-teacher review meetings every6 weeks

Occupational:

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Occupational:Accommodations

College-bound teens and young adults mayrequire assistance with:

Employment Independent Living

Managing money

Organization

Time management

Accommodations/resources for college andoccupational success

Occupational:

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Occupational:Accommodations

CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) offers severalresources to assist adults in handling theseand other important issues. Please visitwww.chadd.orgfor more information.
http://www.chadd.org/http://www.chadd.org/

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Summary Education of teachers and other professionals

working with children and adults with ADHD iscrucial to helping these individuals receive theaccommodations needed to ensure successacademically and occupationally.

Interventions are effective as long as they arebeing implemented and must be maintained overextended time periods.

Collaboration between school and home appearsto ensure greater success in the classroom.

There are many resources available offering awealth of advice to professionals who help those

with ADHD.

Resources

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Resources www.chadd.orgoffers scientifically reliable information in English and

Spanish about ADD in children, adolescents, and adults. Sponsored byChildren and Adults with ADHD (CHADD), the largest ADHD support andadvocacy organization in the United States, it has downloadable fact sheets ofscience-based information for parents, educators, professionals, the media,and the general public. The site also includes contact information for twohundred local chapters of CHADD throughout the United States.

www.help4adhd.orgpresents evidence-based information in English andSpanish about ADD in children, adolescents, and adults. This national clearinghouse of downloadable information and resources concerning many aspectsof ADHD is funded by the U.S. government's Centers for Disease Control andPrevention and operated by CHADD. New material is added frequently, andquestions directed to the site are responded to by knowledgeable health-

information specialists. www.add.orgis a resource in English for adults with ADD. Sponsored by

Attention Deficit Disorder Association (ADDA), the world's largest organizationfor adults with ADHD, it provides information, resources, and networkingopportunities.

Documents

ADHD Web