ATTENTION DEFICIT HYPERACTIVITY DISORDER In Children & Adolescents
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 the rate 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
Essential Features ADHD presents as impairment in: Persistence Resistance to distraction Working memory
Persistence ADHD Individuals do not have problems with such perceptual aspects of attention as: arousal or alertness focus or selective attention span of apprehension or divided attention Rather have an inability to sustain action toward a goal for an adequate period of time which is a motor problem Persistence is on the motor side of attention, it is an output disorder. Output is the problem Most people think of attention as an input problem: how you perceive, select filter and process information
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 not overly 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 to distracting events, ignore them even though we detect them. ADHD is not a problem of perception but inhibition
Working Memory Once distracted ADHD individuals are far less likely 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
Inattention Symptoms (DSM-IV) uFailure to give close attention to details uDifficulty sustaining attention uDoes not seem to listen uDoes not follow through on instructions uDifficulty organizing tasks or activities uAvoids tasks requiring sustained mental effort uLoses things necessary for tasks uEasily distracted uForgetful in daily activities Symptoms must occur Often or more frequently
Hyperactive-Impulsive Symptoms uFidgets with hands or feet or squirms in seat uLeaves seat in classroom inappropriately uRuns about or climbs excessively uHas difficulty playing quietly uIs on the go or driven by a motor uTalks excessively uBlurts out answers before questions are completed uHas difficulty awaiting turn uInterrupts or intrudes on others Symptoms must occur Often or more frequently
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
ADHD Varies by Setting Better Here: Worse Here: Fun Boring Immediate Delayed Consequences Frequent Infrequent Feedback High Low Salience EarlyLate in the Day Supervised Unsupervised One-to-one Group Situations Novelty Familiarity Fathers Mothers StrangersParents Clinic Exam RoomWaiting Room
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 are independent of social class and urban-rural
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 have ADHD)
Medical Risks Sleep problems (39-56%); mainly delayed onset and greater night waking leading to shorter 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
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 ADHD appears to be the areas of the brain controlling Executive Functions and Physical Activity (Smaller / Less Developed) Social causes have poor evidence
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 after controlling for the above factors
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) Prenatal hyperactivity Post-natal inattention
Heredity Family 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+)
Heredity Twin 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 happen only to one person in a family) 15-20% of individual differences (but includes unreliability of measure used to assess ADHD)
Etiologies of ADHD From Joel Nigg (2006), What Causes ADHD? LBW FASD Lead Smoking Perinatal Other Heritable (Genetics)
ADHD Evaluation: Core Considerations Are the symptoms of inattention, impulsiveness, and overactivity, present. MOST Importantly Is there clear evidence of an impulsive style? Is there evidence that these symptoms significantly interfere with the childs functioning both at school and at home? Did these symptoms have a reasonably early onset? (If not, is there a good explanation?). Have these symptoms been an enduring and consistent feature of the childs behavior throughout their development and in the majority of contexts? Is there evidence that the child wishes to perform well but cannot? Are there better explanations for the underachievement? Is there a pattern or specific triggers to the problem behaviors?
6 Step Diagnostic Process Review of Home Behavior Review of School Bx and Collateral Information Review of Developmental History Review of Family/Marital Situation School / Natural Environment Observation Interview of Child
Psychodiagnostic Evaluation A psychodiagnostic Evaluation may be necessary if the assessment produces mixed/inconsistent results or has uncovered 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 new skills Reports that child has trouble with major academic subjects even when attentive.
Ruling out Depression Later onset than ADHD Usually preceded by excessive anxiety Not uncommon to have both as a result of the negative outcomes due to ADHD behaviors. Must treat both When comorbid, associated with a 4x increase in suicidal ideation and 2x increase in attempts Appears to be connected to same genes associated with ADHD. Best differential: EARLY HISTORY
Ruling Out Anxiety Onset later than ADHD Associated with a particular event or in accordance with a time pattern (anniversary). Restlessness is not a primary manifestation of Anxiety (usually a habit, style, or boredom) Usually characterized by panic or dread along with worry. Best measure for presence of anxiety is childs report (parents and teachers under report).
Ruling Out PTSD Must look closely at developmental and early school history. PTSD will stem from a specific event Children with ADHD are at greater risk for PTSD from abuse and risky behaviors.
Ruling Out Bipolar Disorder Childhood BPD manifests as severe and chronic irritability (rather than episodic mania) Also characterized by Disjointed thinking, capricious mood, destructiveness, and dysphoria. 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
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 the differential
Treating ATTENTION DEFICIT HYPERACTIVITY DISORDER In Children & Adolescents
Current Perspective ADHD creates a kind of Myopia for future events or 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 appropriate place & time (Point of Performance) ADHD is better characterized as an Intention Deficit
ADHD & Executive Functioning Executive Functioning is responsible for two types 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
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 but not all cases. Diminished capacity does not excuse accountability (The problem is time and timing not consequences). Behavioral treatment is essential but does generalize or endure after removal. Treatment success depends on the compassion and willingness of others to make accommodations. Maintaining a Chronic Disability perspective is most effective.
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
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
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 erase board) Give immediate feedback Increase frequency of consequences Increase accountability to others Use salient & artificial rewards
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)
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
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 Co...