Presented to NAMI By Grace Yelland, MD Port Angeles, WA January
15, 2015
Slide 2
Lets pretend.
Slide 3
What exactly is ADHD? A neuro-developmental disorder
Characterized by inattention and poor impulse control Relatively
pervasive and persistent over time Not explained by purely
environmental or social causes It is NOT a lack of attention, but
rather a disorder of self control and attention regulation.
Slide 4
The Amazing Frontal Cortex Think of it as the brains secretary
Responsible for executive functioning Prioritize attention,
emotions, responses Keep goals and consequences in mind Without it
we MAKE BAD DECISIONS!
Slide 5
Inattention Cant pay close attention to details, make careless
mistakes Trouble sustaining attention Doesnt seem to listen when
spoken to directly Doesnt follow through on instructions, fails to
finish Trouble organizing activities Avoids or dislikes tasks that
require sustained attention Often loses things needed for tasks and
activities Easily distracted and often forgetful
Slide 6
Hyperactivity and Impulsivity Often fidgets, squirms, leaves
seat Runs or climbs when not appropriate Feeling of restlessness in
adolescents Trouble taking part in leisure activities quietly
Always on the go, driven by a motor Talks excessively, blurts out
answers Trouble waiting turns Often interrupts or intrudes on
others
Slide 7
Hyperactivity and Impulsivity Decrease in ability to inhibit
behavior Can be seen as rude or insensitive Take risks- failure to
consider consequences Much higher rates of trauma, ER visits,
fracture, lacerations, motor vehicle accidents in drivers More
likely to smoke : 50% vs. 27% by age 14-15 More likely to drink
alcohol : 40% vs. 22% More likely to use marijuana : 17% vs. 5%
Money management problems
Slide 8
Why is it important to diagnose and treat? Costs to child,
family and society : Stressful home environment, danger to the
child Poor school performance Poor peer interactions Poor job
performance, lost productivity Anti social behavior- crimes,
substance abuse In adolescents, 20% have set serious fires, 30%
engaged in theft, 40% use tobacco and alcohol, 25% expelled from
high school
Slide 9
History: 1798: Sir Alexander Crichton described mental
restlessness in a book on mental derangements 1902: Sir George
Still, a British pediatrician clearly described ADHD children
(abnormal defect of moral control) 1952: DSM-1 minimal brain
dysfunction 1968: DSM-2 hyperkinetic impulse disorder 1980: DSM-3
ADD with or without hyperactivity 1987: DSM-4 ADHD with three
different subtypes 2014: DSM-5 minor changes to diagnostic
criteria
Slide 10
Is ADHD increasing or over diagnosed? 1990s: big increase in
the number of cases due to better diagnostic tests and
understanding Parents and teachers are more aware and are looking
for a diagnosis Was it better handled in the past without a
diagnosis? Is the complexity of our society to blame? Are schools
overcrowded and parents/children too busy?
Slide 11
Diagnosis No one gold standard test General medical exam- rule
out vision and hearing problems, sleep disorders, thyroid
dysfunction, seizures, other developmental delays Family history-
ADHD, anxiety, depression, bipolar disorder Prenatal exposure-
tobacco, alcohol, other drugs Prematurity, low birth weight
Slide 12
Evaluation School may administer psycho-educational testing
Learning disabilities, intellectual delay Provider will administer
questionnaires to elicit diagnostic criteria Conners, Vanderbilt
Assessment Scales
Slide 13
DSM-5 diagnosis criteria 6 or more symptoms in either category
(5 for 17 and older) Symptoms must be present for at least 6 months
Symptoms started before age 12 (used to be 6) Are present in 2 or
more settings Interfere with the quality of social, school or work
function Symptoms cannot be explained by another disorder
Slide 14
How Common is ADHD? National Survey of Childrens Health
2003-2011 4-17 yrs Overall 8.8% have ADHD 6.8% age 4-10 (1 in 15)
11.4% age 11-14 (1 in 9) 10.2% age 15-17 (1 in 10) Boys are 2-3
times more likely to have ADHD Regional differences Nevada 4%,
Kentucky 15%
Slide 15
What are the Risks? Boys (referral bias?) Children with early
high activity levels, demanding Family history of ADHD Exposure to
tobacco and alcohol during pregnancy Prematurity and low birth
weight Single parent Low educational level ANYONE from any
background can have ADHD
Slide 16
Causes Genetics twin studies, specific gene abnormalities have
been found Environmental factors- alcohol, tobacco, other drugs-
could be a genetic influence as well adults with ADHD are more
likely to have substance abuse therefore pass the gene as well as
the toxin on to their child lead exposure during early childhood
Brain injuries, infections
Slide 17
Aggravating Factors Sugar? Most research discounts that sugar
causes or worsens ADHD but this may be individual. Studies with
kids on sugar vs. artificial sweetener: no clinical difference
Mothers however rated behavior worse when they thought their child
was on sugar (even though they were not!) Food additives-
artificial colors, flavors, preservatives
Slide 18
Feingold Diet In 1975, Dr. Benjamin Feingold described food
additives that worsened ADHD Study of treating kids with his diet:
50% improved! Not substantiated by further studies for a long time
Recent study: some food coloring (red and yellow) and a
preservative (sodium benzoate) did increase hyperactivity Other
additives- aspartame, MSG, nitrites? Take home message: EAT
HEALTHY
Slide 19
What Does Not Cause ADHD Bad parenting- when kids are treated
the bad parenting improves! Yeast Lighting Vitamin deficiency
Slide 20
Biologic Effect on the Brain There is a difference in dopamine
and norepinephrine in brain and CSF Lower electrical activity and
less mature pattern Less blood flow in the frontal cortex and
caudate nucleus- important link to the limbic system Limbic system
inhibits behavior, sustains attention, controls emotions,
motivation and memory PET scans (map of glucose or brain fuel use)
show decreased activity in these areas.
Is ADHD Outgrown? 80% of school aged children with ADHD will
have it in adolescence 30-65% will have it as adults The core
symptoms are improved (many by high school) Goal is to improve
function, not cure the disorder
Slide 23
Treatment- Behavior Modification Only approved method of
treatment in preschoolers Positive Reinforcement Response Cost
(withdraw privileges when unwanted behavior occurs) Token Economy
(a combination of the two)
Slide 24
Behavior Modification Maintain daily schedules Minimize
distractions Provide specific and logical places for homework,
clothes, toys, etc Set small, reachable goals Reward positive
behavior Dont reward negative behavior Find activities where child
can be successful Use charts and checklists Limit choices Use calm
discipline
Slide 25
Ten Guiding Principles Give immediate feedback and consequences
(focus on positive behaviors) Give more frequent feedback Use
larger and more powerful consequences Use incentives before
punishment- discuss with child what behavior you are looking for,
what the reward will be, practice frequently Strive for
consistency- even in different settings Act, dont Yak- quickly
reward the good behavior
Slide 26
Ten Principles Plan ahead for problem situations Keep a
disability perspective- remember your child has a different brain
Dont personalize the problem- stay calm, keep a sense of humor,
give yourself a time out Practice forgiveness- forgive the child,
forgive others who dont understand your child, forgive yourself We
all make mistakes!
Slide 27
And more advice Be specific about what you like in behavior I
like it when you.. Give more effective commands- dont use a
question Why dont you get ready for dinner? Give one command at a
time, break it down further if necessary Reduce distractions when
giving a command- make eye contact, turn off TV, radio, computer
Ask child to repeat the command Make up chore cards, post visibly
Set deadlines
Slide 28
The Token Economy Can use poker chips, marbles, pennies, a
point chart Explain the target behaviors List the privileges Assign
points to the behaviors and cost of rewards Review the list often,
add new behaviors and rewards as needed Punishment may be loss of
points
Slide 29
Other Exercises The statue game Beat the clock Attention checks
Impulsive behavior list Talk to counselors www.CHADD.org and other
websites Library Support groups
Slide 30
Medications Not all patients will improve on meds! (75-80%
will) Stimulants-amphetamine, dexedrine, lis-dexamphetamine
(Vyvanse), mixed amphetamines (Adderall), methylphenidate (Ritalin,
Metadate, Concerta, Focalin), Short acting, long acting and
extended release forms Pills, capsules, liquid, patch Stimulants
have a paradoxical effect Choice of med depends on childs age and
circumstances If one doesnt work, another may
Slide 31
Side Effects Decreased appetite Sleep problems Headache,
stomach ache- usually transient Tics (not a contraindication)
Moodiness, irritability, anxiety Rare- cardiovascular problems in
children with underlying heart disease
Slide 32
Monitoring Regular follow up visits are important Follow
growth, blood pressure Assessment of core symptom improvement
Assessment of side effects Need for more or less medication or
different formulation
Slide 33
Non-stimulant medications Atomoxetine (Strattera)- works on
dopamine May have similar side effects as stimulants Buproprion
(Welbutrin) used in adolescents and adults, also affects dopamine
Venlafaxine (Effexor) affects norepinephrine Clonidine (Catapress)
and Guanfacine (Tenex, Intuniv) bind to receptors in the pre
frontal cortex, affect hyperactivity and impulsivity more than
attention, helpful with aggressive behavior. Side effects primarily
sedation