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	For People with ADHD & Those Who Love Them
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Everything You Want To Know About ADHD

ALAN R GRAHAM, PhD

ACP Consultants, Ltd

ADDvisor.com

Park Ridge, Illinois 60068

847-824-1235

alan@ADDvisor.com

Presented at the Chicago Area AEYC Conference January, 2007

Attention Deficit Disorders: History

• Minimal Brain Damage (1953)

• Minimal Brain Dysfunction (1966)

• Hyperkinetic Reaction of Childhood (DSM-II)

• Attention-Deficit Disorder With/Without Hyperactivity (DSM-III, 1980)

• Attention-Deficit Disorder With Hyperactivity (DSM-III-R, 1987)

• Attention-Deficit/Hyperactivity Disorder (DSM-IV, 1994)

Epidemiology of Attention-Deficit/Hyperactivity Disorder

• Prevalence: 3%-5% of children

• Boy:Girl Ratio: 4:1 (general population)
9:1 (clinic population)

• Adolescents with substantial symptoms: approximately 80%

• Adults with substantial symptoms: 70-85%

• 50-70% likelihood that a parent has ADHD as well

ADHD - A Disorder of Self-Regulation

• Human vs. Animal Brain

• Executive functions affected by ADHD:

– Internalization of speech

– Behavioral inhibition

– Problem solving ability

– Mood management, arousal

– Working memory

• The “CEO” in your brain

Working Memory

• Working memory is a key function that is necessary for performing many cognitive tasks. It is the ability to keep information “online” for a brief period of time, typically a few seconds. Klingberg, 2005

Working Memory Skills

• Comprehension

• Multiple step instructions

• Language learning

• Math Skills

• Attention

• Retrieval

• Multi-tasking

• Problem solving

The Brain and ADHD

Diagnostic Criteria: DSM-IV

• Symptoms present:

– Before age 7

– For 6 months (or more)

– In at least 2 settings

– Clinically significant to impair functioning

DSM-IV Criteria: ADHD Subtypes

• ADHD predominantly inattentive type

– At least 6 of 9 inattention symptoms

• ADHD predominantly hyperactive-impulsive type

– At least 6 of 9 hyperactivity-impulsivity symptoms

• ADHD combined type

– At least 6 inattention symptoms plus at least 6 hyperactivity-impulsivity symptoms

• ADHD not otherwise specified

Positive Attributes of the AD/HD Child

• High-energy

• Creative

• Adventuresome

• Risk-taking

• Able to make snap decisions

Evolution of Symptoms: Preschool and Elementary School

• Fidgety

• Excessive talking

• Erratic performance

• Bossy

• Constant demand for attention

Evolution of Symptoms: Adolescence

• Restlessness

• Talking out of turn

• Problems at school

• Problems with peers

• Difficulty establishing independence from parents

• Poor judgment

Differential Diagnosis

• A diagnosis of exclusion

– Age appropriate activity or developmentally appropriate

– Medical differential diagnoses

– Psychiatric differential diagnoses

– Learning disorders

– Be careful about making assumptions – cultural, education, family

Medical Differential Diagnoses

• Hearing loss; poor vision

• Hyperthyroidism

• Organic Brain disorders - seizure disorders

• Other medical conditions - allergies, diabetes, hypoglycemia

• Medication related - seizure, allergy, asthma

• Substance induced condition

Psychiatric Differential Diagnoses

• Mood disorders

• Anxiety (including PTSD)

• Oppositional-Defiant/Conduct Disorders

• Thought Disorders

• Tourette’s Syndrome; OCD

• Learning/Communication Disorders

• Developmental Disorders (MR, Autism)

Comorbidity

• Oppositional defiant disorder (50%)

• Conduct Disorders (30%)

• Mood Disorders (15%)

• Anxiety (20-25%)

• Enuresis and/or encopresis

• Sleep disorders

Comorbidity

• Substance abuse

• Genetic Disorders

• Prenatal risk factors - (Fetal alcohol syndrome, cocaine exposure)

• Other - lead intoxication

• A cormorbid diagnosis exists in 78% of girls, 48% of boys

Diagnosis

• No definitive “test”

• Baseline medical workup

• Information needed from various sources

• Teacher and school’s role

Diagnostic Procedures

• Structured interview with comprehensive history (P,T,C)

• Rating scales (P,T,C)

– Connors

– Child Behavior Checklist

– BRIEF

– Others: BASC, ADDES, ACTeRS

• Self report assessments (P,C {if over 11})

– Youth Self Report

– Connors-Wells

• Observation in natural and clinical environments (C)

Treatment

• Multidisciplinary approach

– Psychotropic medications

– Parent education and training

– Behavioral therapies

– Educational interventions

– Psychological therapies

– Non medication interventions

Psychotropic Medications

• Psychostimulants

• Strattera

• Antihypertensives

• Antidepressants

Psychostimulants

• Ritalin (methylphenidate) (77%)

– Focalin

– Metadate

– Methylin

– Ritalin LA

– Concerta

– Daytrana transdermal patch

• Dexedrine (dextroamphetamine) (74%)

• Adderall (an amphetamine product) (75%)

• Cylert (73%)- rarely used

• Stimulants are effective in up 90% of all cases

Behavioral Effects of Stimulants

• Increased attention span & concentration

• Decreased impulsivity

• Decreased task-irrelevant activity level

• Decreased aggressiveness

Behavioral Effects of Stimulants

• Increased compliance

• Improved handwriting and fine motor skill

• Improved peer relations & social status

• Improved sports participation

Side Effects of Stimulant Drugs

• Insomnia & decreased appetite (50-60%)

• Headaches and stomach aches (20-40%)

• Prone to crying (10%)

• Nervous mannerisms (10%)

Side Effects of Stimulant Drugs

• Tics (<5%) & Tourette’s (very rare)

• Mild weight loss (a few pounds first 1-2yrs.)

• No effect on skeletal growth

• Mild increases in heart rate and blood pressure

• Cylert: affects liver functioning

Fears About Stimulants

• Lower seizure thresholds

• Leads to aggressive/assaultive behavior

• Tics or Tourette’s Syndrome are common

• Sedates children

• Addictive for children/adolescents

• Greater risk of substance abuse

Medications and Substance Abusers

• Less risk of abuse with Strattera, Concerta

• More risk of abuse with Adderall, Dexedrine and short acting Ritalin

Using Stimulants in Practice

• Give parents a medication fact sheet

• Consider whether to use a long-acting or short-acting stimulant

• Start at a low dose

• Increase incrementally

Using Stimulants in Practice

• Continue titration until success or side effects occur

• If poor response, try another stimulant

• Most children need doses throughout entire week, consider PRN use on weekends

Using Stimulants in Practice

• Body weight is not a primary consideration

• Most children do not need drug holidays--use in summer is indicated

• Discontinue medication for 3-7 days in mid-October to evaluate continued need

Using Stimulants in Practice

• Use for as many years as needed

• For rare, severe cases combine with antidepressants as needed

• Get periodic parent and teacher ratings to monitor effectiveness

Benefits of Strattera

• Works on the Norepinephrine neurotransmitter

• 24/7 coverage

• Use with people with tics or twitches

• Can combine easily with stimulants

• Easy to use with substance abusers

• Insomnia is comparable to placebo

Disadvantages of Strattera

• Can take up to 4 weeks to take effect

• Perceived as not as effective as stimulants

• Don’t know that much about it yet because it is new. (January 2003)

Antihypertensives

• Clonidine

• Tenex

Tricyclic Antidepressants

• Tofranil

• Elavil

• Norpramine

Parent Education and Training

• Parent education

– Child/adolescent management programs

– Behavior modification programs

– Building positive interactions

– Education about the disorder

– Parent/adolescent problem solving and communication training (Robin)

• Parent support groups

– CHADD

– ADDA

– Other community based support groups

12 Management Tips for Children with ADHD
Rob Ward, M.A. & Patricia Purvis, Ph.D. (1997)

• Big clock - Big Time

• Be Fast With Praise

• Praise, Praise and more Praise

• Be a Slot-Machine for Quick, Cheap Kid-valuable Goodies

• Change the Payoffs

• Act Don’t Yak

12 Management Tips for Children with ADHD
Rob Ward, M.A. & Patricia Purvis, Ph.D. (1997)

• Be positive, +

• Scouts, Be Prepared!

• Keep a Disability in Mind

• Pick Your Battles, Make them Few

• Stop Pointing! Don’t Blame Self, Don’t Blame Child

• Be Forgiving

Five Strategies to Build the Resilient Mindset
Goldstein/Brooks

• Teach empathy by practicing empathy

• Teach responsibility by encouraging contributions

• Teach decision-making and problem-solving skills that reinforce self-discipline

• Offer encouragement and feedback

• Help children deal with mistakes

Five Strategies to Build the Resilient Mindset
Goldstein/Brooks

• Teach decision-making and problem-solving skills that reinforce self-discipline

• Offer encouragement and feedback

• Help children deal with mistakes

Behavioral Therapies

• Intervene at the “point of performance

• Reduce negative behaviors

• Increase positive behaviors

• Teach cognitive-behavioral interventions, i.e.: behavioral self control techniques (at point of performance)

• Self-monitoring

• Self-reinforcement

Educational Interventions

• Maintain communication with school personnel (teachers, social workers, nurses, administrators, etc.)

• Advocate in the child’s best interest

• Assist with medication-related problems

• If necessary, request a case study and multidisciplinary staffing to develop an Individualized Educational Plan (IEP) or 504 plan

Tools for Monitoring Student’s Progress

• Behavior rating scales

• Behavior Modification Programs

• Consultations with teachers, parents

Psychological Therapies

• Individual therapy – not effective for ADHD but can be helpful with co-morbid conditions

• Family therapy – very useful for parents and siblings of ADHD child or teen as well as ADHD patient

Primary Tasks of an ADD Coach

• Education

• Structure

– Building systems

– Accountability

• Support

• Skills

– Setting Realistic Goals

– Time management

– Boundaries

Non-Medication Interventions

• Most have only anecdotal evidence , little empirical evidence

• Neurofeedback – mostly anecdotal, some promising empirical evidence, has taken a long time to be considered

• Working Memory Training – growing empirical evidence

• Diet – fatty acids, some encouraging empirical evidence

Working Memory Training

• Recent research has shown that a person can train their working memory.

• Klingberg studied the effectiveness of a working memory computer training program and discovered that working memory capacity can be increased through training.

Cogmed Working Memory Training

• RoboMemo is a training program designed to improve working memory.

• The program requires 30-45 minutes per weekday.

• During this time the children participates in eight rotating exercises that train visuo-spatial and verbal working memory.

• As the child improves the program becomes more difficult to challenge the child.

• To encourage the child through the training program each child is provided with a coach to provide feedback and support.

Everything You Want To Know About ADHD

ALAN R GRAHAM, PhD

ACP Consultants, Ltd

ADDvisor.com

Park Ridge, Illinois 60068

847-824-1235

alan@ADDvisor.com

Presented at the Chicago Area AEYC Conference January, 2007

Attention Deficit Disorders: History

• Minimal Brain Damage (1953)

• Minimal Brain Dysfunction (1966)

• Hyperkinetic Reaction of Childhood (DSM-II)

• Attention-Deficit Disorder With/Without Hyperactivity (DSM-III, 1980)

• Attention-Deficit Disorder With Hyperactivity (DSM-III-R, 1987)

• Attention-Deficit/Hyperactivity Disorder (DSM-IV, 1994)

Epidemiology of Attention-Deficit/Hyperactivity Disorder

• Prevalence: 3%-5% of children

• Boy:Girl Ratio: 4:1 (general population) 9:1 (clinic population)

• Adolescents with substantial symptoms: approximately 80%

• Adults with substantial symptoms: 70-85%

• 50-70% likelihood that a parent has ADHD as well

ADHD - A Disorder of Self-Regulation

• Human vs. Animal Brain

• Executive functions affected by ADHD:

– Internalization of speech

– Behavioral inhibition

– Problem solving ability

– Mood management, arousal

– Working memory

• The “CEO” in your brain

Working Memory

• Working memory is a key function that is necessary for performing many cognitive tasks. It is the ability to keep information “online” for a brief period of time, typically a few seconds. Klingberg, 2005

Working Memory Skills

• Comprehension

• Multiple step instructions

• Language learning

• Math Skills

• Attention

• Retrieval

• Multi-tasking

• Problem solving

The Brain and ADHD

Diagnostic Criteria: DSM-IV

• Symptoms present:

– Before age 7

– For 6 months (or more)

– In at least 2 settings

– Clinically significant to impair functioning

DSM-IV Criteria: ADHD Subtypes

• ADHD predominantly inattentive type

– At least 6 of 9 inattention symptoms

• ADHD predominantly hyperactive-impulsive type

– At least 6 of 9 hyperactivity-impulsivity symptoms

• ADHD combined type

– At least 6 inattention symptoms plus at least 6 hyperactivity-impulsivity symptoms

• ADHD not otherwise specified

Positive Attributes of the AD/HD Child

• High-energy

• Creative

• Adventuresome

• Risk-taking

• Able to make snap decisions

Evolution of Symptoms: Preschool and Elementary School

• Fidgety

• Excessive talking

• Erratic performance

• Bossy

• Constant demand for attention

Evolution of Symptoms: Adolescence

• Restlessness

• Talking out of turn

• Problems at school

• Problems with peers

• Difficulty establishing independence from parents

• Poor judgment

Differential Diagnosis

• A diagnosis of exclusion

– Age appropriate activity or developmentally appropriate

– Medical differential diagnoses

– Psychiatric differential diagnoses

• Boy:Girl Ratio: 4:1 (general population)
9:1 (clinic population)