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.
The Amazing Frontal Cortex Think of it as the brain’s secretary Responsible for executive functioning Prioritize attention, emotions, responses Keep goals and consequences in mind Without it we MAKE BAD DECISIONS!
Inattention Can’t pay close attention to details, make careless mistakes Trouble sustaining attention Doesn’t seem to listen when spoken to directly Doesn’t 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
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
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
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
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
Is ADHD increasing or over diagnosed? 1990’s: 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?
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
Evaluation School may administer psycho-educational testing Learning disabilities, intellectual delay Provider will administer questionnaires to elicit diagnostic criteria Conners, Vanderbilt Assessment Scales
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
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%
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
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
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
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
What Does Not Cause ADHD Bad parenting- when kids are treated the bad parenting improves! Yeast Lighting Vitamin deficiency
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
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)
Behavior Modification Maintain daily schedules Minimize distractions Provide specific and logical places for homework, clothes, toys, etc Set small, reachable goals Reward positive behavior Don’t reward negative behavior Find activities where child can be successful Use charts and checklists Limit choices Use calm discipline
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, don’t Yak- quickly reward the good behavior
Ten Principles Plan ahead for problem situations Keep a disability perspective- remember your child has a different brain Don’t personalize the problem- stay calm, keep a sense of humor, give yourself a time out Practice forgiveness- forgive the child, forgive others who don’t understand your child, forgive yourself We all make mistakes!
And more advice Be specific about what you like in behavior “I like it when you…..” Give more effective commands- don’t use a question “Why don’t 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
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
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
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 child’s age and circumstances If one doesn’t work, another may
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
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
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