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ADHD: Ready...FIRE!..Aim ADHD: Ready...FIRE!..aim Understanding and dealing with kids with adhd 1 The Bottom Line ADHD exists! It can seriously mess you up at all ages! It can be treated! 2 ADHD -- Hyperactivity (6 of 9) A. Hyperactivity: • often fidgets with hands or feet, squirms in seat; • often leaves seat in situations where remaining seated is expected; • often runs, climbs excessively (in adolescents or adults, may be limited to subjective feelings of restlessness); • has difficulty playing quietly; • often “on the go,” acts as if “driven by a motor” • often talks excessively; B. Impulsivity: • often blurts out answers before questions have been completed; • often has difficulty awaiting turn; • often interrupts or intrudes on others. DSM-IV, 1994 3 ADHD -- Inattention (6 of 9) • often fails to give close attention to details, makes careless mistakes; • often has difficulty sustaining attention in tasks or play activities; • seems not to listen when spoken to directly; • does not follow through on schoolwork, chores, work duties (not due to failure to understand or oppositional behavior); • has difficulty organizing tasks and activities; • often avoids, dislikes, or is reluctant to engage in tasks that required sustained mental effort; • often loses things necessary for tasks or activities; • easily distracted by extraneous stimuli; • often forgetful in daily activities. DSM-IV, 1994 4 ADHD - Executive Functions • Volition, planning, purposive goal-directed or intentional action • Inhibition and resistance to distraction • Problem solving and strategy development, selection, and monitoring • Flexible shifting of actions to meet task demands • Maintenance of persistence toward attaining a goal • Self-awareness across time Each EF contributes to the following developmental shifts in the control of behavior: • From external events to mental representations of those events • From control by others to control by self • From immediate to delayed gratification • From the “now” to the “conjectured social future” Barkley, 2000 5 ADHD -- Associated Features low frustration tolerance, TEMPER OUTBURSTS, bossiness, stubbornness, insistence that requests be met, rapidly changing emotions, demoralization, UNHAPPINESS, REJECTION BY PEERS, poor self-esteem, impaired academic achievement, family relationships characterized by resentment and antagonism IQs somewhat lower; [SLEEP PROBLEMS (2-way street)] DSM-IV, 1994 6 Changes in DSM-V Now in different category, i.e., Neurodevelopmental disorders rather than Disruptive behavior disorders Some attention to different symptom sets for older kids and adults Number of symptoms required is slightly reduced with increasing age Requires symptoms before age 12 (not age 7) Can now be diagnosed in conjunction with autism Adds severity levels: Mild, moderate, severe 7 ADHD: Prevalence ADHD: Prevalence • 2-8% of kids (average 5-7%); teacher reports = 2-3x more than parent reports; increasing evidence of ADHD in younger kids (2-3) • 4.7% of adults • varies by gender (3:1 to 9:1 in “favor of” males) • similar across cultures, $, urban-rural, ethnicity • currently increasing, 10% plus 8 Prevalence update: There is little evidence to support the claims of overdiagnosis and/or overmedication. WHAT MIGHT ACCOUNT FOR THE INCREASE? Toxins: lead, tobacco, mercury, insecticides, polychorinated biphenyls, bisphenol A Poverty and maltreatment, “with the poorest children more than twice as likely as the wealthiest to meet criteria for ADHD.” ADHD least prevalent in sunny states & countries Use of television, computers, video games & devices may increase ADHD behaviors, BUT.... 9 ADHD -- Comorbidities 1 • Oppositional-defiant disorder: 40-67% • Conduct disorder: 20-56% • Delinquent/antisocial activities: 18-30% • Anxiety disorders: 10-40% • Major depression: 0-45%) • Bipolar disorder: 0-27% 10 ADHD - Comorbidities 2 Implications of early versus late onset adhd/odd ODD CD Antisocial/borderline personality disorder (very bad!) FAS/FAE, drug effects and RAD: inconsistent even paradoxical symptoms; lack of conscience, empathy; limited understanding of cause & effect; ability to manipulate & sabotage Bipolar: symptom overlap complicates diagnosis; family history of bipolar highly predictive. Characteristics: Symptoms may include grandiose delusions, irritable mood often accompanied by rage, aggression and self-injury (“mean and hurtful”), decreased need for sleep without daytime fatigue, pressured speech, flight of ideas, distractibility varying with mood, increased goal-directed activity, hypersexuality, and auditory hallucinations in some patients Medication issues: mood stabilization should precede stimulants; prognosis worse with early onset. 11 ADHD: Course (optimistic) • Increasing research base, new more effective treatments (behavioral, medical, educational) • Remission (or adaptation) in 20-30% of cases • Less problematic presentation over time; symptoms remain but are adapted to • Niche-seeking Self-employment Part-time, seasonal employment Trades Arts & crafts Military 12 ADHD: Course (Realistic) • Rarely outgrown (but remember 20-30%) • From childhood to adolescence: previously: 50% persistence currently: 70-80% persistence • From adolescence to young adulthood: 12% self-report 66% parent report 13 ADHD: Negative Outcomes in Kids • Difficulties with daily activities, daily routines, chores, community skills • Poor family functioning (problems with parents, siblings, relatives) • Poor peer relationships (home, school, playground, community) • Lack of casual, informal, vicarious learning • Academic difficulties, need for accommodations in school • Accident-prone, risky behaviors • Unrealistic, tend to overestimate their competence All the above results in multiple continuing experiences of FAILURE, plus growing certainty that interactions with others will inevitably be NEGATIVE. Our job: begin providing & creating experiences of SUCCESS; begin providing and creating POSITIVE interactions with others 14 ADHD: Negative outcomes in adolescents • Hyperactivity may decline, but inattention & impulsivity persist • Problems less behavioral, more academic: More grade retentions, suspensions, expulsions, drop-outs; lower GPAs, class rankings, college entrances/graduations • Comorbidities more in evidence (anxiety, depression) • More serious risk-taking behaviors (smoking, drinking, drugs, driving, sex, high-risk sports, hobbies) • Problems with executive functioning more evident (deficits in problem solving, planning, organizing) • Family problems more evident, more disruptive (“experiencing parental limitations as overly burdensome”) • Problems specific to girls: “chronic low self-esteem, underachievement, anxiety, depression, teen pregnancy, smoking” Prince et al, 2003 15 ADHD: Negative Outcomes in Adults • Psychiatric (CD, depression, anxiety, substance abuse, personality disorders) • Employment (more fired, underemployment, job loss, job changes, poorer work performance) • Driving (poorer driving skills; worse driving habits; more serious accidents, tickets, loss of license) • Sexual (earlier sexual behavior, more partners, less safe sex, more kids, more STDs) • Crime (more arrests for theft, disorderly conduct, assault, weapons, drugs, B&E, firesetting) • Parenting difficulties • For adult women: all of the above plus more divorce, $ problems, single parenting, loss of custody of kids, eating disorders, kids with ADHD/ADD 16 Treating ADHD-1 Changing our expectations, from kids who won’t to kids who can’t.... (ODD versus ADHD) But remember comorbidity -- some kids “can’t” part of the time, and “won’t” part of the time. Telling the difference is important and critical. 17 Scheduling 1 Calendars and planners AM, PM routines; mealtimes; bedtimes; weekends; especially one-time special events (plan ahead) Words, pictures, icons, drawings, recordings Make the schedule concrete, externalize Put it on the wall, large size, big print, bright colors (make copies) Add 3x5 cards to carry (laminate, hang around neck) Transitions: minimize in number, prepare for in advance, reinforce for success 18 Treating ADHD A treatment with increasing empirical support: EEG/Biofeedback PROCEDURE & GOALS: Complex initial assessment of brain waves Child watches a fish swim through a maze. Brain activity consistent with attention moves the fish; if attention lags, brain activity changes, fish stops immediately. Aim: “to promote improved self-monitoring...and improved conscious self-regulation of the internal state at such moments (Nash, 2000, p. 32).” Capitalizes on REALLY immediate feedback and the reinforcement and novelty of video games. OUTCOMES: Given 40-60 sessions, there is a measurable and significant increase in some kids’ ability to sustain attention (11 of 17 in one study, 31 of 36 in another study, 12 of 19 in another study). Improvement generalizes to behavior & academics for some kids. May be IQ gains. Of most importance, the increase in sustained attention maintains after the end of treatment sessions. 19 20 Designed for extreme sleepers, the Sonic Bomb has a piercingly loud alarm, blazing orange LEDs, and a supercharged bed shaker. $39.99 www.x-tremegeek.com 21 Nature as Treatment “Last time I checked, it was “Increasing evidence demonstrates the many pretty tough to have a sense of benefits of nature on children’s psychological and wonder when you’re playing physical well-being, including reduced stress, greater ‘Grand Theft Auto’.” physical health, more creativity and increased concentration... [also providing] a sense of wonder and a deeper
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