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

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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.

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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 understanding of our responsibility to take care of the earth.”

Two research studies: “children who experienced the biggest increase in green space near their home after moving improved their cognitive functioning more than those who moved to areas with fewer natural resources nearby;” “the presence of nearby nature bolsters a child’s resilience against stress and adversity, particularly among those children who experience a high level of stress.”

At home: Get the kids outside more. At school: More recess time, greener playgrounds.

“If we had kids moving around and burning off energy, I think we would have much less difficulty with kids having trouble paying attention in the classroom.”

22 Treating ADHD: ABA

• 30+ years of solid, empirical, peer-reviewed science • Individualized, flexible, data-based (“Behave, damn you! Behave as you ought!” And they always do!) • Behavioral laws similar to physical laws • Simple to describe, outline; complex to implement (Science, but also art, magic, blind dumb luck) • Skills-based; not casual, informal

23 Basic behavioral principles • Reinforcement •Extinction •Negative reinforcement •Punishment •Schedules •Satiation •Stimulus control

24 Reinforcement Frequent Small to tiny Immediate Concrete/tangible Salient Varied (not freely available)

(visible) NEUTRAL (losable) (“ho hum”) No way To die for

25 Positive reinforcement in the real world?

26 Treating ADHD-4 Medications Stimulants (ritalin, adderall, concerta, etc.)

First Recommendation: Stimulant medication (or Strattera). Highly effective on core symptoms...improve functions in a number of domains...require no monitoring...not weight dependent. Best dose--optimal effects with minimal side effects

Second/Third Recommendations: Other stimulants (or Strattera). 80% of kids (90%, Barkley, 2003) will respond to one of the stimulants if they are tried in a systematic way.

If no response after 3, then consider other meds and/or reconsider accuracy of diagnosis or possibility of comorbidity.

From the American Academy of Pediatrics, 2002

Several studies of stimulant use in kids 3-5; results are typically positive (89%), but greater variability in treatment outcomes, more attention needed to side effects

27 Here’s one perspective on drugs...it’s wrong.

28 more on stimulants

• Drugs of choice (40+ years research); many new formulations (especially extended release, patch, nasal spray formulations) • Don’t work for everyone (maybe 10-20%) • Virtually immediate results (hours, days) • Outcomes: some show dramatic improvement; some worsen; almost all show some improvement • Conservative dosing is the rule....but higher doses may help (FK) • Recent research has addressed several serious concerns regarding side effects: No brain damage (may in fact promote brain maturation) No behavioral rebound when stopped Growth delay -- minimal effects on height, weight Tics -- meds more likely to help with than to cause Heart rate, blood pressure -- nonsignificant increases Future substance abuse -- less rather than more likely (12 studies) • Adherence issues (many Rx’s not filled, let alone followed, consistently)

29 Treatment of ADHD: Some cautions:

• A “substantial minority” of kids don’t improve with behavior modification or with medications (issues of treatment integrity,medication compliance?).

• Behavior modification and medication do not normalize ADHD children, still are not “the same as” normal kids.

Behavioral approaches Medications are effective are effective while in while in place; when place; when removed, removed, behaviors behaviors return. return.

...but remember EEG/biofeedback may last longer....

30 ADHD: What can we do? (1)

Educate ourselves and others; keep up-to-date on research Work cooperatively with schools, doctors, therapists Provide Structure, Consistency, Predictability Change the physical environment Provide external concrete help

31 ADHD: What can we do? (3)

Sports (skills, sportsmanship) Socialization/interaction with peers Create positive moments Humor Self-control training (and practice)

32 Sports & sportsmanship-1 Kids with ADHD are often less athletic & bad sports. This study targeted dribbling and shooting a basketball for 3 boys with ADHD. Only dribbling improved.. Discussions of sportsmanship had no effect. Then a token economy was introduced to increase sportsmanlike (praising others, high fives, helping others) & decrease unsportsmanlike (whining, complaining) conduct. Sportsmanlike behaviors increased from .95 to 11.25; from .45 to 5.50; and from 1.28 to 7.00 for the 3 boys. Importantly, no unsportsmanlike conduct was exhibited. In addition, shooting percentages decreased and passing increased for each boy.

“In summary, even minor increases in sports competence and interest in sports may be sufficient to ensure that children continue participating in athletic activities, and existing data indicate that sports training positively influences social status and self-concept.”

Hupp and Reitman,1999.

33 ADHD on the Playground - 2

Studied the effects of stimulant medication and contingency management for sportsmanlike behavior with 5 kids in a kickball game. Medication had “very little influence” on sportsmanlike behavior. Delayed rewards (“good job,” choose from cheaper toys in blue box; “great job,” choose from more expensive toys in red box). Delayed rewards did not increase sportsmanlike behavior. However, adding immediate tokens (and praise) to the delayed reward condition increased sportsmanlike behavior in all 5 kids.

34 Helping with WHAT TO SUGGEST:

Ask him/her SELF-CONTROL Count to 10 (or 3, or backwards from 20...) WHAT TO DO: Physical distraction Visualization (“happy place,” Explain, model “frog on lilypad”) Do when calm, NOT when upset Cognitive distraction Develop practice schedule (start Self-talk (whoops, that’s SIT) often, fade with success; involve others; reinforce) Generalize (school, relatives) HOW TO REINFORCE:

IF kid practices with prompts, THEN R+ IF kid suggests practice, THEN R+ (but be careful) IF you prompt use in real life and it works, THEN bigger R+ (if you prompt & it doesn’t work,don’t worry) IF you observe kid use successfully in real life, THEN biggest R+

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