Attention Deficit/Hyperactivity Disorder
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Transcript of Attention Deficit/Hyperactivity Disorder
Jillian C. Schneider, Ph.D.Pediatric NeuropsychologistFairfax Neonatal Associates
February 11 2014
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Background and TrainingDoctoral Degree: Ph.D. in Clinical Psychology from Drexel
University
Pre-doctoral training: Kennedy Krieger Institute/The Johns Hopkins University School of Medicine
Post-doctoral training (two year fellowship): Children’s National Medical Center
Previous employment: independent pediatric neuropsychology practice, contractor with Department of Defense
Publications include book chapters and articles on infectious
disease and mild traumatic brain injury in peer reviewed journals
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Commonly Asked QuestionsWhat is attention?What is ADHD?How is ADHD diagnosed?How is ADHD treated?
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What is Attention?Process whereby individuals receive and
process incoming informationSubtypes:
SpanFocusedSelectiveSustained (vigilance/concentration)AlternatingDivided
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What is Executive FunctioningEnables individuals to engage in
independent, purposeful behaviorDomains:
Inhibitory control, Behavioral/emotional regulationMental flexibilityInitiationWorking memoryPlanning, Organization, Goal settingAbstract reasoning, Problem-solving, Hypothesis
generationSelf-monitoring
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What is ADHD?What are the symptoms?What’s the difference between ADHD and
ADD?Can a gifted child be diagnosed with it?Is it different in girls vs. boys?Do children grow out of it?How common is it?What causes it?
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What is ADHD?
Inattention Hyperactivity
Impulsivity
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InattentionInattention to detail, makes careless mistakesTrouble staying focused and on taskNot listeningNot following through with instructions or tasksDisorganizedAvoids and dislikes tasks that require sustained
effortLoses thingsEasily distractedForgetful
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HyperactivityFidgets or squirms in seatTrouble sitting stillRuns or climbs at inappropriate timesTrouble playing quietlyOften “on the go,” acts as if “driven by a
motor”Talks excessively
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ImpulsivityBlurts out answersDifficulty waiting his/her turnInterrupts or intrudes on others
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ADHD SubtypesPredominantly Inattentive Presentation
6 (5 in adults) or more symptoms of inattention
Predominantly Hyperactive/Impulsive Presentation6 (5 in adults) or more symptoms of hyperactivity or
impulsivity
Combined Presentationat least 6 (5 in adults) symptoms of inattention AND
6 (5 in adults) symptoms of hyperactivity or impulsivity
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ADHD Diagnostic CriteriaSeveral symptoms of inattention and/or
hyperactivity and impulsivity are present before age 12 years
Symptoms are present in two or more settings
Symptoms interfere with or reduce the quality of social, academic, or occupational functioning
Symptoms are not better accounted for by another disorder
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How Common is ADHD?
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ADHD: Boys vs. Girls
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ADHD: Boys vs. GirlsCompared to boys, girls:
Rated lower on scales in hyperactivity and impulsivity
Display fewer behavioral problemsHave more internalizing problems (e.g.,
depression, anxiety)Clinical presentation in girls:
Inattention –spacey, daydreamers, may appear shy
Hyperactivity –extremely talkative
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Can ADHD be Diagnosed in Gifted Children? Yes, ADHD and GT can co-exist.Like most children with ADHD, gifted
children with ADHD: may display problems with sustained attention
and hyperactivity in less stimulating or motivating environments
may display academic inconsistencies and/or underachievement
May exhibit a wider gap between intellectual functioning and social/emotional functioning
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Do Children Grow out of ADHD?• No, most children do not “grow out” of ADHD
• In general, ADHD increases the risk for academic and occupational underachievement, substance abuse, delinquent behavior, relationship problems, trouble managing stress, etc.
• However, many children learn various coping strategies for managing their difficulties.
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ADHD Across the LifespanPreschool
Poor sustained attention, easily distractedElevated gross motor activity
School AgePoor sustained attention, distractibility Inconsistent academic progressRestless, fidgety
Adolescence/AdulthoodProblems with sustained effort and concentrationExecutive functioning weaknesses Internal feelings of restlessnessParticipation in risky activitiesAcademic / occupational underachievement
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Comorbidity: Rule Not the Exception
ADHD
Learning Disability
46%
Speech Proble
ms12%
Anxiety18%Depressio
n14%
Conduct Disorder
27%
Tourette/Tics10%
Autism Spectrum Disorder
25%
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What Causes ADHD: NeurodevelopmentDifferences in brain maturation, structure,
and function
Prefrontal cortexBasal gangliaCerebellum
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What Causes ADHD: Genes and the EnvironmentFamilial and significantly heritable
30-35% of first-degree relatives of children with ADHD also have the disorder
Environmental Risk FactorsPremature birth and birth complicationsMaternal smoking and substance useLead exposure/toxicityTraumatic brain injury
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What Doesn’t Cause ADHD?Bad parentingSugarDietToo much televisionVideogames
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How is ADHD Diagnosed?What kind of psychological work-up should
be done to make a diagnosis?Is there a specific test used to diagnose
ADHD?Where should I go to get a diagnostic
evaluation?
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Diagnosing ADHDDiagnostic requirements:
At least 6 symptoms of inattention and/or 6 symptoms of hyperactivity/impulsivity
Symptoms must: have been present before age 12 have persisted for at least six months be present across two different settings be present to a degree that causes problems and is
inconsistent with developmental levelSymptoms are not better accounted for by
another disorder
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Assessing Symptoms of ADHDThere is NO test for ADHD
Diagnosis is made based on information gathered about presenting concerns/symptoms through: Review of development and clinical historyHistorical review of concerning behaviorsBehavioral observation
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Standardized Assessment of ADHDStandardized assessment may include:
Questionnaires/rating scales completed by parents and teachers
Cognitive testing
Assessment should be individualized to an individual child’s specific problems.
Considerations:Children may do well on standardized testsPerformance may be variable on measures
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Symptoms of ADHD are not better accounted for by another disorder
MedicalHearing/vision
problemsIntellectual disabilityLearning disabilityLanguage disorderSleep apneaSeizure disorderMetabolic disorderSubstance abuse
PsychologicalDepression or AnxietyBehavioral problems Stress or changes and
sudden changes in life
EnvironmentalFamily dynamicsAcademic environment
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Specialists who diagnose ADHDPediatrician/Developmental PediatricianPsychiatristBehavioral Neurologist Psychologist/Neuropsychologist
The person conducting the evaluation should be a professional trained in assessing children’s development, emotions, and behavior and in differential diagnosis
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Neuropsychological EvaluationAssess learning and behavior in relation to an
individual’s brain processes.Intellectual functioningAcademic achievementLanguageVisual processingAttention and concentrationExecutive functioningLearning and memorySensory and motor functioningAffective, behavioral, and social functioning
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Neuropsychological assessment is helpful when…There is suspicion of low cognitive abilitiesThere is low academic achievementIn order to differentiate among coexisting disordersIn order to describe an individual’s strengths and
weaknesses and to tailor recommendations and help with treatment and educational planning
In order to increase validity of diagnostic impressions
There are coexisting medical conditions (e.g., epilepsy)
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How is ADHD Treated?There is no cureThe focus of treatment should be on reducing
the symptoms of ADHD and improving functioning
Common treatment methods include:MedicationBehavioral/Cognitive Behavioral TherapyCombination of Treatment
Medication > Medication + Behavioral Intervention > No Treatment
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MedicationMedications Types:
Psychostimulants (e.g., Ritalin, Adderall, Concerta)Non-stimulants (e.g., Strattera, Tenex, Intuniv)Short vs. Long ActingPill/capsule, Liquid, Skin patch
Side Effects:Decreased appetite, sleep problems, anxiety,
irritability Not a one-size-fits-all approach –finding the right
medication requires careful and continuous fine-tuning
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Behavior / Cognitive Behavior TherapyBehavioral Parent /Teacher Training
Focuses on teaching the child more socially acceptable behavior by training caregivers and teachers in contingency management strategies.
Academic InterventionsEnvironmental modifications, curriculum changes,
testing accommodations, assistive technology Peer-related Interventions
Addresses difficulties that children have with initiating and maintaining appropriate peer relationships
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Alternative and Complementary TreatmentsTreatments that have not been scientifically
validated to improve symptoms of ADHDDietary changesHerbal supplementsChiropractic adjustmentsInteractive metronome trainingEye or vision training and special colored
glassesEEG biofeedback
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ResourcesBooks for Parents
Taking Charge of ADHD: The Complete Authoritative Guide for Parents by Russell Barkley
Parenting Children with ADHD: 10 Lessons that Medicine Can Not Teach by Vincent Monastra
How to Reach and Teach ADD/ADHD Children by Sandra ReifLiving with ADHD: A Practical Guide to Coping with ADHD
by Rebecca KajanderExecutive Skills in Children and Adolescents: A Practical
Guide to Assessment and Intervention by Peg Dawson and Richard Guare
Smart but Scattered: A Revolutionary “Executive Skills” Approach to Helping Kids Reach Their Potential by Peg Dawson and Richard Guare
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Resources Cont.Books for Kids
Clayton’s Path by Brett BishopJoey Pigza Swallowed the Key by Jack GantosHelp Is on the Way: A Child’s Book about ADD
by Marc Nemiroff, Margaret Scott, and Jane Annunziata
OrganizationsCHADD (Children and Adults with Attention
Deficit Hyperactivity Disorder) www.chadd.org
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Questions
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Jillian C. Schneider, Ph.D.Fairfax Neonatal Associates2720-D Prosperity Avenue
Fairfax, Virginia 22031(703) 752-2765
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