Transcript The ADHD Story

The ADHD Story
James J. Messina, Ph.D.
Go to: www.coping.org
for ADHD Articles & Links
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ADHD a Neurobiological
Condition is related to SLD
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Attention Deficit Hyperactivity Disorder
(ADHD) - with Inattention and/or
Impulsivity
Specific Learning Disability (SLD) - with
Auditory, Visual or Kinesthetic Processing
Problems including Dyslexia/Reading
Disorder
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Other Neurobiological
Conditions Related to ADHD:
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Central Auditory Processing Disorder (CAPD)
Sensory Integration Disorder
Motor Planning Disorder
Self-Regulatory Disorder
Autistic Spectrum Disorder - PDD, MSD,
Globally Delayed, Autistic
Neurological Conditions: Epilepsy, Tourette
Syndrome
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What Research is Telling Us
about ADHD
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Genetically transmitted in 70-95% of cases
Results from chemical imbalance or deficiency in
certain neurotransmitters-chemicals which help
brain regulate behavior
Rate at which brain uses glucose, its main energy
source, is lower in subjects with ADHD than those
without (Zametkin et al, 1990)
Depressed release of Dopamine might have role in
ADHD (Volkow et al, 2003)
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Research also tells us about
ADHD that:
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Central pathological deficits of ADHD are linked to
several specific brain regions
 Frontal Lobe
 Its connections to Basal Ganglia
 Their relationships to central aspect of Cerebellum
Less electrical activity in brain & show less reactivity
to stimulation in one or more of above brain regions
Brains are 3-4% smaller-in more severe-frontal
lobes, temporal gray matter, caudate nucleus &
cerebellum were smaller
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PET Scan of Metabolism of
Glucose Adult Brain with ADHD
Positron Emission Tomography (PET) Pictures of
Adult with ADHD
Normal Adult
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ADHD & LD lead to Diminished
Executive Functions
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Deficient self-regulation of behavior, mood,
response
Impaired ability to organize/plan behavior
over time
Inability to direct behavior toward future
Diminished social effectiveness &
adaptability
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What is the Impact of these
Disorders?
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Neurologically based behavioral issues
can keep child from developing normally
 Lack of full coordination of gross &
fine motor skills
 Lack of complete age appropriate
speech, language & communications
 Impaired self-esteem
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What is the Extent of ADHD?
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About 3% of school-aged population have full ADHD
symptoms & another 5-10% have partial ADHD
Another 15-20% of school-aged population show
transient behaviors suggestive of ADHD
Boys are 3 times more likely than girls to have ADHD
Symptoms decrease with age but 50-65% of children
still manifest symptoms into Adulthood (Korn & Weiss,
2003)
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What is the Extent of SLD?
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15% of Americans have learning disabilities with
many going untreated due to lack of diagnosis
10 million children or approximately 1 in 5
children in 1st through 9th grades (Cramer & Ellis,
1996)
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60% of adults with severe literacy problems
have undetected/untreated LD (NALLDC, 1994)
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What is the Impact of ADHD
on people? (Barkley, 2002)
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32-40% of students with ADHD drop out of school
Only 5-10% will complete college
50-70% have few or no friends
70-80% will under-perform at work
40-50% will engage in antisocial activities
More likely to experience teen pregnancy &
sexually transmitted diseases
Have more accidents & speed excessively
Experience depression & personality disorders
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What is the Impact of these
Disorders?
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35% of students with learning disabilities drop
out of school
30% of adolescents with learning disabilities will
be arrested 3 to 5 years out of High School
(Wagner et al, 1993)
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Previously undetected learning disabilities have
been found in 50% of juvenile delinquents Once treated their recidivism drops to just 2%
(Lerner, 1997)
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Attention Deficit Hyperactivity Disorder
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Inattention - Traditionally
known as ADD
Impulsivity - Traditionally
known as Hyperactivity
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ADHD Characteristics
Inattention
Impulsivity
Overactivity
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Inattention-Distractibility
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Doesn’t seem to listen
Fails to finish assigned tasks
Often loses things
Can’t concentrate
Easily distracted
Daydreams
Requires frequent redirection
Can be very quiet & missed
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Impulsivity-Behavioral Disinhibition
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Rushing into things
Careless errors
Risk taking
Taking dares
Accidents/injuries prone
Impatience
Interruptions
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Hyperactivity - Overarousal
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Restlessness
Can’t sit still
Talks excessively
Fidgeting
Always on the go
Easy arousal
Lots of body movement
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Different Names for ADHD
Through the years:
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1902 Defects in moral character
1934 Organically driven
1940 Minimal Brain Syndrome
1957 Hyperkinetic Impulse Disorder
1960 Minimal Brain Dysfunction (MBD)
1968 Hyperkinetic Reaction of Childhood (DSM II)
1980 Attention Deficit Disorder - ADD (DSM III)
with-hyperactivity without-hyperactivity residual
type
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Names for ADHD
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1987 Attention-Deficit Hyperactivity Disorder or
Undifferentiated Attention Deficit Disorder
(DSM III-R)
1994 Attention-Deficit/Hyperactivity Disorder
(DSM IV)
314.01: ADHD, Combined Type
314.00: ADHD, Predominantly Inattentive type
314.01: ADHD, Predominantly HyperactiveImpulsive Type
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What is Learning Disability?
Definition:
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A learning disability is a disorder that affects a
person’s ability to either interpret what is seen
and heard or to link information from different
parts of the brain. These limitations can show up
in many ways - as specific difficulties with spoken
and written language, coordination, self-control,
or attention. Such difficulties extend to school
work and can impede learning to read or write or
do math.
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What are Learning Disabilities
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Neurological in origin
Impede person’s ability to store,
process or produce information
Affect ability to read
Affect ability to speak
Affect ability to compute math
Impair socialization
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LD Language Symptoms
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Pronunciation problems
Slow vocabulary growth
Lack of interest in stories
Poor spelling
Delayed decoding
Poor reading comprehension
Trouble following directions
Lack of verbal participation in class
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LD Memory Symptoms
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Trouble learning numbers, alphabet &
days of the week
Slow acquisition of new skills
Poor memory for routines
Slow recall of facts
Organizational problems
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LD Attention Symptoms
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Trouble sitting still
Extreme restlessness
Impersistence at tasks
Impulsivity
Inconsistency
Poor self-monitoring, insatiability
Great knowledge of trivia
Careless errors
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LD Fine Motor Skill Symptoms
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Trouble learning self-help skills
Clumsiness
Reluctance to draw, trace or color
Poor pencil grasp
Poor letter formation
Fist-like or tight pencil grasp
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Rule outs for Diagnosis of
ADHD
Rule Out’s Diagnosis
Evaluation by use of:
Gifted
IQ Testing-Psychologist
Learning Disability
Academic/Perceptual
Testing-Psychologist
Pediatric NeurologistEEG, 24 hr EEG, MRI etc
Psycho-Social History &
Personality Testing
Neurological Conditions:
Seizures, Tourette’s etc.
Behavioral or Emotional
Problem caused by
anxiety & depression
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GARLIC V.S. ONION-Rule out
System in Diagnosing ADHD
Rule of Thumb of Ruling out Garlic Issues:
 Garlic’s odor outdoes Onion’s so treat Garlic first
 Rule out Garlic issue or treat it prior to addressing
Onion issue
 Lack of success in treating Onion may be because
Garlic was not identified & treated
 Ongoing setbacks may be due to power of Garlic’s
strength & incapability of de-powering it
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Garlic Rule Outs in Diagnosing
ADHD:
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Seizure Disorder or other neurological issue
such as Tourette’s Syndrome
Specific Learning Disability
Vision acuity problem
Hearing problem
Metabolic problem
Genetic problem
Child Psychiatric Problem
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Electroencephalography
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Rule out epileptiform activity and/or epilepsy
especially petit mal seizures which cause
attention lapses
Use sleep deprived prolonged overnight EEG
study to obtain all four stages of sleep
(Tuchman, 1994, 1997; Volkmar & Nelson, 1990; Tuchman et
al 1998; & Chez et al, 1997)
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Use MRI if neurologic examination & EEG or other
clinical indicators suggest focal lesion (CAN 1998)
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Ophthalmologic Screening
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Behavioral in focus
Pure formal visual screening
Rule out processing deficits
Rule out central nervous system abnormality
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Audiological Screening
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Rule out middle ear infection that causes
intermittent hearing problems
Behavioral in focus
Pure formal tone audiometry
Brainstem auditory evoked potential if
necessary
Rule out processing deficits
Rule out central nervous system abnormality
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Metabolic Screening Tests
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Rule out food allergies or nutritional
problems
Metabolic Lab tests are indicated with signs
of metabolic disease e.g. failure to thrive,
small stature etc.
Quantitative amino acids
Urine organic acids
Uric acid & calcium in a 24 hr urine
Thyroid studies
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Cognitive, Speech & Language,
Motor, Sensory & Motor Planning
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Pediatric Psychologist
Speech & Language Pathologist
Occupational Therapist - sensory
integration
Physical Therapist
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Medication Treatment of
ADHD
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STIMULANTS
Ritalin-one dose lasts up to 4 hours
Metadate – Ritalin – once a day lasts up to 12 hrs
Focalin – New Ritalin derivative lasts up to 4 hours
Attenade-Newest Ritalin derivative-lasts 6 hours
Concerta- once a day lasts up to 12 hours
Dexedrine-last 4 hours-spansule lasts 10 hours
Adderall- New Dexedrine - once or twice a day lasts
longer than Ritalin
Cylert-requires liver function testing due to history
of hepatic failure with children who were on it 36
Medication Treatment of
ADHD
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Non-Stimulant Medication:
Strattera – acts as a stimulant with similar side
affects – norepinephrine reuptake inhibitor – not to
be used with Prozac, Paxil or albuterol
Nutraceutical:
Attend - a natural product which combines amino
acids, fatty acids, lipid complexes, homeopathic
medicines, hormone precursors to specific
neurotransmitters
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Plus these interventions:
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Parent Team
Home Modifications
Parent-Teacher Team
504 Plan with Educational
Consistency of parent-teacher-doctor team
Unconditional love from all adults
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Classroom Modifications for
Students with ADHD & SLD
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1. Classroom Modifications
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Establish rules in classroom
Reinforce rules in classroom
Be consistent
Interact with student by: eye contact,
call name, finger on desk, touching
Place student: in front, near positive
peers, in low distracting areas
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2. Classroom Modifications
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Evaluate & structure environment
Reduce external visual & auditory stimuli
Repeat & have student paraphrase
directions
Give short directions
Use predetermined signals
Multiple modalities
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3. Classroom Modifications
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Natural & logical consequences
Develop learning contracts with student
Use environmental clues: prompts,
steps, written lists, schedules
Demonstrate acceptable ways to
communicate displeasure, anger,
frustration & pleasure
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4. Classroom Modifications
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Earphones & study carrels
Reduced rote assignments
Longer time for testing
Read test to student
Assignment books & organizers
Keep notebook for parent teacher
communications after each class day
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5. Classroom Modifications
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Computer games & programs
Peer Buddy Tutors & Helpers
Classroom shadow, 1 on 1 Assistant
Progress notes to parents
Quarterly conferences with parents
Parents selection of teacher for next
school year
Medications monitoring
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6. Classroom Modifications
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Unconditional love of child
Willingness to extend oneself
Openness to doing things differently
Working with parents as a team
Admitting when you are lost
Flexibility
Willingness to change
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7. Classroom Modifications
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Getting outside help
Openness to other’s input
Enthusiasm
Optimism - “We Can” Attitude
Determination to make it work
Commitment to process and to child
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