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Attention Deficit/Hyperactivity Disorder

This article provides information about Attention Deficit/Hyperactivity Disorder (ADHD), including its symptoms, diagnosis process, and treatment options. It also explores the causes and comorbidities associated with ADHD.

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Attention Deficit/Hyperactivity Disorder

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  1. Attention Deficit/Hyperactivity Disorder Jillian C. Schneider, Ph.D. Pediatric Neuropsychologist Fairfax Neonatal Associates February 11 2014

  2. Background and Training • Doctoral 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

  3. Commonly Asked Questions • What is attention? • What is ADHD? • How is ADHD diagnosed? • How is ADHD treated?

  4. What is Attention? • Process whereby individuals receive and process incoming information • Subtypes: • Span • Focused • Selective • Sustained (vigilance/concentration) • Alternating • Divided

  5. What is Executive Functioning • Enables individuals to engage in independent, purposeful behavior • Domains: • Inhibitory control, Behavioral/emotional regulation • Mental flexibility • Initiation • Working memory • Planning, Organization, Goal setting • Abstract reasoning, Problem-solving, Hypothesis generation • Self-monitoring

  6. 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?

  7. Inattention Hyperactivity Impulsivity What is ADHD?

  8. Inattention • Inattention to detail, makes careless mistakes • Trouble staying focused and on task • Not listening • Not following through with instructions or tasks • Disorganized • Avoids and dislikes tasks that require sustained effort • Loses things • Easily distracted • Forgetful

  9. Hyperactivity • Fidgets or squirms in seat • Trouble sitting still • Runs or climbs at inappropriate times • Trouble playing quietly • Often “on the go,” acts as if “driven by a motor” • Talks excessively

  10. Impulsivity • Blurts out answers • Difficulty waiting his/her turn • Interrupts or intrudes on others

  11. ADHD Subtypes • Predominantly Inattentive Presentation • 6 (5 in adults) or more symptoms of inattention • Predominantly Hyperactive/Impulsive Presentation • 6 (5 in adults) or more symptoms of hyperactivity or impulsivity • Combined Presentation • at least 6 (5 in adults) symptoms of inattention AND 6 (5 in adults) symptoms of hyperactivity or impulsivity

  12. ADHD Diagnostic Criteria • Several 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

  13. How Common is ADHD?

  14. ADHD: Boys vs. Girls

  15. ADHD: Boys vs. Girls • Compared to boys, girls: • Rated lower on scales in hyperactivity and impulsivity • Display fewer behavioral problems • Have more internalizing problems (e.g., depression, anxiety) • Clinical presentation in girls: • Inattention –spacey, daydreamers, may appear shy • Hyperactivity –extremely talkative

  16. 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

  17. 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.

  18. ADHD Across the Lifespan • Preschool • Poor sustained attention, easily distracted • Elevated gross motor activity • School Age • Poor sustained attention, distractibility • Inconsistent academic progress • Restless, fidgety • Adolescence/Adulthood • Problems with sustained effort and concentration • Executive functioning weaknesses • Internal feelings of restlessness • Participation in risky activities • Academic / occupational underachievement

  19. Comorbidity: Rule Not the Exception Tourette/Tics 10% Learning Disability 46% ADHD Conduct Disorder 27% Speech Problems 12% Autism Spectrum Disorder 25% Anxiety 18% Depression 14%

  20. What Causes ADHD: Neurodevelopment • Differences in brain maturation, structure, and function • Prefrontal cortex • Basal ganglia • Cerebellum

  21. What Causes ADHD: Genes and the Environment • Familial and significantly heritable • 30-35% of first-degree relatives of children with ADHD also have the disorder • Environmental Risk Factors • Premature birth and birth complications • Maternal smoking and substance use • Lead exposure/toxicity • Traumatic brain injury

  22. What Doesn’t Cause ADHD? • Bad parenting • Sugar • Diet • Too much television • Videogames

  23. 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?

  24. Diagnosing ADHD • Diagnostic 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 level • Symptoms are not better accounted for by another disorder

  25. Assessing Symptoms of ADHD • There is NO test for ADHD • Diagnosis is made based on information gathered about presenting concerns/symptoms through: • Review of development and clinical history • Historical review of concerning behaviors • Behavioral observation

  26. Standardized Assessment of ADHD • Standardized 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 tests • Performance may be variable on measures

  27. Symptoms of ADHD are not better accounted for by another disorder Medical • Hearing/vision problems • Intellectual disability • Learning disability • Language disorder • Sleep apnea • Seizure disorder • Metabolic disorder • Substance abuse Psychological • Depression or Anxiety • Behavioral problems • Stress or changes and sudden changes in life Environmental • Family dynamics • Academic environment

  28. Specialists who diagnose ADHD • Pediatrician/Developmental Pediatrician • Psychiatrist • Behavioral 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

  29. Neuropsychological Evaluation • Assess learning and behavior in relation to an individual’s brain processes. • Intellectual functioning • Academic achievement • Language • Visual processing • Attention and concentration • Executive functioning • Learning and memory • Sensory and motor functioning • Affective, behavioral, and social functioning

  30. Neuropsychological assessment is helpful when… • There is suspicion of low cognitive abilities • There is low academic achievement • In order to differentiate among coexisting disorders • In 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)

  31. How is ADHD Treated? • There is no cure • The focus of treatment should be on reducing the symptoms of ADHD and improving functioning • Common treatment methods include: • Medication • Behavioral/Cognitive Behavioral Therapy • Combination of Treatment • Medication > Medication + Behavioral Intervention > No Treatment

  32. Medication • Medications Types: • Psychostimulants (e.g., Ritalin, Adderall, Concerta) • Non-stimulants (e.g., Strattera, Tenex, Intuniv) • Short vs. Long Acting • Pill/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

  33. Behavior / Cognitive Behavior Therapy • Behavioral Parent /Teacher Training • Focuses on teaching the child more socially acceptable behavior by training caregivers and teachers in contingency management strategies. • Academic Interventions • Environmental modifications, curriculum changes, testing accommodations, assistive technology • Peer-related Interventions • Addresses difficulties that children have with initiating and maintaining appropriate peer relationships

  34. Alternative and Complementary Treatments • Treatments that have not been scientifically validated to improve symptoms of ADHD • Dietary changes • Herbal supplements • Chiropractic adjustments • Interactive metronome training • https://www.understood.org/en/learning-attention-issues/treatments-approaches/alternative-therapies/faqs-about-interactive-metronome-training

  35. Resources • Books 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 Reif • Living with ADHD: A Practical Guide to Coping with ADHD by Rebecca Kajander • Executive 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

  36. Resources Cont. • Books for Kids • Clayton’s Path by Brett Bishop • Joey Pigza Swallowed the Key by Jack Gantos • Help Is on the Way: A Child’s Book about ADD by Marc Nemiroff, Margaret Scott, and Jane Annunziata • Organizations • CHADD (Children and Adults with Attention Deficit Hyperactivity Disorder) www.chadd.org

  37. Questions

  38. Jillian C. Schneider, Ph.D. Fairfax Neonatal Associates 2720-D Prosperity Avenue Fairfax, Virginia 22031 (703) 752-2765

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