Attention Deficit/Hyperactive Disorder

1
Attention Deficit/Hyperactive Disorder

• David Lombard, Ph.D.
• Center for Applied Behavioral Studies
• www.DavidLombard.com

2
(No Transcript)
3
Overview

• What Is AD/HD
• What Causes AD/HD
• How Common
• Common Symptoms
• Common Treatments
• Comparison with Conduct Disorder

4
What has it been called

• First called minimal brain damage
• Afterwards called minimal brain dysfunction
• Next called ADD
• Finally called ADHD

5
What is AD/HD?

• A medical condition characterized by inattention
  and/or hyperactivity-impulsivity.
• One of the most common mental disorders among
  children, affecting approximately 5 to 7 of
  school-age children and about 2-5 of adults

6
What is AD/HD?

• Persistent inability to pay attention
• May have additional characteristics of
  hyperactive motor movements and/or impulsivity
• Usually begin before age 7 but may not be noticed
  until child is older

7
What is AD/HD

• Symptoms of inattention and/or hyperactivity must
  be present in at least two environments
• Symptoms must cause problems for the individual
  in their environment

8
What causes AD/HD?

• Decreased amount of certain neurotransmitters
• There may be a genetic association
• Appears more often in children whose parents
  suffer from AD/HD, alcohol dependence and/or mood
  disorders

9
Pathophysiology

• Delayed in frontal and temporal lobe
• Accelerated maturity of the motor cortex
• SPECT shows reduce circulation
• Pet Scan shows a decrease glucose metabolism
  during activity

10
(No Transcript)
11
ADHD Throughout the Lifespan

• Preschool- Disruptive behavior, aggression
  towards other children, hyperactivity, conduct
  problems, inattentive and overactive
• Middle Childhood- Unfinished tasks (unfinished
  games, uncovered toothpaste), trouble with school
  work, criticism from parents/teachers/peers, low
  self esteem. Depression and conduct disorders can
  develop here.

12
ADHD throughout the Lifespan cont.

• Adolescence- higher rates of anxiety, depression,
  oppositional behavior, social failure, substance
  abuse
• Adulthood- trouble at work, relationships,
  difficulty following directions, remembering, and
  concentrating, emotional and social problems

13
Epidemiology

• CDC estimates 4.4 million youth ages 4-17 have
  been diagnosed with ADHD
• In 2003, 2.5 million youth ages 4-17 are
  currently receiving medication treatment for the
  disorder.

http//www.cdc.gov/ncbddd/ADHD/
14
Percent of Youth 4-17 ever diagnosed with
Attention-Deficit/Hyperactivity Disorder
National Survey of Children's Health
http//www.cdc.gov/ncbddd/ADHD/adhdprevalence.htm
15
Percent of Youth 4-17 ever diagnosed and
currently medicated for Attention-Deficit/Hyperact
ivity Disorder National Survey of Children's
Health
http//www.cdc.gov/ncbddd/ADHD/adhdmedicated.htm
16
Prevalence in the US

• About 2 million children
• About 5 million adults

17
Prevalence World-Wide

• Australia 3.4 of kids New Zealand 6.7
  kids, 2-3 teens Germany 4.2 children
  India 5-29 children China 6-9 children
  Netherlands 1.3 teens Puerto Rico 9.5
  child teens Japan 7.7 children
  Mexico approx. 5 childrenBrazil 5.8 of
  12-14 year olds

18
How common is AD/HD?

• More common in males than females with studies
  showing a ratio of between 31 and 41
• As many as 5 out of every 100 children may have
  AD/HD

19
What are the signs of AD/HD?

• Three main symptoms (signs)
• Problem paying attention (distractibility)
• Being very active (hyperactivity)
• Acting before thinking (impulsivity)

20

• Based on the these criteria, three types of ADHD
  are identified
• 1. ADHD, Combined Type if both criteria A and
  B are met for the past 6 months.
• Tigger type-Hyperactive, restlessness,
  disorganized, inattention, impulsivity

21

• 2. ADHD, Predominantly Inattentive Type if
  criterion A is met but criterion B is not met for
  the past six months
• Pooh type- Inattentive, sluggish, slow-moving,
  unmotivated, daydreamer

22

• 3. ADHD, Predominantly Hyperactive-Impulsive
  Type if Criterion B is met but Criterion A is
  not met for the past six months.
• Rabbit Type- over focused, obsessive,
  argumentative

23
ADHD NOS

• ADHD, NOS is a category for people who have some
  ADHD symptoms, but not enough to meet full
  criteria for the condition.

24
DSM-IV Criteria

• Inattentive type (6 of 9 needed)
• Fails to give close attention to details
• Difficulty sustaining attention
• Does not seem to listen
• Does not follow through on instructions
• Difficulty organizing tasks or activities
• Avoids tasks requiring sustained mental effort
• Loses things necessary for tasks
• Easily distracted
• Forgetful in daily activities

25
DSM-IV Criteria

• Hyperactive-impulsive type (6 of 9 needed)
• Fidgets with hands or feet or squirms in seat
• Leaves seat in classroom inappropriately
• Runs about or climbs excessively
• Has difficulty playing quietly
• Is on the go or driven by a motor
• Talks excessively
• Blurts out answers before questions are completed
• Has difficulty awaiting turn
• Interrupts or intrudes on others

26
DSM-IV Criteria

• Combined type
• Symptoms of both types described
• At times all children are inattentive, impulsive
  and too active
• With children with AD/HD these behaviors are the
  rule not the exception

27
DSM-IV Criteria

• Developmentally Inappropriate Levels
• Duration of 6 Months
• Cross-setting Occurrence of Symptoms
• Impairment in Major Life Activities
• Onset of Symptoms/Impairment by 7
• Exclusions Severe MR, PDD, Psychosis
• Subtyping into Inattentive, Hyperactive, or
  Combined Types

28
ADHD is Not

• Will power
• Inadequate parenting
• Lack of motivation
• Lack of intelligence
• Laziness

29
What are long-term effects?

• Without effective treatment AD/HD can result in
  serious problems
• Academic failure
• Relationships
• Legal difficulties
• Smoking and SUD
• Injuries
• Motor vehicle accidents
• Occupational/vocational

30
(No Transcript)
31
(No Transcript)
32
ADHD Treatments

• Education
• Medication
• Behavior Modification
• Classroom/Workplace Accommodations

33
Multidisciplinary Approach

• Primary Provider
• Psycho-educational Consultant
• academic, aptitude, and psychometric testing
• IQ measurement
• (usually done through the school)
• Social Services
• Counseling Services
• Individual and Family

34
Commonly Used Stimulant Medications for ADHD

• Methylphenidate (MPH) Products
• Ritalin short mid-acting formsConcerta long
  -acting Metadate CD mid-acting Ritalin
  LA mid-actingFocalin mid-acting
• Short acting 3-5 hours Mid-acting 6-8 hours
  
• Long acting 12 hours

35
List of meds approved by FDA
http//www.nimh.nih.gov/health/publications/attent
ion-deficit-hyperactivity-disorder/medications.sht
ml
36
Commonly Used Stimulant Medications for ADHD

• Amphetamine Products
• Adderall mid-acting
• Adderall XR long-acting
• Dexedrine mid-acting
• Dextrostat mid-acting
• Short acting 3-5 hours Mid-acting 6-8 hours
  
• Long acting 12 hours

37
Commonly Used Non-Stimulant Medications for ADHD

• Nonstimulant Products Strattera long-acting
• Other Nonstimulant Products Wellbutrin
  long-acting Tenex mid-acting Clonidine mid-
  acting
• Short acting 3-5 hours Mid-acting 6-8 hours
  
• Long acting 12 hours

38
Pemoline (Cylert) Medication for ADHD

• Secondary choice
• Long-acting
• Short acting 3-5 hours Mid-acting 6-8 hours
  
• Long acting 12 hours

39
What are side effects of treatment?

• Headache
• Involuntary muscle movements
• Loss of appetite
• Mood changes as medication wears off
• Sleep difficulty
• Weight management problems

40
Questions?
41
Conduct Disorder
42
Not just for boys
43
Conduct Disorder

• The term conduct disorder has traditionally been
  used to characterize children who display a broad
  range of behaviors that bring them into conflict
  with their environment.
• These include behaviors that are probably best
  described as coercive or oppositional
• temper tantrums,
• defiance,
• noncompliance

44
Conduct Disorder

• Also included under this general heading have
  been behaviors of a more serious nature (e.g.,
  cruelty to people or animals, aggressiveness,
  stealing) .
• These are more serious in that they
• represent a greater threat to those the child
  interacts with and/or
• have the potential of bringing the child into
  contact with the juvenile justice system

45
Types of Conduct Disorders

• DSM IV features usually associated with the
  general label of conduct disorder are subdivided
  in order to provide for the diagnosis of two
  specific patterns of behavior
• Oppositional Defiant Disorder (ODD)
• Conduct Disorder (CD)

46
Conduct Disorder

• Symptoms
• Bullies, threatens or intimidates others
• Often initiates physical fights
• Has used a weapon that could cause serious
  physical harm to others (e.g. a bat, brick,
  broken bottle, knife or gun)

47
Conduct Disorder

• Symptoms
• Is physically cruel to people or animals
• Steals from a victim while confronting them
• (e.g. assault)
• Forces someone into sexual activity

48
Conduct Disorder

• Symptoms
• Deliberately engaged in fire setting with the
  intention to cause damage
• Deliberately destroys other's property

49
Conduct Disorder

• Symptoms
• Broken into someone else's building, house, or
  car
• Lies to obtain goods, or favors or to avoid
  obligations
• Steals items without confronting a victim (e.g.
  shoplifting, but without breaking and entering)

50
Conduct Disorder

• Symptoms
• Often stays out at night despite parental
  objections
• Runs away from home
• Often truant from school

51
Oppositional Defiant Disorder

• For at least 6 months, shows defiant, hostile,
  negativistic behavior (4 or more of the
  following)-Losing temper-Arguing with
  adults-Actively defying or refusing to carry out
  the rules or requests of adults-Deliberately
  doing things that annoy others-Blaming others
  for own mistakes or misbehavior-Being touchy or
  easily annoyed by others-Being angry and
  resentful-Being spiteful or vindictive

52
Four Dimensions of Conduct Disordered Behavior

• OVERT/DESTRUCTIVE
  OVERT/NONDESTRUCTIVE
• (Aggressive Behaviors)
  (Oppositional Features)
• Fights
  Annoys
• Bullies
  Defies
• Assault
  Stubborn
• Spiteful
  Angry
•  
• COVERT/DESTRUCTIVE
  COVERT/NONDESTRUCTIVE
• (Property Violations)
  (Status Offenses)
• Cruel to Animals
  Runaway
• Vandalism
  Truancy
• Steals
  Substance Use
• Fire setting
  Breaks Rules
• Adapted from Frick, et al., (1993).

53
Prognosis for Conduct Disorder

• In general, the literature suggests that
• children who develop conduct disordered behavior
  later in childhood have a somewhat better
  prognosis
• the severity and variety of early antisocial
  behavior is a powerful predictor of serious
  antisocial behavior in adulthood
• the prognosis may be worse for those who also
  have comorbid disorders.

54
Break Time
55
Cutting and Self-Mutilation

• David Lombard, Ph.D.
• Center for Applied Behavioral Studies
• www.LegalShrink.com

56
Overview

• What is Cutting and Self-Mutilation
• Theories of Why People Cut
• Is it Suicide, a Cry for Help, or Coping
• How is it Treated
• What to Ask to Assess Risk
• What are Your Options for Intervention

57
What do they have in common?

• Angelina Jolie
• Christina Ricci
• Courtney Love
• Princess Diana

58
How Common?

• 12 to 14 of adolescents reported self-injury
  behavior
• 40 to 61 in adolescent inpatient settings
• Higher proportion of females (64) than males
  (36)
• 750 per 100,000- general population
• Typical onset-puberty
• Persist for five to ten years or longer

59
The Cutting Culture

• Websites-Blood Red
• -Razor Blade Kisses
• -The Cutting World
• Films- Thirteen
• Genre of music- emo

60
Examples of Cutting
61
Examples of Cutting
62
Examples of Cutting
63
Examples of Cutting
64
What is Cutting

• Purposeful use of Sharp Objects for Goal of
  Cutting Skin and Seeing Blood
• Cutting Tools
• Knives, Razors, Needles, Cut Glass, Fingernail,
  Surgical Blades, Paper

65
What is Cutting

• Most Commonly Arms, Shoulders Thighs
• More Advanced Hips Below Belt Line (hidden and
  felt more when walking), Top of Feet, Underarms,
  Lower Buttock
• More Dangerous Inside of Mouth, Private Areas,
  Pre-Existing Surgical Scars

66
What is Self-Mutilation

• Often Seen the Same as Cutting
• Much Worse in Severity/Scope of Damage
• Destruction of Large Sections of Tissue Through
  Cutting, Tearing, Biting, or Repetitive
  Puncturing
• Always Hospitalize

67
I cut.

• 'to run away from my feelings'
• 'to feel pain on the outside instead of the
  inside'
• 'to cope with my feelings'
• 'to express my anger toward myself'
• 'to feel like I'm real'
• 'to turn off emotions and hide from reality'
• 'to tell people that I need help'
• 'to get people's attention'

68
I cut.

• 'to tell people I need to be in hospital'
• 'to get people to care about me'
• 'to make other people feel guilty'
• 'to drive people away'
• 'to get away from stress and responsibility'
• 'to manipulate situations or people'

69
Theories of Why People Cut

• To Feel
• Due to Abuse, Neglect, or Other Significant Life
  Trauma the Person Cannot Feel
• In Sad Situations, They Want to Feel SomethingSo
  Cut.
• Allows Them to Feel Physical Pain When They Have
  No Emotional Pain

70
Theories of Why People Cut

• Distraction
• Due to Overwhelming Emotional Pain or Problems
  Dealing with Emotional Pain
• Allows the Shift in Focus From Emotional Pain to
  Physical Pain
• Easier to Understand and Deal With

71
Theories of Why People Cut

• Punishment
• Person Has Failed at Something, Hurt Someone, Or
  Displeased Themselves
• A Way to PunishClearly DefinedClearly Punitive
• In These Cases, Severity of Cutting Increases to
  Mutilation Frequently

72
Theories of Why People Cut

• Physical Reaction
• Person Discovers Cutting and Tries It
• They Feel the Emotional and Physical Rush
• Natural Pain Killers and Pleasure

73
Theories of Why People Cut

• Physical Reaction
• Want the Same Feeling Again
• These Individuals are Likely to Engage in Cutting
  Out of Boredom

74
Theories of Why People Cut

• Control
• A strong Sense Of Helplessness
• Learned Helplessness
• Cutting Self is Completely in Their Control

75
Theories of Why People Cut

• Control
• More Frequent in Homes of Lives with Rigid Rules
• These People Less Likely to Use Drugs

76

• I would say it is just like a drug. It becomes
  something that you feel you cant live without.
  When it works once to fix a problem, you will
  try it again and see that it will work again.
  Eventually your small cuts arent enough and you
  cut more and more. You gain more tolerance.
• --Lia

77
Theories of Why People Cut

• Addiction to Cutting
• Emotional Release is Very Reinforcing
• Physical Release has Bio-Chemical Properties
• Under Control of Cutter

78
Theories of Why People Cut

• Addiction to Cutting
• Easy Access, Low Cost, Immediate Reaction
• These Individuals Tend to Be More Impulsive
• At Higher Risk for Substance Abuse

79
SI keeps me alive. Simple as that.--Angela
80
Self-injury is NOT a suicide attempt. It is a
way of making emotional pain into something
physical that you can see and control.--Melissa
81
Suicide, Cry For Help, or Coping?

• Suicides Attempts Include Intent to Die
• Most Cutters Do Not
• Cry For Help
• Possibly if Cuts Are Visible
• However, Some Wear Cuts as A Badge

82
Suicide, Cry For Help, or Coping?

• Coping Strategy
• Most Likely Reason
• Cutting Makes Sense to Them to Deal with Life

83
How Is It Treated

• Proper Diagnosis
• Depression, Anxiety, Abuse, Addiction,
  Personality Disorder, Thought Disorder
• Focus on Cutting as A Behavior
• Medication to Treat Any Underlying Disorders

84
How Is It Treated

• Psychotherapy to Alter Behavior and Reinforcement
• Find Other Coping Strategies

85
What to Ask

• Basic QuestionsKeep it Easy
• Can Easily Become Defensive
• Fear of Being Labeled Mentally Sick
• Can Easily Become Aggressive

86
What to Ask

• Where
• Where have they cut on themselves
• Where are they when they cut
• What
• What do they use
• What do they do afterwards

87
What to Ask

• When
• When alone or with others (usually alone)
• When angry, sad, upset
• Why
• Harder questionmay not answer
• Who
• Who knows they are cutting
• Can I talk to that person

88
What to Do

• Based on Estimated Level of Severity
• Nothing
• Rarelyonly if person already getting help
• Speak to Significant Others
• To encourage family intervention and help

89
What to Do

• Referral for Mental Health Services
• For evaluation and treatment planning
• Parkcenter, Parkview, Private Insurance
• Hospitalize
• If physical damage severe or mental Health
  Symptoms are severe

90
(No Transcript)