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What Does It All Mean? ADHD, Executive Functioning, Causes and Management

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Title: Taking Charge of ADHD Author: Russell Barkley, Ph.D. Last modified by: Russ Barkley Created Date: 2/18/1999 4:05:50 PM Document presentation format – PowerPoint PPT presentation

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Title: What Does It All Mean? ADHD, Executive Functioning, Causes and Management


1
What Does It All Mean?ADHD, Executive
Functioning, Causes and Management
  • Russell Barkley, Ph.D.
  • Clinical Professor of Psychiatry
  • Medical University of South Carolina
  • Charleston, SC
  • Websites
  • ADHDLectures.com
  • Russellbarkley.org

2
What is ADHD?
  • A disorder of developmentally inappropriate
    degrees of
  • Inattention
  • Hyperactive and impulsive behavior
  • Arises in childhood
  • Persistent over time
  • Results in impairment in major life activities

3
Nature of the Hyperactive Impulsive Symptoms
  • A Neuropsychological Dimension of Poor Inhibition
  • Motor impulsiveness and hyperactivity (task
    irrelevant movements)
  • Fidgeting, squirming, running, climbing, touching
  • Verbal impulsiveness
  • Cognitive impulsiveness (decision making cannot
    wait or defer gratification)
  • Greater disregard of future (delayed)
    consequences
  • Impaired resistance to distractions (sustained
    inhibition)
  • Emotionally impulsive poor emotional
    self-regulation
  • NOTE Restlessness decreases with age, becoming
    more internal or subjective by adulthood

4
Nature of the Inattention Symptoms
  • There are at least 6 types of attention
  • Arousal, alertness, selective, divided, span of
    apprehension, persistence.
  • Not all are impaired. What is?
  • Poor persistence toward goals or tasks
  • The cross-temporal organization and maintenance
    of actions toward goals or assignments
  • Impaired resistance to responding to distractions
  • Less likely to re-engage tasks following
    disruptions
  • Due to impaired working memory (remembering so as
    to do)

5
Prevalence
  • 2-5 of children (using older DSM-III or III-R)
  • 7-8 of children in US (using DSM-IV) (3-4
    million)
  • Adding Inattentive Type doubles prevalence over
    III-R
  • 5.5 of children worldwide
  • 4-5 of adults in US (12 million in US)
  • 3-4 worldwide adult prevalence
  • Varies by age, social class, urban-rural
  • More common in children less so in adults
  • Somewhat more common in middle to lower-middle
    classes
  • More common in population dense areas
  • More common in certain occupations
  • For instance, 12-15 of U.S. military dependents
  • More common among nonprofessional workers
  • No evidence for ethnic differences to date that
    are independent of social class, urban-rural
    demographics or variable access to care

6
ADHD Varies by Setting
  • Better Here Worse Here
  • Fun Boring
  • Immediate Delayed Consequences
  • Frequent Infrequent Feedback
  • High Low Salience
  • Early Late in the Day
  • Supervised Unsupervised
  • One-to-one Group Situations
  • Novelty Familiarity
  • Fathers Mothers
  • Strangers Parents
  • Clinic Exam Room Waiting Room

7
Sluggish Cognitive TempoA New Disorder of
Attention
  • Sometimes called Attention Deficit Disorder
  • Daydreaming/Spacey/Stares/Confused
  • Slow Information Processing (CAPD?)
  • Hypoactive/Lethargic/Sluggish/Sleepy
  • Easily Confused, Mentally Foggy
  • Poor Focused/Selective Attention
  • Erratic Retrieval - Long-Term Memory
  • Socially Reticent/Uninvolved/Isolated

8
More on SCT (2)
  • Not Impulsive also less deficient in other
    executive functions (self-regulation abilities)
  • Rarely Aggressive or have ODD/CD
  • Greater risk for anxiety and depression
  • Equally high risk for learning disabilities (LD)
  • But math disorders may be more likely than
    reading and language disorders with SCT (?)
  • Not as impaired in other domains of life outside
    of school compared to ADHD
  • Parents report far less stress in parenting SCT
    than ADHD children most stress is school related
  • Possibly greater family history of anxiety
    disorders and LD (?)

9
Treatment of SCT
  • Less Likely to Have a Clinically Impressive
    Response to Stimulants?
  • (65 improve but only 20 show clinical response)
  • Other drugs have not been tested Strattera,
    Intuniv, ProVigil, etc
  • Better responders than ADHD children to social
    skills training
  • As good or better responders to behavior
    modification methods
  • Probably better responders to cognitive
    behavioral therapy (self-instruction training)

10
What Are The Academic Risks Linked to ADHD?
  • Academic Under-performance (90)
  • Retention in Grade (25-50)
  • Require Special Education (35-60)
  • Failure to Graduate High School (30-40)
  • Less Likely to Attend College (20)
  • Less Likely to Graduate College (5)

11
Other Developmental Risks
  • Oppositional, defiant, hot tempered (40-65)
  • Depressed, sullen, moody, irritable (20-30)
  • Anxious, fearful (0-25)
  • Peer Relationship Problems (50)
  • Delinquency (25-35)
  • Substance Dependence/Abuse (10-20)
  • Driving Problems (Speeding, Accidents)
  • Earlier Sexual Activity Teen Pregnancy (38)
  • Increased Risk for Sexually Transmitted Diseases
    (16)

12
Health Problems
  • Delayed motor coordination (60)
  • Greater risk for accidents and injuries
  • More likely to develop dental problems
  • Small increase in risk for seizures
  • Bedtime behavior problems (20) and disordered
    sleep(20-25)

13
  • What Causes ADHD?

14
The Neurology of ADHDFrom R. Barkley, Scientific
American, Sept. 1998, p. 47 Reprinted with
permission of Terese Winslow and Scientific
American.
15
Delayed brain growth in ADHD (3 yrs.)From Shaw,
P. et al. (2007). ADHD is characterized by a
delay in cortical maturation. Proceedings of the
National Academy of Sciences, 104, 19649-19654.
Greater than 2 years delay 0 to 2 years delay
Ns ADHD223 Controls 223
16
Early cortical maturation in ADHD childrenFrom
Shaw, P. et al. (2007). ADHD is characterized by
a delay in cortical maturation. Proceedings of
the National Academy of Sciences, 104,
19649-19654.
Fig. 4. Regions where the ADHD group had early
cortical maturation, as indicated by a younger
age of attaining peak cortical thickness.
17
The Genetics of ADHD
  • Heredity Risk to
  • Siblings 25-35 Twin 75-92
  • Mother 15-20 Father 20-30
  • Offspring of an adult with ADHD 27-54
  • Genetic Contribution (80 or more)
  • No contribution of the rearing environment
  • Many Risk genes found to date
  • These genes appear to regulate brain growth and
    some brain chemicals
  • Each contributes a small risk to the disorder
  • Family members have some of these genes and show
    some of the traits of ADHD but often not enough
    to have the full disorder
  • The more risk genes a child has, the greater the
    risk for having the full disorder

18
What Doesnt Cause ADHD?
  • Food Additives, Allergies, Sugar, Milk in Diet
  • Excessive Caffeine in Diet
  • Environmental Allergens
  • Poor Child Management by Parents
  • Family Stress Chaotic Home Life
  • Excessive Use of TV, Video-games
  • Increased Cultural Tempo
  • PTSD, Depression, Anxiety, Learning Disability

19
  • What is Executive Functioning? How is it Related
    to ADHD?

20
(No Transcript)
21
Getting Ready for the Future Requires
  • That you stop and think -BEFORE you act !
  • Use your hindsight (looking backward)
  • To get your foresight (see whats next)
  • To anticipate and prepare for the future
  • So you can be more effective and attend to your
    long-term welfare and happiness
  • This is executive functioning (EF)
  • There are 6 cognitive or mental components
    or parts to EF

22
Self-Awareness
Inhibition
Sensing to the Self
Self-Speech
Emotion to the Self
Play to the Self
Motor Control
23
The EFs Create Four Developmental Transitions in
What is Controlling Behavior
  • External Mental (private or internal)
  • Others Self
  • Temporal now Anticipated future
  • Immediate Delayed gratification

24
The 5 EFs in Major Life Activities
  • Self-Discipline (making your self STOP)
  • Cognitive, behavioral, verbal, emotional
  • Self-Management Across Time (making mental maps)
  • Consideration of past and future consequences
    before acting managing your self relative to
    time and deadlines
  • Self-Organization /Problem-Solving (making
    options)
  • Innovating, planning possible response options,
    problem-solving to overcome obstacles to goals,
    rapid assembly and performance of novel
    goal-directed behavior
  • Self-Motivation (filling the fuel tank)
  • Substituting positive goal-supporting emotions
    for negative goal-destructive ones
  • Self-Regulation of Emotions (moderating your
    feelings)

25
ADHD Impairs Self-Regulation Across Time
26
Understanding ADHD as a Disorder of Executive
Functioning
  • ADHD disrupts the 7 mental capacities that make
    up EF and the 5 EF abilities we use in everyday
    life thereby creating a disorder of
    self-regulation across time
  • ADHD is Time Blindness or a Temporal Neglect
    Syndrome (Myopia to the Future)
  • It adversely affects the capacity to
    hierarchically organize behavior across time to
    anticipate the future and to pursue ones
    long-term goals and self-interests (welfare and
    happiness)
  • Its not an Attention Deficit but an Intention
    Deficit (Inattention to mental events the
    future)

27
Understanding ADHD
  • Its a Disorder of
  • Performance, not skill
  • Doing what you know, not knowing what to do
  • The when and where, not the how or what
  • Using your past at the point of performance
  • The point of performance is the place and time in
    your natural settings where you should use what
    you know (but may not)

28
Implications for Treatment
  • Teaching skills is inadequate
  • The key is to design prosthetic environments
    around the individual to compensate for their EF
    deficits
  • Therefore, effective treatments are always those
    at the point-of-performance
  • The EF deficits are neuro-genetic in origin
  • Therefore, medications may be essential for most
    (but not all) cases meds are neuro-genetic
    therapies
  • But some evidence suggests some EFs may also be
    partly responsive to direct training
  • While ADHD creates a diminished capacity Does
    this excuse accountability?
  • (No! The problem is with time and timing, not
    with consequences)

29
More Treatment Implications
  • Behavioral treatment is essential for
    restructuring natural settings to assist the EFs
  • They provide artificial prosthetic cues to
    substitute for the working memory deficits
    (signs, lists, cards, charts, posters)
  • They provide artificial prosthetic consequences
    in the large time gaps between consequences
    (accountability) (i.e., tokens, points, etc.)
  • But their effects do not generalize or endure
    after removal because they primarily address the
    motivational deficits in ADHD
  • The compassion and willingness of others to make
    accommodations are vital to success
  • A chronic disability perspective is most useful

30
What Are The 4 Stages of Treatment?
  • Evaluation
  • Education
  • Medication
  • Modification (of Behavior)
  • Accommodation
  • Restructuring the home
  • Changes in school
  • Assistance in the community

31
Empirically Proven Treatments
  • Parent Education About ADHD
  • Psychopharmacology
  • Stimulants (e.g., Ritalin, Adderall, etc.)
  • Noradrenergic Medications (e.g., Strattera)
  • Tricyclic Anti-depressants (e.g., desipramine)
  • Anti-hypertensives (e.g., Catapres, Tenex)
  • Parent Training in Child Management
  • Children (lt11 yrs., 65-75 respond)
  • Adolescents (25-30 show reliable change)

32
Empirically Proven Treatment (2)
  • Teacher Education About ADHD
  • Teacher Training in Classroom Behavior Management
  • Special Education Services (IDEA, 504)
  • Residential Treatment (5-8)
  • Parent/Family Services (25)
  • Parent/Client Support Groups (CHADD, ADDA,
    Independents)

33
Experimental Treatments
  • Biofeedback (EMG or EEG)
  • Working Memory Training
  • Mindfulness Meditation Training
  • Omega 3/6 Food Supplements (fish oils)

34
Unproved/Disproved Therapies
  • Elimination Diets removal of sugar, additives,
    etc. (Weak evidence)
  • Megavitamins, Anti-oxidants, Minerals
  • (No compelling proof or disproved)
  • Sensory Integration Training (disproved)
  • Chiropractic Skull Manipulation (no proof)
  • Play Therapy, Psycho-therapy (disproved)
  • Self-Control (Cognitive) Therapies (in clinic)
  • Social Skills Therapies (in clinic)
  • Better for Inattentive (SCT) Type and Anxious
    Cases

35
What Roles Can Parents Play?
  • The Scientific Parent
  • Read widely
  • Experiment with management methods
  • Be a skeptic
  • The Executive Parent
  • Take charge become an advocate
  • The Principle-Centered Parent
  • Be proactive Begin with the end in mind Put
    first things first Seek to understand, then to
    be understood Think win/win Synergize Find
    sources of renewal

36
If the Parent Also Has ADHD
  • Get into treatment as soon as possible (meds.,
    counseling, organizing advice, treatment for
    co-existing disorders, etc. )
  • Let the non-ADHD parent handle homework and
    school-related issues, if necessary
  • Alternate nights with partner as to who
    supervises for the ADHD child
  • Let the non-ADHD parent handle time sensitive
    household responsibilities while the ADHD parent
    gets the non-time sensitive ones
  • Put yourself in time-out when emotions escalate
    toward family members
  • Always review major child discipline decisions
    with the non-ADHD parent
  • The non-ADHD parent drives to children to their
    activities if the ADHD parent is not on medication

37
Conclusion
  • ADHD is a relatively common disorder, affecting 1
    in every 14-20 children
  • ADHD involves deficits in self-regulation and
    executive functioning
  • It is a highly neurological genetic disorder,
    not a myth or a socially causes condition
  • It is associated with numerous impairments over
    development if left untreated
  • It is the most treatable disorder in psychiatry
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