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Outline

The ADHD Story James J. Messina, Ph.D. Go to: www.coping.org for ADHD Articles & Links

ADHD a Neurobiological Condition is related to SLD 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

Other Neurobiological Conditions Related to ADHD: 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

What Research is Telling Us about ADHD 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)

Research also tells us about ADHD that: 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

ADHD & LD lead to Diminished Executive Functions 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

What is the Impact of these Disorders? 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

What is the Extent of ADHD? 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)

What is the Extent of SLD? 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) 60% of adults with severe literacy problems have undetected/untreated LD (NALLDC, 1994)

What is the Impact of ADHD on people? (Barkley, 2002) 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

What is the Impact of these Disorders? 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) Previously undetected learning disabilities have been found in 50% of juvenile delinquents -  Once treated their recidivism drops to just 2% (Lerner, 1997)

Attention Deficit Hyperactivity Disorder Inattention - Traditionally known as ADD Impulsivity - Traditionally known as Hyperactivity

ADHD Characteristics Inattention Impulsivity Overactivity

Inattention-Distractibility 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

Impulsivity-Behavioral Disinhibition Rushing into things Careless errors Risk taking Taking dares Accidents/injuries prone Impatience Interruptions

Hyperactivity - Overarousal Restlessness Can’t sit still Talks excessively Fidgeting Always on the go Easy arousal Lots of body movement

Different Names for ADHD Through the years: 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

Names for ADHD 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 Hyperactive-Impulsive Type

What is Learning Disability? Definition: 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.

What are Learning Disabilities 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

LD Language Symptoms 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

LD Memory Symptoms Trouble learning numbers, alphabet & days of the week Slow acquisition of new skills Poor memory for routines Slow recall of facts Organizational problems

LD Attention Symptoms Trouble sitting still Extreme restlessness Impersistence at tasks Impulsivity Inconsistency Poor self-monitoring, insatiability Great knowledge of trivia Careless errors

LD Fine Motor Skill Symptoms Trouble learning self-help skills Clumsiness Reluctance to draw, trace or color Poor pencil grasp Poor letter formation Fist-like or tight pencil grasp

Rule outs for Diagnosis of ADHD

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

Garlic Rule Outs in Diagnosing ADHD: 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

Electroencephalography 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) Use MRI if neurologic examination & EEG or other clinical indicators suggest focal lesion (CAN 1998)

Ophthalmologic Screening Behavioral in focus Pure formal visual screening Rule out processing deficits Rule out central nervous system abnormality

Audiological Screening 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

Metabolic Screening Tests 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

Cognitive, Speech & Language, Motor, Sensory & Motor Planning Pediatric Psychologist Speech & Language Pathologist Occupational Therapist - sensory integration Physical Therapist

Medication Treatment of ADHD 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

Medication Treatment of ADHD 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

Plus these interventions: Parent Team Home Modifications Parent-Teacher Team 504 Plan with Educational Consistency of parent-teacher-doctor team Unconditional love from all adults

Classroom Modifications for Students with ADHD & SLD

1.  Classroom Modifications 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

2.  Classroom Modifications Evaluate & structure environment Reduce external visual & auditory stimuli Repeat & have student paraphrase directions Give short directions Use predetermined signals Multiple modalities

3.  Classroom Modifications 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

4. Classroom Modifications 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

5.  Classroom Modifications 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

6.  Classroom Modifications 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

7.  Classroom Modifications Getting outside help Openness to other’s input Enthusiasm Optimism - “We Can” Attitude Determination to make it work Commitment to process and to child