ADHD: How Complex Can It Be?

Let’s find out……

What Is ADHD?What the research tells us…

Attention-deficit/hyperactivity disorder (ADHD) is a multifactorial neurobiological disorder (Curatolo, Paloscia, D'Agati, Moavero, & Pasini, 2009)

It affects between 3% and 7% of school aged children in the United States and is the most prevalent neurobehavioral condition among this population in many countries (Findling, 2008).

Although it may be the most studied condition in child psychiatry worldwide, its exact causes and the exact mechanisms underlying this disorder are still unknown (Cortese, 2012).

It appears to be caused by the confluence of many genetic and environmental risk factors, each having a small effect on increasing vulnerability to the disorder (Curatolo et al., 2009).

What the research tells us…

This chronic disorder impairs function at both home and at school since it affects attentional and cognitive functions including: Problem solving Planning Orienting Alerting Cognitive flexibility Sustained attention Response inhibition And working memory.

Other areas such as motivation and delay aversion are also affected. These impairments create a negative impact on social interactions and adolescents with ADHD are at high risk for low self-esteem and poor peer relationships (Curatolo et al., 2009).

What the research tells us…

ADHD frequently exists with other neuropsychiatric and neurodevelopmental disorders including: Oppositional defiant disorder Conduct disorder Anxiety and depressive disorders, Developmental coordination disorder, Sleep disorders, Learning difficulties And substance abuse disorder (Cortese, 2012).

ADHD is a highly inheritable condition with documented brain abnormalities and its symptoms persist into adolescence and adulthood in 37% to 85% of children, according to the National Comorbidity Survey (Findling, 2008).

What the research tells us… ADHD affects approximately 6-10% of the population, while less

than 2% receive treatment.

Child psychiatrist Peter Jensen from the National Institutes of Health found that less than one in eight children who met the diagnostic criteria for ADHD were taking medication.

Many people with ADHD are never hyperactive.

The non-hyperactive ADHD group is often ignored because they do not bring enough negative attention to themselves in school. This type is more often found in females who tend to go untreated until later in life.

Myths

ADHD is the flavor of the month illness. It is a fad diagnosis and just an excuse for bad behavior.

ADHD is over diagnosed. Every child that acts up a bit gets placed on medication.

ADHD is only a disorder of hyperactive boys.

ADHD is only a minor problem. We don’t need to make such a fuss over it.

ADHD is an American invention, made up by a society seeking simple solutions to complex problems.

Myths Bad parents or bad teachers cause ADHD. If only our society was

firmer and stricter with these kids/people there wouldn’t be these problems.

People with ADHD should just try harder. We don’t need to give them excuses.

Everyone outgrows ADHD by the age of 12 or 13.

Natural treatments for ADHD don’t work.

ADHD kids can’t focus on anything; wrong they can actually hyperfocus on activities like video gaming; TV; other stimulating activities

The history of ADHD….

ADHD was first described over 100 years ago by George Still in the Coombs lectures of 1902.

He described this condition as an ‘‘abnormal defect in moral control in children’’.

Encephalitis lethargica, or sleeping sickness appeared as an epidemic during World War I, spread throughout the world, and disappeared in 1927.

After this epidemic, many children showed hyperkinetic behavioral symptoms including: hyperkinesis, impulsivity, learning disability, and short attention span and were labeled as “minimal brain damaged” and later as “minimal brain dysfunction”.

The history of ADHD….

In the 1950s, this label was modified to ‘‘hyperactive child syndrome’’

In 1968 the disorder was renamed in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-II as ‘‘hyperkinetic reaction of childhood’’. (Spencer, Biederman, & Mick, 2007).

During the 1960s and 1970s the focus on what is now ADHD was on motoric hyperactivity and overt impulsivity (Curatolo et al., 2009).

The DSM-III which was published in 1980 represented a paradigm shift in the diagnosis and treatment of ADHD because it began to emphasize inattention as a significant component of the disorder.

The history of ADHD….

The DSM-III also recognized developmental variability in the disorder at different ages and allowed for a residual type if the remaining symptoms caused significant impairment (Spencer et al., 2007).

The DSM-III marked the beginning of attention deficit disorder with or without hyperactivity (Curatolo et al., 2009).

This definition was further defined in the DSM-IV which included three subtypes of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and a combined subtype (Spencer et al., 2007)

Other Facts

ADHD is a serious societal problem: 35% never finish high school (25% repeat at least one

grade) 52% of untreated teens and adults abuse drugs or alcohol 19% smoke cigarettes compared to 10% of the general

population 43% of untreated hyperactive boys will be arrested for a

felony by age 16 50% of inmates in a number of studies have been found

to have ADHD 75% have interpersonal problems

Other Facts

There is a higher percentage of motor vehicle accidents, speeding tickets, driving without a license and suspended or revoked licenses with ADHD people

Medical visits and emergency room visits are much higher

Parents of ADHD children divorce three times more often than the general population

ADHD has been found in every country where it has been studied

Other Facts

Poor parents or teachers certainly make ADHD symptoms worse, but do not cause ADHD.

These children’s behavior often makes even the most skilled parents and/or teacher look inept.

The harder many people with ADHD try; the worse things get for them.

Brain studies show that most people with ADHD experience prefrontal shutdown during concentration tasks.

Other Facts

Many people never outgrow ADHD and have symptoms that interfere with their whole lives. The statistics show that at least half of those children diagnosed with ADHD will have disabling symptoms into adulthood

Stimulants are very effective medications when prescribed properly. In order to effectively treat ADHD a comprehensive treatment approach is essential including: education Support Exercise, Nutrition And often medication.

Natural treatments when used properly and targeted toward specific types of ADHD are often highly effective.

The Physical Brain and what we know

Advances in brain imaging studies have significantly contributed to the biological understanding of ADHD.

Although many differences have been identified in the brain structures of children with ADHD, some of these differences are more consistent and more significant than others. These findings include smaller total brain volumes and reduced volumes in

the right frontal lobe.

These abnormalities change over time in children and adolescents with ADHD. Studies have shown that although volumetric abnormalities in the cerebrum

and cerebellum persist with advancing age, those in the caudate region disappear and are consistent with subjects without ADHD.

The Physical Brain and what we know

Another important finding is that children with ADHD show marked delay in the cortical development of the brain. The gray matter peaks approximately three years later

than subjects with ADHD and the delay is most prominent in the frontal regions which focus on control of cognitive processes including attention and motor planning (Curatolo et al., 2009)

The Physical Brain and what we know

The first study to establish neural effects of a cognitive training program in ADHD provide preliminary evidence that training of cognitive functions targets critical syndrome-associated structures, and indicate it may improve cognitive performance by enhancing dysregulated fronto-cerebellar circuits.

Interestingly, similar results have been demonstrated following methylphenidate administration, suggesting that cognitive training may mimic the effects of psychostimulant medication on the brain. On the whole, the\results postulate a neural account for the potency of

cognitive training in ADHD patients, and hold clinical implications, supporting the pertinence of training programs as part of standard ADHD-treatment (Hoekzema et al., 2010) 

What Causes ADHD?

Head Injury: especially to the left front side of the brain

Genetics: ADHD runs in the family

Toxic Exposure, lack of oxygen at birth, toxic chemicals

Medical Problems: thyroid disease can look like ADHD

Hormonal Influences: ADHD symptoms get worse during times of puberty both in males and females

What Causes ADHD?

Drug abuse: it is important to assess for drug abuse in children who have ADHD

Poor Diet: some children who are sensitive to additives and eat poorly exhibit symptoms of ADHD

Lack of Exercise

Early Neglect and Abuse: when a child is neglected and/or abused it can impact their brain adversely

Comorbidity

What other conditions are often seen in children with ADHD?

Substance Use Disorders; more often seen in children who have been untreated

Depression Anxiety Oppositional Defiant Disorder Conduct Disorder Obsessive-Compulsive Disorder Tic Disorders History of physical, emotional and/or sexual abuse

 

AD/HD in Girls and WomenThe Hidden Disorder

Material by Dr. Patricia Quinn

Many similarities between the genders

“Phenotypic core of AD/HD symptoms similar to what has been observed in boys”

Recent findings stress the severity of the disorder in females

More mood and anxiety disorders in females

Preponderance of inattentive symptoms

Rethink AD/HD in Females

Not so much a “behavior disorder”

More as a “life management” disorder

In males, much of focus in on how they affect OTHERS

In females, we need to focus on how SHE is affected

Female thinks “I am stupid”, Male thinks “That teacher is stupid

Females internalize patterns, much more shame/embarrassment

Mitigating Circumstances

Fewer AD/HD symptoms

Structured environment

High SES

No ODD or CD

High IQ

Social pressure/need for approval

Why Learn about AD/HD in Women

Undiagnosed ADHD has Significant Health Concerns: 2nd most common psychological problem in adults

Affects 4 million women-most undiagnosed

Accidents/injuries

Abuse

Marital difficulties/sexual issues

Unplanned pregnancies

Why Learn about AD/HD in Women

Parenting problems-child with ADHD

Poor self-esteem/depression/anxiety

Chronic stress disorders/fibromyalgia

Sleep disorders

Eating disorders

Consequences of Late Diagnosis in Women

Depressive symptoms

More stressed and anxious

More external locus of control

Lower self-esteem

Emotion-oriented versus task-oriented coping

More psychological distress

Girls are more likely to say they took medication for depression before taking medication for ADHD

Hormones and ADHD

The brain is a target organ for estrogen

Estrogen has a profound effect on mood, mental states, and memory by acting on both monoamine and neurotransmitter mechanisms

Whenever estrogen falls below the “minimum brain estrogen requirement” brain dysfunction may result

Symptoms shared by women in low estrogen states: depression, sleep disturbance, irritability, anxiety, panic, memory deficits, cognitive dysfunction

Puberty; increases symptoms—PMS; increases severity, responds well to SSRIs—Menopause; increase in symptoms and cognitive impairments

The link between ADHD and Eating Disorders

Dr. Dukarm has written a book: Pieces of a Puzzle: The Link between Eating Disorders and ADHD (2006)

Parents have reported; 8% of girls with ADHD had engaged in binge eating (1% purging)

6% ADHD, combined type and 5% ADHD, inattentive type compared to 0% of controls unduly influenced by weight and shape

Baseline impulsivity symptoms best predicted adolescent eating pathology

Peer rejection and parent-child relationship patterns also were predictive

Internalizing problems were significantly correlated with desire to lose weight and eating pathology

Presenting Complaints for Women

Feeling overwhelmed

Chronically disorganized

Chronically late, poor time management

Sense of shame, inadequacy-can’t live up to typical societal expectations

Meal-planning/preparation and other daily living activities a challenge

Problems with friendships

Diagnostic Issues for AD/HD in Women and Older Girls

Often no report of early childhood issues Inattentive type often overlooked by professionals, parents and

teachers Often more teacher compliant Good academic record in early years Hyperactivity/impulsivity less common Symptoms often present at puberty High IQ girls may function well, but at a great cost Often a history of treatment for anxiety and/or depression Often misdiagnosed as bi-polar if hyperactive component is

present

Why is the Brain so Important?

The brain is involved in everything we do, how we think, how we feel, how we act and how well we get along with other people

The brain even determines the kind of person we are at home, at work and at play

When your brain works right, you work right When your brain doesn’t work right, it is very hard for any of us to

be at our best There are things we can do to hurt our brains, such as injuries,

pollution (taking drugs, excessive caffeine, smoking, etc.), poor nutrition and excessive stress

There are things we can do to optimize our brain function, such as proper nutrition, protection and coping with life’s stressors through the use of mindfulness activities

Parental Self Care

Why is self care important for the parents? These kids are very demanding and require a lot of your

focus, problem solving abilities and emotional support If you are not taking care of yourself well, you won’t have

the energy to parent these children Because we know there is a strong genetic component to

this disorder, you might want to have yourself assessed If you have ADHD; get treatment, you will be able to be a

better parent to your child(ren) Take time away from parenting—go away with your

spouse to recharge your batteries

Games ADHD Children Play

“It’s Your Fault”

“No, No Way, Never, You Can’t Make Me Do It”

“I Say the Opposite of What You Say”

“I like to say the first things that come to mind”

What to Do?

First thing to do as a parent is to recognize how complex this disorder is and to learn as much as you can about it

The more you know the better you will be able to understand your child and/or yourself

Take care of yourself, recognize that taking breaks and doing those things in life that help you “recharge your batteries” is important

Get help; get parent skills training

Get your child in therapy; there are several therapies out there that can help; CBT, neurofeedback, play therapies

Create a good support network

Creating Healthy ADHD Environments

Children, adolescents and adults with ADHD work much better in ADHD healthy environments

Set clear goals for yourself as a parent and for your child

Create a list of Family Rules and post them on the refrigerator

Create a good relationship with your ADHD child, without it they most likely won’t want to listen to you; you might want to find what they are good at and participate with them in that activity

Creating Healthy ADHD Environments

Be a good listener

Spend “special time with your child” daily

Be clear about what you expect

When a child lives up to the rules and expectations, be sure to notice!!

Mean what you say; don’t set a rule and then change your mind

Don’t tell a child ten times to do something

Creating Healthy ADHD Environments

Never discipline a child when you’re out of control

Use discipline to teach a child rather than to punish or get even for bad behavior

See misbehavior as a problem you’re going to solve rather than “the child is trying to get you mad.”

It’s important to have swift, clear consequences for broken rules, enforced in a matter-of-fact and unemotional way

Give choices where it’s reasonable

Creating Healthy ADHD Environments

Parents need to be together and support each other

Keep promises to children

Children learn about relationships from watching how their parents relate to each other

Be careful of the nicknames and phrases you use to describe your children

Teach your children from your own real-life experiences

Creating Healthy ADHD Environments

In parenting, always remember the words “firm but kind.” If you are a parent who yells; understand this makes it

more difficult for the ADHD child to hear you

Therapy

Therapy for children and adolescents can help them learn how to cope with the embarrassment they often feel

These kids are often bullied; they need emotional support to deal with this behavior

These kids need social skill training; they often miss “ques” that other adolescents pick up on as a way of communication

Play therapy can help children learn how to control impulsive behaviors; therapists will also help teach good parenting skills

Therapy

Most ADHD children have Negative Thought Patterns, these develop into Negative Beliefs about self

It is important for these to be addressed so they can live a life where they feel more confident about themselves

Success creates good self esteem, the more success ADHDers have the better they feel about themselves

Adults who have ADHD

Suffer from many of the same issue as children; however, these patterns may have had a greater impact since the disorder was not recognized

More shame and negative thinking is typically in place due to more failure in life without understanding why

Often they put themselves in stressful situations which makes the symptoms worse

Women often present with anxiety and depressive disorders when then underlying issue is ADHD

Therapy along with the right medication can help adults overcome many of the negative issues surrounding this disorder

Take Away

This is a very complex disorder that has a negative impact on the lives of those who have it, as well as those who care for them

It is best dealt with through a multi-interventional approach; diet, exercise, medication, therapy, parenting skill training, mindfulness training

It is important for those who live with and care for these folks to understand the importance of self care

Get help, get educated and be willing to look for support

I am offering a parent support group for those interested

Thank you for the opportunity to share thisvaluable information:

For more information, please visit our web site at: www.susan-couch.com

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Call me at 919-695-3189

References

Amen, D. G., Hanks, C., & Prunella, J. (2008). Preliminary evidence differentiating ADHD using brain SPECT imaging in older patients. Journal of Psychoactive Drugs, 40(2), 139-146.

Amen, D. G., Trujillo, M., Newberg, A., Willeumier, K., Tarzwell, R., Wu, J. C., & Chaitin, B. (2011). Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool. Open Neuroimaging Journal, 5, 40-48. doi: 10.2174/1874440001105010040

References

Bekker, E. M., Overtoom, C. C., Kenemans, J. L., Kooij, J. J., De Noord, I., Buitelaar, J. K., & Verbaten, M. N. (2005). Stopping and changing in adults with ADHD. Psychological Medicine, 35(6), 807-816.

Biederman, J., & Spencer, T. (1999). Attention-deficit/hyperactivity disorder (ADHD) as a noradrenergic disorder. Biological Psychiatry, 46(9), 1234-1242.

Biederman, J., Wilens, T., Mick, E., Milberger, S., Spencer, T. J., & Faraone, S. V. (1995). Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder (ADHD): effects of ADHD and psychiatric comorbidity. American Journal of Psychiatry, 152(11), 1652-1658.

Cortese, S. (2012). The neurobiology and genetics of Attention-Deficit/Hyperactivity Disorder (ADHD): what every clinician should know. European Journal of Paediatric Neurology, 16(5), 422-433. doi: 10.1016/j.ejpn.2012.01.009

References Curatolo, P., Paloscia, C., D'Agati, E., Moavero, R., & Pasini, A.

(2009). The neurobiology of attention deficit/hyperactivity disorder. European Journal of Paediatric Neurology, 13(4), 299-304. doi: 10.1016/j.ejpn.2008.06.003

Findling, R. L. (2008). Evolution of the treatment of attention-deficit/hyperactivity disorder in children: a review. Clinical Therapeutics, 30(5), 942-957. doi: 10.1016/j.clinthera.2008.05.006

Hoekzema, E., Carmona, S., Tremols, V., Gispert, J. D., Guitart, M., Fauquet, J., . . . Vilarroya, O. (2010). Enhanced neural activity in frontal and cerebellar circuits after cognitive training in children with attention-deficit/hyperactivity disorder. Human Brain Mapping, 31(12), 1942-1950. doi: 10.1002/hbm.20988

References

Lahey, B. B., Applegate, B., McBurnett, K., Biederman, J., Greenhill, L., Hynd, G. W., . . . et al. (1994). DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents. American Journal of Psychiatry, 151(11), 1673-1685.

Leventhal, B. L. (2013). Attention-deficit/hyperactivity disorder: the short and long of it. Journal of Child and Adolescent Psychopharmacology, 23(2), 128-129. doi: 10.1089/cap.2013.2302

Riccio, C. A., Wolfe, M., Davis, B., Romine, C., George, C., & Lee, D. (2005). Attention Deficit Hyperactivity Disorder: manifestation in adulthood. Archives of Clinical Neuropsychology, 20(2), 249-269. doi: 10.1016/j.acn.2004.07.005

References

Scholte, E. M., van Berckelaer-Onnes, I. A., & van der Ploeg, J. D. (2001). DSM-IV related ADHD symptom ratings by professional caretakers in residential treatment centres. Journal of Child Psychology and Psychiatry and Allied Disciplines, 42(3), 341-346.

Secnik, K., Swensen, A., & Lage, M. J. (2005). Comorbidities and costs of adult patients diagnosed with attention-deficit hyperactivity disorder. Pharmacoeconomics, 23(1), 93-102.

Spencer, T. J., Biederman, J., & Mick, E. (2007). Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. Journal of Pediatric Psychology, 32(6), 631-642. doi: 10.1093/jpepsy/jsm005

Stein, M. A., Fischer, M., & Szumowski, E. (1999). Evaluation of adults for ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 38(8), 940-941. doi: 10.1097/00004583-199908000-00004