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ADHD Update 2012: Paying Attention to Inattention Oren Mason MD oren@mason.md MASSW Fall Conference 2012 October 25, 26, 27 Slide 2 Electronic copies of presentation slides and notes available at: www.attention.md Please consider the environment before printing www.attention.md Slide 3 Learning Objectives Participants will: 1. 1. Learn the neurobiological basis for ADHD 2. 2. Gain skills in screening and diagnosis of ADHD 3. 3. Coordinate school-based interventions for ADHD with medical management Slide 4 ADHD Neurobiology ADHD Neurobiology Slide 5 Abnormalities in ADHD Brain The ADHD brain: The ADHD brain: is smaller overall is smaller overall grows more slowly grows more slowly matures later matures later uses emotional processes more uses emotional processes more uses cognitive processes less uses cognitive processes less Has less dopamine available Has less dopamine available Slide 6 Less Neurotransmitter Available For Cognitive Processing Pet scans, courtesy of National Institute of Mental Health Slide 7 Two Types of Attention Cognitive Attention Cognitive Attention Driven by anterior cingulate Driven by anterior cingulate Learned Learned Based on importance, timeliness, efficiency, learned values Based on importance, timeliness, efficiency, learned values Modulated, adjustable Modulated, adjustable Durable, enduring Durable, enduring High availability High availability Willfully engaged Willfully engaged Time sensitive Time sensitive Socially aware Socially aware Emotional Attention Emotional Attention Driven by basal ganglia Innate Based on interest, emotional engagement, novelty, urgency Powerful, not adjustable, 110% or absent Hyper-focus or inattention Intermittent availability Passively engaged Time blind Socially blind Slide 8 Observers View of Attention Times passage Emotional intensity Blah-ness Slide 9 Interplay of Two Attentions Times passage Emotional intensity Blah-ness Interest-based performance Importance-based performance Slide 10 Abnormal processing in ADHD Normal Adult ADHD Adult ADHD adults fail to utilize the most efficient pathway to process information in an attention-based task. MGH-NIMR Center & Harvard MIT CITP, Bush G, et al. Biol Psychiatry 1999. Slide 11 ADHD: Deficit of Cognitive Attention Times passage Emotional intensity Blah-ness Interest-based performance Importance-based performance NormalADHD Slide 12 ADHD concept Disability of attention control Disability of attention control Hallmarkinconsistent attention Hallmarkinconsistent attention Normal interest-based attention Normal interest-based attention Deficient attention to important matters Deficient attention to important matters Similar deficits in broad executive function: Similar deficits in broad executive function: Planning, scheduling, time management Planning, scheduling, time management Imagination, evaluation, selection of options Imagination, evaluation, selection of options Organization Organization Motivational management Motivational management Maintenance and modulation of effort Maintenance and modulation of effort Self-observation and evaluation Self-observation and evaluation Emotional self-management Emotional self-management Slide 13 ADHD concept Children with ADHD learn to attend and function by artificially inducing emotional engagement Children with ADHD learn to attend and function by artificially inducing emotional engagement Interest-based production when possible Interest-based production when possible Anxiety and shame otherwise Anxiety and shame otherwise Slide 14 Prevalence of ADHD Slide 15 Risks of ADHD ANNUAL DEATHS due to ADHD (USA): 4,000 MVA deaths 1,200 suicides Slide 16 Risks of ADHD Calculated effect of ADHD on life expectancy: 7 year decrease in adults with AD/HD* 3 year decrease in adults with heart disease. *Calculation R. Barkley due to increased smoking, obesity, decreased medical compliance, exercise in adults with AD/HD. Slide 17 Risks increase for ADHD adults Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford. Slide 18 Success decreases for ADHD adults Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford. Slide 19 Hardships for ADHD families PF physical function RP role physical BP bodily pain GH general health REB role emotional- behavioral BE behavior MH mental health SE self-esteem PE parental impact- emotional PT parental impact-time FA family activities FC family cohesion Klassen A F et al. Pediatrics 2004;114:e541-e547 Slide 20 Annual cost of ADHD (US) Annual Societal CostAnnual Medical Cost Heart Disease$50 B$500 B Diabetes$162 B$124 B -------------------------- ADHD Children$45 B$10 B ADHD all ages$143-266 B$12 B Billions of dollars in the USA Slide 21 Screening for ADHD Slide 22 ADHD screening Students with ADHD Students with academic disability Students with ADHD and disability All students Slide 23 Purpose of ADHD screening To identify individuals with a high probability for ADHD who need a full psychological evaluation. To identify individuals with a high probability for ADHD who need a full psychological evaluation. It is not necessary for schools to perform diagnosis in the absence of academic disability It is not necessary for schools to perform diagnosis in the absence of academic disability It is ethically unacceptable to fail to perform screening and parental notification when ADHD symptoms are impacting academic or social performance It is ethically unacceptable to fail to perform screening and parental notification when ADHD symptoms are impacting academic or social performance Slide 24 Indicators for ADHD screening Academic triggers: Academic triggers: Teacher observation of inattention, impulsivity or hyperactivity Teacher observation of inattention, impulsivity or hyperactivity Grades less than predicted (IQ test) Grades less than predicted (IQ test) Inconsistent grades Inconsistent grades Inconsistent performance in classwork vs tests Inconsistent performance in classwork vs tests Behavioral triggers: Behavioral triggers: Truancy, disciplinary issues Truancy, disciplinary issues Underage use of tobacco, alcohol Underage use of tobacco, alcohol Marijuana, illicit drug use Marijuana, illicit drug use Early, indiscriminate, unprotected sex Early, indiscriminate, unprotected sex Slide 25 Indicators for ADHD screening Social triggers: Social triggers: Class clown Class clown Lack of friendships Lack of friendships Lack of long-term friendships Lack of long-term friendships Toxic friendships Toxic friendships Bullying, being bullied or ostracized Bullying, being bullied or ostracized Psychological triggers: Psychological triggers: Depression Depression Anxiety Anxiety Oppositionality Oppositionality Slide 26 Screening tools All ages: All ages: Vanderbilt ADHD Teacher Form (18-item)* Vanderbilt ADHD Teacher Form (18-item)* Primary and middle school Primary and middle school Connors Teacher Report Short Form Connors Teacher Report Short Form High school High school Connors Adolescent Self-Report Connors Adolescent Self-Report Connors Teacher Report Short Form Connors Teacher Report Short Form Adult Self-Report Scale v1.1* Adult Self-Report Scale v1.1* *Available without cost Slide 27 ASRS v1.1 Scoring: Never = 0, Rarely = 1, Sometimes = 2, Often = 3, Very Often = 4 Total score 0-12, ADHD unlikely. Total score 13-24, ADHD likely Slide 28 ADHD Treatment Slide 29 Medication increases dopamine Serial PET Brain Images Showing Striatal Dopamine Transporter Receptor Occupancy After Receipt of a Single Dose of Immediate-Release or Osmotic-Release Methylphenidate in 2 Healthy Subjects Concerta Ritalin Slide 30 Medication Effects Behavioral improvements often profound: Behavioral improvements often profound: Control of attention Control of attention Control of activity Control of activity Self-esteem Self-esteem Academic improvements Academic improvements Standardized test scores improve Standardized test scores improve Self-esteem improves Self-esteem improves Reduced absenteeism Reduced absenteeism Reduced grade retention Reduced grade retention Efficient use of time improves Efficient use of time improves Strattera may improve dyslexia Strattera may improve dyslexia Slide 31 Medication Effects Improvements in home and family life Improvements in home and family life Mothers reduce controlling behaviors Mothers reduce controlling behaviors Family time and participation improves Family time and participation improves Parent stress decreases Parent stress decreases Overall quality of life improves Overall quality of life improves Driving Improvements Driving Improvements Stimulants and Strattera improve attention while driving Stimulants and Strattera improve attention while driving Daytrana decreases collisions Daytrana decreases collisions Driving improvements in simulator studies: Driving improvements in simulator studies: Concerta-15 hours Concerta-15 hours Adderall XR-9 hours Adderall XR-9 hours 3 doses methylphenidate-9 hours 3 doses methylphenidate-9 hours Slide 32 Problems when we dont treat ADHD medically Zoga H, et al. A population-based study of stimulant drug treatment of ADHD and academic progress in children. Pediatrics. 2012 Jul;130(1):e53-62. Per cent of children whose score declined from 4 th to 7 th grade. Slide 33 Who Should Take ADHD Medication? Everyone with AD/HD should undergo trials of medication. Everyone who responds well should take the medications. Slide 34 Medication classifications Stimulants Long-acting Stimulants Non-stimulants Slide 35 Stimulant duration of effect 1 Daytrana [package insert]. New York, NY: Noven Therapeutics; 2012; 2 Vyvanse [package insert]. Wayne, PA: Shire Inc. 2012; 3 Facts and Comparisons. Facts and Comparisons web site. http://www.factsandcomparisons.com/index.aspx. Accessed July 25, 2012; 4 Adderrall [package insert]. Wayne, PA: Shire Inc. 2012; 5 Focalin XR [package insert]. East Hanover, NJ: Novartis. 2012. MedicationBrand NameDuration of action (h) Methylphenidate Transdermal 1 DaytranaUp to 16 Lisdexamfetamine 2 Vyvanse10-14 OROS Methylphenidate 3 Concerta10-12 Mixed amphetamine salts XR 4 Adderall XR9-12 Dexmethylphenidate XR 5 Focalin XR8-10 Methylphenidate ER (SODAS) 3 Ritalin LA6-10 Methylphenidate SRRitalin SR6-8 MethylphenidateRitalin, others3-4 Slide 36 Nonstimulants SR, sustained release; XL, extended release 1 Strattera [package insert]. Indianapolis, IN: Eli Lilly & Co.; 2012; 2 Facts and Comparisons. Facts and Comparisons web site. http://www.factsandcomparisons.com/index.aspx. Accessed July 25, 2012; 3 Intuniv [package insert]. Wayne, PA: Shire, Inc.; 2012; 4 Kapvay [package insert]. Florham Park, NJ: Shionogi Pharmaceuticals; 2012. PreparationTrade Name Duration of action (h) Atomoxetine 1 Strattera>24 Bupropion SR 2 Wellbutrin SR12 Bupropion XL 2 Wellbutrin XL24 Guanfacine 3 Tenex12-24 Guanfacine XR 4 Intuniv24 Clonidine 4 Catapres6-12 Clonidine XR 4 Kapvay12-24 Slide 37 How safe are ADHD medications? Slide 38 Risk with stimulants Effects on growth: Short-term Children with ADHD are slightly shorter and weigh less than peers. Stimulants cause growth in height and weight to slow for at least two years. Long-term By year 4, growth is almost normal. Final adult height is not significantly changed. Slide 39 Stimulant risks Risk of sudden death ages 5-21 General population0.8/100,000/year Stimulant users0.5/100/000/year This is the risk when medications are managed by a knowledgeable physician. Slide 40 Risk of atomoxetineStrattera Risk of non-fatal liver damage: Risk of non-fatal liver damage: 1 in 1,000,000 Risk of fatal auto accident, with monthly 5-mile trip to pharmacy for 1 year: Risk of fatal auto accident, with monthly 5-mile trip to pharmacy for 1 year: 1 en 1,000,000 Slide 41 Side effects diminish with constant use Slide 42 Treatment Strategies Improving efficacy and duration Slide 43 Evaluate symptoms frequently Slide 44 Optimize Efficacy Increase dose until intolerable, then reduce Increase dose until intolerable, then reduce Repeat scales at every visit. Repeat scales at every visit. If one medication gives an inadequate response, try another If one medication gives an inadequate response, try another Consider combination therapy. Consider combination therapy. Slide 45 Potential benefits of combination therapy Slide 46 Efficacy: combination therapy Symptom reduction with combination therapy Wilens, T An Open Study of Adjunct OROS-Methylphenidate. J Child Adolesc Psychopharmacol. 2009 October; 19(5): 485492. Slide 47 Meds, psychosocial support or both Arch Gen Psychiatry.Arch Gen Psychiatry. 1999 Dec;56(12):1073-86 MultiModal Treatment Study in children with ADHD for 14 months in 579 children ages 7-10 Slide 48 Effect of medication Medications for ADHD normalize brain function normalize brain function improve self-control improve self-control improve control of attention improve control of attention improve decision-making improve decision-making________________________ Medications allow the practice of self-control Slide 49 When function is restored, training begins Marlon Shirley Amputee age 5 Paralympics Gold Medal winner for USA in 100m and 200m sprints World record holder in mens 100m sprint for single amputees 10.97 sec Slide 50 Accommodations for ADHD students Medication-optimized Medication-optimized Review and reinforce academic routines Review and reinforce academic routines Not optimized Not optimized Replace deficient self-controls with external controls Monitor task completion Coordinate with parents who must do the same in evening Provide intermittent rewards Provide frequent reminders to sustain attention, effort Individualize motivational structure Token behavioral reward systems Workload reduction Slide 51 Teaching ADHD Students General strategies: General strategies: Increase emotional engagement Increase emotional engagement Support executive function Support executive function Adopt Disability Model Adopt Disability Model 30% ruleADHD students can maintain the executive function of a child 30% junior. 30% ruleADHD students can maintain the executive function of a child 30% junior. 6 th grader3 rd grade function 6 th grader3 rd grade function 9 th grader5 th grade function 9 th grader5 th grade function Do not teach organizational/functional methods Do not teach organizational/functional methods You may require use of a method You may require use of a method Must follow up and reward use of the method Must follow up and reward use of the method Do not expect to withdraw support Do not expect to withdraw support Slide 52 Teaching ADHD Students Increase emotional engagement. Increase emotional engagement. Maintain rewarding environment Maintain rewarding environment Reward every positive thing you can Reward every positive thing you can 10:1 ratio of positive encouragement to correction. 10:1 ratio of positive encouragement to correction. Touch can be very effective Touch can be very effective Polite, respectful, positive, low-key, appropriate Polite, respectful, positive, low-key, appropriate Hand on shoulder/back to signal pay attention Hand on shoulder/back to signal pay attention Slide 53 Teaching ADHD Students Increase emotional engagement. Increase emotional engagement. Allow students to work in areas of interest whenever possible. Allow students to work in areas of interest whenever possible. To create a rewarding environment, take a lesson from video games: To create a rewarding environment, take a lesson from video games: State objective clearly State objective clearly Provide feedback on progress Provide feedback on progress Reward frequently Reward frequently Reward immediately Reward immediately Reward visibly Reward visibly Small tokens are adequate Small tokens are adequate Slide 54 Teaching ADHD Students Increase emotional engagement. Increase emotional engagement. Time outs should deprive a student of a rewarding environment. Time outs should deprive a student of a rewarding environment. Physically separate from rest of class Physically separate from rest of class Involve assignment (worksheet) that must be complete to return to class Involve assignment (worksheet) that must be complete to return to class Time out can be proportionate: 2-sheet, 3-sheet Time out can be proportionate: 2-sheet, 3-sheet Return to class setting without comment Return to class setting without comment Threats of harm can be effective, are not desirable. Threats of harm can be effective, are not desirable. Slide 55 Teaching ADHD Students Increase emotional engagement. Increase emotional engagement. Participatory events effective Participatory events effective Peer tutoring effective Peer tutoring effective Students teaching younger students highly effective Students teaching younger students highly effective Work done should be rewarded Work done should be rewarded Cash awards are very effective. (Get over it.) Cash awards are very effective. (Get over it.) Slide 56 Teaching ADHD Students Support executive function Support executive function Reward/consequence at point of performance. Reward/consequence at point of performance. Teachers cannot augment homework performance Teachers cannot augment homework performance Parents cannot augment school performance Parents cannot augment school performance Daily report cards effective through high school Daily report cards effective through high school Feedback immediate Feedback immediate Example: Example: Assign class 20 math problems Assign class 20 math problems Raise hand when two completed Raise hand when two completed Score and encourage (or repeat) Score and encourage (or repeat) Grades impact performance only when prompt Grades impact performance only when prompt Slide 57 Daily Report Card Homework turned in ListenedParticipatedAssignment in planner Initials Math English Science History Band PE Slide 58 Teaching ADHD Students Support executive function Support executive function Extended time may not be effective Extended time may not be effective ADHD students work best against a deadline ADHD students work best against a deadline Multiple short deadlines often more effective Multiple short deadlines often more effective Slide 59 Teaching ADHD Students Note to Joshs first hour teacher: Josh had a rough morning. He didnt eat breakfast or finish his morning chores. Please have him eat his fruit and some protein. A banana and a yogurt are what I offered, but whatever you have there is fine. He still needs to brush his teeth and make his bed. Check under the quilt; he doesnt always straighten the sheets well. Have him return his brothers tape player and put it away! Ill post on our family website how well you and he did by Friday or next Monday at the latest. Lets keep in touch. Feel free to contact me anytime. Thanks. Slide 60 Teaching ADHD Students Support executive function Support executive function Schoolwork best done in school Schoolwork best done in school Hard deadline (end of class period) improves function Hard deadline (end of class period) improves function Teachers available for guidance Teachers available for guidance Allowing any work at home guarantees that most work will be left for home Allowing any work at home guarantees that most work will be left for home Parents generally ill-equipped to help Parents generally ill-equipped to help Work at home is generally very inefficient Work at home is generally very inefficient Until 6 th grade, homework does not improve performance or indicate progress Until 6 th grade, homework does not improve performance or indicate progress It does give direct feedback on the parents level of executive function It does give direct feedback on the parents level of executive function Memory drillsmath and spellingmay be an exception. Memory drillsmath and spellingmay be an exception. Slide 61 Teaching ADHD Students Support executive function Support executive function When homework is assigned, parents need tools to assume executive function support at home: When homework is assigned, parents need tools to assume executive function support at home: Prior missing work Prior missing work Actual assignment Actual assignment Deadline for completion, waypoints Deadline for completion, waypoints When dealing with late/missing assignments When dealing with late/missing assignments Parents need same day feedback to help correct Parents need same day feedback to help correct Students need same day feedback to adjust Students need same day feedback to adjust Automatic failure for late assignments is counter- productive for most ADHD students. Automatic failure for late assignments is counter- productive for most ADHD students. Slide 62 Accommodation Summary Teachers and parents cooperate to extend support from home to school and back Teachers and parents cooperate to extend support from home to school and back Parents of ADHD children need: Parents of ADHD children need: Timely grade reports Timely grade reports Accurate assignment details Accurate assignment details Immediate behavioral feedback Immediate behavioral feedback Slide 63 Summary ADHD impairs brain function ADHD impairs brain function Medications restore some normal function Medications restore some normal function Medications plus acommodations improve academic progress, social function and family life Medications plus acommodations improve academic progress, social function and family life Screen liberally for ADHD in students Screen liberally for ADHD in students Evaluate progress with symptom scales Evaluate progress with symptom scales Slide 64 Thank you! Questions? Oren Mason MD oren@mason.md MASSW Fall Conference 2012 October 25, 26, 27