Download - ADHD Two Attentions One Deficit
ADHDADHDTwo AttentionsTwo Attentions
One DeficitOne Deficit
Oren Mason M.D.Oren Mason M.D.
[email protected]@attention.md
Feb. 12, 2014 Feb. 12, 2014
ADHD BackgroundADHD Background
ResearchResearch
ADHD Classic Presentation ADHD Classic Presentation
SymptomsSymptoms– InattentionInattention– HyperactivityHyperactivity– ImpulsivityImpulsivity
Prevalence 5%Prevalence 5%
Cause - unknownCause - unknown
Treatment – Ritalin, extra time for testsTreatment – Ritalin, extra time for tests
ADHD GeneticsADHD Genetics
Height
ADHD
Schizophrenia
IQ
Depression
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
Heritability Index
Faraone SV. J Am Acad Child Adolesc Psychiatry 2000;39:1455-7.
Frontal-Striatal DysfunctionFrontal-Striatal Dysfunction ADHD Adult ADHD Adult
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.
Executive FunctionsExecutive FunctionsTime senseTime senseModulation of activity and arousalModulation of activity and arousalFocus or attentionFocus or attention– selectionselection– maintenancemaintenance– modulationmodulation– terminationtermination
Organization, planning and prioritizationOrganization, planning and prioritizationTask skills:Task skills:– initiation initiation – perseverance perseverance – withdrawal/resumption withdrawal/resumption – shifting shifting – completioncompletion
Self-assessment, self-awarenessSelf-assessment, self-awarenessEmotional self-modulationEmotional self-modulation
Executive FunctionExecutive Function
The brain’s capacity to allow us to The brain’s capacity to allow us to separate action and reward.separate action and reward.
Allows us to execute goal-directed Allows us to execute goal-directed behavior across time.behavior across time.
Normal development allows increasingly Normal development allows increasingly complex, prolonged separation of action complex, prolonged separation of action and reward. and reward.
Executive FunctionExecutive FunctionDevelopmental PerspectiveDevelopmental Perspective
EF develop in children as a function of EF develop in children as a function of brain growth/development.brain growth/development.
Teaching methods presume prior brain Teaching methods presume prior brain development. development.
Kids are “moving targets” of progress in Kids are “moving targets” of progress in brain development.brain development.
At least 20% of children lag peers in brain At least 20% of children lag peers in brain development—thus, in EFdevelopment—thus, in EF
MotivationMotivation
Normal executive function presumes an interplay Normal executive function presumes an interplay of cognitive and emotional motivatorsof cognitive and emotional motivators
Just do it.Just do it.
I’m lovin’ it.I’m lovin’ it.
Cogntive Attention
Emotional Attention
MotivationMotivation
Cognitive motivation“Just do it”
Emotional motivation“I’m lovin’ it”
Importance-based performance Interest-based performance
Modulated, adjustable Powerful, not adjustable110% or absentHyper-focus v disengagement
Durable, enduring, high availability Intermittent availability
Willfully engaged Passively experienced
Time sensitive Time blind
Socially aware Socially blind
Task InitiationTask Initiation
Task Task CompletionCompletion
Attention
Self-Awareness
Motivation Drives Exec FxMotivation Drives Exec Fx
Cognition
Emotions
Cogntive Task
Completion
Emotional Attention
Cogntive Task
Initiation
Emotional Task
Initiation
Cogntive Attention
Emotional Self-
Awareness
Cogntive Self-
Awareness
Emotional Task
Completion
Observer’s View of AttentionObserver’s View of Attention
Time’s passage
Emotional intensity
Blah-ness
Interplay of Interplay of 2 Attentions2 Attentions
Time’s passage
Emotional intensity
Blah-ness
Interest-based
attention
Importance-based attention
Frontal-Striatal DysfunctionFrontal-Striatal Dysfunction ADHD Adult ADHD Adult
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.
ADHD AffectsADHD AffectsAll Executive FunctionsAll Executive Functions
Impaired EF Observed Behavior
Attention inattention, distractibility
Sustained effort “not trying”, poor follow-through
Modulation of impulse poor self-control, risk-taking
Organization disorganized locker/backpack, schedule
Social skills may not play well with others, loses friends
Self-observation unaware of behavior, emotions, effectiveness, others
Emotional self-control poor frustration tolerance, lack of empathy
Periods of Productivity--ADHDPeriods of Productivity--ADHD
Time’s passage
Emotional intensity
Blah-ness
Interest-based performance
Importance-based performance
Normal ADHD
ADHD is a Disability ofADHD is a Disability ofExecutive FunctionExecutive Function
Impairs the ability to separate action and Impairs the ability to separate action and rewardreward
ADD/ADHD is a disability of the “To-Do” ADD/ADHD is a disability of the “To-Do” mechanism of the brain.mechanism of the brain.– Not a disability of interest-based functionNot a disability of interest-based function– Disability of Disability of importance-based functionimportance-based function
Affects every action, every secondAffects every action, every second
Disrupts every life path Disrupts every life path
ADHD conceptADHD concept
Children with ADHD:Children with ADHD:Lack the basic, learned self-control mechanism Lack the basic, learned self-control mechanism which school is designed to rehearse.which school is designed to rehearse.
Learn to attend and function by artificially Learn to attend and function by artificially inducing emotional engagementinducing emotional engagement
Interest-based production when possibleInterest-based production when possible
Anxiety and shame otherwiseAnxiety and shame otherwise
ADHD is a DisabilityADHD is a DisabilityNot a DiseaseNot a Disease
Marlon Shirley
•Amputee age 5
•Paralympics Gold Medal winner for USA in 100m and 200m sprints
•World record holder in men’s 100m sprint for single amputees – 10.97 sec
Prevalence of ADHDPrevalence of ADHD
Risks of ADHDRisks of ADHD
ANNUAL DEATHS due to ADHD (USA):ANNUAL DEATHS due to ADHD (USA):
4,000 MVA deaths4,000 MVA deaths
1,200 suicides1,200 suicides
Risks of ADHDRisks of ADHD
Calculated effect of ADHD on life expectancy:Calculated effect of ADHD on life expectancy:
7 year decrease in adults with AD/HD*7 year decrease in adults with AD/HD*
3 year decrease3 year decrease in adults with heart disease.in adults with heart disease.
*Calculation R. Barkley due to increased smoking, obesity, decreased *Calculation R. Barkley due to increased smoking, obesity, decreased medical compliance, exercise in adults with AD/HD.medical compliance, exercise in adults with AD/HD.
Risks increase for ADHD adultsRisks increase for ADHD adults
Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford.
Success decreases for ADHD Success decreases for ADHD adultsadults
Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford.
Annual Cost of ADHD (US) Annual Cost of ADHD (US)
Annual Societal Cost
Annual 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
Accommodations for Accommodations for ADHD studentsADHD students
Medication-optimized Medication-optimized – Review and reinforce Review and reinforce
academic routinesacademic routines
Not optimizedNot optimized– Replace deficient self-controls Replace deficient self-controls
with external controlswith external controlsMonitor task completionMonitor task completion
Coordinate with parents who must Coordinate with parents who must do the same in eveningdo the same in evening
Provide intermittent rewards Provide intermittent rewards
Provide frequent reminders to Provide frequent reminders to sustain attention, effortsustain attention, effort
Individualize motivational Individualize motivational structurestructure
Token behavioral reward systemsToken behavioral reward systems
Workload reductionWorkload reduction
Teaching ADHD StudentsTeaching ADHD Students
General strategies:General strategies:– Increase emotional engagementIncrease emotional engagement– Support executive functionSupport executive function
Adopt “Disability Model”Adopt “Disability Model”30% rule—ADHD students can maintain the executive 30% rule—ADHD students can maintain the executive function of a child 30% junior. function of a child 30% junior. – 66thth grader—3 grader—3rdrd grade function grade function– 99thth grader—5 grader—5thth grade function grade function
Do not teach organizational/functional methodsDo not teach organizational/functional methods– You may require use of a methodYou may require use of a method– Must follow up and reward use of the methodMust follow up and reward use of the method
Do not expect to withdraw support Do not expect to withdraw support
Teaching ADHD StudentsTeaching ADHD Students
Increase emotional engagement.Increase emotional engagement.– Maintain rewarding environmentMaintain rewarding environment
Reward every positive thing you canReward 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 effectiveTouch can be very effective– Polite, respectful, positive, low-key, appropriatePolite, respectful, positive, low-key, appropriate– Hand on shoulder/back to signal “pay attention”Hand on shoulder/back to signal “pay attention”
Teaching ADHD StudentsTeaching ADHD Students
Increase emotional engagement.Increase emotional engagement.– Allow students to work in areas of interest whenever Allow students to work in areas of interest whenever
possible.possible.– To create a rewarding environment, take a lesson To create a rewarding environment, take a lesson
from video games:from video games:State objective clearlyState objective clearly
Provide feedback on progressProvide feedback on progress
Reward frequentlyReward frequently
Reward immediatelyReward immediately
Reward visiblyReward visibly
Small tokens are adequateSmall tokens are adequate
Teaching ADHD StudentsTeaching ADHD Students
Increase emotional engagement.Increase emotional engagement.– Time outs should deprive a student of a Time outs should deprive a student of a
rewarding environment.rewarding environment.Physically separate from rest of classPhysically separate from rest of classInvolve assignment (worksheet) that must be Involve assignment (worksheet) that must be complete to return to classcomplete to return to classTime out can be proportionate: 2-sheet, 3-sheetTime out can be proportionate: 2-sheet, 3-sheetReturn to class setting without commentReturn to class setting without comment
– Threats of harm can be effective, are not Threats of harm can be effective, are not desirable.desirable.
Teaching ADHD StudentsTeaching ADHD Students
Increase emotional engagement.Increase emotional engagement.– Participatory events effectiveParticipatory events effective– Peer tutoring effectivePeer tutoring effective– Students teaching younger students highly Students teaching younger students highly
effectiveeffective– Work done should be rewardedWork done should be rewarded– Cash awards are very effective. (Get over it.)Cash awards are very effective. (Get over it.)
Teaching ADHD StudentsTeaching ADHD Students
Support executive functionSupport executive function– Reward/consequence at “point of performance”. Reward/consequence at “point of performance”.
Teachers cannot augment homework performanceTeachers cannot augment homework performanceParents cannot augment school performanceParents cannot augment school performanceDaily report cards effective through high schoolDaily report cards effective through high school
– Feedback immediateFeedback immediateExample: Example:
– Assign class 20 math problemsAssign class 20 math problems– Raise hand when two completedRaise hand when two completed– Score and encourage (or repeat)Score and encourage (or repeat)
Grades impact performance only when promptGrades impact performance only when prompt
Daily Report CardDaily Report Card
Homework turned in
Listened Participated Assignment in planner
Initials
Math
English
Science
History
Band
PE
Teaching ADHD StudentsTeaching ADHD Students
Support executive functionSupport executive function– Extended time may not be effectiveExtended time may not be effective
ADHD students work best against a deadlineADHD students work best against a deadline
Multiple short deadlines often more effective Multiple short deadlines often more effective
Teaching ADHD StudentsTeaching ADHD Students
Note to Josh’s first hour teacher:Note to Josh’s first hour teacher:““Josh had a rough morning. Josh had a rough morning. ““He didn’t eat breakfast or finish his morning chores. Please He didn’t eat breakfast or finish his morning chores. Please
have him eat his fruit and some protein. A banana and a have him eat his fruit and some protein. A banana and a yogurt are what I offered, but whatever you have there is yogurt are what I offered, but whatever you have there is fine. fine.
““He still needs to brush his teeth and make his bed. Check He still needs to brush his teeth and make his bed. Check under the quilt; he doesn’t always straighten the sheets well. under the quilt; he doesn’t always straighten the sheets well.
““Have him return his brother’s tape player and put it away! Have him return his brother’s tape player and put it away! ““I’ll post on our family website how well you and he did by I’ll post on our family website how well you and he did by
Friday or next Monday at the latest. Let’s keep in touch. Friday or next Monday at the latest. Let’s keep in touch. Feel free to contact me anytime. Thanks.”Feel free to contact me anytime. Thanks.”
Teaching ADHD StudentsTeaching ADHD Students
Support executive functionSupport executive function– Schoolwork best done in schoolSchoolwork best done in school
Hard deadline (end of class period) improves functionHard deadline (end of class period) improves functionTeachers available for guidanceTeachers available for guidanceAllowing Allowing any any work at home guarantees that work at home guarantees that most most work will be left work will be left for homefor homeParents generally ill-equipped to helpParents generally ill-equipped to helpWork at home is generally very inefficientWork at home is generally very inefficient
– Until 6Until 6thth grade, homework does not improve performance grade, homework does not improve performance or indicate progressor indicate progress
It does give direct feedback on the parent’s level of executive It does give direct feedback on the parent’s level of executive functionfunctionMemory drills—math and spelling—may be an exception. Memory drills—math and spelling—may be an exception.
Teaching ADHD StudentsTeaching ADHD Students
Support executive functionSupport executive function– When homework is assigned, parents need tools When homework is assigned, parents need tools
to assume executive function support at home:to assume executive function support at home:Prior missing workPrior missing workActual assignmentActual assignmentDeadline for completion, waypointsDeadline for completion, waypoints
– When dealing with late/missing assignmentsWhen dealing with late/missing assignmentsParents need same day feedback to help correct Parents need same day feedback to help correct Students need same day feedback to adjustStudents need same day feedback to adjust““Automatic failure” for late assignments is counter-Automatic failure” for late assignments is counter-productive for most ADHD students. productive for most ADHD students.
Accommodation SummaryAccommodation Summary
Teachers and parents cooperate to extend Teachers and parents cooperate to extend support from home to school and backsupport from home to school and back
ADHD children (and their parents) need:ADHD children (and their parents) need:– Timely grade reportsTimely grade reports– Accurate assignment detailsAccurate assignment details– Immediate behavioral feedbackImmediate behavioral feedback
Thank you!Thank you!
Questions?Questions?
Oren Mason M.D.Oren Mason M.D.
[email protected]@mason.mdwww.attentionmd.comwww.attentionmd.comTwitter: @attentionmdTwitter: @attentionmd
Attentionality.wordpress.comAttentionality.wordpress.comFacebook: Attention MDFacebook: Attention MD
Feb. 12, 2014 Feb. 12, 2014
ADHD TreatmentADHD Treatment
Medication increases dopamineMedication 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
Medication EffectsMedication Effects
Behavioral improvements often profound:Behavioral improvements often profound:– Control of attentionControl of attention– Control of activityControl of activity– Self-esteemSelf-esteem
Academic improvementsAcademic improvements– Standardized test scores improveStandardized test scores improve– Self-esteem improves Self-esteem improves – Reduced absenteeismReduced absenteeism– Reduced grade retentionReduced grade retention– Efficient use of time improvesEfficient use of time improves– Strattera may improve dyslexiaStrattera may improve dyslexia
Medication EffectsMedication Effects
Improvements in home and family lifeImprovements in home and family life– Mothers reduce controlling behaviorsMothers reduce controlling behaviors– Family time and participation improvesFamily time and participation improves– Parent stress decreasesParent stress decreases– Overall quality of life improvesOverall quality of life improves
Driving ImprovementsDriving Improvements– Stimulants and Strattera improve attention while drivingStimulants and Strattera improve attention while driving– Daytrana decreases collisionsDaytrana decreases collisions– Driving improvements in simulator studies:Driving improvements in simulator studies:
Concerta-15 hoursConcerta-15 hoursAdderall XR-9 hoursAdderall XR-9 hours3 doses methylphenidate-9 hours3 doses methylphenidate-9 hours
Problems when we Problems when we don’tdon’t treat ADHD medically treat ADHD medically
Zoëga 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 4th to 7th grade.
Who Should Take Who Should Take ADHD Medication?ADHD Medication?
Everyone with AD/HD should undergo trials of Everyone with AD/HD should undergo trials of medication.medication.
Everyone who responds well should take the Everyone who responds well should take the medications.medications.
Medication classificationsMedication classifications
StimulantsStimulantsLong-acting Stimulants Long-acting Stimulants
Non-stimulants Non-stimulants
Stimulant duration of effectStimulant duration of effect
11Daytrana [package insert]. New York, NY: Noven Therapeutics; 2012; Daytrana [package insert]. New York, NY: Noven Therapeutics; 2012; 22Vyvanse [package insert]. Wayne, PA: Shire Inc. 2012; Vyvanse [package insert]. Wayne, PA: Shire Inc. 2012; 33Facts and Facts and Comparisons. Facts and Comparisons web site. http://www.factsandcomparisons.com/index.aspx. Accessed July 25, 2012; Comparisons. Facts and Comparisons web site. http://www.factsandcomparisons.com/index.aspx. Accessed July 25, 2012; 44Adderrall Adderrall [package insert]. Wayne, PA: Shire Inc. 2012; [package insert]. Wayne, PA: Shire Inc. 2012; 55Focalin XR [package insert]. East Hanover, NJ: Novartis. 2012.Focalin XR [package insert]. East Hanover, NJ: Novartis. 2012.
Medication Brand Name Duration of action (h)
Methylphenidate Transdermal1 Daytrana Up to 16
Lisdexamfetamine2 Vyvanse 10-14
OROS Methylphenidate3 Concerta 10-12
Mixed amphetamine salts XR4 Adderall XR 9-12
Dexmethylphenidate XR5 Focalin XR 8-10
Methylphenidate ER (SODAS)3 Ritalin LA 6-10
Methylphenidate SR Ritalin SR 6-8
Methylphenidate Ritalin, others 3-4
NonstimulantsNonstimulants
SR, sustained release; XL, extended releaseSR, sustained release; XL, extended release11Strattera [package insert]. Indianapolis, IN: Eli Lilly & Co.; 2012; Strattera [package insert]. Indianapolis, IN: Eli Lilly & Co.; 2012; 22Facts and Comparisons. Facts and Comparisons web site. http://www.factsandcomparisons.com/index.aspx. Facts and Comparisons. Facts and Comparisons web site. http://www.factsandcomparisons.com/index.aspx. Accessed July 25, 2012; Accessed July 25, 2012; 33Intuniv [package insert]. Wayne, PA: Shire, Inc.; 2012; Intuniv [package insert]. Wayne, PA: Shire, Inc.; 2012; 44Kapvay [package insert]. Florham Park, NJ: Shionogi Pharmaceuticals; 2012.Kapvay [package insert]. Florham Park, NJ: Shionogi Pharmaceuticals; 2012.
Preparation Trade NameDuration of action (h)
Atomoxetine1 Strattera >24
Bupropion SR2 Wellbutrin SR 12
Bupropion XL2 Wellbutrin XL 24
Guanfacine3 Tenex 12-24
Guanfacine XR4 Intuniv 24
Clonidine4 Catapres 6-12
Clonidine XR4 Kapvay 12-24
How safe are ADHD How safe are ADHD medications?medications?
Risk with stimulantsRisk with stimulants
Effects on growth:Effects on growth:Short-termShort-term
Children with ADHD are slightly shorter and weigh Children with ADHD are slightly shorter and weigh less than peers.less than peers.
Stimulants cause growth in height and weight to slow Stimulants cause growth in height and weight to slow for at least two years.for at least two years.
Long-termLong-termBy year 4, growth is almost normal.By year 4, growth is almost normal.
Final adult height is not significantly changed.Final adult height is not significantly changed.
Stimulant risksStimulant risks
Risk of sudden death ages 5-21Risk of sudden death ages 5-21General populationGeneral population 0.8/100,000/year0.8/100,000/year
Stimulant usersStimulant users 0.5/100/000/year 0.5/100/000/year
This is the risk when medications are
managed by a knowledgeable physician.
Risk of atomoxetine—Strattera Risk of atomoxetine—Strattera
Risk of Risk of non-fatal non-fatal liver damage:liver damage:
1 in 1,000,000 1 in 1,000,000
Risk of Risk of fatal fatal auto accident, with auto accident, with monthly 5-mile trip to pharmacy for 1 monthly 5-mile trip to pharmacy for 1 year:year:
1 en 1,000,0001 en 1,000,000
Side effects diminish Side effects diminish with with constant constant useuse
Treatment StrategiesTreatment Strategies
Improving efficacy and Improving efficacy and durationduration
Evaluate symptoms frequentlyEvaluate symptoms frequently
Optimize EfficacyOptimize Efficacy
Increase dose until intolerable, then Increase dose until intolerable, then reducereduce
Repeat scales at every visit. Repeat scales at every visit.
If one medication gives an inadequate If one medication gives an inadequate response, try anotherresponse, try another
Consider combination therapy. Consider combination therapy.
Potential benefits of combination Potential benefits of combination therapytherapy
Efficacy: combination therapyEfficacy: combination therapy
Symptom reduction with combination therapySymptom reduction with combination therapy
Wilens, T An Open Study of Adjunct OROS-Methylphenidate. Wilens, T An Open Study of Adjunct OROS-Methylphenidate. J Child Adolesc Psychopharmacol. 2009 October; 19(5): J Child Adolesc Psychopharmacol. 2009 October; 19(5): 485–492.485–492.
Meds, psychosocial support or bothMeds, psychosocial support or both
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
Effect of medicationEffect of medication
Medications for ADHDMedications for ADHD
normalize brain functionnormalize brain function
improve self-control improve self-control
improve control of attentionimprove control of attention
improve decision-makingimprove decision-making________________________________________________
Medications allow the practice of self-controlMedications allow the practice of self-control
Thank you!Thank you!
Questions?Questions?
Oren Mason M.D.Oren Mason M.D.
[email protected]@mason.mdwww.attentionmd.comwww.attentionmd.comTwitter: @attentionmdTwitter: @attentionmd
Attentionality.wordpress.comAttentionality.wordpress.comFacebook: Attention MDFacebook: Attention MD
Feb. 12, 2014 Feb. 12, 2014