The ADHD Story

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The ADHD Story

• James J. Messina, Ph.D.
• Go to www.coping.org
• for ADHD Articles Links

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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

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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

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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)

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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

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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

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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

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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)

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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)

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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

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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)

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Attention Deficit Hyperactivity Disorder

• Inattention - Traditionally known as ADD
  
  
• Impulsivity - Traditionally known as
  Hyperactivity

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ADHD Characteristics

• Inattention
• Impulsivity
• Overactivity

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Inattention-Distractibility

• Doesnt seem to listen
• Fails to finish assigned tasks
• Often loses things
• Cant concentrate
• Easily distracted
• Daydreams
• Requires frequent redirection
• Can be very quiet missed

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Impulsivity-Behavioral Disinhibition

• Rushing into things
• Careless errors
• Risk taking
• Taking dares
• Accidents/injuries prone
• Impatience
• Interruptions

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Hyperactivity - Overarousal

• Restlessness
• Cant sit still
• Talks excessively
• Fidgeting
• Always on the go
• Easy arousal
• Lots of body movement

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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

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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

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What is Learning Disability?

• Definition
• A learning disability is a disorder that affects
  a persons 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.

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What are Learning Disabilities

• Neurological in origin
• Impede persons ability to store, process or
  produce information
• Affect ability to read
• Affect ability to speak
• Affect ability to compute math
• Impair socialization

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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

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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

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LD Attention Symptoms

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

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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

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Rule outs for Diagnosis of ADHD
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GARLIC V.S. ONION-Rule out System in Diagnosing
ADHD

• Rule of Thumb of Ruling out Garlic Issues
• Garlics odor outdoes Onions 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 Garlics
  strength incapability of de-powering it

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Garlic Rule Outs in Diagnosing ADHD

• Seizure Disorder or other neurological issue such
  as Tourettes Syndrome
• Specific Learning Disability
• Vision acuity problem
• Hearing problem
• Metabolic problem
• Genetic problem
• Child Psychiatric Problem

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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)

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Ophthalmologic Screening

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

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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

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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

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Cognitive, Speech Language, Motor, Sensory
Motor Planning

• Pediatric Psychologist
• Speech Language Pathologist
• Occupational Therapist - sensory integration
• Physical Therapist

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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

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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

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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

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Classroom Modifications for Students with ADHD
SLD
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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

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2. Classroom Modifications

• Evaluate structure environment
• Reduce external visual auditory stimuli
• Repeat have student paraphrase directions
• Give short directions
• Use predetermined signals
• Multiple modalities

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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

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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

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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

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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

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7. Classroom Modifications

• Getting outside help
• Openness to others input
• Enthusiasm
• Optimism - We Can Attitude
• Determination to make it work
• Commitment to process and to child