What Does It All Mean? ADHD, Executive Functioning, Causes and Management

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What Does It All Mean?ADHD, Executive
Functioning, Causes and Management

• Russell Barkley, Ph.D.
• Clinical Professor of Psychiatry
• Medical University of South Carolina
• Charleston, SC
• Websites
• ADHDLectures.com
• Russellbarkley.org

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What is ADHD?

• A disorder of developmentally inappropriate
  degrees of
• Inattention
• Hyperactive and impulsive behavior
• Arises in childhood
• Persistent over time
• Results in impairment in major life activities

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Nature of the Hyperactive Impulsive Symptoms

• A Neuropsychological Dimension of Poor Inhibition
• Motor impulsiveness and hyperactivity (task
  irrelevant movements)
• Fidgeting, squirming, running, climbing, touching
• Verbal impulsiveness
• Cognitive impulsiveness (decision making cannot
  wait or defer gratification)
• Greater disregard of future (delayed)
  consequences
• Impaired resistance to distractions (sustained
  inhibition)
• Emotionally impulsive poor emotional
  self-regulation
• NOTE Restlessness decreases with age, becoming
  more internal or subjective by adulthood

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Nature of the Inattention Symptoms

• There are at least 6 types of attention
• Arousal, alertness, selective, divided, span of
  apprehension, persistence.
• Not all are impaired. What is?
• Poor persistence toward goals or tasks
• The cross-temporal organization and maintenance
  of actions toward goals or assignments
• Impaired resistance to responding to distractions
• Less likely to re-engage tasks following
  disruptions
• Due to impaired working memory (remembering so as
  to do)

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Prevalence

• 2-5 of children (using older DSM-III or III-R)
• 7-8 of children in US (using DSM-IV) (3-4
  million)
• Adding Inattentive Type doubles prevalence over
  III-R
• 5.5 of children worldwide
• 4-5 of adults in US (12 million in US)
• 3-4 worldwide adult prevalence
• Varies by age, social class, urban-rural
• More common in children less so in adults
• Somewhat more common in middle to lower-middle
  classes
• More common in population dense areas
• More common in certain occupations
• For instance, 12-15 of U.S. military dependents
• More common among nonprofessional workers
• No evidence for ethnic differences to date that
  are independent of social class, urban-rural
  demographics or variable access to care

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ADHD Varies by Setting

• Better Here Worse Here
• Fun Boring
• Immediate Delayed Consequences
• Frequent Infrequent Feedback
• High Low Salience
• Early Late in the Day
• Supervised Unsupervised
• One-to-one Group Situations
• Novelty Familiarity
• Fathers Mothers
• Strangers Parents
• Clinic Exam Room Waiting Room

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Sluggish Cognitive TempoA New Disorder of
Attention

• Sometimes called Attention Deficit Disorder
• Daydreaming/Spacey/Stares/Confused
• Slow Information Processing (CAPD?)
• Hypoactive/Lethargic/Sluggish/Sleepy
• Easily Confused, Mentally Foggy
• Poor Focused/Selective Attention
• Erratic Retrieval - Long-Term Memory
• Socially Reticent/Uninvolved/Isolated

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More on SCT (2)

• Not Impulsive also less deficient in other
  executive functions (self-regulation abilities)
• Rarely Aggressive or have ODD/CD
• Greater risk for anxiety and depression
• Equally high risk for learning disabilities (LD)
• But math disorders may be more likely than
  reading and language disorders with SCT (?)
• Not as impaired in other domains of life outside
  of school compared to ADHD
• Parents report far less stress in parenting SCT
  than ADHD children most stress is school related
• Possibly greater family history of anxiety
  disorders and LD (?)

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Treatment of SCT

• Less Likely to Have a Clinically Impressive
  Response to Stimulants?
• (65 improve but only 20 show clinical response)
• Other drugs have not been tested Strattera,
  Intuniv, ProVigil, etc
• Better responders than ADHD children to social
  skills training
• As good or better responders to behavior
  modification methods
• Probably better responders to cognitive
  behavioral therapy (self-instruction training)

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What Are The Academic Risks Linked to ADHD?

• Academic Under-performance (90)
• Retention in Grade (25-50)
• Require Special Education (35-60)
• Failure to Graduate High School (30-40)
• Less Likely to Attend College (20)
• Less Likely to Graduate College (5)

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Other Developmental Risks

• Oppositional, defiant, hot tempered (40-65)
• Depressed, sullen, moody, irritable (20-30)
• Anxious, fearful (0-25)
• Peer Relationship Problems (50)
• Delinquency (25-35)
• Substance Dependence/Abuse (10-20)
• Driving Problems (Speeding, Accidents)
• Earlier Sexual Activity Teen Pregnancy (38)
• Increased Risk for Sexually Transmitted Diseases
  (16)

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Health Problems

• Delayed motor coordination (60)
• Greater risk for accidents and injuries
• More likely to develop dental problems
• Small increase in risk for seizures
• Bedtime behavior problems (20) and disordered
  sleep(20-25)

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• What Causes ADHD?

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The Neurology of ADHDFrom R. Barkley, Scientific
American, Sept. 1998, p. 47 Reprinted with
permission of Terese Winslow and Scientific
American.
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Delayed brain growth in ADHD (3 yrs.)From Shaw,
P. et al. (2007). ADHD is characterized by a
delay in cortical maturation. Proceedings of the
National Academy of Sciences, 104, 19649-19654.
Greater than 2 years delay 0 to 2 years delay
Ns ADHD223 Controls 223
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Early cortical maturation in ADHD childrenFrom
Shaw, P. et al. (2007). ADHD is characterized by
a delay in cortical maturation. Proceedings of
the National Academy of Sciences, 104,
19649-19654.
Fig. 4. Regions where the ADHD group had early
cortical maturation, as indicated by a younger
age of attaining peak cortical thickness.
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The Genetics of ADHD

• Heredity Risk to
• Siblings 25-35 Twin 75-92
• Mother 15-20 Father 20-30
• Offspring of an adult with ADHD 27-54
• Genetic Contribution (80 or more)
• No contribution of the rearing environment
• Many Risk genes found to date
• These genes appear to regulate brain growth and
  some brain chemicals
• Each contributes a small risk to the disorder
• Family members have some of these genes and show
  some of the traits of ADHD but often not enough
  to have the full disorder
• The more risk genes a child has, the greater the
  risk for having the full disorder

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What Doesnt Cause ADHD?

• Food Additives, Allergies, Sugar, Milk in Diet
• Excessive Caffeine in Diet
• Environmental Allergens
• Poor Child Management by Parents
• Family Stress Chaotic Home Life
• Excessive Use of TV, Video-games
• Increased Cultural Tempo
• PTSD, Depression, Anxiety, Learning Disability

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• What is Executive Functioning? How is it Related
  to ADHD?

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(No Transcript)
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Getting Ready for the Future Requires

• That you stop and think -BEFORE you act !
• Use your hindsight (looking backward)
• To get your foresight (see whats next)
• To anticipate and prepare for the future
• So you can be more effective and attend to your
  long-term welfare and happiness
• This is executive functioning (EF)
• There are 6 cognitive or mental components
  or parts to EF

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Self-Awareness
Inhibition
Sensing to the Self
Self-Speech
Emotion to the Self
Play to the Self
Motor Control
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The EFs Create Four Developmental Transitions in
What is Controlling Behavior

• External Mental (private or internal)
• Others Self
• Temporal now Anticipated future
• Immediate Delayed gratification

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The 5 EFs in Major Life Activities

• Self-Discipline (making your self STOP)
• Cognitive, behavioral, verbal, emotional
• Self-Management Across Time (making mental maps)
• Consideration of past and future consequences
  before acting managing your self relative to
  time and deadlines
• Self-Organization /Problem-Solving (making
  options)
• Innovating, planning possible response options,
  problem-solving to overcome obstacles to goals,
  rapid assembly and performance of novel
  goal-directed behavior
• Self-Motivation (filling the fuel tank)
• Substituting positive goal-supporting emotions
  for negative goal-destructive ones
• Self-Regulation of Emotions (moderating your
  feelings)

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ADHD Impairs Self-Regulation Across Time
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Understanding ADHD as a Disorder of Executive
Functioning

• ADHD disrupts the 7 mental capacities that make
  up EF and the 5 EF abilities we use in everyday
  life thereby creating a disorder of
  self-regulation across time
• ADHD is Time Blindness or a Temporal Neglect
  Syndrome (Myopia to the Future)
• It adversely affects the capacity to
  hierarchically organize behavior across time to
  anticipate the future and to pursue ones
  long-term goals and self-interests (welfare and
  happiness)
• Its not an Attention Deficit but an Intention
  Deficit (Inattention to mental events the
  future)

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Understanding ADHD

• Its a Disorder of
• Performance, not skill
• Doing what you know, not knowing what to do
• The when and where, not the how or what
• Using your past at the point of performance
• The point of performance is the place and time in
  your natural settings where you should use what
  you know (but may not)

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Implications for Treatment

• Teaching skills is inadequate
• The key is to design prosthetic environments
  around the individual to compensate for their EF
  deficits
• Therefore, effective treatments are always those
  at the point-of-performance
• The EF deficits are neuro-genetic in origin
• Therefore, medications may be essential for most
  (but not all) cases meds are neuro-genetic
  therapies
• But some evidence suggests some EFs may also be
  partly responsive to direct training
• While ADHD creates a diminished capacity Does
  this excuse accountability?
• (No! The problem is with time and timing, not
  with consequences)

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More Treatment Implications

• Behavioral treatment is essential for
  restructuring natural settings to assist the EFs
• They provide artificial prosthetic cues to
  substitute for the working memory deficits
  (signs, lists, cards, charts, posters)
• They provide artificial prosthetic consequences
  in the large time gaps between consequences
  (accountability) (i.e., tokens, points, etc.)
• But their effects do not generalize or endure
  after removal because they primarily address the
  motivational deficits in ADHD
• The compassion and willingness of others to make
  accommodations are vital to success
• A chronic disability perspective is most useful

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What Are The 4 Stages of Treatment?

• Evaluation
• Education
• Medication
• Modification (of Behavior)
• Accommodation
• Restructuring the home
• Changes in school
• Assistance in the community

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Empirically Proven Treatments

• Parent Education About ADHD
• Psychopharmacology
• Stimulants (e.g., Ritalin, Adderall, etc.)
• Noradrenergic Medications (e.g., Strattera)
• Tricyclic Anti-depressants (e.g., desipramine)
• Anti-hypertensives (e.g., Catapres, Tenex)
• Parent Training in Child Management
• Children (lt11 yrs., 65-75 respond)
• Adolescents (25-30 show reliable change)

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Empirically Proven Treatment (2)

• Teacher Education About ADHD
• Teacher Training in Classroom Behavior Management
• Special Education Services (IDEA, 504)
• Residential Treatment (5-8)
• Parent/Family Services (25)
• Parent/Client Support Groups (CHADD, ADDA,
  Independents)

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Experimental Treatments

• Biofeedback (EMG or EEG)
• Working Memory Training
• Mindfulness Meditation Training
• Omega 3/6 Food Supplements (fish oils)

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Unproved/Disproved Therapies

• Elimination Diets removal of sugar, additives,
  etc. (Weak evidence)
• Megavitamins, Anti-oxidants, Minerals
• (No compelling proof or disproved)
• Sensory Integration Training (disproved)
• Chiropractic Skull Manipulation (no proof)
• Play Therapy, Psycho-therapy (disproved)
• Self-Control (Cognitive) Therapies (in clinic)
• Social Skills Therapies (in clinic)
• Better for Inattentive (SCT) Type and Anxious
  Cases

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What Roles Can Parents Play?

• The Scientific Parent
• Read widely
• Experiment with management methods
• Be a skeptic
• The Executive Parent
• Take charge become an advocate
• The Principle-Centered Parent
• Be proactive Begin with the end in mind Put
  first things first Seek to understand, then to
  be understood Think win/win Synergize Find
  sources of renewal

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If the Parent Also Has ADHD

• Get into treatment as soon as possible (meds.,
  counseling, organizing advice, treatment for
  co-existing disorders, etc. )
• Let the non-ADHD parent handle homework and
  school-related issues, if necessary
• Alternate nights with partner as to who
  supervises for the ADHD child
• Let the non-ADHD parent handle time sensitive
  household responsibilities while the ADHD parent
  gets the non-time sensitive ones
• Put yourself in time-out when emotions escalate
  toward family members
• Always review major child discipline decisions
  with the non-ADHD parent
• The non-ADHD parent drives to children to their
  activities if the ADHD parent is not on medication

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Conclusion

• ADHD is a relatively common disorder, affecting 1
  in every 14-20 children
• ADHD involves deficits in self-regulation and
  executive functioning
• It is a highly neurological genetic disorder,
  not a myth or a socially causes condition
• It is associated with numerous impairments over
  development if left untreated
• It is the most treatable disorder in psychiatry