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Tuesday, November 1, 2011

ADHD UC Davis Mind Institute 2010 Notes

University of California
ADHD: Current Research Assessment and Treatment Status
UC Davis Mind Institute, Summer 2010
Dr. Julie Schweitzer and Dr. Faye Dixon

Background:
·         Rate of ADHD in general population is 3 – 10% of children depending on what diagnostic measures are used
·         Environmental factors in pregnancy shown to increase the risk of ADH:
o   Glucocortoroids
o   Pesticide exposure
o   Smoking
o   Alcohol
o   Maternal eating disorders
·         Academic problems associated with ADHD
o   56% need tutoring
o   30% repeat a grade
o   30-40% in special education
·         Impulsivity and inattention continues with 70-80% adolescents, while hyperactivity declines
·         Teen behavior problems include
o   Anti-social behavior
o   Greater frequency of suspensions or dropping out
o   Heavier alcohol and cigarette use
o   Riskier sexual behavior
o   Higher risk of driving accidents
·         Adults commonly continue to have symptoms but their symptoms are different because they are in a different environment
o   More problem maintaining jobs
o   Higher underemployment – earn $9,00 - $15,000 less than non-ADHD
o   More marital problems
o   Depression, substance abuse and anti-social behavior problems continue
·         Evaluations should include:
o   ADHD is a very complicated diagnosis.  It can’t just be done in the pediatrician’s office.  It must involve collaboration and interviews with child, parents, caregivers, teachers, school
o   Look at co-occurring conditions
o   Look at medical history to see what else is contributing or may be looking like ADHD
o   Family stress
o   Family medical history – ADHD looks like it is hereditary
o   Look at academic and intellectual performance
o   Problems need to exist in all settings – home and school and across time
o   Brain imaging is not a necessary diagnostic tool.  (used purely for research purposes).  Blood tests are also not required. CPT tests are also not diagnostic tools.
o   Standardized forms – Vanderbilt is free, Connors and Children’s Symptom Inventory are a few of the best. The Children’s Symptom Inventory is best for people who have ASD.
o   Not just rating scales and interviews that inform us. Need input from people who see the children over time – especially teachers.
o   Review what else has been tried
o   Sleep is a common ADHD problem, but can also affect attention
o   Performance in the clinic may be dramatically different from home or school performance.  That’s why we always rely on an observer to also screen adults.  “Collateral” information is very important.
o   Self-report of teens and young adults is a very ineffective diagnostic tool
·         DSM-IV criteria is very subjective and will be changing soon
o   Hyperactivity is most observable
o   Impulsivity gets kids in trouble the most, most problematic. DSM-V thinking of breaking Impulsivity and Hyperactivity apart as symptom areas
o   Problem behaviors must be evident before the age of 7 (this may change with DSM-V)
·         DSM-V due out in 2013
·         ADHD Sub-Groups:
o   personal theory – subgroups due to different neurotransmitter systems and brain regions involvement and treatment should be different.
o   Norepinepherine and dopamine are key
o   Behavioral intervention and medication are the two standards of treatment
o   Behavior intervention doesn’t treat the core symptoms, medication does
o   Insufficient evidence that the following treatments are effective:  neurofeedback and cognitive therapy. Need replicable, randomized placebo studies.
·         Cultural attitudes
o   Hispanics and Af. Americans are less informed as a group and more concerned about stigma
·         A child’s behavior at 6 significantly influences their performance level at age 17
o   Best prediction of performance in math and reading is attentional focus (not conduct)
·         High school dropout rate dramatically affected by ADHD
o   30,000 people study, control for age, sex, parental mental disorders and childhood adversity
o   15% of all people don’t graduate.
o   Conduct disorder, ADHD (even the inattentive type) are much less likely to graduate. (about 30% drop out rate)
o   Drop outs have a poorer life expectancy, higher social cost, incarceration, less productive
·         Children with ADHD have variable levels of performance
o   One day they are able to do it, the next they aren’t
o   Often mistaken for laziness
o   Perhaps a physiological root to this behavior
o   People with ADHD do better with non-routine tasks – nearly as well as non-ADHD kids.
o   These kids are consistently inconsistent
o   Working memory is known to be a problem for ADHD.  Some of this has to do with slow response time.  This looks like inattention.
o   The kids who are the most hyperactive also are the most variable
o   Kids with ADHD are less able to quiet some areas of their brain when they need to sustain focus on a task
·         Kids with ADHD don’t respond the same way to mistakes, leading to them not learning from their errors
·         There is also neural evidence that inattentive ADHD and hyperactive/impulsive ADHD types respond differently to different circumstances
·         Medication
o   Ritalin has been shown to increase brain efficiency (measured by glucose usage)
o   We know it works, but
o   People don’t adhere to medication prescription
o   Within 6 months to a year, many people have stopped taking their medication
o   Most people respond to a stimulant and most pediatricians should be able to prescribe one.  But in complicated cases, prescribing medications is a complex art form and needs to be done by a psychiatrist comfortable and well versed in working with this population.
·         Video-psychiatry (i.e. skype) has been shown to be as effective as in person treatment.
·         Treatment recommendations for young adults
o   Important to have a partner to work on behavior therapy
o   Set long term goals, break into smaller tasks and build a system to support them in sustaining focus on their goals.
·         Executive functioning and ADHD
o   We know that people with ADHD have executive function problems
o   But you can have executive function issues without ADHD
o   It’s become too broad and over used a term
o   Executive function is not the answer. It’s an easy way to talk about it but not always the most specific way.
o   Brain regions and processing is a better place to focus our attention.
·         Teaching students to understand what areas they are weak in is an important part of treatment.  Because they are consistently inconsistent, it’s hard for a person to recognize why they are having problems in certain areas because some of the time they are able to function in that area.
·         ADHD learners are usually multi-sensory learners
o   Strategies that work with children who have multi-sensory learning disabilities also work with ADHD
o   We should be designing curriculum that is visual, auditory and hands-on
o   And people with ADHD should also look for careers that combine these sensory experiences.

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