Attention & Planning. Prevalence. ADHD and Attention. Incidence. Incidence. ADHD: Updates and Practical Suggestions 4/4/2018

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1 ADHD: Updates and Practical Suggestions Attention & Planning Christopher Boys, PhD Associate Professor of Pediatrics University of Minnesota ADHD and Attention Children with ADHD engage in high risk behaviors Problems with inhibition may be related to problems with modulation of response to reward or risk ADHD C show problems with inhibition independent of level of reward ADHD PI respond to high but not to low rewards for inhibition Prevalence US estimates range from 2% to 18% of schoolage children (Singh, Nature Reviews: Neuroscience 2008). Worldwide estimate about 5.29% of school age children (Wallis et al, Journal of Pediatric Psychology, 2008). DSM IV: Three types ADHD:PI Predominantly Inattentive ADHD: H/I Predominantly Hyperactive/Impulsive ADHD: C Combined DSM IV: Three types Bucket style diagnosis may not capture the disorder best. 80% of clinically referred children display symptoms in all three domains. 1

2 DSM 5: Subtypes retained Onset < 12 (from <7) Developmental perspective extended to adulthood No exclusion criteria for ASD GENDER BOYS: 2.5 to 9 times more likely than girls More boys than girls in both clinic and community samples Girls with hyperactivity tend to be more severe than boys Is this adult perception? Etiology RACE/ETHNICITY African Americans receive higher ADHD ratings than European Americans. Hispanics and African Americans are less likely to receive treatment. Etiology ADHD is a heterogeneous behavioral disorder with multiple possible etiologies Biological Factors The neurobiology of ADHD Abnormal gray and white matter development Neuroanatomic Neurochemical CNS insults ADHD Genetic origins Environmental factors Why abnormal development? 1. Delayed cortical maturation? 2. Environmental toxins/exposure? 3. Genes? 4. Family Structure Treatment with psychostimulant medication Most common treatment Prevents re uptake of dopamine Normalizes abnormal brain activation and behavior Affects development of height and weight? (MTA Longitudinal Study; Swanson et al & 2007) Maybe brain development is altered as well? 2

3 Etiology Known to be familial and heritable Gene candidates: Dopamine receptor and transporters Only weak associations have been found so far in specific genes, but twin studies strongly indicate heritability of ADHD. Etiology Some recent focus on neurotoxins (e.g. lead, alcohol, tobacco, pesticides, perinatal complications, head trauma). The executive system relies heavily on white matter connections between the frontal lobes, subcortical structures and the rest of the cortex. Virtually any disruption will affect these circuits. Girls and ADHD: Recent Findings Girls not significantly different than boys Selected neuropsychological measures Psychiatric family history Stimulant drug response Working memory, planning, and set shifting More commonly diagnosed with ADHD PI than ADHD C Seem to improve in symptomatology with age boys don t Often have more problems with adjustment and LD ADHD evidence argues against a primarydeficit model of ADHD (Willcutt 2010 p402 in Yeates et al. Pediatric Neuropsychology). In a large twin study, those with ADHD were more likely than without ADHD to exhibit a significant deficit (10 th percentile or below) on neuropsych measures, but nearly 25% exhibited no weakness on any specific measure. ADHD evidence argues against a primary deficit model of ADHD (Willcutt 2010 p402 in Yeates et al. Pediatric Neuropsychology). Measures: Inhibition, working memory, vigilance, processing speed, response variability, response modulation, delay aversion. ADHD is very heterogeneous, with some children showing specific deficits and others not, yet the behaviors are similar. Variability also occurs due to sex, age, race/ethnicity, comorbidity and the presence of etiological risk factors. 3

4 A momentary digression: Involvement of the prefrontal cortex is hypothesized, since problems in executive functions are thought to be at the core. It s difficult to find an ADHD only child fmri studies show low activation of the right pre-frontal cortex and basal ganglia (connected to frontal cortex movement) Much variation in population and methods in research. Neuroimaging studies are not really conclusive, but it appears that the frontal regions are involved. Functional neuroimaging studies have reported reduced activation in the frontal striatal circuit. Adult decision making reduced activation also in AC and hippocampus (Iowa Gambling Task Ernst et al 2003) Adolescent inhibition of motor response (Txnaïve) right PFC and AC during failure (Rubia et al 2005). MRI Differences in ADHD Caudate nucleus has been found to consistently differ in ADHD (Semrud Clikeman et al., 2000) Corpus Callosum differs but may be sensitive to medication response differences (Schoebelen, Semrud Clikeman, & Pliszka, in press; Semrud Clikeman et al., 1994) Consistent findings of reduced volume particularly in the right frontal region Neuroanatomical:CC Findings No difference between groups in overall volume or area of the CC ADHD TN group had smallest splenium area (ADHD TN<control, no difference between ADHD CT and control) Smaller splenium associated with higher ratings of impulsivity/hyperactivity (Schnoebelen, Semrud Clikeman, et al., 2005) Splenium smaller= Decreased communication between hemispheres Parietal communication with frontal drives attention 4

5 Further findings Tamm et al. (2004) also found hypofunction in the ACC on a go/no go task with ADHD:C and controls Neuroanatomical Findings Additional studies also found differences in the ACC (Bush et al., 1999) using the Stroop Neuroanatomical Findings Imaging has found differences in the ACC, DLPC, basal ganglia, cerebellum and to a lesser extent parietal lobe Make up the cingulo frontal parietal (CFP) cognitive attention network (Bush, 2011) Treatments Stimulant Treatment: Methylphenidate and other stimulants are highly effective in treating attention, but may not affect EF and behavioral issues Meta analysis of 74 studies found no effect on academic gains (Purdie, Hattie & Carroll, 2002) Often the academic difficulties are due to EF and not a specific learning disorder Medications The best dose for behavior may have a limited or detrimental effect on cognitive functioning (see Hale, 2012) Some will do better on a lower dose for academic work paired with a behavioral plan for problems with EF. Medication can prepare the child to receive the interventions better, still need to do the interventions at home and school Why does it seem like more ADHD? Increasing morbidity with decreasing mortality NICU, Metabolic Newborn Screening, Cancer survival rates, etc Changing learning/behavior profile due to these changes. Hard to sort out attention from executive dysfunction All of it seems to be seen as behavior 5

6 Executive Functions Monitoring Inhibitory Control Shifting Working Memory Attention Planning/Organization Attn/EF Difficulties present Differently By Age Toddlerhood and Early Childhood Not able to follow commands Not able to shift between activities Tantrums Sensory Processing Attn/EF Difficulties present Differently By Age Preschool (2 ½ to 6 years) Typically exhibiting Hyperactivity Language dysfunction Perceptual problems Behavioral Disturbances Sensory Integration problems Attn/EF Difficulties present Differently By Age School Aged Children (6 13 years) Unable to sit still in class or pay attention Difficult to deal with multiple sensory inputs (especially auditory) Significant difficulties in peer relationships Fail to learn from mistakes Lack judgment Developmental Differences in Clinical Presentation Focus of classroom/home turns more to EF between 8 10 years of age. Focus turns to Sequencing and Synthesizing Children have difficulty with locating Step 1, even in the face of good IQ More parental frustration with attention Sequencing/Synthesizing is Often the Key Change At home, parents tend to give fewer Step 1s Go pick up your toys vs Go clean your room At School, the focus shifts from learning to read to reading to learn This can be the start of attention and behavior problems that did not previously present. Not always correlated with IQ 6

7 Proactive Intervention Proactive Interventions are the most effective Setting the situation up before the activity, not trying to play catch up This is not hand holding, it provides scaffolding Have reset points, rally spots Proactive Intervention Monitoring teacher/adult frustration to not promote the escalation from poor attention Developing neutral responses Sound like a broken record Usually only works if the interventions have focused on addressing the executive function weaknesses and processing speed issues Monitoring/Impulse Control Issues When children have difficulty monitoring, they get blind sided by consequences Do not teach decision making, first must teach identifying the point of decision making. In other words, being more aware that a decision has to be made. Not ending up knee deep in the muck before you realize the muck is there. Monitoring (cont.) The child with ADHD will likely need a more explicit, extensive, and/or clear set of rules and expectations, and might need these reviewed with him/her regularly. Often, it is important to limit distractions that are problematic for a student with inhibitory control difficulties. This might include visual and auditory distractions as well as other students or activities that can pull the child s attention away from a task. The child practices and gets good at not attending to situations Neutral Parenting/Teaching (must not get frustrated) Shifting Children with FASD must be prepared to receive directions/instructions. This allows for time to shift to new cognitive set or activity Notable source of frustration for parents and teachers This is where the child gets blindsided Adults are on 3 rd command, Child is on first Deficits in cognitive flexibility also will warrant specific accommodations. Child will need to be reminded to stop and think before responding to task demands, and he will probably need cueing to keep him from continuing to respond in ways that are ineffective. Parents/teachers also should monitor child closely to insure that he understands directions for assignments. Working Memory Working memory is essentially the ability to hold information in memory and perform a specific manipulation to the information. Individuals with working memory problems often have difficulty carrying out multistep activities, losing track of what they are doing as they work, or forgetting what they are supposed to retrieve when sent on an errand. Restaurant Servers 7

8 Working Memory(cont.) Provide simple templates for routines that are repeated. Each day must start fresh, regardless of how the previous day went. A template lays out the standard steps to complete a repetitive task and can be useful for a variety of home and school tasks. The template can be faded out when the procedure or task becomes automatic. However, this should be monitored closely so that the template can be brought back if it appears that it was faded too soon. The template can also be used to address problem areas such as homework completion, personal hygiene, time management (get a snack, math worksheet etc.). IMPORTANT STEP: May need a reminder/behavior change component to remember to check the list Attention Children with ADHD require a higher degree of external structure to limit some of distractibility and inattention. Because they experience difficulties with executive functioning, structure and consistency may help with potential difficulties reacting to unpredictable situations. He/She may become more inattentive or distracted when he/she is uncertain about expectations or the reactions of those around him/her, and he/she may become more likely to act out when frustrated due to difficulties with executive functioning. Is this ADHD or behavior? Planning/Organization Children with ADHD/executive function difficulties have difficulty locating a starting point and developing an efficient strategy. When combined with low frustration tolerance, behavior outbursts can result and mask the underlying problem. If a child with ADHD is experiencing significant difficulties with executive functioning skills, particularly with organizing and planning his/her room and personal belongings. Parents may find helpful insights in helping her create scaffolding regarding executive functioning deficits from the book, Smart But Scattered: The Revolutionary Executive Skills Approach to Helping Kids Reach Their Potential by Peg Dawon, Ed.D. and Richard Guare, PhD. This book provides ideas about how to overcome executive functioning deficits and organizational problems. Summary Attention is tricky to sort out Interventions are hard to develop to address the heterogeneity of attentional difficulties Attention and Executive Functions go hand in hand to disrupt behavior 8