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


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”


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


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.


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.)


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


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


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.”


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.


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?


[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?


[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

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ADHD Two Attentions One Deficit