1. 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.comRussellbarkley.org

2. What is ADHD? n A disorder of developmentally inappropriate degrees of: InattentionInattention Hyperactive and impulsive behaviorHyperactive and impulsive behavior n Arises in childhood n Persistent over time n Results in impairment in major life activities

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

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

5. Prevalence n 2-5% of children (using older DSM-III or III-R) n 7-8% of children in US (using DSM-IV) (~3-4 million)* Adding Inattentive Type doubles prevalence over III-RAdding Inattentive Type doubles prevalence over III-R n 5.5% of children worldwide* n 4-5% of adults in US (~12 million in US)** n 3-4% worldwide adult prevalence*** n Varies by age, social class, & urban-rural More common in children; less so in adultsMore common in children; less so in adults Somewhat more common in middle to lower-middle classesSomewhat more common in middle to lower-middle classes More common in population dense areasMore common in population dense areas More common in certain occupationsMore 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 careNo evidence for ethnic differences to date that are independent of social class, urban-rural demographics or variable access to care

6. ADHD Varies by Setting Better Here: Worse Here: n Fun Boring n Immediate Delayed Consequences n Frequent Infrequent Feedback n High Low Salience n EarlyLate in the Day n Supervised Unsupervised n One-to-one Group Situations n Novelty Familiarity n Fathers Mothers n StrangersParents n Clinic Exam RoomWaiting Room

7. Sluggish Cognitive Tempo A New Disorder of Attention n Sometimes called Attention Deficit Disorder n Daydreaming/Spacey/Stares/Confused n Slow Information Processing (CAPD?) n Hypoactive/Lethargic/Sluggish/Sleepy n Easily Confused, Mentally “Foggy” n Poor Focused/Selective Attention n Erratic Retrieval - Long-Term Memory n Socially Reticent/Uninvolved/Isolated

8. More on SCT (2) n Not Impulsive; also less deficient in other executive functions (self-regulation abilities) n Rarely Aggressive or have ODD/CD n Greater risk for anxiety and depression n Equally high risk for learning disabilities (LD) But math disorders may be more likely than reading and language disorders with SCT (?)But math disorders may be more likely than reading and language disorders with SCT (?) n Not as impaired in other domains of life outside of school compared to ADHD n Parents report far less stress in parenting SCT than ADHD children; most stress is school related n Possibly greater family history of anxiety disorders and LD (?)

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

10. What Are The Academic Risks Linked to ADHD? n Academic Under-performance (90%+) n Retention in Grade (25-50%) n Require Special Education (35-60%) n Failure to Graduate High School (30- 40%) n Less Likely to Attend College (20%) n Less Likely to Graduate College (5%)

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

12. Health Problems n Delayed motor coordination (60%+) n Greater risk for accidents and injuries n More likely to develop dental problems n Small increase in risk for seizures n Bedtime behavior problems (20%+) and disordered sleep(20-25%)

13. What Causes ADHD?

14. The Neurology of ADHD From R. Barkley, Scientific American, Sept. 1998, p. 47; Reprinted with permission of Terese Winslow and Scientific American.

15. Delayed brain growth in ADHD (3 yrs.) 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: ADHD=223; Controls = 223

16. Early cortical maturation in ADHD children Early cortical maturation in ADHD children 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. Fig. 4. Regions where the ADHD group had early cortical maturation, as indicated by a younger age of attaining peak cortical thickness.

17. The Genetics of ADHD n Heredity : Risk to Siblings: 25-35% Twin: 75-92%Siblings: 25-35% Twin: 75-92% Mother: 15-20% Father: 20-30%Mother: 15-20% Father: 20-30% Offspring of an adult with ADHD: 27-54%Offspring of an adult with ADHD: 27-54% n Genetic Contribution (80% or more) No contribution of the rearing environmentNo contribution of the rearing environment n Many Risk genes found to date: These genes appear to regulate brain growth and some brain chemicalsThese genes appear to regulate brain growth and some brain chemicals Each contributes a small risk to the disorderEach 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 disorderFamily 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 disorderThe more risk genes a child has, the greater the risk for having the full disorder

18. What Doesn’t Cause ADHD? n Food Additives, Allergies, Sugar, Milk in Diet n Excessive Caffeine in Diet n Environmental Allergens n Poor Child Management by Parents n Family Stress; Chaotic Home Life n Excessive Use of TV, Video-games n Increased Cultural Tempo n PTSD, Depression, Anxiety, Learning Disability

19. What is Executive Functioning? How is it Related to ADHD?

21. Getting Ready for the Future Requires: n That you stop and think -BEFORE you act ! n Use your hindsight (looking backward) n To get your foresight (see what’s next) n To anticipate and prepare for the future n So you can be more effective and attend to your long-term welfare and happiness n This is “executive functioning” (EF) n There are 6 “cognitive” or “mental” components or parts to EF

22. Inhibition Motor Control Sensing to the Self Self-Speech Emotion to the Self Play to the Self Self-Awareness

23. The EFs Create Four Developmental Transitions in What is Controlling Behavior n External Mental (private or internal) n Others Self n Temporal now Anticipated future n Immediate Delayed gratification

24. The 5 EFs in Major Life Activities n Self-Discipline (making your self STOP) Cognitive, behavioral, verbal, emotionalCognitive, behavioral, verbal, emotional n Self-Management Across Time (making mental maps) Consideration of past and future consequences before acting; managing your self relative to time and deadlinesConsideration of past and future consequences before acting; managing your self relative to time and deadlines n 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 behaviorInnovating, planning possible response options, problem- solving to overcome obstacles to goals, rapid assembly and performance of novel goal-directed behavior n Self-Motivation (filling the fuel tank) Substituting positive goal-supporting emotions for negative goal-destructive onesSubstituting positive goal-supporting emotions for negative goal-destructive ones n Self-Regulation of Emotions (moderating your feelings)

25. ADHD Impairs Self-Regulation Across Time

26. Understanding ADHD as a Disorder of Executive Functioning n 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 n ADHD is “Time Blindness” or a “Temporal Neglect Syndrome” (Myopia to the Future) n It adversely affects the capacity to hierarchically organize behavior across time to anticipate the future and to pursue one’s long-term goals and self-interests (welfare and happiness) n It’s not an Attention Deficit but an Intention Deficit (Inattention to mental events & the future)

27. Understanding ADHD It’s a Disorder of: n Performance, not skill n Doing what you know, not knowing what to do n The when and where, not the how or what n 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)

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

29. More Treatment Implications n 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 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.)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 ADHDBut their effects do not generalize or endure after removal because they primarily address the motivational deficits in ADHD n The compassion and willingness of others to make accommodations are vital to success n A chronic disability perspective is most useful

30. What Are The 4 Stages of Treatment? ý Evaluation ý Education ý Medication ý Modification (of Behavior) ý Accommodation Restructuring the homeRestructuring the home Changes in schoolChanges in school Assistance in the communityAssistance in the community

31. Empirically Proven Treatments n Parent Education About ADHD n Psychopharmacology Stimulants (e.g., Ritalin, Adderall, etc.)Stimulants (e.g., Ritalin, Adderall, etc.) Noradrenergic Medications (e.g., Strattera)Noradrenergic Medications (e.g., Strattera) Tricyclic Anti-depressants (e.g., desipramine)Tricyclic Anti-depressants (e.g., desipramine) Anti-hypertensives (e.g., Catapres, Tenex)Anti-hypertensives (e.g., Catapres, Tenex) n Parent Training in Child Management Children (<11 yrs., 65-75% respond)Children (<11 yrs., 65-75% respond) Adolescents (25-30% show reliable change)Adolescents (25-30% show reliable change)

32. Empirically Proven Treatment (2) n Teacher Education About ADHD n Teacher Training in Classroom Behavior Management n Special Education Services (IDEA, 504) n Residential Treatment (5-8%) n Parent/Family Services (25+%) n Parent/Client Support Groups (CHADD, ADDA, Independents)

33. Experimental Treatments n Biofeedback (EMG or EEG) n Working Memory Training n Mindfulness Meditation Training n Omega 3/6 Food Supplements (fish oils)

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

35. What Roles Can Parents Play? n The Scientific Parent Read widelyRead widely Experiment with management methodsExperiment with management methods Be a skepticBe a skeptic n The Executive Parent Take charge; become an advocateTake charge; become an advocate n 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 renewalBe 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

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

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