Introduction to ADHD Its Impact and Practical Strategies to Help

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Introduction to ADHD Its Impact and Practical
Strategies to Help

• Angel Adams, PhD
• Chartered Clinical Psychologist
• www.prosocial.co.uk

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DEFINITIONA neurodevelopmental disorder that
is genetically transmitted and mediated by
decreased brain dopaminergic functioning. Its
main features are impairments in self-regulation
and attention due to executive functioning
deficits localized in the frontal lobes of the
brain. It is a biopsychosocial condition that
can be potentially life-threatening and least of
all causes debilitating impairment in several
areas of life. It usually comes with
co-morbidity and persists into adulthood.

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WHAT IS ADHD?

• A disorder of age-inappropriate symptoms in
• Inattention
• Poor persistence of responding
• Impaired resistance to distraction,
• Deficient task re-engagement following disruption
• Hyperactivity-Impulsivity (Disinhibition)
• Impaired motor inhibition,
• Poor sustained inhibition
• Excessive and often task-irrelevant motor and
  verbal behavior
• Restlessness decreases with age, becoming more
  internal, subjective by adulthood
• Most cases are developmental disorders delays in
  the rate with which these two traits are maturing
• Some cases are acquired (20 mainly males)
• These may represent pathology and may differ in
  severity, recovery, possibly treatment response

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KNOW THE FACTS

• Education and knowledge about the disorder is
  more powerful than anything else you do. Teaching
  people about their disorder is crucial. Our
  studies show it actually changes more behaviour
  than the active treatment. It gives people
  (teachers, family members, employers) knowledge
  from which they can reframe their understanding
  of sufferers. That's a very powerful act. So much
  change takes place just from giving people
  accurate information.
• Russell A Barkley, PhD (Cape Cod Lecture Series,
  2001)

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Facts Myths about ADHD

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Facts Myths about ADHD

• MYTH ADHD is just a lack of willpower. Persons
  with ADHD focus well on things that interest
  them therefore they could focus on any other
  tasks if they really wanted to.

FACT ADHD looks very much like a willpower
problem, but it isn't. It's essentially a
chemical problem in the management systems of
thefrontal lobe of the brain.
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Facts Myths about ADHD

• MYTH ADHD is just a lack of willpower. Persons
  with ADHD focus well on things that interest
  them therefore they could focus on any other
  tasks if they really wanted to.

FACT ADHD looks very much like a willpower
problem, but it isn't.It's essentially a
chemical problem in the management systems of
thefrontal lobe of the brain.
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Facts Myths about ADHD

• MYTH ADHD is a simple problem of being
  hyperactive or not listeningwhen someone is
  talking to you.

FACT ADHD is a complex disorder that involves
impairments in focus, organization, motivation,
inhibition emotional modulation, memory, and
otherfunctions of the brain's management system.
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Facts Myths about ADHD

• MYTH ADHD is just a lack of willpower. Persons
  with ADHD focus well on things that interest
  them therefore they could focus on any other
  tasks if they really wanted to.

FACT ADHD looks very much like a willpower
problem, but it isn't. It's essentially a
chemical problem in the management systems of
thefrontal lobe of the brain.
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Facts Myths about ADHD

• MYTH ADHD is a simple problem of being
  hyperactive or not listeningwhen someone is
  talking to you.

FACT ADHD is a complex disorder that involves
impairments in focus,organization, motivation,
inhibition emotional modulation, memory, and
otherfunctions of the brain's management system.
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Facts Myths about ADHD

• MYTH Brains of persons with ADHD are
  overactive and need medicationto calm down.

FACT Underactivity of the brain's management
networks is typical of persons with ADHD.
Effective medications improve communication in
the brain's management system (e.g. increase
alertness, decrease impulsivity)
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Facts Myths about ADHD

• MYTH ADHD is simply a label for behavior
  problems such as defiance, and refusal to tow the
  line.

FACT Many with ADHD have few behaviour problems.
Chronic inattention symptoms cause more severe
and longer-lasting problems for learning and
relationships for those with adult ADHD.
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Facts Myths about ADHD

• MYTH Those who have ADHD as children usually
  outgrow it as they entertheir teens.

FACT Often ADHD impairments are not noticeable
until the teen years, when more self-management
is required in school and elsewhere. ADHD may be
subtle, but more disabling during adolescence
than in childhood.Cognitive hyperactivity
remains and is an ongoing challenge to manage
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Facts Myths about ADHD

• MYTH Unless you have been diagnosed with ADHD
  as a child, you can'thave it as an adult.

FACT Many adults have struggled all their
lives with unrecognized ADHD impairments. They
haven't received help because they assumed that
their chronic difficulties, like depression or
anxiety, were caused by other impairments that
did not respond to the usual treatments
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Facts Myths about ADHD

• MYTH ADHD doesn't really cause much damage to a
  person's life.

FACT Untreated or inadequately treated ADHD
syndrome often severely impairs learning, family
life, education, work life, social interactions,
and driving safely. Most of those with ADHD who
receive adequate treatment, however, function
quite well.
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Facts Myths about ADHD

• MYTH They may appear to be irresponsible or
  downright lazy.

FACT People with ADHD often work harder than
their colleagues to keep up
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Facts Myths about ADHD

• MYTH Medications for ADHD are likely to cause
  longer-term problemswith substance abuse or
  other health concerns, especially when used
  bychildren.

FACT The risks of using appropriate medications
to treat ADHD areminimal, whereas the risks of
not using medication to treat ADHD
aresignificant. The medications used for ADHD
are among the bestresearched for any disorder.
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Psychostimulants

• Increased Concentration Persistence
• Decreased Impulsivity Hyperactivity
• Increased Work Productivity (Accuracy)
• Better Emotional Control
• Decreased Aggression Defiance/ODD/CD
• Improved Compliance Rule Following
• Better Working Memory Internalized Language
• Improved Handwriting Motor Coordination
• Improved Self-esteem
• Decreased Punishment from Others
• Improved Peer Acceptance Interactions
• Better Awareness of Game in Sports
• Improved Driving Performance

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Prevalence

• 3-10 school aged
• 67 of children with ADHD have symptoms that
  persist into adulthood. Cognitive hyperactivity
  remains and is an ongoing challenge to manage
• Intelligence or ethnicity
• Males and females..6 to 1
• Adults 11
• Wender regards ADHD as the most undiagnosed
  disorder of adult life.

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Prevalence

• 3-10 school aged
• 67 of children with ADHD have symptoms that
  persist into adulthood. Cognitive hyperactivity
  remains and is an ongoing challenge to manage
• Intelligence or ethnicity
• Males and females..6 to 1
• Adults 11
• Wender regards ADHD as the most undiagnosed
  disorder of adult life.

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Its a Universal Disorder
Germany
Ireland
Diagnostic criteria
Puerto Rico
New Zealand
DSM-IV
Canada
UK
DSM-III-R
Switzerland
DSM-III
Spain
USA
ICD-9
USA
USA Adults
Brazil
Netherlands
0
5
10
Prevalence
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IMPACT OF ADHD

• Teens with ADHD are more likely to
• experience teen pregnancy (40)
• contract sexually transmitted diseases(16),
• speed excessively
• have multiple car accidents
• experience depression (2030)
• engage in antisocial activities (4050),
• use tobacco or illicit drugs more (60-70)

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IMPACT OF ADHD

• Sufferers are far more likely than normals to
• Dropout of school (3240),
• Low rates of college completion (510) (Whitman,
  2000)
• When completing college, earn less money
• More grade retention (25-45 MKE 42 vs. 13)
• Pagani et al. (2001) showed that retention is
  harmful
• More placed in special educational (25-50)
• More are suspended (40-60 MKE 60 vs. 19)
• Reflects disciplinary action more associated
  with CD
• Greater expulsion rate (10-18 MKE 14 vs. 6)
• Higher drop out rate (30-40 MKE 32 vs 0)
• Lower Class Ranking (MKE 66 vs. 53)
• Lower GPA (MKE 1.8 vs. 2.4)
• Fewer enter college (MKE 22 vs. 77)
• Lower college graduation rate (5-10 vs. 35)

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IMPACT OF ADHD

• Lower rates of professional employment
• Underperformers at work (7080)
• More likely to be sacked
• 55 vs. 23 had been sacked
• 16 vs. 6 of jobs held
• Have conflict with managers
• Miss promotions
• Have stalled careers
• Mismanage and endanger their lives

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EMPLOYMENT PROBLEMS

• Enter workforce at unskilled/semi-skilled level
• Greater unemployment at age 21 (22 vs. 7)
• Change jobs more often
• 2.6 vs. 1.4 over 2-8 years since leaving high
  school
• More ADHD/ODD symptoms on the job
• As rated by current supervisors
• Lower work performance ratings
• As reported by current supervisors
• Greater use of sick days health insurance
  claims
• Lower social class status
• By 30s, 35 self-employed (NY Study)

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Inheritability Index .80

• Genes aren't destiny. Genes play a substantial
  role, but they may be triggered
• Environmental stressors in the development of the
  disorder

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GENETIC LOADING

• The most common co-existing disorders in ADHD in
  adulthood
• depression
• anxiety
• substance abuse
• specific learning difficulties
• -- also have a strong genetic component.

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Need to bridge the gap

• Assessment and treatment of ADHD discontinue
  services for adults
• Not understood as a life span disorder

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ADULT SYMPTOMATOLGY

• Low tolerance to stress
• Hot temper
• Mood lability
• Organisational deficits
• Impulsive/inhibition

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EXECUTIVE FUNCTIONING

• Neuroimaging studies show structural and
  functional abnormalities in the frontal lobe
  regions of the brain

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EXECUTIVE FUNCTIONING

• This is the part of the brain that is in charge
  of self-control. The prefrontal lobe is
  chronically under-aroused, and so the ability to
  monitor behaviour is impaired.

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THE CEO

• Planning
• Working memory
• Impulse control
• Inhibition
• Mental flexibility
• Initiation and monitoring of action
• Motivation
• Internalisation of speech

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The Problem is not the skill

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
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Time Management

• Chronic Lateness
• Not prepared
• Procrastination
• Difficulty with Prioritising
• Poor work habits
• Poor follow through
• Trouble Meeting Deadlines

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Disorganisation

• Waste hours on a minor task
• Get distracted by the slightest interruption
• Papers may not get filed
• Office is messy
• Attention span fluctuates

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INTERFERENCE CONTROL REISITANCE TO DISTRACTION

• Need to protect oneself from being disrupted by
  environment
• Tend to have distractions that hurt them when
  there requires thoughtful, planful future
  directed behaviour

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MOTIVATION DEFICIT

• Impersistent
• Needs immediate rewards
• Get bored easily
• High need for stimulation
• Premack principle

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Cognitive Obstacles

• Difficulty setting priorities
• (often take on more than they can handle), spend
  hours on the wrong things
• It takes them longer to do tasks
• Often dont work to their potential

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Problems at the Workplace

• Mixed presentation (Sometimes do brilliant and
  amazing creative things, but other times they're
  just out to lunch)
• Everything seems to come harder for them.
• They're like ducks, appearing to swim
  effortlessly, but furiously paddling under the
  surface.

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Strategies

• Adults with ADHD frequently excel in the
  workplace, once they adapt to their disability,
  use evidence based strategies and develop their
  coping skills
• Entrepreneurs, entertainers, athletes,
  politicians, and business leaders have ADHD (CEO
  of JetBlue, David Neeleman)

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Strategies

• The importance of self-awareness, support
  systems, organized ideas and information, as well
  as identification of the characteristics of
  ADHD-friendly occupations and work places
• Tailor workplace environment (to advantage of
  strong points) while minimizing the negative
  impact of deficits. Knowing how to delegate is a
  valuable but often overlooked skill.

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Strategies for Time Management

• Arrive early to work, when it is quiet, can help
  focus and get work done.
• May need to take work in an empty office or
  conference room, or quiet cubicle.
• Don't answer phone, let voicemail take messages,
  and return calls later at a set time.
• To discourage interruptions, hang a "Do Not
  Disturb" sign on door.
• To minimize visual distractions, face desk toward
  a wall.

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Strategies for Minimising Distraction

• Deal with clutter
• Use "white noise" earphones, classical music or
  other sounds to drown out office noises.
• Jot down ideas in a notebook to avoid
  interruption of the current task.
• Keep a list of ideas that come during meetings so
  communication is more effective.
• Perform one task at a time.

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Speeding Up Neurotransmitters
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Strategies for Internal Distractions

• "Ah-ha!" distractions
• "Oh no!" distractions
• "Ho-hum" distractions

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Strategies toExternalise Time

• If tendency to day dream or hyper focusthen
  "cue" with externalizing time
• Post-it notes
• A watch alarm
• Pop-ups on computer screen, beepers,
• Anything to make time external

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Strategies toExternalise Time
All treatments are at the point-of-performance Me
dications may be essential Behavioral treatment
is essential but does not generalize or endure
after removal Reverse engineer the
EFs Externalize important information (make
lists, posters, signs, etc.) Externalize time
periods related to tasks (use timers) Break up
future tasks into many small ones (do 1
daily) Externalize sources of motivation
(rewards) Permit more external manipulation of
task information (manualize it) The compassion
and willingness of others to make accommodations
are vital to success A disability perspective is
most useful
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Strategies for restlessness

• Take every appropriate opportunity to move
  around at work.
• Take a break every hour
• Calisthenics
• Stroll through the halls in garden
• Fidget to focus

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Strategies for impulsivity

• Learn self-talk strategies to monitor impulsive
  actions.
• Work with a coach to role-play appropriate
  responses to frustrating situations.
• Ask for regular, constructive feedback as a way
  of becoming more aware of how impulsivity might
  manifest
• Practice relaxation and meditation techniques
• Anticipate the problems that regularly trigger
  impulsive reactions and develop routines for
  coping with these situations.

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Strategies to improve memory

• Use a tape recording device or take copious notes
  at meetings.
• Write checklists for complicated tasks.
• Use a bulletin board or computer reminder list
  for announcements and other memory triggers.
• Use a day planner to keep at all times to keep
  track of tasks and events.

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Strategies to Prevent Boredom

• Set a timer to stay on task
• Break up long tasks into shorter ones
• Take breaks
• Need stimulating responsibilities
• and minimal routine tasks

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TO TELL OR NOT TO TELL
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USING THE DISABILITYAS AN EXCUSE?
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While it creates a diminished capacity Does
this excuse accountability? (No!, the problem
is time not consequences)
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TREATMENT

• Coaching
• CBT
• Medication
• Support groups
• Family therapy
• Anger management and stress management   
• Learning better self-care