Attention Deficit/Hyperactive Disorder

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Attention Deficit/Hyperactive Disorder

• David Lombard, Ph.D.
• Center for Applied Behavioral Studies
• www.LegalShrink.com

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Overview

• What Is AD/HD
• What Causes AD/HD
• How Common
• Common Symptoms
• Common Treatments
• Comparison with Conduct Disorder

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What is AD/HD?

• A medical condition characterized by inattention
  and/or hyperactivity-impulsivity.
• One of the most common mental disorders among
  children, affecting approximately 5 to 7 of
  school-age children and about 2-5 of adults

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What is AD/HD?

• Persistent inability to pay attention
• May have additional characteristics of
  hyperactive motor movements and/or impulsivity
• Usually begin before age 7 but may not be noticed
  until child is older

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What is AD/HD

• Symptoms of inattention and/or hyperactivity must
  be present in at least two environments
• Symptoms must cause problems for the individual
  in their environment

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What causes AD/HD?

• Decreased amount of certain neurotransmitters
• There may be a genetic association
• Appears more often in children whose parents
  suffer from AD/HD, alcohol dependence and/or mood
  disorders

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Prevalence in the US

• About 2 million children
• About 5 million adults

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Prevalence World-Wide

• Australia 3.4 of kids New Zealand 6.7
  kids, 2-3 teens Germany 4.2 children
  India 5-29 children China 6-9 children
  Netherlands 1.3 teens Puerto Rico 9.5
  child teens Japan 7.7 children
  Mexico approx. 5 childrenBrazil 5.8 of
  12-14 year olds

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How common is AD/HD?

• More common in males than females with studies
  showing a ratio of between 31 and 41
• As many as 5 out of every 100 children may have
  AD/HD

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What are the signs of AD/HD?

• Three main symptoms (signs)
• Problems paying attention
• Being very active (hyperactivity)
• Acting before thinking (impulsivity)

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Three Types of ADHD

• 1. ADHD, predominantly inattentive type
• 2. ADHD, predominantly hyperactive-impulsive
  type
• 3. ADHD, combined type
• ADHD, NOS is a category for people who have some
  ADHD symptoms, but not enough to meet full
  criteria for the condition.

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DSM-IV Criteria

• Inattentive type (6 of 9 needed)
• Fails to give close attention to details
• Difficulty sustaining attention
• Does not seem to listen
• Does not follow through on instructions
• Difficulty organizing tasks or activities
• Avoids tasks requiring sustained mental effort
• Loses things necessary for tasks
• Easily distracted
• Forgetful in daily activities

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DSM-IV Criteria

• Hyperactive-impulsive type (6 of 9 needed)
• Fidgets with hands or feet or squirms in seat
• Leaves seat in classroom inappropriately
• Runs about or climbs excessively
• Has difficulty playing quietly
• Is on the go or driven by a motor
• Talks excessively
• Blurts out answers before questions are completed
• Has difficulty awaiting turn
• Interrupts or intrudes on others

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DSM-IV Criteria

• Combined type
• Symptoms of both types described
• At times all children are inattentive, impulsive
  and too active
• With children with AD/HD these behaviors are the
  rule not the exception

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DSM-IV Criteria

• Developmentally Inappropriate Levels
• Duration of 6 Months
• Cross-setting Occurrence of Symptoms
• Impairment in Major Life Activities
• Onset of Symptoms/Impairment by 7
• Exclusions Severe MR, PDD, Psychosis
• Subtyping into Inattentive, Hyperactive, or
  Combined Types

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ADHD is Not

• Will power
• Inadequate parenting
• Lack of motivation
• Lack of intelligence
• Laziness

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What are long-term effects?

• Without effective treatment AD/HD can result in
  serious problems
• Academic failure
• Relationships
• Legal difficulties
• Smoking and SUD
• Injuries
• Motor vehicle accidents
• Occupational/vocational

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ADHD Treatments

• Education
• Medication
• Behavior Modification
• Classroom/Workplace Accommodations

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Commonly Used Stimulant Medications for ADHD

• Methylphenidate (MPH) Products
• Ritalin short mid-acting formsConcerta long
  -acting Metadate CD mid-acting Ritalin
  LA mid-actingFocalin mid-acting
• Short acting 3-5 hours Mid-acting 6-8 hours
  
• Long acting 12 hours

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Commonly Used Stimulant Medications for ADHD

• Amphetamine Products
• Adderall mid-acting
• Adderall XR long-acting
• Dexedrine mid-acting
• Dextrostat mid-acting
• Short acting 3-5 hours Mid-acting 6-8 hours
  
• Long acting 12 hours

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Commonly Used Non-Stimulant Medications for ADHD

• Nonstimulant Products Strattera long-acting
• Other Nonstimulant Products Wellbutrin
  long-acting Tenex mid-acting Clonidine mid-
  acting
• Short acting 3-5 hours Mid-acting 6-8 hours
  
• Long acting 12 hours

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What are side effects of treatment?

• Headache
• Involuntary muscle movements
• Loss of appetite
• Mood changes as medication wears off
• Sleep difficulty
• Weight management problems

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Conduct Disorder
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Conduct Disorder

• The term conduct disorder has traditionally been
  used to characterize children who display a broad
  range of behaviors that bring them into conflict
  with their environment.
• These include behaviors that are probably best
  described as coercive or oppositional
• temper tantrums,
• defiance,
• noncompliance

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Conduct Disorder

• Also included under this general heading have
  been behaviors of a more serious nature (e.g.,
  cruelty to people or animals, aggressiveness,
  stealing) .
• These are more serious in that they
• represent a greater threat to those the child
  interacts with and/or
• have the potential of bringing the child into
  contact with the juvenile justice system

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Types of Conduct Disorders

• DSM IV features usually associated with the
  general label of conduct disorder are subdivided
  in order to provide for the diagnosis of two
  specific patterns of behavior
• Oppositional Defiant Disorder (ODD)
• Conduct Disorder (CD)

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Conduct Disorder

• Symptoms
• Bullies, threatens or intimidates others
• Often initiates physical fights
• Has used a weapon that could cause serious
  physical harm to others (e.g. a bat, brick,
  broken bottle, knife or gun)

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Conduct Disorder

• Symptoms
• Is physically cruel to people or animals
• Steals from a victim while confronting them
• (e.g. assault)
• Forces someone into sexual activity

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Conduct Disorder

• Symptoms
• Deliberately engaged in fire setting with the
  intention to cause damage
• Deliberately destroys other's property

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Conduct Disorder

• Symptoms
• Broken into someone else's building, house, or
  car
• Lies to obtain goods, or favors or to avoid
  obligations
• Steals items without confronting a victim (e.g.
  shoplifting, but without breaking and entering)

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Conduct Disorder

• Symptoms
• Often stays out at night despite parental
  objections
• Runs away from home
• Often truant from school

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Co-Morbidity

• As with ADHD, children with Conduct Disorders
  frequently display other types of problems
• Between 34.7 and 48 of children and adolescents
  with CD also show evidence of ADHD.
• Co-morbidity estimates ranging from 12 to 17.6
  have been found for depressive disorders.
• As many as 19 of children/adolescents with CD
  qualify for a diagnosis of anxiety disorder.

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Break Time
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Cutting and Self-Mutilation

• David Lombard, Ph.D.
• Center for Applied Behavioral Studies
• www.LegalShrink.com

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Overview

• What is Cutting and Self-Mutilation
• Theories of Why People Cut
• Is it Suicide, a Cry for Help, or Coping
• How is it Treated
• What to Ask to Assess Risk
• What are Your Options for Intervention

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What do they have in common?

• Angelina Jolie
• Christina Ricci
• Courtney Love
• Princess Diana

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How Common?

• 12 to 14 of adolescents reported self-injury
  behavior
• 40 to 61 in adolescent inpatient settings
• Higher proportion of females (64) than males
  (36)
• 750 per 100,000- general population
• Typical onset-puberty
• Persist for five to ten years or longer

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The Cutting Culture

• Websites-Blood Red
• -Razor Blade Kisses
• -The Cutting World
• Films- Thirteen
• Genre of music- emo

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Examples of Cutting
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Examples of Cutting
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Examples of Cutting
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Examples of Cutting
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What is Cutting

• Purposeful use of Sharp Objects for Goal of
  Cutting Skin and Seeing Blood
• Cutting Tools
• Knives, Razors, Needles, Cut Glass, Fingernail,
  Surgical Blades, Paper

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What is Cutting

• Most Commonly Arms, Shoulders Thighs
• More Advanced Hips Below Belt Line (hidden and
  felt more when walking), Top of Feet, Underarms,
  Lower Buttock
• More Dangerous Inside of Mouth, Private Areas,
  Pre-Existing Surgical Scars

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What is Self-Mutilation

• Often Seen the Same as Cutting
• Much Worse in Severity/Scope of Damage
• Destruction of Large Sections of Tissue Through
  Cutting, Tearing, Biting, or Repetitive
  Puncturing
• Always Hospitalize

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I cut.

• 'to run away from my feelings'
• 'to feel pain on the outside instead of the
  inside'
• 'to cope with my feelings'
• 'to express my anger toward myself'
• 'to feel like I'm real'
• 'to turn off emotions and hide from reality'
• 'to tell people that I need help'
• 'to get people's attention'

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I cut.

• 'to tell people I need to be in hospital'
• 'to get people to care about me'
• 'to make other people feel guilty'
• 'to drive people away'
• 'to get away from stress and responsibility'
• 'to manipulate situations or people'

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Theories of Why People Cut

• To Feel
• Due to Abuse, Neglect, or Other Significant Life
  Trauma the Person Cannot Feel
• In Sad Situations, They Want to Feel SomethingSo
  Cut.
• Allows Them to Feel Physical Pain When They Have
  No Emotional Pain

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Theories of Why People Cut

• Distraction
• Due to Overwhelming Emotional Pain or Problems
  Dealing with Emotional Pain
• Allows the Shift in Focus From Emotional Pain to
  Physical Pain
• Easier to Understand and Deal With

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Theories of Why People Cut

• Punishment
• Person Has Failed at Something, Hurt Someone, Or
  Displeased Themselves
• A Way to PunishClearly DefinedClearly Punitive
• In These Cases, Severity of Cutting Increases to
  Mutilation Frequently

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Theories of Why People Cut

• Physical Reaction
• Person Discovers Cutting and Tries It
• They Feel the Emotional and Physical Rush
• Natural Pain Killers and Pleasure

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Theories of Why People Cut

• Physical Reaction
• Want the Same Feeling Again
• These Individuals are Likely to Engage in Cutting
  Out of Boredom

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Theories of Why People Cut

• Control
• A strong Sense Of Helplessness
• Learned Helplessness
• Cutting Self is Completely in Their Control

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Theories of Why People Cut

• Control
• More Frequent in Homes of Lives with Rigid Rules
• These People Less Likely to Use Drugs

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Theories of Why People Cut

• Addiction to Cutting
• Emotional Release is Very Reinforcing
• Physical Release has Bio-Chemical Properties
• Under Control of Cutter

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Theories of Why People Cut

• Addiction to Cutting
• Easy Access, Low Cost, Immediate Reaction
• These Individuals Tend to Be More Impulsive
• At Higher Risk for Substance Abuse

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Suicide, Cry For Help, or Coping?

• Suicides Attempts Include Intent to Die
• Most Cutters Do Not
• Cry For Help
• Possibly if Cuts Are Visible
• However, Some Wear Cuts as A Badge

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Suicide, Cry For Help, or Coping?

• Coping Strategy
• Most Likely Reason
• Cutting Makes Sense to Them to Deal with Life

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How Is It Treated

• Proper Diagnosis
• Depression, Anxiety, Abuse, Addiction,
  Personality Disorder, Thought Disorder
• Focus on Cutting as A Behavior
• Medication to Treat Any Underlying Disorders

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How Is It Treated

• Psychotherapy to Alter Behavior and Reinforcement
• Find Other Coping Strategies

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What to Ask

• Basic QuestionsKeep it Easy
• Can Easily Become Defensive
• Fear of Being Labeled Mentally Sick
• Can Easily Become Aggressive

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What to Ask

• Where
• Where have they cut on themselves
• Where are they when they cut
• What
• What do they use
• What do they do afterwards

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What to Ask

• When
• When alone or with others (usually alone)
• When angry, sad, upset
• Why
• Harder questionmay not answer
• Who
• Who knows they are cutting
• Can I talk to that person

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What to Do

• Based on Estimated Level of Severity
• Nothing
• Rarelyonly if person already getting help
• Speak to Significant Others
• To encourage family intervention and help

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What to Do

• Referral for Mental Health Services
• For evaluation and treatment planning
• Parkcenter, Parkview, Private Insurance
• Hospitalize
• If physical damage severe or mental Health
  Symptoms are severe