05/11/2018 What is ADHD? (DSM-V) ADHD and Common Issues A. - - PDF document

05/11/2018 1 ADHD and Common Issues Across the Life-Span

Sophie Godbout-Beaulieu, R.Psych Leslie MacIntyre, R.Psych Harpreet Aulakh, R.Psych

What is ADHD? (DSM-V)

• A. Persistent pattern of inattention and/or

hyperactivity-impulsivity that interferes with functioning or development, as characterized by symptoms of Inattention (1) and/or (2) Hyperactivity/Impulsivity.

• B. Several inattentive or hyperactive-impulsive symptoms were

present prior to age 12 years.

• C. Several inattentive or hyperactive-impulsive symptoms are

present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

• D. There is clear evidence that the symptoms interfere with, or

reduce the quality of, social, academic, or occupational functioning.

(1) Inattention

 Often fails to give close attention to details or makes careless mistakes  Often has difficulty sustaining attention in tasks or play activities  Often does not seem to listen when spoken to directly  Often does not follow through on instructions and fails to finish tasks  Often has difficulty organizing tasks and activities  Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort  Often loses things necessary for tasks or activities  Is often easily distracted by extraneous stimuli  Is often forgetful in daily activities

(2) Hyperactivity/Impulsivity

 Often fidgets with or taps hands or feet or squirms in seat  Often leaves seat in situations when remaining seated is expected  Often runs about or climbs in situations where it is inappropriate (teens/adults = restless feeling)  Often unable to play or engage in leisure activities quietly  Is often “on the go,” acting as if “driven by a motor”  Often talks excessively.  Often blurts out an answer before a question has been completed  Often has difficulty waiting his or her turn  Often interrupts or intrudes on others

ADHD In Children

Screen Time Messy Rushing through schoolwork Losing mittens, water bottles, hats Refusal/non compliance Avoids homework Rushing Wanting immediate rewards Anxiety Disorder Mood Disorders (e.g, Depression) ADHD Interrupts the teacher Learning and/or Intellectual Disability Family Dynamics Relationship Issues Easily Frustrated Difficult to toilet train Scraped knees, random bruises Difficulty making and keeping friends Conduct/Oppositional Defiant Disorder Climbing on everything “Immature” Neurodevelopmenta l Disorders (e.g., ASD, Tourette's) Attachment Disorder Trauma Argumentative Delays in executive functioning Forgets to brush teeth

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Mary (10 years)

Mary has a school project due tomorrow morning. She is realizing that she has not yet started working on it and does not know where to start. Her parents

• ften find it necessary to sit down with her to help her complete her

homework, otherwise, she tends to be overwhelmed with the amount needing to be done. They are getting frustrated because they feel like they have to hold her by the hand to complete every little step…even reminding her to bring her cleats along for soccer practice. Every. Single. Time. At school, it often takes Mary longer than most of her classmates to finish her work. She is easily distracted (“Oh! Liam sneezed…I hope I don’t get sick! My nose is runny too. I need to use the bathroom. I hope my friend Kennedy will be there too this time! Oh I can’t go someone already took the pass. Now what was I doing again?”) and often forgets to bring the right material along. Mary is becoming more and more aware of her differences and she is starting to worry about being able to keep up with the others. Recently, she’s been having a hard time falling asleep, often crying and thinking “What’s wrong with me? I’m stupid.”

Marco (10 years)

Marco loooooooves Fortnite. He spends hours upon hours watching Ninja (the famous player), learning the right moves, and of course, practicing his dance moves. When his parents suddenly tell him that it is supper time and that he needs to stop playing, a meltdown is also usually on the evening’s

• menu. It is so hard for Marco to stop playing, let alone with

such little warning (in fact, he didn’t really hear the other 5 reminders). At school, Marco is the class clown. He gets along well with his classmates, but will sometime say hurtful comments without realizing the impact on his friends. He then feels guilty about it all. His teacher constantly has to remind Marco to sit still, be quiet, and to just please listen for more than 60

• seconds. His favourite subject is gym – finally, a time where

he doesn’t have to sit still!

Common presentation in childhood

• Caregivers typically start noticing differences when

children are between 3-4 years.

Preschool School-aged

• verly active
• mischievous
• non-compliant with parents’

requests

• difficult to toilet train
• possible delays in school

readiness

• difficulty sustaining

attention and effort

• impulsivity
• restlessness
• non-compliance
• poor school performance
• learning disorders in a

significant minority of children with ADHD

• Tend to have lower ratings on

hyperactivity, inattention, impulsivity, and externalizing ( = “acting-out”) problems

• Greater intellectual impairments
• More internalizing (ex: depression, anxiety)

problems

• Relational aggression than non ADHD peers
• Studies find a real difference in severity

and presentation between genders

• May be more subtle and less evident by

adults observers; referral bias.

Contributing factors to symptom presentation

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• Reliable and valid diagnosis can

be made for children as young as 3.5 years.

• Developmental history, parents’

interview, teachers’ interview, rating scales, and psychoeducational testing.

• eToolKit Form by Canadian ADHD

Resource Alliance (CADDRA).

ADHD in Teens

Screen Time “Lazy” Messy Not doing/finishing chores and/or homework Losing phone, keys, books, assignments, etc. Arguing/Fighting Refusal/non compliance Procrastinating/ Avoiding Rushing Consequences/rewards don’t seem to help Anxiety Disorder Mood Disorders (e.g., Bipolar, Depression) ADHD Substance Use “Unmotivated” Learning and/or Intellectual Disability Family Dynamics Relationship Issues Easily Frustrated Failing/dropping out Injured often Difficulty making and keeping friends Conduct/Oppositional Defiant Disorder Contact with the law Late “Irresponsible” Neurodevelopmenta l Disorders (e.g., ASD, Tourette's) Attachment Disorder Psychotic Disorder Trauma

Mary (16 years)

It’s a school morning. Mary’s parents wake her up. She says good morning and then and stays in bed day dreaming. Her parents call her a few more times before she realizes she is late and gets up. She begins to rush

• around. She loses track of time in the bathroom thinking about the new

make up she wants to buy and worrying about the project she did last minute that is due today. She can’t find a brush so she uses her fingers. She can’t find a clean shirt or her socks because all her clothes are on the floor, so she wears the first things she sees. Her parents call up to remind her to take her dishes from her room to the kitchen (which she didn’t do yesterday). She gets a text message on her way to the

• kitchen. She is afraid she will forget what she wants to tell her friend or

even to reply so she does it right away. Her friends have been mad at her for “ignoring” them in the past. Her parents get frustrated when they see her on her phone (“You don’t have time to talk to your friends. You are always late. You need to get moving!”). Mary feels sad because she knows she is always late “no matter what she does”. She ends up leaving the dishes in the living room. She begins to worry about being late again for school and getting in trouble. In her rush to leave, she walks out of the house without her lunch, homework or glasses/contacts.

Mary (16 years)

At school, the classroom is loud and there are many conversations going on. She can’t find a pen and realizes that she has the wrong binder (this is math, not geography). She has trouble listening to the teacher because the student behind her is coughing, moving around, and talking to their neighbour. She then starts talking to her friend. The teacher moves her to another seat. Her classmates tease her. She feels embarrassed and ashamed. She begins to day dream. Her day dreams are interrupted by the bell at the end of the lesson. She does not remember what the topic of the class was that day. She arrives at her next class only to realize she has a test that day and the assignment she forgot at home (which she rushed to finish) is due next

• week. She has thoughts such as “I’m going to fail”, “I’m a stupid screw

up”, “I can’t do anything right” and “Everyone else remembered there was a test. There is something wrong with me”.

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Marco (16 years)

The alarm goes off. Marco doesn’t get up. It took him 2 hours to fall asleep because his mind and body wouldn’t settle and he is very tired. His parents ask him to get up several times. He doesn’t, which leads to an argument. He finally gets up, showers and gets dressed. He loses track of time thinking about a wide range of things (e.g., friends, video games, the weekend). When he gets downstairs, his parents express frustration that he is wearing the same pants as yesterday, has no socks, and that his shirt is on inside out. They remind him he is late and he needs to get moving. He can’t find his backpack or his shoes. He gets frustrated and starts yelling at his parents and his younger

• sister. He blames them for moving his things, which is why he can’t

find them. When leaving the house, he worries about going to school because he might have a test or an assignment due which he has not remembered/done. This has happened many times before. He considers skipping school.

Marco (16 years)

He arrives at school late. He gets caught in the hallway after the bell and is told he needs to be more responsible. When he gets to class, he is restless in his chair and has a hard time staying seated. He interrupts the teacher with comments or jokes. He gets in trouble again. He gets a sinking feeling in his stomach when he learns that he did have an assignment due today and that he will get a zero (“I should have skipped”). The teacher holds him back after class to let him know that he is failing. He feels shame, and begins arguing with his teacher. He stops listening when the teacher says he needs to try harder (e.g., go for extra help, stay late to finish things, listen more and not talk to his friends in class) and walks out. He begins to think “It doesn’t matter what I do I mess up so why bother”. Someone in the hall calls him “a stupid loser” and he punches them. He is given a detention. He is very angry so instead of going to detention he goes and gets high with his friends at the skate park. While there, he build a huge jump from things he finds at the park and ends up at the hospital with a broken arm.

Gender Differences: Girls

 Tend to be diagnosed later  After preschool age, girls tend to exhibit inattentive symptoms  More subtle presentations  More verbally impulsive  More at risk for also developing internalizing mental health struggles (e.g., anxiety, depression, eating disorders, etc.).

 Worry  Saying or doing things impulsively that receive negative feedback from peers.  Making mistakes, forgetting things, missing deadlines  Getting in trouble  Depression  Negative view of self (“I’m stupid”, “I’m bad”, “Something is wrong with me”)  Feeling helpless and hopeless (“There is no point”)  Substance Use  Begin to experiment with substances to cope  Impulsive/risk taking

 Conduct Problems

 Poor compliance/defiant  hostile  Possible contact with the law

 Learning Issues

 Miss information and then fall behind  Fail/ or drop out

 Also known to co-occur with:

 OCD  Tic Disorder  ASD

ADHD and Developmental Milestones

 Social Milestones  Youth with ADHD often have Social issues that have a significant impact their view of themselves, the work and their relationships (e.g., reputation as a “bad kid”, difficulty maintaining friends, conflictual relationships with caregivers and educators).  Autonomy  ADHD can interrupt the growing autonomy youth work towards across adolescence.  Development of Identity  Together , struggles with relationships and autonomy can have a significant impact on identity development.  Youth often begin to internalize things like such as “I’m lazy”, “I’m stupid”, “I can’t do anything right”, “I’m not good enough”, “It doesn’t matter what I do I always make mistakes, fail, etc.”

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 Interviews (parents, teens, and teachers)  Developmental and academic history  Review of cumulative report card  Completion of Rating Scales (parents, teens and teachers)

 Connors (attention and behavior problems) - normed  Behaviour Assessment Scale for Children (BASC)

 Psychoeducational Assessment**

ADHD in Adults

Experiences of childhood w/ADHD

Early negative experiences with family, peers, school, Comorbid mental health conditions

Experiences of adolescence w/ADHD

On-going issues with family, peers, school, work Social milestones, autonomy, identity development Comorbid mental health conditions

ADHD

Adult ADHD + Myriad of Significant

and Enduring Issues

Issues in jobs or career – losing or quitting jobs, underperforming Losing phone, keys, wallet, phone, documents, bills Poor organizational skills Procrastinating Forgetting important things Frequent interrupting, blurting, socially inappropriate Anxiety Disorder Mood Disorders (e.g., Bipolar, Depression) ADHD Substance Use Disorders Poor self-control, addictive tendencies Learning and/or Intellectual Disability Family Dynamics Relationship Issues Irritable, upset, blows up Difficulties completing day to day responsibilities Marital/relational issues, likelihood of divorce Maladaptive personality traits Legal issues, parking tickets, speeding fines, fender benders Poor time management/ chronic running late Neurodevelopmenta l Disorders (e.g., ASD, Tourette's) Psychotic Disorder Trauma

SYMPTOM DIMENSION CHILD ADULT

Hyperactivity

Running, climbing, jumping Fidgeting Out of seat Excessive talking Driving at high speed Difficulty waiting in line Can’t relax Restlessness Excessive talking Impatience

Inattention

Daydreaming Seems not to listen Careless mistakes Works slowly Poor reading comprehension Incomplete assignments Procrastination Late/missed appointments Careless mistakes Disorganization Forgetfulness Losing things (e.g keys, glasses Driving accidents and Citations

Impulsivity

Does not wait turn Interrupts others Blurts out answers Does not follow directions Temper outbursts Verbal impulsivity Quits jobs Starts multiple projects Promiscuity Temper outbursts Impulsive spending

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ADHD in Adulthood

 Over 60% of children with ADHD become adults with ADHD  4% prevalence rate in adult population  Adults with ADHD are at risk for a range of negative

• utcomes.

 Compared to their non-ADHD counterparts, adults with ADHD tend to:  make significantly less income  experience higher stress levels than a non-ADHD adult with similar levels of education  have lower ranking occupations  have greater emotional and social problems  have higher divorce rates and more unstable relationships  have a less positive self-image  Increased risk of being in trouble with the law  Poor physical and mental health  Experience parenting challenges with their children

Mary (36 years)

Mary is feeling stressed as she is drives to work because she is running late again. She has been late for work a lot and she knows that her boss has been monitoring her more closely. She is trying to take short cuts and speed, but she is also worried that she’ll get yet another ticket. On the drive, her son calls and he is upset because she forgot to sign a form for school for a fieldtrip. Mary now also feels guilty about letting her son down, but she ends up coming across as short and angry with her son because she is feeling overwhelmed. At work, Mary finds that instead of working on the big project, she is surfing the internet. Her mind is racing with some of the concerns that she is struggling with in her life. Mary is thinking about her boss and her perceived underachievement. She also feels that she is neglecting her

• children. Finally, she is thinking about all the things that she needs to get

done, but feels unable to get to. At the end of the work day Mary feels further behind on the work project. When she get home, she realizes that she forgot to email the teacher and she feels exhausted and defeated.

Marco (36 years)

Marco is unemployed again and he fears that if he does not get a job soon, he may have to declare bankruptcy. Over the years he has worked many jobs, and he has struggled to build a career despite being intelligent and capable. Marco has also struggled in some of his close relationships. He is in his second marriage and he is finding that his wife is constantly voicing frustration with him because he has ‘dropped the ball’. This results in him blowing up and getting

• angry. He knows that this is not helping the relationship,

however, he can’t seem to help himself. Over the years, Marco’s self-confidence has waned and he has struggled with symptoms of depression. Marco is has also gotten into the habit of drinking between 6 to 9 beer multiple nights a week to ‘relax’.

Gender Differences: Women

 Tend to be diagnosed later, or they don’t tend to be diagnosed  More at risk for also developing internalizing mental health struggles (e.g., anxiety, depression, eating disorders, etc.) and poor self –esteem  ADHD is more likely to manifest without being clearly identified and secondary conditions tend to be the focus

• f interventions

 Obtain data from one or more independent sources, usually a significant other (spouse, family member, parent or partner) who knows the person well.  Commonly a comprehensive evaluation can include one or more standardized behavior rating scales. These questionnaires use research comparing behaviors of people with ADHD to those of people without ADHD.

• Diagnostic interview(s) which include the

following:

• Assess for ADHD symptoms
• Screen for other potential conditions that

may mimic ADHD

• Screen for co-morbid conditions**
• Consider familial history of certain key

mental health issues

• Gather comprehensive historic

information (prior to age 12) to assess whether symptoms were present in childhood and/or teens without remission

Adult ADHD and Cormorbid Conditions

 Common for adults with ADHD to have co-occurring psychiatric disorders. For example:

 Anxiety 47%  Mood Disorder 38%  Impulse Control Behaviors 20%  Substance Use Disorder 15%

 Adults more likely that children to have anxiety disorders, substance use and personality disorders  Adults with ADHD and comorbidities are likely to seek treatment because of problems associated with a co-occurring disorder, NOT because of ADHD symptoms

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Obsessive Compulsive Disorder Tic Disorders Autism Spectrum

Strong Supports at EVERY Level Medication

 Research supports this as the first line treatment for management of symptoms of ADHD.  Consultation with a family doctor or psychiatrist is recommended to determine if this option is a good fit for an individual.

Behavioural Interventions

Developing clear consistent rules, expectations, routines and consequences.  Breaking tasks down into manageable pieces  Chunking information  Reminders (alarms, visuals)  Extended deadlines where appropriate  Reduced workload where appropriate  Quiet work spaces

Behavioural Resources

 Children  Incredible Years (book or free program in HRM)  Strongest Families program (IWK)  Russell Barkley – books, ted talks (lifespan)  Teens  Apply same principals as in childhood  Russell Barkely resources  Relationship is the context in which all else occurs  **Building a strong relationship – special time  Increased positive reinforcement (10:1)

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Behavioural Resources

Adults  Books

 Taking Charge of Adult ADHD. Russell A. Barkley, Ph.D., and Christine M. Benton.  You Mean I’m Not Lazy, Stupid or Crazy?! The Classic Self- Help Book for Adults with Book: Attention Deficit Hyperactivity Disorder. Kate Jelly and Peggy Ramundo.  Driven to Distraction. Recognizing and Coping with Attention Deficit Disorder from Childhood through

• Adulthood. Edward M. Hallowell, M.D., and John J. Ratey,

M.D.

 Website:

 Totallyadd.com

Mindfulness

 Growing evidence base for Mindfulness as being quite helpful in learning to better manage attention.  Learning to focus attention on something in the present moment, with intention in a kind, compassionate non- judgmental way.  Apps: Calm, Headspace, Smiling Mind, Sitting Still, Mindshift  Books: John Kabat-Zinn, Sitting Still Like A Frog

Supports for Co-occurring Struggles

 Cognitive Behaviour Therapy (CBT) is the gold standard treatment and/or prevention of a wide range of struggles including: anxiety, mood and substance use disorders.

 Anxiety BC Webiste

 Acceptance and Commitment Therapy (ACT) is a mindfulness based approach which is also growing in its treatment efficacy across a wide range of struggles.  Family Therapy  Individual Parenting Support  IPP’s or Accommodations at school or work