1 No universal agreed upon definition of how adhd is operationalized - - PDF document

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No universal agreed upon definition of how adhd is operationalized

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*variation in the research

• Differences between boys and girls is variable and complex. Mixed research findings.

Other issues surround neurobiological differences between M and F, as well as other environmental factors (sampling basis).

• 3:1 ratio is based upon clinical samples; contrast when looking at non-referred samples

the gender differences range from 1:1 to 3:1

• Teachers given comparable fictional records (diff only in gender) were more likely to

refer boys than girls for consideration of ADHD

• Girls less likely to manifest comorbid types as well as other externalizing behaviors
• Britain uses ICD criteria which is more restrictive, and they conceptualize ADHD from

resulting from family dysfunction, social disadvantage

• Social- those with ADHD can be intrusive, immature, bossy, aggressive; negative social

interactions with peers may lead to rejection, poor reputations, etc

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Slide from: http://www.psychcongress.com/sites/naccme.com/files/318%20Jain_Slides_1.pdf

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Slide from: http://www.psychcongress.com/sites/naccme.com/files/318%20Jain_Slides_1.pdf

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In social sciences, concentration is referred to as the ability to pay selective attention to something while ignoring other things. Controlling ones attention is the ability that we call as concentration. We cannot concentrate on an object or an activity unless we pay selective attention to it. Attention is an on and off activity and we can choose to pay attention to something

• r not. On the other hand, concentration has levels or degrees though it is hard to

measure these levels. Paying attention to something or activity is like focusing the spotlight of a torch in the dark. One can pay attention to several activities at any given time. 8

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ARTICLE in resources that outlines Mirsky model more detailed. Mirsky suggested that attentive functioning results from coordinated action of several elements including: Encode- can they even get the info in? look at working memory ability Sustain- how do they maintain their performance over time. Computer task (14 min) example Shift- go between different tasks (prefrontal cortex, anterior cingulate gyrus) Focus/execute- inferior parietal lobe, superior temporal lobe, stratium. Stability- look at response reaction time, errors, etc.

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Attention plays a role in ALL tasks we do so we are always looking at attention Divided attention- talking on phone while cooking Alternative attention- have difficulty in moving from one task to another; eg. increase mistakes when switching from folding to writing task; people may continue to perform aspects of the original task. Going back and forth between cooking and helping kid with homework

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When we talk about brain development, it is a bottom up process with frontal lobe being last to mature in 20s. Executive function skills are often associated with frontal lobe but do not work in isolation, it is a series of processes and interacts with multiple brain regions. Very complex and also variation in how it is defined and described Research has demonstrated that Children with ADHD have smaller volume prefrontal cortex as compared to same age peers

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Skills associated with higher level adult types of function that you need to utilize everyday.

variety of higher order cognitive abilities involved in the control and regulation of lower-level cognitive processes . Though there are variations in definitions of which specific skills it entails, executive functioning is believed to include skills which help in the guidance, direction, and management of cognitive, emotional, and behavioral functioning in purposeful behavior. The regulatory and management functions include skills such as initiation, cognitive flexibility, inhibition, planning,

• rganization, ability to shift, problem-solving, monitoring, working memory,

sustained and selective attention, and emotional control, particularly in tasks involving non-habitual responses 15

• Dr. Brown gives us a helpful visual image by comparing executive function to the

conductor's role in an orchestra. The conductor organizes various instruments to begin playing singularly or in combination, integrates the music by bringing in and fading certain actions, and controls the pace and intensity of the music. 16

comparing executive function to the conductor's role in an orchestra. The conductor

• rganizes various instruments to begin playing singularly or in combination,

integrates the music by bringing in and fading certain actions, and controls the pace and intensity of the music. An orchestra is made up of many different types of instruments, and each of these instruments is played independently. It is the conductor's role to integrate and

• rganize the different instruments from moment to moment to achieve his musical

goal regarding the piece. The conductor may need to respond to unexpected changes – for example, depending on the acoustics in the concert hall, he may need to ask one section to play louder. 17

http://www.westport.k12.ct.us/media/parents/westport_powerpoint_- _executive_functioning_12.10.09.pdf From Perkins ppt in folder

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When we talk about ADHD, executive function is an important factor. Though not implicitly stated in diagnostic criteria it is in there, subtly through the symptomology.

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Barkely conceptualizes ADHD types as separate conditions. Combined and hyperactivity types are different than inattentive.

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Core impairment = Response Inhibition which then leads to secondary impairments in four neuropsych abilities which then lead to decreased control of behavior and action Due to abnormalities in the prefrontal cortex and connections to other brain regions (striatum) Response Inhibition affects four intermediate executive functions (lighter blue) So, poor response inhibition + deficits in executive functions = poor control Barkley also asserts that individuals with ADHD don’t develop “future orientation and sense of self across time” 21

Behavioral inhibition refers to 3 interrelate processes (see above). Prepotent response: is that response for which immediate reinforcement is available or has been previously associated with that response. Executive function plays role in beginning- having to resist urge to act involves self- regulation– an Executive Function

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These are the Efs involved Kids with ADHD struggle in complex WM tasks (Digit Span Backwards) and mental math, struggle to hold information active in mind Self-regulation- emotional self-control; ability to express emotions internally; intrinsic

• motivation. Kids with adhd more negative and emotional peer interactions, low

persistence of effort Speech- self-directed speech; formulating rules and problem solving; internal reflection, questioning, instruction/ internal rules for governing behavior. Kids with ADHD are less compliant with verbal demands, immature self-directed speech, develop internal speech at later age Reconstitution- ability to create complex and novel behavior sequences in order to attain future goals (generativity or fluency); AKA creative problem solving (verbal fluency). Analysis involves taking old behavior patterns into smaller pieces and synthesis involves recombining behavior patterns into novel solutions. Finding alternative solutions/methods.

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As described previously- the deficits in the inhibition and exec function thereby leads to deficits in various abilities including control, timing, persistence, flexibility, and goal- directed actions. Goal directed motor responses

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No official diagnosis or criteria There is a cognitive-inattentive and behavioral-motor dimension similar to ADHD. Symptom dimensions are distinct from yet partially correlated with those forming ADHD

Some scientists think that SCT and ADHD may differ in the kind of inattention that they produce: While those with ADHD can engage their attention but fail to sustain it over time, people with SCT seem to have difficulty with engaging their attention in the first place

Proposes it represents a dysfunction in the focus/execute component of attention in Mirsky’s model

According to Dr Russell Barkley, a leading proponent of the SCT theory – he calls the condition "the second attention disorder" – between a third and a half of all those diagnosed with the inattentive subtype of ADHD are, in fact, suffering from SCT, and about the same number again remain undiagnosed.

Associated with increased risk for internalizing symptoms (especially anxiety and depression) Stimulants not found to be very helpful with inattention linked to CDD

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Hopefully now are familiar with my stance that we never look at scores or solitary behaviors in isolation. So when looking at ADHD evaluation and consideration, must consider all possible factors.

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Neuropsych is generally based more tests and performance during an evaluation. Contract with interview based/therapy which utilizes more descriptive reports and observations. Both should consider observations when interacting with the client; what does your gut tell you? Does it “feel” like ADHD, mania, or anxiety? Both should also look at how the symptoms are impacting functioning- are the deficits global and impairing multiple contexts and environments? If not (eg. if problems are only at school and nowhere else) may want to look at other possible contributing factors (eg. learning problem, anxiety, etc).

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Need to consider what is their cognitive ability? If the person’s IQ is in the impaired or borderline range- is their attention difficulty in excess of that cognitive ability? Or are you saying they have attention problems but comparing them to average/higher cognitive ability peers. Much overlap in symptomology with other diagnoses and/or mental health issues. Need to think about is the symptoms (inattentive, distractible, agitated, etc) due to trauma, anxiety, etc. Time frame of onset, duration, and frequency of symptoms is crucial, ESPECIALLY when evaluating adults. ADHD is a neurodevelopmental disorder so true ADHD will involve difficulties early on. Therefore, if adult reports difficulties began in early adulthood, in college, after divorce, etc. probably not neurodevelopmental ADHD. May be related to psychosocial and emotional factors, could be due to health issues (obesity, diabetes, brain injury, etc) Environmental demands- are the current expectations of child’s behavior appropriate or conducive to the child? Think about factors in school, teachers, parenting, etc and how those might be impacting the child. Eg. if the child is 4 and expected to sit still for 3 hours- setting them up for failure! Cultural factors- are there possible cultural values and norms which may explain behaviors. For example, does the particular culture allow for children to be rambunctious and active,

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“boys will be boys” mentality Health factors- many medical and health related issues can impact neurological functioning. Always ask about diet, sleep, any significant head trauma (concussions, seizures, accidents, injuries)

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Hyperactivity is much more in your face and obvious. Getting at and finding bumps in the inattention piece is a little trickier so wanted to leave you with useful measure. Rating scale that I used qualitatively- qualitatively because most persons who come in complaining

• f ADD/ADHD are going to score themselves in the elevated range on most if not all of the
• scales. I use it to find out more details and seeing which area they are reporting the highest

level of difficulty and then use that info for intervention recommendations. For example, if they have difficulty in activating to activities my recommendations will start with interventions aimed at behavioral activation. Organizing & Activating- difficulties with organization and getting started on tasks Sustaining- chronic problems in maintaiing attention on work-related tasks (daydreaming, distractibilty when trying to do work; loses track) Energy & effort- keeping up consistent energy and effort for tasks; slow process of info; inconsistent performance Managing affective interference_ mood difficulties; sensitivity, irritbability, frustration WM and recall- forgetfulness, id daily routines and problem in recall of learned info Disclaimer- BROWN is used as a part of diagnosing, don’t diagnose just based on the one measure- ever!

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The BRIEF consists of two rating forms

Parent Teacher

86 items on both questionnaires

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BRIEF breaks down the scores into 2 major areas and then those two areas into different skills Behavioral Regulation: ability to shift cognitive set and modulate emotions and behavior via appropriate inhibitory control. Precursor to appropriate metacognitive problem solving. It enables the metacognitive processes to successfully guide active, systematic problem solving, and more generally supports appropriate self- regulation. Metacognitition: ability to initiate, plan, organize, and sustain future-oriented problem solving. Abiltiy to cognitively self-manage tasks and ability to monitor their

• performance. Ability to actively problem solve in variety of contexts.

Inhibit: Control impulses; stop behavior Shift: Move freely from one activity/situation to another; transition; problem-solve flexibly Emotional Control: Modulate emotional responses appropriately Initiate: Begin activity; generate ideas Working Memory: Hold information in mind for purpose of completing a task 31

Plan/Organize: Anticipate future events; set goals; develop steps; grasp main ideas Monitor: Check work; assess own performance 31

file:///S:/BRAINS%20presentations/6.%20Attention%20&%20Exec%20Functioning%204.7.1 5/Articles%20&%20Readings/westport_powerpoint_-_executive_functioning_12.10.09.pdf

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can result from many causes, including head trauma, tumors, degenerative diseases, and cerebrovascular disease, as well as in several psychiatric conditions, including schizophrenia, attention deficit disorder, and antisocial personality disorder 34

Due to time constraints, did not cover interventions. Look in the BRAINS folders for more articles, research, readings, guides, and intervention.

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