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Attention Deficit/Hyperactive Disorder

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Title: Attention Deficit/Hyperactive Disorder


1
Attention Deficit/Hyperactive Disorder
  • David Lombard, Ph.D.
  • Center for Applied Behavioral Studies
  • www.DavidLombard.com

2
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3
Overview
  • What Is AD/HD
  • What Causes AD/HD
  • How Common
  • Common Symptoms
  • Common Treatments
  • Comparison with Conduct Disorder

4
What has it been called
  • First called minimal brain damage
  • Afterwards called minimal brain dysfunction
  • Next called ADD
  • Finally called ADHD

5
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

6
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

7
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

8
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

9
Pathophysiology
  • Delayed in frontal and temporal lobe
  • Accelerated maturity of the motor cortex
  • SPECT shows reduce circulation
  • Pet Scan shows a decrease glucose metabolism
    during activity

10
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11
ADHD Throughout the Lifespan
  • Preschool- Disruptive behavior, aggression
    towards other children, hyperactivity, conduct
    problems, inattentive and overactive
  • Middle Childhood- Unfinished tasks (unfinished
    games, uncovered toothpaste), trouble with school
    work, criticism from parents/teachers/peers, low
    self esteem. Depression and conduct disorders can
    develop here.

12
ADHD throughout the Lifespan cont.
  • Adolescence- higher rates of anxiety, depression,
    oppositional behavior, social failure, substance
    abuse
  • Adulthood- trouble at work, relationships,
    difficulty following directions, remembering, and
    concentrating, emotional and social problems

13
Epidemiology
  • CDC estimates 4.4 million youth ages 4-17 have
    been diagnosed with ADHD
  • In 2003, 2.5 million youth ages 4-17 are
    currently receiving medication treatment for the
    disorder.

http//www.cdc.gov/ncbddd/ADHD/
14
Percent of Youth 4-17 ever diagnosed with
Attention-Deficit/Hyperactivity Disorder
National Survey of Children's Health
http//www.cdc.gov/ncbddd/ADHD/adhdprevalence.htm
15
Percent of Youth 4-17 ever diagnosed and
currently medicated for Attention-Deficit/Hyperact
ivity Disorder National Survey of Children's
Health
http//www.cdc.gov/ncbddd/ADHD/adhdmedicated.htm
16
Prevalence in the US
  • About 2 million children
  • About 5 million adults

17
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 children Brazil 5.8 of
    12-14 year olds

18
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

19
What are the signs of AD/HD?
  • Three main symptoms (signs)
  • Problem paying attention (distractibility)
  • Being very active (hyperactivity)
  • Acting before thinking (impulsivity)

20
  • Based on the these criteria, three types of ADHD
    are identified
  • 1. ADHD, Combined Type if both criteria A and
    B are met for the past 6 months.
  • Tigger type-Hyperactive, restlessness,
    disorganized, inattention, impulsivity

21
  • 2. ADHD, Predominantly Inattentive Type if
    criterion A is met but criterion B is not met for
    the past six months
  • Pooh type- Inattentive, sluggish, slow-moving,
    unmotivated, daydreamer

22
  • 3. ADHD, Predominantly Hyperactive-Impulsive
    Type if Criterion B is met but Criterion A is
    not met for the past six months.
  • Rabbit Type- over focused, obsessive,
    argumentative

23
ADHD NOS
  • ADHD, NOS is a category for people who have some
    ADHD symptoms, but not enough to meet full
    criteria for the condition.

24
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

25
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

26
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

27
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

28
ADHD is Not
  • Will power
  • Inadequate parenting
  • Lack of motivation
  • Lack of intelligence
  • Laziness

29
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

30
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31
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32
ADHD Treatments
  • Education
  • Medication
  • Behavior Modification
  • Classroom/Workplace Accommodations

33
Multidisciplinary Approach
  • Primary Provider
  • Psycho-educational Consultant
  • academic, aptitude, and psychometric testing
  • IQ measurement
  • (usually done through the school)
  • Social Services
  • Counseling Services
  • Individual and Family

34
Commonly Used Stimulant Medications for ADHD
  • Methylphenidate (MPH) Products
  • Ritalin short mid-acting forms Concerta long
    -acting Metadate CD mid-acting Ritalin
    LA mid-acting Focalin mid-acting
  • Short acting 3-5 hours Mid-acting 6-8 hours
  • Long acting 12 hours

35
List of meds approved by FDA
http//www.nimh.nih.gov/health/publications/attent
ion-deficit-hyperactivity-disorder/medications.sht
ml
36
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

37
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

38
Pemoline (Cylert) Medication for ADHD
  • Secondary choice
  • Long-acting
  • Short acting 3-5 hours Mid-acting 6-8 hours
  • Long acting 12 hours

39
What are side effects of treatment?
  • Headache
  • Involuntary muscle movements
  • Loss of appetite
  • Mood changes as medication wears off
  • Sleep difficulty
  • Weight management problems

40
Questions?
41
Conduct Disorder
42
Not just for boys
43
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

44
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

45
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)

46
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)

47
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

48
Conduct Disorder
  • Symptoms
  • Deliberately engaged in fire setting with the
    intention to cause damage
  • Deliberately destroys other's property

49
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)

50
Conduct Disorder
  • Symptoms
  • Often stays out at night despite parental
    objections
  • Runs away from home
  • Often truant from school

51
Oppositional Defiant Disorder
  • For at least 6 months, shows defiant, hostile,
    negativistic behavior (4 or more of the
    following) -Losing temper -Arguing with
    adults -Actively defying or refusing to carry out
    the rules or requests of adults -Deliberately
    doing things that annoy others -Blaming others
    for own mistakes or misbehavior -Being touchy or
    easily annoyed by others -Being angry and
    resentful -Being spiteful or vindictive

52
Four Dimensions of Conduct Disordered Behavior
  • OVERT/DESTRUCTIVE
    OVERT/NONDESTRUCTIVE
  • (Aggressive Behaviors)
    (Oppositional Features)
  • Fights
    Annoys
  • Bullies
    Defies
  • Assault
    Stubborn
  • Spiteful
    Angry
  •  
  • COVERT/DESTRUCTIVE
    COVERT/NONDESTRUCTIVE
  • (Property Violations)
    (Status Offenses)
  • Cruel to Animals
    Runaway
  • Vandalism
    Truancy
  • Steals
    Substance Use
  • Fire setting
    Breaks Rules
  • Adapted from Frick, et al., (1993).

53
Prognosis for Conduct Disorder
  • In general, the literature suggests that
  • children who develop conduct disordered behavior
    later in childhood have a somewhat better
    prognosis
  • the severity and variety of early antisocial
    behavior is a powerful predictor of serious
    antisocial behavior in adulthood
  • the prognosis may be worse for those who also
    have comorbid disorders.

54
Break Time
55
Cutting and Self-Mutilation
  • David Lombard, Ph.D.
  • Center for Applied Behavioral Studies
  • www.LegalShrink.com

56
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

57
What do they have in common?
  • Angelina Jolie
  • Christina Ricci
  • Courtney Love
  • Princess Diana

58
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

59
The Cutting Culture
  • Websites-Blood Red
  • -Razor Blade Kisses
  • -The Cutting World
  • Films- Thirteen
  • Genre of music- emo

60
Examples of Cutting
61
Examples of Cutting
62
Examples of Cutting
63
Examples of Cutting
64
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

65
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

66
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

67
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'

68
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'

69
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

70
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

71
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

72
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

73
Theories of Why People Cut
  • Physical Reaction
  • Want the Same Feeling Again
  • These Individuals are Likely to Engage in Cutting
    Out of Boredom

74
Theories of Why People Cut
  • Control
  • A strong Sense Of Helplessness
  • Learned Helplessness
  • Cutting Self is Completely in Their Control

75
Theories of Why People Cut
  • Control
  • More Frequent in Homes of Lives with Rigid Rules
  • These People Less Likely to Use Drugs

76
  • I would say it is just like a drug. It becomes
    something that you feel you cant live without.
    When it works once to fix a problem, you will
    try it again and see that it will work again.
    Eventually your small cuts arent enough and you
    cut more and more. You gain more tolerance.
  • --Lia

77
Theories of Why People Cut
  • Addiction to Cutting
  • Emotional Release is Very Reinforcing
  • Physical Release has Bio-Chemical Properties
  • Under Control of Cutter

78
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

79
SI keeps me alive. Simple as that. --Angela
80
Self-injury is NOT a suicide attempt. It is a
way of making emotional pain into something
physical that you can see and control. --Melissa
81
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

82
Suicide, Cry For Help, or Coping?
  • Coping Strategy
  • Most Likely Reason
  • Cutting Makes Sense to Them to Deal with Life

83
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

84
How Is It Treated
  • Psychotherapy to Alter Behavior and Reinforcement
  • Find Other Coping Strategies

85
What to Ask
  • Basic QuestionsKeep it Easy
  • Can Easily Become Defensive
  • Fear of Being Labeled Mentally Sick
  • Can Easily Become Aggressive

86
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

87
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

88
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

89
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

90
(No Transcript)
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