Download ADHD

Definitions
DSM-5
Executive Functions
Treatment Options
Ron Bashian, MD, Fellow, American Academy of Pediatrics
Contact [email protected] , [email protected]
Life and ADHD Coach, www.validationcoaching.com
November 22, 2013
ADHD Definition
Steinberg, Adolescence
 “A biologically based psychological disorder
characterized by impulsivity, inattentiveness, and
restlessness, often in school definitions” (p. 423)
 Primarily biological (ED – neurobiological, with
strong genetic component)
 Although not a specific cause of anti-social behavior,
increases risk of externalizing problems
 Diminished ability to delay gratification
 Often co-existing emotional dysregulation
(Biederman, MGH, 3/13, ~ 50%)
Definition: DSM - 5
 “A persistent pattern of inattention and/or hyperactivity-
impulsivity that interferes with functioning or
developmental level and that negatively impacts directly
on social and academic/occupational activities”
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Neurodevelopmental disorder (onset in developmental period), usual early
manifestation; inconsistent with age or developmental level ; including LD,
autism spectrum, ND motor disorders, communication disorders, intellectual
disability
(Previously) categorized with disruptive behavior disorders; including
conduct disorder (CD), oppositional defiant disorder (ODD)
Not, per se, oppositional behavior, defiance, hostility, or failure to understand
tasks
Several symptoms prior to age 12
Two or more settings
Interfere with, or reduce, quality of social, academic, or occupation
Not better explained by anxiety, mood disorder, personality disorder, etc.
Definition: DSM -5
 Six or more of the following, > 6 months, inconsistent
with developmental level, negative impact, and
occurring often
 Inattention
 Careless work, poor close attention
 Difficulty sustaining attention
 Seems to not be listening
 Often not following through on instructions
 Difficulty organizing tasks and activities (order, time management)
 Often loses things necessary for tasks or activities
 Easily distracted by extraneous stimuli
 Forgetful in daily activities (paying bills, keeping appointments)
Definition: DSM -5
 Six or more of the following, > 6 months, inconsistent
with developmental level, negative impact, and
occurring often
 Hyperactivity and Impulsivity
 Fidgets, taps hands, squirms
 Leaves seat, runs about, climbs
 Can’t play or engage in leisure activities quietly
 Talks excessively
 Blurts out answers before question is completed
 Difficulty waiting his or her turn
 Interrupts, intrudes on others
Definition: DSM -5
 Specify if combined, predominantly inattentive,
predominantly hyperactive-impulsive
 Specify if in partial remission
 Specify severity (mild, moderate, severe)
Executive Functions
 Central control processes in the brain that activate,
integrate, and manage other brain functions www.chadd.org
 “Enable a person to engage successfully in independent,
self-serving behavior…Will you do it and, if so, how and
when” (Brown, citing Lezak, p. 21)
 Brown Model (http://www.drthomasebrown.com/
 Six elements of E.F. work together , usually rapidly and unconsciously
 Become more complex as the individual matures
 Everyone has periodic impairments, but these are chronic and more severe
in individuals with ADHD
 Because these functions are unconscious, having “automaticity”, the issue
is not “willpower.” Such individuals cannot . It is not that they will not.
 In ADHD, salient, engrossing stimuli can cause locked hyperfocus.
Executive Function – Brown model
 Brown model: http://www.drthomasebrown.com/
ADHD Definition - Brown
(Brown, A New Understanding of ADHD, p. 20)
A complex syndrome of
 developmental impairments of executive functions,
 the self-management system of the brain
 a system of mostly unconscious operations.
 These impairments are situationally variable,
 Chronic, and significantly interfere with functioning
in many aspects of the person’s daily life.
ADHD Definition – Qualifiers (1)
 ADHD is best diagnosed by the reliable history of several observers,
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one of whom can be the person in question. There is no diagnostic
“test”, per se, which confirms it.
Other conditions can mimic it and need to be excluded. These include
anxiety, depression, abuse, and medical problems.
The criteria to diagnose ADHD have been set by precedence, past
experience, and a need to standardize them . This is necessary for the
application of appropriate services, accommodations, and meaningful
studies of ADHD.
Thus, there is some arbitrariness, even though a continuity of basic
standards and definitions is present.
Everyone, in some situational or information overload, experiences
some of these deficits. However, in ADHD, these deficits are
chronically present, exist in several domains.
ADHD Definition – Qualifiers (2)
 ADHD rarely occurs alone. More often than not, it occurs with learning
disabilities of some sort and/or emotional components.
 Individuals with ADHD have specific impairments of executive function
(discussed below) which represent an “operating system” rather than
“software” problems.
 People who have ADHD do not suffer from a “will-power.” deficit. It is not
that they will not do something, it is that they cannot do it.
 LASTLY – and very important. Individuals who do not meet the full
criteria of ADHD are helped by our understanding and support. We can do
this by encouragement, identification of strengths, and employing
methods to enhance their sense of empowerment and success.
Executive Functions – Barkley (1)
 Problems: A meta-concept, no recognized definition or agreement on
its essential characteristics
 Capacity to inhibit is conscious and primary among other aspects of
ADHD, as c.f. Brown it being one of six cluster of equally operative and
symptoms operating mostly in automaticity.
 The capacity to inhibit as being conscious, and dependent on other
pre-executive levels (CNS relevant genes>CNS proteins and
enzymes>CNS structures>CNS functions>overt behavior which are
automatic.
 Barkley see little clinical relevance or real-world predictability of
psychometric testing (neuropsychological testing) to “ecological
validity” (Barkley, cf. Laurence’s related “ecological perspectives on
human development” (pp. 9-10).
 (Brown too considers NP tests of EF unreliable, as being performed in
an artificial setting and narrow time frame.
Executive Functions – Barkley (2)
 Therefore, Barkley’s starting point defining EF is as self-regulation, “ a
form of self-directed action aimed at modifying one’s behavior so as to
make a future goal (or value, having utility), end, or outcome more or less
likely to occur (Barkley, 1997), (Executive Functions, 2013, p. 60)
 Following from his pre-executive functions, Barkley’s model (drawing on
Dawkins, 1982)stresses an extended phenotype, both causing and
influenced by actions, social structures, individuals, and inanimate objects
(Executive Functions, 2013, p. 39)
 EF systems may have evolved to solve problems such as theory of mind
(anticipating that others have a mind, an EF system, and act accordingly.)
 Barkley and Brown recognize a key role in specific areas of the brain.
Brown cites, beyond the prefrontal cortex (PCF) parietal, cerebellar, basal
ganglia, and white matter tracts – reflected in both functional connectivity
and patterns of oscillation which represent information exchange (Brown,
p. 5)
Treatment Options
 Education about ADHD – a critical component preceding any discussion
of management. (Brown, p. 98)
 Medication treatment – repeatedly shown to be effective in supporting EF
function, and in some instances to possibly normalize structural
abnormalities (Brown, p. 11)
 Medication treatment shown to be effective in increasing reading scores,
and efficacy is associated with duration of treatment.
 Medication yields stronger effects than behavioral interventions, and
appears to be “the critical ingredient for alleviating ADHD symptoms in
most patients with ADHD” (Hinshaw, quoted in Brown, p. 123)
 Three psychosocial interventions (operant conditioning techniques,
training for teachers, and intensive summer treatment programs) have
supporting evidence for efficacy (Antshel and Barkley, quoted in Brown, p.
120)
 Accommodations: Needed and fully justified
 No treatment option has been shown to have enduring benefit when
discontinued.
ADHD Coaching
 Barkley – Coaching and assistance with EF functions can help people
accommodate , thus reducing impairments from these deficits
(personal communication, May , 2013)
 Motivation is a “critical but often neglected problem .” More
important than “can I understand” may be “Do I want to understand
what I read and why” (Brown, p. 139)
 By providing structure, in a safe and non-judgmental space,
employing methods of positive psychology, active listening, and client
driven priorities, coaching is believed to enhance motivation and create
achievable successes. (ADHD Coaches Organization, EDGE
foundation).
 The Professional Coaching Agreement (PCA) is a formal tool for
motivation, providing structure, respecting value in trying, and both
sparking and sustaining motivation (Sleeper-Triplett, Empowering
Youth with ADHD, p. 151)
Life and ADHD Coaching
Personal statement
In practicing Pediatrics over the years, I found that helping adolescents with
ADHD and their families was especially meaningful. Aside from the use of medication, so
much can be done. It begins with understanding ADHD and its challenges, discovering your
unique personhood, and then finding and using your strengths.
In my personal battle with leukemia and a bone marrow transplant, I
encountered vulnerability and uncertainty. In surviving, I discovered core strengths and
renewed my intention to help adolescents and adults with ADHD determine their inner
strengths, apply them with increasing skill and confidence, and attain deeper meaning,
purpose, and direction in their own lives.
When I do ADHD coaching, I am present without judgment, alongside
individuals, encouraging and challenging them to explore their talents, chart their unique
path, and make explicit positive changes in their lives.
I provide a complimentary 30 minute telephone conference, when you may ask
further questions, I can answer questions about your ADHD, or I can briefly coach you.
Then, if you choose, coaching will begin. You will have the opportunity to explore and
discover deeper personal resources than you may have imagined, and move forward from
there.
Every person is valuable. Every person has untapped potential.
Ron Bashian, [email protected] , [email protected], mobile 703-403-5134
Professional and Personal
Life Highlights
 United States Navy, LCDR, Medical Corps, 1975-1977
 American Board of Pediatrics, 1977 certification, 2009 re-certification
 Chairman, American Academy of Pediatrics committee , 1977,
resulting in newborn thyroid screening in the District of Columbia.
 CHADD, professional member, 1989 to present, excepting
years of leukemia treatment
 Covenant House of DC, Volunteer of the Year, 2003
 Washington Redskins Community Quarterback (Volunteer) of the Year, 2003
 Assistant clinical professor, Department of Pediatrics, Virginia Commonwealth
University School of Medicine, 2008-2013
 Instructor, George Mason University, Fall 2012, Senior Seminar, Peer Reviewed
Literature, Undergraduate Biology Program
 Speaker, Alpha Epsilon Delta, pre-medical honor society,
George Mason University, 2008-2013
 Coordinator, annual Medical Education Colloquium, Alpha Epsilon Delta
Bibliography - I
 Ecological Perspective
 -Steinberg ecological perspective, Eco-System (pp. 9-10) and cf. ecological validity
 -ADHD description, in context, p. 423 (Laurence)
 -Ecological validity academic reference:
http://www.utsc.utoronto.ca/~marksch/Schmuckler%202001.pdf (University of Toronto)
 -Ecological validity even has relevance in the accurate measurement of methylphenidate
effectiveness. (http://www.apa.org/pubs/journals/releases/pha92163.pdf ), 2001,
Experimental and Clinical Psychopharmacology)
Bibliography - II
 JAMA, 310; 1:23, July 2, 2013: News from the Centers for Disease Control and
Prevention, “Costly mental disorders affect millions of US children and teens”
 -Prevalence of ADHD #1 prevalence = 7% , Behavioral and conduct problems 3.5%;
Anxiety 3%, Depression 2.1%; Autistic spectrum 1.1%; Tourette Syndrome 0.2%.
 -During prior year, 4.7% of adolescents 12-17 year old “reported an illicit drug use
disorder”, 4.2% alcohol abuse disorder, 2.8% cigarette dependence in past month).
 -Cost of mental disorders among people 24 or younger (special ed, juvenile justice,
economic losses, estimated at $247 billion.
 -In 2006, mental disorders among the most costly conditions to treat in children.
Bibliography - III
 Definitions/Resources:
 -DSM-IV: http://www.ldawe.ca/DSM_IV.html , with overview
http://www.ldawe.ca/About.html#ADHD
 -DSM –IV vs. V:
http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf
 -ADHD:
 -Edge: https://edgefoundation.org/information/about-adhd/
 -National Resource Center on ADHD : http://help4adhd.org/
 APA:
 -DSM: History, http://www.psychiatry.org/practice/dsm/dsm-history-of-themanual
 -DSM-5 Implementation and Support:
http://www.dsm5.org/Pages/Default.aspx
 -DSM-5 Overview: http://www.dsm5.org/about/Pages/DSMVOverview.aspx
Bibliography - IV
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CHADD:
 -Understanding ADHD home page: http://www.chadd.org/UnderstandingADHD.aspx
 -Symptoms and causes: http://www.dsm5.org/Pages/Default.aspx
 -Evaluation and Treatment: http://www.chadd.org/UnderstandingADHD/Parents-Caregivers-of-Children-with-ADHD/Evaluation-andTreatment.aspx
 -Executive Function: (CHADD – Parents and Caregivers/What is Executive
Function): http://www.chadd.org/Understanding-ADHD/Parents-Caregiversof-Children-with-ADHD/Symptoms-and-Causes/ADHD-and-the-Brain.aspx includes Brown and Barkley definitions
 -Causes and Brain Chemistry: http://www.chadd.org/UnderstandingADHD/Parents-Caregivers-of-Children-with-ADHD/Evaluation-andTreatment.aspx
 -CHADD of Northern Virginia, http://www.meetup.com/novachadd/
Bibliography - V
 Coaching Benefits
 Edge Foundation Research: (ADHD coaching)
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https://edgefoundation.org/information/research/ .
Brown text, Barkley (personal communication
-International Coach Federation - general coaching benefits
http://www.coachfederation.org/need/landing.cfm?ItemNumber=747
&navItemNumber=565
-ADHD Coaches Organization, http://www.adhdcoaches.org/
-JST Coaching Program, http://www.jstcoach.com/
BOOKS - I
 A New Understanding of ADHD in Children and Adults –
executive function impairments , May 2013, Routledge,
Thomas E. Brown, PhD)
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Definition and detailed explanation, (19-38)
Comparisons with old model 39-43)
Education about ADHD (p. 98)
Medication (p. 99)
Motivation (2, 5, 11, 21, 55-62, 107, 139-140)
Emotional dysregulation (56, ff)
Imaging studies (104)
Long term effects of medication treatment on academic functioning (p. 111)
Psychosocial (p. 120, 13)
Coaching (125)
Brown home page: http://www.drthomasebrown.com/
BOOKS - II
 Adolescence, 9th edition, 2011, McGraw Hill, Laurence Steinberg
 -Ecological perspectives on human development (p. 9)
 -Externalizing Problems (pp. 416-425)
 -Attention Deficit /Hyperactivity Disorder (p. 423)
 -Internalizing Problems (pp. 426-434)
 Executive Functions: What they are, How they work, and Why they evolved,
2012, Guilford Press, Russell Barkley, PhD
 Barkley home page: http://www.russellbarkley.org/
BOOKS - III
Highly Recommended, older teens, adults
 Fast Minds – How to thrive if you have ADHD (or think you
might), February 2013, Berkley Books
 Craig Surman, M.D. (coordinator, ADHD Research Program, Massachusetts
General Hospital
http://www.massgeneral.org/psychiatry/doctors/doctor.aspx?id=18170
 Tim Bilkey, M.D., F.R.C.P. (information on Fast Minds at
http://www.timbilkeymd.com/ )
 -Practical guide, self-assessment, scales for young adults
 -Format: Aware (emotions, behavior, habits) Decide (priorities and steps to get ther),
Help (provide yourself with tools) / Design (structure accountability in your life)
 -Forgetful, Achieving below potential, Stuck in a rut, Time challenged, Motivationally
challenged, Impulsive, Novelty seeking, Distractible, Scattered)
BOOKS - IV
GMU eBook:
 ADHD in adults: a practical guide to evaluation and management, Humana
Press, 2013, Craig B. H. Surman, editor.
 Practicing Positive Psychology Coaching - Assessment, activities, and
strategies for success, 2010, John Wiley & Sons, Robert Biswas-Diener
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 Executive Coaching with Backbone and Heart - (A systems approach to
engaging leaders with their challenges), 2007, 2nd edition, Jossey-Bass Business
& Management Series, John Wiley & Sons, Mary Beth O’Neill
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 Co-Active Coaching – changing business, transforming lives , 2011, 3rd edition,
Nicholas Brealey Publishing, Kimsey-House, Henry CPCC, MCC; KimseyHouse, Karen, MFA, CPCC, MCC; Sandahl, Phillip; Whitworth, Laura.
BOOKS - V
 Change Your Questions, Change Your Life: 10 powerful tools for life and work, 2009,
Barrett-Koehler Publishers, Marilee Adams, PhD
 Empowering Youth with ADHD – your guide to coaching adolescents and youth
adults, for coaches, parents, and professionals , 2010, Specialty Press Inc., Jodi
Sleeper-Triplett, MCC, SCAC
 Highly Recommended: How Children Succeed, July 2013, Mariner Books, Paul
Tough (ED – beyond IQ, examining early childhood influences, relating constructs
of task orientation/perseverance elements of character to EF type constructs, and
possible effects of positive psychology on IQ tests. Research derived conclusions)
 Highly Recommended: Mindset: The New Psychology of Success , 2007, Ballantine
Books, 2007, Carol Dweck. (Required reading for Fairfax County teachers in 2012)
BOOKS - VI
 Becoming a Life Coach – a complete workbook for therapists, David Skibbins,
Ph.D., CPCC (Coaches Training Institute), New Harbinger Publications, 2007
 Coaching Questions – A coach’s guide to powerful asking skills, Tony Stoltzfus,
2008, http://www.coach22.com/
 The Heart of Coaching – Using transformational coaching to create a highperformance coaching culture, Thomas G. Crane, FTA Press, 2007
 The Strengths Book: Be confident, be successful, and enjoy better relationships by
realizing the best of you, Robert Biswas-Diener, CAPP Press, 2010
Abbreviations
 Abbreviations:
 APA
 CHADD
 CPC
 CPCC
 DSM-5
 JAMA
 MFA
 MCC
American Psychiatric Association
Children and Adults
with Attention-Deficit/Hyperactivity Disorder
Certified Professional Career Coach
Certified Professional Career Coach
Diagnostic and Statistical Manual of Mental Disorders,
5th edition, American Psychiatric Association,
formerly known as DSM-V
Journal of the American Medical Association
Master of Fine Arts
Master Certified Coach