Pediatric Neurology. COM

Why everything in one book/lecture?

The Problems

• ADHD as classically defined

• Other Executive Function problems

• Co-Occurring Problems of the Syndrome Mix

• Family Problems

The goal of laying out the problems of the Syndrome Mix:

“Okay, my kid has a short attention span, but why does he/she…?”

Our task

• Sort out: – co-occurring– mimicking– exacerbating.

• Unless you identify, you cannot discuss or treat.

Depressing?

•Neurological basis–Not the child’s “fault.”–Not the parents’ “fault.”

Neuroanatomy of ADHD

• MRIs of ADHD group demonstrated smaller:– Frontal cortex– Subcortical areas (striate: caudate,

putamen, gp)• Striate-frontal paths involved with: • motor control• executive function• inhibition of behavior• modulation of rewards.• Rich in catecholamines

Functional Neuroimaging

PET and fMRI (measures neuronal use of deoxyhemoglobin) suggest:– Prefrontal abnormalities– Disturbed dopamine activity

D4 receptor in ADHD

Strongest association with 7 repeat allele of the dopamine D4 receptor gene (DRD4).

Neurophysiology of ADHD

• Too little NE driving the frontal lobes.– “Frontal lobe brakes haven’t been woken up.”

• Too little DA from frontal inhibitory projections onto the striate.– “Frontal lobe brakes are weak.”

norepinephrine prefrontal pathway

dopamine meso-cortical pathway

12-1 Stahl S M, Essential Psychopharmacology (2000)

The brain is a bunch of chemicals with

illusions of grandeur.

ADHD:The Traditional, Boring Definition

Triad of:

• Inattention

• Hyperactivity

• Impulsivity

Six or more symptoms of inattention

(a) fails to give close attention; careless mistakes

(b) difficulty sustaining attention

(c) does not seem to listen when spoken to directly

(h) easily distracted by extraneous stimuli

(e) difficulty organizing tasks

(d) fails to follow through (not volitional/incapable)

(f) avoids tasks requiring sustained organization

(g) looses things needed for tasks

(i) often forgetful in daily activities

Six or more symptoms of hyperactivity-impulsivity

Hyperactivity(a) fidgets/squirms(b) leaves seat(c ) runs or climbs excessively(d) difficulty playing quietly(e) “on the go” or “driven by a motor”(f) talks excessively

Impulsivity(a) blurts out answers

(b) difficulty waiting turn(c) interrupts or intrudes

DSM: 3 Types of ADHD

• ADHD, Predominantly Inattentive Type

• ADHD, Predominantly Hyperactive-Impulsive Type

• ADHD, Combined Type

Typical, Boring and Useless Description of ADHD

“Johnny is very active! He never stops moving. He gets distracted by any little noise, and has the attention span of a flea. Often, he acts before he thinks. His sister, Jill, is often in a fog. Sometimes, she’s just so spaced!”

More Accurate Description

“I can’t take it any more!! We scream all morning to get out of the house. Homework takes hours. If I don’t help him with his work, he’s so disorganized that he’ll never do well. If I do help him, he screams at me. Since he never finishes anything, everyone thinks he doesn’t care….

No matter how much we beg or punish, he keeps doing the same stupid things over and over again. He never considers the consequences of his actions, and doesn’t seem to care if they hurt me. It’s so easy for him to get overwhelmed. Sometimes, he just wants to ‘turn the noise off….’

He is so inflexible, and then blows up over anything. It gets me so angry that I scream back, which makes everything even worse. Now that he’s getting older, the lies and the cursing are getting worse, too. I know he has trouble paying attention, but why does he have all of these other problems as well?”

Psychiatry Hotline

“If you have…”OCD

Schizophrenia

Paranoid

Depressed

ADHD

All

New Concept of ADHD: A Problem with Inhibition

• There is deficient frontal and pre-frontal lobe function in ADHD.

• These pre-frontal lobes are the home of our executive and braking functions.

• ADHDers show executive dysfunction and brakeless behaviors.

New Definition of ADHD

• The inability to inhibit the present with an eye to the future. –Russell Barkley

• “Living RIGHT NOW!!!”

This is what Jack sees:

This is what Mom sees:

Executive Function (EF) (Russell Barkley)

• Frontal lobe (executive) functions:– Inhibition (brakes) – Orchestrating the brain (CEO)– Self talk– Working memory– FORESIGHT– Hindsight– Shifting agenda– Separating emotion from fact

Inhibition / Brakes

Most basic EF is putting on brakes.

1. We need to be able to inhibit distractions/impulses/hyperactivity (can play video games)

2. Unless we stop first, never get to use other EFs.

CEO

• “Self” is a barely coherent collection of parallel processes.

• When speech or memory centers used, we become aware.

• No one is in charge.

• Frontal lobes try their best to orchestrate.

Self-Talk

• Toddlers do it out loud.

• ADHDers never get to practice.

• ADHDers don’t internalize self talk. poor problem solving.

Working Memory

• What we can juggle electrically.

• 512 megs RAM

• Need to access past, present, and future simultaneously.

• Not exercised without brakes in ADHD.

Foresight

• Ability to predict and plan for the future.

• Poor without ability to inhibit present or keep the future in working memory.

• ADHD: prisoners of present.

• Poor foresight is perhaps greatest disability of ADHD.

• (Mothers typically have great foresight.)

Foresight

Hindsight Sense of time

• Ability to recall success of past strategies.

• ADHDers don’t learn from their mistakes!

• Extremely poor in ADHD.

• Poor estimates.• Time moves too

quickly.• Time moves too

slowly.

Shifting Agenda

• Switching requires sustained effort and control.

• Difficult in ADHD.

• Kids need warnings.

Separating Emotion from Fact

• Every event has:1. Objective reality (ex: traffic jam)

2. Emotional tag

• Separating the two requires time to reflect.

• Result is poor ability to judge significance of events.

Actual Symptoms of Executive Dysfunction

• Distractible– Inadequate inhibition of extraneous stimuli.

• Impulsive– Inadequate inhibition of internal stimuli.

• Hyperactive– Physically checking out those stimuli.

More symptoms: Audience: This is IMPORTANT

• Lack of foresight [Shooting self in foot vs. lazy]

• Poor hindsight [How many times punished; help at the time]

• Live at mercy of moment [4 second rule]

• Poor organization [back for books]

• Trouble returning to task [never finish. Don’t care?]

Other Symptoms of Executive Dysfunction

  Poor sense of time [2 hr consult]

  Time moves too slowly [Shopping]

  Poor ability to utilize “self-talk” [think thru?]

• Poor sense of self awareness [A: not a clue]

 Poor reading of social clues [weird]

Still More Symptoms

  Trouble learning from mistakes  Inconsistent work and behavior [Hold against]

  Trouble with transitions [Curse for dinner]

  Hyper-focused at times [off computer]

  Poor frustration tolerance [why not let us help?]

  Frequently overwhelmed [Stop!]

And Still More Symptoms…  Gets angry frequently and quickly  “Hyper-responsiveness” [Sprinkles]

  Inflexible/explosive reactions [Stuck/break]

  Feels calm only when in motion [work]

  Thrill seeking behavior [top in emergency]

  Trouble paying attention to others

• Trouble with mutual exchange of favors.

• Sense of failure to achieve goals.

Difficult Behaviors in ADHD

Symptom ADHD Children (%)

Typical Children (%)

     

Argues with adults 72 21

Blames others for own mistakes

66 17

Acts touchy / easily annoyed 71 20

Swears 40 6

Lies 49 5

Stealing (not involving threats)

50 7 Barkley, RA

JAACAP (29): 546-557

ADHD: Developmental Trends by Age

Motoric hyperactivity

Aggressiveness

Low frustration tolerance

Impulsiveness

Easily distracted

Inattentiveness

Shifts activities

Easily bored

Impatient

Restlessness

CHILDREN

ADULTS

Clinicians should consider

impact on QOL

Milstein R, et al. J Atten Disord 1997;2:159–166.

Wilens T, et al. Review of Psychiatry Series 1999;18(2):1–45.

Co-Occurring Conditions

• Learning Disabilities, incl. Organization• Anxiety• OCD• Tics• Depression• Bipolar Depression• Asperger’s Syndrome• Sensory Integration Disorder

1MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1076–1086.2Barkley R. Attention-deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment, 2nd ed. New York: Guilford Press, 1993.3Biederman J, et al. Am J Psychiatry 1991; 148:565–577.4Milberger S, et al. J Am Acad Child Adolesc Psychiatry 1997;36:37–44.5Biederman J, et al. J Am Acad Child Adolesc Psychiatry 1997;36:21–29.

60

55

50

45

40

35

30

25

20

15

10

5

0

(%)

Oppositionaldefiantdisorder1

Anxietydisorders3

Learningdifficulties2

Mooddisorders2

Conductdisorder3

Smoking4 Substanceusedisorder5

Languagedisorder2

40%

30–35%

20–25% 15–25%

15–20% 20% 19%15%

ADHD: Comorbid Conditions

Learning Disabilities

• 25-30% of ADHDers have LD.• May co-exist and/or mimic and/or worsen

each other. (Which one is it?)

• Organizational disability built into definition.

• Dysgraphia.• Following directions.• Sequence of commands.

Disruptive Behavior Disorders:ODD, CD, Antisocial Personality• 50% of have dx of Disruptive Behavior

• Many sub-dx symptoms including lying, cursing, taking things, blaming, easily angered, etc.

• Sheet Rock Index

• Predictable from executive dysfunction

Oppositional Defiant Disorder(ODD)

• ADHD: too inattentive or overwhelmed to comply.

• ODD: unwilling to comply (even with intriguing task).– Deliberately negative, annoying, spiteful.

Conduct Disorder (CD)

• Overtly hostile and law breaking.

• Violate others’ rights.

• Cruelty to animals, stealing.

• Lack of remorse (vs. ADHD).

Antisocial Personality Disorder

• Pervasive, severe violations of others’ rights.

• Arrested.

Anxiety/OCD Disorder

• 30% of ADHDers

• ½ never tell parents!

• Almost daily painful worries (not due to imminent stressor).

• May not respond or worsen with stimulants.

Anxiety Disorders:vs. normal worry

• GAD kids have more frequent, strong, and disruptive worries.

• GAD kids average >= 6 worries (vs. 1 in controls) • GAD kids do not feel their worry has any positive

effect. It feels “alien.”• Anticipatory anxiety/avoidance. • Assoc. restless, fatigue, dec. concentration,

irritable, muscle tension, insomnia.• Frequent somatic complaints.

Obsessive Compulsive Disorder (OCD)

• Obsessive thoughts/ compulsive acts.• Recurrent, intrusive,“foreign,” unwanted.• Cause anxiety.• Attempted to be neutralized.• OCD concerns for future may compensate

for ADHD foresight/organization problems.– ADHD living present;– Depression living in past;– OCD/Anxiety living in future.

Depression

• 10-30% of children with ADHD.• 47% of adults with ADHD.• Prolonged periods of:

– Loss of joy, sad– Loss of interests/pleasure– Pervasive irritability in children– Withdrawal, self critical– Vegetative symptoms: (sleep/appetite)

Bipolar Depression

• 20% of ADHD children.• Sounds as if “possessed.”• Depression cycling with elevated, grandiose

and pressured moods.• Children may cycle repeatedly in one day.• Severe separation anxiety.• Extreme rages for hours.• Very goal directed.

Bipolar cont’d.

• Little sleep requirement.

• Gory dreams

• Sometimes hypersexual

• Extreme everything: fears/sensitivities

• Sweet craving/ heat intolerance

• ODD

• Substance abuse/ suicide.

Bipolar (versus just ADHD):

• Strong family history of bipolar/substance use.

• Prolonged, violent, disorganized, mean outbursts that last for hours (vs. 30 min in ADHD). “Go for the jugular.”

• Outbursts from limit setting or nothing (vs. from overwhelmed in ADHD).

• ODD

Bipolar vs ADHD cont’d.

• Explosive and “intentionally” aggressive or risk seeking.

• Morning irritability lasts hours (vs minutes with ADHD.

• Separation anxiety, bad dreams, disturbed sleep, fascination with gore.

• Substance abuse.

• Worsen with stimulants.

Tics and Tourette’s

• 7% of ADHDers have tics.

• 60% of Tourette’s have ADHD.

• Tourette’s Plus– OCD/Anxiety, ADHD, ODD….

• Tourette’s Definition– 2 motor tics and 1 vocal tic

• Check for PANDAS

Sensory Integration Disorder (SI)

• Inability to receive and respond to sensory information.

• Volume too high or too low.

• Occupational Therapy.

• Carol Kranowitz, The Out-of-Sync Child.

SI cont’d

 Hypersensitive to touch: sensitive to clothes or getting dirty; withdraw to light kiss.

Hyposensitive to touch: wallow in mud; rub against things; unaware of pain.

Hypersensitive to movement: avoid running, climbing, or swinging.

Hyposensitive to movement: rocking; twirling; unusual positions.

SI cont’d

 May also respond abnormally to sights, sounds, smells, tastes or textures.

 May be clumsy; have trouble coordinating (bilateral) movements; or have poor fine motor.

Asperger’s Syndrome

• Impaired use of social clues (body language, irony, sub-text).

• Concrete thinking.

• Poor “theory of mind.”

• Poor eye contact and socialization.

• Limited range of encyclopedic interests.

• Perseverative, odd behaviors.

• Didactic, monotone voice.

Family Problems

• Family members with their own problems.

• Household is stressed by child. (Dads come home)

Family stressmay lead toresentment

ADHD: Impact of Untreated & Under-Treated ADHD

PatientPatient Family3-5x Parental Divorce

or Separation11,12 2-4 x Sibling Fights13

Family3-5x Parental Divorce

or Separation11,12 2-4 x Sibling Fights13

Society Substance Use Disorders:

2 X Risk8

Earlier Onset9

Less Likely to Quit in Adulthood10

Society Substance Use Disorders:

2 X Risk8

Earlier Onset9

Less Likely to Quit in Adulthood10

School & Occupation46% Expelled6

35% Drop Out6

Lower Occupational Status7

School & Occupation46% Expelled6

35% Drop Out6

Lower Occupational Status7

Health CareSystem

50% in bike accidents1

33% in ER visits2

2-4 x more motor vehicle crashes3-5

Health CareSystem

50% in bike accidents1

33% in ER visits2

2-4 x more motor vehicle crashes3-5

Employer Parental

Absenteeism14

and Productivity14

Employer Parental

Absenteeism14

and Productivity14

1. DiScala et al., 1998.2. Liebson et al., 2001.3. NHTSA, 1997. 4-5. Barkley et al., 1993; 1996.

6. Barkley, et al., 1990.7. Mannuzza et al., 1997.8. Biederman et al., 1997.

9. Pomerleau et al., 1995.10. Wilens et al., 1995.11. Barkley, Fischer et al., 1991.

12. Brown & Pacini, 1989. 13. Mash & Johnston, 1983. 14. Noe et al., 1999.

SolutionsPediatricNeurology.com

Summary of Drug Actions ADHD OCD Anxiety Tics Depres-

sion

Stimulants A+ +/-worse +/-worse +/-worse 0

SSRI’s 0 A A+ 0 A

TCA B 0 B 0 0 (child)

Neurolep-tics

+/-0 0 0 A 0

Sources

• Russell Barkley: – Taking Charge of ADHD– Hyperactive Children: A Handbook

• Ross Greene:– The Explosive Child

Sources, cont’d.

• Chris Dendy:– Teenagers with ADD: A Parents’ Guide

• Thomas Phelan:– All about ADD– Surviving Your Adolescents

• Family

• 18 years on the job

Keep It Positive

• Celebrate ADHD strengths:– “Why not?” attitude– Energy– Creativity

• Communicate that you believe in the child.

• Criticize/Hate ADHD, not the person.

Keep It Positive

• Instead of punishing bad behavior, encourage good response to replace it. (Barkley)

• Redirect rather than punish.

• Only positive reinforcement changes behavior and attitude.

• Don’t mock.

• Need subtle corrections.

Positive: Bank Account

• Imaginary bank account of good/bad times.

• Keep the bank account positive.– Laugh/hug.– Spend time together without being annoying!– Accept apologies.– Take the good times as they come.– Find something to praise.

The “No Fault” Approach(Zeigler-Dendy)

Avoid arguments based on “whose fault.”

• This is the rule.

• It was broken.

• This is the pre-set consequence.

• I feel your pain.

Benefits of No Fault

• Avoids arguments.

• Good with people who refuse to accept blame. (There is no blame.)

• Allows us to criticize the behavior, not the child.

• Might occasionally be unfair, but good in the long run.

Nice Traffic Cop

• Imagine you get pulled over for speeding.

• The policeman gives you the ticket AND starts calling you lazy and worthless….

• When we hand out the punishments, let’s leave the nasty comments behind.

Phelan’s 4 Cardinal Sins

• Don’t nag. It hasn’t worked yet.

• Don’t lecture. Ditto.– “Insight transplants” don’t work.

• Don’t argue. It takes two.

• Don’t offer unscheduled advice.

I.e., if it’s not useful, don’t do it.

Maintain a Disability Outlook (Barkley)

• Cuts through “blame.”• Parents become “therapists” not “victims.”• Realistic outlook minimizes frustration.

– Frustration occurs when outcome < > expectations

• ADHD does not define the child: you can still celebrate the good parts of ADHD and the person!

Seek to Understand

• Model listening and re-phrasing.

• Ask question: “Why did he do that?”

• Answer: “What would someone do if they could only see 4 seconds into the future?”

• It’s their disability. Don’t take it personally. You just happen to be there.

Let the Teen Be a Partner

• Let teen be involved.

• Give choices empowerment

• Negotiate.– No other choice.– Model seeking “Win/Win” solutions.– Parent gets final stand.

• ADHDers love to think it’s their idea.

Plan A: Token/Reward Systems

(Barkley)

Criteria for Behavior Mod.

• Worth changing.

• Under child’s ability to control.

• It’s the child’s problem.

• The reward system is likely to work.

• Cooler heads can apply it

Reward/Token Systems

• ADHDers are moths. Make brightest light productive.

• Bribes= illicit behavior (besides, appeal to ethics hasn’t worked).

• Frequent, strong, immediate feedback.

• Rewards need rotation.

• Rules reviewed before needed.

Reward Systems

• Keep punishments short, immediate.

• Avoid spiraling threats/punishments.

• Goal is correction for “next time,” not sadism.

• Difficult to maintain.

• Best with elementary age children.

• Most children respond to enticements/threats.

• Your child probably isn’t one of them.

• You’re ready for:

Plan B

Dr. Ross Greene

The Explosive Child

Plan B:Behavior modification via

staying calm to prevent “meltdowns.”

“Just STOP!”

What’s Going On?

• First scenario: – Mother: “John, can you please go do two hours

of homework?”– John: “Stop! Go away!”

• Second scenario:– Mother: “John, can I make you fresh pancakes

for breakfast?”– John: “Stop! Go away!”

Just STOP!

• ADHD is deficiency of frontal lobe brakes.

• First step is to STOP.

• It works! Even 5-10 minutes.

• Once under control: – Correct choice is obvious to child.– Correct parenting is obvious to parent.

The Overwhelmed Speedometer

• Imagine a stress speedometer

• At 60 mph, back wheels spin out and crash is inevitable.

• Inherit child at 40mph. – “Calming” brings to 30mph keep at it.– “Calming” brings to 50mph stop before

spinout.

After stopping, next:

Defuse, don’t inflame:

• Lower your voice. Stay calm.

• State rule once.

• Leave.

• Ignore the ravings of an out-of-control blob of neurons.

After stopping:

Discussion will resume later when it can be useful. You are not giving in.

Once calm: negotiate, negotiate, negotiate.

One more time:

Your ADHD child is much more likely over-whelmed than evil.

• Evil behaviors need to be squelched.

• Over-whelmed behaviors need to be calmly defused.

Pop Quiz

A 13-year-old son with ADHD discovers that his bite-plate is missing from its handy container.  He angrily accuses everyone else of having taken it.  His mother explains the blatantly obvious fact that no one else would be interested in his used dental appliance.  He continues screaming and blaming her for its absence.

Question 1

This child is demonstrating good executive function.

a)    True

b)      False

Question 2

The accusatory behavior of this otherwise bright child can best be explained by:

a)   He’s not quite smart enough to comprehend that his bite-plate isn’t worth stealing.

b) He’s overwhelmed by frustration.

Question 3

Yelling back and accusing your child of behaving horribly would:

a)    Prompt him to say, “Oh, thanks for helping me see the error of my ways.”

b) Cause him to be even further overwhelmed.

Question 4

An initial attempt at helping him solve the problem is unsuccessful.  A useful parental response at this point would be:

a) Keep escalating the screaming match.

b) Stop, walk away, retain your composure, and resist the urge to get in the last word. Resume discussion when everyone is calm.

Question 5

   This type of outrageous behavior in your ADHD child:

a) Is a common part of the brakeless behaviors we summarize with the letters ADHD.

b) Is the result of a nasty and selfish child.

Classic ADHD:Just a part of the Syndrome Mix

• Classically defined ADHD

• Other Executive Dysfunctions

• Co-Occurring Problems

• Family Problems

Okay, he has ADHD, but why does he…?

And let’s not forget the positive. ADHD people…

• Have an envious “Why not?” attitude.

• Live in the present.

• Often have extreme passion.

• Can be very creative.

• Can be lots of fun.

Conclusion

• This is the 50 year plan.

• Have some fun.

• The winner is the family that stays together.

KutscherM@pol.net

PediatricNeurology.com