Diagnostic Criteria. Diagnostic Criteria 9/25/2013. What is ADHD? A Fresh Perspective on ADHD: Attention Deficit or Regulation?

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1 What is ADHD? A Fresh Perspective on ADHD: Attention Deficit or Regulation? The Transition from Disorder to Traits Thor Bergersen M.D. Founder, ADHD Boston Attention Deficit/Hyperactivity Disorder As many as 10% meet diagnostic criteria 80% genetically explained 3 Subtypes Primarily Inattentive (often called ADD) Primarily Hyperactive/Impulsive (rare) Combined Type (most common) Diagnostic Criteria Diagnostic Criteria Inattention Hyperactive/Impulsive Careless mistakes Brief attention Not listening No follow through Disorganization Avoid sustained mental effort Loses things Easily distracted Forgetful Fidgets and squirms Leaves seat Run/climb/restless Plays loudly Constantly moving Excessive talking Blurting out answers Can t wait for turn Interrupts Adult Criteria Differences Procrastination Initiation and completion of tasks Sense of time is off Difficulty following conversations Long term project planning challenging Boredom leads to changing careers All or nothing focus ADHD: The Name Could Be Better Not completely accurate People with ADHD can focus on what interests them or in crisis mode Hyperactivity and impulsivity are often not prominent, particularly in girls Terms deficit and disorder pathologize and negate innate individual strengths 1

2 Executive Function: The Coach in the Brain Coach Awake Imagine the regions of the brain as players on a team, each with its own function The very tip of the frontal lobes of the brain (prefrontal cortex or PFC) is the coach Coach awake = Executive Functioning Coach asleep = Executive Dysfunction Players on the team cooperate Plays are practiced and learned Plays are executed Goals are accomplished Team is happy Coach Asleep Fun/Interesting/New: Coach Wakes Up Players practice their own positions Players may be individually strong Players often do not cooperate Goals may or may not be accomplished Team is unhappy He can play video games for hours She reads the Twilight books for hours He works in the garden all day She is on Facebook for hours He can play poker online and forget everything Not Interesting: Coach Asleep Situation Dependent Focus He takes forever to get ready She does not seem to listen He forgets right after I tell him something She s always losing things Interesting subjects with dynamic teachers are easy Persuading and making the sale is fun Sports are often exciting and focus is strong Discrete tasks with immediate reward: no problem Passionate curiosity = complete concentration 2

3 Attention Regulation v. Deficit Executive Functions People with ADHD lack the ability to force attention when interest is lacking Boredom is like kryptonite to concentration, effectively blocking initiation of tasks When interest and therefore focus is present, time can stand still and hours pass without notice Therefore, attention regulation should replace attention deficit Initiation and completion Transitioning Working memory (RAM of the brain) Delayed gratification and impulse control Organization and Prioritization Self Awareness Executive Dysfunction ADHD can look like... Procrastination Forgetfulness Impulsivity (physical/verbal/emotional) Disorganization and inability to prioritize Difficulty transitioning Lack of self awareness Anxiety Depression Obsessive Compulsive behavior Perfectionism Emotional volatility Oppositional behavior ADHD can lead to... The Science Behind ADHD Low self esteem Social difficulty and relationship problems Falling behind academically or at work Family and/or marriage turmoil Fear of inadequacy and failure The PFC runs on dopamine, a common chemical messenger in the brain Dopamine recycling pump density is regulated by our DNA, and ADHD PFC s have a lot High recycle rate = low available dopamine Excess recycling in the PFC = less nerve cell communication = coach asleep 3

4 Nature vs Nurture Diagnosis of ADHD ADHD is very genetic Almost everyone with ADHD has a family member with it, diagnosed or not Some studies show 80% heritability Genetic tests for ADHD are being developed Probably 20% nurture (environment) Early signs possible (age 2-3) Usually certain by age 7 Can be diagnosed at any stage of life Teachers, friends, family often suggest evaluation Primary care M.D. often first point of contact Methods of Evaluation Suggestions for Your Adult Patients with ADHD Interview (parents, child, family) Symptom Checklists (parent, teachers, person who may have ADHD) Neuropsychological Evaluation Quotient Evaluation Clinical Observation Do some reading and online checklists Consider neuropsychological evaluation Talk to friends with ADHD experience Exercise, sleep enough, and eat healthy Don t drink too much or use drugs Consider coaching, therapy, medication Alternative Treatments Medication: Glasses for the Brain Cogmed (working memory training) Neurofeedback Integrated Listening Systems (ILS) Learning Breakthrough Reading Plus Supplements (Omega 3, L-methylfolate) Remember dopamine? Dopamine recycling inhibitors (stimulants) Increase available dopamine More communication in PFC Effects last for 4-12 hours 4

5 Medication: Stimulants Stimulants: Pros and Cons Most commonly prescribed for ADHD 75-80% report significant improvement Only classified as stimulants because they boost dopamine (don t necessarily feel stimulating) DEA labels them controlled substances Need an original, signed prescription each time Both methylphenidate and amphetamine have been prescribed for more than 70 years Potential for abuse or misuse Can cause appetite suppression Insomnia is possible Other Options: Non Stimulants Key Points Strattera: Norephinephrine reuptake inhibitor Wellbutrin: NE/DA reuptake inhibitor Nuvigil: central histamine activator Amantadine: mechanism unknown Intuniv and Kapvay: alpha blockers ADHD is very common and genetic The words deficit and disorder are unfortunate Attention regulation, not deficit, is more accurate Exercise, sleep and diet are important for focus Medication, like glasses, is a tool for focusing Treatment is necessary if impairment is present In Conclusion ADHD is a set of traits, dependent upon interest and novelty of the subject If a person with ADHD is interested in a subject, the impairment is not evident Evaluation and treatment are personal and sometimes family decisions which are situation dependent Questions Thank you for your time and attention! I ll do my best to answer some of your questions. My contact information: 75 2 nd Ave., Suite 310 Needham, MA Thor@ADHDBoston.com 5