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P R E S E N T E D A T T H E K U M I N I - C O L L E G E

M O N D A Y , J U N E 3 , 2 0 1 3

1 0 0 1 WE S C O E H A L L

2 : 1 5 - 3 : 3 0 P M

WELCOME BACK TO KU!

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PRESENTED BYRobert G. Harrington, Ph.D.Department of Psychology and Research In EducationKU School of Education630 J R Pearson HallUniversity of Kansas Lawrence, Kansas 66047rgharrin@ku.edu

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MY BACKGROUND• I have been a Professor in the PRE Dept . of the SOE for the past 34 years. • I teach graduate and undergraduate courses in the program in Development

and Learning.• Among the courses that I have taught are included, Theory and Research in

Intelligence, Classroom Management, Diagnosis and Treatment of Oppositional Defiant Disorders, Attention Deficit Disorders in Children and Adults, Bullying Prevention and Intervention, Behavior Problems and Personality Assessment, Social Skills Development in Children and Adults, Human Development Across the Lifespan.

• Currently, I am working on an online certification program to prevention and intervene in cases of bullying

• I regularly provide inservice training to schools, mental health agencies, hospitals and professional groups on the topic of ADD/ADHD and related topics

• Just completed keynote presentations at Irish International Conference on Education and at Nebraska Autism Disorders Conference

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DESCRIPTION OF MY PRESENTATION It is conservatively estimated that 5 to 6 percent of school-age

children will have attention deficits while in school but what happens to them when they graduate from school? Do their attention deficits just disappear and go away? We just don’t hear much about adults with attention deficits. Are they successful in their lives, in their work, in their relationships? How can someone tell if they have attention deficits as an adult? What can be done to manage and cope with attention deficits in adulthood? What could happen if you are in a relationship with someone with attention deficits? Are there happy endings? The purpose of this mini-course is to explore attention deficits and their effects in adult life.

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OBJECTIVES OF THE PRESENTATION• Two relevant cases of Adult ADD• Can you spot the myths? • What does ADD in Adulthood look like?• How is it diagnosed?• What are the effects of Adult ADD on personal/ emotional

development?• What are the effects of Adult ADD on marital and social

relationships ?• What are the effects of Adult ADD in the workplace?• What can be done to help? • Questions/Answers

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TWO RELEVANT CASES OF ADULT ADD1. Grad Student in Learning Theory Course2. Teacher attending a workshop on Childhood ADHD speaks up

about her husband at the break

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CAN YOU SPOT THE FACTS VS. MYTHS?1. ADD/ ADHD in Adults is just a lack of willpower.2. Everyone has the symptoms of ADD/ADHD and anyone with adequate

intelligence can overcome these difficulties on their own.3. Someone cannot have ADD/ADHD and also have depression, anxiety, or

other psychiatric problems4. Unless you have been diagnosed with ADD/ADHD as a child, you cannot

have it as an adult.5. ADD/ADHD always requires medication.6. It is not uncommon for individuals with adult ADD to seek out relationships

with others with social skills strengths that complement their deficits7. Disorganized physical environments tend to increase the ADD symptoms8. Men have more ADD than women9. In the West we diagnose more ADD/ADHD than anywhere else in the world10.Kids mostly grow out of their ADD symptoms with age.

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ADULT ATTENTION DEFICIT DISORDERAlso referred to as:Adult Attention Deficit Hyperactivity Disorder (Adult ADHD)Adult ADD or AADDNOTE: Adult Attention Deficit Disorder is the term used to

describe the neuropsychiatric condition attention deficit hyperactivity disorder when it is present in adults.

• Up to 60% of children diagnosed with ADHD in early childhood continue to demonstrate notable symptoms as adults.

• It is estimated that 5% of the global population has ADHD (including cases not yet diagnosed).

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WHAT DOES ADULT ADD LOOK LIKE?: IDENTIFICATION AND CLASSIFICATIONDSM-IV TR or the Diagnostic and Statistical Manual of Mental

Disorders, 2000, ed. defines three types of disorder:1) Inattentive type2) Hyperactive/impulsive type3) Combined typeTo meet the formal diagnostic criteria, an individual must display

at least 6 inattentive symptoms for the inattentive type

at least 6 hyperactive symptoms for the hyperactive/impulsive type

all of the above to have the combined typeNote: DSM V is coming out soon! Symptoms are similar to these…..

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SIGNS AND SYMPTOMS-INATTENTIONIN CHILDREN:Forgetful during daily tasksEasily distractedLosing important items Not listening and not responding to name being called outUnable to focus on tasks at hand; cannot sustain attentionAvoids tasks requiring tasks sustained mental effortMakes careless mistakes by failing to pay attention to detailsDifficulty organizing tasks and activitiesFails to follow through on complex instructions and tasks

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SIGNS AND SYMPTOMS-INATTENTIONIN ADULTS: ProcrastinationIndecision, difficulty recalling and organizing details required

for a taskPoor time management; losing track of timeAvoiding tasks or jobs that require sustained attentionDifficulty initiating tasksDifficulty completing and following through on tasksDifficulty multitaskingDifficulty shifting attention from one task to another

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SIGNS AND SYMPTOMS-HYPERACTIVITY/IMPULSIVITYIN CHILDREN: Squirms and fidgets (with hands and/or feet)Cannot sit stillCannot play quietly or engage in leisurely activitiesTalks excessivelyRuns and climbs excessivelyAlways on the go, as if “driven by a motor”Cannot wait for their turnBlurts out answersIntrudes on others and interrupts conversations

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SIGNS AND SYMPTOMS-HYPERACTIVITY/IMPULSIVITYIN ADULTS: Chooses highly active, stimulating jobsAvoids situations with low physical activity or sedentary workMay choose to work long hours or two jobsSeeks constant activityEasily boredImpatientIntolerant to frustration; easily irritatedImpulsive, snap decisions and irresponsible behaviorsLoses temper easily, angers quickly

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CLINICAL EVALUATION OF ADULT ADDFind out what prompted the individual to make an appointment at this timeHave the client complete some questionnaires before the initial visitDiscuss the medical background, work history, home history, family

relationships with the clientAre the client’s conditions being worsened by some condition other than

ADD? A medical problem? A Psychiatric problem? Stress? Sleep disorder? Alcoholism?Asperger’s? Autism? Learning Disability, Dyslexia, Hearing Disorder? Developmental Disorder?

ADD is diagnosed if:No other cause for the client’s symptoms can be foundThe person has a long history of such symptomsThe symptoms are severe enough to cause significant in function or

relationship

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ADULT ADD FACTSAdults with ADD have a deficiency in executive cognitive functioning; resulting in

deficiencies in self-regulation, self-motivation, distractibility, procrastination, organization and prioritization.

Adults with ADD are average to above average in intelligenceAdults with ADD experience a chronic condition that requires coping skillsAdults with ADD experience significant effects on education, employment and

interpersonal relationshipsEmployers, spouses and friends often fail to see the signs of Adult ADD; symptoms

change with maturityAdults are far less likely to evidence traditional hyperactivity symptomsAdults with ADD are more likely to have car accidents, less education, less

professional developmentAdults with ADD often compensate for the need for high stimulation by smoking,

taking alcohol or illegal drugsAdults with ADD often have comorbidities such as depression, anxiety, substance

abuse, learning disabilities, dyslexia; up to 80% will have some comordbidity

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CAUSES OF ADULT ADDSpecific causes are unknownSpeculations:Genetics – Twin studies show that Adult Add is highly

inheritable; 75% of casesEvolutionary Theory – (Hunter V. Farmer Theory) ADHD may

have been adaptiveEnvironmental Theory – alcohol and tobacco exposure during

pregnancy, exposure to lead, premature birth, low birth weight, maternal infections during pregnancy, exposure to pesticides

Diet – Food coloring such as red dye #40; no evidence for sugar or caffeine

Social – Disorganized family life or educational experience, attachment disorder and trauma, foster care, internationally adopted children, sensory integration dysfunction

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CAUSES CONTINUEDNeurodiversity: Issue of emotional tolerance and behavioral

toleranceSocial Construct theory of ADHD: Thomas Szasz, “ADD was

invented and not discovered.” Low Arousal Theory: Excessive activity is needed to

compensate for low arousal; require environmental stimuli to pay attention; if not enough stimulation then the adult creates their own stimulation

Pathophysiology: Frontal lobe, left temporal lobe, cerebellum, dopamine neural transmission

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QUESTIONNAIRES TO ASSESS ADULT ADDAdult ADD History Questionnaire – Client’s personal and family

psychological historyAdult ADD Medical History Questionnaire – Medical issues

related to the diagnosisAdult ADD Symptoms Questionnaire – Client symptoms related

to ADDAvailable at AdultADD.Info

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DIAGNOSTIC AND BEHAVIORAL SYMPTOM QUESTIONNAIREScoring Key: Answer how well each statement describes you

when you don’t use special aids or tricks you have developed to get around or compensate for difficulties you might have. Score each answer as follows:

0. Doesn’t describe me at all1. Describes me somewhat or some of the time2. Describes me pretty well or most of the time3. Describes me very well or almost all the time

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InitiationI have trouble getting started doing things.CompletionI have trouble completing thingsI dislike tasks that require a long series of stepsExecutionI don’t do tasks efficiently ( a good job in a short time)It is hard for me to do two or three tasks in a rowI do not always do what needs to be done

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DistractionI am easily distracted by things I hear or see even when I am trying to

concentrate I get distracted by my own thoughtsPerseverance and FocusI have trouble doing tasks that require keeping my attention on them for

along period of timeI often switch from doing one thing to another even when I don’t have to.I have trouble keeping my attention on one task.InattentivenessI don’t pay attention when I should, make careless mistakesI have trouble listening while others speak to me

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MemoryI get so deeply into one thing that I forget othersI lose or misplace thingsI have trouble being on timeI forget appointmentsI am often late for appointmentsFuture Awareness and PlanningI have trouble making plans long in advanceI rarely get to trains at least 10 minutes early

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Consider a diagnosis of Adult ADD if:A person’s average score on these 34 questions is 2 or higher

andThe symptoms significantly impair the person’s work, school,

family, or personal activities andThe person experiences significant stress from the effects of

the symptoms and;There is no other medical or psychological explanation for

them

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PERSONAL AND FAMILY ADD HISTORYChildhood History of ADDExplain , if necessaryAs a child, I ….--- Had to repeat one or more grades_________________Fidgeted a lot, couldn’t sit still____________________Was distractible, had a short attention span__________________Had a lot of discipline problems__________________Never did as well as I should have in school__________________Was treated for ADD

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Adult History Related to ADD__I have been diagnosed as having ADD__I have been treated for ADD__I have been given one or more tickets for speeding__I was driving a car when it was totaled__I have been in one or more “fender benders”__I think so much that I have trouble getting to sleep__I have to change jobs often (been fired)__I have had periods when I overspent__I have had periods when I gambled too much

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__I have had periods when I was overactive physically __I have had periods when my mind raced__I need a lot of caffeine to get going at the start of the day__I have been hospitalized for a psychiatric disorderFamily History__I believe that a blood relative had/has ADD__A blood relative was given the diagnosis of ADD__A blood relative has taken medication for ADD__I have a blood relative who has manic-depressive (bipolar )

illness

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ADULT ADD RELATED MEDICAL HISTORYMedical IssuesThyroid problems (which)?(Thyroid problems can mimic ADHD. Both thyroid meds and

stimulants can cause weight loss)Glaucoma? (Stimulants can increase eye pressure in people with narrow

angle glaucomaSeizures?(stimulants may cause seizures in people who have already had

themBeen knocked unconscious(Brain injury mimic ADD or make it worse)

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Liver problems(Many medications are metabolized in the kidneys. Some medications, like

Strattera, may cause liver problems.Reynaud’s(Stimulants can make Raynaud’s worse or cause it (cold and white or blue

fingers or toes)Heart Problems(Stimulants are contraindicated in people with heart problems, Very rare

deaths from the use of stimulants have been associated with a history of structural heart disease or cardiac dysrhythmias)

Migraines, if so, what medication do you take from them, if any?(Stimulants may increase blood pressure, An increase in blood pressure

medication may be required by patients taking stimulants or Wellbutrin (buproprion)

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What is your blood pressure? When was it last taken?(Bring blood pressure down to normal before starting stimulants)Is your pulse less than 50 per minute when resting?(May need cardiac work-up unless low pulse is from good physical

conditioning)Is your pulse more than 95 per minute when resting?Stimulants can further increase the pulse and are contraindicated in

people with pulse this rapidDid a blood relative die at an early age of heart problems?(This may be a contraindication to taking stimulants since this fatal

vulnerability may be geneticDo you have twitches or tics(Tics or twitches may be made better or worse by stimulants

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SleepDo you have sleep apnea? (Sleep apnea may cause ADD like symptoms or make ADD

worse)If so, what evaluation or treatment have you had for sleep

apnea?A sleep study may be indicated for t hose with major sleeping

problems. If a person is using CPAP, are they using it regularly with good effect?

Do you have difficulty falling asleep?(May be due to sleep apnea or depression)Difficulty staying asleep?(May be due to sleep apnea or depression)

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Find yourself tired during the day, yawning a lot?(These symptoms may be caused by sleep apnea, Overtiredness may

make ADD symptoms worse or mimic ADD)Do you nap at least a few times a week to stay alert?(This may be a sign of sleep apnea)Do you awaken during the night feeling frightened?(This may be a sign of sleep apnea)Do you snore?Slightly suggestive of sleep apneaHave you been observed to stop sleeping during sleep, and then

awaken with a start?This is a symptom very suggestive of sleep apnea

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Medication ReactionsAre you allergic to a medication (Medication? Reaction?)Do you take an MAOI antidepressant medication?(Stimulants and SSRIs are contraindicated in persons taking MAOIsDiet SupplementsDo you take fish oil?(This may be mildly helpful to people with ADD but good research

support for this is still lacking)Vitamin C?This decreases the absorption and increases the excretion of

amphetamines and thereby reduces it effect

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Do you take an herbal medicine? If so, which?(There are some interactions with stimulants)Do you take over the counter medications? (which)?(Aspirin taken at the same time as stimulants can reduce the absorption

of stimulants. OTC medications containing ephedrine or pseudoephedrine can make the cardiac side of stimulants worse)

Substance HistoryHave you been addicted to or abused drugs? (Persons with such a history may require more careful oversight if

stimulants are prescribed)Have you used “speed” or uppers (Dexedrine or others)?(People’s previous experience taking these medications can suggest

how they will respond now)

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Have you ever taken a stimulant? What effect did it have on you?(A person’s reaction to stimulant medication taken in the past may predict

his or her response to its therapeutic use)Drugs/AlcoholDo you smoke marijuana fairly regularly?(Marijuana often interferes with the use of medications for ADD)Do you smoke cigarettes or cigars? (How many per day?)People with ADD find it harder to stop smoking. It is possible that successful

treatment of the ADD may make it easier to stop. Buproprion, which of some help to some patients with ADD, is a fairly good smoking cessation aid)

Do you smoke caffeinated drinks (if so, how much per day?)(Caffeine may worsen some of the side effects of stimulants like difficulty

sleeping, headache, and atrial fibrillation)

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Do you have at least one drink almost every day? (How many?)(Alcohol can interfere with the effects of stimulants)Have you sometimes had too much alcohol to drink?People taking stimulants may be less likely to realize when their judgment

and reflexes are impaired by alcohol. This may make driving more dangerous.

Is there someone in your home who has abused drugs or who might use drugs prescribed for you?

(If this is so, the patient, must be very careful to keep the stimulant medication in a secure place where it will not tempt the other person in the home to use it.

Females onlyAre you pregnant or planning to get pregnant?(Stimulants may adversely affect fetal development)

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Are you using protection against getting pregnant?(Such protection will reduce the concern about the need for

stimulants during pregnancy)Are you breast feeding or considering breast feeding?Stimulants are carried in breast milk and may adversely affect

the infant

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Have you ever taken a stimulant? What effect did it have on you?

(An individual’s reaction to stimulant medication taken in the past may predict his or her response to its therapeutic use)

Drugs/ AlcoholDo you smoke marijuana fairly regularly?(Marijuana often interferes with the use of medications for

ADD)’Do you smoke cigarettes or cigars (How many per day?)(People with ADD find it harder to stop smoking. It is possible

that successful treatment of the ADD may make it easier to stop. Buproprion, which of some help to some patients with ADD, is a fairly good smoking cessation aid)

Do you drink caffeinated drinks (if so, how much per day?)

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OrganizationI get disorganizedI have trouble organizing tasksMy personal work area is messyI don’t prioritize or plan my dayI can’t work well without structure or directionI waste a lot of time doing nothingPhysical Activity (Hyperactivity)I need to keep walking, moving aroundI have trouble sitting still, I fidget

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Frustration/ImpulsivenessI am easily frustratedI get impatient easilyI interrupt when other people are talkingAnxietyI focus and concentrate better if I am somewhat anxiousMulti-TaskingI often try to do more than one task at a timeI tend to make things more complicated than they need to beSleepI have trouble getting to sleep because my mind is going

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DIAGNOSIS OF ADULT ADDEntirely clinical and therefore controversial! Were the symptoms present in childhood? Get corroborating evidence from family membersGet corroborating evidence from school recordsGet corroborating evidence from employment historyGet corroborating evidence from medical history/family treeNeuropsychiatric evaluation to determine:

intelligencegeneral knowledgeself-reported ADD symptomstests to screen for co-morbid conditions

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NOTE CAREFULLYEvery normal individual may exhibit ADD or ADHD like

symptoms occasionally (e.g., when tired or stressed) but for the ADULT ADD diagnosis:Symptoms should be present from childhoodSymptoms should persistently interfere with functioning in multiple spheresSymptoms from childhood are manifested in adulthood but in perhaps a different manner

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TREATMENT OF ADULT ADDSelf – HelpExercise and eat rightGet plenty of sleepPractice better time managementWork on your relationshipsCreate a supportive work environment

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IN GENERAL: TREATMENT AND THERAPY FOR ADULT ADDTalk TherapyMarriage and Family TherapyCognitive Behavioral TherapyJob CoachingSocial Skills buildingMedical TreatmentSelf-ManagementModification of the Physical EnvironmentDevelopment of Support SystemPositive Attitude; take advantage of personal skills

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SUPPORT GROUPS FOR ADULT ADDPurposes for support groups:Reduces the isolation of struggling alone with the disorderGives you a place to express your feelings among others who

may understandLets you share strategies for success

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BEHAVIORAL COACHINGGoal: Practical solutions to problems in everyday life; not a

substitute for therapyPrioritizingMotivationTime ManagementProcrastinationOrganizationImpulse Control Distraction Reduction

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INTERVENTIONSSELFRelationshipsWorkplace

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EFFECTS OF ADULT ADD ON THE INDIVIDUALMessages received by adults with ADD:• I am a fraud and others will find out• If only I would try harder• My way of doing things is wrong• I am lazy• Just do it like everyone else• I just can’t follow the conversation and I interrupt• I resent the criticism I get from others• I just don’t seem to know what is socially appropriate

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WHAT IS AN ADULT WITH ADD TO DO?1. Accept yourself2. Be realistic about what you can do3. Set goals and celebrate accomplishments4. Understand your limitations and plan for them5. Anticipate your needs6. Get a schedule book7. Allow for de-stressing time8. Plan a meeting with your spouse to figure out you both are doing9. Recognize that partners need respite too10. Don’t overcommit11. Know when to say, “NO” and do not overcommit12. Rearrange your environment13. Do things your way as long as it does it does not irritate or affect others14. Get knowledge about Adult ADD and seek medical help if necessary

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WHAT DOES AN ADD/ADHD MARRIAGE LOOK LIKE?

Spouses report: My husband or wife constantly forgets, misses appointments. I feel like I am raising another child? I can never count on my spouse. It goes from feeling responsible for everything to chronic anger. I did not like the person I had become either. I have 100% of the family responsibility.

Symptoms:“Do you hear what I am saying?”“You never help me around the house”“You are so unreliable”“How could you forget to pick up our son from school again?“You know we can’t afford that new computer you just bought”“Help, my partner does not seem motivated to change”

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WHAT IS A COUPLE TO DO? WHAT GETS IN THE WAY? Transition from hyperfocus dating to marriage or committed

relationshipWalking on eggshellsBelieving ADD/ADHD does not matterMisinterpreting symptomsChore wars

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WHAT IS A COUPLE TO DO? (CONTINUED)? Impulsive ResponsesNag now, Pay laterThe Blame GameThe Partner-Child DynamicDifficulty listening and paying attentionCreate routines and proceduresUnderstand Emotional Overreaction and How to Deal with ItMake to-do listsGet organizedGet partner to repeat requestsUnderstand the preferred channel for interaction: Verbal, Auditory, Pictorial

etc.

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WORK ON BETTER COMMUNICATION BY:

Eliminating distractionsMake good eye contactTake a time outLearn to compromise

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ADD CAN BE A JOB KILLER….FACTS:Adults with ADD earn $4300 less per year than others in the

same positionAdults with ADD are often underemployed or unemployedAdults with ADD are viewed by employers as underachievers

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WHAT TO DO ON THE JOBEnd Distractions

Aha distractions: make listsOh no distractions: make a planHo-hum distractions: set realistic deadlines and take breaks

Schedule more time to complete a task than really necessaryModify the work environment

When and where do you work best?

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ADD AND THE LAW: WHAT CAN AND SHOULD AN EMPLOYER DO? Title I of the Americans with Disabilities Act of 1990 prohibits all employers

with 25 or more employees (15 or more prior to July 1994) from discriminating against individuals with disabilities who are otherwise qualified in the application, hiring firing, advancement and other conditions of their employment

Adaptations and Accommodations:Short Attention Span: Change the scheduleDistractibility: Make quiet work placesHyper-focusing: Break jobs into manageable chunks and monitor completionHyperactivity: Short work breaks should be scheduled throughout the dayMemory: Put it in writingTime Management: Make a habit of arriving 15 minutes earlyOver commitment/Procrastination: Get progress reports

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Social Skills:Work on communication, social contactLeadership style compatibility: Its all about Competence and

CommitmentDirectiveCoachingSupportiveDelegative

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RESOURCESADDA (Attention Deficit Disorder Association) www.add.orgNational Resource Center on ADHD, www.help4 adhd.org

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QUESTIONS AND ANSWERS

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