Psychosocial treatments for Adult ADHD – Final Coursera ADHD Thoughts

A camping trip with my youngest child delayed this last posting on the final lecture from the Coursera class on ADHD. It was buggy, cold, and rained most of the trip. Watching him jumping around in the campsite, hopping from rock to rock in the cold rain, brought home to me one of the important criteria for a true ADHD diagnosis. No matter how active a person is or how often they switch their focus, they cannot be clinically diagnosed with ADHD unless it causes impairment. My son’s natural inclination to be constantly in motion at the campsite may be an evolutionarily desirable trait. Perhaps high-energy children were less likely to be overcome by hypothermia and were more likely to reach adulthood and have children of their own.

Yet ADHD traits are not at all helpful in modern classrooms and offices where children and adults are expected to sit still and focus their brain power on tedious items. That does not mean that ADHD traits are not adaptive for other situations and environments. The trick for adults with ADHD tendencies is to find occupations and environments that work with their natural high energy and high distractibility as much as possible. Then structure their lives and surroundings with external scaffolding to compensate for their relative lack of internal executive organization and function.

As a person with ADHD moves from childhood through adolescence to adulthood the manifestations of their ADHD evolves. A child with ADHD is likely to show high physical activity, aggressiveness, low frustration tolerance, and impulsiveness. An adolescent with ADHD is more likely to sit still but will be easily distracted and inattentive. An adult with ADHD will frequently shift activities, be impatient, restless, and easily bored. Incidentally, this may also be true of a highly gifted individual who is in a unfulfilling occupation. What makes the ADHD adult stand out is that the impairment is usually across multiple domains. A lifetime of  ADHD, especially ineffectively treated ADHD, can highly impair an individual. From finances to occupations, relationships to physical and mental health, ADHD takes its toil. One of the most insipid effects is the demoralization that can occur due to a negative belief system. Adults with ADHD have typically spent years watching themselves fail to meet seeming simple challenges. They may not have good coping skills and may have developed a paralyzing hopelessness that feeds into their self-image.

Medical treatments for ADHD are a critical part of the treatment for adult ADHD, yet pills alone cannot teach new coping skills or help individuals recover from a lifetime of negative self talk. Psychosocial interventions that have shown promise include helping individuals, either individually or in groups, with psychoeducation, problem management, decision-making, procrastination, organization, time and effort management, cognitive modification, and behavior modification. Cognitive Behavioral Therapy (CBT) is very effective for adults with ADHD especially when combined with specific treatment goals and organizational strategies. Therapists can help adults with ADHD externalize their executive functions as much as possible.

Adults with ADHD need to put in more effort than more cerebrally typical people to keep themselves organized and on task. The good news is that many of the behavior interventions that help tame ADHD tendencies are generically healthy for everyone. They include creating regular routines for waking times and bedtime to ensure a full night of sleep. Daily exercise to increase available dopamine for clearer thinking and better focusing. Eating regular nutritious meals with a low glycemic index to prevent hypoglycemia which increases ADHD symptoms.

Environments should have an organizational structure with specific places for items that are easily misplaced such as keys and papers. Electronic reminders, especially ones easily programmable on smart phones, can help individuals stay on task while not getting so lost in an activity that they accidentally miss upcoming events and deadlines. Visible timepieces, concrete plans with start and end times, and regular reviews of what is working and what needs a better strategy all help the adult with ADHD. It is important for the adult to forgive themselves and to be realistic. Recognize what does work vs. what should work. Find the right tools to address outstanding problems and automate and/or outsource problematic tasks whenever possible. Recognize that certain feelings and situations may lead to detrimental impulsivity and prepare plans and coping strategies to avoid or mitigate this type of predictable trouble.

Beyond drugs and psychosocial therapy there are a few other ADHD treatments worth mentioning. Although not enough data is available to determine how to maximize the effectiveness of these treatments, neurofeedback, computerized cognitive training, and targeted working memory training are all showing some promise in treating ADHD.

The bottom line is that, especially given the more liberal definition of ADHD in the DSM-V, if you feel like you are impaired by ADHD, help is available. Although drugs might be part of the solution that works for you, do not neglect your environment. The more you can do to structure your world and life in a way that works with your brain’s natural tendencies, the more effective you will be.

Drugs for ADHD: Coursera ADHD Class Weeks 9 & 10

Drugs are one of the most common, if not the most common, treatment for ADHD. They can help individuals be more productive, calm, and in control of themselves, at least while the drugs are active. ADHD drugs are similar to prescription eye glasses. They help an individual function while they are in use, but they do not cure the underlying condition.

The Coursera class on ADHD takes the standard medical line that if used as prescribed and not abused, ADHD drugs, in most cases, cause no significant or long-term ill effects. Dr. Rostain cites statistics that stimulants are not over-prescribed for ADHD and that untreated ADHD leads to much worse outcomes than medical treatment of ADHD. Most studies on drugs for ADHD last just months, not years. Given that many individuals with ADHD take drugs for 5 years or more, and start at a young age, it is troubling that there aren’t better long-range studies on their effects.

Dr. Rostain covers many myths about stimulant drugs for ADHD. One stood out to me. The myth is that these drugs do not improve academic achievement. He states that stimulant treatment of ADHD improves work productivity, classroom conduct and rule-following, peer interactions, grades, and leads to reduced punishment, fewer days absent, and makes repeating grades less likely. So yes, on stimulants a child with ADHD will appear to be a better student and will certainly be easier for the teacher to have in class. Dr. Rostain didn’t mention that some studies have shown that psychostimulants have not been shown to achieve long-term positive changes in peer relationships, social or academic skills, or school achievement. He also did not mention that there is evidence that stimulant treatment of ADHD in juveniles can damage their developing brains. Long-term use of ADHD can also create a loss of motivation. Students, especially college students, may feel that their success is due to the drugs and a shift of agency may create a dependence on the drugs and low self-esteem.

There are three basic types of drugs used to treat ADHD: stimulants, non-stimulants, and antidepressants. Each affects the signaling of neurons in the brain in a slightly different manner and the lectures on them were too detailed to easily summarize. The comprehensive “What we know” brochure on Managing Medication for Children and Adolescents with ADHD from the National Resource Center on AD|HD is a good place to start. The last couple pages have suggested readings and then a handy reference chart for the drugs which includes the generic names, the brand names, the duration of action for each drug, the form the drugs come in, the dosage ranges, and the common side effects.

Even though there is a great deal of evidence that drugs can help treat ADHD symptoms in the short-term, they still carry risks. Risks that your pediatrician or health services provider may not mention. The best approach if you are considering ADHD drugs for your child is to learn all you can about the various drug options and then carefully, with the help of your child, monitor both the short-term and the long-term effects of any drug you give your child. Pay attention to both the physical side effects, such as stomach aches and sleep problems, and the more subtle psychological effects that may include decreased drive and motivation. Ask yourself, are you trading their initiative and innate personality for a child that is easier to live with and more compliant?

Is it really ADHD? Coursera ADHD Class Week 8 – Assessment

More and more kids in the US have ADHD. This has led many to feel that we are over-diagnosing kids that have other issues, or are just a bit slower to mature, with a psychiatric disorder where none exists. Others argue that we are diagnosing and then medicating students whose only “disorder” is being anti-authority. It reminds me a bit of One Flew Over the Cuckoo’s Nest.

In his ADHD Coursera course, Dr. Rostain makes a strong point that the diagnosis criteria are solid and if applied correctly, will not over-diagnose ADHD. A complete evaluation for a child that shows signs of ADHD involves many steps, checks, and a full case history. Unfortunately, in most cases, this complete workup is not done because it is too time-consuming and expensive. Instead, a couple quick surveys filled out by frustrated parents and teachers and your child too can get a prescription for ADHD “study” drugs.

A complete ADHD assessment includes interviewing both the parents and the child and looking at:

  • Identifying key symptoms
  • Tracking the developmental course of those symptoms and the corresponding concerns
  • Conducting clinic-based psychological tests
  • Complete review of prior school and medical records
  • Complete physical and possibly neurodevelopment screening to rule out other causes of disruptive/distracted behavior
  • Vision, hearing, and formal speech and language assessments
  • Individually administered IQ tests, educational achievement tests, and screening for learning disabilities
  • Differentiating ADHD from other disorders
  • Clarifying the developmental “inappropriateness” of those symptoms and concerns
  • Look for other causes of the symptoms including changes or stressful situations at school and/or home
  • Checking on sleep patterns. Lack of sleep mimics ADHD.
  • Evaluating co-morbid conditions
  • Determining the degree of impairment
  • Assessing the family situation and how they are adjusting and accommodating the child’s behavior
  • Identifying strengths and resources of the child and the family
  • Eliciting priorities for change
  • Identifying community resources

Most of the time all of the above is not done. Having gone through the diagnosis process in our family, I know it was much more straightforward. I just noted that I thought ADHD might be an issue, filled out a couple of surveys that were highly subjective, and presto, we had Ritalin. Since then we have let the prescription lapse. It seems that being in a better educational environment is more effective than drugs for producing happy, productive kids. There are many reasons why a child has high-energy and is easily distracted. If a highly gifted student is in a classroom that is moving too slowly, of course she may be distracted and not paying attention. If a profoundly gifted boy has a third grade teacher that is only covering science at the third grade level and he “corrects” her by pointing out inaccuracies in her explanations, is that a psychiatric disorder?

One of the most used surveys to assess ADHD impairment is the Vanderbilt Assessment Scale. Almost all the questions from the teacher survey can be answered positively when a child is highly or profoundly gifted and is in an inappropriate school environment, but does not have ADHD. If independent IQ testing isn’t part of the screening process, a child could be incorrectly diagnosed and medicated when all he or she needs is a more challenging class. Yes, the teacher survey does include questions about whether the child is above average or not in reading, math, and writing but again, if the gifted, bored child isn’t doing the classroom work, the teacher will probably not rank his “academic performance” as above average. This is one of the reasons SENG has started to heavily publicize the issue of misdiagnosis of gifted kids. Two of the top misdiagnoses of gifted and talented children are ADHD and Oppositional Defiant Disorder (ODD). ODD is frequently co-morbid with ADHD and these misdiagnosis are due to a basic level of ignorance among health professionals and teachers about normal social and emotional characteristics of gifted kids. The medical profession pathologizes that which is uncommon, even if it is just a different normal.

ADHD Psychology, Co-morbidities, and Outcomes – Coursera Class Weeks 6 & 7

ADHD is complex. While defined as an executive function impairment, there are different genes, parts of the brain, brain chemicals, and behaviors involved. We know that certain drugs and behavioral interventions can relieve symptoms of ADHD, yet the medical establishment does not know what combination of interventions will promote optimal functioning in any given ADHD patient. Frequently the best course of action and medication is found through an educated trial and error method. This is stressful for both the child and the family. However, finding ways to manage and treat ADHD impairments is essential. Weeks six and seven in Pay Attention: ADHD Through the Lifespan have focused on the functional impact and complications of ADHD. It has been a bit depressing.

Disorders seen with ADHD include oppositional defiant disorder (ODD), conduct disorder (CD), anxiety disorder, mood disorders (including bipolar disorder, persistent minor depression, and major depression), learning and language disorders, Tourette syndrome, obsessive compulsive disorder (OCD), autistic spectrum disorder, fetal alcohol syndrome, sleep disorders, substance use disorders, and post-traumatic stress disorders.  Whew. The more sever the ADHD, the more likely it is to co-exist with one or more of the above disorders. Parental issues such as depression, low-income, and decreased interest in the child and a deviant child peer group will also increase the likelihood of a comorbid disorder.

Children with ADHD:

  • Are more likely to have learning issues:
    • Speech, language, reading, spelling, math, handwriting, and listening comprehension deficits can all present at higher than normal levels in children with ADHD.
    • Overall, drugs do not correct the learning problems that may be present with ADHD and parents should insist on additional educational help for their ADHD kids with learning issues. Medical interventions can make a child behave better in class but they do not make the child learn more. Specifically, reading, spelling and math issues do not improve with ADHD stimulants although the stimulants may improve handwriting and comprehension. Atomoxetine (Strattera) may sometimes help with reading abilities.
  • Have lower than average intelligence (possibly the result of poor executive function);
  • Are less self-sufficient.

Perhaps due to their initial ADHD-caused difficulties academically and socially, children with untreated ADHD can develop low self-esteem and a type of learned helplessness. They prematurely give up when faced with seeming difficult problems and don’t develop the ability to seek challenges, expect success, persist, and take failure in stride.

The behavioral and cognitive effects of ADHD can cause lifelong issues. 30% to 80% of children diagnosed with ADHD will continue to have symptoms in adolescence and up to 65% will have them as adults. ADHD may just look different as a child grows up. External manifestations such as high activity may decrease, yet internally, inattention and disorganization can persist. The world expects us to develop more and more executive function as we age and this expectation can create real issues for adolescents and adults with ADHD. When key executive functions such as self-regulation, sequencing behaviors, planning ability, organization, working memory, and internalized self-talk are impaired, personal relationships and careers suffer.

Adults with ADHD are more likely to:

  • Have an annual income of less than $25,000;
  • Be high school dropouts or if they do graduate from high school, they are less likely to graduate from college;
  • Be addicted to tobacco and/or use recreational drugs;
  • Be unemployed;
  • Be arrested;
  • Be divorced;
  • Have poor driving records, including revoked licenses, and vehicle crashes;
  • Have poor money management;
  • Have trouble organizing a household and raising children.

The lack of executive function that is a primary deficit in ADHD can cause secondary executive function problems, similar to the learned helplessness created in children with ADHD. These secondary EF problems may respond to coaching and training. People with ADHD can live in the moment and while they may know what to do, they have trouble with execution. Lecturing someone with ADHD or merely teaching them organizational skills is rarely successful. They know what is expected, they just don’t have the internal support to always follow through.

Instead of assuming individuals with ADHD will change their brain wiring and suddenly have organizational skills, it is more effective to “reverse engineer” and externalize executive functions. Technology is making this easier. Smart phones can give time reminders and have nagging due lists. ADHD coaches can help individuals learn how to break tasks into small steps, externalize sources of motivation, and post critical reminders at the point of performance. While drugs are an important treatment component for some people with ADHD, behavior training is essential. Natural settings should be restructured to externalize executive functions and then these accommodations must be maintained.

Given the increasingly high societal and economic cost of ADHD, it is distressing that the current sequester has cut programs for low income children. Early interventions for children with parental support is one of the most effective ways of preventing the negative comorbidities associated with ADHD. Individuals with ADHD have the greatest success when important people in their lives compassionately and willingly help them with their organizational needs. This is only possible if parents, educators, and spouses understand how to best support someone with ADHD.

Improper regulation of neurotransmitters in ADHD – Coursera ADHD – Week 5

This week’s class gave us a more detailed look at the neurochemistry of ADHD. Much of it focused on monoamines, catecholamine synthesis, chemical structures, and neurobiology of the brain. I’ll attempt to distill the information down to what I, as a parent, find most helpful.

The neurotransmitters dopamine and norepinephrine are deficient or dysregulated in ADHD. On the molecular genetic level, research shows that the genes most likely linked to ADHD also affect dopamine and norepinephrine.

The entire mechanism of motivation and attention is complex and involves multiple brain areas and neurochemicals. Although it was not covered in detail, the transmitter serotonin is also thought to modulate brain function and affect the symptoms of ADHD. Because the system is so complex, researchers feel that the issue with ADHD might be more a dysregulation of the neurotransmitter system where the release of chemicals is out of sync than a systematic deficiency of dopamine or norepinephrine. That being said, most ADHD drugs work by increasing their production and/or slowing their re-uptake to extend their effect.

One of the lecture slides was a great venn diagram showing serotonin, norepinephrine, and dopamine functionality. The diagram here, from the World of Caffeine website, is a more complex version of the one used in class. It shows how the three monoamines balance to create optimal attention, motivation, mood, and cognitive function.

World of Caffeine also has a nice summary of how caffeine affects the neurotransmitters. Caffeine is frequently the ADHD stimulant medication of choice for adults with ADHD symptoms.

Outside of the formal lecture, responses to the office hours questions were also posted this week. Amid general course and detailed brain anatomy information, were a few answers about kids and ADHD that stood out:

  • ADHD diagnoses decrease with age due most likely to several factors including the disorder naturally improving with age in some individuals.
  • The current definition of ADHD and system of diagnosis will not over identify children if clinicians are careful in their assessments and look for other explanations for problems with impulse control and attention regulation other than ADHD. However, too often our healthcare system doesn’t allow adequate time for evaluations. This can also lead to missed diagnosis.
  • Exercise and diet cannot prevent the onset of ADHD but they can help improve the symptoms. Dr. Rostain recommends the book Spark by Dr. John J. Ratey for anyone interesting in learning more about using exercise to improve ADHD.
  • ADHD is linked to poor sleep. It is possible the same brain difficulties that lead to ADHD symptoms also interfere with sleep regulation.
  • Although autism and ADHD  are entirely different entities, the same genes are involved.
  • Psychosocial stress increases ADHD risk and insufficient sleep diminishes focusing and productivity for everyone.
  • Brain training can build focus, attention, and cognitive processing but there is limited data on which programs are most effective because the field is very new.
  • There is no correlation between ADHD and IQ other than as a group, children with ADHD have a slightly lower average IQ of 95 rather than the 100 of the general population. This little fact, to me, says that if a child who is highly or exceptionally gifted has symptoms that look like ADHD, extra care should be taken in trying to determine what is actually going on. It might be ADHD but it might just as easily be normal behavior for a stressed, high-energy, gifted child.

In a few of the office hours answers students were referred to Judith Warner’s recent article on ADHD in Time. The gist of the article seems is that ADHD is a true medical condition and if we get too worried about over diagnosis we run the risk of having insurance companies or congress deny effective treatment options to vulnerable kids. She states that it is a developmental disorder not a symptom of social pathology.

Yes, ADHD is a real problem and is classified as a developmental disorder. Yet, carefully treating kids negative affected by it does not preclude an in-depth discussion on modern childhood. It is a disorder triggered or amplified by certain environmental conditions. This makes it all the more important to closely examine what has happened to childhood over the last 20 years to see how we may have turned on the ADHD genes.

Stimulants for ADHD don’t improve long-term outcomes – Coursera – ADHD – Week 4

I am now 1/3 of the way through the class and overall I’ve really enjoyed it. The course description estimated the workload at 2-4 hours per week and that has been correct. The TA’s have done a good job responding to questions about the weekly quizzes and making changes when there is a consensus that a question had confusing wording. This week they are adding another unique feature for a Massive Open Online Course (MOOC) — office hours!  We can submit questions to the professor and Friday he will answer as many as he can.

This week we explored the neuro-imaging of ADHD. Although there are differences seen in PET and fMRI scans in adults with ADHD versus adults without ADHD, neuro-imaging cannot be used to diagnose ADHD. Looking at ADHD from a parenting or educator lens, here is the information I found most relevant.

First, while maximum brain volume is typically reached by age 16 for all children, those diagnosed with ADHD show about a 3-year lag in brain development. This is most likely one of the reasons they seem less mature than their classmates. Once their brains are fully developed at about age 16, people who have ADHD still show smaller and less active orbital-prefrontal cortexes, basal ganglias, and cerebellums. The size difference of these regions compared to a more typical brain is directly correlated with how sever the ADHD symptoms are in a given person. Individuals diagnosed with ADHD also show lower levels of dopamine transporters in the brain’s reward center. Although the lecture didn’t cover it, I suspect that an impaired reward system is one of the reasons some ADHD individuals are susceptible to drug abuse and addition.

One area of brain anatomy and function covered in-depth for the first time this week is the role of the anterior cingulate cortex. Individuals with ADHD have less activity in the anterior cingulate cortex than more neuro-typical people and this can significantly impair their performance. The anterior cingulate cortex is an essential part of the cognitive and emotional executive attention system and has a role in emotion, motivation, timing, focused attention, willed motor control, working memory, pain, error detection, reward, monitoring, and feedback-mediated decision-making. One of these, working memory, is explicitly tested for in IQ tests such as the Stanford-Binet and some researchers feel that working memory is more important than IQ when predicting overall achievement. A child may be highly gifted but not perform as expected if their working memory (and attention for that matter) is less than ideal. Although some high-energy gifted kids are incorrectly diagnosed with ADHD, there is most likely another group of gifted kids that are not recognized as being gifted or having ADHD because their performance is average and their behavior isn’t annoying enough for the adults to suspect ADHD.

So what effect do drugs, especially methylphenidate, have on brain function and anatomy as viewed with neuro-imaging? They definitely increase brain activity while they are in the system, however, they do not change brain structure. The medications can help a child improve their classroom behavior, performance, and teacher and peer interactions in the short-term. Yet psychostimulants do not seem to create long-term changes in outcomes for peer relationships, social skills, academic skills, or school achievement. This little tidbit, buried at the top of page 146 of the 1999 Surgeon General’s report on ADHD, assigned for our week 5 reading, sent me on a search for more studies and more information.

If ADHD medicine is only a short-term fix, why are we drugging our kids’s developing brains? Aren’t there other ways to change their behavior?  And if their symptoms are so bad, why is it common to just prescribe drugs without also helping them with behavioral techniques? The combined treatment of drugs plus behavior modification has better results than just treatment with drugs alone. The drugs may make a child more attentive, less impulsive, and less disruptive but they have no effect on academic achievement. Just because a child is sitting still, better at completing homework, and easier to handle in class, does not mean that child is actually learning more. The lack of long-term improvement with the use of stimulant medication, combined with study results that indicate that they may increase depression in some children and have negative long-term cardiovascular implications, makes me question why they are prescribed so freely in the US. This in-depth, long-term view is beyond the scope of the Coursera class which is more focused on the basics of how ADHD is viewed, diagnosed, and treated by doctors today.

People with ADHD can have a more difficult time completing tasks and attending to directions, especially if they are not interested in or are bored by the subject matter. Our current view has classified ADHD as a disorder because of this impairment. What if evolutionarily speaking, this isn’t the case? What if ADHD tendencies are a different way for a perfectly normal brain to function and the ADHD brain is optimized in some other way that isn’t compatible with our current education system?

The most interesting part of the lecture this week, for me, was something I noticed on a brain scan that wasn’t directly addressed. The brain scan from a study on anterior cingulate cortex dysfunction in ADHD, left me with a strong desire for more research. In it we see differences in brain activity during a counting stroop task for individuals with “normal” brains vs individuals with diagnosed ADHD. The “normal” brain on the left shows the anterior cingulate (green rectangle) lit up with bright yellow and red activity while the ADHD brain on the right shows nothing going on in the anterior cingulated cortex but lots of activity in the frontal stratal, insular and thalamic network. The lecture highlighted the fact that ADHD individuals had to work harder and were slower at solving the task than were other individuals because they were solving the task with a less than ideal brain region. This begs the question, what are the ADHD individuals thinking about and what connections are they making? Clearly there is a lot of something going on in their brains, by colored area alone there is actually more activity than in the “normal” brain. Just because they can’t perform as well on the counting stroop task does not mean that this activity should be deemed suboptimal. See the images yourself on page 1547 of the study.

We know that studies of scans of men’s and women’s brains clearly show that men and women process information differently and use different areas of their brains to solve the same problems. We also know that men’s brains are, on average, larger than women’s brains. This does not mean that men are smarter or that one sex uses the more correct areas of their brains. Perhaps the same is true in people with ADHD. Individuals whose brains are more wired with ADHD tendencies may struggle with tasks that are easier for people with more typically wired brains but does this really mean that ADHD is a disorder?

Coming up the course will explore the neuroplasticity of the brain and interventions shown through neuro-imaging to improve brain functions in individuals with ADHD. Given the lack of proven long-term positive outcomes with drug therapy, I am looking forward to good data on behavioral interventions.

 

 

 

Checking out Coursera – ADHD Class – Week 3

Well this has been quite the week for anyone interested in ADHD. As the New York Times reported on Sunday, the number of children diagnosed with ADHD has risen by 41% in the last decade. Clearly there is something going on here.  While this statistic has gotten a great deal of publicity, it seems to me people aren’t quite sure what to do with it. If other illnesses, say, cancer or cholera increased by 41% in 10 years there would be a massive mobilization on all fronts. We wouldn’t just treat symptoms. We would take a hard look at environmental factors. We wouldn’t assume that better screening was catching cases that have always been present. We would know that something radical had changed in the world of children that was causing them harm.

There is no definitive test for ADHD. There is no way to know, for sure, if we are catching cases that have always been present.  One hint may lie in the DSM-IV criteria for diagnosing ADHD which requires impairment caused by ADHD symptoms. In other words, if ADHD-type behavior and thinking causes no impairment for the individual, then there is no diagnosis.

Have we changed the environment and our expectations of children, especially boys under 10, significantly in the last 10 years? Is their world different enough that their normal, natural behavior is now an impediment to their success in school and life? Or, are they actually behaving differently and there is something vital to ideal development that has disappeared from the typical life of children, especially young children.

I would love to hear Dr. Rostain’s take on all the above questions. If this were a regular university class with live lectures, I am fairly certain that some of this week’s lecture would have been devoted to the recent CDC report. One of the major drawbacks of this type of Massive Open Online Course (MOOC) is that everything is prerecorded, and pre-formulated. While students have been discussing the latest statistics in the online forums, the instructor hasn’t officially given us his analysis of the data. Although it would increase the instructors’ workloads, I think MOOCs would benefit from weekly written or video blog posts by their instructors — tying the prerecorded course materials to recent headlines and perhaps to student concerns from the forums.

This week’s lecture and readings are about the neuroanatomy of ADHD. Although issues with the orbital prefrontal cortex and its control of working memory and executive functions get all the publicity, there are two other regions involved with ADHD. The basal ganglia, which is responsible for motor coordination and procedural knowledge, and the cerebellum, which controls movement and cognitive processes that require precise timing, are also affected. The three different types of ADHD, inattentive, hyperactive-impulsive, and combined, correspond with different levels of impairment in these three different brain regions. The lecture was dense with medical terms and brain anatomy and I’ll have to watch it a few more times.

There is a 3-10% reduction in the regional volumes of all three of these brain regions in people with ADHD. In people diagnosed with ADHD these regions work less effectively and efficiently. Now, here is the kicker, drugs increase the neurotransmitters norepinephrine and dopamine in these areas to help them work better but they do not change the biology of the areas. They do not make these brain areas larger and only make them more effective on a temporary basis when the drugs are present. I suspect that although they can cause immediate relief from some ADHD symptoms, drugs are not the best way of treating ADHD, especially in young children with rapidly growing and changing brains.

We know from the London cab drivers study that our brains can physically grow to keep up with the demand to learn new and specialized information. Thomas Elbert’s study of the brains of violin players shows that our brains change to conform to the current needs and experiences of the individual. Changing our children’s environments and what they do with their time may help their brains, at least in some cases, literally grow out of ADHD. Personally I think that the decrease in recess and child-directed play, especially outside play, needs to be taken more seriously. The lowering of the age for teaching formal academics combined with the child abduction and molestation fears that keep kids supervised and inside have changed the childhood experience. Add in the rampant lack of sleep that can create ADHD-like symptoms and it is no wonder diagnoses of ADHD are increasing. Perhaps instead of increasingly medicating childhood we should bring back PLAY, and regular bedtimes.

Checking out Coursera – ADHD Class – Week 2

Week two the Coursera class on ADHD Through the Lifespan taught by Dr. Anthony L. Rostain, M.D., M.A. of the University of Pennsylvania is focusing on the causes of ADHD. The lecture was well put together and very informative. The reading is from Brain Facts, a free publication from the Society for Neuroscience.

I am getting more enthusiastic about the course now that we are starting to tackle some of the science of ADHD. Although diagnosing ADHD can be an exercise in subjective opinion more that unbiased reality, ADHD does have a biological basis. The problem is that it is a complex genetic disorder where various factors alter the neural pathways. It doesn’t follow simple Mendelian inheritance rules although it is one of the most inheritable psychiatric diagnoses. The mean heritability of ADHD is 0.75 this is almost the same as the mean heritability of height and greater than the heritability of asthma, high blood pressure, breast cancer, or alcoholism. As an aside, autistic-like traits are 0.82-0.87 inherited which is something to keep in mind with the increase in autism diagnoses over the last 10 years.

The best data tells us that 65-75% of ADHD is due to genetics and 25-35% is due to acquired central nervous system injuries. If a parent has ADHD, their child has a 40-54% chance of having ADHD. The chance of a child being diagnosed with ADHD skyrockets when both a genetic factor and an environmental factor are both present. Specific genes associated with ADHD are serotonin and dopamine receptors and transporters, and synaptosomal-associated protein 25. The different types of ADHD may be associated with different genotypes and specific ADHD medications may be more or less effective, depending on which genes are contributing to ADHD in a specific individual.

Taking all this together, I believe there are some strong implications for public policy and preventative parent education programs. For example, after heredity, the largest cause of ADHD is low birth rate. In fact, low birth rate by itself is associated with ADHD as much or more than fetal alcohol syndrome, lead exposure, and the mother smoking during pregnancy, combined. Parents with low birth weight children should be educated on ADHD while they are still in the hospital. They need to know that if one parent has ADHD and their child has a low birth weight, there is an increased likelihood that child may eventually be diagnosed with ADHD. They must also be given ideas and tools for how to help their child learn impulse control and organization skills.

It is interesting to note the increase in ADHD, especially in boys, seems to parallel the decrease in recess, walking to school, and physically active gym classes. We know that serotonin and dopamine are positively affected by exercise and exercise can alleviate ADHD symptoms. I am hoping that Dr. Rostain includes exercise as a treatment option. Many parents, especially of very young children with ADHD, are looking for ways to help their children without medication. Again, if parents are aware of the genetic+environment risk factors for ADHD, they will hopefully be more proactive in helping their kids get effective, regular exercise.

Just like with autism, early intervention and extra effort can lead to improved outcomes for individuals with ADHD. It seems it is far better to help kids proactively develop good habits and coping skills instead of letting untreated or acknowledged ADHD symptoms derail their academic and social lives.

 

Continuing Education

When I was growing up, I viewed continuing education as either non-credit classes for adults with extra time on their hands or very specific classes with continuing education units (CEU) required for professionals to maintain their licensure. Most adults had a definitive end to their serious education. Once they received a high school degree or completed a college degree program, they were basically done with formal education.

While most people continue to learn new things throughout their lives, syllabus-driven learning with specific reading assignments, due dates, and tests usually ends in their late teens or early 20s. This is unfortunate because it makes formal learning seem more and more daunting the older we get. When learning stops, it impacts the mobility, flexibility, and performance of individual workers. It also hurts our economy, especially in industries that are undergoing rapid change.

Better educated individuals have higher earnings and lower unemployment rates and the gap between the economic success of the highly educated vs the less educated is increasing. Given that most people will work into their 60s, it is increasingly unrealistic to think a few years of school will give them all the all the information they will need for the next 40 years. The job that you have in your 40s, may not even exist when you are in your 20s.

What does this mean for today’s children? We need to cultivate within them a joy of learning and the attitude that their education should never end. I believe that in the future, adults will almost seamlessly move from traditional college and university programs to online self-study and back again. Learning will be much more continuous and something that people choose to do to maximize their employability and because learning is fun.

Most people have had at least one negative school experience. Mine was freshman calculus. I barely passed and to this day, when I think about it I get a bit queasy. The information I was supposed to learn still seems just barely out of reach and it has made me wary of other educational challenges. At the time I took the class, there wasn’t a good way for me to go back and actually learn the material properly. I had my grade and it was time to move on to the next semester. True understanding never happened — making it impossible for me to continue to build knowledge, when the new information required a solid foundation of calculus. Gaps in education like these can build over time and can contribute to the stagnation of kids and adults alike. We as a nation need to look at  how we can improve education both during the traditional school years and throughout a lifetime.

For myself, I’m going to be checking out the Khan Academy precalculus and calculus classes to see if I can learn it again for the first time and continue my education.

Checking out Coursera – ADHD Class – Week 1

I am a huge proponent of online education. Especially in the K-12 years, online education can become one of the great equalizers — allowing all kids to learn at their natural pace. As I wrote yesterday, gifted low-income students may have the most to gain from quality, online classes.

Right now one of the complications with online education is it is difficult to figure out the quality, difficulty, and educational effectiveness of any given program. This is particularly true with the free online options. Three of the big players in the free online education game are Khan Academy, iTunes U, and Coursera. Over the last several months I’ve played around with subject matter in Khan Academy and iTunes U and now it is time to take an in-depth look at what Coursera has to offer.

Unlike Khan Academy and most classes and material in ITunes U, Coursera structures its courses as much as possible as true college classes. They have definitive start dates, end dates, quizzes, homework assignments, and online discussion forums for creating class-centered virtual communities.

I am taking a University of Pennsylvania class on ADHD Throughout the Lifespan taught by Dr. Anthony L. Rostain, M.D., M.A. Dr. Rostain is a Professor of Psychiatry and Pediatrics at the Perelman School of Medicine at the University of Pennsylvania.

Gifted children whose needs are not being met may be misdiagnosed as having ADHD. Within the gifted community, many parents and experts know that ADHD type behavior may actually be a gifted child in need of more intellectual stimulation, not, in fact ADHD. I’m taking the class to learn more about ADHD in general and to see whether this issue of misdiagnosis of gifted children is mentioned in general ADHD material. The course is 12 weeks long and started March 18th. They estimate the workload at an easy 2-4 hours a week.

Week 1:

Having watched and listened to numerous web videos throughout the years, the quality and ease of use of the Coursera lecture is quite solid. The slides are integrated into the video, easy to read and appear onscreen throughout the lecture in a larger window than the video of Dr. Rostain. Three or four times during the lecture, it stops for a quick quiz to make sure students are following the material. This week’s reading materials basically covered the same ground as the lecture. This week focused on the DSM-IV definition of ADHD and the statistics on how common it is in children and adults, males and females. Also covered was an overview of diagnosis and treatment.

Sadly, the only mention of IQ was that ADHD occurs equally across all levels of intelligence. ADHD is primarily diagnosed in children by adults who are observing and having to deal with the child’s behavior. Basically the child needs to exhibit 6 symptoms over 6 months to be diagnosed. Although this wasn’t at all covered in the class, a highly gifted student in a class with a teacher who is not aware of common gifted traits could easily be diagnosed with ADHD. Interestingly enough, when parents and teachers rate the same child for the prevalence of ADHD symptoms, no more than half the time do the parents and teachers agree. This can sometimes lead to teachers pressuring parents to medicate students to make them easier to handle in class. A highly gifted student in a completely inappropriate educational environment could be diagnosed with both ADHD and Oppositional Defiant Disorder. Yes, gifted kids can also have ADHD and other issues but any diagnosis of mental disorders should be put on hold until the educational environment is examined. The DSM-IV ADHD diagnostic criteria states that a diagnosis of ADHD cannot be made unless there is, “Clear evidence of interference with developmentally appropriate social, academic or occupational functioning.” If a regular classroom doesn’t meet the needs of the highly gifted student, then it is the classroom that is developmentally inappropriate, not the child’s behavior. Given how we have made kindergarten into the old second grade, perhaps the increasing numbers of boys being diagnosed with ADHD has to do with how we have changed their school environments, not impairments within their brains. I hope later lectures will get into this idea of developmentally inappropriate environments. Within the discussion groups there does seem to be interest in the overlap between giftedness and ADHD diagnosis.

Overall, I’m having fun with the class. It is nice to be on a schedule with other students across the country and the world. The quick quizzes while not rigorous do help focus attention on specific points within the lecture. We will see how this next week goes.