1:03

parents

1:05

as rapidly as professor patriot memory verses caroline as well as any other

1:10

state in sentencing your

1:13

p_c_r_ carryover two hundred thirty cents an interval numerous books videos

1:18

and subbarao and he is a courtesy have been tested from here

1:23

and this is a true for those of us into the t_v_ as well as a problem and he’s

1:27

going to be in a field that we looked for facilitation and hit

1:32

disinvestment paranoia

1:34

i think that this asking him

1:37

let me know the most recent

1:39

up to date

1:41

have version of what we think the dayton some of the issues that are turning

1:45

around each state

1:47

financially speaking about

1:49

advances understand the nature causes impunity steep

1:53

featuring involvement address america

1:59

got as i said earlier at the uh…

2:02

four copies inflation itself

2:04

i didnt derive great satisfaction and pride from having a spoon as

2:08

accomplishes julian

2:09

all the things that she’s done in her career sewing

2:11

maybe you don’t know that julie was one of my

2:14

dissertation students but we won’t say how long ago that one

2:19

what i’d like to do tonight is to single out some of the many advances that have

2:22

occurred in the last ten years in our understanding and management of a d_h_ d

2:27

and by only half an hour so i may have to skip over a few of these

2:31

it and not come in as much detail as i might ordinarily like to do

2:35

but nevertheless i’m going to get what i think are some of the major highlights

2:38

of

2:39

of what’s new about me dat this disorder that we’ve known about for

2:43

over a hundred years now

2:45

before doing so i am required at these public presentations to disclose my

2:49

sources of support so you can see with her happy conflict of interest and of

2:52

course i have many

2:54

but but the most important one is to know that i have to do consult to every

2:59

pharmaceutical company that has eighty-two medications on the market so

3:03

and have it

3:04

what i would like to do it of course as i’ve said talking about major advances

3:07

in understanding to management identifying cause of a p_h_d_

3:11

isomer spent just a little bit of time on the theory of a deep steve what may

3:15

be going wrong

3:17

under the surface of a teacher because what we have right now is a description

3:20

of someone’s behavior

3:23

when we look at symptoms when we use r_d_ s_m_ criteria for diagnosis when we

3:27

lose reading skills in interviews

3:29

on re-doing his documenting what a person does

3:32

that’s like saying that autistic children

3:35

tawk funny flap their hands and don’t make eye contact

3:38

that’s not a theory of all it is a meta description of certain artistic like

3:43

behaviors

3:44

and what we’re doing today the agency is describing certain aviation like

3:48

behaviors but can we formulate an underlying theory like we’re trying to

3:51

do about it in for a teaching i think the answer is yes or no

3:54

try to do that briefly this evening

3:56

and then i’m going to talk about some of the developments in treatment

3:59

to begin with i would like you to

4:01

sort of appreciate just

4:03

the refinement that has gone on in the last decade of even the description of

4:07

eighty h t

4:08

previously we were just sitting here in attentive in your hyperactive impulsive

4:12

but now we can go much further and specify that kind of in attentiveness

4:16

that you have

4:17

after all there are six different kinds of inattention mediated by the human

4:20

brain

4:21

each has a different world network is probably has different neuro

4:24

transmitters

4:25

helped to mediate this

4:28

a_t_t_ does not interfere with all six of those so

4:31

can we get more precise

4:33

sim defining what makes this an attention disorder as compared to the

4:37

kind of an attempt to c_n_n_’s ivy disorders

4:40

or depression

4:41

or the learning disabilities or in schizophrenia

4:45

they also have attention problems

4:47

they’re not all the same

4:49

so all in attention is not eighty h t

4:52

nor is a dat necessarily a disorder that influences all kinds of inattention

4:58

and we have gotten much more precise

5:01

in showing that eighties he specifically as a problem with persistence toward the

5:05

future processes toward our goal

5:07

the ability to say

5:08

stain behavior over time

5:11

toward attach quickly people would call sustained attention

5:14

but william james over a hundred years ago referred to as persistence

5:19

this aspect of attention is quite unique

5:22

because all other aspects of attention

5:24

are on the information processing side of the human brain

5:28

and this is not

5:29

this is on the motor side of the human brain

5:32

this is how behavior is planned

5:35

organized executed

5:37

and sustain toward a goal

5:39

all of which are largely

5:41

output or motor functions of the brain

5:44

not perceptual functions

5:46

so it would be wrong to say that there is something perceptual e wrong and

5:49

eighty h d there’s no mental filter out of work

5:53

there’s no altered perception of reality the a_t_t_ child seat

5:57

the same reality as a child sitting there subsidies

6:01

where they differ is that the aviation individual reacts to death that reality

6:06

responds to those events differently

6:08

than other people

6:09

and one of those differences in responding

6:12

is the inability to sustain

6:14

that response

6:16

until the task is accomplished until the goal is achieved

6:20

so i think that’s an important distinction because it will separate the

6:23

kind of attention problem

6:26

anxiety doesn’t produce that depression doesn’t produce tab

6:29

those aren’t the kinds of things we see in the learning disabilities

6:33

which also have some attentional disturbances associated with them

6:37

the second problem with attention which is of course very tightly linked to the

6:40

first

6:41

is resistance to distraction

6:43

and that makes sense you can see that they’re opposite sides of a common coin

6:47

in other words if you can process that’s because you can resist interference

6:51

and if you’re capable of existing distraction you can probably persist

6:54

towards your goals

6:56

so there really are highly correlated with each other

6:59

the ability to resist interference is what asus

7:03

sites in our persistence

7:05

toward the goals that we are holding in mind the task we need to accomplish

7:09

so there is imperative

7:11

distracted billy

7:12

but unlike what laypeople in teachers think the distract ability is upon the

7:17

sensory side of our brain as i’ve already sent

7:19

the person with a beach he doesn’t perceive is distracting event that you

7:22

didn’t hear or see

7:25

they hear and see the same thing you do and vice versa

7:28

the differences that reacted to that distracting event

7:31

when the board went by the window when they heard the conversation the hallway

7:35

when they heard the harley-davidson go by the classroom

7:38

that provokes a response

7:40

the other children suppress

7:42

because it’s irrelevant to the goal to the task

7:45

the ability to suppress responding to irrelevant events

7:49

is this destructive melody this is the topic it’s not goes to the window looks

7:53

out starts talking about harlem says is that has one wants know if you want one

7:57

by the way to go to the normal beach national running conventions i went

8:00

there last year to really kind of cool

8:03

to see what happens there off and running on this chain of tangential

8:07

thinking and behaving

8:09

but that’s the motor abnormality

8:12

not sensory abnormality

8:14

so the idea that a p_h_d_ children picking up on things

8:18

you and i don’t receive flutes

8:22

there is a third aspect of the attention of the servants that fascinates

8:26

to leave myself

8:27

others who are here to buy the person are you talking about this as well

8:31

and that is

8:33

a_t_t_ individuals can not

8:35

holden mind information

8:37

that guides behavior toward a goal and this shows up very clearly

8:42

because when they’re distracted

8:45

something they do that you and i don’t know

8:47

is they don’t return to the task

8:49

u_n_ ironman were distracted and you will be distracted because some events

8:52

are two compelling to ignore

8:55

the phone call that comes in for instance that you have to take now so

8:58

you start writing and shifting talk

9:00

but what do you know singer and if i go back to what you’re doing

9:04

the aviation person does not

9:06

that distracting event

9:07

house now destroyed this capacity

9:10

to keep the golden mind

9:12

now holding information in mind

9:14

that is guiding behavior toward our goal

9:17

is working memory

9:19

that’s the part of the brain that allows you to do that

9:22

so here we see that there’s an aspect of the p_h_d_ has nothing to do with

9:26

attention

9:27

it has to do with the capacity to keep information in your head

9:32

actively

9:33

in mind

9:34

while you were pursuing that goal

9:37

edinburgh psychology we call that working memory which many people should

9:40

simply refer to is this

9:42

remembering so heads to too

9:45

it is a special kind of memory which is why it’s called working memory

9:49

which distinguishes it from the traditional memory system

9:52

of the hippocampus and storage and retrieval up information

9:57

this does not have to do with that system

9:59

this is a different system

10:01

remembering

10:02

treat do twitching losing your fifties

10:06

under her eyes

10:07

and that’s what women lose in perry menopause big time

10:12

what you are losing is the capacity to hold in mind which we’re doing

10:17

and sega development by wife is affectionately called the but first send

10:21

i went into my office because i needed to handle this but i saw have been

10:25

waiting to be paid for her at her

10:28

men and women

10:29

overhear should be

10:32

novel environmental chronograph prior

10:36

there is a warning that

10:39

endure the wondering if the government generated and policy studies

10:43

but

10:49

villa states the point

10:51

in other words

10:52

but now the events around him

10:55

have become more compelling

10:57

than what you were holding the line

11:00

and so when people age

11:02

or hit menopause

11:04

what you’re experiencing is very similar to what people with the dhtml

11:08

experiencing since childhood

11:09

simply magnify it fire for factor of ten

11:14

but if you took those has a little baby h_d_ government particularly as working

11:18

memory begins to decline

11:20

and in older life

11:22

you don’t lose your memory

11:24

lucia working

11:27

is a fascinating discovery because

11:30

working memory is one of the five major executive functions there may be more

11:34

than five this is debatable

11:36

but most researchers technology at lease

11:39

five distinct executive abilities

11:42

and if working memory is one of them

11:44

and that is the session in a p_h_d_

11:46

it does rate the raised the question

11:49

are the others

11:51

is this an executive disordered

11:54

rather than an attention disorder

11:55

it certainly is more than an attention disorder

11:58

and its findings like that and others

12:00

that have led many of us in this field to begin exploring

12:04

the other executive activities

12:07

and whether a d_h_ tina viduals are deficient in those

12:10

and we’ll talk about them short

12:12

but you can see then that certainly under detention we are coming to realize

12:17

that’d isn’t inattention

12:19

it’s more and

12:21

and that he has some five is not going to reflect that

12:24

in the year twenty eleven

12:26

it will relabel

12:28

this list of symptoms

12:30

as reflecting more than

12:33

which it should treated

12:35

now there’s a second problem jackie develops first

12:39

and it’s an inhibition problem

12:41

and the hyperactivity comes from that

12:43

so that the excessive activity of the young a_d_d_ child is not distinct

12:48

symptom from the others

12:50

it’s part of the inhibitory problem

12:53

it’s a preschoolers

12:55

symptom of in addition deficits

12:57

as a preschooler agents

13:00

hyperactivity is going to decline quite markedly

13:02

such that by adolescents it is becoming more of a subjective internal

13:07

feeling the need to be busy

13:09

and to be engaging in multiple things that you never finish but doing multiple

13:13

things

13:14

and by adulthood hyperactivity is of no value

13:18

for diagnosis it’s one of the findings of my new book that i spoke about

13:21

earlier today an adult eighty each day

13:24

which is one of the first release of show that in adults

13:27

restlessness is actually of

13:29

no doubt in three different about this

13:31

in fact it tends to go with anxiety disorders by itself

13:35

not with adult medium xti

13:37

but the inhibition problem that gave rise to it

13:41

impulse of thinking

13:43

the inability to control your motor reactions to things around him

13:47

persists

13:48

much longer

13:49

into adulthood and it’s one of the top three distinguishing features

13:53

of the absolves the kitchen

13:55

makes impulsive decisions

13:57

fails to think before they act

14:01

so if you need to understand that some of this this sort of superficial

14:05

hyperactivity may decline

14:06

but its underlying problem with inhibition is not declining quite so

14:10

much

14:11

and you can see that here

14:14

even though this is a description of people with a p_h_d_

14:17

we’ve been able to refine that description for her

14:20

down to something more precise that allows us to say

14:24

what eighty eight he is

14:26

and what it isn’t antoinette anxiety disorder is

14:29

and when it isn’t there are no other disorders i’m aware of

14:33

that produce these problems

14:36

chronicling

14:37

unremitting

14:38

dating from childhood

14:41

other disorder

14:43

so if your focus on what is precise about me dat really helps permissions

14:47

and their diagnosis

14:49

is that this is that there is a fine holders of generalized anxiety

14:53

and now we can begin to do that because the other disorders don’t do this

14:57

in a chronic

14:59

unremitting course

15:02

another advance has been in the typing of a_t_t_

15:05

since nineteen ninety four

15:07

we have been experimenting with a way of typing a_t_t_ in our diagnostic man

15:13

we’ve had three types

15:15

we’ve had people who only have the inattentive deficits

15:19

and have less problems of hyperactive impulsive behavior that’s the intent of

15:22

group

15:23

we have the inverse group of people

15:26

and we have the majority who have both of these deficits and we call them the

15:30

combined type

15:32

and we’ve been studying this way of subtyping eighty-eight reason that we

15:36

can now ask the question

15:38

what’s missing useful scheme useful strategy

15:41

ort this turned out to be simply the result of the fact that we had

15:45

to lists

15:47

and as with the chinese restaurant menu

15:50

if you have column a in column b

15:53

you can make three things out of two columns

15:57

in other words it’s not very useful

15:59

and the answer turns out to be the second one

16:03

and so in twenty eleven we will of the end of this approach

16:07

because it has no clinical

16:09

or research value

16:11

it turns out that mediates the isn’t three things

16:15

it’s one thing

16:16

and these are simply variations and severity

16:19

because people move from these into decent firms here over the here because

16:24

they’re hyperactivity is declining

16:26

but that the assembly sense this is three types of something

16:30

when in fact it’s a dimension

16:32

at the recent severity

16:34

and it’s a single disorder in the population

16:37

so this will be cut

16:40

now what’s to replace

16:42

well the europeans have been doing something that we have avoided doing

16:46

but it turns out they were probably right

16:50

at least twenty years they have sub-type paper connecticut disorder which is what

16:54

they called this for me

16:56

into those who were hyperactive with conduct disorder and without condoms

17:02

we are in the u_s_ and north america more generally

17:06

view this is simply co morbidity

17:08

one disorder just happen to occur with another

17:11

and therefore if we were correct

17:13

what you should see in the combined group

17:15

is what you would expect if you added one disorder

17:18

to the second disorder

17:20

additive

17:22

but in fact when you study the combined group

17:25

what you find it it’s not active

17:28

it’s quantum leap

17:30

works

17:31

both disorders start much earlier

17:34

in the combine

17:36

both disorders are highly persistent

17:39

much more so overdevelopment

17:41

then when pete’s disorder occurs along

17:44

the families again tries to these combined shipment

17:47

arm markedly more impaired

17:49

with much higher rates of psychiatric disorders

17:52

critically antisocial personality disorder alcoholism

17:55

drug use and major depression

17:58

we know that one and five of these children

18:02

will have the traits we associate with adults psychopathy

18:06

the psychopath

18:07

these are what we call the callous unemotional traits

18:10

lack of empathy

18:12

lack of conscience

18:13

lack of kilts

18:14

and remorse

18:16

and combined with that

18:17

isn’t instrumental predatory

18:20

form of intentional aggression

18:22

they prayed on the other people

18:25

and this starts very early in the lives of these children

18:29

hof rick has shown that we can identify psychopathic children

18:32

not just adults

18:34

and that they’re likely to be found within this group

18:38

a_d_d_ alone does not give rise to the cycle

18:41

neither does conduct disorder love them

18:43

so there is something about this combination

18:46

that does suck

18:47

which is just one more example

18:49

of light when they occur together

18:52

isn’t just overlap

18:54

it’s a stitch form of a beach t

18:57

so those of us to do behavioral genetic studies are now studying them

19:01

a separate group

19:02

i think that mirror imaging people might want to take a second look at that well

19:06

because if you combine the main

19:08

with your purely a p_h_d_ group your adding and norway’s

19:12

when you could have had more homogeneous groups of people

19:15

because we now believe that there are physiological differences

19:18

between these groups

19:20

for instance this group

19:21

shows a much more reduced response to stress

19:25

whether measured through the hypo pituitary axis and cortisol secretion of

19:29

saliva

19:30

whether measured through the

19:33

sympathetic nervous sleazy parasympathetic nervous system

19:36

and once galvanic skin response and heartbreak deceleration

19:40

and expiratory changes

19:43

these individuals

19:44

couple marked

19:45

altered response

19:46

alone response to stress

19:49

then do ordinary children or each teacher

19:52

so there is something about these individuals both biologically

19:57

psychiatrically

19:59

developmentally

19:59

and familiar with that points to this being a distinct group of people

20:04

and i think you’ll see in the s and five we’re likely

20:07

to use that

20:08

as a more useful approach for clinicians sub-type their patients

20:12

then this

20:14

far less useful view d_d_t_

20:18

now weakened dispense with the hyperactive type

20:21

because it turns out to simply be the preschool stage of the combine type

20:25

in which wanted to build studies have shown that over ninety percent of people

20:29

cold this time

20:30

eventually get the combined

20:32

you just caught them young

20:34

and that’s because the hyperactive impulsive symptoms start earlier

20:38

then the inattention an executive deficits to but within three to four

20:42

years they will be combined type and even if they aren’t

20:45

they miss it by just a single sin

20:48

which means they’re just a milder variant of the combined

20:51

now there are a few children in here who are already only oppositional on that

20:56

won’t say much about them

20:58

but it’s simply a group of children where parents confused oppositional

21:02

behavior with the agency

21:04

as the oppositional disorders outgrown

21:07

the each disappears

21:09

and that’s because oppositional disorder when it occurs alone is benign

21:13

at fifty percent of all cases disappear every two years follow

21:17

now when oppositional disorder occurs with another disorder like bipolar

21:20

disorder reviewed your conduct disorder

21:23

is a highly persistent disorder

21:25

but occurring alone it is not the disorder to get very excited about

21:30

and that’s usually what we’re seeing here i’m not going to spend more time

21:33

skits but the lesson there

21:35

is that there is no hyperactive technical wants

21:38

now this is a group of children worthy of more comment

21:42

because

21:43

while some of these children are clearly variations are combined to children

21:48

and need to be reclassified as such

21:51

that is a group leftover

21:53

are quite different

21:55

and it’s anywhere from thirty to fifty percent of all children

21:59

called inattentive

22:00

only a p_h_d_ children

22:02

researchers have invented the term for these it’s not a diagnosis if you use

22:06

outside this room of missions have never heard of it

22:09

but in the research literature this is the term that is being used to describe

22:12

this unique

22:14

group of individuals

22:15

i believe this is a separate disorder from eighty h_d_ lurking within the

22:20

larger sample of eighty-eight years been another attention disorder

22:23

but even my conservative colleagues like steven shortest

22:27

down the road at u_c_ berkeley

22:29

even though he would say that maybe it is in a separate disorder with agree

22:33

that it’s qualitatively different from the combined type a_t_t_

22:37

whether you’re in the disorder camp or the subtyping abundant here

22:42

finding that is important tonight is that there are many

22:46

qualitative difference is that

22:48

aren’t worthy of appreciation

22:50

first of all the symptoms shown

22:52

in the air c_t_ child

22:54

are the opposite of eighty h_d_ symptoms

22:58

this is a steering child

23:00

at teaching the child

23:02

a passive child

23:04

who is lost art work

23:06

slow-moving

23:08

sluggish

23:09

scalars

23:10

this is the trial that is often viewed as mentally spacey

23:15

foggy

23:16

and appears to not be attending well to reality around

23:22

those in many cases at the end to the since

23:26

of the each to child who is distracted pple

23:29

impulsive

23:30

active

23:31

engaging

23:32

in your face

23:33

but they do you teach our to come into this room you would know in minutes

23:37

it’s an s_a_t_ charlie come into this room you would never know what

23:42

so the difference in the air

23:45

disrupt development

23:46

to the environments quite striking

23:48

this is not the destructive group of children

23:52

p_h_d_ trucks clearly disruptive

23:55

now there are other differences

23:57

a_d_ h_d_ is not information processing disorder

24:00

dissidents

24:02

suggesting there’s something in the peripheral

24:05

or in the sensory analyzers of the brain the post courier aspects of the brain

24:10

where this disorder lines

24:12

those of us in a row psychology

24:14

or tantalized by the finding that

24:16

the symptoms and the processing problems

24:19

reminders of children who have white matter disease of the brain

24:23

where there’s been a disruption in the cortical subcortical loops processing

24:26

information

24:28

eighty h two children do not show

24:30

now i don’t know that that’s the source of their problem i’m just

24:34

drawing an analogy here

24:35

the powder enough cognitive impairment

24:38

resembles that of

24:39

other posterior disorders

24:41

and not of the eda to trial

24:45

when we look at the kind of attention impaired out of the six dimensions of

24:49

attention

24:50

these children are very concerned that the detention

24:53

to the ability to identify rapidly what is important in front of you

24:57

from what is not

24:59

some people call that focused attention

25:01

but it’s really are selective aspect of attention

25:06

when we look at their memory systems the a_t_t_ child has a working memory

25:10

problem they forget to do

25:12

these trials children seem to have a retrieval problem out of storage of

25:15

memory

25:16

but i had a question mark because it’s very understudy

25:20

so i don’t want to pass it off of something definitive

25:23

certainly worth further examination

25:25

what is much more definitive

25:27

is that the social impairment of these children

25:29

by the opposite of a d_h_ teacher

25:32

these are surely children

25:34

reticent

25:35

apprehensive

25:36

less involved

25:38

now unlike the asperger’s an autistic spectrum disorders orthostatic hypo

25:43

schizophrenic disorders they’re not pollute and disinterested and other

25:47

people

25:48

it’s not that they have a disregard for socializing with other cities

25:51

so much more typical of the autistic spectrum children

25:54

they do want friends they are interested

25:57

and they have appropriately so appropriate social skills

26:00

that just a little more anxious

26:02

little shop a little hesitant

26:04

but you don’t see the operatives

26:06

that you see in the s_p_ and indeed skits type of children

26:10

you can see the bizarre aspects of interaction

26:13

that supervisors of their children

26:15

so what you’re really seeing here is a wall flower

26:18

these children have friends

26:20

not as many as normal children

26:22

but far more than eighty aged children do

26:25

haiti child is likely to be friendless by second or third grade that is not

26:29

true with the extra

26:31

these children by definition have no inhibitory deficit

26:35

a dat at its core isn’t in addition to sir

26:39

if we were to place

26:41

in primacy

26:43

one of the three sensitivity p_h_d_ it would be the immigration problem

26:47

that is that one of the central features that theorists have repeatedly going

26:50

back to

26:52

as part of a d_h_ d

26:54

that is not the case with this disorder

26:56

this alone

26:58

supports my argument that this is a separate disorder

27:01

because these children black

27:03

the parent cora feature of the defines the each teacher

27:07

which is the inhibition problem

27:09

there are differences in coe morbidity

27:12

disorders ago with a p_h_d_ are quite different

27:15

a_d_d_ children have markedly higher risk for oppositional disorder as i

27:19

mentioned in my previous talked this afternoon

27:22

a substantial minority go on to develop conduct disorder

27:25

these children carry very low grades for those disorders

27:29

probably no higher than the population greater if they are

27:32

their in significantly higher

27:34

whereas the a_t_t_ child markedly higher in contrast

27:39

research is quite convincing

27:41

that anxiety is much more feature of this group of children

27:44

and even if the each teacher

27:46

now about twenty five percent of the beach to children

27:49

have an anxiety disorder

27:50

but the rates are higher among these children

27:53

it’s less clear that depression

27:55

is elevated

27:56

we used to think that it was

27:58

that they need to children carry a risk of depression too

28:01

and the differences are not impressive at least not at this point

28:04

they’re more aggressive for anxiety

28:08

both children suffer in school

28:10

equally infect

28:11

but if one studies that

28:13

colleen of mistakes

28:15

the reason behind the school failure they choose seem to be qualitatively

28:19

different

28:21

these children have more problems with their arms in school work

28:24

a dat child has problems with production of work

28:28

number of problems done

28:30

and all the hype oversimplified since both groups of children probably have

28:34

both kinds of problems the relative proportion of errors

28:38

i think is worst

28:41

emphasizing

28:41

the immediate future up has a production disorder primarily

28:45

this chart isn’t that a receipt disorder

28:48

now these children have been found

28:50

to be more likely to have math disorders

28:52

but i don’t want to overplay the point because only a few studies have looked

28:55

at this

28:57

but we know the children with massive sorors

28:59

have a pattern of in attentiveness very similar to what we’ve seen here

29:03

and markedly different from what is seen a_t_t_

29:06

a comprehensive review of all research on

29:09

masters or response just a few months ago

29:11

make this point very clearly

29:13

that there are different attention problems associated with now

29:17

suggesting again that these children might be more prone to those problems

29:20

the families of different

29:22

eighty eighty families have more eighty h t

29:24

more schools down here

29:26

or conduct problems and more drug use problems

29:29

these children come from families with more learning disabilities

29:32

and more anxiety disorders

29:34

but we only have a couple of studies

29:36

and again emphasizing

29:38

it’s not a definitive finding family history

29:41

what is beginning to become clear in the last five years

29:44

is that there are differences in treatment response

29:47

the most compelling evidence

29:49

was the

29:50

stimulant steps

29:51

mainly done but not often a date none without a roll of the amphetamines and

29:55

certainly none without a mock fatine

29:57

which is trickier

29:58

but certainly not the phonetic studies show that the response of these children

30:01

to stimulus as unimpressive

30:03

my own study at u_-mass gunman julie was back there chica for gutless

30:08

shows about a twenty percent rate of response among these children

30:12

verses over ninety two percent of combine type children in that study

30:17

responded

30:18

to one or more of the doses of students

30:22

ours was one of the few dose-response studies

30:24

bother to simply found a rather lackluster

30:26

or mediocre response i want to make the point clear here

30:30

we’re not saying that stimulus because children works

30:33

what we’re saying is that they don’t help them

30:35

the response is not dramatic

30:37

not clinically impressive

30:38

you would argue for keeping this trial on medication after the trial

30:43

so even though there’s a slight improvement

30:45

it’s not worth some money side effects

30:48

the effort

30:49

to retain them in the trial

30:50

so we’re beginning to see the potential

30:53

evidence that stimulants are not really

30:55

the drugs for these children like they are

30:57

for combine type a_t_t_

30:59

there is growing body of evidence that these children are among the best

31:03

responders to social skills

31:04

eighty h detroit either don’t respond a social skills training or the skill

31:08

training response please

31:10

very unimpressive it does not generalize

31:13

outside the training environment

31:15

and one-in-four a_d_d_ children they actually get worse

31:19

people need to understand social skills training produces side effects

31:22

that some children engage in what we called t_v_ n c training

31:26

where aggressive children in the group train up the non-aggressive chosen to

31:29

become more aggressive children first

31:32

finally this email for your internet gardens of find

31:36

young children for start school again a garden become much more aggressive

31:39

during the first three to six months of kindergarten

31:42

so there really is eight downside to social skills training the commission

31:46

should not ignore

31:49

we need to remember that social skills training was originally invented in the

31:52

nineteen sixties for the treatment options

31:55

and it continues to show its most robust effects with anxious internalizing

32:01

and reticent people

32:03

the data on people with disruptive acting out to support much less

32:08

impressive

32:09

than it is on internalizing disorders

32:11

and that begins to explain why it’s the shiny d_h_ teacher i’ll

32:15

who seems to respond so well here

32:18

as opposed to disruptive a_t_t_ trial

32:21

now i will argue that these children might do better in behavioral

32:24

interventions there’s now a study of the however

32:27

but we can’t logically draw this inference

32:30

at least a potential reason to

32:32

further research in because the large studied known as the m_t_a_ study larger

32:36

study every kind of a view to treatment

32:39

found that the single best predictor of who did well

32:41

in treatment was anxiety

32:43

the more anxious you were the better you responded to the psychological and

32:47

behavioral and school interventions

32:49

and since these are the most anxious at the eighty each group

32:53

it would lead one to argue that they may well be our best responders to seconds

32:57

of treatment

32:58

we might fight here at work already seen for social skills training

33:02

now cognitive training which is teaching children to talk to themselves has been

33:06

tested

33:08

extensively for eighty hdmi

33:09

sales

33:10

we do not recommended as intervention

33:13

it works better

33:14

for anxiety

33:15

for depression

33:16

for internalizing symptoms

33:18

but home alone

33:19

this is an immediate each day

33:21

so don’t throw the baby out with the past year and assume that because a

33:24

treatment failed for a d_h_ d

33:27

it shouldn’t be used for s

33:29

c_t_

33:30

i actually believe there is good reason to think

33:33

the cognitive training program that would assist these children

33:36

first of all cognitive therapy helps anxious people

33:39

so it mite will help them only with their anxiety

33:43

but because these children appear to have normal internal language

33:46

for a speedy age the children are delayed in internal language

33:50

cognitive therapy might work for the straw

33:53

or is it doesn’t work for a p_h_d_ because of this failure

33:56

to develop appropriate

33:58

internal speech

33:59

and then finally i have pressured the lilly company

34:02

to test for tour with these children and the reason i ask them to do so and they

34:06

are now doing so

34:08

is because of a study published a few months ago

34:11

showing that’s pretty retreat anxiety will become a cruise with a p_h_d_

34:16

stimulus do not read anxiety

34:17

and there is a proposed literature suggested it probably worse incident

34:21

some children but not at all

34:23

but here is an instance

34:25

where we have a drug to treat spokes disorders

34:29

maybe it would help the strong

34:31

neuropsychology listener a scientist in the room also would recognize

34:35

but the kind of attention problem seems to be here

34:38

certainly mimics those that are associated with nora epinephrine

34:41

disorders

34:43

and might well be more responsive to a norepinephrine agent which is what’s for

34:46

tea brigades

34:48

and so just another hypothesis

34:51

not proof

34:53

don’t leave here saying barclay says fifty retreats and seating i have not

34:57

set that whatsoever and they can’t go to dinner

35:01

say that i sent that budetti reason why science would want to look

35:06

more closely

35:08

an asset

35:09

what we can say that in the last decade

35:11

we found another disorder

35:14

it seems to be within the d_d_t_ population but probably isn’t a_t_t_

35:19

i’m not sure yet whether it’s a distinct kind of eighty h t as others argue

35:24

or whether it might earlier suspicions are true that it’s actually separate

35:28

disorder

35:29

and needs to be treated as such india sinn fein

35:32

tedious and five committee bills don’t eat mac forever

35:35

now if any area has seen advances in the last decade

35:39

it has been an ideology the cause of the t

35:42

we can now say

35:44

without a doubt the a_t_t_

35:47

multi causal

35:48

there are many

35:50

roads to rome

35:51

ways to get a p_h_d_

35:53

we can’t just as safely say

35:55

that none of them

35:57

fault with the domain

35:59

social factors

36:00

it is impossible

36:02

to take a normal child

36:03

and expose them to nec societal

36:07

and produce this disorder

36:08

and i believe i can be made now

36:11

unequivocally

36:12

although known causes of a d_h_ t are in the biological factors

36:17

particularly the realm of neurology and genetics which are not dissociated from

36:20

each other better in fact

36:23

related fields of etiology

36:25

and we now know that there could be multiple causes within these domains

36:31

compounding each other and interact with each other

36:33

to produce the v_ chip

36:34

we are beginning to find through

36:37

work such as julies work here

36:39

under limited

36:40

many other studies such as the initials and that can studies

36:43

in the nineteen nineties

36:45

and the m_r_i_ and f_m_ orion and pet

36:48

inspect

36:49

and other neuroimaging devices

36:51

that eighty h d

36:52

is associated with at least four brain regions

36:55

that have been referred to

36:57

by these three

36:58

as the front of stride

37:00

cerebellar circuitry now known to be the inhibition circuit

37:04

of the brain size of the circuit the amount of activity within the circuit

37:08

race directly related

37:09

to impulse control

37:11

so we’re beginning to make some very

37:14

broad conclusions about causation but we can now to see

37:19

the absolutely ridiculous claim such as the syndicated columnist john rosslyn

37:23

that eighty eighty is the result of television

37:26

of port discipline

37:27

of lack of love

37:29

the notion of peter break-in

37:31

and the scientologists

37:33

that eighty h_d_ is the result of family factors

37:36

and not the result of biological factors we have many studies that can disprove

37:41

these ideas

37:43

we have learned from any many studies especially summarized in the brilliant

37:48

textbook by joel made public last summer

37:51

on what causes a beauty

37:53

that about a third of eighty h_d_ he’s acquired

37:57

due to central nervous system injuries

37:59

most of which occur prenatally

38:01

and you can see here a list of the factors

38:04

that have been identified reliably

38:06

some that we have strong suspicions about

38:08

but still need further research associate it with them

38:12

some that we can roll out

38:14

and while cocaine exposed babies have high rates of the peachtree

38:18

research now shows the isn’t the cocaine

38:22

it’s what these women due to themselves

38:25

women who are crack abusers are polly drug abusers

38:28

they smoke

38:29

they drink

38:30

they have high rates of adult dvd

38:33

their malnourished

38:34

and they have premature babies

38:36

those are the things that are causing their babies p_b_h_g_

38:40

not actually the use of the cocaine itself

38:44

so we’re learning then about prenatal

38:47

factors that contribute

38:48

a small percentage of a d_h_ is clearly caused by postnatal injuries after first

38:54

such things as you might expect

38:56

head trauma

38:58

blunt trauma for instance or even penetrating atms

39:01

lead poisoning has a long rich history

39:04

of association with a dat we know that lead is a toxin to determine brain

39:08

that it has a particular affinity for the frontal lobes

39:11

and especially

39:12

for the dopamine pathways

39:14

so it’s understood why that might be the case we’ve known the children with

39:18

leukemia

39:19

can develop a post leukemia eighty h t

39:22

but it now resembles more the s c_t_ pattern of symptoms i’ve mentioned

39:26

which explains why the stimulants are not showing a very impressive

39:30

responsive treating children who survived leukemia for their

39:34

post-treatment abt

39:35

if some fascinating work

39:37

on the role of the immune system

39:38

an a_t_a_ cheaper at petersons of someone a more familiar

39:42

but i learned this morning a meeting with a number of citeseer

39:44

of some absolutely fascinating cutting-edge research going on here at

39:48

the mind institute

39:49

on the role

39:51

immune factors in the immune system

39:53

and only in autism

39:54

probably an eighty h p

39:56

as well

39:57

and of course

39:58

we’ve known the children with peak a view

40:00

have high rates of a_t_t_

40:02

and of the executive deficits that go with them but we’re now finding that one

40:07

doesn’t have to have the severe condition a few keep noria

40:10

that just higher than normal levels as a chemical involve

40:14

in peak a view which is from a aloni in both the mothers and the baby’s blood

40:18

stream

40:18

is associated with higher rates

40:20

of executive deficits and it each day

40:23

suggesting that one doesn’t have to be some toxic

40:26

without allowing us to be peak a view

40:28

but just higher than normal levels may be poisoning

40:32

the frontal system

40:33

and the executive activities that take place there

40:36

we know from julius research from castallanos and many others

40:40

that the brains of a_t_t_ children are smaller

40:44

and less mature

40:45

not enough that there are damaging can be used for diagnosis

40:48

but enough that when we average groups of t_v_ age these games together

40:52

we can begin to see

40:53

about a three to ten percent smaller area

40:56

of brain development in the

40:59

orbital frontal cortex particulars are right side

41:02

in the basal ganglia deep inside the brain particularly the striatum

41:05

in the cerebellum again more on the right then the left

41:09

and also within the interior cingulate

41:12

although the interior section of the semester they seem to be smaller

41:15

as julies research has shown an others

41:17

by george bush for instance of hartford

41:20

dot the george bush another a

41:23

not not yet

41:24

but bushes research like julies finds that the interior single it is massively

41:29

under active

41:30

in various towns

41:31

that d_d_t_ people have trouble with

41:34

when we know from charge research that these are persistent findings

41:39

overtime in from childhood to adolescents

41:42

and contrary to the claims of scientologists

41:44

these are not the result of giving stimulants for children but our founding

41:48

stimulant naive children never treated previously

41:51

the region’s we’re talking about the right orbital frontal area here

41:55

this is the basal ganglia deep inside the brain

41:58

particularly the stratum which is this seems like structure here

42:02

and then the cerebellum which is a very primitive structure at the back of the

42:05

brain

42:06

it’s mainly the central area here as well

42:10

you can see here as well

42:11

in the functional deficits

42:13

this is some of the research by beth k seat

42:16

showing that there are both

42:18

the series the anterior cingulate medial aspect of the frontal lobe

42:22

as well as the great frontal lobe showing that it is associated with

42:26

patterns of under activity

42:28

in people with a p_h_d_

42:30

you can see a separation

42:31

in function between normal

42:33

and a_t_t_ individuals

42:35

in this relatively recent study

42:38

this is a study published just a month ago

42:40

absolute fascinating cereal

42:42

neuroimaging study

42:45

and this study was five yeah

42:47

social and his colleagues at the n_i_h_

42:50

and think you can see here

42:51

date the

42:52

scan children

42:53

every few years four different times across the government

42:58

and then computed which areas of the brain were behind at least three years

43:02

or more

43:03

in their maturation

43:04

to normal brain size not support understand

43:07

study a structure

43:09

brain size

43:10

the study of function

43:12

but what you’re seeing here and the darker than blue

43:15

the greater the leading

43:17

are the areas of the brain that are at least two years behind

43:21

in their maturation

43:22

one can see here graphically

43:24

if one plots the match a regional curves

43:27

from normal children

43:29

and for each each teacher over

43:30

the difference of course showing the delay

43:33

to reaching falls structural brain size in a d_h_ uses one of many studies

43:39

showing that there is a neurobiology kal basis to this disorder

43:43

and quite consistent with argued that this is a developmental disorder

43:47

not been aberration or psychopathology

43:50

that it represents a delay in maturation

43:53

a fascinating finding in the study

43:55

is that there is a small region in the brain this over developed

43:59

short early in the eighty eight ij shle

44:02

it matures too quickly

44:04

and many of you if you know neuroscience note this is the brains of primary

44:08

industries

44:09

and basically what you can conclude from this time

44:12

is that this is probably the source of the hyperactivity

44:15

you’ve got and over rich or motor system

44:18

and then under majority executive system that ordinarily would be regulating it

44:23

and hence you have a

44:26

discredited individual

44:28

now important emphasized said bushes study took no measures of symptoms

44:32

it can say nothing about whether or not

44:34

these individuals are normal by adolescents and children and my girl

44:38

your talk today or not

44:40

and certainly this is not a study of brain function

44:43

functional neuroimaging studies like julies and others down here and

44:46

elsewhere

44:47

clearly showed that there are functional differences

44:50

in children and adults with a p_h_d_

44:53

but the shaw study is remarkable

44:55

in once again documenting

44:57

the developmental delay that a_t_t_ produces

45:00

i won’t spend time on here

45:02

i have showed a slight only data list rate the complexity

45:05

of the neuroscience research going on we know there are at least three different

45:10

circuits

45:11

within these brain structures not want

45:14

and that each of these while regulated to a large extent by dopamine

45:18

may produce different symptoms and different behavioral expressions

45:22

so that some children might be disturbed and one aspect of the past way

45:26

others in two or three

45:28

helping to explain some of the heterogeneity that we see in a d_h_ is a

45:32

very fascinating research but

45:33

to recycle them

45:35

or recently punctual nick

45:36

and have your across the lungs

45:38

on brain circuitry let’s just to show you like a t_v_ schematic

45:42

that there are these three brain circuits

45:45

each of which involves dopamine each of which would produce a different set of

45:49

deficits

45:50

ingredients to the individuals

45:52

why is the brain smaller

45:53

well i think genetics holds the answer

45:55

we’ve known for decades since the early studies by marcin pile up

46:00

and dennis cantwell u_c_l_a_ at the honor of being this year’s cantwell

46:04

lecturer next tuesday

46:05

at the neuropsychiatric institute at u_c_l_a_

46:08

in honor of dennis is work

46:11

going all the way back even when i was an undergraduate we’ve known that he dat

46:15

strongly inherited disorder

46:17

you can see the risk to relatives of the child has a p_h_d_

46:20

the higher risks of siblings and twins

46:23

and the fact that their parents are likely to have the same disorder

46:26

and look at the market elevation

46:28

if the parent has a p_h_d_ in the risk to children

46:32

beverages forty to fifty percent

46:34

meaning if you’re an adult with a view to half of your children

46:37

are going to express this disorder

46:40

markedly higher elevation

46:42

a fascinating funding for research but i don’t want too much

46:45

is the first paper demonstrating the possibility

46:49

imprinting in the genes for p_b_h_g_

46:52

we know that mammals

46:54

when they give their genes to their offspring

46:56

are likely to take the gene

46:58

with a little flat called on the phone from

47:01

that tells whether the gene

47:02

came from the mother

47:03

or the father

47:05

sent the gene seem to express differently

47:07

depending upon its origin

47:09

and although the gene himself as identical when you look at it sequence

47:13

it the way it activates these different depending upon which sucks it came from

47:18

so that the parents and improve your genes

47:21

with the gender of origin

47:23

and gurus and

47:24

chakkar at

47:25

the hospital for sick children

47:27

have published the first study suggesting that that there may be

47:31

genetic imprinting

47:33

impeach ki

47:34

depending upon whether the genes come down from the father is with the mother

47:37

signed the family

47:38

may alter the expression and severity of the eighty h p

47:42

and to some extent determined

47:44

risk for other comorbid disorders

47:46

now this needs to be replicated but

47:48

i’m just trying to show you the excitement in this period of research

47:52

and the fact that were beginning to see

47:54

novel area of research and never before studied psychiatric disorders in

47:58

children

47:59

and that is the notion that

48:01

although genes may be identical

48:03

the gender origin of the gene parent contributing the gene

48:07

may well alter the expression of that team to some extent

48:10

now we know from many different studies now numbering more than forty

48:14

when the most reliable findings in research and he’d be tricky

48:18

is the striking heritability

48:20

heritability except

48:21

number we calculate and twin studies the tells us

48:24

how much of the variation in the human population

48:27

in fact right

48:29

is the result of differences in our teens

48:31

takes human height for instance

48:33

if i remember all of you

48:34

and plot your height on a distribution

48:37

i could show that ninety one percent of the variation and height among people in

48:41

this room

48:42

is entirely due to differences in your genes

48:45

and you would have understand that paul families get vargas two twelve children

48:48

short families who have children

48:50

obviously this being the physical traits

48:52

genes are playing a very instrumental role

48:55

inhuman variation in height

48:57

but what we’re fighting here

48:58

is that the variation in eighty eight he symptoms and human population

49:02

is just as genetically influenced

49:05

as human hunting

49:06

in dvd hd-dvd

49:08

is among the top three

49:10

genetically influenced psychiatric disorders

49:12

ever discovered

49:13

rivaled only bipartisan and bipolar disorder

49:17

and we are seeing

49:18

that the traits that make up eighty h tds executive inattentive

49:22

and impulsive traits

49:24

are among the most strongly genetically influenced psychological traits ever

49:29

discovered by science

49:31

intelligence is not the strongly genetically influenced anxiety carries

49:35

only a thirty to forty percent genetic influence less than half of what we see

49:39

in eighty three

49:42

suggesting that we are seeing a marked contribution to genetics

49:46

its contribution to the frontal cortex

49:48

and specifically

49:49

to the symptoms that underlie

49:51

the each team as well

49:53

now print studies art uniform

49:56

across paul studies

49:57

in showing no role of the rearing environment in this disorder

50:01

which is why john groomsmen is absolutely overly wrong

50:05

he’s not only one he’s worse than wrong

50:08

to be worse there are ways to make a declarative statement about what we know

50:12

in the face of all research pointing to the contrary it would be like denying

50:17

gravitational

50:17

effects on the earth’s surface

50:20

and yet we see many people who still believe in the role of parents

50:24

as a contributor to the each t

50:26

and the twin studies say this simply is not

50:30

if you’re looking for an environmental effect

50:32

look at something unique that happened only to this trial

50:36

not to other family members

50:37

and here is where we could see

50:40

biological hazards we’ve already discussed

50:42

the smoking the drinking the premature t

50:45

and the violence

50:48

they highlight heritability has led researchers to begin searching for jeans

50:52

for a_t_t_

50:53

an eighty eight he has been one of the most successful psychiatric disorders

50:57

in terms of identifying reliable candidate genes

51:00

better than bipolar disorder better than autism

51:03

we have been able to identify set of ferry reliable jeans not necessarily

51:07

from it all studies because of the each is genetically heterogeneous

51:12

but in another studies to show when we do what’s called a meta-analysis that

51:16

these gene seem to be holding up

51:18

and the most reliable once at the top

51:21

and then further it down

51:22

the end of the page even just

51:24

a month ago

51:25

the finish studies a dvd h t

51:28

again showed these genes particularly deviates

51:31

as a candidate running for a p_h_d_ now i can’t go into what these teams do it

51:35

you can read about them here quickly

51:37

but the point is that most of these seventeen front of them

51:40

which means regulate dopamine in the human brain

51:44

so we’re going to find

51:45

the dopamine genes are quite likely to be involved in the p_h_d_

51:49

also probably

51:50

are norepinephrine jeans because some of these genes such as d eighty one

51:54

not don’t just influenced opening teams but also drop in africa take

51:58

and the norepinephrine transporter as well

52:01

now what you may not notice it within the last year researchers found that

52:05

this gene critics who will respond to baffle founded a dance pretty rough

52:10

opening the door to the possibility that in very

52:13

your future

52:14

we will be able to do genetic

52:16

typing of children

52:17

and choose the most appropriate rug

52:19

without what we do now which is purely flying blind

52:22

and putting children on medicines and waiting to see what happens

52:26

would be a fascinating area

52:28

of research

52:29

i don’t want to overplay that there was a failure to replicate that finding but

52:33

there are two studies to show that it does

52:35

so it means open the possibility

52:38

their genes determine the best drugs that you respond

52:42

not lastly i want to emphasize in advance here by richard haas group in

52:46

saint louis that shows that there’s probably an interaction

52:49

between environmental biohazard sc

52:52

and genetic risk

52:53

and we can see that here quite clearly

52:55

this is whether your mother smoked during pregnancy or not no or yes

52:59

this is whether you have the dat gene i’ve already mentioned plus meaning you

53:03

do

53:04

minus means you don’t have that christine

53:06

and here’s the d_r_ d fourteen

53:08

look at what happens as we begin combining wrist jeans with an

53:12

environmental toxin

53:13

the most important finding is here

53:15

if you are a few days that carries both christine’s and your mother smoked

53:19

during pregnancy

53:20

uart eight times more likely to get this disorder that anybody with any of those

53:24

single costs

53:26

that is a clear gene by environment interactions also now been found for

53:30

alcohol and it’s beginning to be found other disorders as well

53:34

suggesting that things are more complicated than we thought it isn’t

53:36

just one or the other

53:38

there probably is some interactive effect and i think as i learned this

53:41

morning

53:42

the same thing is probably going to be found for autism as well

53:46

so what can we expect in the future

53:48

you when i can expect the probably in the next five to ten years

53:51

all of the risk change for a dat will be known that looks like there’s probably

53:54

going to be at least twenty of them

53:56

because we’ve now stand the entire human genome

53:59

and that’s the number that seems to be coming up as far as locations alan

54:03

cranston so it’s apologetic disorder

54:05

but that’s going to let us sub-type people

54:08

based on their genetics

54:09

and republican a find that there are different kinds of a d_h_ t

54:12

and different life course cus

54:14

my own milwaukee study has genotype all of the children

54:17

and found that the eighty-one

54:19

is a predictor severe dvd h_d_

54:21

of risk for cigarette addiction

54:23

of your workplace evaluations and therefore performance and up your grade

54:27

point average in high school

54:29

all of which is sort of

54:31

el-ad says a little bit to suggest that

54:33

some teens have life course expression

54:36

and curie rhys

54:37

for certain kinds of impairment and while my study needs to be replicated

54:41

understand jim swanson is finding very similar effects for the d_o_d_ fourteen

54:45

and others so that we may see that depending upon which of these jeans you

54:49

get in and what combination

54:51

there are different risks associated with your kind of a p_h_d_

54:55

and not others

54:55

and as i’ve already mentioned we’re beginning to see the jeans they predict

54:59

drug response

55:00

we may see drug companies developing utterly new chemicals

55:04

for your genotype

55:06

which of course there is something that is not space-age technology here

55:10

but is well within our grasp once we know

55:13

what these genes are and how they express

55:16

in the human brain

55:17

and there may well be that

55:19

fasting possibility

55:21

that genes don’t just predict response to drugs

55:24

probably predict response

55:27

psycho-social treatments

55:29

to summarize advances in research shows that

55:32

eighty eight years of neuro genetic disorder

55:34

than about two thirds of all cases

55:36

are the familial genetic type

55:38

that the remainder are due to various injuries

55:42

events that take place most often prenatally

55:45

some post natalee

55:46

and that no one sees up here

55:49

tv

55:50

video games

55:51

sugar

55:52

and the more popular notions

55:54

that lay people have about a p_h_d_

55:56

but it turned out to be false

55:59

my time is running out and i could spend an entire power on this

56:02

but i simply want to point out that were building models

56:05

five eighty eight years of disorder of the exec system

56:08

that we can break the exec system

56:10

not only into

56:13

innovation which is the principal executive deficit

56:16

but into for others

56:18

there is not a horrible working memory system

56:20

which i have reinterpreted and my writings as the visual imagery system

56:24

there’s the verbal working memory system

56:26

which according to vitality is really just self speech the voice in the mind

56:31

there’s the emotion regulation system which i believe it’s the same one that

56:34

gives a self motivation

56:36

and there is the planning mechanism

56:38

which generates potential responses

56:41

it sort of the innovative

56:43

problem solving

56:44

almost like a simulator would be

56:46

allowing you to simulate mentally

56:48

multiple possible ways of getting to your calls

56:51

and choosing the most effective among them

56:53

to in fact put into play

56:55

research is beginning to show that a_t_t_ interferes with all five of these

57:00

executive systems

57:01

which means that eighty eighty children are just

57:04

uninhibited

57:04

they also have problems with visual imagery

57:08

nonverbal working memory which by the way if you’re not familiar with it

57:11

is the origin of the sense time subjective awareness of time

57:15

which explains why he dat

57:17

so disrupts the individual’s ability to deal with time

57:20

why they’re always late

57:22

never prepared

57:23

never work in time

57:24

begins to explain why each of the children can follow rules and

57:28

instructions

57:28

because they’re internal languages thirty to forty percent behind normal

57:32

children

57:33

and it’s internal language that allows us to do what we’re told

57:36

and the governor own behavior by what we tell ourselves to do that

57:40

it explains very clearly what you do you teach children have a motivation deficit

57:44

why they can play video games for hours

57:46

because the motivation is external

57:49

and provided as a continuous

57:51

reinforcement schedule why they can’t do homework for minutes because homework

57:55

provides no consequences

57:57

and demands internal

57:59

motivation

58:00

self created motivation

58:01

he dat is a self motivation deficit disorder

58:05

which is why they can’t function well

58:07

in environments where there are no consequences

58:09

for immediate

58:11

gratification

58:12

also explains why they are so poor problem solving

58:16

and generating potential possible ways of solving their problems

58:20

and why we see this influence people for call

58:23

spatial and motor fluency tasks

58:26

suggesting that there’s a problem with the planning mechanism

58:28

as well

58:29

i wish i could go over this

58:31

in more detail

58:32

but i’ll just leave you with the implications of an executive you have a

58:35

duty

58:37

giving a teaches an executive disorder tells us that mediate is a form of time

58:41

blindness

58:42

that need to teach the children have been nearsightedness to the future

58:45

that future events have to be immediate and compelling

58:48

before the individual is capable of dealing with them that events that lie

58:52

at a distance across time

58:54

are of no value to these children they can’t

58:57

muster anticipatory responses

58:59

and prepare

59:00

for future events

59:02

put it in another way the each individual lives inferno

59:06

and past and future carved little consequence in the regulation

59:10

of their behavior

59:11

it tells us that needed each team is not a disorder of knowing what to do

59:15

but it is sort of doing what you know

59:18

that it’s a performance problem

59:20

that the a_t_t_ trouble not benefit from skill training

59:23

because they know what their children know but they can’t do is to look at

59:27

their children do with that knowledge

59:29

think of your brain as a two-party system

59:31

the posterior part of the brain is the information acquisition system

59:35

it is where knowledge is acquired and stored

59:38

the final part of the brain

59:39

is a system that puts what you know

59:42

into every day but that to function

59:44

it’s where the rubber meets the road

59:46

it’s where you choose what you know to be as socially accepted as a you will be

59:51

able to be

59:52

they dat like a meat cleaver

59:54

has separated these two mechanisms

59:56

so that what is known

59:58

does not carry forward

59:59

to influence what he’s done

60:02

and even the most brilliant dvd people

60:04

dust stupid things in life

60:07

and we begin to understand this distinction between performance aspects

60:12

a functioning

60:13

and knowledge aspects and it begins to tell us they repeatedly but not to do

60:18

don’t emphasize skill training

60:20

people with a p_h_d_ are not stupid

60:22

and not be ignorant

60:23

they know what other people their age usually no

60:27

the problem isn’t implementing let me know

60:30

they can’t do what they know

60:32

that critical points in the environment that we call the point of performance

60:37

and what is the real like this tells us

60:38

is something that will give you a dvd would say

60:41

only treatment

60:43

treat a performance disorder

60:45

must be

60:46

point of performance

60:49

treatments done away from that point of performance

60:52

will be of absolutely no value

60:54

to dealing with performance disorders

60:57

you must be arrange these critical natural environment with the problems

61:01

occur to help them sure what they know

61:04

to use what they have

61:06

and not put the in long-term psychotherapy

61:09

or playgroups or other things that have no bearing

61:13

on the point

61:14

of performance

61:16

the implications for treatment i’ve already mentioned they are numerous

61:20

skill training is not enough

61:22

we need to work at the point of performance

61:24

we need to look at medication from a very different perspective

61:28

medication for eighty eight he is not psychopharmacology

61:31

it is normal genetic

61:34

therapy

61:34

we can demonstrate that right down to the influence of single teams

61:38

and the way they regulate transport mechanisms

61:41

and postsynaptic sensitivities in single nerve cells

61:45

in the human brain

61:46

we are no longer at an age when we don’t know where didi h_d_ comes from

61:51

we request working at the level

61:53

molecular mechanisms on brain cells

61:56

and proteins that are free

61:58

in those brain cells

62:00

and we can see exactly

62:01

what these medications do

62:03

we know that methylphenidate

62:05

blocks the transporter and that eighty eight individuals

62:07

have more transporters on their nerve cells

62:10

because the issue trotter

62:11

have longer transporter genes

62:13

and longer teens bill greider transport mechanisms so we can link

62:18

jeans

62:19

to a brain mechanism

62:20

to a truck response

62:22

in a very interesting closed-loop now

62:24

that we’ve never been able to close before

62:26

in our explanations

62:28

aviv each key

62:29

and i believe that we need to represent his appropriately to the public

62:34

using medication for a_t_t_ is tantamount to insulin to a diabetic

62:38

it is literally a form of genetic treatment

62:41

at the level of nerve cells within the brain

62:45

productive bring over everything

62:46

you’re not masking the problem you’re not failing to do with some hidden

62:51

psychodynamic or intro familial conflict none of those are pertinent you

62:55

literally are treating the disorder at its source

62:58

and that is an important take-home message

63:00

for many families

63:04

and unimportant

63:06

i could go through many many

63:09

development

63:09

let me leave you with some of the developments

63:13

we don’t have an array

63:15

of medications

63:16

for eighty h t

63:17

the stimulant of which there are two types

63:20

which there are many different delivery systems and more recently

63:24

than on stimulants such as which he wrote

63:27

johnston approved for a dat

63:29

but of course other drugs like antihypertensive ps

63:32

try cytokine depressants that also have a truck hurt

63:35

of helping

63:36

to treat me dat da clearly not as dramatically

63:40

fastest institute

63:41

what is new impeach the research

63:44

that we have

63:45

five delivery system clean out the five keys

63:49

which people need i think to appreciate because some of this is new areas of the

63:52

last six months

63:54

we have to tell us what are the immediate release

63:56

not offended a

63:58

and threatening compounds that we’ve had

64:00

going back to the nineteen fifties in the nineteen thirties

64:03

but we now have

64:04

the methylphenidate pump

64:06

which is concerned which is a miniature almost like a tube of toothpaste

64:10

that went swallowed

64:12

extremes

64:13

liquid methylphenidate for a period of eight to twelve hours

64:17

providing much more continuous coverage in the a_t_t_ individual

64:21

this is what medication three times a day would do

64:24

with immediate ritalin

64:25

and this is what happens

64:26

when you scored out liquid novel from the date

64:29

using this pumping system

64:30

you get a nice

64:32

even continuously

64:33

blood flow of blood level

64:35

that eliminates the valleys

64:37

and the lack of control from the immediate please absolutely ingenious

64:41

system invented by also

64:43

pharmaceuticals and bought up by johnson johnson

64:45

we have the pallet technology system

64:47

which is like they will contact

64:49

cold medicines

64:51

different

64:52

pallets spot methylphenidate or adderall

64:55

coated with different i release

64:57

that does all of at different hours of the day

65:00

some dissolving immediately upon ingestion

65:02

others an hour

65:03

to three for file although we have to eight to ten out of coverage

65:09

this is what he would get with the immediate release them threatening and

65:12

this is what you would get from appellate system

65:15

it takes away the valley

65:17

provides a smoother

65:19

gradation of coverage across the day

65:21

absolute godsend for each teacher often because these extended release systems

65:25

and eliminated

65:27

the need to administer medicines

65:28

at noontime in the schools

65:30

and the associated stigma

65:32

and humiliation that many children were exposed to for many years

65:36

we also have the patch system the forty p

65:39

which is the trial

65:40

methylphenidate in a skin patch

65:42

which can be absorbed continuously

65:44

through the skin eliminating the need to squabble medicines

65:49

outside of course if you get continuous coverage across the day

65:52

the down side as you can take this cut off a couple hours before bedtime or

65:56

you’re not going to sleep

65:57

and the other downside is one important four people in a skin rash

66:01

it is quite annoying

66:03

and that is the methylphenidate irritation of the skin

66:06

but again another delivery system helping us to reach out

66:09

to some cases of a_t_t_ where

66:11

i’m not

66:12

delivery system would be better and finally last august

66:15

comes in most recent invention

66:17

that the f_d_a_ had to create a new name for

66:19

that is the pro drug system

66:21

this is an out of robert reformulated into a drug called five minutes

66:25

by this isn’t absolutely fascinating mechanism because what by the recipient

66:31

is amphetamine bound up with

66:35

life seemed compound

66:36

that prevents the amphetamine

66:38

from being activated

66:40

anywhere

66:41

except

66:42

in stomach and apprenticed

66:45

only in fact area

66:47

will this drug

66:49

activate

66:49

because in the stomach and upper intestine

66:52

there is a protein that splits the light

66:55

seen compound

66:57

off from the amphetamine

66:58

allowing him threatening to go to work

67:01

this is the first not accused of ball and fending

67:04

ever invented

67:06

now as a down or is a by product not a downside but it outside totally

67:10

accidental

67:12

it turns out that this binding mechanism

67:15

issue to the three more hours of coverage

67:17

this trouble s twelve to fourteen hours

67:20

through the longer acting stimulants currently available

67:23

which for adults in particular

67:25

extraordinarily beneficial because of the longer hours of responsibility

67:28

that adults have

67:30

now we have seen developments and psycho-social treatments

67:33

time doesn’t permit me to go through all of them

67:36

and we’ve seen a number of new treatments being proposed to test it

67:39

that continue to remain experimental

67:42

not yet proven shouldn’t be offered to the public although they have been

67:47

but biofeedback for instance where we’ve got lots of promising uncontrolled

67:51

studies

67:52

to randomized trials action l three they didn’t find anything so that needs to

67:56

get sorted out

67:58

we’ve got cognitive training of working memory

68:00

one positive study

68:02

but waiting to see if it replicates

68:04

we’ve got however call scorecard training children and time management

68:07

and organization

68:09

howard is using my theory of a p_h_d_ in the eighty h decrease of massive

68:13

problems with a human sense of time

68:16

and howard’s trying to show that

68:17

can we get in and train that

68:20

if we catch children young enough so he’s got a manual schools and for

68:24

families

68:25

i’m time management training

68:28

brad smith and others

68:29

are working on after-school programs for teenagers

68:32

animals for cal civ trip non-compliant group of a_t_t_ people

68:36

and with brad and others have done

68:37

is to create after-school programs for teens don’t have to go anywhere

68:41

the city state school

68:43

go to a particular

68:45

incomes of paraprofessional

68:46

trained by any chance expert to offer

68:49

after-school services whether that’s true touring further social skills

68:53

whether that’s assistance with

68:55

their sports or other areas of a_t_t_ such as time management

68:59

the teenager doesn’t have to go anywhere

69:01

there is no stigma associated with going to be psychiatry clinic who really

69:05

eliminate some of the hurdles

69:07

to compliant among a p_h_d_ teens

69:09

very fascinating experimental program going on

69:12

both in virginia and caroline

69:14

and then of course

69:15

steve sufferance working independently that of course ramsey

69:18

and rothstein at university and something at

69:21

showing the cognitive behavioral training although it fails for each

69:24

teacher over appears to be effective as a supplement

69:27

for medications for each details

69:30

so i hope i’ve left you with the idea that this is an

69:33

rapidly advancing area of research and eighty h t we’re learning lots of new

69:37

stuff

69:38

continues to be a very exciting area

69:40

not once a month thirty four years of work in this area

69:42

i’ve i’ve been bored there’s always something new coming at us

69:46

and one of the things we can now say is that

69:48

each d

69:49

although it certainly not a benign disorders i said earlier

69:52

this among the most treatable psychiatric disorders

69:55

we have more treatments

69:56

that are more effective

69:57

for more people

69:59

believe it or not been any

70:01

area psychiatry so there’s a great deal of hope that we can provide a better

70:06

future for these children and adults

70:08

and we’ve previously been

70:10

sexual so much

70:21

season is going to ask for people some people that i think at his other

70:27

presentation

70:28

relentlessly until the sale of the starting line for the cities

70:33

websites

70:35

internet

70:36

accidents happen before impact will be available

70:40

misconduct

70:41

critically-acclaimed again time for about five minutes when the questions

70:49

at least in the service of moderating

70:51

sir

70:53

start acting like sheltered workshop

70:57

steve woodward mcveigh

71:01

it remind

71:03

well certainly department carrie nation of that i had to refer to is shown

71:07

workshops because that’s a

71:09

a particular intervention that’s been used for more profoundly

71:12

developmentally disabled individuals but one could certainly like and that the

71:16

phil collins summer treatment program

71:18

and the other

71:19

extend chances intervention programs as being backed into that sort of a

71:24

controlled environment where people come for six or seven hours a day

71:28

exposed to multiple

71:29

training programs

71:31

think the only thing that’s disappointing about these kinds of

71:34

studies

71:35

is that we we have found it

71:37

even environment that we regulate that way

71:39

we get marked improvements in peachtree symptoms

71:43

but there’s no generalizations and on training environment

71:46

there’s nothing that indoors when you stop the training program and that’s

71:49

been the downside

71:51

of these programs

71:52

and we’re trying to solve that through how do we program for generalization how

71:56

do we get the skill to indore haven’t quite worked out yet but it’s just that

72:00

might be possible

72:01

and if you’re ready for cock up you know that

72:03

i did make an argument for

72:04

with teenagers moving more

72:06

into

72:07

vocational training in addition to academic

72:10

training of these individuals

72:11

in order to help

72:12

make them better prepared to enter the workforce and they currently have

72:15

i don’t know that that needs to be done it so intense it in burma sheltered

72:18

workshops i think simple vocational

72:20

technical schools suffice to provide that

72:23

but i think

72:24

the months if you’re talking about is very important one and that is much more

72:28

environmental regulation to a more intensive degree earlier and longer over

72:33

time

72:34

because what we’re learning as we have interventions that work but if they’re

72:37

limited to childhood they make no difference by adulthood

72:40

and they don’t jury over into un treated environments that we didn’t pay

72:44

attention to but i think those pop problems are potentially

72:51

yeah

72:53

hill

72:54

yes not for the faint of heart we want to raise the information you’re going to

72:58

see and or birthday the information at four o’clock session is in the new book

73:06

i want to make sure it is i don’t want to mislead people

73:09

mike my new book is a scholarly silence

73:13

and although it is written for

73:15

clinicians and professionals to read

73:18

but he certainly is not a trade book

73:20

that’s not net howells driven to distraction

73:23

unnamed people who do science will appreciate it because i think it’s

73:26

probably the most definitive statement

73:29

putting adult medium state on the map

73:31

as as a legitimate adult disorder

73:35

if you’re obviously educated well-read you would be able to go to that book but

73:39

i tell people to use it more a sort of a desk reference

73:42

open it to the chapter

73:43

on workplace problems open to the chapter

73:47

early sexual activity driving to a fourth is not meant to be a continuous

73:51

bedtime reading hardly russia novel

73:54

but by any means sep i want to make clear what it is and what it isn’t but

73:58

certainly that’s where all of the results including the new result i

74:01

didn’t talk about tonight

74:03

clinic referred adults with the v_ chip

74:05

it’s all done dot as far as what you saw last year

74:08

you would have to look at my handbook for diagnosis

74:10

combined with trond its recent book on

74:12

the causes of a p_h_d_

74:14

to really begin to pick this up

74:16

and then some of these

74:17

are studies that were published a swim in the last few weeks too few months of

74:21

those are not going to be book at this point

74:25

i think we have a friend and cover

74:29

uh… except for thursday with

74:32

video gaming is on a cartridge university influences severity of the

74:36

well-timed grocery tenant and in canada and steve houghton in upper class turned

74:41

up

74:42

have looked at video-game playing in a p_h_d_ children

74:44

and what they found of course is what parents find at a future travel sustain

74:48

their attention to a video game

74:50

longer than they will to something that’s not computer-generated or

74:53

computer delivered

74:54

so in that sense they have a play those games longer than they do their homework

74:58

but what i was if you look at the way they play the game and what they’re

75:01

doing during the game

75:03

first of all the time to play more solitary wears

75:06

most children

75:07

video games with

75:10

and groups

75:11

and eighty each other more solitary that they have to do with their social

75:14

rejection

75:15

the second thing is you see the executive deficits the more the video

75:18

game demands a lot of management organization strategy overtime you

75:23

finding each other can’t compete with the normal child executive aspects of

75:27

picnicking

75:28

so as rosemary pointed out

75:31

they play video games better than they do other things they are not normal

75:35

in the way the approach gaming and gaming doesn’t make the normal writer

75:38

but it certainly doesn’t

75:40

contributor eighty h d

75:41

as some people have argued that t_v_ video-game playing or cause of a p_h_d_

75:46

and instead i think they got the chicken in the reversed

75:49

people with aviation more likely to watch television are more likely to play

75:52

video games are also more likely to talk my cell phone and not read for pleasure

75:56

but that doesn’t make the state’s causes of a p_h_d_ those of the things that

75:59

people with a_t_t_ gravitate toward

76:01

when they’re given choices in their leisure times

76:07

hi i’m mad

76:09

not finishing our professional and member of the communities

76:13

back in my home

76:15

on yahoo

76:17

very taken with the part about the genetics because

76:20

my husband seventy one two years ago at the list i had aspects and how much his

76:25

head of course all his life

76:27

uh… i have assignments

76:30

compulsive obsessive i have two grandsons with a p_h_d_

76:35

my husband to be risk misdiagnosed like alcoholism with a p_h_d_

76:41

anxiety disorder

76:43