Using the vignette from the attached ADHD chapter, research the current psychopharmacological interventions and treatment options for the client’s diagnosis. After reviewing the current research, write a paper discussing the treatment protocol for the client using your researched psychopharmacological intervention.
The paper should clearly articulate expected outcomes, taking into account all diversity-related factors (e.g., ethnicity, gender, age) and associated treatment complications and/or modifications. You should clearly articulate what the key issues are (e.g., metabolic changes, biochemical differences) as well as the practical consequences for effective treatment.
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Time Blind:
A New Take on ADHD
Joshua D. Wyner, PhD, LMFT, LPCC
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Decision Making
3
Decision Making
Activation
Inhibition
Initiate a potential action
Check against prior experience
“It’s night time, driving fast would be fun!”
“I can’t see too far ahead,
and I’m scared I might hit something.”
Activation
Inhibition
+
_
Prefrontal Cortex
Final Decision
Activation is the idea of having a potential action.
Before activation is inhibition which takes into consideration past experiences.
Activation and Inhibition combined can lead to the final decision.
Example: Child touches fire because it’s shiny, but after he gets burned, he will likely not
touch fire again.
Decision making is emotional first and we make decisions based on our emotions.
Emotion is reflexive and heuristic.
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Decision Making
Activation
Inhibition
Initiate a potential action
Check against prior experience
Caudal Anterior Cingulate Cortex is responsible and activates when we assess social
conflict.
Emotionally process potential social interaction issues and relate it to long term welfare.
©2008 Hagmann, et al.
Caudal Anterior Cingulate Cortex
Involved in managing social conflict
Aids in consequence assessment
Processes long-term welfare
Rostral Anterior Cingulate Cortex
Involved in emotional conflict
Also aids in
Suppresses emotional system
Prefrontal Cortex
5
Decision Making
Activation
Inhibition
Initiate a potential action
Check against prior experience
Rostral Anterior Cingulate Cortex is more related to direct conflict with others.
Activates when it is necessary to repress emotional reactivity.
Caudal Anterior Cingulate Cortex
Involved in managing social conflict
Aids in consequence assessment
©2008 Hagmann, et al.
Processes
Rostral Anterior Cingulate Cortex
Involved in emotional conflict
Also aids in consequence assessment
Suppresses emotional system
Norepinephrine
Diffuse
Regulates arousal (homeostatic state)
Prefrontal Cortex
Aids in affect-related
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Decision Making
Activation
Inhibition
Initiate a potential action
Check against prior experience
Rostral Anterior Cingulate Cortex
Involved in emotional conflict
Also aids in
©2008 Hagmann, et al.
Suppresses emotional system
Norepinephrine
Diffuse
Regulates arousal (homeostatic state)
Aids in affect-related memory storage
Prefrontal Cortex
Norepinephrine seem to be helpful in memory storage and overall arousal level which is
related to emotional experience during situations.
Has to do with alertness and connectedness.
Norepinephrine is extended throughout the brain
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Decision Making
Activation
Inhibition
Initiate a potential action
Check against prior experience
Anterior Cingulate Cortex
©2008 Hagmann, et al.
Involved in conflict management
Also aids in consequence assessment
Suppresses emotional system
Processes long-term welfare
Norepinephrine
Diffuse
Regulates arousal (homeostatic state)
Prefrontal Cortex
Aids in affect-related memory storage
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Decision Making
Attention-Deficit/Hyperactivity Disorder (ADHD)
Example: paying attention to the teacher and also paying attention to external stimuli such as
lights, someone passing by, someone drinking something, your phone ringing, etc. But not
considering things such as the color of the wall.
The Anterior Cingulate is smaller and fails to activate in ADHD
Anterior Cingulate Cortex
Involved in conflict management
Lack of somatic markers
Also aids in consequence assessment
Suppresses emotional system
People with ADHD are less likely to have emotional reaction or are less strong than those
who do not have ADHD.
Processes long-term welfare
Inability to connect the present emotional
state with future consequence
Norepinephrine
Emotional reactivity is not as pronounced in ADHD.
Does not have as many somatic markers
ADHD people are not able to connect current situations with future consequences.
Diffuse
Regulates arousal (homeostatic state)
Aids in affect-related memory storage
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Decision Making
Attention-Deficit/Hyperactivity Disorder (ADHD)
The Anterior Cingulate is smaller and fails to activate in ADHD
Lack of somatic markers
Stare at the Red Dot
The dot in the middle is what should be focused on, and the blue dots are external stimuli.
ADHD people are less likely to focus on the red dot as it is not as obvious to them and does
not have a strong emotional value.
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Looking at the dots, ADHD is similar to being color blind and not being able to identify the
difference. ADHD people would not know which one needs to be focused on.
Decision Making
Attention-Deficit/Hyperactivity Disorder (ADHD)
Hyperactive type is not knowing which one to do and doing them all at once.
Inattentive type is not knowing which one to do and not doing any of them until someone
tells them which one to do/focus on.
The Anterior Cingulate is smaller and fails to activate in ADHD
Lack of somatic markers
Stare at the Red Dot
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Decision Making
Hyperfocus (Perserverence) is doing the task that has emotional value and they don’t
want to stop doing it
Attention-Deficit/Hyperactivity Disorder (ADHD)
The Anterior Cingulate is smaller and fails to activate in ADHD
Forgetfulness is being unable to remember due to lack of somatic markers.
Lack of somatic markers
©2011 Honestdiscounts.com
©2013 Gamerfitnation.com
Inattentiveness
(lack of emotional salience)
Hyperfocus
(unable to stop current task)
©2013 Bottomlinehealth.com
Forgetfulness
(unable to consolidate memory)
Perseverence
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Decision Making
Attention-Deficit/Hyperactivity Disorder (ADHD)
The Anterior Cingulate is smaller and fails to activate in ADHD
Inability to connect the present emotional
state with future consequence
©2011 Honestdiscounts.com
Inattentiveness
(lack of emotional salience)
©2013 Gamerfitnation.com
Hyperfocus
(unable to stop current task)
Perseverence
Inattentive is not doing anything or paying attention.
©2013 Bottomlinehealth.com
Forgetfulness
(unable to consolidate memory)
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Impulsivity is switching between tasks
Decision Making
Risk-taking behaviors are not seen as risky to the ADHD person therefore they will continue
to do the task.
Attention-Deficit/Hyperactivity Disorder (ADHD)
The Anterior Cingulate is smaller and fails to activate in ADHD
Inability to connect the present emotional
state with future consequence
Inveracity (lying) is saying something that isn’t true
Inveracity is conflict avoidant and a reflexive response and ADHD people do not have
recollections and it is not thought out as a lie.
Doesn’t mean ADHD people do not lie.
©1940 Disney
Impulsivity
(lack of emotional salience)
Risk-taking Behaviors
(unable to stop current task)
Temporal myopia is the present-centered focus.
Inveracity
(Conflict Avoidance)
The ADHD individual is Temporally Myopic
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Treatment
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Treatment
Attention-Deficit Hyperactivity Disorder
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
Goal is to focus on:
-increasing access to somatic markers
-assist by addressing clarity from norepinephrine activity
-work in time domain to help present-centered approach when it becomes too extreme
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Treatment
Attention-Deficit Hyperactivity Disorder
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
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Treatment
Want to often use medications that increase dopamine activity (psychostimulant)
Ritalin is go-to medications for ADHD for dopamine and norepinephrine
similar to methamphetamine and binds to the same receptor sites as amphetamine
Dosaminergic specific.
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Psychostimulants
Norepinephrine-dopamine reuptake inhibitors (NDRIs)
NE/DA releasing agent
Potential addiction risk
Therapeutic Dosing
2-4 hour half-life
2-4x/day dosage
Key Considerations
Adrenergic Side Effects
Short half-life
Ritalin
(Methylphenidate)
Longer onset time than cocaine
Addiction & Dependence Risk
Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.
18
Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Psychostimulants
Norepinephrine-dopamine reuptake inhibitors (NDRIs)
NE/DA releasing agent
Therapeutic Dosing
2-4 hour half-life
2-4x/day dosage
Adrenergic Side Effects
Insomnia
Headache
GI Upset
Ritalin
(Methylphenidate)
Appetite Suppression
Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.
Insomnia can be a direct and non-direct effect of ADHD since there is not an emotional
connection with sleep.
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Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Psychostimulants
Norepinephrine-dopamine reuptake inhibitors (NDRIs)
NE/DA releasing agent
Therapeutic Dosing
2-4 hour half-life
2-4x/day dosage
Key Considerations
Adrenergic Side Effects
Short half-life
Ritalin
(Methylphenidate)
Longer onset time than cocaine
Addiction & Dependence Risk
Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.
20
Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Psychostimulants
Norepinephrine-dopamine reuptake inhibitors (NDRIs)
NE/DA releasing agent
Therapeutic Dosing
2-4 hour half-life
2-4x/day dosage
Addiction & Dependence Risk
Rebound Irritability
Rebound Depression
Ritalin
(Methylphenidate)
Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.
21
Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Psychostimulants
Norepinephrine-dopamine reuptake inhibitors (NDRIs)
NE/DA releasing agent
Therapeutic Dosing
2-4 hour half-life
2-4x/day dosage
Key Considerations
Adrenergic Side Effects
Short half-life
Ritalin
(Methylphenidate)
Longer onset time than cocaine
Addiction & Dependence Risk
Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.
22
Dexadrine is a longer lasting psychostimulant
-right handed isomer
Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
More dopaminergic
Psychostimulants
Trace Amine Receptor (TAAR1) Agonist
Monoamine Releasing Agent
Tends to release monoamines
Therapeutic Dosing
~10 hour half-life
Increase dopamine concentration in sending cell for action
potentials
2-4x/day dosage
Key Considerations
Adrenergic Side Effects
Addiction & Dependence Risk
Primary action on dopaminergic systems
Dexedrine
(Dextroamphetamine)
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Vyvance is a prodrug and needs to go through metabolic first pass
Slightly less addictive
Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Smoother than other psychostimulants
Possibly because it requires liver bypass
Psychostimulants
Trace Amine Receptor (TAAR1) Agonist
Monoamine Releasing Agent
Therapeutic Dosing
Most insurance doesnt cover this ($300 a month)
~1 hour prodrug half-life
~10 hour half-life
2-4x/day dosage
Key Considerations
Adrenergic Side Effects
Theoretically lower addiction risk
Prodrug increases onset delay & activity length
Vyvanse
(Lisdexamfetamine)
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Adderall is the First engineered drug for ADHD
Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Psychostimulants
Trace Amine Receptor (TAAR1) Agonist
Works on synergistic systems and pathways (norepinephrine and
dopamine)
Monoamine Releasing Agent
Therapeutic Dosing
10-13 hour half-life
2-3x/day dosage
Key Considerations
Adrenergic Side Effects
Adderall
(75% Dextroamphetamine
25% Levoamphetamine)
Addiction & Dependence Risk
Levoamphetamine has greater peripheral action
Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.
Can cause insomnia, so you can take it with a sedative medication.
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Evekeo is just amphetamine 50/50
Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
When norepinephrine increases it causes a more peripheral
stimulation
Psychostimulants
Trace Amine Receptor (TAAR1) Agonist
Monoamine Releasing Agent
Therapeutic Dosing
10-13 hour half-life
1-2x/day dosage
Key Considerations
Adrenergic Side Effects
Addiction & Dependence Risk
Evekeo
(Amphetamine Sulfate)
Levoamphetamine has greater peripheral action
May allow for lower dosing in some patients
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Extended release is designed to dissolve at a slower pace
Treatment
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Reduced rebound effects
Psychostimulants
Take 1x/day most likely
Extended-Release Variations
Dexadrine Spansule
Adderall XR
Improved dosing schedule
Decreased rebound effects
Decreased peak levels
Ritalin SR
Concerta
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Treatment
Attention-Deficit Hyperactivity Disorder
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
28
Treatment
Attention-Deficit Hyperactivity Disorder
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
29
An extended release medication
Treatment
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
Typically used for high blood pressure
Alpha-Adrenergic Agonists
Increase NE pathway activity
Targets peripheral and norepinephrine
Therapeutic Dosing
14-18 hour half-life
1-2x/day dosage
Side Effects
Drowsiness
Intuniv
(Guanfacine ER)
Reduced appetite
Headache, GI Upset
Arnsten AF (October 2010). The use of α2A adrenergic agonists for the treatment of attention-deficit/hyperactivity disorder. Expert Rev Neurother (10): 1595–605.
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Treatment
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
You can take adderall in the morning and intuniv at night to reverse the
effects
Intuniv is not as effective as adderall or as when you take them simultaneously
Alpha-Adrenergic Agonists
Psychostimulants
Increase NE pathway activity
Norepinephrine-dopamine reuptake inhibitors (NDRIs)
Intuniv
(Guanfacine ER)
Adderall
(Dextroamphetamine & Levoamphetamine)
31
Treatment
Attention-Deficit Hyperactivity Disorder
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
32
Treatment
Attention-Deficit Hyperactivity Disorder
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
33
Intervene when action is happening
Treatment
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
Focus on Point of Performance
Interventions should occur at the place and time
when the failure to act normally occurs
With kids, externalizing works best.
Avoid giving ADHD clients “homework”
Develop rewards that are immediate and portable
Avoid mere admonishments of prior actions
Avoid simply “letting them learn the consequences”
Externalize the feedback/reward
from PrototypeMama, 2013
Adapted from Barkley (2012).
Give present-oriented tasks
Present-oriented jobs are best for them (photography, firefighter, therapist,
etc.)
34
Try making it internalized overtime to help them
Treatment
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
Building routines helps offset disinterest and once it is done for some time,
it
becomes built in.
Focus on Point of Performance
Externalize the feedback/reward
Clients with ADHD have an impaired ability to represent the world internally
Externalized interventions should connect back to internal
representations whenever possible
These routines must be sustained for long periods in order to
promote learning
from PrototypeMama, 2013
Adapted from Barkley (2012).
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Breaks are necessary because you can’t process all information
Breaks allow us to have some downtime
Treatment
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
Breaks should be more frequent for ADHD clients
For kids, give them a break between getting home from school and starting
homework
Implement Routines & Breaks
Self-regulation resources are finite
Relaxation, meditation, and mindfulness helps with self awareness and
Self-regulation
10-minute breaks during strenuous self-regulation tasks
Utilize relaxation, meditation, and mindfulness techniques
Adapted from Barkley (2012).
36
Treatment
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
Involve the Family
Twin studies estimate heritability of ADHD at 76%*
The likelihood of at least one parent having ADHD as well is ~50%†
Self-regulation is strongly influenced by perceived environmental stability
*Faraone, SV, Perlis, RH, et. al. (2005). Molecular genetics of Attention-Deficit/Hyperactivity Disorder. Biological Psychiatry. 57(11).
†St. Sauver, J. (Sep 2004) Mayo Clinic Proceedings. 79, 1124-1131.
37
Marshmellow experiment
Treatment
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
Involve the Family
Self-regulation is strongly influenced by perceived environmental stability
38
Treatment
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
Involve the Family
Twin studies estimate heritability of ADHD at 76%*
The likelihood of at least one parent having ADHD as well is ~50%†
Self-regulation is strongly influenced by perceived environmental stability
* Faraone, SV, Perlis, RH, et. al. (2005). Molecular genetics of attention-deficit/hyperactivity disorder. Biological Psychiatry. 57(11).
† St. Sauver, J. Mayo Clinic Proceedings, September 2004; vol 79: pp 1124-1131.
39
Focusing on the task is difficult
Treatment
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
Neurofeedback
Mixed Results
Thought to increase prefrontal cortical activity
Utilizes immediate emotional cues
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Treatment
Attention-Deficit Hyperactivity Disorder
Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
(Greater distinctions between stimuli)
Increase overall arousal level via norepinephrine activity
(Greater overall clarity)
Work with client in the temporal domain to increase stimulus salience
(Address Time Blindness)
41
Demoralization (trauma) – experience of being told you’re not good at
stuff
and believing it
Distinct from depression
Treatment
Attention-Deficit Hyperactivity Disorder
Treatment Considerations
Poor diagnostic criteria because it is mostly related to lack of somatic markers
Depression vs Demoralization
ADHD often causes demoralization, which is misdiagnosed as depression
Addiction
Addiction profiles for Psychostimulants are much lower than believed
Poor Diagnostic Criteria
ADHD is neither an attention-deficit nor a hyperactivity problem
42
Acknowledgements
43
Acknowledgements
Russell A. Barkley, PhD
John C. Schureman, PhD, LMFT
44
Acknowledgements
Barkley, R.A. (2000). A new look at ADHD: Inhibition, time, and self-control. [VHS Tape].
Barkley, R.A., Brown, T.E., (2008). Unrecognized Attention-Deficit/Hyperactivity Disorder
in adults presenting with other psychiatric disorders. CNS Spectrums 13(11).
Russell A. Barkley, PhD
Barkley, R.A. (2012). Executive Functioning and Self-Regulation: Extended phenotype,
synthesis, and clinical implications. New York: Guilford Publications.
Barkley, R.A. (2013). Taking Charge of ADHD: The complete, authoritative guide for
parents. 3rd Edition. New York: Guilford Publications.
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