 Well good morning everyone. This is a feisty group I can see. We're gonna have some fun today. I'd like to welcome you to the 19th annual Nadani Calciano Memorial Youth Symposium. I'd like to ask you all to please take your seats so that we can start this program. My name is Karen Gosling and I'm going to be your moderator for the day and before I start with some acknowledgements I just like to go over a few housekeeping items. So right off the bat you should all have a program ahead of in front of you. It's got a few do's and don'ts for the day. It's got the program agenda and more importantly on the back you'll have your course evaluation. You're going to be hearing about that that this is a pretty critical for you to hand in so that you can get CE credits for those of you who are getting CE and CEU CME credits. So if you could all please take a moment right now to dig up those cell phones and put them on silence. Nobody wants to be that person right. So the bathrooms we have bathrooms located right here and then there are also bathrooms in the sunroom which is where you came into the registration so plenty of bathrooms there. Refreshments and lunch is going to be provided in the Bayview room which is where you came through and that's where all the table presentations will be during the breaks and during lunch. Our primary mode of communication for this symposium is through email and so many of you received emails. If you could please take a moment to go through look at the Minilla folder on your table. If you've had an email change would you please update your email. We'd love to keep you updated with what's coming up next and especially for the 20th anniversary. So please take a moment throughout the day to update your email and your name on the Minilla folder on your desk. When we leave this afternoon we're all going to exit out of the sunroom which is where you came in. We're not going to be going out of these stairs right here. For those of you wanting credit for this it's critical that you sign out and hand in your course evaluation. We ask that everyone hands in their course evaluation because we love to hear about the presenters and what you'd like to hear about for next year. So please hand those in when you go out through the through the sunroom. Good news this year is parking is free so you don't have to worry about parking validation so that's excellent. And if you have any questions throughout the day please don't hesitate to ask anyone at registration ask me anyone of the symposium advisory panel. We're happy to help you. So today's presentation is being recorded by Community TV of Santa Cruz County. It's going to be for future broadcast and in about three weeks it's going to be on YouTube. We hope this is going to allow this amazing material to be presented to a broader audience. So look out for that in about three weeks. So before we get started with the program there are some people that really need to be acknowledged for their amazing dedication to the health of the Santa Cruz community. The Naderne Calciano family have dedicated the last two decades to providing our community with vital education to ensure the health of future generations. Not only do they dedicate their time but they're incredible supporters of the Dominican Hospital Foundation which provides countless opportunities and resources for our entire community. You'll hear more from Joshua this morning but please now acknowledge help me acknowledge the Calciano Naderne family. I would like to now take a moment to thank our annual health care sponsors. When you get through the table presentations please take a check at the Dominican Hospital booth the hospital foundation booth and you'll see some businesses that provide support for all of the foundation programs throughout the year. They really help make these events possible and also provide other vital equipment for the hospital allow for a lot of community programs community education and exercise classes. So we'd like to make sure you go by take a look at the businesses and make sure that you have an opportunity to thank them whenever you can because that's what makes this these kind of presentations possible. I'd also like to thank the Dominican Hospital Foundation staff for their support. They have done an incredible amount of work for this so just want to thank the Dominican Hospital Foundation and their staff so thank you. With that I'd now like to bring up Alicia Nehera to the stage. Alicia is the program manager for the Santa Cruz County Mental Health and Substance Abuse Services and she serves on the board of the Symposium Advisory Committee. Welcome Alicia. Thank you and good morning everyone. I'm just here to reiterate something that Karen already told you but if you plan on getting CEUs or CMEs it's crucial that you stay throughout the day and you sign out. As Karen said everyone is going to exit through the way that you entered not this way as in years past. So when you exit turn in your evaluation and sign out we will not be giving any partial credits so if you have to leave it before it ends I'm sorry but you will not get credit so don't even ask. Also just to let you know that your certificates will be mailed to you and it'll take about four to six weeks to get them so be patient. You will get them. All right thank you and enjoy the day. Thank you Alicia. It's now my great pleasure to bring up Joshua Nadone Calciano to the stage. Joshua was just 18 years old when he lost his older brother John. At the inception of the symposium in 1999 Joshua took on an active role as a family representative and later took on the role of co-chair of the advisory board. Joshua is now the nurse administrator at the Department of Veteran Affairs in Sacramento and continues to be an integral member of the symposium team. Please join me in welcoming Joshua Nadone Calciano. Good morning everyone. I live up in Sacramento and we were coming my wife and I were coming home to Santa Cruz last night and we were just amazed by over 17 the flooding and we know we see it on the news and we see the road was washed out but that's we were to say impressed how much damage was done so but I want to welcome all of you to our 19th annual Johnny Natterny Calciano Memorial Symposium and I also want to welcome all the various organizations as Karen talked about. For many years we've had these organizations come in and I feel that it's a great opportunity for all of you to network and to really get to know the support organizations that are in our community. I'd also like to acknowledge the high school students being in high school this these days is a lot different than when I was in high school with cyberbullying and all those interesting things that we have now and I think that the high school students have the greatest challenge to take what they learned and convey it to their peers so that they can learn from them as well. My brother John would have been 45 years old and as I've grown up from an adolescent to a husband now a father I often think about what my brother's life would have been like today and although this symposium bears his name I believe it it comes represents all families who struggle with suicide drugs alcohol and have lost loved ones. My family is incredibly gratified to have seen this symposium over the years in memory of our brother developing to the widely attended event of today and as difficult as our loss is seeing the sense of the community coming together as to prevent similar tragedies from happening our community is a very healing force. We continue to be impressed by the diversity of the attendees clinicians counselors educators parents and public safety officials that have attended this symposium your elder year your post symposium comments have really told us that we were making impact on our community. My family's deepest appreciation going out to all those that have planned the details of each annual symposium especially if I could have all the members of the advisory committee stand please. These are the hard-working group of people that have helped us bring the symposium event year after year. I have never met a more dedicated passionate group of people and I am honored to have been part of that. To the tireless volunteers to who you met as you were walking in for their logistics and helping a plan and the Dominican Foundation for their support which is the philanthropic arm of the Johnny Natterney symposium and with their support we have established the Johnny Natterney Endowment Fund and lastly to all of you because of your continued support for nearly two decades this symposium has expanded on topics ranging from autism to suicide and your quest and continued quest for knowledge is what allows us to bring such wonderful speakers year after year. We could not simply have had such a wonderful event without you. Thank you for your support and somewhere I want to thank all of you for being here today and I hope that you find this information useful in your work and it will continue to join us year after year. Thank you. So now this year is a little unique I'd like to have a very special presentation so if I could have George and Molly Jaro come up to the stage please. So a little bit about my friend George. So George received his nursing degree from the State University of New York at Alford in 1979. He has worked in the mental health field since 1981 and has been a Dominican and Santa Cruz for 33 years. He retired from Dominican last year in 2006. He joined our symposium in 2003 and has been an integral part of its development and its progress the last 13 years. So on behalf of the President George, your dedication to this symposium. I just want to say that I'm very proud to have been and continue to be involved in this annual event and it's such a special thing to bring our community together in honor of John and to help forward the cause of creating peace and harmony in each individual's lives as well as our community. And again thank you very much. Now it is my distinct pleasure to introduce Dr. Julie Schweitzer. Dr. Schweitzer is a professor at the Department of Psychiatry and Behavioral Sciences. She's the director of the Attention Impulsivity and Regulation Air ADHD program at the MIND Institute at UC Davis School of Medicine and director of the UC Davis Schools of Health Mentoring Academy. Her goal is to apply translational research methods using the combination of behavioral and psychological methods fMRI to better characterize and develop targeted treatments for self-control and attention disorders in child and children and adults. This includes identifying subtypes of attentional impulsive related disorders associated with a tenoid site hyperactivity. In addition she conducts investigational initiated clinical trial research using cognitive and psychopharmacological approaches in ADHD and autism. She has a long history of studying reward related functioning and across populations including typical development ADHD, schizophrenia, substance abuse disorders. She's also currently funded for communication and dissemination projects for ADHD. I'd like to welcome Dr. Julie Schweitzer. Good morning everyone I am so honored to be here today and I have to say the word of the day I think is dedication because I also in all of my communications with people from the organization have been so impressed with their dedication and their thoughtfulness and organization. It's really nice to see the organizational skills as well that's always helpful for us as presenters and this model of the family working with the community I think is so wonderful and I think that's really how you get change right and that's how you get change that permeates and over time will really make a difference so kudos to all of you for the your family for thinking about how to work with the community and to inspire others and to make change that really is sustainable so I'm grateful that you invited us so later today you'll also see my colleagues Dr. Murat Pakarek who's here who's our division director and Chalice Akihutri in our direct about patient services and Dr. Katherine Fassbender who's a preeminent neuroscientist and she'll be so many of the things what I'll be talking about here will be followed up through their conversations as well I've left some time hopefully at the end of my presentation for some questions and then at the end of the day we also have a panel where we'll have more questions as well if there's a burning question that somebody has there's a lot of you but you can raise your hand actually enjoy much more of the interaction with the audience then standing up here for 70 minutes but we'll see okay I didn't have a slide up here about my funding but we receive a fair amount of funding from the National Institutes of Health for much of our research and I also have an investigator initiated grant from Shire Pharmaceuticals for some neuroimaging research but none of that funding influences what we're talking about today here's an outline about what I'll be talking about over the typical symptoms the impact of ADHD first in childhood then in adulthood what it looks like across development what you need to be thinking about assessment some updates on treatment and some of our approaches that we're taking to try to make changes in terms of getting out treatment out to more people so what is ADHD it's what it says attention deficit hyperactivity disorder there are three types of ADHD though they're not called presentations rather than subtypes people oftentimes refer to the inattentive type of ADHD as ADD but that term as it hasn't actually been official within a diagnostic system since 1994 so when people say ADHD they're referring to the inattentive as well as a combined type it's a neurodevelopmental disorder so you'll be hearing about some of our brain imaging research or we show that there's a biological basis for it and it changes across development so these are the core symptoms not everybody has all three of these but a lot of people just have the inattentive symptoms but a fair number especially the younger ages have the impulsivity and the hyperactivity and the inattention that's what we call the combined presentation as people mature though oftentimes you see much more of the inattention the impact of ADHD is tremendous not just on the individual but the family and the society and these are some of the statistics of what you see about ADHD they oftentimes come into our clinic because they're worried about achievement in their children that's why they make the appointment their child is failing in school so that's why we see them but throughout their lifespan there's lots of impact some of this is interesting I think in terms of now people have quantified the economic impact so look at this in terms of incremental cost due to ADHD per year 143 to $266 billion that's a big number so if we can address and prevent and treat ADHD we can have an impact as well as in the financial health of our community people with ADHD when they're young the the issues with peer relations oftentimes in addition to the academic issues is preeminent but as people mature we get more concerned about substance abuse, suicidality, sexual behavior in terms of they're more likely to have a child in earlier age less likely to use protection and so forth accidents rates are higher across the board to not just and driving but in many other ways as well what we're becoming more and more interested is we're looking at adolescents in our lab is about irritability and emotional ability and this is just some data recently from one of our projects showing this is year one to year two so these are teens and you see that there's a decrease in irritability over time but these are the ADHD subjects and you can still see even with that decrease over time there's still much more irritable than typical adolescents same thing for emotional ability is that and it's decrease over time for adolescents with ADHD but it's still much higher than what you see in healthy controls and this is important because in other words when I'm saying it's not just the in attention the hyperactivity but it's the emotional functioning that gets impacted by ADHD and that we need to pay attention to that because that has a lot of implications for our treatment this is one of our figures from a project I work with Josh Greslaw looking at across different disorders and you see all these different disorders and then you look at what are the ones that are most associated with high school dropout rates and it turns out it's ADHD and in a conduct disorder which is I think pretty interesting because we all know that these are very impactful disorders yet if you target this population with ADHD you're much more likely to have an impact on reducing dropout rates but also tobacco dependence has had a surprisingly high impact as well. This is from another group Lily Heckman who's been following people for decades and LNCG those are controls and what they have here just compared to ADHD children who grow up and you see there's a huge difference in terms of whether or not they obtain a bachelor's degree or not and then what you look at here is people who have remitted some other symptoms so if these sisters means they continue to have some symptoms but not the full ADHD diagnosis and here are these are people continue have the full diagnosis and you can see there's a difference there too so as the symptoms decrease as they do in some people their likelihood of obtaining a bachelor's degree is is greater which of course has a huge economic impact as well right because if you're obtaining a college degree your likelihood to get there likely to get a job that pays better and you can put more back into the economy as well as sustaining yourself and your family. This is again looking at across different emotional symptoms and oops sorry about that and this is just to show again this is looking at these sisters versus per sisters and you can see overall the control subjects tend to have fewer emotional symptoms anxiety and depression and so forth but those people when they have more of the symptoms so they meet full criteria for ADHD they're much more likely to have all these other symptoms so that again the idea is you can't just look at the ADHD symptoms you have to look at emotionality and other symptoms as well and consider treatment for those. There's also been an interesting story here about whether or sex differences between boys and girls with ADHD and it turns out in some areas there's some evidence for some areas not so much evidence so in terms of neuropsychological functioning there isn't as much evidence that there's a difference in performance but girls are being recognized that they have more of this emotional ability, irritability and so forth so that needs to be attended to. What's also I think really interesting is that we're seeing more eating disorders in these girls as well so that's something that people should be screening for. In childhood the difference in prevalence is much stronger where boys have much higher rates of ADHD than the girls by adulthood that decreases dramatically. I think this is also because we don't know for sure why but I think the symptoms of inattention people start queuing into those and looking at those and girls are much more likely to display those symptoms. Females are also much more likely to go for treatment. Oftentimes it's not the ADHD that's driving us at the anxiety or depression but if you dig a little deeper some of these people will have the ADHD and so therefore in adulthood women with ADHD are more likely to seek treatment than men with ADHD, whether it's for the ADHD specifically when they come in for treatment or not. The possibility is there that it actually does exist. These is to talk about some of the differences that we see with maturity. The inattentive symptoms change in their presentation but they tend to be much more stable. The impulsivity declines to some extent especially the risk taking but hyperactivity is where you see the greatest difference and what we see is that obviously they're not running around the room in adolescence and adulthood but you hear people talking about running around in their head. So they're thinking from thought to thought to thought. They have a hard time doing a cohesive sentence sometimes or paragraph. They may be grabbing things off your desk or themselves so they're fidgeting but it's less of the gross motor or more of the fine motor and again you hear a lot of this verbal hyperactivity and that's what you tend to see. So this is a cartoon that personifies the difference in when you look at the different developmental stages and it says mom can Trent come over today? The mother says Trent, Trent's a little reckless. Reckless? What's that supposed to mean? Reckless means doing things without thinking or caring about the consequences. Does that sound like anyone you know? I'm a seven year old kid. It sounds like everybody I know. So at seven what your expectations are and at three versus 17 versus 37 and so forth are quite different. So you need to keep that in mind and hopefully the recklessness does decrease but again that's in the teenagers where we start seeing more people because of concerns about that and the academic still. So this is a slide here just to talk about some of those differences and in the preschool ages to behavioral disturbance kids are taking things from one another. They're not doing the sharing. They're having a hard time sitting in a circle. That's why they get referred. School aged again they start worrying more about the academics. Still there's issues about behavioral disturbance or they're trying to get their work done at a table and they're bothering the child sitting next to them or they're impulsively blurting things out to the teacher and again there's issues about about socially relationships and peer acceptance. By adolescence a lot of this gets starts getting internalized. So you start seeing issues with self esteem in adolescence but you also start getting more worried about academic impairment if you're worried about whether your child is going to make it to college or not. But then some concerns again with the anxiety and depression as well start emerging and at risk taking with the smoking and the smoking and the alcohol and drugs and also because that's when they get their driver's license. Oftentimes one gets concerned about driving and I'm concerned about driving and texting and adolescence in particular and we oftentimes actually recommend that people adolescence with ADHD wait until they're older to get their their license 18 or so. College age many of the same issues. People are on their own. They have to make their own decisions about when to get up whether they're going to attend class or not. And so because that that increased independence there's greater concerns about their ability to follow through. So then you get more concerns again about academic failure. The self esteem continues and colleges is actually where you see a huge increase in alcoholism. And that's because they're around it and so much more so many more ways because they're at a frat house or something like that. They have they have access. They may not have had before. In adulthood it's more the same. The self esteem issues continue but concerns about employment and underemployment also emerge and in word relationship issues also can become very problematic as well as relationship issues at work. And so this is this refers to the risk taking. So dad you know how sometimes something that seems like a really good idea turns out to be not such a good idea. And here you see the yes. At the time at the moment and so Dr. Fassbender will talk about what some of the reasons why we think there's that impulsivity and that need to do something exciting and so forth. How sometimes it has really bad outcomes for people. The parents that I think are not so surprised. So I get this question a lot. When should one seek an evaluation and ADHD is unusual compared to a lot of other child psychiatric disorders because the time one waits until thinking about ADHD to actually going in for an evaluation can be three years. And when you're looking at something like autism it's weak. Even for depression and anxiety. But people have a lot of concerns about making that first leap into getting help. And so why is that why do people start thinking about ADHD. Oftentimes it's a teacher around age six or seven or eight when the child's expected to sit still in the classroom. It might be that there's a family history of ADHD. It's not unusual for us at all to have a be working with a child and the father sometimes mother says I was just like that as a child. And then oftentimes we refer them to Dr. Packer act and he starts doing the evaluation as well in adulthood. But that family history is people are becoming more aware of ADHD. I think people are thinking about that and starting earlier to think about an evaluation. Certainly there are other symptoms that look like ADHD as well. And that might be a reason why people come in to seek an assessment. But usually the issue is that there's problems not just a one setting like the home that's usually the home or the school. And there's a there's a big difference in terms of your what people are expecting from an evaluation and what they should expect from an evaluation. What's realistic. And when people are trying to make that decision that whether or not to have an evaluation. One reason the obvious is to get better idea about what your child is at their normal quote unquote. And what's the reason behind these behaviors. And what can they get treatment and so forth. Or maybe they want documentation for school to get special services. But there's the other reasons is that they may feel very frustrated and that what they are doing isn't helping enough. And again as I mentioned earlier behavioral issues and academic is oftentimes a reason. And so if you don't get help these issues can continue to be problematic. And hopefully we can do some things during an evaluation process to help get people on the right footing. There's different people who evaluate ADHD. These are the people who have the most experience or medical professionals with these particular training. Clinical professional there's a wide range of people who have. But it really depends on the individual. There are a number of people psychiatrists who don't have training in ADHD if they just trained as primarily in adulthood. Same thing for clinical psychologists to have different areas of expert expertise. So you need to talk to the individual to get an idea if this is something that's they're comfortable doing. You have to have an idea what you're expecting out of the evaluation. Do you already know your childhood ADHD. But you just need to have it in black and white. And the stamp of approval. Are you are you really just looking for medications. Some people don't even want the diagnosis. They just want the medication. Are they looking are they really against medication. We see that as well. They really want some tools to help them and to help the school. So you I think it's really important for people to have an idea what their goals are when they're going out and seeking evaluations to help ensure that they're getting what their needs that their needs are met because that will determine who you see when you decide to seek out health. Whether you're going to see a psychologist whether it's a psychiatrist or pediatrician and so forth because they can do they have different areas expertise. So I think people need to be clear about that. There's a difference between a screening and an evaluation. My concern is that oftentimes what people wind up getting is just a screening. And sometimes that's sufficient but sometimes it's not especially if there's comorbidity. So screening can take 15 minutes or if you go to our clinic more like an hour and a half two hours. But if you go for an evaluation that can be six hours or so forth. The screening is really just rating scales and interviews and quick observations. That's oftentimes what you get when you see a pediatrician when you go for when you have an evaluation is much more in depth. You do more observation to interview with the parent and the child is much deeper. Oftentimes what you're trying to do is figure out if there's something else that could be causing the issues that you're seeing and not ADHD that takes a much longer period of time to do that kind of interview. I tend to use broad based and specific ratings like oops I keep doing that. I will learn eventually. The conners I use for ADHD specific the child behavior checklist in the vascular what we call broadband instruments to look across different categories of externalizing internalizing symptoms. Pediatricians typically use a Vanderbilt which is fine as a screen they're free. So that's great but it's not normed for age or gender. So that's why I prefer using something like the conners it is norm. Same thing with the ADHD RS. We tend to do is we look at things whether or not maybe there's some other reason that the symptoms could be occurring but also as I said the comorbidity. Learning disabilities are also very common in ADHD but 30 40 percent of kids with ADHD have learning disabilities too and those are there they need to be evaluated and they need to be addressed. Sometimes we'll do an IQ and an achievement and some neuropsych testing but that's not necessary necessarily required in every situation. And so that's where again it comes back to who you're seeking out for your treatment and evaluation. A psychologist is the people who do this. This is not that a medical professional does not do that. A medical professional prescribes. Psychologists do not. Social workers are very good at providing supportive information and also doing some diagnostic work. So you have to have an idea of what you want. Of course so I think what we see a lot in our clinic is people who've actually come in from multiple evaluations. And I can see that as one matures the issues change. So then you need to have a reevaluation but we see people who come in who have three evaluations and no treatment. And I don't know if that's because they're looking for something else and the answer that they've received. But it really delays the time into when the intervention should be starting. So I think it would be much more efficient for families if they had an idea of what they were looking for be clear about that. Be clear with their treatment provider as well what they're looking for. And then get on to doing implementing the interventions that should help address the symptoms. Okay. All right. Now it seems to have stuck. Okay. All right. So here's the pros and cons of the screening. It's short. That's why a lot of pediatricians are able to do it. But unfortunately it's not really. It's not going to give you all that other information that I talked about. So that's why if you and if you want documentation for a school typically they won't accept that they want the full battery. Evaluation is much more in depth. Takes more time. It can be more costly. It might be harder to find providers who can who are able to do that. But the advantage of it is that you get a much better idea of how this child is performing and what's relevant to what their needs are. But it can be it can be as I said earlier is time consuming and it can be costly. So this is just referring to what the diagnostic issues are with ADHD especially since we have something called DSM five diagnostic and statistical manual five which came out just a few years ago which is a change for what we were using for years. So there are some differences. It used to be that you had to be had evidence of ADHD before the age of seven. Now it's changed to the age of 12. There's some recognition that there are symptoms that sometimes don't emerge until middle childhood. You have to see impairment across different settings. So home and school not just one place. There's a comorbidity. Something that I learned from one of my mentors Dr. Russell Barclay that I think is really important is also to think about the parents and how are the parents doing. Do they have ADHD. If they have ADHD then they're going to have a harder time in terms of intervention because they're going to have a harder time following through oftentimes. So you have to make that consideration. Are they very stressed. Are they feelings frustrated. Are they having depression anxiety and so forth because this child is not the context is the family consolation. So you need to start considering that as well. Another change with the SM five is that now we can officially diagnose ADHD along with autism and DSM for you if you had autism you cannot be given a diagnosis of ADHD but we know people were being treated for it. It's just that it wasn't an official diagnosis. These are other measures that I think are important. I'm not going to go through all of them but to think about social skills one of my favorites to ask about if the child is having trouble sleeping at night whether or not they had the overhead light on. I cannot tell you how many times I've heard that they do. My natural response is well you don't necessarily need a medication for that. You can try a night light and try a light on the closet light on the hallway. But please don't start with medication because your child has overhead light on. So these are things to ask as well. I look at report cards because it just gives me critical information especially when they're younger. There's a lot of information about where they actually have descriptions from the teachers about behavioral performance not just great and so forth. Self report measures as a child matures so by the age of nine or so we start also doing a screen for anxiety and depression. I talked to the parents about their discipline styles and whether they agree with one another that can be a huge source of conflict and confusion for the child. Typically medical history is not relevant. If there is a concern that's when I definitely make a referral to my colleagues. Dr. Packarac is a colleague as well occasionally to neurologist. But if people are telling you that they need a spec scan or MRI to diagnose ADHD run. Because that is not accurate. Unless you suspect that there is some abnormality. The person has seizures or there's some other evidence of something organic happening. But for ADHD diagnosis that is not indicated. We use imaging brain imaging every day. But we use it as a research tool. Most of the time you don't need brain imaging at some point you might be able to use it to look more at when we're trying to do differential diagnoses. But if somebody is telling you that they need to do that. Then they are misinformed. And this is not just me saying that this is the imaging community is saying that and even the National Institute of Mental Health. Has put a statement about this on their website saying imaging is not necessary. And it's expensive. And SPECT in particular is a concern of mine because it involves radiation why expose somebody to radiation. Especially a child if it's not necessary if it's not going to be helpful. So after you gather your information from your diagnostic interview and testing and so forth and rating scales then you need to think about what is that information giving you. What does it point to. Because obviously you want to use that information to direct your efforts. Because you really have to start prioritizing about what's going to help the family the most. Oftentimes it's going to be medication so for traditional medication most primary care physicians are skilled to do this some not all are comfortable levels I will say that. And they prefer. A child psychiatrist at least do the initial work. Dr. Packrock will talk more about this but clearly if there's a more complicated situation I always refer to a psychiatrist think about what type of therapy will talk more about that. Again think about their parents whether they need to be referred for treatment as well. So I'll go more in depth about these there are a variety of the different interventions that are used with children. And these are I think probably the ones they're most well known and I recommend all of them. These are evidence based programs there are others out there. But they all really work in the same way they're clearly different nuances in them. But PCI T incredible years in the fine children one thing that I think is true with all of them is they look at that parent child relationship. And they focus on that relationship first. And how you can enhance that relationship to then make the behavioral component be that much more effective. PCI T is really neat. Where we I had some early training they call the bug in the ear. So they will have a parent will have a speaker and it can be a therapist from the other room observing them with their child and they guide the parent of what to do in their interaction style. That's really cool. That started out with very young children. I think they're expanding it. And I know there's I have some colleagues at UC Davis who are trying a short a brief PCI T to see if that works as well. But it can be really remarkable to see how the parent responds to the feedback and then intern the child. So the cool thing is happening in the moment right. So the parent and child are right there and the therapist is on the other side giving giving feedback. The incredible years is started off of the the the younger years. But now they have a whole set of materials for adolescents and so forth as well I believe the fine children is again about ages six to 12. Dr. Barkley also has treatment interventions for adolescents as well as some of his colleagues. These are all very manualized and I recommend all of them. They're all terrific and they they vary as I said in certain ways. But they all work on the premise of the relationship as well as goal setting and rewards and making very salient cues and so forth to the to the children to help the parents with them. I think it's really important that the family understands that ADHD is not going to respond to the treatment and then continue to have that intervention works forever. If they go for a 12 week intervention training course that's not going to fix ADHD. ADHD is chronic. We do see that symptoms dissipate for many in adolescence and adulthood but they have to have that they have to have this idea that there are times you're going to have two steps back two steps forward and one step back and they have to recognize that and there are times when parents can get very frustrated. So if you have them think of it more more akin to something like diabetes that there's always there's this underlying difference in physiology and that there are things that you can do in terms of the environment and medication as well. But the symptoms aren't going to miraculously respond to a 12 week program and they're going to be dissipated. The child gets into it and the next grade a new teacher and sometimes you have to start from square one. But hopefully there's learning over time. So behavior therapy definitely can make a difference. Again oftentimes it's in goal setting giving rewards and so forth and setting up the situation and to address comorbidity. It's not going to change those ADHD symptoms. It's not going to change the hyperactivity that is part of the child. We'll talk later maybe that's not such an issue as much as people think it is anyway. But you might use behavior therapy because also you can have a lower dose of medication and some for some people medication doesn't work but typically we always recommend it. People try behavior therapy as well in addition to medication. So what are the the type of intervention I'm going to give you here some very specific I've been more broad earlier really that you want to teach the parents and the child to focus on the specific behavior to be very concrete instead of saying you are good today Johnny fantastic say John I really like the way that you filled out your planner today and you remember to put your homework in your backpack that's fantastic so again be very specific have goals for the day for the week and for the month. As one matured you expect those goals to be broader help them if they're having a hard time where they're having a hard time keeping their hands to themselves keep their hands engaged doing something else. So that is the way to deal with the the in compatibility. Think about what are the times that tend to trigger some of this ADHD behavior for a lot of people it's uncertainty or when they have to make a change in their schedule. So if you have more structure oftentimes that can help. We really like to promote the idea of class classroom wide incentive programs so that's where the whole class can be on a reinforcement program this way the child with ADHD is the so marginalized and the stigma is less. And the truth is when everybody responds they connect more like a team and it's a more positive environment. This again some more implications more specific ideas for how you want to go about the interventions that are general. This is from Russ Barkley but these are these are old ones that still work. And you have oftentimes with ADHD it's not that the individual doesn't know how to do behavior. They know how to do the behavior but at the time something else is more interesting. Whether it's what their classmate was doing something they're thinking about the night before or what they're doing later in the day. So what you have to do is at the time you have to have you have to have consequences for the behavior and that includes positive behavior positive consequences. At the moment if the reward is too delayed it's not going to have the effect. So that's why it's really important that the parents and the teachers are the ones who are doing these implementation of the behavioral systems. And just because somebody has ADHD doesn't mean that they can't be shouldn't be held accountable. They need that feedback that's going to bring about the change in behavior. You want to also prioritize what you're targeting but you want to make sure that it's really clear when you set up a behavior as one of your goals that you have very clear rewards or removal. I don't like to say punishment but maybe a loss in a token economy. Let's see. So compassion is also really important because these can be really challenging children. I think there needs to be compassion for the parents as well as the kids. And it's not volitional with these kids. It's not something that's under their control and people can get really frustrated because one of the interesting things about ADHD is that people with ADHD are highly variable. So there are times when they are just completely on and you'll hear that from teachers with the child that everything that was expected of them. And then the next day they go and their behavior falls completely apart and they're not listening at all. They're not paying attention. They're not following through. And the teacher says, well, I know that Susie can do it because Susie just was great yesterday in class. She did everything I have to forget. Today she's completely falling apart. And then the teacher gets frustrated. And the child gets frustrated because Susie was trying but there's that variability and that really is inherent in ADHD. So people have to understand that as part of the disorder. So one way of helping is that you give lots of physical cues. And nowadays we have lots of auditory cues because we can use planners and digital planners and cell phones and satellites and things like that. And the more that people can do that, the more help it is. But it really is individualized. You have to work with the individual and see what works with them. But if you can do that help have these external supports, a lot of people have sticky notes all over there. The mirror in the bathroom and so forth, those sorts of things, salient cues that is going to help the individual because they have issues with working memory. And the more they have to rely on their memory, the harder it is for them. So these external cues, breaking things down, tasks that are large tasks with a deadline for a term paper so that breaking that up into what you would do each week rather than in three months, those sorts of things help people feel more successful. And they're going to be in the long run just going to help them feel like they have a sense of accomplishment. So again, with tokens, praise, and so forth all this, make it very salient and those environmental supports should also help. This is mainly when you're thinking about academic work, think about how long the task is, maybe for some children with ADHD, it can't be that long. They can't sit still for 60 minutes. Maybe it's just 20 minutes and then they get a break and they walk around and then they come back. Think about novelty. That's key with ADHD. They get bored very, very easily. And so you have to think about how you're presenting it, the information you're presenting, the worksheets, things like that have made a difference. If you make a worksheet, look more interesting. We'll talk about later of why gaming is so popular with ADHD. But a lot of that is because of the novelty. So people can read this on their own. But I think you'll also have the slides that you can look at. Something that's fairly new is the Organizational Skills Training Program that Howard Abokov developed at NYU. Linda Pfeifner, who's right here nearby, UCSF also has a program. There's some overlap. They really look focusing on the attention and organizational issues. And it's really nice to see that there's some good evidence base for these programs. This is fairly revolutionary in treatment for ADHD. But they're very practical suggestions. And these are manualized so you can find them at Amazon and so forth. Especially Linda Pfeifner's work is really geared toward the inattentive types. So it's nice to see that those considerations are being made, that not everybody at ADHD is the same. And you have to look at what their symptoms are. I love this book. This is fairly recent. I had the pleasure of meeting Maggie Sibley just a few weeks ago at FIU. And there is such a need for treatment programs for adolescents with ADHD. And she has this beautiful manual that she's developed that's very clear. Lots of examples. But also she starts with motivational interviewing. How many people here? Raise your hand if you know what motivational interviewing is. Great. Fantastic. Terrific. OK. That's fairly new to the idea of ADHD. And she incorporates motivational interviewing for the child and for the parent, which I think is so brilliant to think about how they both have to have that, to think about what is going to make the difference to help as a team to work together to address the challenges that adolescents face with ADHD. This is just to emphasize again what I just said a minute ago about how not everybody with ADHD is alike. And just I had to show some of our neuroimaging data because we spent a lot of time on it. And this is a lot of the first slide is really a project that Dr. Fassbanger really led and Dr. Mazahari came in and did some really clever data analysis. This is looking at ADHD and an attentive subtype, combined subtype and typically developing. And the main message here is just that they're not the same. This is using EEG. And there's a difference in terms of the brain. The brain waves and so forth. And you can just see the typical children are down here. They're very different from both subgroups. But the subgroups are different as well. This is a very large project I was involved with across the country in multiple sites. And again, this was using fMRI though, what we call resting state. And we compared C versus I here as combined type versus inattentive. And the main take home message here again is these brain networks differ between these two groups. And so that tells you that on a biological basis, there is a difference between how these kids are functioning. So that needs to be taken into account. And until recently, like I said, Dr. Pfeiffer's work, there hasn't been treatments recognizing that. And we're hoping in the future there will be more that now that we have these biological data, because for years, I had colleagues who said, ah, there really isn't that much difference. And eventually the combined type become the inattentive type. But these data are very persuasive. This is actually, at that time, this was published in 2013. This was the largest group of functional imaging data from an ADHD group with 193 subjects. Nowadays, we have a lot more. But this is fairly nice. Again, raise your hand if you've heard of sluggish cognitive tempo. OK, we have a few people out there. That's great. So this is something that's, I think I first heard about maybe at least 15 years ago. But we thought of it as something very different. I thought that was the real Uber. Not Uber has a different meaning now. They're really restrained. I can't, now I feel like I have to talk about Lyft. But it's a real equal time. It's the inattentive type to an extremes how I initially looked at it. But the conceptualization of it has really changed over time. And it's not classified as a legitimate disorder. But there's growing evidence that there is this thing where people are not just inattentive. And even people with combined type have symptoms like this. And these are people who, they dreamy, like they're looking off into space. They're not disruptive. So the teachers aren't going to notice them right away because they're just off in their own little world. The problem is the world's going on. And they're off in their own little world thinking about whatever. And that's not helping them academically. And that's where they're, I think the primary challenges are for children, for adults, as I'm sure it's getting their work done. And so more and more people are looking at this. And it's been interesting because this is one of the earliest disorders where there was evidence in genetic basis. These kids did look different. And across lots of behavioral studies, you see a difference as well. So what was really cool is that Dr. Fessbender was very clever. And she thought about a way to try to look at that amongst her own data set. And so she did a comparison and looking at the inattentive symptoms versus the sluggish cognitive tempo symptoms. So we have a rating scale as an SCT rating scale. And we have an inattentive rating scale. And parents did both. And then what she did is she looked at brain imaging functioning during a task and how it differed in relationship to performance on those rating scales. And this is a very complicated slide. So I do apologize. But the take home message is that we had two conditions when they were doing a task in an MRI scanner. This is where they weren't giving any cues to tell them to prepare to respond for each trial that would come up. In this condition, they were given cues in the form of different colored hands to tell them what kind of trial would be emerging in the next stimulus. And the main take home message, so SCT are areas of the brain where you see a strong response in relationship to the higher SCT ratings. Inattentive, the IA areas of the brain are where you see a higher correlation between attentive symptoms and brain functioning. And the main point is they're different. And so that's what here, in particular, this brain range is down here, is where you see a significant difference in this parietal, occipital area of the brain. And so this area of the brain there's a clear difference. So my point is there's a different perspective about what SCT is versus inattention, that they are. They are really probably representative of different symptoms and a different network that's occurring in the brain. So once again, we'll probably have to come up with some different treatments that are specific to those kind of symptoms. When I was working on an inpatient unit many years ago, when we actually had children with ADHD on an inpatient unit, which is unheard of nowadays, but these were children who were very severe, one thing we noticed was that when they had Nintendo therapy, their ADHD symptoms remitted. It was amazing. And now, everybody has some form of Nintendo therapy, right? It's on your cell phone or your tablets at home. And people will notice and they'll say that my child can sit for hours and hours and hours doing gaming. And it's amazing. Their attention is so terrific during gaming yet. They can't do that for their homework or they can't. There's no way they can do that in a classwork. But they can't have ADHD because they can do an hour long of Candy Crush or whatever the current popular game is. Obviously, I'm not up with it because I don't know what it is. I know it was Candy Crush when I made the slide. But anyway, the point is there is something in these games that is making a huge change in behavior and perhaps brain functioning as well. And can we use that for good? Instead of wasting a lot of time, can we harness that? Because what we know what it does is it gives immediate reinforcement. We've got that novelty that I talked about earlier. And it definitely holds their attention. And so that's what a lot of our lab is working on now is how to harness the positive aspects to help it also have helped children with ADHD. So this is an example of a clinical trial that we're involved in. Adam Gazzelli, who's at UCSF, this is based on a project that he designed actually initially for the aging population. And now he's working with the company called Akili. And we're just one site of many UCSF, I think, is also engaged in this and many other sites across the country where it's a tablet-based therapy. And kids get randomized to a tablet where they have a race car game to help train attention versus a different kind of game. And so if people are interested and want to drive all the way to Sacramento, we are accepting patients. And the cool thing is that it's done at home. And so a lot of the treatments that we're trying to work out in our lab is where they are done at home. So you don't have to see a psychologist or a psychiatrist could be delivered much more convenient way. And so the idea is that you're training attention. And this is a very controversial area, I have to say. There's been a lot of negative about this as well. It's positive. And I think it's really too early now to know whether or not what the effects are. We did an early study. We published about maybe four or five years ago now where we actually did find a really positive effect within a different program in behavior. But then our children became less interested in what we were offering in terms of these cognitive games. They became less interested because they were boring in comparison in what they could be doing on their cell phone. So what's neat about this project is that Adam Gazzelli also has professional game developers involved in developing the software. So it's much more exciting for the kids. And we haven't had anybody who's dropped out because they're bored with it. So again, it's controversial. I think the approaches vary from one to the next. And that has to be kept in mind. And I think this is an evolving area. But I think there is some potential here. Also, there are some huge limitations that we need to take into account. So this is a project that we're recently funded by for the National Institutes of Mental Health. And what we're looking at is using virtual reality. So the kids will have as most we're looking at different options, but most likely we'll load the Samsung phone. And that's not the one that blows up. Believe me, we're not going there using a safe one. And they're wearing a gear headset at home. And they'll be practicing learning how to ignore distractions in maybe 20, 25 minutes a day. And we're going to test out maybe about five or six weeks. And we're building a virtual classroom. And we'll have avatars in the classroom. So the child will be immersed feeling like they're in the classroom. And they'll be doing a math test and some other tests. And they'll have children in the classroom who'll be talking to one another, sending passing notes, a pencil dropping, a teacher walking by, and so forth. And the reason I got the idea for this was multiple reasons. But one reason was I was working with talking with a parent of a child with ADHD. And she said, you know, if my child could just learn to be not so distractible in class, it would make such a huge difference. And she said, when I was when I was in law school, what I used to do, I would study in a cafe. And I would take out my readings. And I just had to learn to block out the noise. And eventually I learned to do that. So then I started thinking, what if one had the ability to give kids lots of practice and the setting that they needed it to be, and they could do it in a more fun way? So that's the idea that they practiced it at home. Because you can't have that much control over what's happening in a real classroom. But you can in a virtual classroom. And so I think that this is successful. We could expand upon that. We're building it right now for an elementary school classroom. But you could easily do a high school classroom. You could do a work site. The potential, I think, is tremendous. But what I really love about it, again, is that people can do this at home. They don't have to worry about rushing in to find time to come in for appointment. Because we'll get the data on a daily basis. This is another project that we're funded from the National Institute of Child and Health and Human Development, and my CHD. And this is a small project that we have. And this is to increase self-control. And this is based on my master's thesis a long time ago. And what you see here, what we did is it's similar to the Marshmills study. Have people are familiar with Walter Michelle's Marshmills study? OK, there's a few people. It was actually done not too far from here. It was done at Stanford. And what he did is he gave children the choice between one marshmallow or if they were willing to wait for the experimenter to come back in the room, they could have two. And so these were young children, three to five years of age about. And there's really adorable videos on YouTube simulating this, not the original children, but simulations of this. And you'll see that the children send them poke at the marshmallow or they lick it. And they look around and see if anybody's watching them. And then some of them just gobble it down. They just can't wait. Some of them just kind of stare at it. Huge challenge. Anyway, so I did something where that was one trial. What was really cool is that he found these people for decades and he found that how they performed on that marshmallow test predicted academically how they did, whether or not they were more likely to use substances of abuse. It predicted physical characteristics as well. So there are BMI, I think other maybe cardiac events and so forth as well. So it was really powerful. So what we did years ago is I gave kids multiple opportunities to choose not between marshmallows but between different types of candy and stickers, whatever interested them. And then we did a pre-test and we found out that most kids were not willing to wait much more beyond five to 10 seconds. And that's what this represents here is how long they're willing to wait. They wanted it now. But then what we did is we did a shaping study. And I actually based it on an animal research study that I saw where they taught pigeons to wait for longer and longer periods of time. I thought, well, why don't we try that in kids? So that's what we did. We gradually increased how long they had to wait for the three stickers or the three M&Ms. And then we tested them after the shaping procedure. We saw here's how much longer they were willing to wait. And during that time period, I didn't tell them what to do. They developed strategies on their own. So they would sing to themselves or they'd play with their fingers and they'd make up little games. And it was really interesting to watch how so many of them have different kind of strategies that they developed. And so the idea was, can we now do this in a more current environment? And obviously for many young children, the universal reinforcers, not M&Ms anymore, although I'm sure they'd be happy to take some. But it's gaming. So now we're going to be testing it out with young children to see whether we can teach them to wait for more game playing. So maybe 30, 45 seconds of game playing versus five seconds of game playing. So we'll do the same thing where we'll gradually increase how long they have to wait for and then how much of the reward they have. And the cool thing is, if this works, then parents can have this as an app on their cell phone. So if they're with a child in the grocery store driving on a long drive, instead of the cell phone being used for immediacy, this might actually be a tool to teach their kids to learn to wait, which I think is becoming a loss art. I think fewer and fewer people have patience and know how to wait and are able to develop their own strategies. I remember years ago, people who are in line as the supermarket, you would glance at the magazines, right? They were right there. That's why they were there. People, I'm sure the publishers were hoping you'd pick them up and read them. Nowadays everybody's staring at their phone. So I'm sure the magazine sales are plummeting. But my point is people are becoming more and more impatient. And if we can teach ways to help remind people how to become patient, I think it'll be much more to our benefit. And I have to say that a person who was always very interested in this study was Nora Volca. Nora Volca was the director of the National Institutes of Drug Abuse. She's so interested in this, and you'll hear from Catherine later, is because there is just tremendous link between impulsivity and substance abuse that she was interested in because she saw that we were able to change that. This is a study that's guarded us a fair amount of interest. And this was what we did in fidgeting. This is Arthur Hartanto here. And he was the one who carried out the analysis. He was very dogged about this and very persistent on this. And so what we did is we had kids who were these actographs like this. And they wore one primarily on the ankle. And they were doing a cognitive test. Dr. Fasper will talk about this more later called the flanker, where they had to pay really close attention. And what we did is we measured their physical movements while they were playing the game. And this is a figure here showing how, so TD is typical children. That's what this line here is here, ADHD or children with ADHD. And this is when they got a correct response in that. It's called the flanker task. And this is when they were wrong. And what you see here is that when the children with ADHD move more, we saw that they got more correct. So their amount of movement was helpful, it appears. And what's different about our study from some other studies, some other studies had looked across an entire session. And instead of what we did, we were able to see on a second by second basis performance and accuracy on a task and tie that directly to physical movement. So that's why I think our task has an innovation over some of the other earlier studies by Dr. Mark Rapour, who really was a pioneer in this area. So we saw more intense movements. To some extent, more frequent that really the intensity movements was much stronger. And my idea for this project was really just looking at kids with ADHD when they were working. And I saw that they seemed to be putting their whole body into it sometimes. And when they're working hard on the challenging problem, I thought there must be something to that. That maybe this is a way of increasing the arousal system in their brain and heightening their attention. So the problem is that oftentimes this fidget or activity is disruptive to other people. And parents get irritated and teachers get irritated and try to get the children to relax and calm down. It may turn out that that physical activity is actually a good thing that is helping them learn. So we have to find a way that we have to do more research in this area. We have to find a way to balance that so that kids can express themselves physically when they need it to help improve their attention, but do it in a way that doesn't disrupt others. Because that is, I think, in the classroom, that is the biggest concern is that if you allow children to be on bouncy balls and have toys to play with, it's disruptive to other people. And there's not, there's so many of these fidget tools out there. I just heard yesterday that there was somebody that had a Kickstarter campaign that expected to get some thousand and wanted to get millions of dollars to develop these fidget tools. And it turns out there's no evidence behind it at this point. We have our data that suggests there's relationship, but nobody's actually, actually tested how those specific tools work. And so we'd like to do that. Microport, no, I'm sorry. Bill Pelvis, Rubit FIU, is starting to look at some of these things. But we need to have a lot more because these companies are springing up everywhere. And there may be something to it, but I think I would like it to be more systematic than people rushing out and buying all these things and then asking the classrooms to adapt and we don't actually know what the effect is. So hopefully, hopefully we'll write another grant about this or if anybody wants to donate some money, we're always appreciative to see if it'll work. It might be something very simple in terms of, but it will take time to do the careful evaluation. So this is a project by a very clever, very dedicated junior, she's actually a fellow a pediatric developmental and behavioral pediatric fellow, just part of her group Samantha Cohen. And she was, she's a very clearly interested in yoga. She does it routinely herself and she found a, there was a graduate student in the School of Education who was also very interested in yoga and they devised a very clever study to look at whether or not yoga could change behavior of preschoolers who are at risk for ADHD. So these were kids who didn't necessarily make the full definition, but they had a number of the symptoms of it. So they were at likelihood to at some point become ADHD. And so what she did is, before I get into the data, I should tell a little bit more about the study, she worked with a preschool. So they went to the preschool. She had official yoga teachers work with the kids. And the initial, there were two versions of the study. The first part, the kids were pulled out of the classroom who had high rates of ADHD symptoms. And the yoga teachers worked with them to teach them poses. And they were really cute. They're adorable. And they're doing their breathing exercises and their poses. Unfortunately, it was really hard to get a group of kids who have a high rate of ADHD symptoms together to be calm. So that was the number one lesson that she learned. If you get a bunch of them together, they rally each other up. And I'm sure the teachers knew that. The yoga instructors took it off for them to figure out. So the second iteration of the project, the children with ADHD, the whole classroom did the yoga exercises together. It worked much better. And the teachers were there. Because the yoga teachers are great at teaching yoga, but they don't have training necessarily on how to deal with children who are disruptive. But so having the combination, it was a good lesson about how to do this. That being said, so she got mixed results. It wasn't necessarily that she got improvement across the board. That's not what she saw. But she did see some areas suggesting that this might be worth exploring on a larger basis. And so these are looking at ratings. These are inattentive ratings on this side here. And this is hyperactivity and impulsivity ratings. And this says inattention, but it should actually be hyperactivity and impulsivity, my understanding. And so these are apparent reported. And what you see is that, for some of the symptoms, actually, so this is the ADHD RS preschool version. And then this is the SDQ. So maybe that's why it says hyperactivity inattention here. It didn't work for everybody. So this is looking at change. And this is a neat graph where it looks at what the score was that they started out with. And then whether or not there was change. And for certain people, there was a tremendous amount of change. And so you have the yoga group here. And so the yoga group is here. And then you have a weightless control group. And for certain people, it seems to work. For others, it doesn't. And I think that's, in general, the way we're going in medicine as well as mental health treatment, is that not every treatment is going to work for everybody. And we have to start talking about what we call precision medicine more and thinking about how we can find out who interventions are going to work for and have an idea of who that is before we start them. And so those are rating scales which are subjective. And this is one of the many measures that she had. This was an attention task. So this is an objective measure because it was a computer administer task. And this is just to show distractibility. And you see there is a decrease in errors related to distractibility. So there's some hint here that there is something to this. And hopefully other people will follow this up in the future. This is completely changing gears. I just wanted to show you another project that we were doing. This was a behavioral health center of excellence. It was actually funded by state tax dollars. And this is a communication dissemination project. And it's really it's to build a website about ADHD and ADHD resources. And how do you know what's legitimate. Because if you go into the internet and you type in ADHD you'll get a lot of information such as from chat and so forth. It is legitimate. And then you get a lot of information like the anti- chat groups that that are very strong in their opinions but don't have evidence oftentimes to back it up. So as a parent if you first start having concern about ADHD and you go to the web to a website and start searching you could wind up extremely confused. And that's why I think it oftentimes takes three years for people to go and seek help because people don't know what to believe. So our goal with this website is we are bringing families in we're talking to them we're asking them what they want to see on a website. We're building it's where we have information that we feel is evidence based. But also we're looking at how to physically present that information. A lot of the websites I see still have way too much text. And for people with ADHD that doesn't work. So we're trying to make it much more aesthetically pleasing and easy to understand. So that's a project that we're we're rolling out we're in the midst of. That was Dr. Daniel Scholesi is another developmental behavioral pediatrician who's working on that. OK. So we have a video now. This is from somebody who was a patient of mine initially who is referred to Dr. Packard is a very articulate well spoken woman who talks about what it feels like to have ADHD in her experiences. All of you I'm sure know people with ADHD. We are off or we are on we are waking up or we are asleep and slow and behind. So this is really exciting to me to see that there is documentation that there's a study showing that this isn't just us being too sleepy. It's not something that we're not trying hard enough that it's it's seen across other people with ADHD. I am a very very lucky person to have support from family friends colleagues neighbors community and I wouldn't be able to be here and be as successful in my life as I am without the kind of supports that the three doctors have spoken about. I have a treatment plan that is encompasses psychiatry psychology counseling exercise I monitor my diet. I have I also have opportunities to express myself through art and poetry and all these kinds of things are what allow me to have my personality come out without the hindrances so much of my diagnosis. So so this whole whole set of support that has been talked about tonight. I want to share a few specific things that might be helpful for you as either things that if you yourself have ADHD you could share with other people around you or if you are treating or supporting someone else with ADHD that you could also learn that might be helpful for your loved ones or your patients to know. So in terms of in terms of deciding to commit to treatment again I was I was very fortunate growing up to have supportive family. I did not have treatment at all other than my the support of my family and school school is really helpful having short classes just just like Dr. Schweitzer and Dr. Dixon were speaking about when you get to college all of a sudden you have these really long classes and have to decide what what you're going to do with your time and that's when we started getting really serious about about what are we going to do how why did I go from straight A's to failing how come I don't know how to decide when I'm going to go to sleep or when I'm going to do my homework or any of that it just everything kind of fell apart so it's in college that's just kind of learning and understanding but I didn't really start treatment until until after I'd already dropped out of Georgetown and I want to say about academics right here in Sacramento Cal State Sacramento has an office for services with students with disabilities that when I was ready to go back to school was incredibly helpful I highly recommend connecting people with ADHD to that to that school they have a high tech center which utilizes the these new technologies to to help us get through and also it helps alleviate some several symptoms because I learned how to use technology and use tools and use support of my peers to be able to rise to what my my capacity is which is actually a really great we often hear all these negative things about us and I want to share a little bit about that too. We put even even supportive people but we hear all around us especially as we age a hyperactive female in her 30s is not as acceptable as a small boy who is able to run outside and play. So I hear things like calm down slow down stop being so hyper you're too energetic you have too much energy you're too happy all these things hurt after a while so that we're having the two in front of all these statements I recommend to everybody to stop and think like is it something that's actually negatively impacting you is someone's high energy actually a problem for you and if so say why like when I come home and you're so you have so much energy it makes me feel like blah blah blah try to express what you're actually trying to say instead of just labeling your to this or to that. So that's that's another little pointer. The driving the driving situation is really serious. I when I get into a car I know that I am in control of a huge vehicle well it's not huge this piece of machinery that someone else's life my life of course but someone else's life could be in danger. We have a great bus system here. I I take it if I wake up and I'm getting ready for work and I'm like you know what I'm just the medication hasn't kicked in yet. I'm done with something soft. I take the bus or I walk and please all it takes is once to be distracted and and cause something really serious for your own life and other people. So please take the bus or find other ways to get to work. And let's see. I guess yes. So please make sure that we're we know that we accept each other's differences. We don't all have to be the same. We don't all have to like maybe someone with ADHD might say to you all you're so you're too predictable. Why are you sitting there so calmly. You know why don't you have more energy and actually some of some of the things that I feel about things I hear is like why aren't you more excited. When I hear slow down sometimes I just want to say I'd rather run away. When I'm told to shush because I'm talking I feel like I'm trying to try harder to dissolve. So depression is an anxiety or really real with people with ADHD because we're constantly letting people down. And the thing we hear the most is just try harder just try harder. Look we're trying really really hard. We're just different. So I really enjoyed seeing the suggestions occupational suggestions also. Those were great. And those are things that that my my team my my treatment team has helped me with here as well. Remarkable woman. And it's been so I've been so privileged to see her grow and develop over time. But so many different words of wisdom that she had there that I think you really need to take to heart. But when I see her the other thing that I think about is we do we talk as professionals. We talk about the negative impacts and so forth. But these people have so much to contribute. And I think that's something that constantly need to remind myself. And I feel I need to remind others is that ultimately I have hope because I have seen so many people with ADHD whether they know they have it or not have been able to be just incredible innovators and creative thinkers. And they have done so much. And I think about what if they were in the right circumstances. If they did have a supportive environment. If they had people around them who understood what their strengths were. If they had insight and I think that's a lot of it as especially as they mature as gaining that insight. So I think what I do want everybody to think about that. Because she talked about the hurt that she experiences. And that self-esteem issues that I mentioned earlier. And that does that takes a toll. And to be really thinking about what your prior priorities are as a parent or as a partner or as a co-worker supervisor or as a therapist because we these people are capable of doing exceptional things. But they have to find their niche and they have to find what works for them. So anyway. Now more about ADHD in adults. So these are where we oftentimes see the symptoms. It's this organization. I difficulty estimating time. And relationship issues whether as I said earlier whether it's work or home and so forth. I talk frequently about a very common scenario that I haven't worked with adults in our clinic is that we have somebody who has been a sales person or consulting where they're able within their job to move a lot. And then they get promoted to a desk job. And they hate that. They have deadlines. They have tons of paperwork that is not their strength and they get unhappy. So those are the sorts of things that people people need to think about and know about themselves. It's going to let me advance. Okay. In terms of diagnostics issues. You have to have. There has to be history of symptoms during childhood. This can't be a sudden occurrence. There's some controversy right now in literature whether it is adult onset of ADHD. I think at this point the evidence is still leaning toward probably not. But it's an interesting different way of looking at things. So I'm sure we'll be hearing more about that in the next several years and through the research literature. Earlier as I said the same thing with children as adults. Are there other reasons for people who are experiencing symptoms? It's not ADHD. Is it stress? Is it anxiety, learning disabilities, any of those things? College students are I think where we oftentimes when hearing the most about at least in the press about college students coming in with ADHD. A lot of them do tend to have ADHD because a lot of them had in childhood it didn't dissipate. And now that they got treatment. They're going into college rather than going into the military or going directly to work. They're actually trying to earn a college degree. One thing it's really tricky is that there's there's concern about diversity. And I'll talk about that in a minute as well. Also to note that in with historically black colleges, the rates of self reported diagnosis of ADHD are lower. So if you are involved with under represented minorities, you might want to reach out to see if they are coming into the clinic if ADHD might be behind with some of the challenges are. In terms of assessment, rating scales and interview, but the key difference here is that I don't rely on just on self report because people with ADHD do not have great insight. So we if they are in a relationship oftentimes talk to the partner, we always have ratings from from from somebody else, whether it's a partner, roommate, parents, if it's somebody who has parents who are still they're in contact with and they're not too elderly. So that's really, really key. And you have to look at all sorts of things and and look at as I said earlier, we know about emotional ability and irritability. So you want to look at that you want to look at presence of substance use as well. But then also when you're doing your evaluation, there are things like Dr. Barkley has a executive functioning rating scale that he sells to Guilford was really needed by these rating scales. When you use them, it talks about symptom degree of symptoms across all these very practical areas. And that helps you guide your treatment. Also what I said here about previous records is also really key. I even like to if I can get elementary school grade reports from an adult, that's fantastic. That can make all the difference in the world. This isn't a fairly old report now from the New York Times, but there's this concern about this. I said about diversion and also people really using in fainting ADHD diagnosis and apparently sometimes the parents are colluding because they're worried about their children's GPA. That is a concern without a doubt. And you can fake ADHD. You can go on the internet and you can list all the symptoms and you can go into a practitioner and you can talk about and describe all the symptoms because they're very well documented. So people have to be aware about that and be concerned about that. That's why I always for young adults insist that we have some contact with the parents. But as it says sometimes there's some concern about the parents colluding as well. So I think it's okay to be skeptical. But as I said it really does exist for many people. So that takes a lot of detective work and maybe right away you don't prescribe medication. You wait several sessions to get to know the person. And you see if they hang in there. And if they hang in there maybe it was legitimate. So there's other treatments besides medication, unlike childhood behavioral issues with ADHD, cognitive behavior therapy does work with adults. It doesn't work so well, children's behavior therapy works with kids but not cognitive behavior therapy. Whereas I think because there's some frontal lobe development in adults the cognitive therapy does have some role. And these are the areas that it can help with. There's some suggestion that coaching might work. So that's rather than seeing a therapist instead you're working with the coach on it day to day sorts of things. Just like you would with sports. You set a very clear goal. And then you get feedback and how you're doing turning your goal. There's early evidence that meditation and mindfulness might work as well. So there's some studies coming out of UCLA. And I think that's a definitely interesting area to pursue. Academic accommodations can oftentimes be helpful. But we wish there was more information on that. So in terms of future directions, we're a translational lab. So that means we do everything from some more basic science and brain imaging research all the way through intervention studies epidemiology. What we like to do is try to merge those findings together to then guide our work whether it comes to developing better evaluation tools. But right now we're very heavily focused on intervention. And what we want to do is use our neuroscience findings to guide our treatment because that historically has not been done in ADHD. Those have been very separate camps. And yet we're building all this information. And I think we can use much more and develop much more targeted tools depending upon these neuro psychological and neuroimaging profiles that someday we may come through. And so that's I think really the goal for the future is that we can't ADHD such a broad term is to then look at the individual and have these treatments that are really specific to the symptoms and the situation as well as the age of development. And what's so neat about adolescence, even though it can be a really tricky time, it's just also potential time for tremendous growth in many, many ways. I have my son is 16 now and I remember when he was there was about one month when he was 14. And I was looking down at him. He was shorter than I was. By the end of the month, I was looking up this dollar, which is great now because he can reach other things I can't reach in the kitchen. And he's very helpful in when we're traveling, lifting up the suitcases as well. So you see all that change in height. There's also a lot of going on in the brain at the time. And if we can capture that growth and then use it to design treatments that can help intervene in a way, I think we might be much more successful. But we're just starting to look at that. And I think that's really the direction that we need to go in. And these are some resources for you all. There's a number of really great websites that do have evidence based, eventually we'll have ours up. Chad is a wonderful organization. There's national and local chapters. Penn is terrific parent educational network. They are based out of San Francisco. I think they have a chapter in San Jose. They have one in Sacramento and I think in Phoenix. They are just a fantastic group. Understood.org is a website that they're also promoting. And that's really a neat website. So there's some resources. And this is just a few of the people over the years who's been working with us. I've been very fortunate to have a fantastic team. Again, they're also very dedicated, spend hours and hours and hours. And it's a really the, not just a dedication, but the curiosity. So many of these we work with a lot of young people that they have that keeps us going and growing. And is really to the benefit of the people that we work with. So here's just a few of them. Many of them have gone up to graduate school and and onward to do great things. But we're definitely a team effort. Thank you for your attention. We have a teeny bit of time for questions and then we'll have more time for questions in the afternoon. Any quick questions? So the question is about percentage of people in the population of ADHD. For childhood, it keeps moving. And there's different statistics. The one this is the statistic I'm most comfortable with is from five to seven percent of children. The CDC came out with a estimate of 11%. But that was just based on parent, parent ratings, not teacher. And the five to seven is based on more of the gold standard where it was looking at parent teacher and then an expert in terms of so I five to seven percent is what I go with because how the ascertain that for adults is four point four percent. And it's across across several countries. It's not so far from that. Great question. Red shirt. That's a great question is about sleeping resources for sleep. So I would say there's a lot of issues in there. Some of it could be whether they're a medication or not because that sometimes can impact sleep. A lot of times sometimes it can impact sleep. It can improve sleep actually because of people are have too much rumination and they can't quite their mind that can help. For other individuals is the stimulants are keeping them up tonight. The dose is too high too late in the day. Sleep hygiene. I think there's there's actually still recently an online training for sleep hygiene. And I think a lot of it is actually probably relevant to ADHD as well. So learning the context where they are what they're doing before they get to bed. And there's a lot of suggestions out there that there shouldn't be any screen time within a couple hours or so before one goes to sleep. I'm really excited about the potential for meditation. I think again we have way too little evidence but there are there's some apps out there for meditation and they have some design for children. And the idea is really to practice controlled breathing and to learn how to quell your thoughts because you focus more on the breathing. And I think I'd be really interested in exploring because I think there might be some potential that won't work for all children. I think not all children are going to have just I just don't think they're going to have the self control and so forth. So I guess those are some of your Dr. Packer may have some other suggestions about that. But those are some and I know some parents who just say that they have to have their children very involved in physical activities earlier in the day and that that can make a huge difference. Time for another question. So this is a great question it's about working memory and the route of what the working memory deficits are. That's actually a controversy in the field. I think there's evidence for a few different things. Some people say that it is the ability initial ability to encode the information so they're distracted initially and their attention isn't very good about bringing the information in when it's presented. I think that's part of it. I don't think that's all of it. They clearly seem to have more difficulties with manipulation of information. So even once it's encoded they're not because working memory is very different from just recall. Working memory is using that information and manipulating it. So somebody giving you a phone number and writing it down but you don't have your cell phone or a pen you just have to rehearse it in your mind or listen to a teacher and take notes and try to listen while you're taking notes at the same time. So that requires there's a lot of juggling that's going on and I think it's probably there's something about that manipulation part as well. So people have looked at capacity if the capacity is reduced and so forth. So I don't know for sure we are 100 percent there but we have loads for probably over 20 years of imaging data showing that there's in certain areas of the brain there's actually hyperactivity for people with ADHD when they're doing working memory but they're not using regions of their brain that were considered most efficient. So the processing level is the processing is very different as well. So I think we have time for one brief question. That is a great question. I think they will be. Yes. We might take out some of the unpublished data slides but I think they will be. That was a great short question. Thank you. Appreciate it. Thank you for your time and I'm looking forward to the rest of the afternoon. Thank you so much Dr. Schweitzer. That was fantastic. I'm very excited for the future. So we have a short 15 minute break. Please make sure that you visit the resource tables outside and for those of you who wanted to have more questions we have boxes here for your questions. So please write your questions down. Put them in the boxes at the top here. See you in 15 minutes.