Professional blog

Time Blind: A New Take on ADHD Joshua D. Wyner, PhD, LMFT, LPCC

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Decision Making

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Decision Making Activation Inhibition

+ _

Activation

Inhibition Final Decision

“It’s night time, driving fast would be fun!” “I can’t see too far ahead, 
 and I’m scared I might hit something.”

Prefrontal Cortex

Check against prior experienceInitiate a potential action

3 Activation is the idea of having a potential action. Before activation is inhibition which takes into consideration past experiences. Activation and Inhibition combined can lead to the final decision.

Example: Child touches fire because it’s shiny, but after he gets burned, he will likely not touch fire again.

Decision making is emotional first and we make decisions based on our emotions.

Emotion is reflexive and heuristic.

Involved in managing social conflict Aids in consequence assessment

Processes long-term welfare

Rostral Anterior Cingulate Cortex Involved in emotional conflict

Suppresses emotional system

Decision Making

Prefrontal Cortex

©2008 Hagmann, et al.

Activation Check against prior experienceInitiate a potential action

Also aids in

Inhibition

Caudal Anterior Cingulate Cortex

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Prefrontal Cortex

©2008 Hagmann, et al.

Rostral Anterior Cingulate Cortex Involved in emotional conflict

Also aids in consequence assessment Suppresses emotional system

Norepinephrine Diffuse

Regulates arousal (homeostatic state)

Decision Making Activation

Check against prior experienceInitiate a potential action

Aids in affect-related

Involved in managing social conflict Aids in consequence assessment

Processes

Inhibition

Caudal Anterior Cingulate Cortex

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Diffuse Regulates arousal (homeostatic state) Aids in affect-related memory storage

Decision Making

Norepinephrine

Activation Check against prior experienceInitiate a potential action

Involved in emotional conflict

Suppresses emotional system Also aids in

Prefrontal Cortex

©2008 Hagmann, et al.

Inhibition

Rostral Anterior Cingulate Cortex

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Caudal Anterior Cingulate Cortex is responsible and activates when we assess social conflict. Emotionally process potential social interaction issues and relate it to long term welfare.

Rostral Anterior Cingulate Cortex is more related to direct conflict with others. Activates when it is necessary to repress emotional reactivity.

Norepinephrine seem to be helpful in memory storage and overall arousal level which is related to emotional experience during situations. Has to do with alertness and connectedness.

Norepinephrine is extended throughout the brain

Diffuse Regulates arousal (homeostatic state)

Anterior Cingulate Cortex Involved in conflict management

Suppresses emotional system Processes long-term welfare

Decision Making

Norepinephrine

Activation Check against prior experienceInitiate a potential action

Prefrontal Cortex

©2008 Hagmann, et al.

Also aids in consequence assessment

Aids in affect-related memory storage

Inhibition

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Inability to connect the present emotional state with future consequence

Lack of somatic markers

Attention-Deficit/Hyperactivity Disorder (ADHD) Decision Making

The Anterior Cingulate is smaller and fails to activate in ADHD

Diffuse Regulates arousal (homeostatic state)

Involved in conflict management

Suppresses emotional system Processes long-term welfare

Also aids in consequence assessment

Aids in affect-related memory storage

Anterior Cingulate Cortex

Norepinephrine

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Attention-Deficit/Hyperactivity Disorder (ADHD) Decision Making

Stare at the Red Dot

Lack of somatic markers

The Anterior Cingulate is smaller and fails to activate in ADHD

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Emotional reactivity is not as pronounced in ADHD. Does not have as many somatic markers

Example: paying attention to the teacher and also paying attention to external stimuli such as lights, someone passing by, someone drinking something, your phone ringing, etc. But not considering things such as the color of the wall.

People with ADHD are less likely to have emotional reaction or are less strong than those who do not have ADHD.

ADHD people are not able to connect current situations with future consequences.

The dot in the middle is what should be focused on, and the blue dots are external stimuli. ADHD people are less likely to focus on the red dot as it is not as obvious to them and does not have a strong emotional value.

Attention-Deficit/Hyperactivity Disorder (ADHD) Decision Making

Stare at the Red Dot

Lack of somatic markers

The Anterior Cingulate is smaller and fails to activate in ADHD

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The Anterior Cingulate is smaller and fails to activate in ADHD

Forgetfulness
 (unable to consolidate memory)

Inattentiveness
 (lack of emotional salience)

Hyperfocus
 (unable to stop current task)

Attention-Deficit/Hyperactivity Disorder (ADHD) Decision Making

Lack of somatic markers

©2011 Honestdiscounts.com ©2013 Gamerfitnation.com ©2013 Bottomlinehealth.com

Perseverence

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The Anterior Cingulate is smaller and fails to activate in ADHD

Forgetfulness
 (unable to consolidate memory)

Inattentiveness (lack of emotional salience)

Hyperfocus (unable to stop current task)

Attention-Deficit/Hyperactivity Disorder (ADHD) Decision Making

©2011 Honestdiscounts.com ©2013 Gamerfitnation.com ©2013 Bottomlinehealth.com

Perseverence

Inability to connect the present emotional state with future consequence

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Looking at the dots, ADHD is similar to being color blind and not being able to identify the difference. ADHD people would not know which one needs to be focused on.

Hyperactive type is not knowing which one to do and doing them all at once. Inattentive type is not knowing which one to do and not doing any of them until someone tells them which one to do/focus on.

Inattentive is not doing anything or paying attention.

Hyperfocus (Perserverence) is doing the task that has emotional value and they don’t want to stop doing it

Forgetfulness is being unable to remember due to lack of somatic markers.

The Anterior Cingulate is smaller and fails to activate in ADHD

Inveracity
 (Conflict Avoidance)

Impulsivity
 (lack of emotional salience)

Risk-taking Behaviors
 (unable to stop current task)

Attention-Deficit/Hyperactivity Disorder (ADHD) Decision Making

©1940 Disney

Inability to connect the present emotional state with future consequence

The ADHD individual is Temporally Myopic

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Treatment

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Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
 (Greater distinctions between stimuli)

Increase overall arousal level via norepinephrine activity
 (Greater overall clarity)

Treatment

Work with client in the temporal domain to increase stimulus salience
 (Address Time Blindness)

Attention-Deficit Hyperactivity Disorder

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Impulsivity is switching between tasks

Risk-taking behaviors are not seen as risky to the ADHD person therefore they will continue to do the task.

Inveracity (lying) is saying something that isn’t true Inveracity is conflict avoidant and a reflexive response and ADHD people do not have recollections and it is not thought out as a lie. Doesn’t mean ADHD people do not lie.

Temporal myopia is the present-centered focus.

Goal is to focus on: -increasing access to somatic markers -assist by addressing clarity from norepinephrine activity -work in time domain to help present-centered approach when it becomes too extreme

Treatment

Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
 (Greater distinctions between stimuli)

Increase overall arousal level via norepinephrine activity (Greater overall clarity)

Work with client in the temporal domain to increase stimulus salience (Address Time Blindness)

Attention-Deficit Hyperactivity Disorder

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Ritalin
 (Methylphenidate)

Psychostimulants Norepinephrine-dopamine reuptake inhibitors (NDRIs)

Therapeutic Dosing

Key Considerations

2-4 hour half-life

Adrenergic Side Effects

2-4x/day dosage

Short half-life Longer onset time than cocaine Addiction & Dependence Risk

NE/DA releasing agent

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.

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Ritalin
 (Methylphenidate)

Psychostimulants Norepinephrine-dopamine reuptake inhibitors (NDRIs)

Adrenergic Side Effects Insomnia

NE/DA releasing agent

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.

Headache GI Upset

Appetite Suppression

Therapeutic Dosing 2-4 hour half-life 2-4x/day dosage

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Want to often use medications that increase dopamine activity (psychostimulant)

Ritalin is go-to medications for ADHD for dopamine and norepinephrine similar to methamphetamine and binds to the same receptor sites as amphetamine Dosaminergic specific.

Potential addiction risk

Insomnia can be a direct and non-direct effect of ADHD since there is not an emotional connection with sleep.

Ritalin
 (Methylphenidate)

Psychostimulants Norepinephrine-dopamine reuptake inhibitors (NDRIs)

Therapeutic Dosing

Key Considerations

2-4 hour half-life

Adrenergic Side Effects

2-4x/day dosage

Short half-life Longer onset time than cocaine Addiction & Dependence Risk

NE/DA releasing agent

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.

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Ritalin
 (Methylphenidate)

Psychostimulants Norepinephrine-dopamine reuptake inhibitors (NDRIs)

Therapeutic Dosing 2-4 hour half-life 2-4x/day dosage

Addiction & Dependence Risk

NE/DA releasing agent

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.

Rebound Irritability Rebound Depression

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Ritalin
 (Methylphenidate)

Psychostimulants Norepinephrine-dopamine reuptake inhibitors (NDRIs)

Therapeutic Dosing

Key Considerations

2-4 hour half-life

Adrenergic Side Effects

2-4x/day dosage

Short half-life Longer onset time than cocaine Addiction & Dependence Risk

NE/DA releasing agent

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.

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Dexedrine
 (Dextroamphetamine)

Psychostimulants Trace Amine Receptor (TAAR1) Agonist

Therapeutic Dosing

Key Considerations

~10 hour half-life

Primary action on dopaminergic systems

2-4x/day dosage

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Monoamine Releasing Agent

Adrenergic Side Effects Addiction & Dependence Risk

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Vyvanse
 (Lisdexamfetamine)

Psychostimulants

Therapeutic Dosing ~1 hour prodrug half-life

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Trace Amine Receptor (TAAR1) Agonist Monoamine Releasing Agent

2-4x/day dosage ~10 hour half-life

Key Considerations

Prodrug increases onset delay & activity length

Adrenergic Side Effects Theoretically lower addiction risk

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Adderall
 (75% Dextroamphetamine
 25% Levoamphetamine)

Therapeutic Dosing 10-13 hour half-life 2-3x/day dosage

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Psychostimulants

Sinacola, R.S., Peters-Strickland, T. (2012) Basic Psychopharmacology for counselors and psychotherapists. (2nd Ed.) New Jersey: Pearson Education.

Trace Amine Receptor (TAAR1) Agonist Monoamine Releasing Agent

Key Considerations Adrenergic Side Effects

Addiction & Dependence Risk Levoamphetamine has greater peripheral action

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Dexadrine is a longer lasting psychostimulant -right handed isomer

More dopaminergic

Tends to release monoamines

Increase dopamine concentration in sending cell for action potentials

Vyvance is a prodrug and needs to go through metabolic first pass Slightly less addictive

Smoother than other psychostimulants Possibly because it requires liver bypass

Most insurance doesnt cover this ($300 a month)

Adderall is the First engineered drug for ADHD

Works on synergistic systems and pathways (norepinephrine and dopamine)

Can cause insomnia, so you can take it with a sedative medication.

Evekeo
 (Amphetamine Sulfate)

Therapeutic Dosing 10-13 hour half-life 1-2x/day dosage

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Psychostimulants Trace Amine Receptor (TAAR1) Agonist

Monoamine Releasing Agent

Key Considerations Adrenergic Side Effects

Addiction & Dependence Risk Levoamphetamine has greater peripheral action

May allow for lower dosing in some patients

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Dexadrine Spansule

Extended-Release Variations

Adderall XR

Ritalin SR Concerta

Improved dosing schedule

Decreased rebound effects

Decreased peak levels

Treatment Increase ability to assign somatic markers via increased prefrontal dopaminergic activity


(Greater distinctions between stimuli)

Psychostimulants

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Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
 (Greater distinctions between stimuli)

Increase overall arousal level via norepinephrine activity
 (Greater overall clarity)

Treatment

Work with client in the temporal domain to increase stimulus salience
 (Address Time Blindness)

Attention-Deficit Hyperactivity Disorder

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Evekeo is just amphetamine 50/50

When norepinephrine increases it causes a more peripheral stimulation

Extended release is designed to dissolve at a slower pace

Reduced rebound effects

Take 1x/day most likely

Increase ability to assign somatic markers via increased prefrontal dopaminergic activity (Greater distinctions between stimuli)

Increase overall arousal level via norepinephrine activity
 (Greater overall clarity)

Treatment

Work with client in the temporal domain to increase stimulus salience (Address Time Blindness)

Attention-Deficit Hyperactivity Disorder

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Intuniv
 (Guanfacine ER)

Alpha-Adrenergic Agonists

Therapeutic Dosing

Side Effects Drowsiness

Reduced appetite Headache, GI Upset

14-18 hour half-life

Increase NE pathway activity

1-2x/day dosage

Increase overall arousal level via norepinephrine activity
 (Greater overall clarity)

Treatment

Arnsten AF (October 2010). The use of α2A adrenergic agonists for the treatment of attention-deficit/hyperactivity disorder. Expert Rev Neurother (10): 1595–605.

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Intuniv
 (Guanfacine ER)

Increase NE pathway activity

Increase overall arousal level via norepinephrine activity
 (Greater overall clarity)

Treatment

Adderall
 (Dextroamphetamine & Levoamphetamine)

Psychostimulants Norepinephrine-dopamine reuptake inhibitors (NDRIs)

Alpha-Adrenergic Agonists

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An extended release medication

Typically used for high blood pressure

Targets peripheral and norepinephrine

You can take adderall in the morning and intuniv at night to reverse the effects

Intuniv is not as effective as adderall or as when you take them simultaneously

Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
 (Greater distinctions between stimuli)

Increase overall arousal level via norepinephrine activity
 (Greater overall clarity)

Treatment

Work with client in the temporal domain to increase stimulus salience
 (Address Time Blindness)

Attention-Deficit Hyperactivity Disorder

31

Increase ability to assign somatic markers via increased prefrontal dopaminergic activity (Greater distinctions between stimuli)

Increase overall arousal level via norepinephrine activity (Greater overall clarity)

Treatment

Work with client in the temporal domain to increase stimulus salience
 (Address Time Blindness)

Attention-Deficit Hyperactivity Disorder

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Focus on Point of Performance

Treatment Work with client in the temporal domain to increase stimulus salience


(Address Time Blindness)

Interventions should occur at the place and time when the failure to act normally occurs

Externalize the feedback/reward

Develop rewards that are immediate and portable

from PrototypeMama, 2013

Avoid mere admonishments of prior actions

Avoid simply “letting them learn the consequences”

Adapted from Barkley (2012).

33 Intervene when action is happening

Give present-oriented tasks Present-oriented jobs are best for them (photography, firefighter, therapist, etc.)

With kids, externalizing works best. Avoid giving ADHD clients “homework”

Focus on Point of Performance

Treatment Work with client in the temporal domain to increase stimulus salience


(Address Time Blindness)

Externalize the feedback/reward

from PrototypeMama, 2013

Clients with ADHD have an impaired ability to represent the world internally

Externalized interventions should connect back to internal representations whenever possible

These routines must be sustained for long periods in order to promote learning

Adapted from Barkley (2012).

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Implement Routines & Breaks

Treatment Work with client in the temporal domain to increase stimulus salience


(Address Time Blindness)

Self-regulation resources are finite

10-minute breaks during strenuous self-regulation tasks

Utilize relaxation, meditation, and mindfulness techniques

Adapted from Barkley (2012).

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Involve the Family

Treatment Work with client in the temporal domain to increase stimulus salience


(Address Time Blindness)

Twin studies estimate heritability of ADHD at 76%*

The likelihood of at least one parent having ADHD as well is ~50%†

Self-regulation is strongly influenced by perceived environmental stability

*Faraone, SV, Perlis, RH, et. al. (2005). Molecular genetics of Attention-Deficit/Hyperactivity Disorder. Biological Psychiatry. 57(11).
 †St. Sauver, J. (Sep 2004) Mayo Clinic Proceedings. 79, 1124-1131.

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Try making it internalized overtime to help them

Building routines helps offset disinterest and once it is done for some time, it becomes built in.

Breaks are necessary because you can’t process all information Breaks allow us to have some downtime

Breaks should be more frequent for ADHD clients For kids, give them a break between getting home from school and starting homework

Relaxation, meditation, and mindfulness helps with self awareness and Self-regulation

Involve the Family

Treatment Work with client in the temporal domain to increase stimulus salience


(Address Time Blindness)

Self-regulation is strongly influenced by perceived environmental stability

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Involve the Family

Treatment Work with client in the temporal domain to increase stimulus salience


(Address Time Blindness)

Twin studies estimate heritability of ADHD at 76%*

The likelihood of at least one parent having ADHD as well is ~50%†

Self-regulation is strongly influenced by perceived environmental stability

* Faraone, SV, Perlis, RH, et. al. (2005). Molecular genetics of attention-deficit/hyperactivity disorder. Biological Psychiatry. 57(11).
 † St. Sauver, J. Mayo Clinic Proceedings, September 2004; vol 79: pp 1124-1131.

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Neurofeedback

Treatment Work with client in the temporal domain to increase stimulus salience


(Address Time Blindness)

Mixed Results

Thought to increase prefrontal cortical activity

Utilizes immediate emotional cues

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Marshmellow experiment

Focusing on the task is difficult

Increase ability to assign somatic markers via increased prefrontal dopaminergic activity
 (Greater distinctions between stimuli)

Increase overall arousal level via norepinephrine activity
 (Greater overall clarity)

Treatment

Work with client in the temporal domain to increase stimulus salience
 (Address Time Blindness)

Attention-Deficit Hyperactivity Disorder

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Attention-Deficit Hyperactivity Disorder

Depression vs Demoralization ADHD often causes demoralization, which is misdiagnosed as depression

Treatment Considerations

Addiction Addiction profiles for Psychostimulants are much lower than believed

Poor Diagnostic Criteria ADHD is neither an attention-deficit nor a hyperactivity problem

Treatment 41

Acknowledgements

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Demoralization (trauma) – experience of being told you’re not good at stuff and believing it Distinct from depression

Poor diagnostic criteria because it is mostly related to lack of somatic markers

Acknowledgements

Russell A. Barkley, PhD John C. Schureman, PhD, LMFT

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Acknowledgements

Russell A. Barkley, PhD

Barkley, R.A. (2012). Executive Functioning and Self-Regulation: Extended phenotype, synthesis, and clinical implications. New York: Guilford Publications.

Barkley, R.A. (2000). A new look at ADHD: Inhibition, time, and self-control. [VHS Tape].

Barkley, R.A., Brown, T.E., (2008). Unrecognized Attention-Deficit/Hyperactivity Disorder in adults presenting with other psychiatric disorders. CNS Spectrums 13(11).

Barkley, R.A. (2013). Taking Charge of ADHD: The complete, authoritative guide for parents. 3rd Edition. New York: Guilford Publications.

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