0:04

Welcome to the Attention Deficit

0:06

Disorder Expert Podcast Series by

0:08

Attitude magazine. I'm

0:12

Carol Fleck

0:14

and on behalf of the Attitude

0:16

team, I'm pleased to welcome you

0:19

to today's ADHD experts presentation titled

0:21

Cognitive Disengagement Syndrome, a Distinct

0:24

Kind of Inattention. Leading

0:27

today's presentation is Dr. Joseph Frederick.

0:30

Dr. Frederick is a clinical

0:32

psychologist at the Center for

0:34

ADHD at Cincinnati Children's Hospital

0:36

Medical Center. He

0:38

is also the lead psychologist in

0:40

the first Cognitive Disengagement Syndrome clinical

0:42

service at the medical center. Cognitive

0:46

Disengagement Syndrome affects up to 40% of children

0:48

with ADHD. Some

0:52

of the symptoms include trouble getting

0:54

going, taking longer than

0:56

others to complete activities or tasks,

0:59

and excessive daydreaming. Cognitive

1:02

Disengagement Syndrome is a new name

1:04

for what was formerly called sluggish

1:06

cognitive tempo. Because

1:09

some of the symptoms overlap with ADHD,

1:11

it can be difficult for clinicians to

1:13

discern one condition from the other. Today

1:17

we'll talk about symptoms and treatment

1:19

options and how Cognitive Disengagement Syndrome

1:22

is similar and different from ADHD. We'd

1:26

like to begin today's webinar by asking

1:28

this poll question to our live audience.

1:31

In what area does your

1:33

child with ADHD and or

1:36

Cognitive Disengagement Syndrome need

1:38

the most help with morning

1:40

routine, academics, sleep,

1:43

homework, excessive daydreaming? Please

1:46

select your answers and comment in the text

1:48

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1:50

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1:52

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1:55

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thanks our sponsors for supporting our

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webinars. Sponsorship has new

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influence on speaker selection or

3:40

webinar content. So without

3:42

further ado, I'm so pleased to welcome

3:44

Dr. Joseph Frederick. Thank you so much

3:46

for joining us today and for leading

3:48

this discussion. Yeah,

3:51

thank you so much for the warm introduction

3:53

and for Carol and Attitude for having me

3:55

today and for all the listeners

3:57

who joined and taking time out of your day

3:59

to learn. a little bit more about what

4:02

is cognitive disengagement syndrome, what have

4:04

we learned, and most importantly, what

4:06

can we do in some next

4:08

steps? And I hope to go

4:10

through that with you all today.

4:12

What I'd like to do before we get

4:15

started is if you are not already, I'd

4:17

like you to imagine that you are a

4:19

teacher in a classroom, where you

4:21

have 20 or so kids. And what

4:23

I want to think about are first, the

4:25

symptoms of ADHD. We know

4:27

that they fall into the two categories

4:30

of excessive hyperactivity and poor

4:32

impulse control and the

4:34

symptoms of inattention. In a

4:37

classroom setting when there's a child

4:39

who has the hyperactive impulsive symptoms,

4:41

trouble sitting still, being fidgety or

4:44

restless, verbally impulsive or

4:46

physically impulsive, these behaviors are

4:48

very clear. They're noticeable in

4:51

the classroom. When

4:53

we consider a child who

4:55

has the inattentive symptoms of

4:57

ADHD, so difficulties, sustaining mental

4:59

effort on tasks that may

5:02

be boring or mundane, being

5:04

externally distracted, trouble

5:06

attending to details, as the child

5:08

gets older and schoolwork becomes more

5:11

common in the classroom, also

5:13

these behaviors and symptoms are clear

5:15

and they're noticeable. We've

5:18

learned over the past two decades that

5:20

there are a subset of kids who

5:22

in the classroom are likely in

5:24

their seat. They appear to

5:27

be listening. They're not overly

5:29

impulsive, but internally

5:31

they're distracted. Their mind is

5:33

wandering, they're lost in their thoughts.

5:36

They're staring off into space. They have

5:38

a harder time expressing their thoughts.

5:41

Rather than being hyperactive, these

5:44

children present with more sleepiness

5:46

or tiredness, having a hard

5:48

time completing day-to-day activities

5:51

quickly. These are the

5:53

set of symptoms and behaviors that were

5:55

first coined sluggish cognitive

5:57

tempo and has recently been

5:59

changed. to cognitive disengagement syndrome. And

6:01

this is going to be the bulk

6:03

of today is talking through what exactly

6:05

CDS is and what are some recommendations

6:07

for you all. Our

6:10

first understanding or

6:12

possible identification of kids who had

6:14

CDS actually was back in the

6:17

1790s when the

6:19

first medical textbook discussed two

6:21

different types of attention deficit.

6:24

One, which we believe describes the

6:26

inattentive ADHD. So

6:28

individuals who were described as

6:31

being very distractible, attention shifting,

6:33

hard time sustaining attention. Where

6:36

another form of an attention

6:38

deficit was for individuals described

6:40

as being under-arassed or having

6:42

low levels of mental energy or

6:45

stamina. Wasn't a lot of

6:47

conversation or text about the second type

6:49

of attention deficit at this time, but

6:51

we believe this is the first reference.

6:54

And it wasn't until the 1960s, 1970s where specific

6:56

symptoms of

7:00

SCT at that time such

7:02

as daydreaming, drowsiness, lethargy were

7:05

included in rating scales. So

7:07

different rating scales that were

7:09

completed to assess for different

7:12

behavioral conditions, emotional problems. And

7:14

then the 1980s when the DSM-3 and the

7:17

DSM, that's our

7:19

mental health manual that has all

7:21

the different types of diagnoses like

7:23

ADHD. And the

7:25

DSM-3 allowed the diagnosis of

7:28

ADD with and without hyperactivity.

7:31

And at that time, individuals who had

7:33

ADD without hyperactivity

7:36

had higher levels of what was called

7:38

sluggish cognitive tempo. The daydreaminess,

7:40

the drowsiness, the lethargy.

7:43

The research from the 1980s to the 2000s really stalled

7:48

until a very prominent study of

7:50

a large clinic sample of children

7:52

with ADHD found that there

7:54

was a separate set of symptoms in

7:56

children who presented with the sluggish cognitive

7:59

tempo. In the

8:01

past two decades, we've witnessed

8:03

an explosion of research on

8:05

understanding the nature, the

8:07

consequences, the outcomes of SET.

8:11

Last year, myself and some other researchers

8:13

and clinicians got together for a working

8:15

group to first discuss an

8:17

update of where the research was, so

8:20

we can discuss some next steps for

8:22

future directions, and importantly start

8:24

to talk about a change in terminology.

8:27

As I said, back in the 1980s, the

8:29

set of symptoms were coined by

8:31

a researcher as the sluggish cognitive

8:34

tempo. Through our own

8:36

research, clinical work, and

8:38

real-life conversations with families, many

8:40

of them described this term as quite

8:42

offensive or pejorative. It's

8:45

calling their child to have a sluggish

8:47

cognitive, kind of implying

8:49

a intellectual or a cognitive

8:51

deficit which none of the

8:53

research has suggested thus far. Through

8:56

a lot of very lively conversations and

8:58

going a lot of back and forth

9:00

on, what is a terminology that is

9:03

going to capture the core nature

9:05

of these symptoms, but also as

9:08

less offensive and as more of

9:10

a description? The team

9:12

landed on the cognitive

9:14

disengagement to capture the

9:16

internal distractions, the disengagement

9:18

of the daydreaming of the mind wandering. That's

9:21

going to be the term that I use

9:23

throughout my presentation. What

9:26

are we talking about here? What is CDS? We

9:29

think about CDS. Think

9:31

about three different types of features

9:34

or domains falling into

9:36

these categories. The daydreaminess, so

9:39

individuals who are lost in their thoughts, spacing

9:42

or zoning out, appearing to

9:44

be lost in a fog, staring

9:47

blankly into space, symptoms

9:49

that reflect mental confusion, so losing

9:51

one's train of thought or absent-mindedness,

9:54

having a hard time putting their thoughts

9:57

into words or expressing their thoughts. confused,

10:00

needing a lot longer to

10:02

think about or respond to

10:05

questions or activities, then

10:07

as I said opposite of the

10:09

hyperactivity, the hypoactivity, which

10:11

are these symptoms of being easily tired

10:14

or fatigued, having low levels of energy,

10:17

more sleepiness or slow-moving

10:19

behaviors. So there's 15

10:21

symptoms behaviors that we have found

10:23

over the years in the research

10:26

to best capture this construct. And

10:29

in terms of different assessment

10:31

tools and how we measure these symptoms,

10:34

on the screen here you'll see a

10:36

couple of well-validated measures that have

10:39

been used to capture these 15

10:41

symptoms of CVS. My

10:43

colleague Dr. Steven Becker and his

10:45

team developed the Child and Adolescent

10:48

Behavior Inventory or the CABI. This

10:51

includes 15 items that parents

10:53

and teachers can measure on

10:55

the frequency of these symptoms for

10:57

kids. What's nice about this measure

10:59

is we have norms and so

11:01

we can compare a child's score

11:04

in comparison to same-age peers.

11:07

We also have a self-report measure

11:09

called the Child Concentration Inventory. As

11:11

you would imagine for an older

11:13

child and an adolescent, a lot of

11:16

these symptoms are internal, daydreamy,

11:18

being internally distracted, mind-wandering.

11:20

So we also wanted to develop

11:22

a self-report measure so individuals

11:25

can report on how often they feel like

11:27

they're engaging in these symptoms. Russell

11:30

Barkley has a scale called the

11:32

Barkley SET scale and we also

11:34

have a measure in adults. It's

11:36

called the Adult Concentration Inventory. That

11:38

measure at this time we do

11:40

not have norms and in

11:42

the adult population this is an area that

11:44

we're hoping to gain a little bit more

11:46

research on. But here are some of the

11:49

measures that are widely available. They're free, they're

11:51

accessible that you are able to use. So

11:55

so far I talked a little bit about

11:57

what is CDS, the history of CDS. But

12:00

here's some really key objectives for today.

12:02

Are we just talking about something else?

12:05

Is this just in a 10 of ADHD? Is

12:07

this just depression? Is this a form

12:09

of an anxiety disorder? Is this a

12:11

learning disability? Is this sleepiness? These

12:14

are some common questions and things that

12:16

have been very important to us to

12:19

better understand what is the nature of

12:21

CDS? What is the overlap with other

12:23

mental health conditions? Then

12:25

second, why do we care? Why are

12:27

we having a webinar? Why are we

12:30

talking about CDS? Then finally, which is

12:32

very important to me, what can we

12:34

do? What are some recommendations? What are

12:36

some next steps for children, adolescents who

12:38

may present with and have CDS? For

12:42

that first objective, what you'll see

12:44

on the screen here are the

12:46

most common conditions that often co-occur

12:49

with CDS. If a

12:51

child who has symptoms and

12:53

behaviors of CDS, the different types

12:55

of conditions such as ADHD, depression,

12:58

anxiety, autism,

13:01

language or learning, difficulties or delays

13:03

that we have found in the

13:05

research to be the most common

13:07

overlap. At the same

13:09

time, the research fairly consistently over

13:11

the past two decades, have found

13:14

that CDS is not the same

13:16

as these conditions. We're not

13:19

capturing the same construct. It's

13:21

not redundant. They overlap, they're

13:23

related, but they're also separate as we'll talk about

13:25

in the dive in here. As

13:28

we talked about earlier, for about a quarter to

13:30

a half of kids who have ADHD, primarily

13:33

the inattentive presentation, will also

13:35

have elevations in CDS. At

13:38

the same time, when we measure

13:40

the symptoms of inattention, the symptoms

13:43

of CDS, the research would say

13:45

that these are separate. They load

13:47

onto different factors, so they're not

13:49

the same. They're not completely redundant.

13:53

When we ask families if their child

13:55

has been diagnosed or not with depression,

13:58

that's 7-9 percent. will

14:00

say that their child has CDS also, will

14:03

have the rates of depression when we ask

14:05

a parent yes or no. But

14:07

when we look at a symptom level,

14:09

it's a lot more overlap. So about

14:11

30% to 50% of kids will have

14:14

elevated symptoms for both CDS and depression.

14:17

I think we can say that makes sense

14:19

when we talked about some of the symptoms

14:21

of the daydreaminess, the low levels of energy,

14:23

the sleepiness. Those are also symptoms of depression.

14:26

This is one of the challenges that we

14:28

have in the ADHD field, but also in

14:30

mental health in general, is the high levels

14:32

of good morbidity in the lab with other

14:35

conditions. And so this is something

14:37

that we're also very aware of as we're doing

14:39

our work. Also with

14:41

anxiety, about 10% to 20% of kids will

14:44

also have symptoms of anxiety.

14:47

There's been more recently a few studies,

14:49

less so compared to these other areas,

14:51

but individuals who are on the autism

14:54

spectrum having elevations in CDS. And

14:56

then finally, presenting with

14:59

you reading disabilities or language delays,

15:02

which we also think about some of the symptoms of CDS,

15:04

the mental confusion, the trouble

15:06

expressing thoughts, having a

15:08

hard time putting thoughts into words, think

15:11

about some of the overlap with language

15:13

learning. Most

15:16

importantly, the research has also found

15:18

that about a quarter to a

15:20

half of kids will primarily have

15:22

the symptoms of CDS without ADHD,

15:24

depression, or these other mental health

15:27

conditions. So yes, there's overlap, but

15:29

there's also the separation and there's

15:31

this distinction. So

15:33

let's take and let's kind of look through

15:36

how might there be similarities and

15:38

differences between a symptom and an

15:40

impairment and how an

15:42

attentive ADHD or CDS may

15:45

be related to their symptoms. So

15:47

if I have a child who comes in and a

15:49

parent complains that my child has a hard time paying

15:51

attention, we first know there's many

15:54

reasons a kid may have a hard

15:56

time paying attention. So it really speaks

15:58

to conducting a thorough evaluation. Now

16:00

for Todd who has an attentive ADHD,

16:03

the troubles paying attention may be due

16:05

to those underlying challenges

16:07

and sustained attention, sustained mental

16:09

effort, especially on tasks that

16:11

are boring, mundane, they take

16:14

a long time. We know

16:16

children with an attentive ADHD

16:18

struggle sustaining their attention, or

16:21

it may be due to high

16:23

levels of external distractibility, noises,

16:25

sounds, other stimuli going on

16:28

in their environment. For

16:30

Todd with CDS primarily, what's

16:32

going to drive the troubles

16:34

paying attention are the excessive

16:36

internal distractibility, the lost in

16:38

one's thoughts, the daydreaminess, the

16:40

mind is wandering, the

16:42

fogginess, the spacing out. Now

16:44

if a child has both, there may be more

16:47

than one reason that a child then is having

16:49

difficulties paying attention. Now let's

16:51

take a common complaint such as a

16:53

child having a hard time starting and

16:55

finishing tasks. With Todd with

16:57

an attentive ADHD, this may be

16:59

due to trouble initiating, starting a

17:02

behavior, and then maintaining that attention.

17:04

It may be due to the challenges

17:06

with working memory deficits, being able to

17:09

hold multi-step directions, keep what they have

17:11

to do in their mind, and then

17:13

complete the task. Now

17:15

for a child with CDS, it may be

17:17

difficult for them to start and finish the

17:20

task due to the pace of

17:22

which their movement and their activity. It may

17:24

take them a little bit longer to get

17:26

started. It may take them a little bit

17:28

longer to complete. And then

17:30

along the way, those internal distractions.

17:33

Additionally, we take energy levels and

17:35

motivation. We know kids who have

17:38

an attentive ADHD that for certain

17:40

things that are boring, that are

17:42

mundane, maybe a hard time initiating

17:44

it, having the motivation to want

17:46

to do those type of tasks

17:48

and activities. For kids

17:50

with CDS, it starts to be

17:53

this general state of underactivity, tiredness,

17:55

and energy levels that is

17:57

not as much task-specific.

18:00

like we see in an attempt of ADHD. Very

18:03

importantly, and this is a lot of the

18:05

research has found, when we think about core

18:08

morbidities, we know kids who have ADHD, the

18:11

rule rather than the exception is

18:13

those co-occurring conditions. Different

18:16

internalizing conditions like anxiety,

18:18

depression, also externalizing. So

18:20

more oppositional behaviors, emotion

18:23

dysregulation, difficulties managing tantrums.

18:25

Then some kids also have some

18:27

of the hyperactive impulsive symptoms. Quite

18:31

conversely, for kids with CDS,

18:33

they're more likely to have

18:35

those internalizing co-orbitities, the anxiety,

18:38

the shyness, the depression, the social

18:40

withdraws, we'll talk about here in

18:42

more detail. And then very

18:44

different than the inattentive ADHD, little

18:47

to no symptoms of the

18:49

hyperactive impulsive. So really the

18:51

focal point of this slide is thinking about

18:53

how the same symptom and impairment, there may

18:55

be similarities with CDS and the intent of

18:58

ADHD. But also there could be

19:00

some differences. Why

19:02

do kids have CDS? Where does this come

19:04

from? Now we know with ADHD, there's a

19:07

high heritability. We know there's a very strong

19:09

genetic basis. This is an

19:11

area of research that I'm hoping over the next

19:13

several years, we'll see a lot more studies come

19:16

out, but it is a very tiny body of

19:18

research. There have been three

19:20

twin samples where we can examine

19:22

the genetic differences in CDS, about

19:25

modest to moderate heritability. So there

19:27

does seem to be a genetic

19:30

impact on CDS. We're not quite

19:32

sure of the specific genes. I mean,

19:34

that is very complicated and it's likely

19:36

a combination of different genetics, but

19:39

it's less heritable compared to ADHD. So

19:41

that speaks to the role of environment,

19:44

prenatal factors, childhood factors,

19:46

or life stressors. We

19:48

do have a couple studies that

19:50

say children who had prenatal alcohol

19:53

exposure, traumatic brain injuries, cancer,

19:56

or spina bifida, so medical

19:58

prenatal factors have high... higher

20:00

rates of CDS. Then

20:02

there's also been some differences in demographics,

20:05

that individuals who with a

20:07

lower socioeconomic status, more conflict

20:09

in the family, or

20:12

more conflict interpersonally with peers

20:14

or others, also start to

20:16

have high levels of CDS. So

20:18

we start to think about might be symptoms of

20:21

the internal distractions, the disengagement

20:23

for some individuals, some

20:26

form of a coping response or coping mechanism

20:28

due to ongoing stressors in their environment. This

20:30

is definitely an area that I'm hoping in

20:32

the next few years, as I said, we'll

20:34

have more research, but this is where we

20:36

are now in terms of the etiology of

20:39

CDS. Majority

20:41

of these findings, as I said, we also

20:43

wanna replicate so we can have more confidence

20:45

in our findings. So

20:48

how does CDS impact kids

20:50

day-to-day functioning? Well, we

20:52

think about the two different types of cognitive

20:55

areas, processing speed, kind of the speed and

20:57

the rate and the pace, able

20:59

to complete activities and do things, and

21:01

mind wandering, which we know mind wandering

21:04

is a very common phenomenon. Some

21:06

of you may now, your mind might be wondering about

21:08

what you have to do after this call, or what

21:10

you have to do during the day. My

21:13

mind might be wondering on things that I'm

21:15

gonna do over the weekend. This is a

21:17

very common phenomenon that many of us have.

21:19

And these have been the two areas that

21:22

most of the research has focused related to

21:24

the cognitive areas. Some of

21:26

the studies have shown that CDS and processing

21:28

speed are not the same, but they

21:30

may be related, especially in younger kids.

21:33

And when we think about the different types

21:35

of processing speed, for any of you that

21:38

are familiar with the WISC, when we give

21:40

a battery to kids to measure their processing

21:42

speed, there's two different types

21:44

of sub-tests, coding and symbol

21:46

search. Coding asks the child

21:49

to write down and copy a symbol

21:51

that they see, and they have to

21:53

see how quickly they can do it. Symbol

21:56

search, they visually are looking

22:00

symbols and they have to circle whether they

22:02

see the same symbol or there's not the

22:04

symbol there. So coding has

22:06

more of the motor demands or the

22:08

writing, the graph of motor. Symbol

22:11

search is more visual. Some of

22:13

the research would suggest that CDS may

22:15

impact more of the motor demands such

22:17

as the coding subtest. And

22:20

so in terms of how quickly a

22:22

child can maybe copy down notes when

22:24

they're in class, writing down

22:26

their answers, it may take them a little

22:28

bit longer. Where children with ADHD

22:30

may have a harder time attending to those

22:32

details. They may be made more of the

22:34

careless mistakes when it comes to symbol search

22:36

or coding. Now when

22:39

we think about mind-wandering we have

22:41

a few studies that have shown

22:43

that compared to the symptoms of

22:45

inattention ADHD, anxiety and depression, CDS

22:48

is more strongly associated with mind-wandering.

22:50

So it started to suggest that

22:53

maybe at the core of CDS

22:55

is an over-engagement to mental

22:57

content, to mental representations in

22:59

terms of mind-wandering. Just

23:02

things in the past, the present,

23:04

the future. Daydreaming when the

23:06

content of those internal thoughts is more

23:08

specific. Then we start to

23:10

think about may this be the reason

23:12

that kids with CDS start to have

23:14

higher levels of depression and anxiety. You

23:17

spend so much time internally you kind

23:19

of give room an opportunity to worry,

23:21

to ruminate. Maybe that might be the

23:23

link. And this was one of the

23:25

reasons that the name was changed to

23:27

the cognitive disengagement to really reflect those

23:29

findings. Then

23:32

what about academics? We know that for kids with

23:34

ADHD academic performance, academic functioning

23:36

is an area that we often

23:38

target in intervention. We also know

23:41

that CDS impacts academics. Some studies

23:43

that have shown CDS

23:45

is associated with lower grades. Poor

23:48

organization. Organization seems to be an

23:50

area that children with CDS struggle

23:52

with. And then some studies have

23:55

been a little bit inconsistent with

23:57

lower academic achievement. One

23:59

area that's very important is

24:01

related to behaviors that enable

24:04

you to perform well academically.

24:07

Asking questions in class, taking

24:09

notes, studying, working

24:11

in groups, those types of

24:13

behaviors kids with CDS may struggle with

24:15

the most, and that may be due

24:18

to some of that disengagement. Now

24:21

we know that for children with ADHD,

24:23

they often experience difficulties in the peer

24:26

domain. We tell them making

24:28

friends, keeping friends, we think about the

24:30

reason why for a child with

24:32

ADHD, it may be due to

24:34

the impulsive behaviors, the emotion dysregulation,

24:36

trouble attending the social cues. We

24:39

have found that not only

24:41

are children with CDS cognitively

24:44

disengaged, those internal distractions, they're

24:46

more likely to be socially disengaged

24:49

as well. This is one of

24:51

the most troubling findings in the

24:53

area that I'm very interested and

24:55

motivated by is how can we

24:57

improve the social engagement of children

24:59

and adolescents with CDS? The

25:01

research has found that kids who have

25:03

CDS are more likely to have conflicted

25:05

shyness, they want to interact at that

25:08

high level of anxiety, that high level

25:10

of being uncomfortable. They're more

25:12

likely to be withdrawn and isolated from

25:14

the peer group. This is

25:16

also happening when we

25:18

conduct real-time recess observations,

25:21

and our group here at SSA Children's

25:23

conducted one of these studies where we

25:26

observed children with CDS with and without

25:29

in the recess during on the playground,

25:31

and we found that kids who are

25:33

elevated in CDS spent more time alone

25:35

by themselves compared to other kids. Start

25:38

to think about how troubling that can be for a

25:40

child long-term and developmental. Have

25:43

a harder time attending to subtle

25:45

social cues. If we

25:47

think about the pace of conversations, especially

25:50

as kids get older, there's a lot

25:52

of humor. It's fast paced, the topic

25:54

switch. It might be harder for a child

25:56

with CDS to keep up, and then risk

25:58

for peer victimization as we get older. This

26:00

is a very, very important area that we

26:02

often talk about in our intervention part. So

26:06

what about sleep? I have a lot

26:08

of people ask me, Dr. Frederick, those symptoms and behaviors

26:10

of CDS, these kids just having a really

26:12

hard time falling asleep. Could

26:14

they just be sleep deprived? So we

26:17

know that first off, when we do

26:19

the research to say, are these symptoms

26:21

and behaviors the same as sleepiness and

26:23

sleep loss, similar to

26:25

depression, anxiety, they overlap, but they're

26:27

separate. These are not the same. We

26:30

do have some studies to suggest that in

26:32

kids and adults, high

26:34

levels of CDS may be associated with more

26:36

evening preference, what we call kind of

26:38

night hours, wanting to stay up with

26:40

her, which leads to maybe later sleep

26:42

onset, going to bed later, not

26:44

getting enough sleep. So maybe there's a mismatch

26:47

between their clock when they want to sleep,

26:50

especially in adolescence, when they want to get

26:52

up in the morning, early school start times. So

26:54

that might lead to some of the sluggishness, the

26:57

sleepiness that we see in the morning and throughout

26:59

the day. There's been two

27:01

studies that have looked at polysomnography

27:03

indices of sleep. So we start

27:05

to look at like sleep apnea,

27:08

restless leg, limb movements, there's

27:10

been no clear associations thus

27:12

far. And finally,

27:14

there was a study found

27:17

that when you experimentally restrict

27:19

sleep, which would be a really hard

27:21

study to do, I want to thank the teenagers

27:23

that participated in this study. But when we have

27:26

teenagers who were said, let's extend your sleep, let's

27:28

get you a little couple more hours, let's restrict

27:30

your sleep. Those who were

27:32

in the restrict sleep phase had a

27:35

higher level of CDS. Start

27:37

to think that makes a lot of sense. If

27:39

you restrict sleep, one of the first

27:41

thing that goes is your attention and then

27:43

that energy. And so that clearly

27:45

seems to be a possible ideological

27:48

factor, but also CDS may impact

27:50

sleep as well. So

27:53

thus far we've talked about what is CDS,

27:56

how's it related with other conditions? How does

27:58

this impact day to day? And

28:00

a lot of the research that

28:02

I summarized was from what we

28:04

call quantitative studies, where we have

28:06

families, children complete rating scales, they

28:09

complete different tests. It was

28:11

important for our group to interview these families,

28:13

to talk to these families and see, are

28:16

they talking about CDS? What language did they

28:18

use to discuss this? How do they feel

28:20

like it impacts their day to day? So

28:23

we conducted this study here at our group

28:25

here, and we had about 15

28:27

to 20 families. And the focus of this

28:29

was to interview the parents and children to

28:31

learn a little bit more about the real

28:34

world lived experiences of CDS.

28:37

So here's some of the quotes, obviously

28:39

the names here have been changed

28:42

to protect everyone's identity. But

28:44

we think about the quotes, you can start to

28:46

see some of the descriptions in the terms. And

28:49

I see a lot of these in emails that

28:51

I get from families, and also my clinical work in

28:53

our service. So we had one parent

28:55

say, he calls it zone down. We will

28:57

be talking to him. He starts staring out into

28:59

space and says, Oh, I zoned out. What did

29:01

you just say? It's just that

29:03

Charlotte's slow. That's Charlotte, we're used to

29:05

it. So some families say that some of these

29:08

behaviors were part and parcel to who the job

29:10

was. These are just kind of some of their

29:12

characteristics that they're noticing. Then

29:14

we had a parent say, I asked him once what

29:16

he was doing when he was in the backseat quiet

29:18

for 40 minutes. And he says, I'm

29:20

watching TV in my mind. So

29:22

you see some of those excessive internal distractions.

29:25

And then the language that parents are using.

29:28

And what about kids? When we asked kids,

29:30

what are these behaviors like? What do they

29:32

feel like? How do you talk about them? I

29:36

have one child that said, my mom calls

29:38

it Annalyn. It is this place where my

29:40

imagination rests, like a little oasis. There's

29:43

a bunch of rainbows, and all my

29:45

ideas for books and stories and role

29:47

plays are there. You can start to

29:49

see that the daydreaminess also leads to some of these

29:52

positive attributes and these strengths, some

29:54

creativity, some different characters, ideas. Some

29:57

days going to Annalyn would probably be very

29:59

interesting. It would be enjoyable. It would be

30:01

relaxing. And then we had a child say

30:03

this was very interesting. I love going into

30:05

that world. It just want to be able

30:07

to pull myself out of it. So

30:10

the control, how do we

30:12

help kids engage cognitively once

30:14

they're internally distracted? And

30:17

then a child said, I really hate it when

30:19

I get lost in my thoughts, because I overthink

30:21

a situation. You spend so

30:23

much time in your head getting lost

30:25

in your thoughts, the mind wandering, might

30:27

that lead to difficulty solving problems, stress,

30:30

feeling overwhelmed? And

30:32

what about strengths? What about those positive attributes that I

30:35

just briefly touched on? We

30:37

had a child say that the spacing out is kind

30:39

of my thing and my favorite part, because I just,

30:41

you know, it gives me a small break. And I get to

30:43

get back to my work. So being able to

30:46

give children a sense of a break, a mental break. I

30:48

feel like when she goes off and she's daydreaming, she's

30:51

thinking about what she's going to work on.

30:53

Her imagination goes crazy. So creativity,

30:55

imagination seems to be a positive attribute.

30:58

And be able to think outside the

31:00

box, coming up with other ideas

31:02

or solutions to these different problems. And

31:06

then finally, we asked the

31:08

parents specifically, how do these

31:11

behaviors of CVS impact your

31:13

child day to day? Are there

31:16

certain times of the day, certain

31:18

activities where these behaviors negatively impact?

31:21

And some of the common areas that parents rated

31:23

were the morning routine. Many,

31:25

many, many parents, and I hear this fairly often,

31:28

trouble getting out of bed in the morning, taking

31:30

a long time to get through the morning

31:32

routine, having higher levels of

31:34

the sleepiness. Academics, either

31:37

keeping track, organization during school,

31:40

after school, sleep, trouble

31:42

falling asleep, daytime sleepiness,

31:45

and then also homework specifically. We

31:48

asked parents, what have you tried? What have you done? And

31:51

a lot of them said they've tried

31:53

different strategies, helping with sleep, having

31:55

good sleep hygiene, verbal reminders, trying

31:57

to have day to day routines.

32:00

similar that we would suggest for a child

32:02

who had ADHD. But many

32:04

of these families said they were unsure what to do.

32:07

One parent said specifically, we

32:09

really do not know what exactly to do except

32:11

bring him back to Earth. From

32:14

this interview, it really spoke to

32:16

us that these families, they're noticing

32:18

these symptoms and behaviors, these are

32:20

impacting, but that how do

32:22

we help? What are the recommendations and interventions?

32:24

That was the area where I feel like

32:26

we needed to really

32:28

help bridge the gap between the research and

32:30

the clinical work. What

32:33

about interventions? Let's talk a little bit

32:35

about what do we know that helps

32:37

intervene and address CDS. We know

32:39

for ADHD, we often recommend

32:41

this multimodal approach. Environmental

32:43

behavioral management at home,

32:46

educational accommodations or interventions at

32:49

school, like a daily report

32:51

card, classroom accommodations, medications,

32:53

stimulant, not-stimulant medications. At

32:56

this time, there are no specific

32:59

evidence-based interventions and treatments for CDS.

33:02

Where we are now is how can we take

33:04

this framework for ADHD? Within

33:07

those areas of environmental, school

33:09

accommodations and medications, are

33:12

there different bits and pieces that we

33:14

can use to address CDS, or

33:16

are there areas that we need to modify? Specifically,

33:19

when we think about parent management

33:21

training or behavioral parent training, we're

33:24

working with caregivers and parents, and many of you

33:26

maybe have gone through this in terms of groups

33:29

or your own reading, the attitude sent out. How

33:32

do we use our preferential attention? Positive

33:34

reinforcement, giving clear commands.

33:37

But also, how do we use

33:39

negative consequences like time out, ignoring?

33:42

Those type of responses may not be as

33:44

effective for kids with CDS, given that they're

33:46

not likely to have those behavioral problems. They're

33:49

not likely to be disruptive. What

33:51

are some of the changes that we can take? There

33:54

is some promise. We have three studies

33:56

to date that have shown some... effectiveness

34:01

for the interventions for inattentive

34:03

ADHD may help reduce CDS.

34:06

So first, there was a

34:08

study that did a combination of

34:10

parent training, working with parents on

34:13

some of those parent management training

34:15

skills, teacher consultations through different interventions,

34:17

accommodations, and then child skills was

34:20

helpful at reducing CDS. There's

34:22

another study that found that a school-based

34:24

homework and organization intervention, so helping

34:27

kids with organization systems at school, keeping

34:29

track of their homework, keeping track of

34:31

what they have to do, reduce

34:34

the symptoms of CDS. Then

34:36

finally, in a study of only about

34:38

14 adolescents, but it was a study

34:41

that looked at a sleep intervention for

34:43

kids with ADHD, found very

34:45

strong effects based on self-report,

34:47

parent report, and teacher report

34:49

to decrease the symptoms of

34:51

CDS. So this starts to

34:53

say that some of those

34:55

interventions of parent management training,

34:58

teacher consultation, homework, organization,

35:00

and sleep may be

35:02

really important areas at decreasing CDS

35:05

symptoms. Now

35:07

what about for medication? We

35:09

know that stimulant medication is

35:11

often the first line recommendation

35:13

for inattentive ADHD. We do

35:15

not have any specific studies

35:18

that have found medications, enough of the

35:20

research to say that these are our

35:22

guidelines, so nothing to say that this

35:24

is what we would recommend. The

35:26

research would say that for

35:29

some children, having high levels of

35:31

CDS may actually reduce the effectiveness

35:33

of stimulants. So if any

35:35

families, what I often talk about is a

35:38

first initial recommendation is trying the

35:40

stimulant medication if your child also

35:43

has an inattentive ADHD, but

35:45

if it seems to not be working to not give up home,

35:47

it is a very small body

35:50

of research to suggest that non-stimulants

35:52

such as atomoxetine or sertara may

35:55

decrease symptoms of CDS. And

35:57

obviously, you know, one thing to think about is that for

36:00

comprehensive evaluation is that the kurtada

36:02

is also struggling with

36:04

depression, anxiety, sleep

36:06

problems. We want to intervene both

36:09

on the treatment side and the

36:11

medication side. So there is some

36:13

interest right now in the field

36:16

for different medications like antidepressant medications,

36:18

anti-anxiety, or medications that help with

36:20

daytime sleepiness. Maybe those would be

36:22

some would show some promise for

36:25

decreasing CVS. So

36:28

I'm at the time of my talk now where

36:30

what I want to do is share with all

36:33

of you as parents, teachers, professionals,

36:35

individuals that may be impacted or

36:37

know someone with CVS to share

36:40

with you some of my own learnings and

36:42

my own observations. So as Carol

36:45

mentioned earlier, we have started a

36:47

clinical service here in our center

36:49

for ADHD for CVS to find

36:51

more information about this on our

36:53

website. And we've worked with

36:55

families. We've been doing evaluations. We've

36:57

been doing therapies, interventions with the

36:59

goal ultimately to start to come

37:01

up with some specific interventions that

37:03

we can provide. And I

37:06

want to share with you just some of

37:08

my own observations, strategies, learnings that may be

37:10

helpful for you at this time. We

37:14

think about overall, we think about environmental

37:16

recommendations, just at home. In

37:18

many of these, I would recommend to a family of

37:20

a child who has ADHD. It's

37:22

having that consistent daily routine in

37:24

terms of the time of sleep,

37:27

the time of homework, the time

37:29

of activities. How

37:31

can we simplify the day? Children

37:33

with CVS often may get overwhelmed easily.

37:36

They may have a harder time

37:38

keeping up and keeping pace. So how

37:40

can we simplify their day to day?

37:42

How can we have clear, consistent daily

37:44

routines, having visuals where they can know

37:47

their schedules may help them feel less

37:49

stressed or overwhelmed. And then time. Having

37:52

enough time to complete routines and activities.

37:54

We know based on what we talked

37:56

about for kids with CVS, may take

37:58

them a little bit more taught,

38:01

not because they're externally distracted, not

38:03

because of the rushing through, just the pace

38:05

at which they do things. Just be a

38:07

little slower. And all of us differ in

38:09

the pace at which we go through life

38:11

and we go through these routines. So having

38:13

enough time, having enough time in the morning,

38:15

having clear time limits for our homework, so

38:18

they feel like they have that time to

38:20

be able to complete these activities. Directly

38:22

practicing organization skills. So this

38:24

may be related to at

38:26

home or at school, having

38:29

a binder, having a planner,

38:31

keeping track of homework, having

38:33

a to-do list, directly practicing

38:35

those organization skills. And

38:37

then finally, given how CDS is so

38:40

strongly associated with sleeping

38:42

difficulties and that social

38:44

disengagement, ensuring good sleep

38:46

hygiene practices, having opportunities

38:48

and encouraging physical

38:51

activity and exercise, and having

38:53

opportunities for positive social experiences,

38:56

and knowing that a child's preference

38:58

socially may be for more one-on-one.

39:00

They may prefer smaller group settings,

39:02

maybe a few friends at a

39:04

time, so they can go at

39:06

their pace. So these are just

39:08

some general recommendations. Now

39:11

specifically, when we think about

39:13

due to the weaknesses and the challenges

39:15

of CDS, think about the language

39:17

that we use. Being mindful

39:20

of how quickly our

39:22

tone and how complex our language is.

39:25

This is very true for kids with ADHD,

39:27

but also for a child with CDS. Your

39:29

tone, pace, and the complexity is going to

39:32

be very important. A neutral tone, matter

39:34

of fact, in a slower pace. So

39:37

using concise words, using fewer words that

39:40

are very clear and they're one step.

39:42

If a child with CDS is told

39:44

to do multiple things at once, we're

39:47

talking very quickly that has

39:49

a lot of different messages in there or things to do,

39:51

they then have to take in that

39:54

information, organize that, and

39:56

then respond. And due to the difficulties with the

39:58

pace and the distractions, this may

40:00

be difficult. So just bring that awareness to

40:03

what is the language and can

40:05

I either slow down the pace? Can

40:07

I be more clear and direct and

40:10

have those one-step simple directions for children?

40:13

And then we think about very similar

40:15

within a 10 of ADHD, but also

40:17

important for CVS is when it comes

40:19

to tasks like cleanups or getting ready

40:22

or score, breaking it down

40:24

into very clear steps. Maybe

40:26

having opportunities to have some breaks, either

40:29

attention breaks or physical breaks. If they're

40:31

starting to kind of have a lower

40:33

level of energy or their stamina starting

40:35

to decrease to helping them with their

40:38

attention and then problem

40:40

solving. As I said, kids who

40:42

have CVS oftentimes get overwhelmed easily.

40:45

So can we really directly work

40:47

on identifying the problem, brainstorming

40:49

some solutions and going through and

40:52

picking the best solution and teaching

40:54

them that directly. This can be come

40:56

up when there's topics that are scholarly,

40:59

things at home that you're struggling with.

41:01

Can we have some opportunity to practice

41:03

problem solving? And then

41:05

finally, how do we bring attention

41:08

and awareness to a child's internal

41:10

distractions? This is one of

41:12

the challenges is how can we help

41:14

kids become more cognitively and socially engaged

41:16

in their environment? So here are a

41:18

few ideas. Having attention checks. This could

41:21

be throughout the day during

41:23

conversation, during homework, during studying,

41:26

checking in and asking where is my attention

41:28

right now? This could be

41:30

something that as a parent or as

41:33

a teacher, as an intervention specialist, that

41:35

you're initiating, but also helping the child

41:37

bring that awareness for themselves of

41:39

after every certain amount of time or

41:42

an interval, just checking in where is

41:44

my attention? Am I off? Am

41:46

I thinking about something else? I

41:48

need to bring my attention back and having more of

41:50

those to build that awareness. Helping

41:52

kids with some more verbal self-talk. So

41:55

when they're told to do things of

41:57

like, you know, multi-step direction, out

41:59

loud, repeating back to themselves what they have to

42:01

do, or repeating the key

42:04

pieces so they can remember, and

42:06

so they're also not mentally getting

42:08

mixed up, getting confused. Then

42:11

for children of supporting them in

42:13

using certain responses, if they

42:15

feel like they need a little bit more time to think, so

42:18

saying like, just give me a minute, let

42:20

me think about that, or give

42:23

me a few seconds here so I can think about that right

42:25

now, hold on, I'm going to respond here in a minute. They

42:27

can verbally say that, so the other person

42:30

knows they're taking the time to think, they

42:32

may not respond as quickly as

42:35

our expectations are. Then

42:38

what about for more of the

42:40

behavioral side for CDS? Awareness

42:43

of time. This is extremely

42:45

important. As I said, having enough

42:47

time, having extended time, having ample

42:49

time is very important for kids

42:51

with CDS. How can we have

42:53

clear time limits on daily routines

42:56

and homework? How can we make time

42:58

real? Having a limit when it comes

43:00

to homework, maybe working with the teacher

43:02

to see how long should it take my

43:04

child to work on homework and

43:06

can we set a limit and then grade the

43:09

amount of work that's completed within that time. Because

43:11

if you're a child who has CDS, it

43:14

may take you a lot longer to complete your

43:16

work, so then you may get penalized, may have

43:18

points taken off. We're trying to

43:21

focus on the quality rather than the

43:23

quantity. How can we

43:25

help children directly estimate how long things

43:27

will take? This is something that I

43:30

do with kids in my clinic where when we

43:32

think about an after-school schedule, we write

43:34

down what are the key pieces of your afternoon

43:36

schedule, how long do you think it's going to

43:38

take? What's your estimation? Five

43:41

minutes, 15 minutes, 20 minutes, and

43:43

then let's do an experiment. Let's see how

43:45

long it took you and can you see, were

43:48

you close or do you need to put in

43:50

more time? Then another idea is,

43:52

can we work on the child gradually doing

43:55

things a little quicker? If every

43:57

task is five minutes, can we move it to four

43:59

to three? three minutes, if we start to

44:01

slowly increase their awareness and the pace

44:04

at which they do things, that is

44:06

an idea, a strategy. We

44:08

think about behavioral activation. This

44:10

is a core component for

44:12

children with depression, but identifying

44:15

pleasurable, meaningful activities

44:18

that children with CDS can engage in.

44:20

We want to promote their engagement, promote

44:23

their behavioral engagement. And

44:25

then in the morning, there is a

44:27

specific technique from a sleep intervention developed

44:29

by Alison Harvey and her colleagues, that

44:32

is called the rise up routine. So

44:34

in the morning, we know this is often

44:36

a challenge for kids with CDS. But having

44:38

a routine in the morning where we try,

44:41

we aim to refrain from snoozing, increase

44:44

physical activity, we

44:46

increase sunlight or getting, you

44:48

know, showering, cold water, extra

44:51

physical activity in the morning,

44:53

having upbeat music, exciting music,

44:56

or phoning or texting a

44:58

friend. Any of those activities with

45:00

the goal is we want to get kids out

45:02

of bed quicker. The longer a

45:05

child stays in bed, sleep in,

45:07

builds up that sleepiness, it get

45:09

more sleepy. So working with kids

45:12

on identifying a morning routine to

45:14

get them up, increase light, increase

45:16

exercise and physical activity as much

45:18

as possible. And then finally,

45:20

during the day, having those opportunities

45:22

to engage in physical activities, where

45:25

they are able to avoid that urge to

45:27

want to kind of lay in their bed

45:29

or lay down as we know that leads

45:31

to more of that sleepiness. An

45:35

intervention, a specific intervention that has been

45:37

very popular lately that might show a

45:39

lot of promise for CDS is mindfulness.

45:42

So no mindfulness works on with

45:44

individuals of building their non judgmental

45:46

awareness of their mind wandering in

45:49

ways to shift their mind back

45:51

to the present moment. Might

45:53

this be helpful for kids,

45:55

adolescents and adults with CDS? You

45:58

think it might make sense when we think about some of

46:00

the mechanisms we've talked about of those

46:02

internal distractions, of can we bring the

46:05

awareness of internal distractions, of when their

46:07

mind wanders, the time their mind wanders,

46:09

and what are some ways we can

46:12

help them anchor their attention back to

46:14

the present? Is that

46:16

through their breath? So paying attention

46:18

to when they're inhaling and exhaling,

46:21

is it paying attention to certain

46:23

physical sensations? Is it

46:25

grounding strategies? So paying attention to

46:28

things that they see, they feel,

46:30

they hear, they smell on a

46:32

specific task, but building that

46:34

awareness and being able to refocus on

46:36

the present moment. And then

46:38

for some kids, if the daydreams are really

46:40

interfering them during the school day, or it's

46:43

interfering them, one idea that

46:45

hasn't been tested, but something that we've thought

46:47

about is having like a daydream journal, having

46:49

a piece of paper, a notepad, where they can

46:51

write down the things that they think about. So

46:53

instead of focusing on so much of here, they

46:55

can write it down and then they can address

46:57

that at a later point. Now

47:00

what about for school? So we know with

47:02

ADHD, and I'm sure many of you

47:04

familiar with this, the different

47:07

classroom accommodations, daily report card,

47:10

here are some general tips and

47:12

recommendations related to school. This

47:14

is definitely an area in our research

47:16

that I'm hoping we get more research

47:18

coming out soon about what are the

47:20

type of accommodations or interventions that may

47:22

be helpful, but here's some initial ideas.

47:25

I think first is the education. For

47:28

teachers, professionals, counselors, their awareness that

47:30

when a child is having a

47:32

hard time paying attention, that it

47:34

may not be just right away

47:37

due to the difficulties with, I'm sorry, looks

47:39

like our slides advanced there, with

47:42

the school, with the being inattentive or

47:44

rushing through. So just awareness of what

47:46

is CVS? What does this look like

47:49

in the classroom? Extended time,

47:51

this would definitely be a

47:53

promising accommodation, given that needing a

47:55

little bit more time to complete

47:58

homework, to complete tests. Can

48:01

we reduce the emphasis on

48:03

busy work, unnecessary homework demands?

48:05

Due to the pace at which kids with

48:08

CVS complete their work, not wanting

48:10

to penalize them for being late or

48:12

for not getting enough of the problems done,

48:14

because that is a core piece of CVS.

48:17

So, this would work on some like collaboration

48:19

with the teachers on having those time limits

48:21

after school. Are there areas that

48:24

the child can complete a certain amount of

48:26

problems about, where they are focusing

48:28

more on quality rather than the quality?

48:32

Similar to like in a 10 of ADHD,

48:34

when we think about prompts and attention checks,

48:36

having more of those frequently during the day,

48:38

maybe on their desk, having a visual

48:40

prompt to stay focused, write down my

48:43

daydreams if I am distracted, listen to

48:45

the teacher. We think about a

48:47

daily report card. That is a very

48:49

effective intervention for kids with ADHD in

48:51

the classroom. Some of

48:53

the studies that I have referenced have used

48:55

something like the daily report card, where maybe

48:58

the daily goals are staying on task, responding

49:01

quickly, asking questions, saying

49:03

I need more time, starting a

49:05

conversation with peers, responding when the

49:08

teacher says my name. Those

49:10

are the daily goals that they are getting

49:12

that positive reinforcement on. Then

49:14

finally, having scheduled attention breaks throughout

49:17

the day, and then organization skills.

49:19

So, having a way to keep

49:22

track of homework, writing down deadlines,

49:24

what they need, working with the

49:26

teacher on getting them to break down their initials

49:28

on the assignments, different organization symptoms.

49:30

We want to simplify the

49:33

chaos and the clutter to really help them stay

49:35

on track with things. Here

49:38

are some next steps in terms of where I

49:40

hope our research, our clinical work is going in

49:43

the next five to 10 years. At

49:45

this time, CDS is not recognized

49:47

as a mental health disorder according

49:49

to the DSM or the ICD,

49:51

which are the two common manuals

49:54

for diagnosing mental health disorders. There

49:56

are some reasons why. They saw what we talked about. We

49:58

know a lot about what this... looks like, how

50:01

it relates to other conditions. But

50:03

some of the areas we're unclear on is the

50:05

etiology, where exactly, what are

50:07

the etiological factors, and then treatment

50:10

response in terms of medication

50:12

or interventions. So that's an area

50:14

we're hoping to get more research

50:16

on. And then specific disorders like

50:19

social anxiety, OCD, PTSD, overlap with

50:21

dissociation. There seems to be on

50:23

the surface those might be related.

50:25

So something we want to dive

50:27

into more. And then finally

50:29

those specifically designed interventions and medications.

50:33

I'll wrap up real quick in terms of overall,

50:35

why are we doing this? And one of the

50:37

reasons we wanted to develop our service here at

50:39

Children's was an email from a mother that reached

50:42

out to us who said, I have a son

50:44

who's 16 who lives with the

50:46

symptoms, not 100% match the symptom list

50:48

for CDS. He's been diagnosed

50:50

with ADHD by his pediatrician,

50:52

tricepver stimulant medications. I

50:55

see my son struggling socially,

50:57

academically, extracurricular activities. I

50:59

feel like now I'm seeing some kinds of depression. Aside

51:02

from these symptoms, he has every single described symptom

51:04

of CDS that I have read about. I'm

51:07

at a loss as what to do or where to take him. So

51:10

we're hoping that more of this conversation, more

51:12

of the research, and that our clinical services

51:15

will start to help move the needle

51:17

for children, adolescents, or adults who may

51:19

struggle with CDS. So I

51:22

really appreciate everyone's time. And I think this

51:24

would be an opportunity here to switch over

51:26

to some Q&A. Excellent.

51:29

Thank you so much. Before

51:31

we start the Q&A, I'd like to

51:33

thank Play Attention once more for sponsoring

51:36

this webinar. I'd also like

51:38

to share the final results from today's

51:40

poll question. In what area

51:42

does your child with ADHD and

51:44

or CDS need the most help?

51:47

34% said academics, 18% said homework, 16% said morning

51:53

routine, and 15% said

51:56

excessive daydreaming. Now

51:59

to your questions. Can CVS

52:01

develop or increase in severity in the

52:03

teen years? That

52:06

is an excellent question. So there is

52:08

some resources to suggest that the age

52:10

of onset for CVS

52:13

may be later than ADHD

52:16

and start to increase over

52:18

the school age and teenage years.

52:20

And we may think that might

52:22

be why there's such an overlap

52:25

with those internalizing conditions that are

52:27

common during the teenage years, such

52:29

as depression and anxiety.

52:31

So it does start to seem like these set

52:34

of symptoms later age of

52:36

onset compared to ADHD, but

52:38

also over time, steadily

52:40

increasing. And that might start to give

52:43

rise to the rates of depression and

52:45

anxiety. We're not sure why. Is

52:48

that due to brain changes? Is that

52:50

due to more social stressors? We

52:52

know social stressors are related to CVS.

52:54

So to answer the question, yes.

52:56

And there's a lot of nuances there

52:58

that hopefully we can shed some more light on. What

53:02

have you learned about the evolution of

53:04

CVS over time? And can

53:06

the child grow out of CVS? Yeah,

53:10

that's a, let's say one of

53:12

the areas that we know much

53:14

little about compared to like the

53:17

childhood adolescent is adulthood and also

53:19

like older adults. So we

53:21

know that the rates of CVS, they

53:23

are common in young adults

53:25

and also adult populations. We

53:27

know they can be associated with like certain

53:30

sleeping difficulties when

53:32

it comes to work or occupational functioning.

53:36

We don't know as much

53:38

about like long-term longitudinal studies

53:40

about how the symptoms are

53:42

kind of unfolding over time. There does

53:45

seem to be, as I said, like

53:47

increasing in the teen years starts to

53:49

continue throughout adulthood. We're

53:52

unclear about what are factors that might

53:54

modify that. Might

53:56

there be certain types of

53:58

life changes, development. stages

54:00

that impact the course of CVS. That's

54:02

a definitely an area that we're hoping

54:04

to gain some more research on as

54:07

well. Okay, how

54:09

would a parent get a diagnosis for CVS

54:11

for a child's IEP? That's

54:14

a really great question on

54:16

many fronts. So as I said one of

54:18

the challenges with CVS is since it's not

54:20

in the DSM, the

54:23

diagnosis in terms of how we diagnose

54:25

it is a little bit different than

54:27

ADHD. So within ADHD

54:29

there is a diagnosis called

54:32

other specified ADHD. This

54:34

is for a child who looks

54:36

like they may have ADHD but

54:38

for a certain reason in the

54:41

criteria they don't meet the diagnosis.

54:43

So when I am doing our

54:45

evaluations here for families I may

54:48

often use other specified ADHD with

54:50

the features of CVS

54:52

or the symptoms of CVS. It

54:54

also may be for a child who already

54:57

has ADHD is on the IEP if

54:59

they had a an evaluation

55:01

and an assessment with anyone

55:04

that's trained in providing assessments

55:06

and diagnosis would qualify

55:08

for assessing these symptoms. So this could

55:10

be a counselor or a psychologist or

55:12

a psychiatrist. It

55:15

may take some education. I think there are

55:17

differences in the awareness of CVS so it

55:19

may be bringing this up of like this

55:22

is something I'm concerned about. I

55:24

would say professionals who are

55:26

aware of ADHD will have

55:28

more awareness of CVS given

55:30

the evolution. So that may

55:32

look like filling out some of

55:34

those rating skills that I presented on earlier

55:37

in the context of the

55:39

full assessment and then bringing

55:41

some of those findings to the IEP meeting

55:43

to say that my child also has these

55:46

other set of symptoms. They're called

55:48

CVS. This is recognized. It's

55:51

not a diagnosis yet but here are

55:53

some key symptoms that may impact my

55:55

child's performance in the classroom and then

55:57

here are some of those maybe different

55:59

accomplishments. recommendations for different recommendations to

56:01

add on the I.C.P. That

56:04

would be kind of how I would think about

56:06

walking through that process. Okay.

56:09

Does this aspect of

56:11

inattention improve over time

56:13

as a child gains

56:15

better executive functioning? Yeah,

56:18

that might be the million dollar question. I

56:22

don't know 100%. I

56:25

mean, we do know that, you know, I think

56:27

one of the interesting things about this is we

56:29

know that ADHD, I mean,

56:32

one of the core deficits of

56:34

ADHD is executive functioning in terms

56:36

of the brain imaging studies, the

56:38

troubles in the front part of the brain. CDS

56:40

is not as much associated with

56:42

executive function. It actually might

56:45

be impacted by the part of the brain

56:47

that's what's called our default mode network. That's

56:49

the part of the brain that's activated when

56:51

we're at rest, when we're not really focusing

56:53

on certain things. That might be

56:55

where the mind wandering goes. So

56:57

it may be that as children

56:59

get older and some of that

57:01

self-awareness starts to improve in terms

57:03

of the internal awareness, maybe

57:05

that helps bring awareness to when

57:07

their mind is wandering their internal

57:09

distractions. They gain maybe

57:12

improved language skills, expressive language

57:14

skills. They might

57:16

be more aware of strategies to help manage

57:18

the sleepiness as well. So since

57:21

executive functioning in ADHD and

57:23

CDS aren't related, I wouldn't

57:25

expect necessarily those improved executive

57:27

functions to translate 100%, but

57:30

I could also see it helping in

57:32

terms of the awareness, the improved problem

57:35

solving skills, language skills, and that may

57:37

help decrease those symptoms in CDS. We

57:41

had quite a few questions around autism

57:43

and CDS. So

57:45

one question is, how does the brain

57:47

function and neurobiology in CDS, how does

57:50

that differ from autism? Yeah,

57:52

that, it's an excellent question. We

57:55

do not, to my knowledge, have studies that

57:57

have looked at the differences in the in

58:00

the neurobiology or brain

58:02

imaging for CDS and autism.

58:04

There's only been a handful

58:06

of studies individuals

58:08

with autism that have elevated

58:10

symptoms of CDS. They

58:12

think we can start to see the overlap, when

58:15

we've talked about the symptoms on the surface.

58:17

So, being in your own

58:19

world, the daydreaming, the

58:21

internal distractions, how there are some

58:24

individuals with autism who also have

58:27

those different difficulties. I am not sure,

58:30

and I don't know, since we don't

58:32

have those studies. I will say

58:34

that, when we know with

58:36

autism, we're trying to work

58:38

on helping with the social

58:40

skills or the script of how to

58:42

interact. Many kids with CDS, I

58:45

have individuals, it may look

58:47

like autism, because if they're socially

58:49

disengaged. But a lot of these

58:51

children, they have the skills, if

58:53

they're in a comfortable environment, if it's one-on-one,

58:56

they have the skills to interact, they

58:58

have that reciprocity, to have back and forth

59:00

conversation. It's maybe when they're in a larger

59:02

group, like in a classroom, or

59:05

on sports teams, extracurricular activities,

59:07

when they're overwhelmed, we start

59:09

to see more of that disengagement. So,

59:11

I think the underlying reasons of why

59:13

a child with autism or CDS may

59:16

have these challenges, those underlying reasons may

59:18

be different. I can't point to specific

59:20

parts in the brain, but we can

59:23

start to think about specific areas for

59:25

intervention, like social skills training directly for

59:27

CDS, or managing that anxiety

59:29

that comes with CDS may also be

59:31

an important thing to focus on, plus

59:34

work. What's

59:36

the difference between maladaptive daydreaming

59:39

disorder and CDS? Yes,

59:41

I know, I believe that there was a, one

59:44

of those researchers presented, I think, on

59:46

the maladaptive daydreaming. Yes. That

59:49

is an area where, to my

59:51

understanding, we talked about the

59:53

internal distractions in CDS as

59:56

involving this just over-engagement in

59:58

thoughts. This could

1:00:00

be just a mind wandering, daydreaming,

1:00:04

mind blanking, where some individuals

1:00:06

to see, yes, it's just like they're not

1:00:08

having as many thoughts, their mind just blanks,

1:00:10

which leads to the staring off. My

1:00:13

understanding with maladaptive daydreaming

1:00:16

is the intensity

1:00:19

and what the daydreams are are

1:00:21

much more intense. They're maybe spending

1:00:23

a lot more time of

1:00:26

maybe hours focusing on certain

1:00:29

stories or fantasies or

1:00:31

creating certain characters that

1:00:33

sometimes have this reinforcing

1:00:36

component to it, something that they're seeking

1:00:38

out. Again, I don't know as much

1:00:41

of the maladaptive daydreaming, but to my

1:00:43

understanding, it's more about the intensity as

1:00:47

reinforcing. Whereas CDS, yes, there's that

1:00:49

proneness, but some of these kids

1:00:52

are also saying that it's

1:00:54

deliberate, but it's also spontaneous, that

1:00:56

these thoughts just appear, that

1:00:59

they're internally distracted. This

1:01:01

might be due to just they're thinking

1:01:03

about random things, they're thinking about real

1:01:05

things, made up things, past, present, future.

1:01:08

I think the scope and the context

1:01:10

is a little bit different. If I

1:01:12

was conducting a study on that, I

1:01:15

would imagine there's going to be

1:01:17

some of that overlap. I would

1:01:19

just say maladaptive daydreaming seems to

1:01:21

be much more narrow and specific.

1:01:23

Whereas CDS, we also have that

1:01:26

behavioral component. We have the sluggishness,

1:01:28

the slow moving, the mental confusion

1:01:30

that seems to be somewhat distinct

1:01:32

from maladaptive daydreaming. A

1:01:34

few people have asked about any kind of

1:01:37

nutrition or supplement

1:01:39

recommendations that might help

1:01:41

with CDS. Yeah,

1:01:43

I think if I take

1:01:45

a step back, and obviously I'm as a psychologist,

1:01:48

this is something obviously would work

1:01:51

with your child's pediatrician or primary

1:01:53

care. I just take a

1:01:55

step back and think about what are the certain nutrition

1:01:57

diets that are going to help

1:02:00

improve a child's attention and their

1:02:02

energy and their motivation. So that's what

1:02:04

I often talk about. Like in

1:02:06

the context of ADHD, you know,

1:02:08

having a, having a

1:02:10

well-balanced diet, having enough

1:02:12

opportunity for exercise, ensuring

1:02:14

sleep. Um, you know,

1:02:17

there are, I know with ADHD, there

1:02:19

have been some studies that some small

1:02:21

effects for like, you know, omega-3 fatty

1:02:23

acids in terms of maybe improving attention,

1:02:26

maybe that might be something that would

1:02:28

be helpful. And in terms of increasing

1:02:30

attention or energy levels, we don't

1:02:32

have any type of studies that have looked

1:02:34

at nutritional supplements.

1:02:38

I would just encourage, you know,

1:02:40

everyone to think about if my

1:02:42

child in general was struggling with

1:02:44

the sleepiness, the tiredness, the daydreaminess,

1:02:46

you know, he would really ideally

1:02:49

optimize, you know, their diet, having

1:02:51

a well-balanced diet, having moderate levels

1:02:53

of sugar intake, having opportunity for

1:02:55

exercise, physical activity, ensuring good sleep.

1:02:58

So that would be my response

1:03:00

to that. But I am hopeful

1:03:03

that we start to, as more

1:03:05

of the intervention medication work starts to come

1:03:07

out, that we can do some trials on,

1:03:09

you know, different supplements or nutritionists to see

1:03:12

could those be a complimentary approach to

1:03:14

these other interventions? Well,

1:03:17

unfortunately we're out of time and that

1:03:19

has to be our last question. But

1:03:21

Dr. Frederick, thank you so much for

1:03:23

joining us today and for sharing your

1:03:26

expertise with our ADHD community.

1:03:28

We really appreciate that. Absolutely. It's a

1:03:30

pleasure. These were unbelievable questions. I really

1:03:32

appreciate it. Um, many of

1:03:34

these questions that made me start to think,

1:03:36

I'll be honest, I'm like, I want to

1:03:38

learn more about these different ideas. So I

1:03:41

really appreciate the opportunity. And as I said,

1:03:43

you can learn more about our information online

1:03:45

and I'm available. If anyone wants to, you

1:03:47

know, if they have other questions, I'm happy

1:03:49

to do the best in answering them. Well,

1:03:52

thank you. And thank you so much to

1:03:54

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