Chapter 5 AttentionDeficitHyperactivity Disorder ADHD

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Chapter 5Attention-Deficit/Hyperactivity
Disorder (ADHD)
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Attention-Deficit/Hyperactivity DisorderClinical
Features

• Excessive, impairing, persistent pervasive
  levels of
• Activity
• Inattention
• Impulsivity

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Attention-Deficit/Hyperactivity DisorderClinical
Features

• age-inappropriate
• Characteristic patterns of behavior, no physical
  symptoms
• Behavior varies among children
• Associated with problems in social, cognitive,
  academic, familial, and emotional domains of
  development and adjustment

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History of ADHD

• Described in medical literature since mid 1800s
  as a defect in moral control
• Encephalitis epidemic of 1917-1918 gave rise to
  the concept of a brain-injured child syndrome,
  often associated with mental retardation
• Concept evolved to minimal brain damage and
  minimal brain dysfunction in the 1940s and
  1950s

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History of ADHD (cont.)

• In 1950s- referred to as hyperkinetic impulse
  disorder motor overactivity seen as primary
  feature
• By 1970s, deficits in attention and impulse
  control, in addition to hyperactivity, seen as
  the primary symptoms
• Knowledge of brain function has grown disorder
  is now seen as problem of self-regulation and
  behavioral inhibition

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Core Characteristics DSM IV- TR

• Inattention 6 or more of the following symptoms
• Fails to pay close attention to detail, makes
  careless mistakes
• Difficulty sustaining attention
• Often does not seem to listen
• Often does not follow through with instructions
  fails to complete tasks
• Has difficulty organizing activities
• Avoids tasks requiring sustained mental effort
• Often loses things
• Easily distracted
• Often forgetful

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Core Characteristics

• Not a deficit of attentional capacity can
  remember same amount of information for a
  short-time as other kids
• Difficulty with selective attention - more likely
  to be distracted by extraneous noises
• Difficulty with sustained attention trouble
  keeping focused when task is repetitive or
  uninteresting

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Core Characteristics (cont.)

• Hyperactivity - Impulsivity 6 or more of the
  following
• Fidgeting, difficulty staying seated when
  required
• Moving, running, climbing about
• Trouble playing quietly
• Excessive talking
• Acts as if driven by a motor
• Blurts out answers before question completed
• Difficulty awaiting turn
• Interrupts or intrudes on others

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Core Characteristics (cont.)

• Hyperactivity-impulsivity best viewed as a single
  dimension since they typically co-occur hard to
  stop or regulate their behavior
• Behavior is excessively energetic, intense,
  inappropriate, and not goal-directed
• More motor activity than other children,
  especially in the classroom when asked to sit
• Can display cognitive impulsivity, behavioral
  impulsivity, or both

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DSM-IV (TR) Subtypes

• Predominantly Inattentive Type (ADHD-PI)
• Less common
• Slow processing speed, difficulties with
  selective attention and verbal memory
• Often co-morbid learning (visual-spatial
  deficits) and/or mood disorders
• a separate disorder?

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DSM-IV (TR) Subtypes

• Predominantly Hyperactive-Impulsive Type
  (ADHD-HI)
• Rarest form, primarily preschoolers
• Possibly not a separate subtype but early
  expression of combined subtype

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DSM-IV (TR) Subtypes

• Combined Type (ADHD-C)
• Associated with aggression, defiance, peer
  rejection, suspension, and placement in special
  education classes
• Greater difficulty with motor inhibition,
  sequencing planning

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Additional Diagnostic Criteria

• Excessive, long-term, and persistent behaviors
  (at least 6 months)
• Behaviors appear prior to age 7
• Age-inappropriate
• Behaviors occur in several settings
• Behaviors cause impairments in at least 2
  settings
• Behaviors not due to another disorder or serious
  life stressor (e.g., MV accident, chronic abuse)

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Limitations of DSM Criteria

• Developmentally insensitive
• Categorical view of ADHD
• Requirement of an onset before age 7 uncertain
• Requirement of persistence for 6 months may be
  too brief for young children

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Associated Characteristics

• Cognitive Deficits
• Deficits in executive functions including
  processes such as working memory, planning
  organization
• Trouble applying intelligence (although usually
  have normal intelligence)
• Academic delays (80) by late childhood
• Learning disorders (25), especially in reading,
  spelling, math
• Distorted self-perceptions

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Associated Characteristics (cont.)

• Speech and Language Impairments
• 30 to 60 of children with ADHD also have
  impairments in speech language
• Deficits in verbal fluency - frequent shifts
  interruptions in conversation, fewer language
  links such as pronouns conjuctions
• Difficulties with verbal comprehension
• Excessive loud talking

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Associated Characteristics (cont.)

• Medical and Physical Concerns
• Sleep disturbances common, partly due to use of
  stimulant medications
• Slight growth deficits until mid-adolescence,
  apparently unrelated to use of stimulant
  medications
• Motor clumsiness sports, handwriting
• Tic disorders (often throat-clearing, grimacing)
• Associated with accident-proneness and risky
  behaviors
• Increased risk of substance abuse
• Associated with ODD, CD, anxiety and mood
  disorders

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Associated Characteristics (cont.)

• Social Problems
• Do not apply social rules and conventions despite
  awareness of them, dont learn from mistakes
• Family patterns include negative interactions
  (high mother-child conflict), child
  noncompliance, high parental control, marital
  conflict
• Many parents also have ADHD
• Maternal depression, paternal antisocial behavior
• Siblings also treated with negativity, feel
  victimized by ADHD sibling feel this is
  minimized by parents
• Peer difficulties may have few friends, little
  social support due to inappropriate, impulsive
  sometimes aggressive behavior

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Associated Characteristics (cont.)

• In the following video, Seans mother describes a
  number of Seans behaviors that alerted her to
  the nature of his problems
• What examples of Seans behavior exemplify a
  diagnosis of ADHD?

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Sean
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Prevalence

• 3 - 5 of all school age children
• Diagnosed more frequently in boys (3 times more
  likely)
• Referral differences for girls versus boys
• DSM criteria may be more appropriate for boys
• Gender differences in community versus clinic
  samples
• Slightly more prevalent among lower SES groups
• Found in all countries and cultures, although
  rates vary

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Developmental Course

• Likely that ADHD is present at birth, but
  difficult to identify
• Hyperactivity-impulsivity usually appears first
• Onset often in preschool years, and usually by
  school age
• Deficits in attention increase as school demands
  increase
• In early school years oppositional and socially
  aggressive behaviors often develop
• Most children still have ADHD as teens, although
  HI behaviors decrease
• Problems often continue into adulthood

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Interrelated Theories of ADHD

• Motivation Deficits
• Diminished sensitivity to rewards and punishment,
  resulting in deterioration of performance when
  rewards infrequent
• Deficits in Arousal Level
• low arousal, resulting in excessive
  self-stimulation (hyperactivity) in order to
  maintain an optimal level of arousal
• Deficits in Self-regulation
• inability to use thought and language to direct
  behavior, resulting in impulsivity, poor
  maintenance of effort, deficient modulation of
  arousal level, and attraction to immediate
  rewards
• Deficits in Behavioral Inhibition
• inability to control behavior, which is the basis
  for the many cognitive, language, and motor
  difficulties associated with ADHD

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Theories and Causes

• Genetics
• ADHD runs in families
• Adoption and twin studies indicate a strong
  hereditary basis for ADHD
• Dopamine transporter gene (DAT) and the dopamine
  receptor gene (DRD4) appear to be implicated

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Causes of ADHD (cont.)

• Pregnancy, Birth, and Early Development
• none have been shown to be specific to ADHD-
  however, pregnancy and birth complications, low
  birth weight, malnutrition, early neurological
  trauma, and diseases of infancy may be related to
  later symptoms of ADHD
• maternal substance abuse associated with ADHD
• no empirical support for diet, allergies or lead
  poisoning as causes of ADHD

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Causes of ADHD (cont.)

• Neurobiological Factors
• ADHD believed to be largely a neurobiological
  disorder
• consistent support for the implication of the
  frontostriatal circuitry (prefrontal cortex and
  basal ganglia)
• smaller cerebral volumes smaller cerebellum
• neurotransmitters involved include dopamine,
  norepinephrine, epinephrine, and serotonin

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Causes of ADHD (cont.)

• Family Influences
• Accounts for small amount of variance in ADHD
  symptoms
• ADHD symptoms may be associated with insensitive
  early care-giving in some cases
• Family conflict may increase the severity of HI
  symptoms
• Family problems may result from interactions with
  a child who is impulsive and difficult to manage
• Family problems may be associated with the later
  emergence of oppositional and conduct problems

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Treatment

• Medication
• Stimulant medications most effective treatment
  for management of symptoms and associated
  impairments
• Most common ones used are dextroamphetamine
  (Dexedrine) and methylphenidate (Ritalin)
• Stimulants alter activity in the frontostriatal
  brain region by affecting important
  neurotransmitters
• 80 of children show improvements in sustained
  attention, impulse control, completion of tasks,
  academic productivity
• May improve social interactions and
  cooperativeness
• May reduce destructive aggressive behaviors
• Side effects
• Controversy

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Treatment

• Parent Management Training (PMT)
• Provides parents with skills to help manage
  childs behavior, reduce parent-child conflict,
  and cope with difficulties of raising a child
  with ADHD
• Immediate, frequent powerful consequences,
  consistency, planning, not personalizing
  practice forgiveness
• Behavior Management Principles goal setting,
  use of rewards sanctions such as time-out and
  loss of privileges, noticing praising strengths
• Breaking down structuring tasks
• Anger management relaxation training for parent
• Difficult to assess long-term outcomes

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Treatment (cont.)

• Educational Intervention
• Focus on managing behaviors that interfere with
  learning, providing classroom environment that
  capitalizes on childs strengths and improves
  academic performance
• Goal-setting, incentives, response-cost (loss of
  privileges, activities, points, time-out)
• Clear expectations, cuing
• Use of visual aids written instructions

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Treatment (cont.)

• The following video Edward, a gifted eighth-grade
  student with ADHD, is discussed
• How does Edwards teacher help him get the extra
  structure that his ADHD requires?

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Edward ADHD
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Treatment (cont.)

• Intensive Interventions
• Combines medications, PMT, and educational
  interventions e.g., summer camp treatment program
• Challenges of research application to subtype,
  gender, improvements in what areas of functioning
• Additional Interventions
• Individual family counseling, support groups
• Controversial Treatments
• Provide false hope, delay other treatments
• Diet restrictions, allergy treatments,
  megavitamins, chiropractic adjustment, biofeedback