Download - © Cengage Learning 2016 Eric J. Mash David A. Wolfe Attention-Deficit/Hyperactivity Disorder (ADHD) 8

© Cengage Learning 2016 © Cengage Learning 2016

Eric J. MashDavid A. Wolfe

Attention-Deficit/HyperactivityDisorder (ADHD)

8

© Cengage Learning 2016

• Attention-deficit/hyperactivity disorder (ADHD) is exhibited as persistent age-inappropriate symptoms of inattention, hyperactivity, and impulsivity that are sufficient to cause impairment in major life activities– Characteristic behaviors vary considerably

from child to child

– Different behavior patterns may have different causes

Description


• Early 1900s – Children who lacked self-control and showed

symptoms of overactivity/inattention in school were said to have poor “inhibitory volition” and “defective moral control”

• Following the worldwide influenza epidemic from 1917-1926– “Brain-injured child syndrome”

• 1940s-1950s: “minimal brain damage” and “minimal brain dysfunction”

History


Historical Example


• Late 1950s – ADHD was called hyperkinesis

• Led to definition of hyperactive child syndrome, in

• By the 1970s– Deficits in attention and impulse control, in

addition to hyperactivity, were seen as the primary symptoms

• 1980s saw increased interest in ADHD– Rise in stimulant use generated controversy

History (cont’d.)


• Key symptoms fall under two well-documented categories– Inattention

– Hyperactivity-impulsivity

• Using these dimensions to define ADHD oversimplifies the disorder– Attention and impulse control are closely

connected developmentally

Core Characteristics


DSM-V Diagnostic Criteria for ADHD


DSM-V Diagnostic Criteria for ADHD (cont’d.)


• Inability to sustain attention, particularly for repetitive, structured, and less enjoyable tasks

• Deficits may be seen in one or more types of attention– Attentional capacity

– Selective attention

– Distractibility

– Sustained attention/vigilance (a core feature)

Inattention


• Inability to voluntarily inhibit dominant or ongoing behavior

• Hyperactive behaviors include– Fidgeting and difficulty staying seated

– Moving, running, touching everything in sight, excessive talking, and pencil tapping

– Excessively energetic, intense, inappropriate, and not goal-directed

Hyperactivity-Impulsivity


• Impulsivity – Inability to control immediate reactions or to

think before acting

– Cognitive impulsivity includes disorganization, hurried thinking, and need for supervision

– Behavioral impulsivity includes difficulty inhibiting responses when situations require it

– Emotional impulsivity includes impatience, low frustration tolerance, hot temper, quickness to anger, and irritability

Hyperactivity-Impulsivity (cont’d.)


• Predominantly inattentive presentation (ADHD-PI)

• Predominantly hyperactive–impulsive presentation (ADHD-HI)

• Combined presentation (ADHD-C)

ADHD Presentation Types


• Inattentive, drowsy, daydreamy, spacey, in a fog, and easily confused

• May have learning disability, process information slowly, have trouble remembering things, and display low academic achievement

• Often anxious, apprehensive, socially withdrawn, and may display mood disorders

Predominantly Inattentive Type (ADHD-PI)


• Primarily symptoms of hyperactivity-impulsivity (rarest group)

• Primarily includes preschoolers and may have limited validity for older children

• May be a distinct subtype of ADHD-C

Predominantly Hyperactive-Impulsive Type (ADHD-HI)


• Children who have symptoms of both inattention and hyperactivity-impulsivity

• Most often referred for treatment

Combined Type (ADHD-C)


• Appears prior to age 12

• Persists more than 6 months

• Occurs more often and with greater severity than in:– Other children of the same age and sex

• Occur across two or more settings

• Interferes with social or academic performance

• Not explained by another disorder

Additional DSM Criteria


• Limitations of DSM criteria for ADHD– Developmentally insensitive

– Categorical view of ADHD

• DSM criteria shape our understanding of ADHD– DSM criteria are also shaped by, and in some

instances lag behind, new research findings

What DSM Criteria Don’t Tell Us


• Children with ADHD often display other problems in addition to their primary difficulties– Cognitive deficits

– Speech and language impairments

– Developmental coordination and tic disorders

– Medical and physical concerns

– Social problems

Associated Characteristics


• Cognitive processes

• Language processes

• Motor processes

• Emotional processes

Cognitive Deficits: Executive Functions


Examples of Impaired Executive Functions


• Intellectual deficits – Most children with ADHD have at least normal

intelligence - the difficulty lies in applying intelligence to everyday life situations

• Impaired academic functioning– Children with ADHD frequently have lower

productivity, grades, and scores on achievement tests

Cognitive Deficits: Intellectual and Academic


• Learning disorders are common for children with ADHD– Problem areas: reading, spelling, and math

• Distorted self-perceptions – Positive bias: exaggeration of one’s

competence

– Self-esteem in children with ADHD may vary with the subtype of ADHD

– Distortions in perceptions of quality of life

Cognitive Deficits: Learning Disorders and Self-Perceptions


• Formal speech and language disorders

• Difficulty understanding others’ speech

• Excessive and loud talking

• Frequent shifts and interruptions in conversation

• Inability to listen

• Inappropriate conversations

• Speech production errors

Speech and Language Impairments


• As many as 30-50% of children with ADHD display motor coordination difficulties– Clumsiness, poor performance in sports, or

poor handwriting

• Overlap exists between ADHD and developmental coordination disorder (DCD)– Marked motor incoordination and delays in

achieving motor milestones

Developmental Coordination and Tic Disorders


• Tic disorders occur in 20% of children with ADHD– Sudden, repetitive, nonrhythmic motor

movements or sounds such as eye blinking, facial grimacing, throat clearing, and grunting

Developmental Coordination and Tic Disorders (cont’d.)


• Health-related problems– Higher rates of asthma and bedwetting

• Studies’ findings are inconsistent

– Sleep disturbances may be related to use of stimulant medications and/or co-occurring conduct or anxiety disorders

Medical and Physical Concerns


• Accident-proneness and risk taking– Over 50% are described as being accident-

prone

– At higher risk for traffic accidents

– At risk for early initiation of cigarette smoking, substance use disorders, and risky sexual behaviors

– Reduced life expectancy

– Higher medical costs

Medical and Physical Concerns (cont’d.)


• Family problems include:– Negativity, child noncompliance, excessive

parental control, sibling conflict, maternal depression, paternal antisocial behavior, and marital conflict

• Family difficulties may be due to co-occurring conduct problems

Social Problems


• Peer problems – ADHD children can be bothersome, stubborn,

socially awkward, and socially insensitive• They are often disliked and uniformly rejected by

peers, have few friends

• They are unable to apply their social understanding in social situations

• Positive friendships may buffer negative outcomes

Social Problems (cont’d.)


• Up to 80% of children with ADHD have a co-occurring psychological disorder

• Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)– Role of COMT gene

– A common genetic contribution for ADHD, ODD, and CD

– Family connections – there is evidence for a contribution from a shared environment

Accompanying Psychological Disorders and Symptoms


• Anxiety disorders– About 25% of children with ADHD experience

excessive anxiety

– Co-occurring anxiety worsens symptoms or severity of ADHD

• Findings are inconsistent

– Children with co-occurring ADHD and anxiety:• Display social and academic difficulties

• Experience greater long-term impairment and mental health problems

Accompanying Psychological Disorders and Symptoms Anxiety Disorders


• Mood disorders– ADHD at 4-6 years is a risk factor for future

depression and suicidal behavior

– 20-30% of children with ADHD experience depression

• Family risk for one disorder may increase the risk for the other

• Controversy regarding relationship between ADHD and pediatric bipolar disorder (BP)

Accompanying Psychological Disorders and Symptoms Mood Disorders


• Prevalence rates vary widely with sampling methods– Estimates: 6-7% of school-age children and

adolescents in North America and 5% worldwide have ADHD

– ADHD is one of the most common referral problems seen at clinics

Prevalence and Course


• ADHD occurs more frequently in boys

• Overall rates decrease in adolescence for both sexes - ratio remains the same

• Ratio in clinical samples is 6:1 with boys being referred more often than girls– ADHD in girls may go unrecognized and

unreported

• DSM criteria (cutoffs and symptoms) may be more appropriate to boys than girls

Gender


• Girls with ADHD may be more likely to display inattentive/disorganized symptoms

• Clinic-referred school-age children with ADHD display similar symptoms

• Girls with ADHD who display impulsive-hyperactive behaviors– More likely to develop eating disorder

symptoms

Gender (cont’d.)


• ADHD affects children from all social classes– Slightly more prevalent among lower SES

groups

• Findings are inconsistent regarding relationships among ADHD, race, and ethnicity

• ADHS is found in all countries and cultures– Rates vary

Socioeconomic Status and Culture


• Cultural differences may reflect cultural norms and tolerance for ADHD symptoms

• ADHD is a universal phenomenon that is diagnosed more often in boys than girls in all cultures– Expression, associated features, impairments,

and outcomes are quite similar wherever it occurs

Socioeconomic Status and Culture (cont’d.)


• Infancy– Signs of ADHD may be present at birth - no

reliable or valid methods exist to identify it

• Preschool – Hyperactivity-impulsivity symptoms become

more visible and significant at ages 3-4

– Children with symptoms for at least 1 year are likely to continue to have difficulties later in middle childhood and adolescence

Course and Outcome


• Symptoms are especially evident when the child starts school

• Oppositional defiant behaviors may increase or develop– By age 8-12, defiance and hostility may take

the form of serious problems– Increased problems may encompass self-

care, personal responsibility, chores, trustworthiness, independence, social relationships, and academic performance

Course and Outcome Elementary School


• Many children with ADHD do not outgrow problems and some can get much worse

• At least 50% of clinic-referred elementary school children continue to suffer from ADHD into adolescence

• Adult challenges – Some individuals either outgrow or learn to

cope with their disorder by adulthood

– ADHD is established as an adult disorder

Course and Outcome Adolescence and Adulthood


• Explanations for ADHD– Trait from evolutionary past as hunters

– ADHD is a myth fabricated because society needs it

– Some theories• Cognitive functioning deficits

• Reward/motivation deficits

• Arousal level deficits

• Self-regulation deficits

Theories and Causes


A Possible Developmental Pathway for ADHD


• ADHD runs in families

• Adoption studies

• Twin studies – 75% heritability estimates for hyperactive-

impulsive and inattentive behaviors

• Specific gene studies– Genes may contribute to the expression of

ADHD – focus on dopamine regulation

Genetic Influences


• Factors that compromise development of the nervous system before and after birth may be related to ADHD

• Mother’s use of cigarettes, alcohol, or other drugs during pregnancy are associated with ADHD– Contributing factors, rather than a causal

association

– It is difficult to disentangle substance abuse influence and other environmental factors

Pregnancy, Birth, and Early Development


• Research shows differences on:– Psychophysiological measures

• Diminished arousal or arousability

– Measures of brain activity during vigilance tests

• Under-responsiveness to stimuli/deficits in response inhibition

– Blood flow to prefrontal regions and pathways connecting them to limbic system

• Decreased blood flow to these regions

Neurobiological Factors


• Abnormalities primarily in the frontostriatal circuitry are implicated– This region includes the prefrontal cortex and

the basal ganglia

– ADHD children have smaller total and right cerebral volumes (by 3-4%), smaller cerebellum, and delayed brain maturation

• Specific regions of the thalamus may also be involved

Brain Abnormalities


• No consistent differences have been found between children with and without ADHD– Some neurotransmitters may be involved

• Dopamine, norepinephrine, epinephrine, and serotonin may be involved

• Most evidence suggests a selective deficiency in availability of dopamine and norepinephrine

– Using medication for effective treatment of ADHD symptoms does not prove that deficits are the cause of symptoms

Neurophysiological and Neurochemical Associations


• Sugar is not the cause of hyperactivity

• Allergic reactions and diet– Possible moderating role of genetic factors

may explain why food additives affect the behavior of some children

• Low levels of lead may be associated with ADHD symptoms

• The role of diet, allergy, and lead as primary causes of ADHD is minimal to nonexistent

Diet, Allergy, and Lead


• Importance of family influences– Family influences may lead to ADHD

symptoms or to a greater severity of symptoms

– Family problems may result from interacting with a child who is difficult to manage

– Family conflict is likely related to the presence, persistence, or later emergence of associated oppositional and conduct disorder

Family Influences


• Less than half of the children with ADHD receive treatment– Of those who receive treatment, many

discontinue prematurely

• The primary treatment approach combines:– Stimulant medication

– Parent management training

– Educational intervention

Treatment


Treatments for Children with ADHD


• Stimulants have been used to treat ADHD since the 1930s – Among the most effective stimulants are

dextroamphetamine and methylphenidate• May help normalize frontostriatal structural

abnormalities and functional connections

– Effects are temporary and occur only while medication is taken; beneficial in short-term

• Questions surround long-term benefits and later adjustment

Medication


• Provides parents with a variety of skills– Managing the child’s oppositional and

noncompliant behaviors

– Coping with emotional demands of raising a child with ADHD

– Containing the problem so it does not worsen

– Keeping the problem from adversely affecting other family members

Parent Management Training (PMT)


• Parents are:– Taught to understand biological basis of

ADHD

– Given set of guiding principles

– Taught behavior management principles and techniques

– Encouraged to spend time each day sharing enjoyable activity with their child

– Taught how to reduce their own levels of arousal

Parent Management Training (PMT) (cont’d.)


• Teacher and child must set realistic goals and objectives

• Response-cost procedures are used to reduce disruptive or off-task behaviors

• Many strategies are basic good teaching methods

• School-based interventions for ADHD have received considerable support

Educational Intervention


• Summer treatment programs– Maximize opportunities to build effective peer

relations in normal settings and provides continuity with academic work so gains from school year aren’t lost

– Are coordinated with stimulant medication trials, PMT, social skills training, and educational interventions

Intensive Interventions


• Family counseling and support groups – Help family members develop new skills,

attitudes, and ability to relate more effectively

• Individual counseling– Helps children with ADHD deal with their

problems and feelings of isolation and abnormality

– Helps build their sense of self-competence

Additional Interventions


• Children with ADHD have problems that should not be minimized

• Each child is unique and has assets and resources that need to be recognized and supported

Keeping Things in Perspective

Download - © Cengage Learning 2016 Eric J. Mash David A. Wolfe Attention-Deficit/Hyperactivity Disorder (ADHD) 8

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