8. attention-deficit/hyperactivity disorder (ADHD)

key symptoms fall under 2 well-documented categories

• inattention

• hyperactivity-impulsivity

what does it mean for ADHD to have excellent reliability?

symptom clusters consistently appear together

what does it mean for ADHD to have discriminant validity?

factor analyses consistently identifies separate symptom clusters

deficits can be seen in 4 types of attention (either 1 or more)

• attentional capacity

• selective attention

• distractibility

• sustained attention (a core feature)

hyperactivity

under-controlled motor behavior, poor sustained inhibition of behavior, the inability to delay a response or defer gratification, or an inability to inhibit dominant responses in relation to ongoing situational demands

impulsivity

an inability to control immediate reactions or to think before acting

3 examples of hyperactive behaviors

• fidgeting and difficulty staying seated

• moving, running, touching everything in sight, excessive talking, and pencil tapping

• excessively energetic, intense, inappropriate and not goal-directed

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

3 presentation types of ADHD

ADHD-PI, ADHD-C, ADHD-HI

ADHD-PI

predominantly inattentive presentation, inattentive to details, easily distracted, careless, not listening, unfocused, disorganized, unable to sustain effort, and forgetful

ADHD-HI

predominantly hyperactive-impulsive presentation, like ADHD-C in concerns in inhibiting behavior and in behavioral persistence, more likely to be aggressive, defiant, rejected by peers, and suspended from school or placed in special education classes

ADHD-C

most often referred for treatment, combined presentation

6 diagnostic criteria for ADHD

• appear before age 12

• persist for more than 6 months

• occur more often and w greater severity than in other children of the same age and sex

• occur across 2 or more settings (e.g., home, school, other activities)

• interfere w, or reduce the quality of, social, academic, or occupational functioning

• not be better explained by another mental disorder (e.g., mood disorder, anxiety disorder)

2 limitations of DSM-5-TR criteria for ADHD

• developmentally insensitive (created largely based on school-aged boys)

• categorical view of ADHD (a disorder that a child either has or doesn’t have)

cognitive deficits in 4 kinds of EFs

• cognitive processes

• language processes

• motor processes

• emotional processes

cognitive processes

working memory, mental computation, planning, anticipation, and flexibility of thinking

language processes

verbal fluency and the use of self-directed speech

motor processes

allocation of effort, following prohibitive instructions, response inhibition, and motor coordination and sequencing

emotional processes

self-regulation of arousal lvl and tolerating frustration

how do children w ADHD have intellectual deficits if most of them have at least typical intelligence?

bc the difficulty lies in applying intelligence to everyday life situations

are learning disorders common for children w ADHD?

yes

3 distorted self-perceptions

• positive illusory bias

• self-esteem in children w ADHD may vary w the subtype of ADHD

• distortions in perceptions of quality of life

positive illusory bias

exaggeration of one’s competence

examples of speech and language impairments

• formal speech and language disorders

• difficulty understanding others’ speech

• impairment in pragmatic language skills

• excessive and loud talking

• frequent shifts and interruptions in convo

• inability to listen

• inappropriate convos

• speech production errors

examples of health-related problems

• higher rates of enuresis, encopresis, and asthma

• dental health concerns, poor fitness, eating concerns/disorders, and sleep disturbances

concerns w accident-proneness and risk taking

• 3 times more likely to experience serious accidental injuries

• at risk for early initiation of cigarette smoking, substance use disorders, and risky sexual behaviors

• reduced life expectancy and higher medical costs

peer concerns

• get into trouble even when trying to be helpful

• often disliked and uniformly rejected by peers, have few friends

• unable to apply their social understanding in social situations

• may not interact properly w online social communication

• positive friendships may buffer negative outcomes

what are some co-occurring disorders?

• ODD

• anxiety

• depression

• motor coordination difficulties

• tic disorders

• developmental coordination disorder (DCD)

developmental coordination disorder (DCD)

marked motor incoordination and delays in achieving motor milestones

tic disorders

sudden, repetitive, nonrhythmic motor mvmts or sounds such as eye blinking, facial grimacing, throat clearing, and grunting

when do symptoms start becoming more visible and significant?

ages 3-4 (preschool)

genetic causes of ADHD

• ADHD is heritable: concordance rates for MZ twins are 50-80% but for DZ twins, they are around 33%

• genes associated w dopamine and serotonin

• mutations reported in dopamine transporter gene (DAT1) located on chromosome 5 and in dopamine D4 and D5 receptor genes

early environmental genetic influences

• factors that compromise the dev of the nervous system before and after birth

• mother’s use of cigarettes, alcohol, or other drugs during pregnancy

  • comprised fetal dev may create a malleable state that increases the influence of a negative environment

Jeffrey Gray’s two system model

behavioral activation system

• responsible for approaching stimuli and adjusting to achieve reinforcement

• strong need for immediate reinforcement

• behavior governed by achieving immediate reinforcement

behavioral inhibition system

• underactive

• responsible for inhibiting behavior

• contributes to difficulty managing action

2 dopaminergic pathways

• mesolimbic pathway - heightened reward sensitivity

• frontal-striatal neural circuit - impaired inhibition

2 changes in neural networks in gray matter

• smaller volumes in prefrontal cortex, temporal lobes, anterior cingulate

• reduced density in areas involved in sensory processing, impulse control, and emotion modulation

change in neural network in white matter

• reduced integrity and delayed dev

which NTs may be involved in ADHD

dopamine, norepinephrine, epinephrine, serotonin

what does gray matter contain, where is it found, and what’s its role in ADHD

contains neuronal cell bodies (the “thinking” part of the neuron)

outer layer of the brain (cortex), subcortical structures (basal ganglia, thalamus), spinal cord

differences in volume and density linked to challenges in attention, emotion, regulation, and EF

what does white matter contain, where is it found, and what’s its role in ADHD

myelinated axons (the “wiring” that connects brain regions)

deep brain tissue, connecting pathways (corpus callosum, internal capsule), spinal cord tracts

altered connectivity and signal transmission may affect coordination btwn brain regions involved in self-regulation

3 brain abnormalities associated w mesolimbic neural circuit

• heightened reward sensitivity

• underactivity of behavioral inhibition system (BIS)

• overactivity of the behavioral activation system (BAS)

4 brain abnormalities associated w the frontal-striatal neural circuit

• impaired inhibition

• maturational delay

• dysregulation of the major NTs

• reduced neural connectivity

2 cognitive deficits as a result of abnormalities in the DMN

DMN is active when you’re not engaged in a task but ADHD causes decreased activation of DMN

• daydreaming and mind-wandering

• difficulty inhibiting the DMN

Barkley’s neurodevelopmental model for ADHD

foundational/main deficit is poor behavioral inhibition

attentional capacity

the amount of info we can remember and attend to for a short time — children w ADHD don’t have deficits in this

selective attention

the ability to concentrate on relevant stimuli and ignore task-irrelevant stimuli in the env

alerting

refers to an initial rxn to a stimulus; involves the ability to prep for what’s abt to happen

goodness of fit

the match btwn the child’s early temperament and the parent’s style of interaction

most effective stimulants and why are they effective

dextroamphetamine and methylphenidate (Ritalin)

alter activity in the frontostriatal region of the brain by affecting NTs (dopamine) important to this region

focus of stimulant treatment

managing ADHD symptoms at school and home

parent management training (PMT)

focuses on teaching both effective parenting and strategies for coping w the challenges of parenting a child w ADHD provides parents w a variety of skills to help them

educational interventions

teacher and child must set realistic goals and objectives

focus of educational intervention

managing disruptive classroom behavior, improving academic performance, teaching prosocial and self-regulating behaviors

intensive interventions: summer treatment programs

360 hrs of day-treatment in a period of 8 weeks, the equivalent of 7 yrs of weekly therapy

examples of family problems

• negativity noncompliance

• excessive parental control.

• sibling conflict

• maternal depression

• paternal antisocial behavior

• marital conflict

what does the primary treatment approach combine?

• stimulant meds

• PMT

• educational intervention