Attention Deficit Hyperactivity Disorder

DSM-5 Criteria for ADHD Diagnosis

1. Persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning

   1. Inattention: (6 or more) that have persisted at impairing levels for at least 6 mos. OFTEN:

   2. Hyperactivity and Impulsivity (6 + for individuals < 17 years; 5 for age 17 and older); 6 months @ impairing levels. OFTEN: ** age adjustment

2. Several Inattention and/ or HA/I symptoms present prior to age 12 years

3. Several Inattention or HA/I symptoms present in two or more settings (home, school, work, peers; other)

4. Clear evidence that symptoms cause impairment (reduced quality of social, academic or occupational functioning)

5. Symptoms do not occur exclusively during course of schizophrenia or are not better explained by another disorder

Criteria Domain 1a: Inattention

1. Inattention: (6 or more) that have persisted at impairing levels for at least 6 mos. OFTEN:

   1. Fails to give close attention to details or makes careless mistakes

   2. Has difficulty sustaining attention in tasks or play activities

   3. Does not seem to listen when spoken to directly

   4. Does not follow through on instructions and fails to finish schoolwork

   5. Has difficulty organizing tasks or activities

   6. Avoids, dislikes tasks that require sustained mental effort

   7. Loses things necessary for tasks or activities

   8. Easily distracted by extraneous stimuli

   9. Forgetful in daily activities

Criteria Domain 1b: Hyperactivity and Impulsivity

1. Hyperactivity and Impulsivity (6 + for individuals < 17 years; 5 for age 17 and older); 6 months @ impairing levels. OFTEN: ** age adjustment

   1. Fidgets with or taps hands or feet or squirms in seat

   2. Leaves seat in situations where remaining seated is expected

   3. Runs about or climbs in situations where it is inappropriate (in adolescents or adults, may be limited to feeling restless)

   4. Unable to engage in leisure activities quietly

   5. Is on the go, acting as if driven by a motor

   6. Talks excessively

   7. Blurts out an answer before a question has been completed

   8. Has difficulty waiting his/her turn

   9. Interrupts or intrudes on others (games, conversations, activities)

ADHD Specifiers

• Combined presentation: Criteria for both Inattention and HA/I met (most common clinical presentation - 6 or more from each list)

• Predominantly inattentive presentation: Criteria for Inattention met but criteria for HA/I not met in last 6 months 

• Predominantly HA/I presentation: Criteria for HA/I met but criteria for Inattention not met in last 6 months

• Also specify:

  • Severity and whether individual is in partial remission

Types of ADHD and associated symptoms: Predominantly Hyperactive/Impulsive

• The strong link between hyperactivity and impulsivity suggests an overall deficit in regulating behavior.

• Multiple dimensions of HA/I

  • Quality of activity

    • Distinguish normal high levels of activity from hyperactive

      • Compare his activity of age peers (match gender) and quality of activity level

      • Hyperactive - intense, unfocused, and inappropriate for the situation

      • Impulsivity - interrupting, emotional dysregulation, etc. 

  • Situational influences

    • Highly situationally specific and multidimensional 

  • Impulsivity: multiple dimensions

Types of ADHD and associated symptoms: Predominantly Inattentive

• An inability to sustain attention or stick to tasks or play activities, to remember and follow through on instructions or rules, and to resist distractions

  • Multiple dimensions

    • Working memory

    • Selective attention

    • Sustained attention/vigilance

  • Variability in ADHD-I

    • Subthreshold problems and vastly different presentations

  • Sluggish Cognitive Tempo:

    • ADHD PI (predominantly inattentive) 30-60% 

    • Cognitively confused, daydreamy, lost in own world, co-occurrences of depression and anxiety 

Attentional capacity (working memory)

Short term capacity, and hold 7 bits of info at one time, immediate sphere of attention

• Cognitive symptom - deficits in working memory 

• Present with the ADHD-PI type

Selective attention

Ability to concentrate on relevant information when distracted by irrelevant stimuli

Distractibility - A term used to describe deficits in selective attention

Sustained attention/vigilance

Ability to maintain a persistent focus of attention across time (primary deficit especially when task is boring and repetitive)

Deficits in sustained attention are one of the core features of ADHD

Sluggish Cognitive Tempo

Cognitively confused, daydreamy, lost in own world, co-occurrences of depression and anxiety

• A cluster of symptoms that includes daydreams, sleepy/drowsy, underactive/slow moving, tired/lethargic, easily confused, stares blankly, lost in thoughts, in a fog, slow thinking and responding, spacey/alertness changes from moment to moment, apathetic, unmotivated, or low initiative and persistence

• ADHD-PI presentation consists of children whose inattentive symptoms are linked to concerns with arousal and sluggish cognitive tempo (SCT)

Types of ADHD and associated symptoms: Combined presentation

• Describes children who meet symptom criteria for both inattention and hyperactivity–impulsivity.

  • Most often referred for treatment

Common comorbidities and associated adaptive impairments

ODD, CD, speech impairments, mood disorders, anxiety, health problems, tic disorder, accident proneness, risk taking behaviors, peer rejection

Common comorbidities

• ODD (35 - 70%)/CD (30-50%)

• Learning disorders (30-60%)

• Depression/Anxiety disorders (20-30%)

Associated adaptive impairments: Health-Related Concerns

• Poor motor coordination; serious health problems; poor sleep regulation

  • Bruises, burns, poisons, accidental injuries 

  • Restless sleep, bad effect on executive functioning

• higher rates of enuresis and encopresis

• Asthma

• dental health concerns

• poor fitness

• eating concerns/disorders

• sleep disturbances

  • Resistance to going to bed

  • difficulty falling asleep

  • fewer total hours asleep

  • involuntary sleep movements such as teeth grinding or restless sleep

  • obstructive sleep apnea

Associated adaptive impairments: Accident-Proneness and Risk Taking

• 3x more likely to experience serious accidental injuries, such as broken bones, lacerations, severe bruises, burns, poisonings, or head injuries

• Young adult drivers with ADHD are at higher risk than others for traffic accidents

• ADHD is a significant risk factor for the early initiation of cigarette smoking, substance-use disorders, Internet- and video game-use concerns and addictions, and risky sexual behaviors such as multiple partners and unprotected sex

• Impulsive behavior is the most significant childhood characteristic that predicts reduced life expectancy

Associated adaptive impairments: Peer difficulties

• Families of children with ADHD experience many difficulties, including interactions characterized by negativity, noncompliance by the child, excessive parental control, and sibling conflict

  • impaired social perception and understanding

  • lack of skill in correctly recognizing emotions in others 

  • lack of skill in in regulating their own emotions and behavior

  • aggressiveness that frequently accompanies ADHD often lead to social conflict and a negative reputation

  • Peer rejection

    • ADHD-C or HA/I peer dislike, high levels of emotion regulation, aggression, etc.

    • Understand social situations, but core problems interferes with that

IQ and achievement

• Score 5-9 lower on IQ tests → include subtests related to specific deficits of children with ADHD (e.g., working memory), their lower test scores are not surprising

• Inattention has been estimated to account for about a 2- to 5-point lowering of overall IQ-test scores in children with ADHD 

• Inattention at 7 years of age has been found to be the most consistent and strongest predictor of poor academic outcomes at age 16 years

• Frequently have lower productivity, grades, and scores on achievement tests

• Learning and achievement problems

  • Lower grades and test scores, higher placement in special education, higher dropout rates

Positive illusory bias

A person’s report of higher self-esteem than is warranted by his or her behavior. This exaggeration of one’s competence may, for example, cause a child with ADHD to perceive their relationships with their parents no differently than do control children, even though their parents see things in a more negative light.

Causes of ADHD

• Genetic influences

• Neurobiological influences (e.g. frontostriatal circuitry of the brain)

• Environmental influences (e.g., parental risk factors, diet)

Causes of ADHD: Family factors

• Family influences may lead to ADHD symptoms or to a greater severity of symptoms

  • Especially important is the goodness of fit, or the match between the child’s early temperament and the parent’s style of interaction

• Family concerns may result from interacting with a child who is impulsive and difficult to manage

• Family conflict or parental psychopathology is likely related to the presence, persistence, or later emergence of associated oppositional and conduct disorder symptoms

  • In children with an inherited biological risk for ADHD, family conflict or parental psychopathology such as maternal depression may heighten the emergence of early ODD and later comorbid ADHD and CD 

• ADHD has a strong biological basis and is an inherited condition for many children

General Course of ADHD: Infancy/toddlerhood

Temperment - Modest links, non-specific risk factor

General Course of ADHD: Preschool period

1. Core symptoms of hyperactivity and impulsivity are highly detectable

2. Due to rapid maturation of PFC across the preschool period, self-regulation difficulties are common

General Course of ADHD: Elementary School

1. Symptoms of inattention become particularly evident when the child starts school

2. This is when children are usually identified as having ADHD and referred for special assistance

3. Symptoms of inattention continue through grade school, resulting in low academic productivity, distractibility, poor organization, trouble meeting deadlines, and an inability to follow through on social promises or commitments to peers

4. Oppositional defiant behaviors may increase or develop.

General Course of ADHD: Adolescence

1. ADHD continues into adolescence for at least 50% or more of clinic-referred elementary school children

2. Most teens with ADHD continue to display significant impairments in their emotional, behavioral, and social functioning

General Course of ADHD: Adulthood

1. Some children with ADHD either outgrow their disorder or learn to cope with it, particularly those with mild ADHD and without conduct or oppositional concerns

2. Better outcomes are more likely for children whose symptoms are less severe and who receive good care, supervision, and support from their parents and teachers and who have access to economic and community resources, including educational, health, and mental health services

3. Adults with ADHD are restless, easily bored, and constantly seeking novelty and excitement; they may experience work difficulties, motor vehicle violations and accidents, impaired social relations, and suffer from depression, low self-concept, substance use, and personality disorder

4. Adults with a history of childhood ADHD are also at higher risk for antisocial involvement, arrests, convictions and incarcerations, and homelessness

Case of Robbie

3 yo, attention span of 20 second, and persistent sleep difficulties, violent temper tantrums, and constantly moving, high levels compared to peers his age, high stress in family ending in divorce, symptoms worsened then  → ADHD and ODD, poor social and academic development 

Case of Teddy

Difficult infant, hard to soothe, attentive and organized for his age, and increasingly positive course

Differences in Robbie and Teddy Case Studies

Family climate, teddy normal on tests, robbie was an extreme outlier in comparison to other 3 yo boys

Gender Differences

• Boys > girls: 2.5: 1; in clinic samples, 6:1

• Girls with ADHD

  • More likely than boys to have ADHD PI with very low levels of disruptive behavior

  • Detectability is lower, so less likely to be diagnosed 

Treatment: Stimulant medications

• Pros

  • Rapid effects and target under activated parts of the brian 

  • 75-80% improve in all core symptoms 

• Concerns

  • Normalize core symptoms in only about 50% of children → improvement in symptoms that don't span into the normal range of functioning

  • Modest effect on academic achievement

  • Some children do not respond to medications at all (20-25%)

  • No long-term effects of the medication 

  • Sleep problems, decreased appetite, stomach plains, growth suppression

• Maybes

  • Might increase risk for later substance use problem in adolescents (falsified)

  • Preschoolers concern, strongly advise non-drug treatment with preschoolers

Treatment: Parent Management Training

• Parent management training → Managing disruptive child behavior at home, reducing parent–child conflict, and promoting prosocial and self-regulating behaviors

• Parent management training (PMT) - A program aimed at teaching parents to cope effectively with their child’s difficult behavior and their own reactions to it.

• It provides parents with a variety of skills to help them:

  • manage their child’s oppositional and noncompliant behaviors;

  • cope with the emotional demands of raising a child with ADHD;

  • contain the problem so that it does not worsen; and

  • keep the problem from adversely affecting other family members.

• Education, management principles and techniques, increase active engagement with child, reduce levels of personal frustration

Treatment: Educational Interventions

• Educational intervention → Managing disruptive classroom behavior, improving academic performance, teaching prosocial and self-regulating behaviors

• Response-cost procedures - A technique for managing a subject’s behavior that involves the loss of reinforcers such as privileges, activities, points or tokens in response to inappropriate behavior.

• Techniques for managing classroom behavior are similar to those recommended to parents

• The teacher and child set realistic goals and objectives, set up a mutually agreed-upon reward system, carefully monitor performance, and reward the child for meeting goals

Multimodal Treatment Study of Children with ADHD: key findings

• Core Symptoms

  • After 14 months of treatment, medication only and combined > behavior only and community care

• Other outcomes related to positive functioning:

  • Combined treatment best

• 10-24 months of post-treatment:

  • Same pattern, effect weaker, but after 36 months, no significant treatment group differences

• Implications

  • Can successfully treat ADHD< but must monitor children and families for long periods of time

  • Intervention-prevention programs starting up, promising direction 

• (1) Stimulant medication was superior to behavioral treatment and to routine community care in treating the symptoms of ADHD

• (2) Combining behavioral treatments with medication resulted in no additional benefits for the core symptoms of ADHD overmedication alone, but it did provide modest benefits for non-ADHD symptoms and other outcomes related to positive functioning