ADHD

attention-deficit/hyperactivity disorder (ADHD)

describes children who display persistent age-inappropriate symptoms of inattention, hyperactivity, and impassivity that are sufficient to cause impairment in major life activities

inattentive

lacking the ability to focus or sustain one's attention. children who are inattentive find it difficult to sustain mental effort during work or play and behave carelessly, as if they are not listening

hyperactive

displaying an unusually high level of energy and an inability to remain still or quiet

impulsive

prone to acting with little or no consideration of possible consequences. this term is frequently used to describe children who suffer from ADHD

what are the primary symptoms/key elements of ADHD?

inattentiveness (IA), and hyperactivity-impulsivity (HI)

Why doesn't increased efforts and stricter rules help children with ADHD?

because most children are already trying hard; they want to do well but are thwarted by their limited control

What are the core symptoms/features of ADHD?

- age-inappropriate inattention, and/or hyperactivity/impulsivity

- problems with sustained attention/focusing

- problems controlling one's behaviour

- absence of care when performing a cognitive act

In order to be diagnosed with ADHD, does the child have to have both hyperactivity and inattention?

No, they both don't need to be present, at least one does.

What is the estimated average cost of ADHD treatment in the US?

$32 billion a year, about $11,000 per child

When and how was ADHD first described?

It was first described in 1902, by George Still who believed that ADHD arose out of poor inhibitory volition and defective moral control

How was ADHD described in 1917-1926?

Because of a flu epidemic, children stared to show behavioral problems (due to brain swelling) of irritability, impaired attention, and hyperactivity, so ADHD became know as brain injured child syndrome (associated with mental retardation)

What was ADHD referred to in the 1940s-1950s?

Minimal brain damage and minimal brain dysfunction (MBD)

in the late 1950s what was ADHD referred to?

Hyperkinesis, which was attributed to the poor filtering of stimuli entering the brain.

What was ADHD referred to after hyperkinesis?

hyperactive child syndrome as motor activity was then considered the main feature of ADHD

how was ADHD defined in the late 1970s?

it was argued that in addition to hyperactivity, deficits in attention and impulse control were also primary symptoms of ADHD; this helped define the DSM criteria

what has recently been emphasized as the central impairments of ADHD?

- poor self-regulation

- difficulty in inhibiting behavior

- motivational deficits

how can ADHD be identified in children? (not talking about symptoms)

only by characteristic patterns of behavior which vary quite a bit from child to child

what the first three symptoms, listed in the DSM-IV, that a child can have under inattention for at least 6 months so that they would qualify as having ADHD?

a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

b) often has difficulty sustaining attention in tasks or play activities

c) often does not seem to listen when spoken to directly

What are the fourth, fifth, and sixth symptoms, listed in the DSM-IV, that a child can have under inattention for at least 6 months so that they would qualify as having ADHD?

d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to to understand instructions)

e) often has difficulty organizing tasks and activities

f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental efforts (i.e., schoolwork)

What are the seventh, eighth, and ninth symptoms, listed in the DSM-IV, that a child can have under inattention for at least 6 months so that they would qualify as having ADHD?

g) often loses things necessary for tasks or activities (i.e., toys, school assignments, pencils, books,)

h) is often easily distracted by extraneous stimuli

i) is often forgetful in daily activities

What are the first three symptoms, listed in the DSM-IV, that a child can have under hyperactivity-impulsivity for at least 6 months so that they would qualify as having ADHD?

a) often fidgets with hands or feet or squirms in seat

b) often leaves seat in classroom or in other situations in which remaining seated is expected

c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to feelings of subjective feelings of restlessness)

what are the fourth, fifth, and sixth symptoms, listed in the DSM-IV, that a child can have under hyperactivity-impulsivity (hyperactivity) for at least 6 months so that they would qualify as having ADHD?

d) often has difficulty playing or engaging in leisure activities quietly

e) is often "on the go" or often acts as if "driven by a motor"

f) often talks excessively

what the seventh, eighth, and nineth symptoms, listed in the DSM-IV, that a child can have under hyperactivity-impulsivity (impulsivity) for at least 6 months so that they would qualify as having ADHD?

g) often blurts our answers before questions have been completed

h) often has difficulty awaiting turn

i) often interrupts or intrudes on others (i.e,. butts into conversations or games)

what are some of the limitations of the DSM-IV for ADHD?

1. categorical view (present or not present); research supports dimensionality

2. failure to adjust the number of required symptoms for either age or level of maturity (developmentally insensitive)

3. the required age of 7, as the age of onset, may be too young

4. symptoms must persist for 6 months may be misleading for very young children (too short)

5. symptoms must be demonstrated across at least two environments, may add equivocation (ambiguity) to the diagnosis (conflicting information; blending is better)

what are the common complaints of ADHD (inattention)?

- the child doesn't or won't listen, follow instructions, or finish chores or assignments

according to lecture what types of things fall under inattention (IA)?

- problems with concentration; easily distracted

- not listening

- forgetful and disorganized

- the child fails to complete assignments; difficulty persevering with tasks

what is the primary attentional deficit in ADHD?

sustained attention (i.e, persistence, vigilance)

attentional capacity

the amount of information we can remember an attend to for a short time; children with ADHD are capable of remembering the same amount of information for a short time as other children

selective attention

the ability to concentrate on relevant stimuli and not be distracted by noise in the environment (i.e., when studying for a test (relevant stimuli) how easily are you distracted by voices in a room?)

distractibility

a common term for a deficit in selective attention; children who have ADHD are much more likely to be distracted by stimuli that are highly salient and appealing

sustained attention

vigilance; is the ability to maintain a persistent focus over time or when fatigued

what do children with ADHD work best on?

They work best on self-paced tasks that they have chosen and on tasks that they find especially interesting that do not require them to sustain their attention.

What suggests that children with ADHD may have trouble in alerting and preparation?

The fact that these children may show performance deficits from the very beginning of a task, not just a decrement over time.

alerting

an initial reaction to a stimulus, and involves the ability to prepare for what is about to happen

How may a child with an alerting affect respond to situations?

They respond too quickly in situations requiring a slow and careful approach and too slowly in situations requiring a quick response

Why is it best to view hyperactivity-impusivity as one dimension?

Because when children display one symptom, they usually display the other as well.

what is the main problem in ADHD?

it seems to be one of controlling motor behavior

What sets children with hyperactivity-impulsivity apart from active children?

Unlike other children with a high energy level, children who have hyperactivity-impulsivity tend to accomplish very little (they aren't goal-directed)

According to the lecture, what types of things fall under hyperactivity-impulsivity (HI)?

- Inhibiting inappropriate behaviors and self regulation

According to the lecture, what constitutes hyperactive behavior?

- Excessively energetic behavior that is not goal directed

- Constant fidgeting, difficulty staying seated, constantly moving, excessive talking

According to the lecture, what constitutes impulsive behaviors?

- Difficulty waiting ones turn

- Inability to resist immediate gratification

According to the lecture, which symptoms of the main three found in ADHD emerge first?

hyperactivity-impulsivity emerges before inattention

what have studies show of sleeping ADHD children?

Even when asleep, children with ADHD display more motor activity than other children.

What is the largest difference found in children with ADHD?

When a child with ADHD is in a situation that requires the child to inhibit motor activity, you can see the most difference.

What is hard for children with impusivity?

- They have trouble stopping ongoing behaviour or to regulate their behavior in accordance with the demands of the situation or the wishes of others (i.e., blurting out answers whether right or wrong)

- They have difficulties resisting immediate temptations and delaying gratification

cognitive impusivity

reflected in disorganization, hurried thinking, and the need for supervision

behavioral impusivity

have difficulty inhibiting their response when the situation requires it; includes calling out in class or acting without considering the consequences

what are the two categories of impusivity?

cognitive impulsivity and behavioral impusivity

what are cognitive and behavioral impusivity predictors of?

problems with academic achievement, particularly in reading

what does only behavioral impulsivity predict?

rule-breaking behavior and thus may be a specific sign of increased risk for conduct problems

what are the subtypes of ADHD?

1) ADHD-PI (primarily inattentive)

2) ADHD-HI (primarily hyperactive-impulsive)

3) ADHD-C (combination of PI and HI)

What is the least common subtype of ADHD?

ADHD-HI

What characterizes ADHD-PI?

• Slow cognitive processing speed;

• daydreamers;

• drowsy;

• spacy;

• in a fog;

• easily confused

what is ADHD-HI and C associated with?

• Aggressiveness

• Defiance

• Peer rejection

• School suspensions

• Placement in special education classes

What is suggested about ADHD-PI compared to HI and C?

It has been suggested that ADHD-PI may be a completely separate disorder

What do children with ADHD-PI often have?

They often have a co-morbid disorder - an anxiety and/or mood disorder

subtype

a group of individuals with something in common - symptoms, etiology, problem severity, or likely outcome- something that makes them distinct from other groupings

What are children with ADHD-PI normally seen as having?

a learning disability, processing information slowly, find it hard to remember things, and display low academic achievement.

how are children with ADHD-PI normally rated?

as anxious and apprehensive, socially withdrawn, and may display mood disorders; about half of these children do not manifest the disorder until after age 7

of the three subcategories of ADHD which child is the most likely to be referred for treatment?

the child with ADHD-C

Which of the subgroups for ADHD is the rarest?

ADHD-HI

Who is primarily included in the ADHD-HI group?

Preschoolers; may have limited value for older children

To diagnose ADHD using the DSM, the behaviors must also:

- appear before age 7

- occur more often and with greater severity than in other children the same age and sex

- continue for more than 6 months

- occur across several settings (i.e., home and school)

- produce significant impairments in the child's social or academic performance

What can mimic the symptoms of ADHD?

Illnesses, accidents, middle ear infections, mild seizures, chronic abuse, or stressful life events (i.e., a major move)

what must be done before a diagnosis of ADHD can be done?

a through assessment that includes a developmental history, parent and teacher reports, normed assessment instruments, and behavioral observations

Why is it important to assess both symptoms and impairment functioning for ADHD?

Because a child can display ADHD symptoms without necessarily displaying significant impairment, or a child may display subclinical levels of ADHD symptoms but still suffer significant maladjustment

Who are more accurate raters of ADHD?

Teachers more so then parents

what cognitive defects do children with ADHD display?

executive function defects, intellectual deficts, impaired academic functioning, learning disorders, and distorted self-perception

Executive functions

The cognitive processes in the brain that activate, integrate, and manage other brain functions; they underlie a child's capacity for self-regulation, such as self-awareness, planning, self-monitoring, and self-evaluation.

What are the processes of executive functioning?

Cognitive processes, language processes, motor processes, and emotional processes

Cognitive processes

• Working memory

• Mental computation

• Planning and anticipation

• Flexibility of thinking

• The use of organizational strategies

Language processes

Such as verbal fluency, communication, and the use of self-directed speech

Motor processes

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

Emotional processes

Such as self-regulation of arousal level, tolerating frustration, and mature moral reasoning

which categories do children and adolescents with ADHD consistently show deficits in?

in one or more executive functions, especially response inhibition, vigilance, working memory, and planning

What are the types of impaired executive functions found in children with ADHD?

- Organize, prioritize, and activate

- Focus, shift and sustain attention

- Regulate alertness, effort and processing speed

- Manage frustration and modulate emotions

- Working memory and accessing recall

- Monitor and regulate actions

What intellectual deficits do children with ADHD tend to have?

They have trouble applying their intelligence to everyday life situations

How many ADHD children often qualify for a learning disorder by late childhood?

80%

What do children with ADHD normally struggle with in school?

Reading, spelling, and math

Positive illusory bias

An exaggeration of one's competence

Approx. how many children with ADHD also have a speech and language impairment?

30-60%

What type of sleep disturbances are common in children with ADHD?

- Resistance to going to bed

- Difficulty falling asleep

- Fewer total hours of sleep

- Involuntary sleep movements (i.e., teeth grinding/ restless sleep)

Developmental Coordination Disorder (DCD)

A condition characterized by marked motor incoordination (i.e., clumsiness and delays in achieving motor milestones); overlaps with ADHD

Tic disorders

Sudden, repetitive, nonrhythmic motor movements or sounds such as eye blinking, facial grimacing, throat clearing, and grunting; about 20% of children with ADHD also have this

What is ADHD a significant risk factor for?

- Cigarette smoking

- Substance abuse

- Risky sexual behaviors

What is the most common comorbid disorder for ADHD?

OOD/CD (oppositional defiant disorder/conduct disorder)

What are girls with ADHD versus girls without ADHD more likely to have?

Conduct, mood, or anxiety disorders

What are the typical speech and language problems children with ADHD have?

- Excessively loud

- Frequent topic shifts

- Interruptions

- An absence of clear connecting links in their conversation

In children with ADHD, those who experience the most severe social disability are at greatest risk for what?

For poor adolescent outcomes and other disorders such as depression and conduct disorder

Why are children with ADHD constantly rejected by peers?

These children do not play by the same rules as others and don't seem to learn from past mistakes, despite their awareness of expected social behaviors and desire to conform to them; blunders appear more thoughtless than intentional

What is normally experienced by the parents of children with ADHD?

Mothers = Depression

Fathers = Anti-social behaviors (i.e., Substance abuse)

What is conflict like at home (ADHD)?

Conflict between children and their mothers is severe during the preschool years and continues into childhood and adolescence; conflict with fathers is less frequent but still greater then other children and fathers

What do families with ADHD children report?

More mental health problems, greater parenting stress and less parenting competence, fewer contacts with extended family members, greater caregiver strain, less instrumental support, and slightly higher rates of marital conflict, separation, and divorce; increased alcohol consumption

What percentage of children with ADHD develop CD?

30-50%

What have longitudinal studies found about the relationship of ADHD, CD, and ODD?

They have found the ADHD leads to CD and ODD

what does a diagnosis of bipolar in young children do in regards to ADHD?

sharply increases the child's risk for previous or co-occuring ADHD; but the reverse isn't seen

about what percentage of children with ADHD experience excessive anxiety?

25%

about what percentage of children with ADHD experience depression of a mood disorder ?

20-30%

what is the gender difference found in ADHD?

2-4% in girls and 6-9% in boys

What symptoms are girls with ADHD more likely to express?

Inattentiveness/disorganization symptoms; They are also more likely to be hyperverbal then hyperactive.