ADHD Flashcards

ADHD: Attention-Deficit/Hyperactivity Disorder

What is ADHD?

• ADHD is categorized as a neurodevelopmental disorder in the DSM-5.
• It is exhibited as persistent age-inappropriate symptoms of inattention, hyperactivity, and impulsivity, causing impairment in major life activities.
• The condition is pervasive and not context-specific.
• Characteristic behaviors vary among children, with some showing more inattention and others more hyperactivity-impulsivity.
• Key symptoms fall under two categories: Inattention and Hyperactivity-Impulsivity.

DSM-5 Diagnostic Criteria: ADHD

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, characterized by (1) and/or (2):

1. Inattention: Six or more symptoms must persist for at least 6 months, inconsistent with developmental level, negatively impacting social and academic/occupational activities.

   • The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions.

   • For individuals 17 and older, at least five symptoms are required.

   • Specific symptoms include:

     a) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

     b) Often has difficulty sustaining attention in tasks or play activities (e.g., difficulty remaining focused during lectures, conversations, or lengthy reading).

     c) Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

     d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

     e) Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

     f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

     g) Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

     h) Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

     i) Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

Inattention Details

• Inability to sustain attention, particularly for repetitive, structured, and less-enjoyable tasks.
• Deficits may be seen in one or more types of attention:
  • Selective attention: tuning in to relevant stimuli while tuning out irrelevant stimuli.
  • Distractibility: a deficit in selective attention; becoming easily distracted by external, irrelevant stimuli.
  • Sustained attention/vigilance (a core feature of ADHD): maintaining attention for lengthy periods of time, especially on tasks that are not interesting.
  • Alerting: initial response to a stimulus allowing for preparation for the task.

DSM-5 Diagnostic Criteria: ADHD contd…

2. Hyperactivity and Impulsivity: Six or more symptoms must persist for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities.

   • The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.

   • For older adolescents and adults (age 17 and older), at least five symptoms are required.

   • Specific symptoms include:

     a) Often fidgets with or taps hands or feet or squirms in seat.

     b) Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

     c) Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)

     d) Often unable to play or engage in leisure activities quietly.

     e) Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

     f) Often talks excessively.

     g) Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).

     h) Often has difficulty waiting his or her turn (e.g., while waiting in line).

     i) Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

Hyperactivity-Impulsivity Details

• 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.
• Impulsivity includes:
  • Inability to control immediate reactions or to think before acting.
  • Cognitive impulsivity includes disorganization, hurried thinking.
  • Behavioral impulsivity includes difficulty inhibiting behavioral responses when situations require it.
  • Emotional impulsivity includes impatience, low frustration tolerance, hot temper, quickness to anger, and irritability.

DSM-5 Diagnostic Criteria: ADHD contd…

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

ADHD Presentation Types

• Predominantly Inattentive Presentation (ADHD-PI): Meets diagnostic criteria for inattention (A1) but not hyperactivity-impulsivity (A2).
• Predominantly Hyperactive-Impulsive Presentation (ADHD-HI): Meets diagnostic criteria for hyperactivity-impulsivity (A2) but not inattention (A1).
• Combined Presentation (ADHD-C): Meets diagnostic criteria for both inattention (A1) and hyperactivity-impulsivity (A2).
  • Subtype specifiers for ADHD

Associated Characteristics

• Cognitive Deficits
• Speech & Language Impairments
• Medical & Physical Concerns
• Social Problems

Cognitive Deficits

• Executive Functions
  • Cognitive processes (e.g. working memory)
  • Language processes (e.g. self-directed speech)
  • Motor processes (e.g. response inhibition)
  • Emotional processes (e.g. emotion regulation)
• Intellectual Deficits
  • Most children with ADHD have at least normal intelligence—the difficulty lies in applying intelligence to everyday life situations
• Academic Functioning
  • Children with ADHD frequently have lower productivity, grades, and scores on achievement tests
• Specific Learning Disorder
  • Problem areas: reading, spelling, and math
• Distorted Self-perceptions
  • Positive illusory bias: exaggeration of one’s competence
  • Self-esteem in children with ADHD may vary with the subtype of ADHD

Speech and Language Impairments

• 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

Medical & Physical Conditions

• 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
• Accident-proneness, risk-taking, and impulsivity
  • 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

Social Problems

• 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
• 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
    • They may not interact properly with online social communication (i.e. Facebook)
  • Positive friendships may buffer negative outcomes

Accompanying Psychological Disorders and Symptoms

Oppositional Defiant Disorder & Conduct Disorder

• A common genetic contribution for ADHD, ODD, and CD
• Family connections - there is evidence for a contribution from a shared environment

Anxiety Disorders

• About 25-50% 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

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)

Developmental Coordination & Tic Disorders

• 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
• 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

Pregnancy, Birth & Early Development

• 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
  • Compromised fetal development may create a “malleable” state that increases the influence of a negative environment

Family-Related Factors

• 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

Treatment

Parent Management Training (PMT)

• 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
• Parents are:
  • Taught to understand biological basis of ADHD
  • Given a 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

Educational Interventions

• 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

Mock Test/Exam Question

There are three subtype specifiers that apply to ADHD. List the three subtype specifiers (write them out in full—do not use abbreviations) and explain how a psychologist would decide when each one applies (9 marks).

Mock Test/Exam Question: Model Answer

There are three subtype specifiers that apply to ADHD. List the three subtype specifiers (write them out in full—do not use abbreviations) and explain how a psychologist would decide when each one applies (9 marks).

Model Answer (1 mark for correctly naming the subtype; 2 marks for the correct, and complete, explanation):

1. Predominantly inattentive presentation (1 mark): Criterion A1 (inattention) is met (1 mark) but Criterion A2 (H-I) is not met (1 mark)
2. Predominantly hyperactive-impulsive presentation (1 mark): Criterion A2 (H-I) is met (1 mark), but Criterion A1(inattention) is not met (1 mark)
3. Combined presentation (1 mark): both criterion A1 inattention) and A2 (H-I) are met (2 marks)