ecap ch 5

Chapter 5: Attention-Deficit/Hyperactivity Disorder (ADHD)



FOCUS AREAS

  • Changes to ADHD criteria for DSM-5

  • In which version of DSM-5 did ADD/ADHD first appear?

  • What are the two predominant symptom categories of ADHD?

  • In which chapter of DSM-5 is ADHD located?

  • Age-related specifiers for ADHD diagnosis

  • Examples of symptoms of inattention and hyperactivity-impulsivity

  • Common issues by age group: preschool, school-aged, adolescence

  • Gender pattern

  • Summarize the various etiological hypotheses related to ADHD

  • Common functional consequences and co-existing problems associated with ADHD

  • Noted situations in which signs of the disorder may be minimal or absent

  • Examples of main treatments for ADHD

  • Terms: behavioral inhibition, sustained attention, selective attention




  • “Restless and inattentive” associated with ADHD (1930-40s) → attributed minimal brain dysfunction (MDB) from brain trauma to the frontal lobe

  • MDB theory lost validity due to not enough evidence to support claims

  • DSM 2 categorized symptoms: overactivity, restlessness and inattention → hyperkinetic reaction of childhood

    • Reaction was controversy and debate → affected children passive inattentive symptoms with hyperactive and impulsive behavior in other kids

  • Third revision DSM (DSM 3) attempt made to address both versions replaced unified hyperkinetic relation of childhood → attention deficit disorder (ADD) + 

  • ADD has two subtypes

    • ADD with hyperactivity

    • ADD without hyperactivity

  • After revised disorder topic of debate (lack of research) = one single categorical domain = ADHD



Clinical description and associated features 

  • DSM 5 maintain concept from DSM 4 but subtypes disorder into symptoms based on:

    • Inattentive symptoms

    • Impulsive hyperactive symptoms 

  • People with disorder classified as meeting criteria for one of the three → based on degree child demonstrates 

    • Primarily inattentive presentation

    • Primarily hyperactive impulse presentation

    • Combined presentation 

  • Overfall changed minimally from DSM 4-5 

    • Symptoms evident prior to 12 years old (used to be 7) 

    • Only 5 symptoms required for 17 and younger (used to be 6)

  • Mainly only changed where it is located in DSM

  • Used to be in chapter on disorders (first diagnosed infancy, childhood, adolescence) 

  • Now relocated to neurodevelopmental disorders in DSM 5

  • DSM5 ADHD SYMPTOMS: inattentive presentation

    • Careless attention to details

    • Problems sustaining attention over time

    • Does not appear to listen 

    • Poor follow through (schoolwork, homework, chores)

    • Poorly organized

    • Poor ability to sustain mental attention (homework, independent seatwork at school)

    • Loses necessary materials (pencils, notebooks, assignment sheets, homework)

    • Easily distracted

    • Forgetful 

  • Require for diagnosis

    • 6 of the 9 symptoms

    • Symptoms prevalent across situations (2 or more settings)

    • Interfere with performance (social,academic,work)

    • Evident prior to 12 years of age

  • Late-onset inattention → may be trauma, anxiety, family challenges 

  • Symptoms only at school → maybe learning disability NOT adhd

DSM5 ADHD SYMPTOMS: hyperactive impulsive presentation

  • Requires 6 of 9 (under 17) 

  • Include 6 hyperactive and 3 impulsive 

  • Symptoms (hyperactivity)

    • Fidgety or squirmy behavior 

    • Problems remaining seated

    • Excessive motion

    • Problems engaging in quiet play

    • Constantly being on the go

    • Incessant talking

  • Symptoms (impulsivity) 

    • Blurts out answers, comments

    • Is impatient, has problems with turn taking

    • Is intrusive to others

Jeremy and leonard case example

  • Jeremy (4th grade)

    • Constant movement (walks on springs)

    • Interrupts, disrupts, blurts, talks non-stop

    • Obvious behavior → causes stress to teacher

  • Leonard (same class)

    • Opposite of jeremy → quiet, withdrawn, “daydreamer”

    • Doesn't participate unless topic interests him (he did really well at programming computers)

    • School performance low even though hes smart

    • Easily labeled as “slow learner” until the teacher sees his computer skills

  • Both of them have ADHD 

  • Symptoms present completely different

  • This is why ADHD is hard to define 

  • Still has ongoing controversy (ex: stimulant overprescribing) 

  • Jeremy demonstrated hyperactive impulsive presentation

  • Jeremy has hyperactive impulsive presentation

Combined presentation

  • Need to have predominantly inattentive + predominantly hyperactive presentation 

    • Children less than 17

      • Require at least 12 symptoms (6 from each!)

    • Children older than 17

      • Require a total of 10 symptoms (5 from each!)

  • Children with ADHD core features: overactivity, impulsivity, inattention impact learning and relationships → emphasized each stage of development

Early precursors to ADHD hyperactive-impulsive presentation

  • Hard to diagnose prior to 3 years of age

  • In infancy children with difficult temperament → higher risk to develop ADHD

  • Other risk factors

    • Excessive activity

    • Poor sleep patterns

    • Irritability

  • Parents report these infants difficult to soothe when upset compared to non-ADHD

Different developmental periods

  • Toddler (1-2.5 years)

    • Demonstrate higher levels underregulated behaviors

    • Ex: lack self control 

  • Preschool (3-6 years)

    • Lack of self control persists

    • Non ADHD peers demonstrate greater self control

    • ADHD kids described more demanding, stressful, problematic 

    • Especially during “free play”

  • School aged child (6-11 years)

    • Developmental task increasing sense of competence

    • ADHD: 

      • challenges in meeting increased academic and social demands

      • Academically vulnerable

    • AHD: hyperactive impulsive

      • Academic difficulties 

      • More children's impulsivity 

      • Inability to inhibit responses → may compete with effective learning

      • Learning issues to jump into tasks without listening to full directions

      • Sacrifices accuracy for speed

      • Low frustration tolerance

      • Tend to abandon tasks with no immediate solution 

      • greater risk for accidental injury

  • Adolescent (12-19 years)

    • At least half will continue meeting criteria through adolescence 

    • Poorly equi[ed to meet challenges managing curriculum (middle + highschool)

    • Poorly on increased workload and independent study skills

    • Poor work habits 

    • Lack of organizational skills

    • Poor follow through → result academic difficulties

    • Increased risk for driving accidents 

    • Risk for high risk behaviors: substance use higher in ADHD populations 

Prevalence and course 

  • Estimate ADHD 3-7% in school aged children

  • 90% diagnosed with ADHD will have hyperactive impulsive symptom presentation

  • Might mislead in terms of prevalence → more children with inattentive symptoms can be diagnosed

ADHD and gender

  • Ratio male to female frequency reported 2:1 to 9:1 

  • Current question: are there gender differences in the prevalence of ADHD (for subtypes) DEBATABLE TOPIC

  • Research suggest females with ADHD may be more impaired than males in areas: psychosocial functioning

    • Higher rates of depression, anxiety, self esteem, levels of stress

    • Might be possible 90% diagnosed demonstrate impulsive hyperactive or combined 

    • Female rates identification reflects presentation different types 

  • Children who have inattentive presentation more likely to be female 

  • Females twice as likely to have inattentive type 

  • Earliest age to diagnose ADHD 3 years old

    • Symptoms of inattention not noticed until years later

  • ⅔ of school age children diagnosed, have additional diagnosable disorder 

  • High rates comorbidity internalizing + externalizing disorders 

    • Make disorder more prone to poor outcomes 

    • Best understood in context of different developmental pathways→ differ on comorbid features 

  • Academic and learning problems 

    • Common in kids with ADHD → difficulties impulsivity, poor attention to detail, problems concentration

  • ADHD + specific learning disorders

    • Prevalence rates for comorbid ADHD + SLD(specific learning disability) hard to predict → wide variations how SLD defined + measured

    • Comorbidity rates estimated 16-21%

  • ADHD + internalizing problems 

    • Symptoms depressive disorder + bipolar present different children and adults

    • Children: symptoms depression + bipolar overlap with ADHD→diagnose difficult

    • Major symptoms in children: irritability

      • Often manifest to 

        • Restnessless

        • Agitation

        • Short attention span

        • Problems concentrating

        • Impulsive responses → resemble symptoms ADHD

    • Children with bipolar often experience cycles shifting moods

    • Bipolar symptoms: pressured speech (incessant talking) distractibility + overactivity → same as ADHD

    • Symptoms anxiety and restlessness → confused with ADHD

    • 70% of depressed children also have comorbid ADHD

    • 90% of younger (prepubertal) children and 30% adolescent referred bipolar comorbid ADHD

    • Higher rates comorbidity for overanxious disorder without ADHD

    • Many children who have ADHD → sleeping problems : staying asleep, falling asleep

  • ADHD and externalizing disorders

    • Children + adolescents comorbid adhd and disruptive behavior disorders (OCD and CD) more seriously maladjusted → worse outcomes compared to children ADHD alone

    • 35%-60% children with ADHD also ODD 

    • 50% children ADHD develop CD

    • Diagnosis ADHD in childhood strong predictor for substance use as family history of substance abuse

    • Hyperactive teens ADHD likely to use cigs and alc than non-hyperactive 

    • Higher levels of substance use (all substances) non ADHD peers

  • ADHD and social relationship problems 

    • Half children ADHD problems in relationships with peers

    • Significant discrepancy social skills and cognitive ability

    • Labeled subtype “socially disabled” (ADHD+SD)

    • Children with ADHD and SD higher levels substance abuse, family problems, mood problems, conduct problems

Etiology (causes)

  • ADHD most prevalent childhood disorders

  • Controversy remains exact CAUSE

  • Involves complex interaction biological and environmental factors 

Biological and neurological features 

  • Focused on 4 potential sources info:

    • Structural regions of brain

    • Genetic transmission

    • Neurotransmitter functions

    • Neurocognitive processing

  • Brain structures

    • With FMRI and SPECT brain scans revealed less activity in frontal brain region + more activity in cingulate gyrus → kids with ADHD vs without 

    • Frontal system responsible for executive function

    • Cingulate gyrus involved in directing response selection + attention

    • Three areas of executive functioning problematic for people with ADHD:

      • Working memory

      • Sense of time

      • Reductions of dopamine in the basal ganglia

    • Parietal lobe associated with governing sense of time

    • Problems with prospective memory (remembering to remember) result in poor follow through with tasks

  • Genetic transmission

    • 50% of children ADHD parents has it too

    • As much as 75% of etiology due to genetic factors

  • Neurotransmitters

    • Low levels of catecholamines (dopamine, norepinephrine, epinephrine) in kids with ADHD

    • Catecholamines associated with attention + motor activity

    • Medications for ADHD 

      • Ritalin, dexedrine, cylert  increase number of catecholamines in brain 

  • Neurocognitive processing

    • Increased interest examining executive functioning and arousal levels → how contributes to cognitive, emotional, behavioral processing

    • Executive functioning processes need to be flexible → shift focus between tasks → adapt strategies when needed

    • Ability to monitor, evaluate, and revise strategies important for problem solving

    • Task being able to hold info is using working memory

    • Increased self regulatory functions evident when toddlers transition to preschool

    • Good self esteem results internalizing good role models by parents, utilizing inner language → guides direct appropriate behavior and inhibits inappropriate responses

Barkley's model of ADHD

  • Focuses on understanding ADHD through executive functions

  • Model built around concept of behavioral inhibition 

  • Model developed specifically to address deficits in processing → apply to hyperactive-impulsive presentation

  • Emphasized model does not explain inattentive presentation

  • In model

    • Child's degree of success from four central executive functioning tasks

      • Working memory (tasks like sequential ordering/planning)

      • Self regulation (activity states to initiate goal directed behavior+sustaining effort)

      • Internalization of speech (slows down reactivity promoting inner reflection)

      • Reconstitution (analyzing and synthesizing info)

  • Deficits in behavioral inhibition → poor problem solving strategies

    • Inability to integrate and coordinate info generated by four central processes

  • Deficits in one area can result negative outcome in academic performance

  • ⅓ students with hyperactive-impulsive presentation failed to graduate HS, 21% enrolled in college

  • Addresses role of inattention in model between two forms

    • Sustained attention 

    • Selective attention

  • Children who have hyperactive version of ADHD problems sustaining attention over time

  • ADHD may be less noticeable in unfamiliar settings since they can focus on what they want (selective attention)

Assessment, treatment, intervention

  • Essential clinicians obtain accurate clinical picture of ADHD to rule out other diagnoses

  • Semistructured interview conducted with parents/caregivers to obtain info on developmental history

    • Birth history

    • Developmental milestones

    • Medical history

    • Educational history

    • Emotional and social history

    • Family dynamics

  • Important to obtain parental expectations and impressions of child presenting problem 

Behavioral rating scales for ADHD

  • Multiple for ADHD+other disorders

  • Parallel forms: parents, teachers, older children → allows cross informant comparison

  • 3 main scales

    • ASEBA 

    • Conners rating scales-3

    • BASC-2

  • ASEBA +CRS-3 both dimensional and categorical data

  • BASC-2 is dimensional data only

Executive function rating scales

  • Other scales measure executive functioning 

  • Brown ADD scales

  • Parent + teacher forms (ages 3-12)

  • Self report scale (8 years to adult)

  • Measures the following areas (EF)

    • Organization

    • Attention

    • Sustained effort 

    • Emotional regulation

    • Working memory

    • Monitoring

  • Integrates history and screens for comorbidity

Other areas of assessment

  • ADHD often = academic issues

  • IQ+ academic testing rules out intellectual disabilities 

  • Identifies the learning disorders

Treatment alternatives

  • Treatment varies by 

    • Comorbidity, symptoms, level of impairment

  • Settings:

    • Home → parent training, family work

    • School → behavior management, on task plans

    • Peers → social skills training

    • Most research → stimulant medication

Stimulant meds

  • MTA study found stimulants > behavior therapy (initially)

  • 6-8 year follow up: initial treatment does not predict later functioning

  • Best predictor: symptom trajectory + socio-demographics

  • Combined ADHD→ worst outcomes in adolescence 

  • Stimulants improve:

    • Attention

    • Behavior

    • Parent child interaction

    • Aggression output

    • Aggression reduction

  • Long term negative outcome: reduced height gain 

Behavior management + functional assessments

  • Meds alone are often insufficient

  • Need behavioral programs → especially for combined presentation

  • FBA (functional behavioral assessment) → guides specific behavior plans for individual

  • Parent training (PT)

    • Improves parenting → reduces stress

    • Decreases ADHD symptoms and noncompliance

    • Based upon contingency management

  • PT and teacher consultations = best outcomes 

  • Daily communication logs → monitors home and school behaviors 

  • Proven to be effected when both are combined


FOCUS AREAS

  • Changes to ADHD criteria for DSM-5

  • In which version of DSM-5 did ADD/ADHD first appear?

  • What are the two predominant symptom categories of ADHD?

  • In which chapter of DSM-5 is ADHD located?

  • Age-related specifiers for ADHD diagnosis

  • Examples of symptoms of inattention and hyperactivity-impulsivity

  • Common issues by age group: preschool, school