21 ADHD

Question 1

According to Hawes, is the main problem with ADHD one of over-diagnosis or misdiagnosis?

Answer 1

Misdiagnosis. The problem is not that children in the normal range are being diagnosed as ADHD, instead, kids with some other problem are being labelled ADHD.

Question 2

What is the prevalence of ADHD among children?

Answer 2

10-11%

Question 3

What two subtypes of ADHD appear to be borne out by the research of the past 20 years?

Answer 3

1. Inattention/disorganisation

2. Hyperactivity/impulsivity

Question 4

How do the two groups of symptoms of ADHD evolve over the lifespan?

Answer 4

Hyperactivity symptoms are more pronounced in preschool and decline over time.

Inattention symptoms are increasingly apparent with age.

Question 5

For what two reasons are inattention symptoms increasingly apparent with age?

Answer 5

1. Peers undergo rapid maturation of prefrontal cortex, while ADHD kids lag behind
2. School demands intensify

Question 6

What are the three presentations of ADHD in DSM-5?

Answer 6

1. Predominantly innattentive
2. Predominantly hyperactive/impulsive
3. Combined presentation

Question 7

Does evidence suggest that ADHD symptoms represent a discrete syndrome OR extreme standing on a normal-varying trait?

Answer 7

Evidence suggests that ADHD symptoms form a continuous dimension rather than a discrete taxon

Question 8

What is the comorbidity of ADHD with the other two externalising disorders?

Answer 8

50% with ODD

20% with CD

Question 9

What’s the male:female split for ADHD?

Answer 9

2:1

Question 10

ADHD has significant phenotypic overlap with which other externalising disorder?

Answer 10

ODD, particularly the hyperactive/impulsive features

Question 11

What two factors justify the classification of ADHD as a neurdevelopmental disorder?

Answer 11

1. It clusters with autism, motor coordination, reading/learning disabilities.
2. It’s associated with immaturities in neural development.

Question 12

What is believed to be the aetiology of ADHD, as opposed to that of ODD and CD?

Answer 12

Assumption is that core deficits of ADHD result from neurological development –rather than a conduct disorder, which is under environmental control.

Question 13

What are the A-D criteria of ADHD? (Without going into the symptoms)

Answer 13

A. Several symptoms (6 for kids; 5 for adults) must be present.
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several symptoms present in two or more settings (e.g., home/ school/work; friends/relatives; other activities)
D. Clear evidence that the symptoms interfere with social, academic, or occupational functioning.

Question 14

In what 4 ways might DSM-5 criteria for ADHD underidentify adults?

Answer 14

1. Some symptoms are inapplicable to adults (e.g. climbs on things)
2. Cut-off point of 5 symptoms may under-identify adults
3. Features that cause impairment in adults may differ from those that cause impairment in children
4. Adults may select lifestyles in which deficits have less impact, i.e. artists, not accountants

Question 15

Why is the diagnosis of ADHD in the likes of Richard Branson and Paris Hilton questionable?

Answer 15

ADHD is a disorder. It implies impairment.

Question 16

What are the 9 symptoms in the Inattention presentation of ADHD?

Answer 16

a. Often fails to give close attention to details or makes careless mistakes in schoolwork / work/other activities
b. Often has difficulty sustaining attention in tasks/play activities
c. Often does not seem to listen when spoken to directly
d. Often does not follow through on instructions; fails to finish schoolwork / chores/work duties
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (for adolescents/adults: preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities
h. Often easily distracted by extraneous stimuli (for adolescents/adults: may include unrelated thoughts).
i. Often forgetful in daily activities (for adolescents/adults: returning calls, paying bills, keeping appointments).

Question 17

What are the 9 symptoms in the Hyperactivity/Impulsivity presentation of ADHD?

Answer 17

a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected
c. Often runs about or climbs in situations where it is inappropriate. (In adolescents/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”
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed
h. Often has difficulty waiting his or her turn
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; for adolescents/adults, may intrude into or take over what others are doing).

Question 18

On the evidence of twin/adoption studies, what is the heritability coefficient of ADHD?

Answer 18

.7

Question 19

What chemicals have been associated with ADHD?

Answer 19

Pesticides
Prenatal nicotine
Lead

Question 20

What dietary factor has been demonstrated to be a trigger of ADHD?

Answer 20

Around 8% of ADHD kids are triggered by synthetic food colours

Question 21

What were the two key findings in the Hawes et al. (2013) study of parental practices as predictors of ADHD features?

Answer 21

1. High levels of parental involvement was associated with reduced hyperactivity/inattention across early childhood, but increased hyperactivity/inattention in late childhood. Interaction effect.
2. Increases in child age associated with increased hyperactivity / inattention across middle childhood, but only among children exposed to high levels of inconsistent discipline. With low levels of inconsistent discipline, older kids better behaved. Interaction effect.

Question 22

What 2 pieces of evidence are there that ADHD symptoms may elicit negative parenting styles?

Answer 22

1. Treatment with psychostimulants caused an increase in parenting quality (Schachar et al. 1987)
2. High levels of child hyperactivity uniquely predict:
   - decreased levels of parental involvement 12 months later
   - increased problems with monitoring/supervision
   - increased corporal punishment (Hawes et al. 2011)

Question 23

What are the three types of gene-environment correlation?

Answer 23

(i) Passive gene-environment correlation.
The association between the genotype a child inherits from her parents and the environment in which the child is raised. E.g. Parents create a home environment that is influenced by their own heritable characteristics. Biological parents also pass on genetic material to their children. When the children’s genotype also influences their behavioral or cognitive outcomes, the result can be a spurious relationship between environment and outcome. For example, because parents who have histories of antisocial behavior (which is moderately heritable) are at elevated risk of abusing their children, a case can be made for saying that maltreatment may be a marker for genetic risk that parents transmit to children rather than a causal risk factor for children’s conduct problems.

(ii) Evocative (or reactive) gene-environment correlation
This happens when an individual’s (heritable) behavior evokes an environmental response. For example, the association between marital conflict and depression may reflect the tensions that arise when engaging with a depressed spouse, rather than a causal effect of marital conflict on risk for depression.

(iii) Active gene-environment correlation
When an individual possesses a heritable propensity to select environmental exposure. For example, individuals who are characteristically extroverted may seek out very different social environments than those who are shy and withdrawn.

Question 24

What two types of gene-environment correlation might explain the link between ADHD and poor parenting?

Answer 24

Evocative rGE: The child’s genetic characteristics evoke negative responses from parents
Passive rGE: The same genes that underlie ADHD in the child underlie parenting problems in the parents

Question 25

What link did Harold et al. (2013) find between a child’s genetic vulnerability to ADHD and parental hostility? And how might that parental hostility affect the child?

Answer 25

Adoption-at-birth study shows indirect association between ADHD symptoms of birth mother and hostility of adoptive mother, via child impulsivity. (Harold et al., 2013)

The child’s genes make environment more negative. But the negative environment –hostile parenting –also makes the condition more likely, over and above the child’s genetic vulnerability to ADHD.

Question 26

The association between inconsistent parenting and ADHD symptoms is stronger for those with which genetic variation?

Answer 26

For those with the long allele of the Dopamine receptor DRD4 gene.

Question 27

What are the two pathways in the Dual Pathway Model of ADHD (Sonuga-Barke, 2005)?

Answer 27

1. Deficits in inhibitory-based executive processes
   Failure of response inhibition: the ability to inhibit an inappropriate prepotent or ongoing response in favour of a more appropriate alternative.
2. Motivational dysfunction involving disruptive signaling of delayed reward
   ADHD arises from neurobiologic impairment in the power and efficiency with which the contingency between present action and future rewards is signalled.

Question 28

In Sonuga-Barke’s (2005) Dual Pathway Model of ADHD, what is the delay aversion hypothesis?

Answer 28

Child experiences failure, and negative emotion, in situations where gratification must be delayed. Negative emotion becomes associated with cues of the situation when delayed gratification is necessary. So ADHD behaviours may be strategy to cope with negative emotion by:

1. attending to most interesting/absorbing aspects of the environment
2. acting on that environment hyperactively

Question 29

How can delay aversion be amplified?

Answer 29

1. Hyperactive behaviour may elicit negative responses from parents/caregivers
   The child thus avoids delay, and does not learn to develop skills to manage delay effectively
2. Inconsistent parenting: if rewards are promised but not delivered as predicted, delay may come to signal uncertainty/disappointment

Question 30

In Sonuga-Barke’s (2005) Dual Pathway Model of ADHD, in which way might the two pathways contribute differentially to the two core dimensions of ADHD?

Answer 30

1. INATTENTION-DISORGANISATION
   Reflects breakdowns in top-down control mechanisms of executive functioning (anchored in a frontal striatal circuit)
2. HYPERACTIVITY & IMPULSIVITY
   Reflects breakdowns in bottom-up signaling, perhaps involving reactive control/motivational response processes (anchored in frontal-limbic circuitry).

Question 31

According to NHMRC guidelines, who should diagnose ADHD?

Answer 31

Diagnosis should only be formulated following assessment by a specialist clinician. i.e. not by a GP or non-specialist psychologist

Question 32

What 4 factors should be assessed for a comprehensive ADHD diagnosis?

Answer 32

1. physical examination
2. assessment of family
3. social and educational circumstances
4. coexisting conditions

Question 33

Can young children (under 7 years) be diagnosed with ADHD ?

Answer 33

Yes, BUT… Significant caution is needed as can be difficult to distinguish impairment from normal expectations in this period.
Diagnosis may not be reliable until child has had at least one year in school which allows time to assess how they manage the transition into school and settle into this new environment.

Question 34

What treatments for ADHD are NOT supported by current evidence (according to the NHMRC)?

Answer 34

Elimination or restriction diets
Diet supplementation; essential fatty acids (e.g. fish oils) Chiropractic treatment
Behavioural optometry 
Biofeedback (including neurofeedback)
Homeopathy 
Acupuncture 
Physical activity 
Massage
Sensory integration therapies

Question 35

How do child-focussed treatments such as CBT work for ADHD?

Answer 35

They don’t. Given that the core deficits of ADHD are inattention and disorganisation, it’s unrealistic to expect child to be able to apply cognitive self-talk strategies to themselves effectively.

Question 36

What are 2 ‘well-established’ interventions for treatment of ADHD?

Answer 36

1. Behavioural parent training (or family therapy based on social learning theory)
2. Behaviour modification in classroom

Question 37

What is the problem with context-targeted interventions such as intensive classroom behavioural programs?

Answer 37

They can have strong effects, but don’t generalise to other settings.

Question 38

What were the results of the 14 month Multimodal Treatment Study of Children (1999) with ADHD, comparing stimulant medication with psychosocial intervention (>35 sessions of parent-training + regular teacher consultations + 8-week behavioural bootcamp)?

Answer 38

Medication superior on measures of ADHD symptoms & related disruptive behaviours

Question 39

On the evidence of the 1999 Multimodal Treatment Study is it worth combining medication and behavioural intervention?

Answer 39

Combination overall not significantly superior to medication alone, but significant for some MTA outcome variables:

• Overall clinical improvement
• Decreased comorbid symptoms (e.g. aggression)
• Academic improvement
• Parent-child relationship
• Social skills

Question 40

What is the only intervention that appears to act on the core features of the disorder?

Answer 40

Only stimulant medication.

Question 41

What are two caveats to the use of stimulant medication in kids?

Answer 41

• Individual differences in response to stimulants are vast

- Side effects may preclude use