ADHD Flashcards
Criteria
Persist pattern characterised by
● 6+/9 inattention symptoms (or 5+/9 if over 17)
● OR 6+/9 hyperactive/impulsive symptoms (or 5+/9 if over 17)
● several symptoms present before age 12
● several symptoms present in 2+ settings (e.g., home, school, work)
Inattention
- Seems not to listen when spoken to
- concentration
- sustained attention
- Initiating tasks
- following through
- forgetfulness
- loses things
- Careless mistakes
- Planning or organising
Hyperactivity
- Fidgetiness
- Restlessness (runs around for children)
- Trouble sitting in the seat
- Difficulty being still (driven by motor)
- Difficulty waiting turn
- Interrupts or intrudes on others
- Blurts out answers
- Difficulty playing/relaxing quietly
- Talkative
Differentials
Differentials:
● ODD, CD (violating others rights intentionally, or hostility developing following )
● SUD (highly comorbid)
● Anxiety, Trauma (inattention, restlessness)
● ID, SLD
● other neurodevelopmental disorders, incl. ASD
● ED, BPD, bipolar (impulsivity)
● BPD (common: impulsivity, relationship difficulties, ?sense of identity, ?trauma)
● Hearing and vision impairments
Causes/Aetiology
Overall
Genetic + envrionment >
brain abnormalities >
cognitive impairments >
learning and academic problems + behavioural symptoms
Genetic
.80-.85 heritiability
- 40-60% of parents with ADHD will have a child with the disorder. There is an added challenge of raising a child with ADHD when the parent has disorder
Neurobiological
- Brain size (smaller)
- Dysfunction in the prefrontal lobe
- Only meaningful in group comparisons
Neurochemical
- Dopmaine (more DAT receptors - dopamin uptakers - explains hyperactivity being active increases dopamine so they are hyperactive to increase dopamine)
- Seratonin
Cognitve and behavioural Theoriesl:
- Executive dysfunction: Deficits in “higher-order” cognitive processes (planning, sequencing, sustained attention, working memory)
Hot/ cold executive functioning –
hot (reward sensitivity and delayed gratification)
cool (skills used when emotion isn’t a factor - working memory and cognitive flexibility, inhibition)
Deficits in hot result in impulsivity/hyperactivity
Deficits in cool result in inattention, memory, inhibition
Delay aversion/reward motivation:
- sensitivity to re-
wards and an aversion to delay
As a result, they have difficulties in motivating themselves and performing well when rewards are unavailable or delayed (disruptions in the reward pathways of the brain)
- Motivational account of ADHD
- Inattention and hyperactivity are attempts to reduce experience of delay situations where delay cannot be avoided
Problem with self-regulation – inhibition and activation
- Hyperactivity= Inability to voluntarily inhibit dominant or ongoing behaviour
- Impulsivity=Inability to control immediate reactions or to think before acting
- Stroop test: Inhibition: the act of tuning out irrelevant stimuli
* Inhibition is considered an executive function
Environmental factors are not thought to cause, but may contribute to the expression, severity, course of ADHD and comorbid conditions
Environmental (if already genetic risk)
- Diet - lack zinc, iron, fatty acids
- Birth complications, Low birth weight
- Maternal depression, smoking, stress, unhealthy food (highly processed food increases externalising behaviours)
- Pesticides, toxins
Psychosocial
- Stress within family, parental psychopathology, trauma
- Do not cause
ADHD, - may lead to a greater severity
of symptoms
NOT SUGAR!!!! - doesn’t make you hypo
Assessment
- Interview - trauma hx, dev hx, medical hx eg accidents, their expectations (tik tok, stimulants etc)
- Dev hx with parent (risk factors eg genetics, maternal smoking, maternal poor nutrition, poor nutrition first few years of life, toxins)
- DIVA- structured diagnostic interview
- Frequency of symptoms typical (as experienced by most people sometimes)
- School observation
- Collateral info (school reports, Plunkett book)
- Developmental age (normal?)
- Poor time management and chronic forgetfulness contribute to prior existing problems
- Maladaptive core beliefs (I’m a failure)
- Compensatory strategies (avoidance and defensive anger – which maintain core beliefs)
psychometrics
CAARS: Conners Adult ADHD Rating Scales (T 65+)
Conner’s 3 (6-18 years - parent, teacher and self if 8+)
WEISS - impact on the functioning
Exec functioning inc memory - DKEFS, WAIS or WMS (not diag. but PS and WM deficits in some ppl - memory or attention/encoding affected?)
Saffron CB Model
Core impairments (eg inattention, inhibition, impulsivity)
lead to a Failure to utilise compensatory strategies (eg organising, planning, time management, procrastination, OR parents/teachers scaffolding) which leads to Functional Impairment.
lead to a History of; failure, underachievement and rela problems (failure to utlise compensatory strategies),
leading to Dysfunctional cognitions & beliefs (eg not living up to others expectations, I’m not good enough),
leading to Mood disturbance (depression, guilt, anxiety, anger).
Stimulants pro and con
PRO:
- Work - quickly - 70%
- Reduce inattention, productive, classroom conduct, peer relationships
- Stimulants superior to behavioural interventions: MTA trail 579 children 1999
- Atomoxetine: non-stimulant for someone with SUD
- meds have a lower rate of SUD (2x fold) and criminality 4 years follow up (not getting kicked out of school, fewer detentions, less time with antisocial peers)
CON:
- may not work after 3 years
- Eat/sleep side effects
- 4cm height loss, 7kg weight increase in long run
- 7% sell
- nervousness, cardiovascular concerns, no advantage in grades
- MEDS = work in the short term but not a cure
- Block “DAT” receptor so dopamine stays in the synapse for longer
- The brain adapts and has DAT – chronic use means going off stimulants will be bad due to having more uptake “dat” so less dopamine = feeling less good
NOTE:
- Note: Meds≠ confirmation of diagnosis
- If ADHD + anxiety = behavioural management NOT stimulants
NON STIM therapy
- meds + therapy = most effective
Family therapy
- Managing disruptive
behavior, reducing
parent-child conflict, self-
regulating behaviors
Educational intervention
- Managing disruptive classroom
behavior, improving academic
performance,
Group therapy
- normalising
CBT
- Psychoeducation - understand the brain and how to do things + NOT ALONE + demystify misconceptions
- Emotional regulation skills
- Work on beliefs and cognitions (lazy, dumb etc)
- Relationship difficulties
- Grief reaction for lost opportunities and on-going consequences
- Address avoidance
Work on comorbid: anxiety, depression
Mindfulness
- enhance self-regulation through 3 interacting processes: enhanced attention control, improved emotional regulation, and altered self-awareness
- not proven yet
DBT
- emotional regulation , impulse control
Skills
- Environmental engineering (eg hooks, filing system, calendars - repetition is essential)
- Planners - when doing something like drinking coffee make a habitual link
- chunking, putting off procrastination,
- Make time real (watch, timer etc)
- Notepad to attend to things later
- Physical breaks between
- Contingency management - not helpful if rewards long way away (break down into smaller futures bc poor delayed gratification)
- Accountability from others, work periods short, salient rewards,
- LIFE: eating, sleeping, drinking water etc
Reinforcers:
- Can use charts but need immediate rewards!
- Behavioural reinforcements need to be consistent across settings
Solanto et al: treatment
- 8-12 weeks skill-based: breaking down complex tasks, minimising distractions, prioritising effectively, visualization long-term reward, effective use of planners, breaking down tasks
- Overall, metacognitive/CBT therapy appears to help with attention but no improvement in hyperactivity
Mindefulness
- enhance self-regulation through 3 interacting processes: enhanced attention control, improved emotional regulation, and altered self-awareness
- evidence not great yet?
Group therapy
- “I’m not alone”
- Works
What is the integrated approach to treatment
- Integrated approach: distress-tolerance/impulse control (DBT) self-regulation, group therapy for normalising and acceptance, and organisational skills for academic, occupational and family functioning.
Process
- Minimize rambling and free-associating
- Consider audio taping for memory problems
- Consider note-taking as essential
- Developing tactics to increase the chance that an individual will implement into action what is discussed
- schedules, limiting distractions, providing environments for h/w
- rewards, non-punitive consequences (can’t be too far in future)
- finding activities the individual can excel in (e.g., sports, hobbies)
- limiting excessive scaffolding so indv. can develop skills, have early experiences of failure and chance to cope
- Prioritise goals and problem list
- Structure and introduce time management
- The therapeutic alliance is essential
- Keep the session focused
- Challenge core beliefs
- Assess readiness for change (MI?)
Prognosis
- With age, inattentive symptoms persist and hyperactive symptoms may decline
(but still more than others)
(may also be function of matching their environment)
– while symptoms can decrease overtime impairemnet doesn’t
cormorbidity
- Anxiety: difficulties with concentrating, irritability
- OCD: avoidance, not completing work, distractibility
- PTSD: hyperactivity, distractibility
- Bipolar: impulsivity, concentration, hyperactivity, racing thoughts
- Borderline Personality Disorder: Impulsivity
- Eating disorders: Eating can be done within the context of impulsivity (bulimia)
- Learning Disabilities: academic underachievement, important to look for both
