ADHD

Question 1

Is ADHD real?

Answer 1

• argued that it is a product of Western culture, setting unrealistic expectations for kids, pharmacological companies profiting off medications
• but the prevalence of ADHD is similar worldwide
• the use of meds as Tx is 5x higher in North America
• ADHD predicts impairment in social, school settings, higher mortality

Question 2

inattention

Answer 2

• inability to sustain attention particularly for structured, repetitive, less-enjoyable tasks

Question 3

hyperactivity-impulsivity (HI)

Answer 3

• hyperactivity: inability to voluntarily inhibit dominant or ongoing bx
• impulsivity: inability to control immediate reactions or to think before acting

Question 4

ADHD DSM-5 criteria

Answer 4

(A) persistent (6 months) pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning (must be out of proportion to peers, cannot just be due to new demands of school/adjustment period)
(B) several symptoms were present before age 12 (neurodevelopmental disorder)
(C) several symptoms were present in two or more settings (genes will affect bx pervasively)
(D) clear evidence that symptoms interfere with/reduce the quality of social, academic, occupational functioning
(E) symptoms do not occur exclusively in the course of other disorders like schizophrenia

Question 5

ADHD inattention criteria

Answer 5

• six or more symptoms have persisted 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
• not solely due to oppositional behavior, defiance, hostility, or failure to understand tasks or instructions
• For older adolescents and adults (age 17 and older), only five symptoms are required
• fails to give close attention to details, makes careless mistakes
• has difficulty sustaining attention in tasks or play
• does not seem to listen when spoken to directly
• doesn’t follow through on instructions and fails to finish schoolwork, chores, duties
• difficulty organizing tasks and activities (managing sequential activities, keeping belongings in order, poor time management)
• avoids, dislikes engaging in tasks that require sustained mental effort
• loses things necessary for tasks/activities
• easily distracted by extraneous stimuli (for older teens, may include unrelated thoughts)
• forgetful in daily activities

Question 6

ADHD HI criteria

Answer 6

• 6 or more symptoms 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
• Sx aren’t a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions
• for older adolescents and adults (17 and older), only 5 symptoms are required
• fidgets with or taps hands or feet or squirms in seat
• leaves seat in situations when remaining seated is expected
• runs about or climbs in situations where it is inappropriate (in adolescents, may be limited to feeling restless)
• unable to play or engage in leisure activities quietly
• “on the go” or ‘driven by a motor’ (uncomfortable being still for too long, other people cannot keep up)
• talks excessively
• blurts out answers before a question has been completed
• difficulty waiting his or her turn
• interrupts or intrudes on others (doing things without permission, for adults - taking over what others are doing)

Question 7

ADHD specifiers

Answer 7

• ADHD-C (combined): both Criterion A1 (inattention) and Criterion A2 (hyperactivity–impulsivity) are met for the past 6 months
• ADHD-PI (predominantly inattentive): If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity–impulsivity) is not met for the past 6 months
• ADHD-HI (predominantly hyperactive–impulsive): Criterion A2 (hyperactivity–impulsivity) is met but Criterion A1 (inattention) is not met for the past 6 months
• ## “in partial remission”: full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning

Question 8

ADHD severity specifiers

Answer 8

• mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning
• moderate: Symptoms or functional impairment between “mild” and “severe” are present.
• severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning

Question 9

is ADHD categorical or dimensional

Answer 9

• DSM is categorical, but new research suggests it’s dimensional (sx present in everyone to varying degrees)
• using inattention vs. HI may be a simplification (attentional difficulties are highly related to impulsivity and vice versa)

Question 10

assessment of ADHD

Answer 10

• rating scales and interviews
• strong focus on observable signs of inattention/HI
• K-SADS semistructured interview
• SNAP-IV for parent/teacher report that maps closely onto symptomatology

Question 11

who reports on child ADHD

Answer 11

• parents
• teacher report is crucial (they have a normative framework = good idea of inter-individual variability)
• NOT kids: often unreliable and tend to under-report (also a lack of self-insight)
• categorization of ADHD depends on how information from reports are combined
• if you look at parent reports OR teacher reports on their own = more diagnoses of ADHD-PI or ADHD-HI, but if you combine them with the ‘or’ rule, you see more ADHD-C (different sx prevalent in different settings)

Question 12

heterogeneity in ADHD presentation

Answer 12

• many different presentations implies that there might be different causes of the disorder
• could imply that ADHD is actually multiple different disorders
• HI can evolve to become combined, can change to PI as you age (natural progression of context and presentation)
• most people go through all three subtypes - implying that ADHD is one disorder with different dimensions
• there is one subtype of ADHD-PI that never changes throughout life (will never exhibit HI sx)

Question 13

cognitive disengagement syndrome

Answer 13

• sluggish cognitive tempo
• subtype of ADHD-PI that never exhibit any HI sx (there are individuals for whom the correlation between inattention and HI is very low)
• CDS can be differentiated from ADHD based on a meta-analysis
• CDS sx are more correlated with each other than with ADHD sx (good reliability, test-retest, inter-rater)

Question 14

temperament profiles research in ADHD

Answer 14

• inspired by RDoc
• 3 different domains based on temperament/neurobiology: mild (near the mean on temperament and ADHD characteristics), Surgent (high positive affect), Irritable (high on fear/anger, discomfort)
• unresolved heterogeneity that may impair epidemiology - could use emotion-trait profiles to further differentiate between diverse presentations

Question 15

ADHD prevalence rates

Answer 15

• point: 5-9% in school-age
• 6-month: 10.5% of 4-11 years
• lifetime (adolescent sample): 8.7%
• most common type is combined, ‘and’ rule decreases combined type
• prevalence rates increase if using the ‘or’ rule

Question 16

epidemiology contextual differences in ADHD

Answer 16

• more common in low-SES communities
• racial differences unclear (minorities over-represented in low-SES)
• hyperactivity can be see as more problematic in certain cultures (especially where you value social harmony)

Question 17

epidemiology gender rates

Answer 17

• 3:1 favouring boys in community samples
• 6:1 favouring boys in clinic samples (boys get treated more, probably because their sx are more evident)
• in community samples, boys are more likely to be diagnosed with all types (but gender gap is more narrow for ADHD-PI)
• in clinic samples, the gender gap for subtypes disappears (girls equally likely to be diagnosed with all subtypes)

Question 18

developmental course of ADHD

Answer 18

• should be present at birth (but no reliable measures before age 3)
• in preschool, if sx persist for a year, they’re likely to have chronic challenges
• marked HI in preschool because cognitive and motor sx are developing
• elementary school, inattention becomes more noticeable, HI declines slightly through elementary (developing attentional processes, learning to conform to rules, but still higher than typical)

Question 19

prognosis for adulthood in ADHD

Answer 19

• used to be thought that sx resolved in adolescence
• about 33% of kids with ADHD continue to meet criteria in adulthood, the rest may just decrease to a subclinical threshold

Question 20

adulthood outcomes (Klein et al.)

Answer 20

• recruited probands with ADHD and comparison group - followed up at 41 years (probands differed from controls on SES and IQ)
• more likely to not finish high school
• less likely to have a graduate degree
• lower annual salary
• more likely to have been divorced
• more likely to be incarcerated
• more likely to be dead (likely due to attention/safety problems)

Question 21

correlates of ADHD

Answer 21

• associated with impaired academic functioning (intellectual ability isn’t lower, just difficulty expressing intelligence in academic setting)
• lower physical health, higher mortality
• social impairment (with family and peers), tend to have less friends (exacerbated by co-occurring ODD/CD)
• formal speech and language disorders: speaking impulsively, speech production errors, excessive loud talking, difficulties listening)

Question 22

comorbidity with ADHD

Answer 22

• CD and ODD are more prevalent (about 50% meet criteria for ODD), anxiety (25-50%), depression (20-30%) tic disorders (20%), learning disabilities
• earlier onset of ADHD = more likely to have ODD and CD

Question 23

heritability and environmental influences

Answer 23

• twin studies show about 75% heritability estimates
• environmental: factors that compromise the nervous system (maternal use of cigarettes, drugs)
• parents with ADHD have different parenting techniques, more chaotic home environment that is conducive to HI and inattention (passive GxE interaction)

Question 24

medication for ADHD Tx

Answer 24

• stimulants like dextroamphetamine (Dexedrine) and methylphenidate (Ritalin, Concerta)
• increase dopamine levels
• increase activity in the PFC
• fast-acting, but effects are temporary (when the drug is discontinued)
• side effects include weight loss (decreased appetite), slows in growth, increased heart rate, difficulty falling asleep
• can develop tolerance - often parents give kids ‘drug holidays’ when environmental demands are lower

Question 25

drawbacks of medications for ADHD

Answer 25

• may not help in 20% of cases
• won’t get rid of sx completely, just reducing severity
• may not help academic performance, peer relationships, family functioning in all kids
• benefits may not be maintained and will stop once the meds are discontinued
• tolerance is likely to occur, leading to reduced efficacy over time

Question 26

parent management training for ADHD

Answer 26

• contingency management: help parents establish clear expectations and set rules, giving positive reinforcement, predictable and consistent punishment
• not always as helpful as meds, but more likely to see long-term gains
• structuring environments in ways that are conducive to positive bx

Question 27

behavioural classroom management for ADHD

Answer 27

• contingency management in the classroom
• evidence for effectiveness

Question 28

behavioural peer interventions for ADHD

Answer 28

• social skills training done in clinic or office using discussion and role-playing are not generally successful (in group therapy settings, ADHD peers together is too distracting)
• but other programs targeting peer relationships in recreational settings (summer camps, sleep-away) that use contingency management techniques show significant improvement

Question 29

cognitive interventions for ADHD

Answer 29

• building skills to control attention and bx
• verbal self-instruction, problem-solving
• not enough evidence for benefits

Question 30

organizational skills training for ADHD

Answer 30

• focused on helping with academic achievement, reducing impairment
• implementing a prescriptive system to help with bx (stop forgetting things at school, keeping track of assignments)

Question 31

multimodal treatment of ADHD (MTA study)

Answer 31

• comparing outcomes for various tx (meds, bx, combined, treatment as usual)
• enrolled 579 kids with ADHD-C according to parent and teacher report (80% male, aged 7-9)
• random assignment to meds group, psychosocial tx (PMT, educational intervention, summer programs), combined meds + psychosocial, community treatment (TAU)
• from baseline to follow-up, all groups improved on core sx of ADHD
• only meds AND combined groups showed more improvement than psychosocial and TAU (only on core sx, not other areas of functioning)
• combined and psychosocial groups showed more improvement on parent-child conflict than TAU (combined was no different than medication group)
• combined and meds groups did not differ significantly from each other
• bx was only better than TAU for parent-child conflict, but not for core sx
• 8-year follow-up: no differences among any of the tx groups, but all doing better (still worse than a control group)

Question 32

MTA study moderators

Answer 32

• Tx group: meds/combined = 62% responders, TAU/Bx = 30% responders
• within meds/combined, parental depression high = 45% responded, parental depression low = 69% responders
• within parental depression low, severity high = 41%, severity low = 73% responders
• within parental depression high, severity high = 29%, severity low = 59%
• within parental depression high, severity high, IQ high = 48%, IQ low = 10%
• most important moderators for a bad prognosis were high parental depression, high severity, low cognitive abilities (IQ)
• most important moderators for a good prognosis were low parental depression, low severity