ADHD Flashcards
Three presentations of ADHD
Inattentive
ADHD-I
Combined
ADHD-C
Hyperactiveimpulsive
ADHD-HI
DSM inattention
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
● Often has trouble holding attention on tasks or play activities.
● Often does not seem to listen when spoken to directly.
● Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
● Often has trouble organizing tasks and activities.
● Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as
schoolwork or homework).
● Often loses things necessary for tasks and activities (e.g.
school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile telephones).
● Is often easily distracted
● Is often forgetful in daily activities
ADHD Hyperactivity and Impulsivity
Often fidgets with or taps hands or feet, or squirms in seat.
● Often leaves seat in situations when remaining seated is
expected.
● Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling
restless).
● Often unable to play or take part in leisure activities quietly.
● Is often “on the go” acting as if “driven by a motor”.
● Often talks excessively.
● Often blurts out an answer before a question has been completed.
● Often has trouble waiting their turn.
● Often interrupts or intrudes on others (e.g., butts into conversations or games)
ADHD in the DSM-5
Criteria based on age and conditions
Ages 16 and under > At least 6 symptoms for at least 6 months
- Ages 17+ > At least 5 symptoms for at least 6 months
Must meet the following conditions:
* Symptoms present before age 12
* Symptoms present in two or more settings
* Evidence that symptoms interfere with functioning
* Symptoms cannot be better explained by another disorder (e.g. anxiety)
ADHD in the DSM-5
Comorbidities:
- Oppositional defiant disorder (e.g. patterns of negative, hostile, disobedient,
behaviour) - Conduct disorder (e.g. uncaring of social norms, manipulation, aggression)
- Learning disabilities
- Depressive disorder
- Anxiety disorder
Diagnostic concerns
Inattentive ADHD-I
Harder to detect in early elementary school years
Age inappropriate difficulties with inattention are harder to identify early on
- Children are typically more inattentive
Diagnostic concerns
Hyperactiveimpulsive
ADHD-HI
Not separate from ADHD-C
- Could be an early form or developmental stage of ADHD-C
ADHD Diagnostic Concerns generally and contributing factors
Controversy about misdiagnosis and over-diagnosis of ADHD
* ADHD is one of the most common referral to clinical psychologists
Contributing factors?
* suggested that changes in the elementary curriculum explain increasing
referral rates
o emphasis on early literacy skills
o greater amount of academic curriculum
ADHD Impracticality of DSM-5 criteria: age requirements
Impracticality of DSM-5 criteria:
* the presence of symptoms before age 12 years
* the presence of symptoms for a period of at least 6 months
Pro: Ensures that ADHD is not a transient reaction to a stressor
Con: considered impractical by some
* difficulty that clinicians may experience in attempting to collect accurate data about the past 6 months
ADHD Diagnostic Concerns
Impracticality of DSM-5 criteria: multiple settings
the presence of symptoms in at least two different settings > cross
situational consistency
Pro: ensures consistency of impairment across environments
Con: Time of observations, demands of the setting, and level of structure differs across environments
- Need to observe and compare the behaviours taking into account the differences in
the settings - Modest degree of agreement among parents and teacher ratings > blend reports
from both sources and to count the number similarly endorsed symptoms
Blend reports from both - count symptoms endorsed across settings
impairment in one setting might be greater than impairment in other setting
ADHD Diagnostic Concerns
Impracticality of DSM-5 criteria: presence of number of symptoms
Presence of a certain number of symptoms:
* Ages 16 and under > At least 6 symptoms for at least 6 months
* Ages 17+ > At least 5 symptoms for at least 6 months
Using 6 or more symptoms to diagnose may be insensitive to sex bias
* Suggested that girls display fewer DSM symptoms and show less severe
symptom levels than boys
* Leads to higher number of false negatives among females
….perhaps cutoff scores should be adjusted to address the sex bias
Rates of diagnosis: ADHD
About 3-7% of the school-age population are diagnosed with ADHD
ADHD males vs females
Estimates of male-to-female ratios ranging from 2:1 to 9:1
Co-occurence ADHD
44% have at least one co-occurring disorder and 33% have two co-occurring disorders
*Learning disorders
* Oppositional defiant disorder
* Conduct disorder
* Depressive disorder
* Anxiety disorder
other concerns about inattention and hyperactivity/impulsivity
Inattention and hyperactivity/impulsivity could be
- a phase (related to developmental trajectory of the brain),
- a response to an environment (e.g. levels of stress), or even
- a side effect of another condition
Children with ADHD also show:
- Deficits in social, academic, and adaptive functioning
- Deficits in motivation
- Emotional deficits
- Neuropsychological deficits
- Deficits in motor control and coordination
- Deficits in self-regulation
- Low self-esteem, mood lability
- Behavioural problems: aggression, low frustration tolerance, temper outbursts
- Boys with ADHD – more aggressive and oppositional behaviours than girls
.demands a thorough and comprehensive assessment
etiology of ADHD
No single cause of ADHD – likely multiple factors
* Genetic (e.g. DRD4, DAT1, BDNF)
* Neurobiology
* Prenatal (e.g. prematurity, low birthweight, alcohol exposure, maternal health)
ADHD
Natural brain development
Why is this important for clinical assessment?
Studying the natural development of the brain provides insights into the
processes that lead to several deficits that a child might show (and grow out of)
Grey matter and white matter development (Sowell et al., 2003):
The brain is not yet done
developing in childhood.
Frontal regions develop
more slowly, which has
top-down control over
attention and impulsivity.
White matter volume development trajectory - rainbow
Gray matter volume- exponential decay - over connectivity in the brain
High variability of child brain development (Tamnes et al., 2017)
The inter-individual differences in development are large between children.
Concern about diagnosis of ADHD include medicating children who are still on the natural
developmental curve → medication might then impact the natural development
Neurobiology of ADHD
Brain regions
dysfunction in the FRONTAL LOBES
* similar impulsivity, impaired attention, etc. with frontal trauma
STRIATUM (caudate, putamen, and globus palidus)
* motor output
Neurobiology of ADHD
chemically
dopamine and norepinephrine
* stimulant medications
Assessing ADHD
Comprehensive assessment
- Presence of symptoms
- The number, type, severity, and duration of symptoms
- Situations in which the symptoms are displayed
- Verbal and nonverbal abilities
- Short and long-term memory abilities
- Presence of co-occurring disorders
- Social competence / adaptive behaviour
- Educational and instructional needs
steps in assessing ADHD
- Interviews
- Observations
- Rating scales
- Academic and intelligence testing
- Neuropsychological testing
steps in assessing ADHD
1. Interviews
Starting the assessment
* Initial interviews with the parents and teachers
PARENTS
* To what extent does the child present symptoms of inattention or hyperactivity
* Prenatal and postnatal developmental information
* Medical / social / academic histories
* Medications taken presently & previously
* View of the problem
* The pervasiveness of problems
* Parental styles
* Disciplinary techniques
* Environmental factors & resources available
- example of a structured interview KSADS-PL (Kiddie Schedule for
Affective Disorders and Schizophrenia)
TEACHERS
* When symptoms occur in class
* Specific behaviours that interfere with school functioning
* Severity of the symptoms
* Factors that worsen problem behaviours
* Academic strengths and weaknesses
* Social skills
The quality of the child’s peer relationship
Teachers can help identify how the child should behave according to age-similar peers
steps in assessing ADHD
2. Observations
Observations:
* Observations in multiple settings should be done
* Should be scheduled at different times
Clinician has a chance to observe:
* Antecedents and consequences of behaviours
* Intensity and duration of problem behaviours
* Factors that help sustain the behaviours
* Classroom structures
steps in assessing ADHD
3. Rating scales
- Rating scales
* Should include:
- Broadband rating scales
- Measures range of psychopathology
- Example: Swanson Nolan and Pelham (SNAP-IV)
- Detects: conduct disorder, dysthymic disorder, manic episodes, etc
- Narrowband rating scales
- Measures range and depth of specific disorder
- Example: Connors’ Parent and Teacher Rating Scales Revised (CPRS-R, CTRS-R)
- Parent, teacher, youth self-report versions
- Age range: 3-17 years
- Grade range: PreK-12
- Student version: age 12-17 years
- Subscales: Oppositional, Cognitive/Inattention, Hyperactivity-Impulsivity, Anxious-Shy,
Psychosomatic, Social Problems, Perfectionism - ADHD Index score
- DSM-IV Symptom Subscales (Inattentive, Hyperactive-Impulsive)
- Administered to parents and teachers
- Start with broadband scales first
- Can be used for differential diagnosis and assessment of comorbid features
- Facilitate the recollection of general information about child’s behaviours
- E.g. bed wetting, fidgeting in class
- Helps with detection of a wide range of psychopathology
steps in assessing ADHD
4. Academic and Intelligence testing
- Patterns of strengths and weaknesses revealed by intelligence tests are
useful in evaluating the child’s cognitive abilities and in treatment planning - NOTE: IQ tests are not sensitive enough for sole use in diagnosing ADHD
steps in assessing ADHD
5. Neuropsychological Testing
Attention = multidimensional construct
* Alertness
* Arousal
* Selectivity
* Sustained attention
* Distractibility
* Span of apprehension
Continuous Performance Test (CPT)
* most common laboratory cognitive test used to diagnose ADHD
* good level of sensitivity but poorer specificity
* 2 computer versions
