ADHD Flashcards
Is ADHD Real?
Many have argued that ADHD is a product of Western Culture, unrealistic expectations concerning children’s behaviour, or the pharmaceutical industry. But the province is similar worldwide, use of mediation to treat ADHD is5x higher in N.American than rest of world, and the presence of ADHD is associated with marked impairment.
Core Characteristics of ADHD
Inattention: Inability to sustain attention, particularly for repetitive, structured, and less-enjoyable tasks.
Hyperactivity/Impulsivity: Hyperactivity - Inability to voluntarily inhibit dominant or ongoing behaviour. Impulsivity - inability to control immediate reactions or to think before acting.
DSM-5 Criteria - Inattention
You need to have at least 6 inattentive symptoms, and 5 or fewer hyperactive/impulsive symptoms.
DSM-5 Criteria - Hyperactivity/Impulsivity
6 or more hyperactivity/impulsivity symptoms, and 5 or fewer inattentive symptoms.
DSM-5 Criteria - Combined
At east 6 inattentive and 6 hyperactive symptoms. Age 17 and older: cut off moves down and becomes 5 and 5.
DSM-5 Criteria - Additional Criteria
Symptoms continue for more than 6 months. Persistence, impairment, and non-normative. Several symptoms were present prior to age 12. Several symptoms are present in at least 2 settings.
DSM-5 Diagnostic Criteria ADHD-PI
Inattentive, drowsy, daydreamy, spacey, in a fog, and easily confused.
DSM-5 Diagnostic Criteria ADHD-HI
Primarily hyperactive. Primarily diagnosed among preschool-aged children.
ADHD-C
Both inattention and hyperactivity/impulsivity. Most often referred for treatment.
ADHD: Categorical or Dimensional
DSM treats ADHD as categorical: 6 and 6 threshold, but we all fall somewhere on this spectrum. Research suggests it’s dimensional. DSM criteria shapes our understanding of ADHD. Having this system of classification informs how we think about the disorder, but as the DSM gets updated our symptom list and diagnostic criteria gets refined overtime - means that DMS might lag behind new findings.
Assessment of ADHD
Rating scales and interviews: Parent report, teacher report is critical for placing children’s behaviour. Often do not ask youth: can be unreliable in young children, children tend to under-report their own symptoms. Diagnostic interviews. Symptom rating scales. Strong focus on observer signs of inattention and hyperactivity/impulsivity. Kiddie SADS: semi-structured interview. Difficulty sustaining attention on tasks or play activities. Difficulty remaining seated.
Combining reports from parents and teachers
Categorizing of children depends upon how reports form multiple informants is combined. When you look at parent or teacher repots alone, you see more diagnoses of inattentive or hyperactive/impulsivity. But if I used the combined reports (‘or’ rule) many of those cases become combined.
Heterogeneity in ADHD Presentation
Many different presentations of ADHD. Implies there are likely different causes. DSM-5 shapes our thinking, but lags behind research findings.
Cognitive Disengagement Syndrome Symptoms
Are coherent among themselves (more highly correlated with each other than with symptoms of other disorders). From a distinct dimension or set of dimensions of symptoms from those comprising other disorders. Are internally consistent. Show reasonable test-retest reliability over short time periods. Have significant stability and invariance over long periods from 2-9 years. Show comparable low-to-moderate relationships between parent and teacher ratings, as seen in other child psychopathologies. Are evident cross-culturally.
Epidemiology of ADHD - Prevalence
Prevalence of ADHD differ across different studies and different estimates. But we see a coalescing of around 8-10% of people.
Epidemiology of ADHD - Cultural and contextual differences
Similar prevalence across the globe. Children in many cultures and countries meet diagnostic criteria for ADHD. Slightly more prevalent among children in low SES situations. SES is a risk factor for ADHD. Racial differences not clear.
Epidemiology of ADHD - Gender
Symptoms of girls will often get under diagnosed, especially by inattentive girls. Hyperactive girls might not fit with our expectations of how girls should behave, so may be more likely to get diagnosed. Boys more likely to show over symptoms.
Developmental Course
Infancy: Because of strong biological basis of ADHD, symptoms should be present from a very early age. But no reliable and valid measures to assess below age 3.
Preschool: If symptoms last for about a year, child is likely to continue having challenges.
Elementary school: When most kids get diagnosed, due to change of scenery.
Beyond elementary school hyperactivity. might continue to decline slightly, but will still be higher than most all people without ADHD.
Prognosis
Previously thought that symptoms of ADHD resolved in adolescence. New studies show that people who had diagnoses earlier on still show higher rates in adulthood than people who were never diagnosed.
Adult Outcomes of ADHD (Klein et al., 2012 study)
Recruited 207 boys who were referred to a clinic for behaviour problems. Participants were rated as hyperactive by psychiatrist or by teacher + parent. When the boys (probands) were 18, they recruited comparison participants. Followed up 20 years alter when boys were 41 to see what the long term differences in adulthood between kinds who had ADHD vs kids who didn’t. Probands who participated did not differ from probands who were lost on childhood characteristics, nor on rates of ADHD or substance used at age 25. Comparisons who participated tended to have higher SES and higher IQs.
Comorbidity with other psychological disorders
Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). Anxiety disorders. Depression. Tic Disorders.
Correlates of ADHD - Intellectual ability and academic functioning
ADHD itself is not associated with decreased intellectual ability. Academic functioning is impaired: Because of inattention and hyperactivity-impulsivity, the typical schooling context might not allow people to show their full ability.
Correlates of ADHD - Formal speech and language disorders
Symptoms of ADHD impact language abilities. Speech production errors.
Correlates of ADHD - Deficits in interpersonal function
Conflicts with family. Increased conflict with siblings and peers. Exacerbated by co-occuring ODD/CD and general conduct issues.
Etiology of ADHD - Heritability & Environmental influences
Heritability: Based on twin studies, heritability estimates for inattentive and hyperactive/impulsivity are ~75%.
Environmental influences: Factors that compromise development of nervous system may be related to ADHD.
Mostly caused buy bio + genetics, then maintained, mitigated, and exacerbated by environmental influences.
Treating ADHD - Medication
Stimulants have used to treat ADHd since the 1930s. Among the most effective stimulants are dextroamphetamine and methylphenidate. Increase activity in the prefrontal cortex. Side effects: decreased appetite, weight loss, slowing of growth. 20% of children may not improve, may not help academic performance or relationships, beneficial effects may not be maintained over time and will stop once medication stops, tolerance can often occur.
Behavioural Treatments: Parent Training
Very parent-focused, might not even meet the child. Goal: Supporting caregivers managing challenging child behaviour & promoting positive behaviours. Defiant Children approach: Standard approach. Supporting Caregivers approach: Integrated approach. Short term approaches.
Parent-focused program structure: 1. Psychoeducation
Provide parents education about ADHD in children. Breaking down the basis of what ADHD can look like in children and in families. Opportunity to educate parents and lay the foundation.
Parent-focused program structure: 2. Improve parent-child relationship.
Emphasis on providing children with positive attention & affirmation. Can use positive attention to increase the behaviours that we want to see. Special time: Task for parents where for 10 minutes a day they provide their child with positive attention. Have parents fill out a though record: Monitor their mood and thoughts.
Parent-focused program: 3. Behavioural Strategies
Behaviour charts & rewards for positive behaviour. Time-outs and privilege removal that the parents can use. Routine and structure building.
Parent-Focused program: 4. Communication Strategies
Encouraging firm and assertive communication when necessary. Make sure parents mean what the say, make sure its direct and not a question, make sure child is paying attention when parent is giving a command.
Parent Training Programs: The evidence
Overall, meta-analyses and systematic reviews point to benefits for children AND for parents. Evidence for significantly reduced ADHD symptoms in children. Small to medium-positive effects on parent outcomes. However, these effects may not be sustained over time: Moderate effect sizes at post-treatment, small effect sizes at follow up.
Cognitive interventions
Cognitive techniques that children can use to control attention and behaviour (verbal self-instruction, problem solving). Insufficient scientific evidence of benefit.
Organizational skills training
Can help with impairment related to ADHD (e.g. school failure). Benefits in academic domain.
Multimodal Treatment of ADHD (MTA): 3 key objectives
1) Compare long-term medication and behavioural treatments for ADHD.
2) Determine if there are additional benefits if meds and behaviour treatment are combined.
3) Compare systematic administration of treatment to treatment as delivered in community settings.
MTA Study
Random assignment into four groups, treated for 14 months, assessed for 2 years.
MTA Study: Treatments
1) Medication management: Stimulant medication, 28 day titration period.
2) Psychosocial treatment: Parent training, educational interventions, summer treatment program.
3) Combination treatment (medication management + psychosocial)
4) Community treatment as usual (TAU): Could be nothing, could include any of the above.
Long-Term Patterns of Remission From MTA Study (Sibley et al., 2022)
Several of follow-ups with MTA sample 2 years post-intervention (youth were !10y.o) to 16 years post-baseline (when youth were ~25). The intervention helped, but do symptoms and impairment return across time?
Treatment Studies: Chronic-Tuscano Et Al. 2013. Mothers of Children with ADHD.
Targeting maternal depressive symptoms and parenting children with ADHD. Mothers were randomized into two groups: standard parent training (routine building, time-outs, privilege removal), and an integrated intervention where they received more info such as relaxation exercises, mood monitoring activities etc.
Treatment Studies: Chronic-Tuscano Et Al. 2013. Mothers of Children with ADHD - Big Takeaways
Integrated Intervention post-treatment: Produced small to moderate impacts on maternal depressive symptoms, negative parenting, child disruptive behaviour, and family functioning compared to behavioural parent training. However, this effect wasn’t sustained over time. Integrated intervention: positive impacts post-treatment. Parent training: impacts on “positive parenting” at later follow ups.
