ADHD Flashcards
What proportions of adults retain diagnosis of ADHD in adulthood?
1/3
What are some evidences that ADHD is real?
Low education attainment, substance abuse and criminality if not treated
What are the DSM-5 critertia for a diagnosis of ADHD?
Diagnosis
- symptoms persisted more than 6 months in more than 2 settings
- negatively impact academic, social, occupational functioning
- need at least 6symptoms for child under 17yo or 5symptoms for older than 17yo
- symptoms prior to 12yo
- not better accounted for by a different psychiatric disorder
LOOK AT TABLE
What are the two categories of ADHD and the specifiers?
Grouped into two categories
- Inattention
- Hyperactivity and impulsivity
Specifiers
- ADHD-I→ stress on inattention
- ADHD-H→ leaning more into the hyperactivity
- ADHD-HI→ both
How are usually people with ADHD-I?
Describe as
- Inattentive, drowsy, daydreamy, spacey, in a fog, easily confused
- may have learning disability, low academic achievement, trouble remembering
- often anxious and socially withdrawn
- more often diagnosed in girls
May be 2 subtypes
- Recovered from behavioral
- only inattentive→ sluggish cognitive tempo/ later onset, fewer speech problems, less aggressive
How is inattention deficits define in ADHD?
Difficulty during work or play to focus on one task or to follow through on requests or instructions
- inability to sustain attention for repetitive structured and less enjoyable tasks
–>might sometimes have hyperfocus
–> deficit in regulation of attention
Deficits may be seen in
- selective attention/distractibility
- sustained attention/vigilance (core feature)
- alerting
What is the difference between Hyperactivity and Impulsivity?
Hyperactivity→ inability to voluntarily inhibit dominant or ongoing behavior
Hyperactivity behaviors includes
- fidgeting, difficulty staying seated
- moving, running, climbing about, touching everything in sight
- excessive talking and pencil tapping
- accomplishing little despite extreme activity
Impulsivity→ unable to control immediate reactions or think before
acting
- Cognitive impulsivity: disorganization, hurried thinking, need for supervision
- Behavioral impulsivity→ difficulty inhibiting responses when situations
require it (talking when not supposed to)
—>probably all related symptoms
What are people with ADHD-HI usually like?
Most often referred for treatment
ADHD-H and ADHD-HI more likely to
- problems inhibiting behavior
- problems with behavioral persistence
- aggression, defiance, peer rejection, suspension from school, and placement in special education classes
What is the epidemiology of ADHD?
Lifetime prevalence→ 4-8% of school age children in NA
- 8.1% of adults in the US report a lifetime history of the disorder
- Approximately 4.4% of U.S. adults meet criteria for current ADH
- estimated worldwide prevalence is 5.2%
Gender→ 2.5M:1F
- 2-4% for girls and 6-9% for boys
Cultural differences→ found in all countries with compulsory education but
- highest rates in south america and africa
- lowest rate in japan and china
- more diagnosed in boys in all cultures
—>Cultural differences may reflect cultural norms and tolerance for ADHD symptoms
–>compulsory education acting as triggering social factor
What are the associted outcomes of ADHD?
Poor academic and vocational performance
- Fewer years of school, lower status
More interpersonal problems
- Problems with parent-child relationships
Higher rates of accidents
- Broken bones
- Car accidents
- Speeding tickets
Initiate sexual activity at an earlier age
- Increased risk of STIs and unplanned pregnancies
Reduced Life expectancies
What are the rates of comorbidity for ADHD?
80% of children with ADHD have co-occuring psychological disorder
Also comorbid with Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)
- Abt 50% of children meet criteria for ODD by age 7 or later
- About 30-50% of children develop CD
- Common predisposing cause for ADHD, ODD, and CD
Anxiety Disorders→ 25%
Mood disorders→ 20-30%
Substance use→ increased rates of substance use and SUD
- earlier onset of use
What is the course of ADHD in childhood?
Infancy and preschool
- can be more visible at ages 3-4
BUT even more visible in elementary school
- oppositional defiant behaviors may increase
- 8-12 defiance and hostility may be more serious problems (e.g., lying,
aggression)
- Increased problems w/ self-care, personal responsibility, chores,
trustworthiness, independence, social relationships, academics
What is the course of ADHD like in adolescence?
Adolescence→ Some might outgrow it BUT 50% don’t
- significant impairments
- more likely to exhibit oppositional defiant behaviors, anxiety/depression, and involvement with the juvenile justice system
Avon Longitudinal Study of Parents and Children
- homotypic evidence→ ADHD at 7.5 associated with ADHD at 14
- also associated with externalizing disorders (ODD, CD)
- GAD, PTSD, MDD
—>Of all disorders, ADHD showed the most cross-domain effects
- ex: at age 7.5, ADHD was a stronger predictor of GAD at 14 than any other disorder (including any internalizing)
What is the course of ADHD like in adulthood?
Adulthood→ rates of ADHD diagnosis persistence ranged from 5.7-77%
- BUT all studies observed high rates of symptomatic persistence (60-86%)
- hyperactivity is less relevant for adults
- might be because adults can choose their environment more
- adults might be able to better mas symptoms
What are the main significant impairment of ADHD in adulthood?
Compared to control groups, adults with ADHD had significant impairment in
- Educational functioning
- Occupational functioning
- Mental health
- Physical health
- Antisocial personality disorder
- Criminality,
- Substance misuse
What are the comorbidity rates for ADHD in adulthood?
Comorbidity
- Substance Use Disorder
- 4X more likely to have Mood Disorders
- 5X more likely to have Anxiety Disorders
- 2X more likely to have Personality Disorders (esp ASPD)
- higher rates of NSSI
- Suicide attempts (14%)
What is the difference between homotypic and heterotypic continuity of a disorder?
Homotypic Continuity→ Having a disorder at one time point predicts having the same disorder at a later time point
- ex: ADHD in childhood associated with ADHD in adulthood
Heterotypic Continuity→ Having a disorder at one time point predicts having a different disorder at a later time point
- ex: ADHD in childhood is associated with MDD or SUD in adolescence and/or adulthood
What are the two different explanations for heterotypic continuity in ADHD?
Failure Model
- impulsivity/ hyperactivity/ inattention lead to higher levels of interpersonal conflicts, poor skills development
- increases risk for subsequent depression and other psychopathologies
—>cascading effects
Shared etiopathogenetic factors
- Irritability in childhood shared among CD, ODD, depression, anxiety disorders
- Genetic or constitutional factors influencing ADHD in childhood predispose them to anxiety and depression in adolescence and adulthood
- Familial risk for psychopathology explains both
- ex: parents with depression are more likely to have children with depression BUT also ADHD
What are the different etiology of ADHD?
Runs in family→ 1/3 of biological relatives of children with ADHD have disorder
- Adoption studies→ 3x higher in biological parents
- twin studies→ 80% heritability estimates for HI and IA behaviors
- estimates for heritability is 0.75
Pregnancy and early development
- Factors compromising development of nervous system before and after birth may predict later ADHD symptoms
- low brith weight
- exposureto lead
- BUT none specific to ADHD
Mother’s use of alcohol and nicotine during pregnancy associated with ADHD
- but which way for causation
Reciprocal negative interactions between parents and children
- passive and evocative rGE
- children with ADHD→ less compliant, more oppositional, less able to follow parental requests
- parents with ADHD with children with ADHD→ lower levels of involvement and positive parenting, higher level of inconsistent discipline
- study with mom and child doing homework→ mother was more likely to yell command without waiting for child to answer and was more important predictor of problems for child
How is emotion regulation in ADHD?
Emotion Regulation Difficulties (ERD) in ADHD
- 21-66% of teens and adults with ADHD have ERD
Can predict course
- Poor positive ER→ increase in inattention symptoms over time
- Good ER→ decrease in inattention symptoms
—>important corelate of ADHD
What could be the neuroatonomy behind ADHD?
Focus on PFC and striatum
- PFC→ regulating
- Striatum→ Motivation
In ADHD
- Volumetric reductions in PFC, ACC, caudate, corpus callosum, and cerebellum
- Reduced activation in PFC and striatum→ not always
Dopamine function→ inconsistent effect with GO/NO GO task
- harder to inhibit behavior
- in controls→ for inhibition, more activation in PFC and striatum VS for GO task, more activation in basal ganglia
- in ADHD→ more confusing and disorganized activation
Also might be hypodopaminergic functioning-> constant need for stimulation
What is the rise in the diagnosis of ADHD in the US?
risen by 41%
- such that 11% of all youth between the ages of 4 and 17 years have by now received this diagnosis
What is the gender paradox in psychological disorders?
for the sex or gender with lower prevalence of a given condition the disorder, when it exists, will be more severe, requiring a greater genetic vulnerability or accumulation of other risk factors to lead to its onset
What were the findings of the Berkeley girls with ADHD study?
ALso important impairment in childhood and adolescence
- combined presentation-> more risk for suicide and NSSI
- not more substance abuse and eating pathology
- continued into adulthood EXPECT for peer rejection and anti social behaviors
–>even when diagnosis disspear, still have impairment (ex: unplanned pregnancy)
What could explain the rise in diagnosis of ADHD in the US?
Accomodation can be sought and treatment can be reimbursed
Also educational policy-> student scores on high-stakes standardized testing
- public school made responsible for student’ levels of achievement
- those effects not found in private school or middle class
–>districts might push for ADHD diagnoses of low-achieving youth, given that a special education
designation would remove that child’s scores from the district’s overall average
What are the two evidence-based forms of intervention for ADHD?
Medication-> stimulants and noradrenergic
Behavioral (youth) or cognitive (adults) psychosocial treatment
- management skills
-emotion regulation
- for child, extrinsic reward system
–>combination treatment appear optimal
