ADHD/LD Flashcards
To keep it straight
When does ADHD/LD emerge in development?
What % have one, the other, or both?
How to they look across the developmental years?
Do they have psych comorbidities?
Emerge in childhood, associated difficulties often persist in some form into adulthood, resulting in occupational concerns ranging from performance issues and underemployment to increased injury risk
High rate of comorbidity in clinical samples and in nonreferred samples recruited from the community, although broad variability of overlap: a quarter or less to two-thirds.
Centers for Disease Control: approximately 5% of school-aged children in the United States are diagnosed with ADHD without LDs and approximately 5% have LDs without ADHD. 4% are diagnosed with both conditions (i.e., roughly 30% comorbidity in this sample).
Centers for Disease Control (CDC) survey:
one in five male high school students; one in ten females lifetime prevalence
Base rates during childhood range from 10% to 20%, depending on the child’s sex (i.e., boys twice as high as girls).
50% persistence to adulthood in clinical samples
Clinical profiles of ADHD and LD are complex and change over time, in part as a function of developmental demands and successful remediation and/ or learning. It is also emphasized that both ADHD and LDs are “continuum disorders,” that is, disorders that exist at the extremes of the normal distribution
Both disorders are associated with increased risk for a range of emotional, behavioral, and psychosocial issues
What are the explanations of why there is comorbid ADHD/LD?
Shared genetic and environmental risk factors (Fisher & DeFries, 2002, Gayan et al., 2005) and shared underlying processing deficits (e.g., Denckla, 1993, Seidman, Biederman, Monuteaux, Doyle, & Faraone, 2001) to interactions between the disorders whereby the existence of one disorder influences the diagnosis and course of the other.
DSM ADHD definition
how has it changed?
How do the behaviours change over time?
Dichotomous conception of ADHD, and reframed it as a multidimensional spectrum disorder based on the primary symptom clusters of inattention and/ or hyperactivity/ impulsivity (i.e., predominantly hyperactive/ impulsive type, predominantly inattentive type, and combined type).
ADHD in adults is now formally acknowledged and requires a lower number of symptoms (i.e., five symptoms from either the Inattention cluster or the Hyperactivity and Impulsivity cluster). While this new symptom threshold is less than the six symptoms required for children, it is still higher than the four symptoms suggested by the only two existing empirical studies of diagnostic thresholds for adults
The primary areas of problem behaviors often change in the same individual over time. That is, the child who shows excessive hyperactive/ impulsive or combined type symptoms can, and often does, become mainly inattentive as an adult.
Dyslexia def’n (Evidence Based; not DSM)
Dyslexia is a specific learning disability that is neurobiological in origin. It is characterized by difficulties with
A) accurate and/ or fluent word recognition and
B) by poor spelling and decoding abilities.
These difficulties typically result from a deficit in the phonological component of language that is often
- unexpected in relation to other cognitive abilities and the provision of effective classroom instruction.
Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge.
DSM LDs Criteria
Symptoms must persist for six months, despite intervention.
Academic skills are “substantially and quantifiably below those expected for the individual’s chronological age” and cause “significant interference” with academic, occupational, or everyday functioning. difficulties are confirmed by “individually administered standardized achievement measuresand comprehensive clinical assessment.”
For individuals 17 or older, a documented history of impairing learning difficulties may be substituted for the standardized assessment.
Onset is during school years, but effects may not become fully obvious until learning demands increase. difficulties are not better accounted for by another disorder, lack of language proficiency, or inadequate instruction.
Not accounted for by IQ
Specifiers for the types of academic domains affected: reading, written expression, and/ or mathematics.
Full diagnosis includes the level of severity of the specific LD (i.e., mild, moderate, and severe) and the subdomains affected.
Reading LD Subdomains
Word reading accuracy
Reading rate or fluency
Reading comprehension
Written Expression LD Subdomains
Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression
Math LD Subdomains
Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning
NVLD?
In contrast to the DSM-IV, which included a category for unspecified LD, the DSM-5 restricts the Specific LD category to only academic skill deficits. As a result, people with what was called nonverbal/ social/ visual-perceptual LD (i.e., NVLD or NLD) may no longer meet criteria for any specific form of LD, despite having executive and other deficits that globally impede their academic and social learning
Discrepancy as a criteria for LD?
Ongoing controversy on this issue, especially in identification of LD in the high-IQ individual. In such cases, most or all of the achievement scores may fall within normal ranges but well below expectations for aptitude.
Arguably, reliance on on the DSM V criteria of “a documented history of impairing learning difficulties” could be used.
ADHD: Presentations and Possible Underlying Deficits
- Why do kids get referred?
Disruptive behavior and poor school performance are the most typical referral reasons for children with ADHD. By contrast, many ADHD adults refer themselves for evaluation due to difficulties in day-to-day functioning, at home and/ or at work, many of whom have not been diagnosed
Excessive motor activity
Poor inhibitory control over behavior Difficulties focusing, sustaining, and shifting attention
Inconsistent and context dependent performance, suggesting that motivational factors and reinforcement contingencies are important.
Emerge in the preschool years
Often persist in altered form into adolescence and adulthood
Changes in the manifestations reflect mixed influences related to biological maturational changes, as well as successful application of self-applied or formal treatment interventions
Hyperkinesis decreases; problems with inattention and executive function may persist or even become more apparent
ADHD typical dx criteria
ADHD is diagnosed when one or more of the three core symptoms lead to significant functional deficits at home, school, and/ or the preschool years when acquisition of preacademic skills can become disrupted by
- poor impulse control,
- motor over-activity, and difficulties
- attending to instruction
ADHD Comorbities for children
Other dx’s that have ADHD
Psych
Personality
For adults?
Psychiatric Disorders: Lots:
While the symptoms of ADHD decline with increasing age, the probability of having a comorbid psychiatric diagnosis increases. By adulthood, 13% of individuals with ADHD are free of comorbid diagnosis.
Children: Acting out; low ed attainment
Adults: Mood and anxiety, substance abuse, antisocial; increased rates of divorce, occupational instability.
Antisocial and Substance Abuse: 10x more common among young ADHD vs. controls (more likely conduct disorder; ODD; incarceration)
Mood/Anxiety: Hard to differentiate; they may co-exist vs. one causes the other.
Personality disorders: While not fully developed, this approach provides interesting alternative formulations for personality disorder in ADHD. That is, some neurological tendencies due to ADHD may predispose to the development of certain personality pathologies.
Language Disorders and Autism
A percentage of children with or without concomitant language problems demonstrate particular difficulty understanding what they hear despite normal hearing sensitivity. Problems may be particularly apparent when material is unfamiliar or if it is presented in a noisy or distracting environment, such as a classroom. CAPD is thought to arise when central neural processes underlying the analysis of auditory information by the brain are functionally compromised. The disorder encompasses deficits in one or more of the following auditory behaviors:
The relative presence of ADHD and/ or CAPD is not clear, in part because each exists in different nosology systems. In short, ADHD and CAPD may be different conditions that are sometimes comorbid, or the same condition assessed by different disciplines.
Autism: As much as 20% with a diagnosis of ADHD demonstrate symptomology associated with Autism Spectrum Disorder
Genetic Disorders: ADHD is commonly diagnosed in several genetic disorders, including Klinefelter syndrome, Turner syndrome, neurofibromatosis, tuberous sclerosis, Fragile X, and Williams syndrome.
Motor Disorders Among the neurodevelopmental disorders, motor and tic disorders have among the highest rates of comorbidity with ADHD. Approximately half of children diagnosed with a tic disorder also meet criteria for ADHD
LD: Presentations and Possible Underlying Deficits - dyslexia
Language delays are particularly noteworthy indicators for potential dyslexia
School-age children with LD have difficulty learning basic skills out of proportion to their age-peers and/ or intellectual endowment. For dyslexic children this may be seen in slow acquisition of letter names and/ or letter sounds, look-say vocabulary, and later in spelling.
Difficulties with word problems can be seen with either dyslexia and/ or dyscalculia.
Dyslexia and/ or Reading Disorders Characteristics
Dyslexia is the prototypical form of LD and is the most common type.
Slow and inaccurate single word recognition, despite adequate intelligence and instruction, and the absence of gross sensory or motor problems.
Accurate or fluent word decoding characterize it, but spelling is commonly also affected and often to a similar degree.
Abnormal phonetic awareness and processing has been found in the majority of studies of reading disabled children in line with the emphasis on phonology in the triangle model.
Reading disorder is currently thought to usually reflect inadequate processing/ representation of phonemic units, resulting in a difficulty with single word decoding in reading, writing, and spelling.
Neuropsych of Dyslexia
In what areas are the greatest deficits?
- Weak ability to rapidly name objects, colors, letters, and/ or numbers, which is referred to as rapid automatic naming. RAN is one of the best predictors of later reading achievement in children with and without reading disabilities, independent of their level of phonemic awareness, not linked to ADHD.
- Double-Deficit Hypothesis: Finish dyslexic adults, reported deficits in phonological awareness and phonological memory, as well as deficits in rapid naming.
- Broader problems in auditory-verbal attention, working memory, vocabulary, spoken language comprehension, and general knowledge are also frequent in people with reading disabilities
- Brighter adults with dyslexia compensate more effectively for reading difficulties, a theme that is common in studies of LD.
When their language and metalinguistic skills are stronger, those with dyslexia can compensate more effectively for underlying difficulties with phonological awareness.
With relevance to compensation, they also found that stronger vocabulary and nonverbal processes (i.e., Perceptual Organization Index) were associated with stronger comprehension.
Broad assessment of spoken language, attention, executive functions, and general knowledge are all-important when evaluating reading problems.
studies have not found clear evidence that deficits in visual skills are causal in reading disorder
LD effect sizes were largest for word attack, reading recognition, reading comprehension, and spelling. Effect sizes also were large for writing and math, reflecting the frequent co-occurrence of written expression and math disabilities with reading disabilities.
effect sizes were largest for phonological processing, processing speed (including rapid naming), vocabulary, verbal intelligence, general information, and verbal memory.
Dyscalculia and/ or Math Disorders Characteristics
Mixed combinations of problems in mathematics, including difficulty with learning and retrieving number facts (e.g., times tables),
Executing calculation procedures/ operations (e.g., long division, adding mixed numbers),
Understanding mathematical concepts (e.g., fractions, percents, or negative numbers)
Developing problem-solving strategies
Frequently (but not always) present in association with other learning impediments, especially a reading/ spelling disability or ADHD
Neuropsych of Dyscalculia
In what areas are the greatest deficits?
Explanations; “primary dyscalculia,” where the deficit reflects abnormality in underlying numerical cognition (i.e., domain specific),
Vs. “secondary” to other more general cognitive impairments, such as deficits in memory, attention or visual-perceptual and spatial understanding
Evidence has revealed involvement of combinations of general cognitive capacities (i.e., domain general).
Written calculation and math problem-solving skills predicted by retrieval of semantic knowledge, executive functioning, and visuospatial skills.
Those who were impaired in both areas (i.e., double deficit) had the most impaired skills.
Math Calculation score was predicted by the Processing Speed and Working Memory scores, and the Math Reasoning score was predicted by the Comprehension-Knowledge, Fluid Reasoning, and Working Memory scores. This, too, showed the importance of attention, working memory, processing speed, and reasoning and acquired knowledge for math skills.
Alternative theory: domain-specific abilities, such as the role of lower-level “building blocks of numerical cognition”
Eg: Numerical cognition is one of such domain-specific ability categories, which include subitizing and counting, comparative judgments and distance effect, and automaticity of numerical processing
And: automaticity of numerical processing, which refers to the rapid subjective understanding of the numerical symbol system,
Anxiety: worsen and/ or even simulate DD. adults may remain highly anxious and thus dysfunctional when attempting computations. For example, Buelow and Frakey (2013) found that math anxiety affected performance on the Arithmetic subtest of the Wechsler Adult Intelligence Scale-Fourth Edition but did not affect performance on other Working Memory subtests that did not require arithmetic.
Dysgraphia
Writing is a complex task requiring the mastery and integration of a number of subskills, including fine motor control, visual and tactile perception, language, memory, and executive functioning.
- producing legible handwriting or spelling,
- difficulty organizing and sequencing their ideas.
- problems with spelling and other writing mechanics (such as punctuation and grammar), vs. others maintain the more narrow view that regards the disorder as an abnormality of complex motor skill or handwriting
Nonverbal Learning Disability
controversy over whether NVLD is a specific LD separate from other disorders, such as math disabilities, ADHD, developmental coordination disorders, and ASDs
Why do adults get referred for ADHD?
What does the course look like?
Adults with ADHD are more likely to have dropped out of school, received below average grades, and/ or performed below their potential. Such academic deficits certainly explain the well-documented lower occupational status of probands compared to controls
Time management (e.g., not paying bills or filing taxes) and organizational problems (e.g., not finishing or tracking long-term projects, running a household) become especially more apparent during the teen years and adulthood. Many adults also self-refer after the diagnosis of a child or other family member triggers their own recognition of the symptoms (Faraone et al., 2004). In addition, they seek consultation after learning about the condition through the media, or when seeking accommodations in school or work settings (Wolf & Wasserstein, 2001). Some are referred by spouses or other medical professionals (Faraone et al., 2004). Irrespective of the referral source, adults with ADHD fall into two broad categories: those who were originally diagnosed as children and those who were never diagnosed. The first group often includes those who were hyperactive and/ or oppositional as children. The second group may be more difficult to recognize and frequently show an inattentive presentation and/ or variable levels of compensation skills.
LD life course
School age children: Avoid academics; disruptive; less well liked by peers; social pragmatic difficulties -> Low self esteem -> psych comorbidity -> adult dissatisfaction with time to learn, graduate, lower grades -> but by adulthood, most adults can learn; just more slowly.
LD: Presentations and Possible Underlying Deficits - dyscalculia
For children with dyscalculia this may be seen in slow acquisition of number facts, such as automatic recall of single-digit addition or memorizing the times tables. Later, children with dyscalculia may have struggles learning/ recalling math operations and/ or appreciation of quantity and spatial relations.
