Child Abnormal: ADHD

Question 1

ADHD as a diagnosis?

Answer 1

• Controversial diagnosis

Increase in number of kids being medicated, is it correct adjustment for kids getting what they need?

Question 2

History of ADHD

Answer 2

1980s the core became about inattention, with kids facing inattention and hyperactivity forming a group

Question 3

Impact comparison to other disorders?

Answer 3

Not a disorder that has huge amount of distress compared to other disorders (491) –> maybe due to medication?

Question 4

DSM5 ADHD

Answer 4

A persistent pattern of

inattention and/or hyperactivityimpulsivity

Question 5

Inattention

Answer 5

Fails to give close attention to details or makes careless mistakes
in schoolwork / work/other activities
b. Has difficulty sustaining attention in tasks/play activities
c. Does not seem to listen when spoken to directly
d. Does not follow through on instructions; fails to finish schoolwork /
chores/work duties
e. Has difficulty organizing tasks and activities
f. Avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (lengthy papers).
g. Loses things necessary for tasks or activities
h. Easily distracted by extraneous stimuli (unrelated thoughts).
i. Forgetful in daily activities

Question 6

Inattention a misnomer?

Answer 6

Attention takes many forms (e.g., arousal, alertness, selective, divided, span of apprehension, persistence)

In ADHD there is no problem with perception, filtering, processing etc, it is the disturbance of prolonged attention to particular stimuli –> ADHD is a failure to direct behaviour forward in time to persist toward delayed end points

Question 7

Ability to resist distractions?

Answer 7

Children with ADHD do not perceive/encode distractions
differently, rather they:
Respond to distractions more than other children…
React to events that are irrelevant to the goal….
Get off task much faster than others…
Have difficulty re-engaging with tasks following interruptions…
Skip from one incomplete task to another
This ‘inattention’ may largely reflect impaired working memory

Question 8

HYPERACTIVITY & IMPULSIVITY

Answer 8

• Some kids only get inattention, however most common is both

Often fidgets with or taps hands or feet or squirms in seat.

b. Often leaves seat in situations when remaining seated is expected
c. Often runs about or climbs in situations where it is inappropriate.
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor”
f. Often talks excessively.
g. Often blurts out an answer before questions completed
h. Often has difficulty waiting his or her turn
i. Often interrupts or intrudes on others
(e. g., butts into conversations, games, or activities).

Question 9

Emotional impulsivity?

Answer 9

• Currently missing from DSM-5
• ADHD is not a mood disorder or emotional disorder, BUT
  nonetheless associated with poor emotional control.
• Children with ADHD exhibit rapid and unmoderated emotional expression (esp. Impatience; low frustration tolerance; quickness to anger; prone to emotional excitability/arousal)
• Difficulties self-soothing, down-regulating, in order to express emotion in ways that are socially acceptable, or consistent with longer-term goals

Question 10

What type of disorder is ADHD?

Answer 10

Historically there were externalising (ADHD, ODD, CD) and disruptive disorder (ODD & CD)

Now new idea of neurodevelopmental disorders
includes ADHD, autism, learning disorders

Rather than a discrete diagnosis, it is about development of neuro capacities

Question 11

Comorbidity of ADHD & externalising disorders (ODD,CD)

Answer 11

• Highly comorbid (about 50% ODD; 20% CD).
• Likewise, more common in males than females (2:1)
• Phenotypic overlap with ODD/CD, particularly
  hyperactive / impulsive features.

Question 12

Difference between ADHD & ODD

Answer 12

• ADHD often don’t mean to cause harm, not bad kids where as ODD there is deliberate irritability of others
• most kids in middle, worried giving kids with ODD stimulants as misdiagnosed?

Question 13

Neurodevelopmental disorder

Answer 13

• move away from function to neurodevelopment immaturity in these functions
• ADHD clusters with autism, motor coordination, reading/learning disabilities, is associated with early alterations/immaturities in neural development & shows a trajectory that maps onto that of self-regulatory capacities.

Question 14

Diagnostic Criteria

Answer 14

A. Several symptoms present prior to age 12 years.
B. Several symptoms present in two or more settings
(e.g., home/ school/work; friends/relatives; other activities)
C. Clear evidence that the symptoms interfere with social,
academic, or occupational functioning.
D. Not better explained by another condition.

–> has to have significant impact on kids life across settings, not just reacting to certain environments

Question 15

Other comorbidities

Answer 15

Highest is ODD & learning disorders

Question 16

Developmental trajectory

Answer 16

Hyperactivity symptoms –> Most pronounced in preschool and decline over time (normality for some)
Inattention symptoms –> Increasingly apparent with age as peers undergo rapid maturation of prefrontal
cortex as school demands intensify

Question 17

Environmental Causes of ADHD

Answer 17

• Teratogens and toxins: Exposure during critical periods in pregnancy to household, outdoor pesticide, prenatal nicotine
• Strong evidence for effect of lead
• Not strong evidence for dietary factors

Question 18

Heritability of ADHD

Answer 18

-0.8 heritability in twin studies (hugely significant, almost same as height)

Question 19

Effects of Parenting on ADHD causation

Answer 19

• High levels of parental involvement associated with
  reduced hyperactivity/inattention only when child very young
• Increasing hyperactivity/inattention across middle childhood, but only among children exposed to high levels
  of inconsistent discipline (over a year period)

Question 20

Hostility of parents?

Answer 20

Other studies show parent-child hostility doesn’t drive ADHD, and that ADHD drives parent-child hostility

• ADHD symptoms elicit negative responses? experimental (RCT) data shows not only improvement of ADHD symptoms but improvement of quality of parenting

Question 21

Gene-environment correlation?

Answer 21

Adoption study done Testing genetically unrelated mothers and offspring allowed researchers to test for evocative rGE while controlling for confounding passive rGE

• high correlation between biological mothers ADHD symptoms and child impulsivity/activation
• childs impulsivity/activation predicts how hostile adoptive mother becomes & predicts fathers report of symptoms

Question 22

Effect of dopamine?

Answer 22

• Association between inconsistent parenting and ADHD symptoms stronger for those with the long allele of DRD4 gene
• slip means more vulnerable to parenting
• our genome changes to our environment, kids with ADHD more dopamine switched off

Question 23

DUAL PATHWAY MODEL OF ADHD (Sonuga-Barke, 2005)

Answer 23

• Two distinct processes, involving distinct but overlapping neural architecture, and both shaped by environmental processes.
• 1. Deficits in inhibitory-based executive processes
     Response inhibition: the ability to inhibit an inappropriate prepotent or ongoing response in favour of a more appropriate alternative (CANNOT STOP CERTAIN BEHAVIOURS)
     (A prerequisite for self-control, emotional regulation, cognitive flexibility, Underpinned by the frontal striatal circuit, Dopamine is a key neuromodulator of this circuit)
• 2. Motivational dysfunction involving disruptive signaling
     of delayed reward ADHD arises from neurobiologic impairment in the power and efficiency with which the contingency between present action and future rewards is signaled. (MOTIVATIONAL DEFICIT IN DELAYED REWARD)
• This leads to…reduction in the control exerted by future rewards on current behaviour, an increase in the extent to which future rewards are discounted. Based is frontal-limbic circuitry (including amygdala) But again…dopamine a key neuromodulator

Question 24

DUAL PATHWAY MODEL OF ADHD (Sonuga-Barke, 2005) - Delay Aversion Hypothesis

Answer 24

• Over time the negativity associated with this failure becomes associated with situations that signal the need to delay gratification.
• This ‘delay aversion’ manifests as attempts to avoid/escape delay by attending to the most interesting/absorbing aspects of the environment or acting on that environment (hyperactively)
• Environments can amplify delay aversion

Question 25

Establishing a valid diagnosis

Answer 25

• There is no single test to identify ADHD
  –> Available “objective tests” are primarily Continuous
  Performance Tests (CPTs): TOVA (Test of Variables of Attention) & Conner’s CPT
  –Diagnosis must be multi-factorial
• Clinical Interview (assessment of primary complaint)
• Collateral interviews (child, school etc)
  *** Never diagnose ADHD in a 1:1 interview
  – Individuals with ADHD can often function well in certain settings with no signs of symptoms when they are interested and maintain total focus, group symptoms are a must

Question 26

Multi-Modal Treatment Study for ADHD (MTA)

Answer 26

• Medication alone and medication combined with other therapies more effective than therapies on their own

Question 27

Does stimulant use for ADHD predict later substance use?

Answer 27

No, very little evidence

‘protective effect’