Externalising disorders Flashcards
definition
“disruptive behaviour disorders. The deviant behaviour is directed outward”.
examples
Oppositional defiant disorder (ODD)
Childhood-onset conduct disorder
Adolescent-onset conduct disorder
o The two types of conduct disorder have different causes
ADHD subtypes
inattentive
hyperactive-impulsive
combined
Subtypes are not always stable – may change subtype with time
Must have symptoms for at least 6 months and have significant impairments
Problems need to be across contexts – home and at school for example – significant differences between the environments
Difficult to give diagnosis if they only have impairment in just one domain – might think there are problems with the specific contexts – e.g. at home – might have had conflict with siblings rather than because they have ADHD
inattentive subtype
Major difficulty is to maintain attention
Need to look at what the appropriate levels of attention are
Children less likely to be inattentive than adults
hyperactive-impulsive subtype
Major difficulty is the high activity levels
Attention may be close to normal
combined subtype
Children have difficulty with attention and activity level
symptoms of inattention
Need at least 6 symptoms for diagnosis
o Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
o Often has trouble holding attention on tasks/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.
symptoms of hyperactivity and impulsivity
• 6/9 symptoms needed for diagnosis:
o Often fidgets with or taps hands/feet or squirms in seat
o Leaves seat in situs when remaining seated 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 his/her turn.
- Often interrupts or intrudes on others (e.g., butts into conversations or games).
DSM-V added impulsivity symptoms
“Tends to act without thinking
Often impatient
Uncomfortable doing things slowly
Finds it difficult to resist temptations”
ADHD comorbid with:
Disruptive disorders
Anx
Depression
Learning disorders – difficulties memorising material, etc.
• Symptoms can be quite severe if comorbid
prevalence of ADHD in children and adolescents
Most studies conducted in the West – biased perception of the findings
More prevalent in males (10%) than females (<5%) – girls more likely to have inattentive subtype – more likely to have ADHD comorbid with anxiety – but less likely to have learning disabilities
7-8% in children but less often in adolescence (3%)
Africa, Middle East, South Africa most prevalent
3-10% in most countries
Some children’s symptoms diminish with time – they outgrow the disorder – but for some the condition remains stable
Some problems less well tolerated in some cultures than others
ADHD affects children’s functioning
cognitive
language
motor development
emotion
school perf
health
cognitive functioning
(learning difficulties, academic underachievement, poor school readiness
less prepared to learn, lots are expelled because of their behaviour, problems with peer interactions
don’t take turns, don’t understand intentions of others, usually for children with combined or hyperactivity type, inattention have social problems because they are passive or withdrawn
don’t remember sequence of interaction)
language functioning
(speech problems, delays in language development)
motor development functioning
(poor motor coordination - clumsy)
emotion functioning
(deficits in emotion regulation – e.g. anger, sadness, poor frustration tolerance)
school performance functioning
(dislike tasks that mean studying for long periods of time
poor grades, disruptive behaviour)
health functioning
(more accidents, smoking and alcohol problems)
developmental course of ADHD
ADHD was thought to be a childhood disorder
Longitudinal studies have found that ADHD persist into adulthood in up to 60% cases
Childhood and adulthood ADHD share many characteristics
Some symptoms developmentally different – not on the go all the time, climb all over the place, symptoms expressed differently
Other studies look at the clinical presentation – similar in child- and adulthood
Other evidence from treatment outcomes – response to medication, psychological treatment
Other evidence from genetic studies
fMRI and neuropsychological studies – what happens in the brain when they are doing cognitive tasks?
characteristics of adult ADHD
Inattention, impulsivity and hyperactivity
Restlessness
Problems with the reg of activity levels to the demands of a situ
Lack of organised behaviour – e.g. at work and home
Emotional instability, e.g. frustration and mood swings
affect on adults functioning
The association between ADHD and impairment is more robust in adults than children (Rchild = .30 v Radult = .70
In rank order from most to least impairing:
o Education
o Family life
o Occupation
education functioning
(e.g. difficulties in handling academic workload, organising assignments)
family life functioning
(e.g. have lower average levels of family cohesion and marital adjustment)
occupation functioning
(e.g. less likely to be employed, especially full-time, more likely to quit their job)
aetiology of ADHD
Genes
Env
Brain and neurophys factors
genetics - data from twin and family studies
Relatives of indvs with ADHD are 2-8x more likely to have ADHD compared to relatives of indvs without ADHD
Candidate genes = genes involved in dopaminergic and serotonin transmission
7-8 genes identified
Specific env condition needed to express condition
There is a genetic component – quite heritable
smoking during pregnancy and prematurity
Smoking during pregnancy is a risk factor for ADHD (odds ratio = 2.39) – association may be due to confounders – might also experience other problems, e.g. drug addiction, poverty – need to consider methodological problems
Low birth rate is associated with increased risk for ADHD
Children born preterm are more likely to have a diagnosis of ADHD, in particular inattention
the family environment and ADHD
During parent-child interactions children with ADHD are more oppositional, less compliant, and less stable to follow parental requests – negative and argumentative
Parents of children with ADHD are more critical, controlling and demanding and less responsive
It is likely that parents and children exacerbate each other’s. behaviour (bi-directional influence) – influence behaviour in a negative way
Studies show that reducing child ADHD symptoms via medication decreases parent’s control and negativity indicating the child’s influence on parenting – improved interactions
Parent’s characteristics (e.g. ADHD symptoms, depression) also imp
diet
Preservatives can influence behaviour of preschool children – more hyperactivity
Low levels of iron/FAs at risk of ADHD symptoms
Findings are very promising – can develop diet interventions – preferable to medication
Few studies have found small effects
brain - the default mode hyp
ADHD can be considered as a disorder related to disconnection of brain regions of the default mode network (DMN; brain regions that activated “when the brain is at rest”
Hypothesised that indvs with ADHD have difficulties at the transition from rest to task performance but DMN’s function is unimpaired during rest
Differences in brain structure, size and function – prefrontal lobes
Cerebellum smaller in size – initiation of cognitive and motor responses
ADHD is a problem as parts of the brain are quite disconnected – struggle with connection of different tasks – default mode hypothesis
integrative developmental model hyperactive/impulsive type of ADHD - Barkley
Argued that reduced behavioural inhibition (defined as the ability to delay a motor response) is core feature of ADHD
reduced BI leads to impaired exec functioning inc:
“Non-verbal WM (holding info in mind)
Internalised speech/verbal WM (self-talk, language to guide self)
Self-reg of affect (ability to regulate emotions)
Reconstruction (higher order thinking processes, e.g. analysis, synthesis)
Motor control and fluency (planning and execution of actions)”
the delay aversion hyp
Studies indicate children with ADHD show dysfunctions of reward and motivation
Children with ADHD impulsive as they try to avoid delay – choose immediate over large delay rewards
Sonuga-Barke argued ADHD can be explained by both cog and motivational deficits (the dual pathway model)
the dual pathway model (Sonuga-Barke)
2 problems are independent – why there are 2 subtypes
empirical evidence for delay aversion in children with ADHD
Maudsley’s Index of Delay Aversion (MIDA)
Choice between:
o Immediate small reward after 2s OR
o Delayed large reward after 30s
Main index:
o % of selection of larger reward (% larger reward) - DV
delay aversion - MIDA
There was a sig group effect: p = .01
Sig age effect: p=.001
There was no sig interaction between group x age: p=.95
evidence for inhibitory deficits in children with ADHD - go/no go (GNG)
Children were instructed to respond as fast an accurately as could to go stim by pressing the left/right computer mouse button indicating direction of green left/right-pointing arrow respectively, but not to respond to No-Go stim
Main index: prob of commission to No-Go stim
inhibition - GNG
Sig group effect: p=.01
No sig age effect: p=.41
No sig interaction between group x age: p=.49
Couldn’t stop response
stop signal task
Ps instructed to respond to ‘Go’ stim by pressing a response button and, whenever an auditory tone occurred, to inhibit their response to the ‘Go’ stim
Six 32-trial blocks
Main index: Stop Signal RT (SSRT)
inhibition - SSRT
No sig group effect: p=.12
Sig age effect: p=.001
No sig interaction between group x age: p=.94
