Lecture 10 ADHD

Question 1

DSM-5 ADHD criteria A

Answer 1

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, characterised by 1 and/or 2

> =6 symptoms, >=5 in adolescents and adults, at least 6 months, inconsistent with developmental level, direct negative impacts

symptoms not solely manifestation of oppositional behavior

Question 2

A1 Inattention

Answer 2

a. 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 3

difference from normal inattention

Answer 3

attention intact in ADHD

difficulties in persistence: the capacity to sustain action/attention towards a goal/task

failure to direct behaviour forward in time, to persist toward delayed end points

reflect impaired working memory

impaired ability to resist distractions, do not perceive distractions differently, rather

• respond to distractions more
• react to event 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

Question 4

A2 hyperactivity/impulsivity

Answer 4

a. 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

Question 5

missing impulsivity

Answer 5

emotional impulsivity

ADHD not a mood disorder or emotional disorder, BUT nonetheless associated with poor emotional control

rapid and unmoderated emotional expression (impatience, low frustration tolerance, quickness to anger, prone to emotional arousal)

Difficulties in self-soothing, down-regulating, in order to express emotion in ways that are socially acceptable, or consistent with longer-term goals

Question 6

Externalising disorders

Answer 6

ADHD, ODD, CD

Highly comorbid (about 50% ODD; 20% CD).

more common in males than females(2:1)

Phenotypic overlap with ODD/CD, particularly hyperactive / impulsive features.

Question 7

currently conceputlaised as neurodevelopmental disorder

Answer 7

clusters with autism, motor coordination, reading/learning disabilities.

associated with early alterations/immaturities in neural development

shows a trajectory that maps onto that of self-regulatory capacities

Question 8

other diagnostic criteria

Answer 8

B. Several symptoms present prior to age 12 years.

C. Several symptoms present in two or more settings (e.g., home/ school/work; friends/relatives; other activities)

D. Clear evidence that the symptoms interfere with social, academic, or occupational functioning.

E. Not better explained by another condition.

Question 9

comorbidities

Answer 9

2/3 of children with ADHD present with ≥ 1 comorbid Axis I disorder

Question 10

Developmental trajectory

Answer 10

hyperactivity: most pronounced in preschool, decline overtime
inattention: increasing apparent with age, as peers undergo rapid maturation of prefrontal cortex, as school demands intensify

Question 11

factors of ADHD

Answer 11

teratogens & toxins during critical periods in pregnancy:

• pesticides
• prenatal nicotine
• lead
• paracetamol

dietary factors: synthetic food colours 8% of ADHD

genetics: average genetic contribution of ADHD based on twin studies = 0.8

Question 12

relationship of parenting practice with ADHD

Answer 12

high levels of parental involvement -> reduced hyperactivity/inattention across early childhood

high levels of inconsistent discipline -> increasing hyperactivity/inattention across middle childhood

Question 13

parent-child hostility and child ADHD

Answer 13

time 1 ADHD relates to time 2 mother-child hostility

1) ADHD symptoms elicit negative responses from parents and family

Children treated with stimulants show improvements not only in symptoms of ADHD but also quality of parenting

Question 14

2. gene-environment correlation

evocative vs passive rGE

Answer 14

evocative: child characteristics that are genetically based, evoke negative responses from parents
passive: same genes that underlie ADHD in child, underlie parenting problems in parents
- tested by longitudinal adoption-at-birth design, testing genetically unrelated mothers and offspring -> evocative rGE, controlling confounding passive rGE

Question 15

indirect pathways in adoptive parent-child

Answer 15

1) biological mother ADHD symptoms -> child impulsivity/activation -> child ADHD symptom (age 6)
2) biological mother ADHD symptoms -> child impulsivity/activation -> adoptive mother hostility to child -> child ADHD symptom

Question 16

gene x environment interaction in ADHD

Answer 16

association between inconsistent parenting and ADHD symptoms stronger for those with the long allele of DRD4 gene (genetic risk)

Question 17

dual pathway model of ADHD

Answer 17

Two distinct processes, involving distinct but overlapping neural architecture, both shaped by environmental processes

1) deficits in inhibitory-based executive processes (response inhibition):
- 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: neurobiologic impairment in the power and efficiency with which the contingency between present action and future rewards is signaled.
   - reduction in the control exerted by future rewards on current behaviour
   - increase in the extent to which future rewards are discounted
   - based is frontal-limbic circuitry (including amygdala) dopamine a key neuromodulator

Question 18

delay aversion hypothesis

Answer 18

negativity associated with failure to signal future rewards becomes associated with situations that signal the need to delay gratification

manifests as attempts to avoid/escape delay by attending to the most interesting/absorbing aspects of the environment or acting on that environment (hyperactively)

Question 19

how does environment amplify delay aversion

Answer 19

Negative/punitive parenting reactions to hyperactive behaviour make delay experience even more aversive

Inconsistent parenting: If rewarding events are promised but not delivered as predicted, delay may gradually then come to signal uncertainty/disappointment

The more child avoids delay the fewer opportunities to develop organisational skills to manage delay effectively.

Question 20

valid diagnosis for ADHD: tests

Answer 20

no single test to identify ADHD

Available “objective tests”are primarily Continuous Performance Tests (CPTs):
–TOVA (Test of Variables of Attention)
–Conner’s CPT
–Gordon Computerized Diagnostic System
–I.V.A. CPT

Diagnosis must be multi-factorial

Question 21

valid diagnosis: clinical interview

Answer 21

-Diagnostic Assessment of Primary Complaint

–Review of Psychiatric Systems (e.g., attention, hyperactivity/impulsivity, oppositional & conduct difficulties, mood, anxiety, psychosis, trauma, neurovegetativesystems, tics, substance abuse, etc.)

–Medical, Psychiatric, & Developmental History

–Detailed Educational History

–Detailed Family & Social History

Question 22

valid diagnosis: collateral interview

Answer 22

–Child
–Primary Caregivers (parents, grandparents, etc.)
–Teachers, School Counselors
–Sunday School Teachers
–Sports, Music, Coaches

Question 23

valid diagnosis: age effects

Answer 23

Normative versus ‘clinical’ significance of symptoms, “Some” symptoms by age 7 years

inattentive subtype exhibited a later onset

adult population survey found that only 50% of individuals with clinical features of ADHD retrospectively reported symptoms by age 7, but 95% reported symptoms before age 12 & 99% before 16

DSM-V will possibly reset age to 12 years to decrease rate of false negatives

Question 24

valid diagnosis: setting

Answer 24

Symptoms in ≥ 1 setting:
–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
–Symptoms in group settings are a must!

Question 25

valid diagnosis: rating scales

Answer 25

–SNAP 
–IV (for parents & teachers)
–Conners(for teachers, parents, and affected adults)
–ACTeRS(for teachers & parents)
–Child Behavior Checklist
–Behavior Assessment System for Children (BASC)
–ADHD Rating Scale –IV 
–Brown ADD Scales

Question 26

Multi-Modal Treatment Study for ADHD (MTA)

Answer 26

Medical management (titrated stimulants)
Intensive Behavior Therapy
Combined treatment
Treatment as Usual in the Community (TAU)

All groups showed reductions in ADHD

On primary outcome measure (ADHD sx), medication alone and combined did better than behavioral alone and TAU

On many measures, combined was not significantly better than medication alone

Only combined was better than TAU on oppositional symptoms, aggression, depression/anxiety symptoms, social skills, parent-child relationship, and reading achievement

Higher medication doses were needed in the medication only group relative to the combined treatment group

Question 27

Combined Treatment was superior in terms of

Answer 27

Parent and teacher satisfaction with treatment

Normalization of child behavior

Improvements in functional outcomes

• Family interactions
• Peer relationships
• Academic functioning

Question 28

MTA 6-8 year follow-up

Answer 28

Original treatment assignment not associated with any of the 24 outcomes 6-8 yrs later

ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes

• Children with the best initial tx response and most favorable clinical presentation at baseline fared best over time
• Children with behavioral and sociodemographic advantage, with the best response to any tx, had the best long-term prognosis

As a group, children with combined-type ADHD exhibit significant impairment in adolescence (on 9 of 21 measures)

This suggests a need for sustained treatment over the long term

Question 29

Treatment of ADHD conclusion

Answer 29

Psychosocial interventions (parent training; classroom programs) improve functioning.

However, only stimulant medication appears to act on the core features of the disorder.

Stimulants do not ‘cure’ ADHD

Individual differences in response to stimulants are vast, and side effects may preclude use