Lecture 3: ADHD Flashcards
ADHD Past & Present Diagnoses
1917- Post Encephalitic Behavior Disorder
1940-1950-Minimal Brain Dysfunction (MBD)
1960’s – Hyperkinetic Reaction of Childhood
- there was a type of “ping-pong” effect that occurred in the scientific community, varying between which aspect seemed more dysfunctional, inattention or hyperactivity
- Inattention is really what impedes progress at school, which led to the focus on attention deficits…
1970– Attention Deficit Disorder (ADD)
*Specifiers – With/without Hyperactivity
1980-Present: Attention Deficit / Hyperactivity Disorder (ADHD)
*The slash is critical, as it denotes that both aspects do not necessarily present together.
*Previously, it was thought that the presentation will generally stay the same at different ages, but increasing
evidence was mounting that different presentations occur different developmental stages
*With the DSM-5, it is “presentations” instead of subtypes
Inattention (IN); Hyperactive-Impusive (HI); Combined
Prevalence of ADHD
3-9% of elementary school population, may range up to 14%
More common in males than females, ranging from 4:1 to 9:1
One of the most common disorders of childhood
*this is possibly due to ADHD being an easy “go-to” diagnosis, with the thinking that if the diagnosis is wrong, there is plenty of time to reevaluate and re-diagnose later
accounts for a large number of medical and mental health referrals
Diagnostic Criteria for ADHD
Symptom Criteria
- core symptoms of hyperactivity and impulsivity and/or inattention
- 6 or more symptoms of either category
Duration Criterion
*symptoms have persisted for at least six months
Developmental Criterion
*symptoms are inconsistent with developmental level
Impairment Criterion
- clear evidence of clinically significant impairment in social, academic, or occupational functioning
- *this might be the most important criterion, as behavior is deemed pathological primarily when it creates impairment in functioning
Age Criterion
- some symptoms that cause impairment were present before age 12 (previous age was 7)
- *in general, it is tough to diagnose the very young due to developmental considerations, diagnosis is rarely given before age 3-4
Situation Criterion
- some impairment from symptoms is present in multiple settings
- *sometimes the symptoms only exist in school settings – not necessarily ADHD
Exclusion Criterion
*psychotic disorder or other mental disorder
Specifier
*“in partial remission” included for adolescents-adults with symptoms but not meeting full criteria
Major Changes to DSM-5
Change from three subtypes into three specifiers:
- combined presentation
- predominantly inattentive presentation
- predominantly hyperactive/impulsive presentation
ADHD across the lifespan: more examples were added to increase applicability to adults
Changing age of onset to 12 (formerly 7)
Removed autism from exclusion criteria
*e.g. twins with autism, boy with ADHD, climbing on everything, eating purell
DSM-5 Symptoms of Hyperactivity
Often fidgets with hands or feet, squirms in seat
*e.g. video of interview with Jack, five-year-old boy
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often runs about or climbs excessively in situations in which it is inappropriate
Often has difficulty playing or engaging in leisure activities quietly. Is often “on the go” or often acts as if “driven by a motor”
Often talks excessively when inappropriate to the situation
Hyperactivity, general
Children with ADHD are more active, restless and fidgety than normal children during the day AND during sleep
different types of hyperactivity:
- gross motor activity
- restless/squirmy
- occasionally there is a form of verbal hyperactivity
Hyperactivity often varies according situation
Degree of hyperactivity may vary with age
DSM-5 Symptoms of Impulsivity
often blurts out answers before questions have been completed
often has difficulty awaiting turn
often interrupts or intrudes on others
*Six symptoms of hyperactivity AND impulsivity are required for diagnosis
DSM-5 Symptoms of Inattention
Often has difficulty organizing tasks and activities
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
Often loses things necessary for tasks or activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Cross-situational
*instead of separate section, specifiers/symptoms were added that were more relevant to adults (e.g. workplace)
Attention, general
The greatest difficulties are with sustaining attention, being vigilant
- playing video game for 4 hours is not an example of paying attention – a child with ADHD is able to do this, as it is exciting and engaging
- What a child with ADHD is not able to to is sustained attention when the task takes effort, when is something that they do not want to do…
Most clearly seen in situations requiring the child to attend over time too dull, boring and repetitive tasks
Theoretical Considerations 1970s-present
“Top Down” theories – cognitive control
*Barkley–deficits in rule governed behavior and response inhibition
“Bottom Up” theories – motivational/energetic factors (it may be more intrinsically rewarding to be impulsive)
*Sagvolden – reinforcement gradient
Sluggish Cognitive Tempo (SCT)
Dr. Ohr: “presentation of a presentation”
Subset of children with predominantly inattentive presentation who show few or no symptoms of hyperactivity or impulsivity
*forgetful
- daydreams, sluggish/slow to respond, drowsy/sleepy
- **Not explained by depression
- easily confused
- seems to be “in a fog”
- stares into space
- acts overtired
- underactive/lacks energy
ADHD Proposed Developmental Progression
Difficult infant temperament as early precursor
Initial development of ADHD most often during preschool years
*tentative to diagnose until later due to potential conflicting developmental factors
Decline in level of activity and improvement in attention and impulse control in adolescence, but 80% still continue to meet diagnostic criteria
*it shows up in different ways: sexual promiscuity, alcohol/drug use, rule breaking behaviors (truancy, stealing, sexual assault)
**these behaviors are simply more likely, not a destined path for children ADHD, just one of the paths that have been clearly documented
Etiology: Biological Risk Factors
Genetics
*.80 heritability with twins, 50+ risk if parent has diagnosis, dopamine type 2 gene
Neurological Insults – anoxia, seizure disorders, encephalitis
Neurotransmitter deficiencies – – decrease the risk of economic
Anatomical atypicalities – smaller corpus callosum
Cerebral blood flow – decreased to prefrontal and frontal regions and pathways
Etiology: Psychosocial Factors
Less evidence for psychosocial factors
Parent-child conflict may exacerbate problems
Lack of consistent parenting strategies, poor limit setting
However, psychosocial factors may contribute to development of comorbid disorders that may complicate the clinical picture
ADHD Prognosis in Adulthood
As many as 67% of children with ADHD display symptoms in adulthood serious enough to interfere with academic, vocational or school functioning
Type of ADHD that persist into adulthood is more highly genetic than type that remits and childhood
*the younger the presentation of any pathology, the more likely it will persist
ADHD in adults is sometimes considered a “hidden disorder” as symptoms are often obscured by other problems
Prevalence is thought to be 2 to 4% with sex ratio of 2:1 or lower
ADHD Common Comorbid Conditions
Prevalence, high to low:
Oppositional Defiant Disorder
Anxiety Disorder
Mood Disorder
Learning Disorder
Conduct Disorder
Recent Changes in Defining ADHD:
4 Executive Functions (Barkley)
Prolongation
Separation and Regulation of Affect
Internalization of language
Reconstitution
Prolongation: Holding and evaluating events in working memory
* unable to bring rules/consequences to mind in the moment
Separation and Regulation of Affect: Splitting facts from feelings
Internalization of language: Reflection, self-control, willpower
Reconstitution: Break events into parts and reassemble into new ideas
Barkley’s Research Validating Executive Function Deficits
Children with ADHD have difficulty with:
- inhibiting behavioral responses
- working memory
- planning and organization
- verbal fluency
- perseveration
- motor sequencing
- various frontal lobe functions
Issues and Controversies
Overmedicated/Overdiagnosed?
Allen Frances:
Will changes to DSM-5 trigger a fad of adult ADHD “leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs”
After much consideration, “inattentive restrictive presentation” was not included
- this category would have reflected SCT – no impulsivity, no hyperactivity
- *Dr. Ohr was very surprised to learn of its omission
Comorbidity with bipolar disorder (impulsive behavior very common with BPD) & ODD
Are there other ignored subtypes? (SCT)
What about diagnosis prior to age 4?
General Lecture Notes / Considerations
ADHD YouTube video (boy on roller skates)
Certain lyrics were very representative of disorder:
*his actions occurred unintentionally – however, it is common to see children become oppositional and perform intentional defiant acts following unintentional outbursts
Executive Functioning
*children are unable to bring rules/ consequences to mind in the moment
Dr Ohr: this is just one piece of a very complex puzzle – EF has many different components, many factors at play – e.g. lack of NT’s, which decreases blood flow, producing a oxygen deprived environment
*or the consequence exists, but does not have the reinforcement power (e.g. understanding that by behaving a certain way will increase likelihood that others will want to play with you)
Difficulty Titrating Medications
*children are in constant physical development, as they go through growth spurts it becomes very difficult to maintain the proper level of medication
**Barkley: he started out as viewing meds as a last resort, but shift in thinking is growing evidence pointed to ADHD as a neurodevelopment disorder (where it is now classified in the DSM-5)
Treatment of ADHD
Stimulant Medications
Other Medications
Psychosocial Treatments
Educational Accommodations
ADHD: Commonly Used Stimulant Medications
Ritalin
Dexedrine
Adderall
Concerta
Between 70 to 80% of children with ADHD respond positively to stimulant drugs
Side Effects of Stimulants
Loss of appetite, weight loss, sleeping problems, irritability
Restlessness, stomachache, headache, rapid heart rate, elevated blood pressure, sudden deterioration of behavior
Symptoms of depression with sadness, crying, and withdrawn behavior
Intensification of tics, possible Tourette’s and growth suppression
Side effects usually transient in nature and result of inappropriate medication levels
If one medication results in side effects, another might be used without side effects
Sometimes other medications are used to minimize side effects
Good clinical judgment by the clinician may help to minimize side effects
NonStimulant Drugs in ADHD Treatment
Strattera
norepinephrine reuptake inhibitor
Antidepressants (e.g.Tofranil, Wellbutrin)
Anti-hypertensives (Clonidine)
ADHD Psychosocial Treatments
Parent training
Behavioral management
Social skills training
Cognitive behavioral therapy
Psychotherapy for comorbid conditions
ADHD Educational Interventions
Special Education Services for existing learning problems
Classroom accommodations
Classroom behavior modification programs
Multimodal Treatment for ADHD
In treating ADHD it is essential to treat the full range of difficulties that impact on child and family functioning
Treatment of ADHD will often need to be “multimodal” in nature
Findings from the multimodal treatment studies suggest that stimulant medication is effective in reducing core symptoms & psychosocial treatments are of value in addressing associated comorbidities
Assessment of ADHD
Direct Observation–functional behavioral analysis
Parent, Teacher & Self-Reports
- BASC –Behavior Assessment System for Children
- CBCL–Child Behavior Checklist
- Conners (Only test that includes Impairment measure)
Semi-Structured Interviews of Visual Attention
TOVA–Test of Variables of Attention
Clinic-Based Diagnostic Assessments
Matching Figures Task
Continuous Performance Task (CPT)
*These do not facilitate differential diagnosis between ADHD, ODD, & CD–they do not correlate strongly with behavior rating scales
Interventions / Treatments
Behavioral:
Patterson
*Parent Management Training
Eyberg
*Parent-Child Interaction Therapy
Webster-Stratton
- Incredible Years
- (based primarily on Patterson’s Coercion Hypothesis)
CBT:
Kazdin
*Problem-Solving Skills Training (PSST)
*PSST-P: Addition of in vivo Practice
Group:
ADHD Summer Treatment Program
*8 weeks, 8 hours/day, 5 days/week
*Parental involvement mandatory
MTA Cooperative Group
*combined treatment strategy
