Lecture 4: ADHD Flashcards
adhd sympom clusters & presentations & prevalences
Two symptom clusters in DSM-5:
* Inattention (9 symptoms)
* Hyperactivity/impulsivity (9 symptoms)
-> 6/9 symptoms per cluster, pervasiveness (>1 setting), impairment, symptoms present <12 y/old
Three presentations:
* Inattentive (~30%)
* Hyperactive/impulsive (~5%)
* Combined (~65%)
wat valt op aan die prevalenties
er zijn dus maar heel weinig mensen met alleen de hyperactieve presentatie
four neurocognitive domains impaired in ADHD
- cognitive control
- timing
- emotion dysregulation
- reinforcement sensitivity
wat is er nog meer te zeggen over neurocognitive functioning
- Neurocognitive profiles observed on group level, also children without problems
- Neurocognitive profiles -> heterogeneity
- Problems are often first recognized at school -> higher demands placed on neurocognitive functions
ADHD voordelen
- nooit saai
- energiek
- enthousiast
- creatief
- veel humor
- kan keihard werken
- doorzetter
- anderen helpen
- oplossingen bedenken
- spontaan
prevalence ADHD
- children: 3.7% (1 in elke schoolklas)
- adults: 2.5%
subthreshold ADHD:
- 11-18% of children
- similar, but sometimes milder problems and impairments
- predictive of onset full threshold ADHD
gender ratio ADHD
3 boys: 1 girls
is adhd iets van deze tijd?
the prevalence of ADHD did not increase over the last 30 years, so no
ik ben druk omdat ik ADHD heb -> cirkelredenering
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causes of ADHD
multifactorial:
- genetic factors (high heritability) -> vulnerability
- prenatal factors (maternal stress, intoxication)
- interactions with environment (diathesis stress model)
- ADHD: inattention, hyperactivity, impulsivity
- Highly prevalent
- High comorbidity with several other disorders – makes differentiation clinically challenging
- Causes are multifactorial – gene-environment interactions
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Nuanced response: “If you are diagnosed with ADHD, you will have that forever”
ADHD is a neurodevelopmental condition, meaning it begins in childhood and typically persists throughout life. However, the way ADHD presents can change over time. Some people develop coping strategies, making symptoms less disruptive, while others continue to experience significant challenges into adulthood.
Research shows that while hyperactivity may decrease with age, difficulties with attention, executive function, and impulse control often remain.
ADHD is not curable, but management strategies (therapy, medication, lifestyle changes) can help individuals lead fulfilling lives.
Some adults who struggled in childhood may find that their symptoms become less impairing as their environment changes (e.g., choosing a career that fits their strengths).
Nuanced response: “ADHD is very mild, we should not call it a disorder”
ADHD exists on a spectrum, meaning some individuals have mild symptoms, while others experience severe difficulties that affect daily life.
ADHD is not just about being “a little inattentive” or “a bit restless”—it can significantly impact education, work, relationships, and mental health.
Studies show that untreated ADHD increases the risk of anxiety, depression, substance use, and difficulties with employment and finances.
The term “disorder” is used because ADHD affects the brain’s ability to regulate attention, impulses, and executive function, which can create real challenges.
Nuanced response: “ADHD means you’re just acting a bit young, time will solve this”
ADHD symptoms can resemble behaviors seen in younger children (such as impulsivity or difficulty sitting still), but ADHD is not just about immaturity.
Studies show that ADHD involves differences in brain development, particularly in areas related to attention, impulse control, and executive function.
While some children with ADHD develop better self-regulation over time, many continue to struggle into adulthood if they don’t receive proper support.
Without intervention, ADHD-related difficulties can lead to academic struggles, emotional distress, and self-esteem issues.
ADHD symptoms in preschool
- behavioural problems
- hyperactivity
e.g.
- bouncing
- attention fluctuates
- constantly needing structure
ADHD symptoms in school-age
- academic problems
- social problems/peer problems
- low self esteem
- oppositional behaviour
- accidents
ADHD symptoms in adolescence
- planning problems
- social problems
- low self-esteem
- addiction
- behavioural problems
- antisocial behaviour
ADHD symptoms in student time
- cognitive under-functioning
- difficulty finding a job
- performance anxiety
- substance abuse
- accidents
ADHD symptoms in adulthood
- job related problems
- low self esteem
- substance abuse
- accidents
- relationship problems
symptom manifestation: hoe komen peer problemen tot stand?
- difficulties recognizing emotional expressions, especially subtle expressions
- people with ADHD may not seem interested due to forgetting birthdays, not texting, etc. lots of demands they cannot seem to keep up with
- weaker emotion regulation -> more peer problems (exp: answered people have neutral faces when they have emotional expressions -> maybe due to attention)
- children with adhd receive up to 5 times more corrective feedback, therefore the student-teacher relationship is less warm and with more conflict.
hoe ontstaat die cycle in student teacher relationship
when you only give the child negative attention, the child will show more negative behaviour
Later in life, childhood ADHD is a risk factor for:
- Traffic incidents
- Substance abuse
- Aggression/delinquency
- Sexual risk-taking (e.g., STD’s, teenage pregnancies)
- Gambling problems
- Financial risk taking (e.g., compulsive buying, not saving money)
- Food related risk taking (causing obesity)
- …many more negative outcomes
-> early intervention and prevention is crucial
do people grow out of adhd?
some children do, others do not:
- 20-45% meet full criteria as adults
- 25-48% have impairing symptoms
but fluctuation is the norm: most people do not show adhd symptoms all the time
metafoor voor ADHD
een auto zonder rem, meerdere computerschermen tegelijkertijd
kan je uit ADHD groeien?
at a group level, children with ADHD have a delayed cortical development: this delay is most prominent in prefrontal regions important for control of cognitive processes, including attention and motor planning
in adulthood this is on the same level!
hoe veranderen de symptomen van adhd
motor and verbal hyperactivity decreases, but hyperactivity in the brain is still present
relative age effect=
ADHD more often diagnosed in youngest children in class
- diagnostic error? (Younger children in the same grade naturally have less developed self-regulation, attention, and impulse control compared to their older classmates. -> mistaken for adhd)
- risk factor? (some argue that being the youngest in a class might create real challenges (e.g., struggling with expectations set for older peers), leading to long-term difficulties in school -> risk factor)
- Opposite Effect: “Being-Old-for-Grade” (Being older than classmates (e.g., due to a delayed school entry) is sometimes linked to better academic performance, self-control, and fewer ADHD diagnoses)
-> not just delayed development, but kind of a double deficit, and you will be recognized earlier on
- Symptom presentation and comorbidity/impairment changes across
development, symptoms often fluctuate over time - Childhood ADHD is a risk factor for many problems later in life
- ADHD prevalence decreases with age
- Sometimes, ADHD remits (minder worden):
- Delayed cortical maturation
- Birthdate effect
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nuanced answer:
“If you give children a fidget spinner, they’ll be able to focus better”
moving helps children with ADHD perform better, maar dit geldt niet voor fidget spinners
nuanced answer: “Children with ADHD are just lazy, if you motivate them enough there is
no problem”
3 clinical adhd models (zijn er een hoop)
- Functional Working Memory Model
- Delay Aversion Theory
- Dual-pathway Model
functional working memory model=
“ADHD symptoms are the result of overwhelmed demands on impaired working memory”
- Working memory = the ability to maintain, control and manipulate goal-relevant information -> crucial cognitive function, which is impaired in many children with ADHD
- WM demands are often too high for children with ADHD (e.g., “finish math exercise 3-6, then continue with reading chapter 5”)
- Children with ADHD seek for behavioral ways to compensate
- Hyperactivity stimulates their brain: “activates brain-based arousal mechanisms that support the executive/supervisory attentional component of working memory”
empirical evidence for functional working memory model
- better WM performance in children with ADHD with higher activity levels -> moving helps children perform better (but: not all motor activity, bv. niet fidget spinners).
- the more difficult the task, the more children with ADHD move. dit is ook zo voor controlegroepen, maar niet zo hyperactief als kinderen met adhd. -> initieert de vraag of we kinderen wel moeten vragen om stil te zitten, of dat we ze de mogelijkheid moeten geven om te bewegen gedurende cognitieve performances?
delay aversion theory =
- ADHD symptoms as a choice to avoid delay,
because delay = aversive - ADHD is associated with problems dealing with delayed reward
- difficult if there is nothing going on: bv als de leraar weggaat, kunnen ze dat niet aan dat er niks aan de hand is
- Delay discounting: “€50,- today or €100 next month?”
- Delay aversion: need immediate rewards rather than delayed ones -> leads to risk-taking behaviours -> short term rewarding, long term harmful
soorten risk taking behaviours
harmful:
* Substance use
* Unsafe sex
* Spending a lot of money at once
* Reckless driving
* Gambling
* Binge-eating
maar ook prosocial:
* lending money
* inviting people to birthdays who may not be as popular
all children are more hyperactive during idle time
Idle time is recovery time, a time for pause and rest. You can sit with your thoughts for a moment and mentally breathe.
dual pathway model
ADHD explained by impairment in:
1. Executive functioning: lastig begrijpen wat er gebeurd en wat ervan hen verwacht wordt, snel beslissen en alles afwegen.
2. Motivational/reward system: need more and longer rewards to change their behaviour. also difficulties motivating themselves, therefore really need external motivation/reinforcement
model in schrift tekenen
Executive functions are needed to process information and guide goal-directed behavior:
- Attention
- Inhibition
- Working memory
- Flexibility/switching
- Organization/planning
- Emotion-regulation
-> all these executive functions are impaired in children with ADHD
dual pathway: reward sensitivity
the reward threshold is later for optimal performance: ppl with adhd need more reinforcement for the same performance
wat helpt volgens dual pathway model als behandeling
- executive functions: deminishing the demands (eerst met ouders, later zelf leren)
* Divide tasks in multiple steps
* Provide structure (fixed places, rituals)
* Use to-do lists
* Keep instructions short and repeat them
* Ignore motor activity
* Prevent distraction (e.g. no window-
seat) - increase motivation door reinforcement/rewards
* Use reward systems
* Reinforce desired behavior immediately
* Make desired behavior explicit
* Create attractive tasks (e.g. gamification)
* Anticipate for problems
* Praise:correct 5:1
(cognitive training does not generalise)
results for dual pathway model experiment
4 groepen: feedback only/geen reward, 1 euro, 10 euro, game spelen
- control performed better than adhd
- controls already optimal with feedback only
- adhd improves with reward (more improvement with higher reward)
- adhd does not normalize: bij control is early/middle/late performance ongeveer gelijk. bij adhd fluctueert het heel erg
-> adhd is characterized by deficits in both pathways (EF and motivation)
implications van dat onderzoek
- Children with ADHD need additional motivation, especially on long tasks (>5 minutes)
- Nevertheless, their performance is worse relative to children without ADHD
- Strategies to diminish working memory demands should be applied
- Strategies to increase motivation should be applied
de 3 modellen in 1 zin
- Functional WM model: ADHD symptoms could be functional
- Delay aversion: ADHD symptoms often manifest as a rational choice to avoid delay
- Dual-pathway model: ADHD is characterized by problems in executive functioning and motivational differences
