Week 3: ADHD Basics & Epidemiology Flashcards
Is ADHD real?
What is the evidence for this?
What 3 things is a diagnosis associated with?
Who consumes all the drugs?
Many have argues that ADHD is a product of western culture and pathologizing common mental experience and unrealistic expectations concerning children’s behavior or a product of the pharmaceutical industry promoting its interests
HOWEVER
The prevalence of ADHD is similar worldwide if you conduct thorough testing.
Presence of ADHD is associated with marked impairment:
Problems with peers (no friends)
Problems with school (failure)
Mortality (more likely to be in fatal accidents)
BUT
In the USA, 92-95% of ADHD medication is bought by the USA. So in NA this is way higher than the rest of the world.
For the purposes of this course, ADHD is real.
Core characteristics of ADHD
1) Inattention
Inability to sustain attention, especially for repetitive, structured and less-enjoyable tasks (can stick to stuff they like, video games)
2)
Hyperactivity/Impulsivity
Hyperactivity - inability to voluntarily inhibit dominant or ongoing behavior
Impulsivity - inability to control immediate reactions or to think before acting
DSM-5 Criteria (3 types)
Primarily inattentive: ADHD PI
- At least 6 inattentive symptoms, fewer than 6 hyperactive symptoms
- 17 or older; 5 inattentive symptoms, fewer than 5 hyperactive symptoms
Primarily hyperactive: ADHD HI
- At least 6 hyperactive symptoms, fewer than 6 inattentive symptoms
- 17 or older - at least 5 hyperactive, fewer than 5 inattentive
Combined - ADHD C
- At least 6 hyperactive and at least 6 inattentive symptoms
- 17 and older, 5 & 5
Reflects the fact that normatively, these symptoms decrease with age
DSM-5 Criteria (additional)
4 things
1) Symptoms must persist for more than 6 months
(this could be too small for young children who could be going through a phase)
2) There must be persistence (ongoing), impairment (must get in the way) and non-normative m(must be different from what we expect from a child of that age)
3) Several symptoms were present BEFORE 12 YEARS OF AGE
Used to be 7 in DSM IV
Could be diagnosed later but have to have symptoms before
4) Several symptoms are present in at least two settings
Typically home and school
Emphasizes that you need two people’s report (parent and teacher)
DSM-5 Criteria (Severity)
3 classifications
Mild:
Few, if any, symptoms in excess of those requires to make the diagnosis. Symptoms cause minor impairment in social or occupational functioning
Moderate:
Symptoms of functional impairment between mild and severe are present
Severe:
Many symptoms in excess of those required to make the diagnosis are present or several symptoms that are particularly severe. Or the symptoms result in marked impairment socially or occupationally.
-Such a child could not be in a regular classroom
Categorical vs dimensional
What says it is categorical?
What says it is dimensional?
DSM says ADHD is categorical
Research says it is dimensional
Assessment of ADHD:
What do you use?
Who do you ask?
Are there differences in reports with these people?
Are children useful for diagnosis/
What do you focus on when assessing ADHD?
Rating scales and interviews
- Teacher report is crucial as we need to know about functioning at home and at school
- Parents reports of symptoms/impairments at school is better correlated with their assessment for home than the teacher report for school (and vice versa)
- Teachers also see many children so can place this vs. a normative standard
- Situations at school press for hyperactivity/attention whereas at home the parents will adapt and not make the child who lacks concentration do tasks that require it
Do not ask youth, they underestimate their issues and it is not a reliable report. Good to check they understand though
Diagnostic interviews
Symptom rating scales
Focus is on OBSERVABLE signs of inattention and hyperactivity/impulsivity
An example of a diagnostic interview for ADHD is the
Kiddie SADS semi-structured interview
Many points to assess, involves clinical judgment by clinician
Combining reports from parents and teachers:
What diagnoses do you get with AND and OR rules?
When you look at parent or teacher alone, you see more ADHD-PI or ADHD-PH (possibly cos of different contexts).
Use the OR rule = many of these cases become ADHD-C
Neurophysiological diagnosis of ADHD
Is there a test?
What do you rule out first?
No blood test equivalent
But usually try to rule out biological factors that could cause inattention
Neuropsychological tests are not currently used in diagnosis but can provide information about symptoms or functioning that is not directly visible
Epidemiology of ADHD (Overview)
What is the point prevalence of ADHD?
What is the 6 month prevalence?
Lifetime prevalence?
Epidemiology of ADHD
- Prevalence of ADHD
- Point prevalence: 5-9% of school-age children in N. America
- Ontario Child Health Study
- 6-month prevalence: 10.5% of children aged 4-11 years
- National Comorbidity Survey - Adolescents
- Lifetime prevalence: 8.7%
Epidemiology of ADHD (Subtype differences by reporter)
Overall ADHD C 3.4%, HI 0.8%, PI 1.8%
Prevalence if diagnosis made using
“or” rule for symptoms to combine
parent and teacher report
C 5.1%, HI 2.1%, PI 6.7%
Prevalence if diagnosis made using
“and” rule for symptoms to combine
parent and teacher report
C 0.8%, HI 1.9%, PI 2.1%
Epidemiology of ADHD (Cultural and contextual differences)
Children in many cultures and countries meet diagnostic criteria for
ADHD
Slightly more prevalent among children living in poverty
Epidemiology of ADHD (Gender)
What ratios for each sex?
How do boys and girls typically present (what symptoms)?
3 boys:1 girl ratio in community
6 boys:1 girl ratio in clinics
Boys are sent to get treatment more. Could mean there are suffering girls who do not get treatment
Symptom presentation varies by gender
-In community samples, boys are more likely than are girls to be diagnosed with all subtypes of ADHD, but the gap is wider for ADHD-C and ADHD-HI than it is for ADHD-PI
-Girls more likely to be inattentive, drowsy, daydreamy, hyberverbal
-Boys more likely to display overt defiance and aggression
-May be more likely to be referred because of it
-Note that you do not see the same differences in presentation between boys and girls in
clinically referred samples (so maybe it is the oppositional ones that get referred as they are referred by parents dealing with this oppositional form
The developmental course of ADHD
Infancy:
-“Should” be present at birth. No idea if it is
-No reliable and valid measures to assess symptoms below three years of
age
Preschool:
- Hyperactivity-impulsivity appears around 3 to 4 years of age
- Often interferes with parent-child relationship
- If symptoms last for about a year, child is likely to continue to have challenges
Elementary school:
- Inattention becomes noticeable with cognitive demands of school
- Start to see some decline in hyperactivity-impulsivity over the elementary school years
This means they get better but still have issues greater than that of non-ADHD kids
