Outline – Lecture 5, Feb. 4/03 Ch. 5: ADHD Overview of ADHD [Attention-Deficit/Hyperactivity Disorder] Primary Clinical Features Prevalence & Developmental course Co-morbidity & Associated problems Theories and Causes Assessment & Treatment of ADHD

Overview of ADHD Considered a severe disorder with biological underpinnings Symptoms: age-inappropriate inattention, hyperactivity, and impulsivity Associated with problems in social, cognitive, academic, familial, and emotional domains of development and adjustment

History of ADHD Early 1900’s- considered to be due to poor “inhibitory volition” and “defective moral control” Great encephalitis epidemic of 1917-1918 gave rise to the concept of a brain-injured child syndrome, which was often associated with mental retardation In 1950’s- referred to as hyperkinetic impulse disorder with motor overactivity seen as primary feature By 1970’s, deficits in attention and impulse control, in addition to hyperactivity seen as the primary symptoms Most recently, more focus on child’s impulsivity

Primary Clinical Features Inattention or distractibility Selective attention vs Sustained attention Impulsivity Difficulty inhibiting behaviour Hyperactivity Excessive activity and restlessness Centrality of attention deficit now being questioned.

Diagnosis & Prevalence of ADHD DSM-IV - 3 subtypes To qualify for a diagnosis, the behaviours: must appear before the age of 7 must be severe and persistent must impair the child in at least two areas of life Prevalence: 3-5% of all school-age children Rates decline from childhood to adolescence More boys than girls [3 - 9 boys to 1 girl] Cross-cultural differences in rates

DSM-IV: Subtypes Predominantly Inattentive Type: Symptoms of inattention without hyperactive or impulsive behaviours. Predominantly Hyperactive-Impulsive Type: Symptoms of hyperactivity and impulsivity but no inattention Combined: Symptoms reflecting both inattention & hyperactivity-impulsivity

Limitations of DSM Criteria Developmentally Insensitive Categorical view of ADHD Requirement of an onset before age 7 uncertain – particularly for inattentive form Requirement of persistence for 6 months may be too brief for young children

Developmental Course: Infancy No reliable or valid way to diagnose the disorder prior to age 3. It is believed that ADHD often begins in infancy or early childhood, and can possibly be evidenced from birth and even pre-natally. Hyperactivity-impulsivity appears first

Developmental Course: Preschool Most commonly reported age of onset is 3 to 4 years Symptoms of ADHD become more visible. Children with ADHD commonly display: negative temperament impulsive behaviours & decision making boredom non-compliance temper tantrums deficits in academic skills

ADHD in Middle Childhood The symptoms of ADHD usually become quite noticeable when a child begins school. Inattention can result in poor academic performance, even if intelligence is not a problem. Transition times (after recess; between classes, especially if room changes are required) can be particularly difficult. Problems in peer relations may also develop at this stage. Oppositional and socially aggressive behaviors develop in 40%-70% of ADHD children

Adolescence & Beyond ADHD continues into adolescence for about 50% to 80% of the school-aged children who have been diagnosed. Impulsivity may make the adolescent more likely to engage in risky behaviour. Difficulties with academics and peer relations continue. New difficulty: treatment compliance. Most problems continue into adulthood

Characteristics of Adolescent ADHD tendency towards substance abuse feelings of anxiety easily frustrated sleep disorders problems with anger management may be under or over reactive difficulty concentrating difficulty maintaining relationships chronic forgetfulness time management problems disorganized lifestyle periodic depression mood swings feelings of restlessness impulsive or risk-taking behavior low self esteem chronic patterns of underachievement

ADHD in Boys and Girls SIMILARITIES expression of the disorder & severity of symptoms impulsivity academic performance social functioning parent-child interactions family rates of ADHD response to medications DIFFERENCES boys show more: hyperactivity aggression and antisocial behaviour impairment in executive functions girls: show more verbal and non-verbal intellectual impairment may be less likely to be diagnosed

Associated Problems Academic problems Social and conduct problems Cognitive deficits Social and conduct problems Problems in interpersonal and peer relationships More prone to accidents & injury Deficits in adaptive functioning Motivational deficits Deficits in self-regulation & inhibition

ADD without Hyperactivity vs ADD with Hyperactivity ADD ADHD -socially withdrawn -more behaviour problems -less popular -more self conscious -more self destructive -slower cog. tempo -more impulsive -more likely to have LD -more likely to have CD

Co-Morbidity Conduct Disorder [CD] ADHD vs CD ADHD+CD -more cognitive -more antisocial -lower academic deficits parents achievement -more achievement -more family -more school deficits hostility expulsions -more off-task beh. -lower SES -more antisocial beh. -more prominent -more social skills -substance abuse organic etiology -worse prognosis -poorer occupational adjustment -more parent hostility -more parental delinquency

Co-Morbidity Learning Disabilities [LD] Other co-morbidities include: ADHD vs LD ADHD+LD -more deficits -more deficits -most pervasive in sustained in selective attentional deficits attention attention Other co-morbidities include: Anxiety Depression Oppositional Defiant Disorder Tourette’s Syndrome

Theories of ADHD Motivation Deficits Deficits in Arousal Level Deficits in Self-regulation Deficits in Behavioral Inhibition Also See Figure 5.2

Causes of ADHD Biological Pregnancy & Birth Complications Genetics Neurobiology Pregnancy & Birth Complications Diet, Allergies, Lead Psychosocial Factors Family influences Negative feedback in classroom

Assessing ADHD Interviews Naturalistic observation Behavioural ratings and checklists Biological assessment Tests to evaluate inattention and impulsivity: Matching Familiar Figures Test Children’s Embedded Figures Test Continuous Performance Test Waiting tasks

Treatment of ADHD Pharmacological treatment Behavioural Intervention stimulants concerns Behavioural Intervention Parent Management Training Classroom management Cognitive-behavioural & Self-regulation Multimodal treatments

Classroom Strategies Classroom Characteristics Teacher Characteristics lighting, temperature, ventilation space and seating Teacher Characteristics tolerance, assistance teaching style Instructional Techniques and Homework Modifications language, cueing, check comprehension division of work Evaluation alternate forms