Chapter 22 Attention Deficits and Hyperactivity Overview Characteristics of attention-deficit/hyperactivity disorder (ADHD) Causes of ADHD Components of the diagnostic process Different approaches to management Natural history and outcomes Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Introduction One of the most prevalent neurodevelopmental/mental health conditions in childhood Developmentally inappropriate levels of inattention, distractability, and/or hyperactivity Impaired adaptive functioning at home, school, in social settings Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Diagnosis of Attention-Deficit/Hyperactivity Disorder No medical or psychological test Diagnosis involves “ruling in” symptoms of ADHD and “ruling out” other causes Two clusters of symptoms: inattention and hyperactivity/impulsivity ADHD-C (combined type) most common and most studied form; means significant number of symptoms in both clusters: Evident before age 7 Persisting for 6 months Occurring across multiple settings Causing impairment Unaccounted for by another disorder Other ADHD forms exist: ADHD-I, ADHD-HI, ADHD-NOS Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Prevalence and Epidemiology 7%–10% of U.S. children; 5% worldwide Persists into adulthood in 2%–5% of U.S. population Ratio of boys to girls: 6:1 to 12:1 Boys referred more due to aggressive behavior, oppositional and conduct disorders Girls referred for inattentive subtype, associate learning and internalizing disorders, disordered eating Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Clinical Presentation Preschool Symptoms: excessive activity level and impulsivity, “intense” temperament, cognitive inflexibility, aggression toward peers Only severely affected meet criteria; greater rate of developmental delay, coordination disorders, language disorders, and mood and anxiety disorders Should be assessed for language, cognitive, sensory, and autism spectrum disorders Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Clinical Presentation (continued) Elementary school and beyond Symptoms: listening and compliance, task completion, work accuracy, socializing problems 65% of children with ADHD in early childhood meet criteria in adolescence Some children not diagnosed until adolescence Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Common Coexisting Conditions Many coexisting conditions Externalizing disorders More than half of children with ADHD Oppositional defiant disorder, conduct disorder Internalizing disorders Bipolar disorder: 11%–23% Anxiety disorders: 15%–35% Learning disorders: 10%–40% Tic disorders: 6% Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Associated Impairments Executive functioning—sustaining and shifting attention, working memory, organizing, self-monitoring Academic—verbal memory, listening comprehension, organization of verbal and written output, language Social and adaptive—“reading” nuances of social behavior, inhibiting impulsive responses, socially appropriate language Sleep patterns—inconsistent patterns, maintaining daytime alertness, decreased rapid eye movement, increased nighttime activity Motor coordination—motor problems that impair written work, athletic activities Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Causes of Attention-Deficit/ Hyperactivity Disorder Genetics Most common etiological factor Siblings 5–7 times more likely to have ADHD; child of parent with ADHD, 25% chance Multiple genes are candidates for susceptibility to ADHD Other etiologic factors Prenatal exposure to cigarettes, lead, alcohol, drugs Intrauterine growth retardation, brain infections, prematurity Low cerebral blood flow Prematurity, low birth weight Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Causes of Attention-Deficit/ Hyperactivity Disorder (continued) Structural and functional differences in the brain Differences in shape, thickness, and volume of five regions Tested through neuroimaging: MRI, fMRI, PET, SPECT Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Evaluation Process Assessment of four areas: Symptoms of ADHD Conditions that might cause same symptoms Coexisting conditions Associated medical, psychosocial, learning issues Assessment includes Comprehensive history Physical/neurological exam Academic assessment Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Treatment of Attention- Deficit/Hyperactivity Disorder Most treatment plans include Education about ADHD—can include information and connection to support and advocacy groups Behavioral counseling and social skill intervention—can include individual or group sessions, parent training, classroom management programs, social skill-building, emotional support, cognitive behavioral therapy, coaching Educational treatment—can include substantial repetition or alternate methods of instruction, environmental modifications and behavior management techniques, special education Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Treatment of Attention-Deficit/ Hyperactivity Disorder (continued) Pharmacological treatment Stimulant medications Most effective and most common Reduce symptoms in 70%–90% of children Must be carefully monitored for downsides, such as side effects and later substance abuse Nonstimulant medications Example: antidepressants Available for children who do not benefit from stimulants (10%–30%) or have adverse side effects Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Treatment of Attention-Deficit/ Hyperactivity Disorder (continued) Pharmacological treatment with coexisting conditions: a variety of medical treatments exist for children with ADHD combined with intellectual disabilities, externalizing disorders, internalizing disorders, tic disorders, medication combinations Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Alternative Therapies Some evidence for effectiveness, but more studies needed Elimination diets Elimination of additives, allergenic foods, sugar Nutrient supplementation Iron, zinc, magnesium as well as multinutrients Essential fatty acids Brain training techniques Electroencephalogram (EEG) biofeedback Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Outcomes ADHD symptoms decline over time, but functional impairments can persist into young adulthood ADHD youth are at higher risk for coexisting conditions such as antisocial, mood, anxiety, eating disorders Conduct disorders can predict more severe outcome risks (failure to graduate, early sexual activity and parenthood, substance abuse) Multimodal Treatment of ADHD (MTA; MTA Cooperative Group, 2004), largest clinical trial to date, indicates Optimally managed medication treatment effective Behavioral treatment particularly important in subgroups with coexisting symptoms and psychosocial adversity Children with coexisting anxiety disorders are a particularly treatment-responsive subgroup More studies are needed on various treatments See the textbook Children with Disabilities, Seventh Edition, for full citation and reference information. Chapter 22 slides in Children with Disabilities, Seventh Edition, Online Companion Materials. Copyright © 2013 Paul H. Brookes Publishing Co., Inc. All rights reserved.