1. 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

2. 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

3. History of ADHD
Early 1900’s- considered to be due to poor “inhibitory volition” and “defective moral control”
Great encephalitis epidemic of 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

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

20. 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

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

22. 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