1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.