1. Attention-Deficit/Hyperactivity Disorder (ADHD)8
Attention-Deficit/Hyperactivity Disorder (ADHD)

2. Description
Attention-deficit/hyperactivity disorder (ADHD) is exhibited as persistent age- inappropriate symptoms of inattention, hyperactivity, and impulsivity that are sufficient to cause impairment in major life activities
Characteristic behaviors vary considerably from child to child
Different behavior patterns may have different causes

3. History
Early 1900s
Children who lacked self-control and showed symptoms of overactivity/inattention in school were said to have poor “inhibitory volition” and “defective moral control”
Following the worldwide influenza epidemic from
“Brain-injured child syndrome”
1940s-1950s: “minimal brain damage” and “minimal brain dysfunction”

4. Historical Example
Figure 8.1 English physician George Still was one of the first to describe the symptoms of ADHD
Source Courtesy The Lancet, April 19, 1902

5. History (cont’d.) Late 1950s By the 1970s
ADHD was called hyperkinesis
Led to definition of hyperactive child syndrome, in
By the 1970s
Deficits in attention and impulse control, in addition to hyperactivity, were seen as the primary symptoms
1980s saw increased interest in ADHD
Rise in stimulant use generated controversy

6. Core Characteristics
Key symptoms fall under two well- documented categories
Inattention
Hyperactivity-impulsivity
Using these dimensions to define ADHD oversimplifies the disorder
Attention and impulse control are closely connected developmentally

7. DSM-V Diagnostic Criteria for ADHD
Table 8.1 DSM-5 Diagnostic criteria for attention-deficit/hyperactivity disorder
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright ©2000). American Psychiatric Association.

8. DSM-V Diagnostic Criteria for ADHD (cont’d.)
Table 8.1 DSM-5 Diagnostic criteria for attention-deficit/hyperactivity disorder
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright ©2000). American Psychiatric Association.

9. DSM-V Diagnostic Criteria for ADHD (cont’d.)
Table 8.1 DSM-5 Diagnostic criteria for attention-deficit/hyperactivity disorder
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright ©2000). American Psychiatric Association.

10. Inattention
Inability to sustain attention, particularly for repetitive, structured, and less enjoyable tasks
Deficits may be seen in one or more types of attention
Attentional capacity
Selective attention
Distractibility
Sustained attention/vigilance (a core feature)

11. Hyperactivity-Impulsivity
Inability to voluntarily inhibit dominant or ongoing behavior
Hyperactive behaviors include
Fidgeting and difficulty staying seated
Moving, running, touching everything in sight, excessive talking, and pencil tapping
Excessively energetic, intense, inappropriate, and not goal-directed

12. Hyperactivity-Impulsivity (cont’d.)
Inability to control immediate reactions or to think before acting
Cognitive impulsivity includes disorganization, hurried thinking, and need for supervision
Behavioral impulsivity includes difficulty inhibiting responses when situations require it
Emotional impulsivity includes impatience, low frustration tolerance, hot temper, quickness to anger, and irritability

13. ADHD Presentation Types
Predominantly inattentive presentation (ADHD-PI)
Predominantly hyperactive–impulsive presentation (ADHD-HI)
Combined presentation (ADHD-C)

14. Predominantly Inattentive Type (ADHD-PI)
Inattentive, drowsy, daydreamy, spacey, in a fog, and easily confused
May have learning disability, process information slowly, have trouble remembering things, and display low academic achievement
Often anxious, apprehensive, socially withdrawn, and may display mood disorders

15. Predominantly Hyperactive-Impulsive Type (ADHD-HI)
Primarily symptoms of hyperactivity- impulsivity (rarest group)
Primarily includes preschoolers and may have limited validity for older children
May be a distinct subtype of ADHD-C

16. Combined Type (ADHD-C)
Children who have symptoms of both inattention and hyperactivity-impulsivity
Most often referred for treatment

17. Additional DSM Criteria
Appears prior to age 12
Persists more than 6 months
Occurs more often and with greater severity than in:
Other children of the same age and sex
Occur across two or more settings
Interferes with social or academic performance
Not explained by another disorder

18. What DSM Criteria Don’t Tell Us
Limitations of DSM criteria for ADHD
Developmentally insensitive
Categorical view of ADHD
DSM criteria shape our understanding of ADHD
DSM criteria are also shaped by, and in some instances lag behind, new research findings

19. Associated Characteristics
Children with ADHD often display other problems in addition to their primary difficulties
Cognitive deficits
Speech and language impairments
Developmental coordination and tic disorders
Medical and physical concerns
Social problems

20. Cognitive Deficits: Executive Functions
Cognitive processes
Language processes
Motor processes
Emotional processes

21. Examples of Impaired Executive Functions
Table 8.2 Impaired executive functions in ADHD and examples of resulting impairments
Source Based on Brown, 2000

22. Cognitive Deficits: Intellectual and Academic
Intellectual deficits
Most children with ADHD have at least normal intelligence - the difficulty lies in applying intelligence to everyday life situations
Impaired academic functioning
Children with ADHD frequently have lower productivity, grades, and scores on achievement tests

23. Cognitive Deficits: Learning Disorders and Self-Perceptions
Learning disorders are common for children with ADHD
Problem areas: reading, spelling, and math
Distorted self-perceptions
Positive bias: exaggeration of one’s competence
Self-esteem in children with ADHD may vary with the subtype of ADHD
Distortions in perceptions of quality of life

24. Speech and Language Impairments
Formal speech and language disorders
Difficulty understanding others’ speech
Excessive and loud talking
Frequent shifts and interruptions in conversation
Inability to listen
Inappropriate conversations
Speech production errors

25. Developmental Coordination and Tic Disorders
As many as 30-50% of children with ADHD display motor coordination difficulties
Clumsiness, poor performance in sports, or poor handwriting
Overlap exists between ADHD and developmental coordination disorder (DCD)
Marked motor incoordination and delays in achieving motor milestones

26. Developmental Coordination and Tic Disorders (cont’d.)
Tic disorders occur in 20% of children with ADHD
Sudden, repetitive, nonrhythmic motor movements or sounds such as eye blinking, facial grimacing, throat clearing, and grunting

27. Medical and Physical Concerns
Health-related problems
Higher rates of asthma and bedwetting
Studies’ findings are inconsistent
Sleep disturbances may be related to use of stimulant medications and/or co-occurring conduct or anxiety disorders

28. Medical and Physical Concerns (cont’d.)
Accident-proneness and risk taking
Over 50% are described as being accident- prone
At higher risk for traffic accidents
At risk for early initiation of cigarette smoking, substance use disorders, and risky sexual behaviors
Reduced life expectancy
Higher medical costs

29. Social Problems Family problems include:
Negativity, child noncompliance, excessive parental control, sibling conflict, maternal depression, paternal antisocial behavior, and marital conflict
Family difficulties may be due to co- occurring conduct problems

30. Social Problems (cont’d.)
Peer problems
ADHD children can be bothersome, stubborn, socially awkward, and socially insensitive
They are often disliked and uniformly rejected by peers, have few friends
They are unable to apply their social understanding in social situations
Positive friendships may buffer negative outcomes

31. Accompanying Psychological Disorders and Symptoms
Up to 80% of children with ADHD have a co-occurring psychological disorder
Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)
Role of COMT gene
A common genetic contribution for ADHD, ODD, and CD
Family connections – there is evidence for a contribution from a shared environment

32. Accompanying Psychological Disorders and Symptoms Anxiety Disorders
About 25% of children with ADHD experience excessive anxiety
Co-occurring anxiety worsens symptoms or severity of ADHD
Findings are inconsistent
Children with co-occurring ADHD and anxiety:
Display social and academic difficulties
Experience greater long-term impairment and mental health problems

33. Accompanying Psychological Disorders and Symptoms Mood Disorders
ADHD at 4-6 years is a risk factor for future depression and suicidal behavior
20-30% of children with ADHD experience depression
Family risk for one disorder may increase the risk for the other
Controversy regarding relationship between ADHD and pediatric bipolar disorder (BP)

34. Prevalence and Course
Prevalence rates vary widely with sampling methods
Estimates: 6-7% of school-age children and adolescents in North America and 5% worldwide have ADHD
ADHD is one of the most common referral problems seen at clinics

35. Gender ADHD occurs more frequently in boys
Overall rates decrease in adolescence for both sexes - ratio remains the same
Ratio in clinical samples is 6:1 with boys being referred more often than girls
ADHD in girls may go unrecognized and unreported
DSM criteria (cutoffs and symptoms) may be more appropriate to boys than girls

36. Gender (cont’d.)
Girls with ADHD may be more likely to display inattentive/disorganized symptoms
Clinic-referred school-age children with ADHD display similar symptoms
Girls with ADHD who display impulsive- hyperactive behaviors
More likely to develop eating disorder symptoms

37. Socioeconomic Status and Culture
ADHD affects children from all social classes
Slightly more prevalent among lower SES groups
Findings are inconsistent regarding relationships among ADHD, race, and ethnicity
ADHS is found in all countries and cultures
Rates vary

38. Socioeconomic Status and Culture (cont’d.)
Cultural differences may reflect cultural norms and tolerance for ADHD symptoms
ADHD is a universal phenomenon that is diagnosed more often in boys than girls in all cultures
Expression, associated features, impairments, and outcomes are quite similar wherever it occurs

39. Course and Outcome Infancy Preschool
Signs of ADHD may be present at birth - no reliable or valid methods exist to identify it
Preschool
Hyperactivity-impulsivity symptoms become more visible and significant at ages 3-4
Children with symptoms for at least 1 year are likely to continue to have difficulties later in middle childhood and adolescence

40. Course and Outcome Elementary School
Symptoms are especially evident when the child starts school
Oppositional defiant behaviors may increase or develop
By age 8-12, defiance and hostility may take the form of serious problems
Increased problems may encompass self- care, personal responsibility, chores, trustworthiness, independence, social relationships, and academic performance

41. Course and Outcome Adolescence and Adulthood
Many children with ADHD do not outgrow problems and some can get much worse
At least 50% of clinic-referred elementary school children continue to suffer from ADHD into adolescence
Adult challenges
Some individuals either outgrow or learn to cope with their disorder by adulthood
ADHD is established as an adult disorder

42. Theories and Causes Explanations for ADHD
Trait from evolutionary past as hunters
ADHD is a myth fabricated because society needs it
Some theories
Cognitive functioning deficits
Reward/motivation deficits
Arousal level deficits
Self-regulation deficits

43. A Possible Developmental Pathway for ADHD
Figure 8.2 A possible developmental pathway for ADHD
Source Cengage Learning 2013

44. Genetic Influences ADHD runs in families Adoption studies Twin studies
75% heritability estimates for hyperactive- impulsive and inattentive behaviors
Specific gene studies
Genes may contribute to the expression of ADHD – focus on dopamine regulation

45. Pregnancy, Birth, and Early Development
Factors that compromise development of the nervous system before and after birth may be related to ADHD
Mother’s use of cigarettes, alcohol, or other drugs during pregnancy are associated with ADHD
Contributing factors, rather than a causal association
It is difficult to disentangle substance abuse influence and other environmental factors

46. Neurobiological Factors
Research shows differences on:
Psychophysiological measures
Diminished arousal or arousability
Measures of brain activity during vigilance tests
Under-responsiveness to stimuli/deficits in response inhibition
Blood flow to prefrontal regions and pathways connecting them to limbic system
Decreased blood flow to these regions

47. Brain Abnormalities
Abnormalities primarily in the frontostriatal circuitry are implicated
This region includes the prefrontal cortex and the basal ganglia
ADHD children have smaller total and right cerebral volumes (by 3-4%), smaller cerebellum, and delayed brain maturation
Specific regions of the thalamus may also be involved

48. Neurophysiological and Neurochemical Associations
No consistent differences have been found between children with and without ADHD
Some neurotransmitters may be involved
Dopamine, norepinephrine, epinephrine, and serotonin may be involved
Most evidence suggests a selective deficiency in availability of dopamine and norepinephrine
Using medication for effective treatment of ADHD symptoms does not prove that deficits are the cause of symptoms

49. Diet, Allergy, and Lead Sugar is not the cause of hyperactivity
Allergic reactions and diet
Possible moderating role of genetic factors may explain why food additives affect the behavior of some children
Low levels of lead may be associated with ADHD symptoms
The role of diet, allergy, and lead as primary causes of ADHD is minimal to nonexistent

50. Family Influences Importance of family influences
Family influences may lead to ADHD symptoms or to a greater severity of symptoms
Family problems may result from interacting with a child who is difficult to manage
Family conflict is likely related to the presence, persistence, or later emergence of associated oppositional and conduct disorder

51. Treatment Less than half of the children with ADHD receive treatment
Of those who receive treatment, many discontinue prematurely
The primary treatment approach combines:
Stimulant medication
Parent management training
Educational intervention

52. Treatments for Children with ADHD
Table 8.3 Treatments for children with ADHD
Source Cengage Learning 2013

53. Medication Stimulants have been used to treat ADHD since the 1930s
Among the most effective stimulants are dextroamphetamine and methylphenidate
May help normalize frontostriatal structural abnormalities and functional connections
Effects are temporary and occur only while medication is taken; beneficial in short-term
Questions surround long-term benefits and later adjustment

54. Parent Management Training (PMT)
Provides parents with a variety of skills
Managing the child’s oppositional and noncompliant behaviors
Coping with emotional demands of raising a child with ADHD
Containing the problem so it does not worsen
Keeping the problem from adversely affecting other family members

55. Parent Management Training (PMT) (cont’d.)
Parents are:
Taught to understand biological basis of ADHD
Given set of guiding principles
Taught behavior management principles and techniques
Encouraged to spend time each day sharing enjoyable activity with their child
Taught how to reduce their own levels of arousal

56. Educational Intervention
Teacher and child must set realistic goals and objectives
Response-cost procedures are used to reduce disruptive or off-task behaviors
Many strategies are basic good teaching methods
School-based interventions for ADHD have received considerable support

57. Intensive Interventions
Summer treatment programs
Maximize opportunities to build effective peer relations in normal settings and provides continuity with academic work so gains from school year aren’t lost
Are coordinated with stimulant medication trials, PMT, social skills training, and educational interventions

58. Additional Interventions
Family counseling and support groups
Help family members develop new skills, attitudes, and ability to relate more effectively
Individual counseling
Helps children with ADHD deal with their problems and feelings of isolation and abnormality
Helps build their sense of self-competence

59. Keeping Things in Perspective
Children with ADHD have problems that should not be minimized
Each child is unique and has assets and resources that need to be recognized and supported