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ADHD 2.0

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grant emory

on 14 February 2013

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Transcript of ADHD 2.0

ADHD First mention of a disease similar to ADHD.
He distinguishes two possibilities of abnormal inattention:
"The incapacity of attending with a necessary degree of constancy to any one object."
"A total suspension of its effects on the brain."

"The barking of dogs, an ill-tuned organ, or the scolding of women, are sufficient to distract patients" 1798 The contemporary concept of ADHD as defined in the DSM-IV-TR is relatively new.
However, children presenting symptoms of inattention, hyperactivity, and impulsivity have been described by several authors during the last 200 years. Sir Alexander Crichton 1844 Heinrich Hoffmann “Fidgety Phil”
Describes symptoms of inattention and hyperactivity in Philipp.
“Johnny Look-in-the-air”
A boy showing significant symptoms of inattention.

Fidgety Phil has become a commonly used allegory for ADHD Created the “Struwwelpeter” an illustrated children’s book. 1902 The Goulstonian Lectures:
Discussed “the particular psychical conditions (…) which are concerned with an abnormal defect of moral control in children”

Described 20 cases of children with a “defect of moral control as a morbid manifestation, without general impairment of intellect and without physical disease”

15 cases of boys and five cases of girls.
This is “a disproportion which (…) is not altogether accidental” Sir George Frederic Still 1932 Hyperkinetic Disease of Infancy:

Children cannot stay still for a second, run up and down the room, climb about preferring high furniture in particular, and are displeased when deterred from acting out their motor impulses.

Increased excitability and a tendency to become aggressive for marginal reasons. Franz Kramer & Hans Pollnow 1937 Charles Bradley Used Benzedrine after pneumoencephalograms and noted it caused a striking improvement in behavior and school performance in some of the children.

Bradley’s observations of stimulant effects in hyperactive children were revolutionary and are considered important discoveries in psychiatric treatment. Benzedrine is no longer used.

Methylphenidate was synthesized in 1944 by Leandro Panizzon and marketed as Ritalin.

Name derived from his wife’s name— "Rita" Trauma is not necessary to develop ADHD disorder.

A behavior pattern may be found in children who present no clear-cut history of physical damage.

Referred to as Hyperkinetic Impulse Disorder. 1937 Held a conference and stated that brain damage should not be inferred from problematic behavior signs alone. 1963 Oxford International Study Group of Child Neurology 1968 Hyperkinetic Reaction of Childhood

“The disorder is characterized by overactivity, restlessness, distractibility, and short attention span, especially in young children; the behavior usually diminishes by adolescence” Franz Kramer & Hans Pollnow Leah Domzalski, Grant Emory, Amanda Hoffman, Janae' Ishmael, Tenisha Peterson a. Children with inattentive types:
- Unable to sustain attention at an age appropriate level
i. Parents may complain that these children cannot concentrate, are easily distracted, go from one activity from the other, are disorganized, and are forgetful and prone to daydream b. With hyperactivity, children are continually on the go as if driven by a "motor".
i. Behaviors include: climbing, running about, excessive talking, or continually and inappropriately leaving their seats during class c. Impulsivity: acting without thinking
i. Children may blurt out answers without taking the time to see the answer through, they interrupt or intrude on others by butting into conversations and games, or they may have difficulty waiting their turn. Age of Onset 1. Hyperactive Type
- Emerges in the
preschool years

2. Combined Type
- Emerges around
early primary school
years (5-8)

3. Inattentive Type
- Emerges later (8-12) BUT...
Why these differences? Hyperactive and Impulsive behaviors= greater disruption to family and classroom Although not consistent in research, there is evidence that the earlier symptoms arise, the greater the probability for a negative and more severe prognosis. Therefore, more readily identified than the more subtle symptoms of inattentiveness. Criteria for ADHD 1. Specific defining of onset
2. Duration of symptoms
3. Importance of setting 2. Duration:
- ADHD Combined: If both Criteria A1 and A2 are met for past 6 months

- ADHD Inattentive: If Criterion A1 is met but Criterion A2 is not met for the past 6 months

- ADHD Hyperactive-Inattentive: If Criterion A2 is met but Criterion A1 is not met for the past 6 months Inattention:

a. Often do not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

b. Often has trouble attention on tasks or play activities.
Often does not seem to listen when spoken to directly.

c. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

d. Often has trouble organizing activities.

e. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

f. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

g. Is often easily distracted.

h. Is often forgetful in daily activities.

i. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level: ADHD In School ADHD children struggling in school does NOT mean that:
- they are less intelligent
- they are just being "lazy" or "unwilling" to do the work

Instead, it is important to remember that it is caused by neurological differences that interfere with attention. ADHD in School -Inattentive Type: missing details in lessons, trouble focusing on one task, easily distracted
-Hyperactive/Impulsive Type: trouble sitting behind desk for long periods of time, fidgeting, blurting out answers before full question is asked
-In General: hard to keep track of homework and assignments due to inadequate organization skills, losing items, forgetfulness ADHD in School: Working with the School System - Asking for accommodations
- seat placement, breaks, extra time for testing, etc.
- Teacher training
- 504 forms
- official list of accommodations to be followed
- IDEA and IEP
- official education tailored to specific student ADHD and the Family Dynamic - ADHD children require more supervision, consistency
- Effect on siblings
- Reinforcing good behavior is key
- How parents can help with homework:
- encourage organization
- have a designated homework spot
- frequent breaks ADHD in the Social and Emotional Contexts - Emotional immaturity common
- Feeling isolated
- Low self-esteem
- Small, structured settings are often beneficial ADHD Overdiagnosis Is ADHD Diagnosed in Accord With Diagnostic Criteria? Overdiagnosis and Influence of Client Gender on Diagnosis (Bruchmüller 2012)

Four Vignettes
1- Full diagnosis of ADHD
2- Not ADHD, 2 criteria missing
3- Not ADHD, 3 criteria missing
4- Full diagnosis of GAD, but have some overlap with ADHD
Criteria met by DSM-IV and ICD-10 RESULTS Differences Between Males and Females Conclusion Why is there such a big difference between male and female diagnosis?
What does this tell us about the diagnosis of ADHD? Living with ADHD Case Study 1- 20 year old male Combined ADHD
Diagnosed at 8
Has family members also diagnosed with ADHD
Symptoms- problems focusing on a task or paying attention, restlessness, and hyperactivity
Takes Adderal and Ritalin
Parents always very strict, but tried to get him to concentrate more. Other than that, not very supportive
School did not help accommodate
Was secluded by classmates because he acted differently
Despite lack of support, still managed to enter college and received an emissions license Hyperactivity:

a. Often gets up from seat when remaining in seat is expected.
b. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
c. Often has trouble playing or enjoying leisure activities quietly.Is often "on the go" or often acts as if "driven by a motor".
d. Often talks excessively.


a. Often blurts out answers before questions have been finished.
b. Often has trouble waiting one's turn.
c. Often interrupts or intrudes on others (e.g., butts into conversations or games).
d. Some symptoms that cause impairment were present before age 7 years.
e. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
f. There must be clear evidence of significant impairment in social, school, or work functioning.
g.The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.
h. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Case Study 2- 21 year old female Inattentive ADHD
Diagnosed at age 8
Brother and father also have ADHD
In social situations, she has trouble with listening to full conversations. In academic situations, it’s difficult for her to read multiple pages of a textbook or listen to a lecture and absorb the information. Another major symptom she has is that she constantly loses important items.
Adderall and Vyvanse
Parents very supportive. Did all they could to help her
Her elementary school didn’t accommodate her. Treated differently in elementary school and felt left out of long conversations. By middle school, she was able to take tests during a longer time period than the other students. By high school, she was doing well and didn’t need much extra individualized learning programs.
Her grades changed dramatically in college after starting her medication regimen. Case Study 3- Dr. Suplita STOP... And pull out your notes... We will cover comorbid disorders and treatment options: Which particular subtype of ADHD have you been diagnosed with and how old were you when you received this diagnosis?

Is there anyone in your immediate family who was also diagnosed with ADHD?

What symptoms of ADHD do you have?

Do you take any medication for your ADHD? If so, what kind and which symptom(s) does it treat?

Are there any particular activities/skills/tasks you excelled at despite being diagnosed with ADHD?

Are there any particular activities/skills/tasks you found difficulty because of your ADHD? References: ADHD Mythbusters. (n.d.). Retrieved from http://www.adhdaware.org/
Bailey, E. How ADHD Impacts the Daily Life of a Child. Retrieved from
Bruchmüller, K., Margraf, J., & Schneider, S. (2012). Is ADHD diagnosed in accord
with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis. Journal Of Consulting And Clinical Psychology, 80(1), 128-138. doi:10.1037/a0026582
Flippin, R. (2006). ADHD and Education: When and why ADD students need formal
accommodations- and how to get them. ADDitude. Retrieved from
Flippin, R. (2006). ADHD Accommodations: 6 modifications teachers can use in the classroom with
ADD children. ADDitude. Retrieved from http://www.additudemag.com/adhd/article/1664.html
Klaus W. Lange, Susanne Reichl, Katharina M. Lange, Lara Tucha, Oliver Tucha
Atten Defic Hyperact Disord. 2010 December; 2(4): 241–255. Published online 2010 November 30. doi: 10.1007/s12402-010-0045-8
Powers, R. L., Marks, D. J., Miller, C. J., Newcorn, J. H., & Halperin, J. M.
(2008). Stimulant treatment in children with attention-deficit/hyperactivity disorder moderates adolescent academic outcome. Journal of Child and Adolescent Psychopharmacology. (2008); 18(5): 449–459. doi:10.1089/cap.2008.021
Rajwan, E., Chacko, A., & Moeller, M. (2012). Nonpharmacological
interventions for preschool ADHD: State of the evidence and
implications for practice. Professional Psychology:
Research And Practice, 43(5), 520-526. doi:10.1037/a0028812
Segal, J. & Smith, M. (2012). ADD/ADHD and school. Retrieved from
http://www.helpguide.org/mental/adhd_add_teaching_strategies.htm RESULTS
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