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on 24 January 2014

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Transcript of ADHD

Attention Deficit/Hyperactive Disorder
The Basics
Attention Deficit/Hyperactive Disorder (ADHD):
describes children who display persistent age inappropriate symptoms of inattention, hyperactivity, and impulsivity that are sufficient to cause impairment in major life activities.
Though ADHD symptoms and have been recognized as a problem since the late 18th century, it was not until 1902 that an English Physician described as a disorder
Primary treatments (ex: stimulant medication)
Intensive treatments (ex: summer programs)
Additional treatments (ex: family counseling)
Recommended treatment is combination of three primary treatments
Both early intervention programs and specific deficit intervention (such as working memory & inattention) are surfacing
By Elizabeth Garabedian and Brian O'Keefe
Late 1950's-1960's
Now referred the symptoms of ADHD as hyperkinesis
this disorder was thought to be because of the brain filtering stimuli incorrectly
During this time, the idea of "The Hyperactive Child Syndrome" was born.
This was mainly characterized by increased motor activity, however it was soon understood that there were other factors

Early 1900's
The introduction of compulsory schooling where students were expected to be self-controlled and attentive became popular.
This led to a greater focus on the idea of children inattentiveness
in 1902, English Physician George Still believed the symptoms arose from "inhibitory volition" and "defective moral control"
Between 1917 and 1926 a large outbreak of influenza was believed to have caused brain trauma and thus the hyperactivity and inattentiveness of children.
A child during this time who had any sort of head injury was labeled as a brain-injured child
By the 1940's children were labeled even if
had no head trauma
"Children must have at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria, while
older adolescents and adults (over age 17 years) must present with five
. While the criteria have not changed from DSM-IV,
examples have been included to illustrate the types of behavior children, older adolescents, and adults with ADHD might exhibit.
The descriptions will help clinicians better identify typical ADHD symptoms at each stage of patients’ lives. Using DSM-5, several of
the individual’s ADHD symptoms must be present prior to age 12 years, compared to 7 years
as the age of onset in DSM-IV. This change is supported by substantial research pub- lished since 1994 that found no clinical differences between children identified by 7 years versus later in terms of course, severity, outcome, or treatment response" (DSM-V, 2013)
Accompanying Psychological Disorders and Symptoms
As many as 80%
of ADHD afflicted children have comorbid psychological disorders (Mash & Wolfe, 2013)
Commonly include oppositional and conduct disorders, anxiety, and mood disorders
50% of ADHD children meet criteria for Oppositional Defiant Disorder (ODD) by 7 or later (Kutcher et. al, 2004), and somewhere between 30-50% of ADHD children will develop the more serious conduct disorder (Beauchaine, Hinshaw, & Pang, 2010)
Associated Characteristics
Cognitive, speech and language, developmental coordination, and medical/physical deficits can occur with ADHD
1970's and Beyond
During this time, people came to realize that hyperactivity was not the only issue. There were also:
deficits in attention (1970's)
impulse control (1970's)
poor self regulation (2006)
difficulty in inhibiting behavior (2006)
motivational deficits (2006)
Key Characteristics
lacking the ability to focus or sustain one's attention. Children who are inattentive find it difficult to sustain mental effort during work or play and behave carelessly as if they are not listening.
displaying an unusually high level of energy and an inability to remain still or quiet
prone to acting with little or no consideration of possible consequences
Though hyperactivity and impulsiveness are distinct symptoms, the DSM lumps them together in one subset of symptoms because it is rare for one to appear without the other.
Cognitive Deficits:
Deficits in executive functioning, intellectual ability, impaired academic performance, learning disorders, and distorted self perception
Executive functioning - cognitive (working memory), language (verbal fluency), motor (response inhibition), and emotional (self-regulation) processes
ADHD children's IQ is slightly below average, but generally normal intelligence (Mash & Wolfe, 131)
Lambek et. al contrasted Executife Functioning Deficits (EFD) with both ADHD diagnosed children and general population. Results showed ADHD children to have significant EFD compared to children without it, although only 50% of children in the study had EFD
Speech and Language:
30-60% ADHD children have impairments (Mash & Wolfe, 132)
Affects can vary from appropriate word choice, speech production, rambling on, and erroneously or unrelated comments --> often unclear links
Motor coordination:
30-50% children experience motor difficulties
Often develop Tic disorders - sudden movements or sounds which are random and repeated
Medical and Physical Concerns:
Health-related problems
Fasmer et. al (2011) shows higher prevalence of athsma in diagnosed ADHD cases (24.4% vs. control group's 11.3%)
Sleep problems, but unclear if this is due to side effects of medication
Risk taking & accidents
Impulsive behavior the most common factor in accident-proneness and injuries
One longitudinal study found "...impulse behavior was the most significant childhood characteristic that predicted reduced life expectancy (an average of 8 years or less)" (Mash & Wolfe, 133)
Family issues
Family conflict linked to child's conduct problems (partially a result of the disorder
Peer problems
Often view their behavior in a more positive way than others around them, leading to a disconnect between peers and the child
Lack of regulation in emotional and behavioral responses leads to social conflict and a bad reputation (Mash & Wolfe, 133)
Social Issues:

Carpenter et. al - Social functioning difficulties in ADHD: Association with PDD risk

(Background) PDD refers to group of disorders including Aspergers Syndrome and Autism
Social factors associated between AHDH and PDD (Pervasive Development Disorder)
Social Immaturity most common comorbid factor, followed by peer rejection
Social Immaturity --> hyperactive factors, peer rejection --> aggression and low IQ
indicates midbrain dopamine synthesis in the COMT (NIMH, 2005)
Studies show that ADHD leads to onset ODD and CD later in life. Severe cases of either disorder paired with ADHD is related to the COMT gene, which is associated with regulation of neurotransmitters in areas of the brain affected by ADHD
This means there are certain children who are genetically predisposed to have a higher risk of developing ODD and CD later in life. (Mash & Wolfe, 136)
Roughly 30-50% of ADHD children will develop CD
Anxiety Disorders:
25% of ADHD children experience excessive anxiety (Mash & Wolfe, 136)
Studies on whether anxiety worsens ADHD symptoms are inconclusive, but those with both have greater long-term impairment and mental health problems
Stimulus medication discussion: What do you think about the use of medication in children with ADHD?
- Is it too prevalent at this day and age? Why?
- What responsibilities do parents/family members have?
- How can we bring overdiagnosis numbers down?
- What treatment options seem to resonate with you?
Essential features:
Persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and is more severe than is typically observed in individuals at comparable level of development.
Some hyperactive-impulsive or inattentive
symptoms must have been present before seven years of age.

Some impairment from the
symptoms must be present in at least two settings
. (School, home, etc.)
There must be clear evidence of
interference with developmentally appropriate social, academic or occupational functioning.
The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorders and is not better accounted for by another mental disorder.

Diagnostic Criteria
Predominately Inattentive Type (ADHD-PI):
describes children who primarily have symptoms of inattention
easily confused
Predominately Hyperactive-Impulsive Type (ADHD-HI):
Describes children who primarily have symptoms of hyperactivity-impulsivity
problems in inhibiting behavior
aggressive or defiant
rejected by peers
suspended from school
placed in special education classrooms
Combined Type (ADHD-C):
describes children who have symptoms of both inattetnion and hyperactivity

Children with ADHD do not have a deficit in
Attentional Capacity
, meaning they are able to remember the same about of short term information as a child without ADHD

Selective Attention
refers to the ability one has to concentrate on relative stimuli without being distracted by irrelevant stimuli in the environment. Children with ADHD tend to have a deficit in this and have a high

When a child is given a repetitive or boring task and asked to complete it, their performance determines their
Sustained Attention
. Children with ADHD often times have trouble with these types of tasks from the start and not a gradual decrease in performance over time.
Do you think the DSM-IV or DSM-V is better at diagnosing ADHD?
ADHD-HI is the rarest subtype and it mostly applies to preschool children.
It is possible that ADHD-HI should be categorized under ADHD-C because it is not known if they are two distinct subtypes or simply the same children at two different ages.
Do you have any issues with DSM-IV in regards to diagnosis of ADHD?
Problems With DSM-IV
Developmentally Insensitive:
though it states that the symptoms of ADHD must be inconsistent with developmental level, the same symptoms apply to children of all ages.
The number of symptoms needed to make a diagnosis also does not change with age.
Categorical View of ADHD
Behaviors change over time and children may move in and out of DSM-IV criteria depending on age, maturity, and other such environmental factors.
Both statistical and neurobiological research support the idea that ADHD is dimensional rather than categorical.
It is believed that ADHD should be described as a delay in normal traits that all children possess to some degree (Marcus & Barry, 2011; Shaw et al., 2011).
Age Limit
setting the bar that symptoms must be present before age 7 limits the diagnosis because symptoms may not become evident until later in life.
Best estimates show that 6%-7% of children in North America suffer from ADHD
About 5% of children world wide are diagnosed with ADHD
It is often difficult to diagnose because professionals and parents do not always see the child in multiple settings
Where a teacher might only see inattention, the parents may notice oppositional symptoms
ADHD tends to occur more frequently in boys than girls
boys: 6%-9% between ages 6-12
girls: 2% to 4% between ages 6-12

"DSM criteria were developed and tested mostly with boys with ADHD and many of the symptoms such as excessive running around, climbing, and blurting out answers in class are generally more common in boys than girls."
(Marsh & Wolfe, 2013)
Socioeconomic Status and Culture
there are slightly more children with ADHD in lower SES's than higher ones
Though findings regarding relationships among Race, Ethnicity, and ADHD are inconsistent,
higher rates of ADHD behavior in African American students rather than European American students
lower rates in Asian, American Indian, and Pacific Islander children
Though having lower rates of ADHD, Caucasians seem to have the greatest knowledge and access to treatment
ADHD has been identified in every country it's been studied and the rates are:
South America and Africa: 8%-12%
Japan and China: 2%-5%
North America: 4%-6%
Start at:
Throughout Life
Symptoms of ADHD change with development

Difficult Infant Temperament
Hyperactivity between ages 3-4
Inattention issues around the time the child enters school

ADHD symptoms decline in prevalence and intensity
as the child gets older, however many adults still
suffer from restlessness and other ADHD

Genetic Influences
Findings from family studies, adoption studies, twin studies and specific gene studies suggest that ADHD is partially inherited, though the mechanisms are not yet known.
Pregnancy, Birth, and Early Deveopment
Factors that could increase the chance of ADHD:
pregnancy and birth complications
maternal exposure to severe stress during pregnancy
low birth weight
early neurological trauma
diseases during infancy

Evidence also suggests that mothers of children with ADHD use more
alcohol, tobacco, and drugs than mothers of children without
ADHD even when they are not pregnant (Mick, Biederman,
Farone, et al., 2002)
Neurobiological Factors
Studies on ADHD and the brain show abnormalities in the frontostriatal circuitry of the brain
prefrontal cortex
basal ganglia
Children with ADHD also tend to have a smaller prefrontal cortex than children without ADHD
Newer studies provide some evidence that brain circuits may develop differently or later in ADHD particularly in the prefrontal region of the brain (Fair et al., 2010; Shaw et al., 2007).
From medication, we can infer that the neurotransmitters
dopamine, norepinephrine, epinephrine, and serotonin may be
involved in the development of ADHD, however we
cannot draw conclusions based solely on
medication effects.

Diet, Allergy, and Lead
There is no substantial evidence linking sugar, food allergies, or food additives to ADHD, however the debate about this topic continues.
Slight subclinical elevations in lead exposure have been linked to ADHD recently.
slight increased lead exposure in combination with other risk factors such as nicotine during pregnancy may increase a child's risk for ADHD

Family Influences
Psychosocial factors do not usually cause ADHD, however family problems could possibly lead to more severe symptoms and an emergence of a conduct problem alongside ADHD
Theories and Causes
Though there is strong evidence that ADHD is a neurodevelopmental disorder, other influences such as biology and environment help to shape the expression of ADHD in each specific child
Stimulant Medication:
Most commonly used = Dexedrine (Dextroamphetamine) & Ritalin (Methylphenidate)
Active in the frontostriatal region, altering neurotransmitters (specifically dopamine) in the area (Mash & Wolfe, 149)
About 80% children with ADHD experience sustained attention, impulse control, and concentrated work effort on medication
Stimulant medication isn't addictive to most children and they do not increase the risk of substance abuse (Looby, 2008)
Stimulant consumption in the U.S. has more than TRIPLED since 1990 (Mash & Wolfe, 150)
5-9 = 4.5%, 10-15 = 8.5%, 15-19 = 4.8% -->
Rate is increasing among adults (Mash & Wolfe, 150) [As of 2009]
Parent Management Training (PMT):
Have parents understand biological basis of ADHD
Behavior management - maximizing success and minimizing problem behavior with techniques / systems
Also teach parents how to lower their arousal
Summer Treatment Programs:
Examples include Dr. William Pelham camp, which includes 360 hours of treatment in 8 weeks of the summer
Both parents and children report large improvements, however research and availability are issues
MTA (Multimodal Treatment - NIMH) Study:
4 Groups - Medication, Behavioral Treatment, Medication and Behavioral Treatment, and Community treatment (66% medication)
Stimulant medication provided more benefits to ADHD symptoms than behavior and community treatment
Behavior treatment paired with medication did not improve the symptoms of ADHD any more than medication alone, but did contribute to positive non-ADHD related functioning (Mash & Wolfe, 154)
Mood Disorders:
As many as 20-30% of ADHD children suffer from depression, and that number increases with age
Family risk factor is often prevalent way of catching and preventing
Depression is not merely from ADHD affects
Dispute over ADHD & pediatric bipolar (manic-depressive) disorder, due to overlapping symptoms
"A million more kids had a parent-reported ADHD diagnosis in 2007 compared to 2003; a 22% increase in 4 years" (SN Visser et. al, 2010)
Questions and Comments?
Family Counseling and Support Groups:
Includes all family members as opposed to PMT
National hotlines, forums, support networks from others who have gone through / are going through similar struggle
Individual Counseling:
Sometimes necessary to deal with self-esteem issues and dealing with growth and positive functioning (friends, school)
Little research on the effectiveness of individual counseling
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