Attention-Deficit/Hyperactivity Disorder

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Attention-Deficit/Hyperactivity Disorder

• (ADHD)

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Historical Context

• George Sill
• Inattentive, impulsive, overactive, lawless,
  aggressive
• defect in moral character
• 1917-1918 Encephalitis epidemic
• Children left with similar characteristics
• Similar pattern also noted in children with brain
  injury, birth trauma, and exposure to
  infections/toxins.
• Focused on Hyperactivity
• Formerly called hyperkinesis, hyperkinetic
  reaction, hyperkinetic syndrome

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Historical Context (contd)

• DSM-III
• Focus shifted to deficits in attention
  impulsivity
• Distinction between ADDH and ADD without H
• DSM-III-R
• Relabeled ADHD
• ADD without H was dropped
• 8 of 14 behaviorsdiagnosis
• Any mix of inattention, hyperactivity, and
  impulsivitydiagnosis

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Current Trends

• DSM-IV
• Relabeled attention-deficit/hyperactivity
  disorder
• Two factors making up three subtypes
• Predominantly inattentive type
• Predominantly hyperactive type
• Combined type (most often described and
  investigated
• Based on factor analytic studies (empirical
  support)

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Diagnostic Criteria

• Problems with (1) attention, or (2) hyperactivity
  and impulsiveness.
• Onset before age 7
• Display symptoms for at least 6 months
• Symptoms must
• Be at odds with developmental level
• Be pervasive AKA occur in at least 2 settings
  (only 1 settingsituational ADHD)
• Not occur exclusively during course of PDD,
  schizophrenia, or other psychotic disorder
• Not be better accounted for by another mental
  disorder

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Diagnostic Criteria (contd)

• Inattention6 (or more) of the following
• often fails to give close attention to details or
  makes careless mistakes.
• often has difficulty sustaining attention
• often does not seem to listen when spoken to
  directly
• often does not follow through on instructions and
  fails to finish
• often has difficulty organizing tasks and
  activities
• often avoids, dislikes, or is reluctant to engage
  in tasks that require sustained mental effort
• often loses things necessary for tasks or
  activities
• is often easily distracted by extraneous stimuli
• is often forgetful in daily activities

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Diagnostic Criteria (contd)

• Hyperactivity and Impulsivity6 (or more) of the
  following
• Hyperactivity
• often fidgets with hands or feet or squirms in
  seat
• often leaves seat in classroom or in other
  situations in which remaining seated is expected
• often runs about or climbs excessively in
  situations in which it is inappropriate
• often has difficulty playing or engaging in
  leisure activities quietly
• is often "on the go" or often acts as if "driven
  by a motor"
• often talks excessively

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Diagnostic Criteria (contd)

• Hyperactivity and Impulsivity6 (or more) of the
  following
• Impulsivity
• often blurts out answers before questions have
  been completed
• often has difficulty awaiting turn
• often interrupts or intrudes on others

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Diagnostic Criteria (contd)

• Subtypes
• If both A1 and A2 for past 6 months, then
  Combined Type.
• If A1, but not A2 for past 6 months, then
  Predominantly Inattentive Type.
• If A2, but not A1 for past 6 months, then
  Predominantly Hyperactive-Impulsive Type.

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Inattention

• Children and adolescents with ADHD
• Pay less attention to their work
• Appear able to concentrate in some situations,
  but are unable to focus attention in others.
• Concentrate when interested and motivated, but
  not during repetitive, boring, routine
  situations.
• 2 forms of attention
• Selective attention
• Sustained attention

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Selective attention

• The ability to attend to relevant environmental
  stimuli or not be distracted by irrelevant
  stimuli.
• Distractionmore likely when tasks are boring,
  distasteful, or difficult.
• Researchers found no evidence that children with
  ADHD are more distractible than normal children.
• Researchers also found that placing children with
  ADHD in environments with reduced irrelevant
  stimuli was not effective.

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Sustained attention

• Paying attention to a task over a period of time.
• Examined using continuous performance tests.
• Errors
• Omissionnot reacting to target
• Comissionreacting to non-target
• Researchers found that children with ADHD make
  more of both error types are slower than normal
  children.
• However, research has inconsistently shown a
  performance decline as length of task increases.
• Taken together, researchers question
  inattentiveness as central to ADHD diagnosis.

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Hyperactivity

• Taken from parent and teacher reports
• Direct observation through actometers
• Excessive movement of children with ADHD relative
  to normal children.
• Situational specificity (Porrino et al., 1983)
• ADHD boys gt normal boys
• Overall
• Reading mathematics at school
• Playing on weekends
• Sleeping
• Conclusion Differences between children with
  ADHD and normal children are most noticeable
  during sedentary or highly structured situations.

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Impulsivity

• Deficiency in inhibiting behavior.
• Examined using Matching Familiar Figures Test
  (MFFT).
• Generally, can discriminate children with ADHD
  from normal children.
• Examined using Stop-Signal task.
• Children with ADHD have greater deficits in
  Stop-Signal task than normal children.
• Conclusion Deficits in inhibiting motor response
  is central to ADHD.

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Comorbidity

• Learning Disabilities
• ODD and CD
• Anxiety and Mood Disorders
• Tourettes
• Bipolar Disorder

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Prevalence

• School-aged population
• Clinic cases 3 to 5
• Parent and teacher report gt20
• Sex ratio (boys girls)
• 4-91

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Etiology

• Biological
• Brain damage?minimal brain dysfunction
• Delayed brain maturation
• Brain dysfunction
• Genetics

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Etiology (contd)

• Environmental toxins
• Food additives
• Sugar
• Lead
• Cigarette Smoking
• Alcohol
• Fluorescent lighting
• Anticonvulsants
• Theophylline

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Etiology (contd)

• Environmental and psychosocial factors
• Diathesis-stress model
• Parental and family influences
• Best support for
• Neurotransmitters
• Genetic transmission

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Associated Characteristics

• Intelligence
• Greater risk for LD
• Academic problems
• Executive functions

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Associated Characteristics (contd)

• Social and Conduct Problems
• Personal characteristics
• Social characteristics
• Peers
• Teachers
• Family relationships

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Associated Characteristics (contd)

• Accidents and injuries
• Adaptive Functioning
• Problematic situations

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Developmental Course

• Infancy
• Preschool
• School age
• Adolescence
• Adulthood

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Assessment

• Criteria for a good assessment?
• Interviews
• Rating Scales
• Direct Observations
• Other

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Treatment Pills or Skills?

• Pharmacological
• Behavioral
• Combined