Attention-Deficit/Hyperactivity Disorder

1. Attention-Deficit/Hyperactivity Disorder (ADHD)

2. 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”

3. Historical Context (cont’d) • 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 behaviors=diagnosis • Any mix of inattention, hyperactivity, and impulsivity=diagnosis

4. 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)

5. 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 setting=situational ADHD) • Not occur exclusively during course of PDD, schizophrenia, or other psychotic disorder • Not be better accounted for by another mental disorder

6. Diagnostic Criteria (cont’d) • Inattention—6 (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

7. Diagnostic Criteria (cont’d) • Hyperactivity and Impulsivity—6 (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

8. Diagnostic Criteria (cont’d) • Hyperactivity and Impulsivity—6 (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

9. Diagnostic Criteria (cont’d) • 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.

10. 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

11. Selective attention • The ability to attend to relevant environmental stimuli or not be distracted by irrelevant stimuli. • Distraction=more 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.

12. Sustained attention • Paying attention to a task over a period of time. • Examined using continuous performance tests. • Errors: • Omission—not reacting to target • Comission—reacting 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.

13. 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 > 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.

14. 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.

15. Comorbidity • Learning Disabilities • ODD and CD • Anxiety and Mood Disorders • Tourette’s • Bipolar Disorder

16. Prevalence • School-aged population • Clinic cases: 3 to 5% • Parent and teacher report: >=20% • Sex ratio (boys: girls) • 4-9:1

17. Etiology • Biological • Brain damageminimal brain dysfunction • Delayed brain maturation • Brain dysfunction • Genetics

18. Etiology (cont’d) • Environmental toxins • Food additives • Sugar • Lead • Cigarette Smoking • Alcohol • Fluorescent lighting • Anticonvulsants • Theophylline

19. Etiology (cont’d) • Environmental and psychosocial factors • Diathesis-stress model • Parental and family influences • Best support for: • Neurotransmitters • Genetic transmission

20. Associated Characteristics • Intelligence • Greater risk for LD • Academic problems • Executive functions

21. Associated Characteristics (cont’d) • Social and Conduct Problems • Personal characteristics • Social characteristics • Peers • Teachers • Family relationships

22. Associated Characteristics (cont’d) • Accidents and injuries • Adaptive Functioning • Problematic situations

23. Developmental Course • Infancy • Preschool • School age • Adolescence • Adulthood

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

25. Treatment: Pills or Skills? • Pharmacological • Behavioral • Combined