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Week 3
Week 3
Week 3
- 30s and 40s – “restless and inattentive” behaviours – associated with minimal brain dysfunction (MBD)
– brain trauma to the frontal lobe
o Lost its momentum – lack of evidence
o DSM-II – categorized those symptoms as the hyperkinetic reaction of childhood
- DSM-III – attempt to address both version of the disorder by replacing the unified hyperkinetic reaction
of childhood with a new category of ADD (attention-deficit disorder)
o ADD with hyperactivity vs ADD without hyperactivity – but lack of research ADHD in
further editions of the DSM
Aetiology (causes)
- ADHD – one of the most prevalent childhood disorders but controversy regarding the cause
o Probably a complex interaction between biological and environmental factors
Biological and neurological features
- Potential neurobiological basis for ADHD, four sources of information: structural regions of the brain,
genetic transmission, neurotransmitter functions, neurocognitive processing
Brain structures
- Less activity in the frontal brain regions and more activity in the cingulate gyrus in children with ADHD
o Frontal system – executive functioning, cingulate gyrus – focusing of attention and directing
response selection
- Three areas of executive function that can be especially problematic – working memory, sense of tiem,
sustained effort
o Altered perception of time – reduction of dopamine in the basal ganglia poor time
management + parietal lobe
o Problems with prospective memory poor follow-through and incomplete tasks
Genetic transmission
- 50% of children with ADHD have a parent who also has ADHD
o As much as 75% of aetiology might be attributed to genetic factors
Neurotransmitters
- Low levels of catecholamines (dopamine, norepinephrine, epinephrine) in children with ADHD –
attention and motor activity
- Medication for ADHD – increase the number of catecholamines in the brain (Ritalin, Cylert, Dexedrine)
Neurocognitive processing
- Increasing interest in examining how executive functioning and arousal levels in children with ADHD
contribute to cognitive, emotional and behavioural processing deficits
- Inherent need to be flexible and readily shift focus between tasks when required
o Ability to monitor, evaluate, revise strategies
o Working memory
- Developmentally, increased self-regulatory functions are evident as toddlers transition to preschool
o Increased self-control results from the child’s ability to internalize good role models provided by
parents and the increased utilization of inner language which guides and directs appropriate
behaviour and inhibits inappropriate responses
Treatment alternatives
- Treatment alternatives for ADHD still vary – depend on associated targets, symptoms, the nature and
extent of functional impairment
- Interventions can be applied at home, at school, in interactions with peers
Stimulant medications
- Stimulant medication more effective in alleviating the core symptoms of the disorder than behavioural
therapy
o Follow-up of long-term effects after enrolment in the 14-month program – enrolment didn’t
predict level of functioning
Symptom trajectory was the best predictor – children showing the best behavioural and
sociodemographic profiles demonstrating the best responses to any treatment
- Stimulant medications can be found in various forms
o Short-acting (Decedrine and Ritalin) and slow-release (Ritalin-SR) and longer-acting forms
(Ritalin-LA)
o Control of core symptoms – impulsivity-hyperactivity, inattention
o Reduced aggressive behaviours, improved parent-child interactions
- Negative outcomes – lack of height gain
Interventions in the home and school environment
- Parent training programs can be an effective method of improving parenting skills while reducing parent
stress, core symptoms of ADHD and noncompliance
- Use of contingency management programs based on information provided from a functional behavioural
assessment
- Including teacher consultations in the PT programs can also be helpful
o Enhanced communication between home and school
Lecture
Basics of ADHD
- Two symptom clusters in the DSM-5
o Inattention (9 symptoms)
o Hyperactivity/impulsivity (9 symptoms)
o 6/9 symptoms per cluster, pervasiveness (>1 setting), impairment, symptoms present < 12
- Three presentations
o Inattentive – 30%
o Hyperactive/impulsive – 5% - rare on its own, hyper activeness leads to inattention
o Combined – 65%
- Four domains impaired
o Cognitive control, timing, emotion, dysregulation, reinforcement sensitivity
- Neurocognitive profiles observed on group level – heterogeneity within the disorder
- Problems are first recognized at school – higher demands placed on neurocognitive functions
- Prevalence
o Children 3-7% (1 in every school class), boys > girls
o Adults – 2.5%
- Prevalence subthreshold ADHD (same treatment, needed early)
o 11-18% of children
o Similar, but sometimes milder, problems and impairments
o Predictive for the onset of full threshold ADHD in adolescence
- No increase in prevalence over the last 30 years
- High comorbidity – 70% of people with ADHD have another disorder – differentiation can be difficult
- ADHD is a multifactorial disorder
o Genetic factors (high heritability) vulnerability
o Prenatal factors (maternal stress, intoxication)
o Interactions with the environment (diathesis-stress model)
Development
- Ex: peer problems – difficulties recognizing emotional expressions, in particular subtle expressions
(more often saw subtle expressions as neutral)
o ADHD – weaker emotion recognition more peer problems
- Ex: children with ADHD receive up to 5 times more corrective feedback
o Teachers provide more corrective feedback when the student-teacher relationship is less close
- Childhood ADHD is a risk factor for
o Traffic incidents
o Substance abuse
o Aggression/delinquency
o Sexual risk-taking
o Gambling problems
o Financial risk taking
o Food related risk taking
- Children with ADHD
o 20-45% meet full criteria as adults
o 25-48% have impairing symptoms
o Fluctuation is the norm
- At group level, children with ADHD have a delayed cortical development
o Same sequence just delayed (prefrontal regions)
- Birthdate effect – ADHD more often diagnosed in youngest children in class – difficult to meet
expectations, children with ADHD could be struggling even more
o Opposite – “being-old-for-grade” – also present, but less