Week 3

Chapter 5: Attention-deficit/hyperactivity disorder (ADHD)

- 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

Clinical description and associated features

- The DSM-5 – conceptualization of the disorder from the previous version
o Two subtypes based on two predominant symptom categories – inattentive symptoms and
impulsive-hyperactive symptoms
- Three presentations
o Primarily inattentive presentation
o Primarily hyperactive-impulsive presentation
o Combined presentation
- The diagnostic criteria have changed a bit from the DSM-IV-TR
o Symptoms must now be evident prior to 12 years (rather than 7)
o Only 5 symptoms are required for people 17+ instead of 6 which is for younger kids
- Previously it was located in the Disorders First Diagnosed in Infancy, Childhood, Adolescence in the
subsection on Disruptive Behaviour Disorders – controversial, ADHD doesn’t have to be disruptive
o Now in Neurodevelopmental Disorders (intellectual disability, communication disorders, ASD,
ADHD, specific learning disorder, motor disorders)
Predominantly inattentive presentation
- 9 symptoms for the inattentive presentation:
o Careless attention to details
o Problems sustaining attention over time
o Doesn’t appear to listen
o Poor follow-through
o Poorly organized
o Poor ability to sustain mental attention
o Loses necessary materials
o Easily distracted
o Forgetful
- A diagnosis also requires that
o The symptoms are pervasive across situations (2+ settings)
o Interfere with performance
o They have been evident prior to 12 years of age
- These children are often misunderstood and undiagnosed – internalizing symptoms and low academic
performance
- Challenges in meeting increased academic and social demands in the school setting
o Sluggish information-processing style + problems with attention
o Difficult for them to filter essential from nonessential details – information overload, inability to
selectively limit their focus
- Difficulties with homework (sustaining attention for boring tasks) and apparent lack of motivation
Predominantly hyperactive-impulsive presentation
- 6/9 symptoms for a diagnosis of a predominantly hyperactive-impulsive presentation
- 6 hyperactive symptoms
o Fidgety or squirmy behaviour
o Problems remaining seated
o Excessive motion
o Problems engaging in quiet play
o Constantly being on the go
o Incessant talking
- 3 symptoms of impulsivity
o Blurts out answers, comments
o Is impatient, problems with turn taking
o Is intrusive to others
- Academic problems because of their impulsive nature (approach tasks incorrectly – don’t wait to get all
of the instructions)
Combined presentation
- Meet criteria for both of the presentations – require at least 12 symptoms
o When older than 17 – 10 symptoms

ADHD from a developmental perspective

- The core features of overactivity, impulsivity, inattention – impact on learning and relationships based
on the nature of developmental tasks in each age
Early precursors to ADHD hyperactive-impulsive presentation
- ADHD is very difficult to diagnose before 3 years of age, but retrospective parent interviews have
identified a number of early precursors
o Difficult temperament  risk for developing ADHD
o Excessive activity, poor sleeping patterns, irritability + more difficult to soothe
- Toddler period (1-2.5 years) – higher levels of underregulated behaviours
- Preschool (3-6) – lack of self-control persisted, more demanding, stressful, problematic especially in
“free play”
ADHD and the school-age child (6-11 years)
- School-aged children faced with the developmental task of increasing their sense of competence and
mastery
o ADHD children – challenges in meeting increased academic and social demands
o The nature of problems depends on the presentation
- Hyperactive-impulsive presentation – inability to inhibit responses
o Rushing through assignments
o Low frustration tolerance, tend to abandon tasks
o Greater risk for accidental injury
ADHD and the adolescent (12-19)
- At least half of the children diagnosed with ADHD will continue to meet the criteria in adolescence
- Poorly equipped to meet the challenges of managing the curriculum in middle and high school
(independent study)
o Poor work habits, lack of organizational skills, poor follow-through
- Increased risk for reckless driving accidents, participation in other high-risk behaviours (substance use)

Prevalence and course

- Estimates in school-aged children – 3-7% of the total population
ADHD and gender
- Ratios of male-to-female frequency have been reported from 2:1 to 9:1 – still an area of debate
 - Females with ADHD may be more impaired than males in areas of psychosocial functioning – higher
rates of depression, anxiety, self-esteem, levels of stress
- Children who had the inattentive presentation were more likely to be female (twice as likely)
- Barkley – the earliest age of diagnosis is around 3 years old
o Symptoms of inattention – not likely to be noticed until much later
o 2/3 of elementary school-aged children who’re diagnosed with ADHD – additional disorders
ADHD and comorbidity
Academic and learning problems
ADHD and specific learning disorders
- Prevalence rates for comorbid ADHD and specific learning disabilities (SLDs) – difficult to predict
accurately (wide variations in how SLDs are defined and measures)
- Comorbid rates between 16 and 21%
ADHD and internalizing problems
- Symptoms of depressive disorder and bipolar – present differently in children and adults
o Children – symptoms often overlap with ADHD – differential diagnosis is difficult
- One major symptom of depression in children – irritability – restlessness, agitation, short attention span
problems concentrating and impulsive responses – resemble ADHD
- Children with bipolar – rapid cycles of shifting moods, with brief and multiple mood swings
o Pressured speech, distractibility, overactivity – mistaken for ADHD
- Symptoms of anxiety (distractibility, nervous agitation, restlessness, poor concentration) – also similar
to ADHD
- Up to 70% of depressed children have comorbid ADHD
o Another study – 90% of the younger children and 30% of adolescents population referred for
bipolar disorder had comorbid ADHD
o Higher rates of comorbidity for overanxious disorder and somatic complaints than in children
without ADHD
o Many children with ADHD – problems staying and falling asleep
ADHD and externalizing disorder
- Children and adolescents with comorbid ADHD and disruptive behaviour disorders (ODD and CD) are
more seriously maladjusted and have much worse outcomes than just ADHD
- As many as 35%-60% of children with ADHD will also have ODD, 50% of children with ADHD will go
on to develop CD
- A diagnosis of ADHD in childhood can be a strong predictor for substance use as having a family
history of substance abuse
o Hyperactive teens with ADHD – significantly more likely to use cigarettes and alcohol
ADHD and social relationship problems
- Half of children with ADHD – problems in their relationships with peers
o Discrepancy between social skills and cognitive ability
- Labelled this subtype – socially disabled (ADHD+SD) - higher levels of substance abuse, family
problems, anxiety, mood problems, conduct problems

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

Barkley’s model of ADHD

- Focuses on understanding ADHD through the executive functions
o Built around the concept of behavioural inhibition – a central feature of the disorder
- This model is only for hyperactive-impulsive presentation
- The child’s degree of success of behavioural inhibition – central to determining the nature of outcomes
of four central executive function tasks
o Working memory, self-regulation, internalization of speech, reconstruction
- Deficits in behavioural inhibition  poor problem-solving strategies, inability to integrate and
coordinate information generated by the 4 central processes
o Negative outcome for academics
o 1/3 of students with the hyperactive-impulsive presentation failed to graduate from high school,
21% enrolled in college
- Barkley – addresses the role of inattention by distinguishing between two forms of inattention that are
qualitatively distinct: sustained attention and selective attention
o Deficits in selective attention – inattentive version of ADHD, but children with the hyperactive
presentation can also have attention problems
o Sustained attention for essentially effortful tasks and “contingency based attention”/self-
rewarding attention – ADHD may be less noticeable in unfamiliar settings or when tasks are
novel  misattribution that these children can be focused when they want to

Assessment and treatment/intervention

Detailed clinical and developmental history
- A semi-structured interview should be conducted with the parents and caregivers to obtain information
about the child’s developmental history
Parent, teacher, youth rating scales
- Important criterion – manifests across situations
o Important to obtain input from home and school
- Number of behavioural rating scales
 o Parallel forms that can be completed by parents, teachers, older children
- Three of the most popular ones – AEBA, the Conners Rating Scales, the Behaviour Assessment System
for Children
o ASEBA and CRS-3 – information from both a dimensional and categorical approach
o BASC-2 – index of functioning based on a dimensional classification system
- Brown Attention-Deficit Disorder Scales – available as parent and teacher questionnaires and a self-
report form
o Executive functioning in 6 areas: organization, attention, sustained effort, modulating emotions,
working memory, monitoring or evaluation
- Behaviour Rating Inventory of Executive Function (BRIEF) – also available in parent and teacher rating
forms – a rating of executive functions in two areas: behavioural regulation and meta-cognition
Other areas of assessment
- Academic difficulties – often part of the profile of children with ADHD
o Individual intellectual and academic assessment
- Cognitive assessment – also helpful in evaluating processing deficits in areas of cognitive efficiency,
processing speed, working memory

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

Theoretical models of ADHD

Functional working memory model
- ADHD symptoms are the result of overwhelmed demands on impaired working memory
- Predictions of the model
o WM demands are too high for children with ADHD
o Children with ADHD seek behavioural ways to compensate
o Hyperactivity stimulates their brain
- Better WM performance in children with ADHD with higher activity level
o The more difficult the taks, the more children with ADHD move
o All children are more hyperactive when large demands placed on WM
- Implications
o If movement is functional for some children with ADHD, how should that be approached?
 Heterogeneity – some approaches work for some children
- Not all motor activity may be functional
o Children’s use of fidget spinners was associated with poorer attention across both phases of
treatment
Delay aversion theory
- ADHD symptoms as a choice to avoid delay, because delay = aversive
- Leads to many risk-taking behaviours which are rewarding in the short-term
- All children are more hyperactive during idle time, but the difference larger for ADHD children
Dual pathway model
- ADHD is explained by impairments in
o Executive functioning
o Motivational/reward systems

- Executive functioning – needed to process information and guide goal-directed behaviour

o Attention, inhibition, working memory, flexibility/switching, organization/planning, emotion-
regulation
- Motivation
 o Reward sensitivity higher for children with ADHD
o Ex: controls don’t vary so much on a task depending on type of motivation, children with ADHD
do
- Implications
o Children with ADHD need additional motivation, especially on long tasks (>5 minutes)
o Their performance is worse relative to children without ADHD
o Strategies to diminish working memory demands should be applied