Professional Documents
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Attention-Deficit/Hyperactivity Disorder (ADHD)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Disorder (ADHD)
Andrea Chronis-Tuscano, Ph.D.
Associate Professor of Psychology
Director, Maryland ADHD Program
University of Maryland
Overview
Definition & Features
Etiological Factors
Evidence-Based Assessment &
Treatment
Professional Practice Parameters
required)
APA, 2000
symptoms required)
motor
Talks excessively
Blurts out answers
Difficulty waiting in lines or awaiting turn
Interrupts or intrudes on others
Runs about or climbs inappropriately
Fidgets with hands or feet or squirms in seat
Leaves seat in classroom or in other situations in
which remaining seated is expected
APA, 2000
or academic/occupational functioning
Some symptoms that cause impairment
are present in 2 or more settings (e.g.,
school/work, home, recreational
settings)
Not due to another disorder (e.g.,
Autism, Mood Disorder, Anxiety
Disorder)
APA, 2000
Subtypes
Combined Type
Clinical levels of both inattention and
hyperactivity/impulsivity
Most common subtype
Predominantly Inattentive Subtype
Clinical levels of inattention only
Often not identified until middle school
Sluggish cognitive tempo
school entry
Developmentally insensitive
Symptoms based on field trials conducted with
elementary school aged boys (Lahey et al., 1994)
Categorical (not continuous) view
Requirement of onset before age 7
arbitrary
Requirement of 6 months duration too
brief
Requirement that symptoms be
demonstrated across 2 settings
Associated Problems
Peer problems
Inattentive symptoms ignored
Hyperactive/impulsive symptoms actively rejected
Not deficient in social reasoning/understanding, but
rather the execution of appropriate social behavior
Family dysfunction/parental issues
No clear causal relationship between family problems
and ADHD
Family problems can impact the severity and
developmental course/outcomes of ADHD
Self-esteem
Inflated: Positive illusory bias (Hoza)
Low self esteem associated with comorbid depression
Developmental Course
ADHD is persistent across lifespan in most cases
Methodological issues impact estimates of persistence
ADHD severity, psychiatric comorbidity, and parental
psychopathology predict persistence (Biederman et al., 2011)
Inattention remains stable; hyperactivity declines with
age
DSM-IV criteria may not capture adolescent/adult
manifestations of impulsivity
Adult outcomes including psychiatric comorbidity
When ADHD co-occurs with conduct disorder, chronic
criminality and serious substance use can result
When ADHD co-occurs with depression, risk of suicide
Etiological Factors
Etiological Factors
Average heritability of .80 - .85
Environmental factors are not the cause, but may
contribute to the expression, severity, course, and
comorbid conditions
Dysfunction in prefrontal lobes
Involved in inhibition, executive functions
Genes involved in dopamine regulation
Dopamine transporter (DAT1) gene implicated
7 repeat of dopamine receptor gene (DRD4)
implicated
Gene x environment interactions
Possible differences in size of brain structures
Prefrontal cortex, Corpus callosum, caudate nucleus
Abnormal brain activation during attention &
inhibition tasks
structure, function
(particularly abnormalities in
frontostriatal circuitry):
Prefrontal cortex
Basal ganglia
Cerebellum
memory
Neurotransmitters
Neurotransmitter differences,
emotional/behavioral regulation
Executive Functioning
Deficits
Examples:
Cognitive: working memory, planning, use of
organizational strategies
Language: verbal fluency, communication
Motor: response inhibition, motor coordination
Emotional: self-regulation of emotion, frustration
tolerance
But
EF deficits overlap with ADHD symptoms
EF deficits are not unique to ADHD
Not all children with ADHD have EF deficits
Barkleys Theory
ADHD is not a problem with
knowing what to do; it is a problem
of doing what you know.
-Barkley, 2006
Behavioral disinhibition is the basis of
deficit
Evidence-Based Assessment
& Treatment of ADHD
Evidence-Based
Assessment
Teacher- and parent-completed questionnaires
Structured clinical interview with parent(s)
IQ/Achievement testing to screen for learning
Well-Established ADHD
Treatments
Stimulant Medications
Behavioral Interventions
Behavioral parent training
Behavioral classroom management
Intensive summer treatment programs
Medication: Stimulants
Most well-researched, effective, and commonly
These medications
Stimulant Medications
Research has shown that stimulants:
term
Decrease disruption in the classroom
Increase academic productivity and on-task behavior
Improve teacher ratings of behavior
stimulants
Smaller effect size relative to the stimulants
Limitations of Stimulant
Treatment
Individual differences in response
Not all children respond (approximately 80%)
Limited impact on domains of functional
impairment
medication
No long-term effects established
Long-term use rare
Limited parent/teacher satisfaction
Some families are not willing to try
medication
Well-Established
Non-Pharmacological
Treatments
Behavioral parent training
33 well-conducted studies
Behavioral Treatment
Components
Behavioral Treatment
Considerations
behavioral interventions
implementation
(TAU)
2/3 received medication
MTA Cooperative Group,
1999
Overall Results
All groups showed reductions in ADHD sx over time
On primary outcome measure (ADHD sx),
Practice Parameters
Summary
1. ADHD is a highly prevalent, brain-based disorder which
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