Attention-Deficit Hyperactivity

Disorder

LOGO
 Attention-Deficit/Hyperactivity
Disorder

ADHD is a neurodevelopmental
disorder of childhood that is
characterized by developmentally
inappropriate levels of:
Hyperactivity
Impulsivity
Inattention
 ADHD: Prevalence

 3-9% of the elementary school

population
 more often in males than females, with
the sex ratio being about 3:1 to 9:1
 most common disorders of childhood
accounting for a large number of
referrals to pediatricians, family
physicians and child mental health
professionals
 ADHD Risk Factors

Maternal cigarette use

Maternal alcohol use
Unusually long or short labor
Forceps delivery
Toxemia
Meconium staining
Minor physical anomalies
 History of ADHD

 Characteristics of this disorder have been

recognized for at least a century

 The disorder has been referred to by a variety of

labels:
 Minimal Brain Dysfunction (MBD)

 Hyperkinetic Reaction of Childhood

 Attention Deficit Disorder (ADD)

 Attention Deficit Hyperactivity Disorder (ADHD)

 History of ADHD

 Characteristics of this disorder have been

recognized for at least a century
 The disorder has been referred to by a variety of
labels:
 Minimal Brain Dysfunction (MBD)

 Hyperkinetic Reaction of Childhood

 Attention Deficit Disorder (ADD)

 Attention Deficit Hyperactivity Disorder (ADHD)

 History of ADHD

 1980’s:
 DSM III & DSM III-R stimulates ADHD research
 development of new assessment methods
 new treatment methods
 increased focus on biological factors.
 1990’s:
 Neuroimaging
 genetics
 reevaluation of DSM
 DSM-IV:
Hyperactivity

Often fidgets with hands or feet,

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
 DSM-IV
Hyperactivity

 Is often "on the go" or often acts as if

"driven by a motor”

 Often talks excessively when

inappropriate to the situation

6 or more of hyperactive and/or

impulsive symptoms required for
diagnosis
 More on Hyperactivity

 Children with ADHD are more active,

restless, and fidgety than normal children
during the day and during sleep
 There are different types of hyperactivity:
 Gross Motor Activity
 Restless/Squirmy
 Verbal hyperactivity
 Hyperactivity often varies according to
situation
 Degree of hyperactivity may vary with age
 DSM-IV:
Impulsivity

Often blurts out answers before

questions have been completed
Often has difficulty awaiting turn
Often interrupts or intrudes on others

Six symptoms of hyperactivity and

impulsivity are required for diagnosis
 DSM-IV:
Inattention

 Often fails to give close attention to details

or makes careless mistakes
 Often has difficulties sustaining attention in
tasks or play activities
 Often does not seem to listen when spoken
to directly
 Often does not follow through on
instructions and fails to finish homework,
chores, or duties in the workplace
 DSM-IV:
Inattention

 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

6 or more symptoms needed for diagnosis

 More on Inattention

“Attentional" problems may be

most obvious on specific types of
attentional tasks:
 sustained attention: responding to
tasks, being vigilant
 situations requiring the child to attend
over time to dull, boring, and
repetitive tasks
 Diagnostic Criteria Overview

 Symptom Criteria - Core Symptoms of

Hyperactivity & Impulsivity and/or Inattention
(Six or More Symptoms of either category)
 Duration Criterion - Symptoms have
Persisted for at Least 6 Months
 Developmental Criterion - Symptoms are
Inconsistent with Developmental Level
 Impairment Criterion - Clear Evidence of
Clinically Significant Impairment in Social,
Academic, or Occupational Functioning
 Diagnostic Criteria

Age Criterion - Some Symptoms that

Cause Impairment Were Present Before
Age 7
Situation Criterion - Some Impairment
from Symptoms is Present in Two or
More Settings
 Types of ADHD

Combined Type
 Symptoms of hyperactivity, impulsivity and
inattention
Hyperactive/Impulsive Type
 Symptoms of hyperactivity and impulsivity
Predominately Inattentive Type
 Symptoms of inattention
 Impairment in ADHD

Social Impairment – What does it look

like?
Academic Impairment – Long term
outcomes for children with ADHD not so
good
Family Impairment
Occupational Impairment
Driving Impairment
 ADHD Across the Lifespan

ADHD is a chronic disorder

60%-80% of children continue to meet
diagnostic criteria in Adolescence
50%-70% of children will continue to meet
diagnostic criteria in Adulthood

ADHD in childhood is different from

adolescence and different from adulthood
 Presentation of ADHD in
Adolescence

Gross motor activity tends to disappear

Predominance of Inattention,
Restlessness (rather than hyperactivity)
and impulsivity
What is a developmentally appropriate
level of impulsivity in adolescence?
 ADHD in Adults

More similar to adolescent presentation

Mainly problems with inattention and
impulsivity
How much inattention and impulsivity
affect an adult male? A father?
 Occupational Impairment

Similar problems to those seen in the

academic environment
Often unprepared, untimely, easily
distracted
“Under Achievers”
 Social Impairment

Still there in adolescence and adulthood!

If you don’t attend when people talk, they
often think you aren’t interested
 Sensation Seeking/Substance Use

Adolescents and adults with ADHD are

more likely than those with out to engage
in risky behavior including:
Marijuana use
Alcohol Use
Drunk Driving

This is true even when accounting for the

presence of oppositional defiant disorder
and/or conduct disorder
 Driving impairment

Leading cause of death in 15-24 year olds

are motor vehicle accidents
Adolescents and adults with ADHD are
more likely to have an accident, to have
more accidents, to speed, to receive traffic
citations, to receive more traffic citations,
to have their licenses suspended/revoked,
to drive without a license, to drive under
the influence
 Driving Impairment

One of the most common causes of MVAs

is plain old inattention
Adolescents in particularl are more likely
to speed, to not use a seatbelt, and to
drink and drive

Hmm….what does this mean for people

with ADHD
 But What About Cognitive
Impairment
It’s a NEUROdevelopmental disorder,
right?
So why hasn’t this lady mentioned
cognitive problems?
 ADHD & Neuropsychological
Deficits
 Results from research involving
neuropsychological testing has often
suggested that children with ADHD have
problems:
 inhibiting behavioral responses
 with working memory
 with planning and organization
 with verbal fluency
 with perserveration
 in motor sequencing
 with other frontal lobe functions
 Neurological Findings

Siblings of children with ADHD who

do not have ADHD, have milder yet
significant impairments in
executive functions
This suggests a possible genetic
risk for executive function deficits
in families
 Other Neurological Findings

Differences in cerebral blood flow

Differences in cerebral metabolism
Differences in the corpus collosum
 Neurotransmitter Deficits

 Neurotransmitter dysfunction in children

with ADHD has been suggested for many
years
 Originated from observations of the
response of children with ADHD to
different type of stimulant drugs
 The fact that stimulant drugs have an
impact on ADHD and that they increase
dopamine has contributed to the
neurotransmitter dysfunction
hypothesis
 Comorbidity & ADHD

Why is it essential to consider the

possibility of comorbid conditions in
assessing children with ADHD?
Importance of distinguishing between
comorbid conditions and mimicry
What is the frequency of comorbidities in
children with ADHD?
 Comorbidities

 Learning Disabilities - 19 to 26%

 Oppositional Defiant Disorder - 40%
 Conduct Disorder - 25% children; 45-50%
adolescents
 Anxiety Disorders - 30%
 Depressive Disorder - 10 - 30%
 Bipolar Disorder – up to 20%
 Tics and Tourette’s Disorder – 7% of children
with ADHD have a tic disorder
 40 to 50% of those with Tourette’s disorder have
ADHD
Onto Assessment and
Diagnosis!
 Behavioral Observations

However, if a child is literally climbing the

walls, it might be good to note that
Always remember that children may be
inclined to be on their “best behavior” in
new situations
Coding systems available for looking at
hyperactive and inattentive behaviors
 Cognitive Measures

Not recommended for use in diagnosis

Most evaluators use them in combination
with many other measures.
These are lab measures that directly
assess impulsivity, inattention, and
executive function
TREATMENT
 Treatment of ADHD

Stimulant Medications
Other Medications
Psychosocial Treatments
Educational Accommodations
 Stimulant Medications

 Ritalin
 Dexadrine
 Adderall
 Concerta
 70-80 % of children with ADHD respond well to
stimulant drugs
 Stimulant drugs represent an empirically
supported treatment for core symptoms of
ADHD
 Stimulants are a trial and error method
 Stimulant Side Effects

 loss of appetite, weight loss, sleeping

problems, irritability
 restlessness, stomachache, headache, rapid
heart rate, elevated blood pressure, sudden
deterioration of behavior
 symptoms of depression with sadness,
crying, and withdrawn behavior
 intensification of tics (muscle twitches of the
face and other parts of the body), possible
Tourette’s, and growth suppression
 Long term effects?
 Stimulant Side Effects

Side effects are often:

 transient in nature
 result of inappropriate medication levels
If one medication results in side effects,
another might be used without side effects
Other medications are used to minimize
side effects
Good clinical judgment by the clinician
may help to minimize side effects
 Non-stimulant Medications

Non-Stimulant ADHD Medication

 Straterra - a norepinephrine reuptake inhibitor-
selectively blocks the reuptake of norepinephrine,
which increases its availability
Other Non Stimulant Drugs
 Anti-depressants (e.g., Tofranil, Wellbutrin)
 Anti-hypertensives (Clonidine)
 Psychosocial Treatments

Parent Training
Social Skills Training
Cognitive Behavioral Treatments
Psychotherapy for comorbid conditions
 Educational Interventions

Special Education Services for existing

learning problems
Classroom accommodations
Classroom behavior modification
programs
 504 Plan
 The Daily Report Card

Specific set of behaviors relevant to the

specific child
Everyday teacher marks how the child did
on these behaviors
Child is rewarded (or not) based on
performance at school
Integrates the classroom and home
 ADHD Treatment:
Conclusions
 It is essential to treat the full range of difficulties
that impact on child and family functioning
 Treatment of ADHD needs to be “multimodal”
 Findings from the Multimodal Treatment Study
suggest that:
 Stimulant medication is effective in reducing core
symptoms
 Psychosocial treatments are of value in addressing
associated comorbidities
TERIMAKASIH