Attention Deficit Hyperactivity Disorder

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Attention Deficit Hyperactivity Disorder
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What is ADHD?

• A disorder characterized by
• attention deficits (difficulty sustaining
  attention/poor oncentration)
• hyperactivity
• Impulsivity
• mood swings
• short temper, aggressiveness
• high sensitivity to stress
• impaired ability to make follow plans
• Fidgeting, constant motion or activity
• Disorganization.
• Difficulty getting along with others
• Have difficulty reading social cues

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DSM-IV Criteria for ADHD

• Either A or B
• A. 6 or more manifestations of inattention
  present for at least 6 mos. To a maladaptive
  degree greater than what would be expected,
  given persons developmental level (e.g.,
  careless mistakes, not listening well, not
  following instructions, easily distracted).
• B. 6 or more manifestations of hyperactivity-impul
  sivity present for at least 6 mos. To a
  maladaptive degree greater than what would be
  expected, given persons developmental level
  (e.g., squirming in seat, running about
  inappropriately).
• Some of the above present before age 7.
• Present in 2 or more settings (e.g., at home at
  school or work)
• Significant impairment in social, academic, or
  occupational functioning
• Not part of other disorders such as
  schizophrenia, an anxiety disorder, a mood
  disorder.

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What distinguishes ADHD from normal
hyperactivity?

• All kids have some level of hyperactivity, so
  what makes ADHD unique??
• A diagnosis of ADHD is appropriate if maladaptive
  behaviors are extreme for a particular
  developmental period, persistent across different
  situations, linked to significant impairments
  in functioning. The diagnosis is reserved for
  truly extreme cases!!!
• The diagnosis does not apply to children who are
  rambunctious, active, or slightly distractible,
  in the early schools years (this is normal for
  this age).

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Recent Hot Issue in the dramatic increase of
diagnosed cases of ADHD---

• Has ADHD become a designer diagnosis for
  children who are more active difficult to
  control??
• Possibly!! Active behavior that would have been
  considered normal years ago, is now considered
  aberrant.
• The Result A push to medicate kids who may be
  difficult to control or deal with in classroom
  settings.
• ABA could be used here, in place of drugs!!!!

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General Examples of problem behaviors that are
affected by ADHD

• Academic difficulties-may do poorly in school due
  to impulsivity inattentiveness.
• Social behaviors-may be tactless, obstinate,
  bossy, aggressive, have difficulty getting along
  with peers.
• Occupational difficulties-may have difficulty
  taking orders from others, difficulty dealing
  with co-workers, struggle to be productive, etc.
• Antisocial behaviors being aggressive, having
  difficulty relating to others.

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Specific problem behaviors of ADHD

• Kids cant sit still during classroom activities
  at mealtimes.
• Cant stop talking at times when required to be
  quiet.
• Activities movements are haphazard constant.
• They quickly wear out shoes clothing, smash
  their toys, exhaust family members teachers.
• Have difficulty getting alone with peers
  establishing friendships.

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Specific problem behaviors (contd.)

• They may misinterpret others intentions, such as
  acting aggressively because they assume that a
  neutral action by a peer was meant to be
  aggressive.
• They may know correct social behavior in
  situations, but have difficulty transforming the
  information into appropriate behavior in
  real-life social interactions.
• About 15-30 of kids with ADHD have a
  learning disability. Half of kids with ADHD are
  placed in special ed classrooms.

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When does ADHD usually become a problem?

• During the preschool years, when children have
  difficulty controlling their activity
  interacting with their peers.
• However, ADHD may also become a problem in
  adolescence.
• 65 - 80 of kids with ADHD still meet criteria
  in adolescence adulthood.

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Prevalence of symptoms in ADHD normal
adolescents (Barkley, 1990)

• Symptom ADHD Normal
• Fidgets 73.2 10.6
• Easily distracted 82.1 15.2
• Difficulty remaining
• Seated 60.2 3.0
• Blurts out answers 65.0 10.6
• Difficulty (attention) 79.7 16.7
• Interrupts others 65.9 10.6
• Talks excessively 43.9 6.1

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Three types of ADHD

• 1. Predominantly Inattentive type Children with
  problems primarily of poor attention (ADD).
• 2. Predominantly Hyperactive-Impulsive type
  Children whose difficulties result primarily from
  hyperactive-impulsive behavior.
• 3. Combined type Children who have both sets of
  problems. This type makes up the majority of
  diagnosed cases. Most at risk for conduct
  disorder as well.

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Recent thoughts on the classification of ADHD

• Evidence suggests ---it may be best to think of
  ADHD as two separate disorders
• 1. One of inattention
• 2. One of hyperactive/impulsive behavior
• Most theory research does not make a
  distinction.

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ADHD Comorbility

• ADHD is often comorbid with
• Anxiety
• Depression (unipolar depression)
• Conduct Disorder

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What is the prevalence of ADHD?

• Difficult to determine--due to the varied
  definitions of the disorder of populations
  sampled.
• Estimates2- 7 in the US
• 3 7 worldwide

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Who is affected more Males or Females??

• Males are 2-3 times more likely to be diagnosed
  with ADHD than are females.
• Figures change depending on sample (those
  referred to a clinic vs. general pop.).
• Clinic samples show greater percentage of males,
  since they were referred to the clinics because
  of antisocial aggressive behaviors.

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Girls ADHD

• 1. Like boys with ADHD, girls diagnosed with
  combined type were more likely to have a comorbid
  diagnosis of conduct disorder or oppositional
  defiant disorder than girls without ADHD.
• 2. Girls with combined type have more disruptive
  behavior symptoms than girls with inattentive
  type.
• 3. Girls with combined type were viewed more
  negatively by peers than girls with the
  inattentive type and girls without ADHD. Girls
  with inattentive type were also viewed more
  negatively than the comparison girls.
• 4. Girls with ADHD had a of neuropsychological
  deficits such as executive functioning (planning,
  problem solving), compared with girls without
  ADHD.

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What causes ADHD?

• Theories
• Genetics
• Prenatal/perinatal factors
• Environmental Toxins
• Psychological factors
• Neurological factors

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Genetics ADHD

• There is a genetic predisposition for ADHD.
• When parents have ADHD, 50 of their child do
  too.
• Adoption a of identical twin studies show a
  genetic link. MZ concordance rates are as high as
  .70 - .80 (Tannock, 1998).

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Prenatal/Perinatal Factors

• Factors predictive of ADHD
• Low birth weight (perinatal)
• Maternal smoking (prenatal) increases
  dopamine release in babys brainleading to
  hyperactivity behavioral disinhibition.
• --Millberger et al., (1996) reported that 22
  of mothers of kids with ADHD smoked a pack of
  cigarettes per day during pregnancy, compared
  with 8 of mothers whose kids did not develop
  ADHD.
• Alcohol (prenatal)

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Environmental toxins ADHD

• A. Dietary factors
• In 1970s Feingold argued that food additives
  upset the CNS of hyperactive children. He
  proposed a diet free of artificial additives
  (flavors/colors).
• Well controlled studies do not support the
  efficacy of the Feingold diet (Goyette Conners,
  1977).
• Refined sugar also not found to be liked to ADHD.
  
• B. Non-food related substances
• Although it was theorized that lead poisoning may
  be linked with hyperactivity attentional
  problems, kids with ADHD dont have higher
  lead-levels than age-matched controls.

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Psychological Theories

• 1. Bettelheims (1970s) Diathesis-Stress theory
  of ADHD.
• This view argues that kids with predisposition
  for ADHD coupled with authoritarian parenting
  develop the disorder.
• As parent becomes more impatient negative with
  the child, the parent-child interactions become
  battles a disruptive-disobedient pattern is
  formed. This generalizes to other settings
  besides the home (e.g., school, social settings,
  etc.).

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2. Learning theories

• Hyperactivity could be reinforced by the
  attention it elicits, leading to increases in the
  frequency of the negative behaviors.
• Ross Ross (1982) argue that hyperactivity may
  be modeled on the behavior of parents siblings.
  However, research has not supported this.

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Neurological factors

• Brain function structure differs for children
  with without ADHD.
• The Frontal lobes of kids with ADHD are under
  responsive to stimulation cerebral blood flow
  is reduced.
• The frontal lobes, caudate nucleus, globus
  pallidus of kids with ADHD are smaller than
  normal.
• Kids with ADHD show poorer performance on
  neuropsychological tests of frontal lobe function
  (such as inhibiting behavioral responses).

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Neurological Factors (contd.)

• Kids with ADHD also have a smaller than average
  right prefrontal cortex. The right prefrontal
  cortex is thought to be associated with
  behavioral withdrawal. (Left prefrontal-behavior
  al approach).
• The cerebellum is also smaller than usual. Note
  that cerebellar dysfunction is associated with
  difficulty switching attention.
• Its unclear whether brains were different to
  begin with or developed differently based on
  their experience.

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Measuring ADHD behavior

• 1. Choice-Delay Task- Ss are given a choice
  between an immediate reward of a lesser value or
  a delayed reward of a greater value and asked to
  pick one.
• E.g., Which would you prefer, 5 now or 6
  tomorrow? Or which would you prefer, a cookie now
  or a slightly larger cookie in 15 min.?
• People w/ADHDmore likely than others to choose
  the smaller, but more immediate reward. This is
  used to index impulsivity or difficulty
  inhibiting a behavior.

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2. The Stop Signal Task

• Ss are asked to watch a screen or listen for a
  sound. When they hear it, they are to press a
  button as fast as possible.
• On some occasions, another stimulus is presented
  a split sec after the first stimulus is used to
  indicate the Ss must not press the button. Thus,
  Ss have to learn to inhibit their button
  pressing.
• With the intermediate delays, people with ADHD
  are more likely than controls to press the
  button.

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3. The Attentional Blink Task

• Ss watch a series of black letters flashed on a
  screen, a new one every 90 ms. In each set, one
  of the letters is blue. Another letter,
  designated as the probe letter, might or might
  not appear after the blue letter. The task is
  first to name the blue letter the to say
  whether or not the probe letter appeared after
  the blue letter.
• Most people miss the probe letter (they say no
  even though it was present) if it appears about
  two 2 7 letters after the blue letter. This is
  called the attentional blink you pay attention
  to the blue letter for about 200-600 ms after
  seeing it, so you have trouble paying attention
  to anything else.

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Attentional blink (contd.)

• The same is more evident for people with ADHD,
  they usually miss the probe letter even if it
  arrives almost a second after the blue letter.
• Interpretationpeople with ADHD have trouble
  controlling their attention they cant shift it
  when they need to.

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ADHD Treatment

• 1. Medication- stimulants prescribed since 1960s
  (Ritalin).
• Stimulant effects-paradoxical improve ability to
  concentrate/reduce disruptions.
• In double-blind designed studies, 75 of kids
  with ADHD showed dramatic improvements with
  stimulants.

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How does Ritalin work?

• Amphetamine methylphenidate stimulate the
  release of dopamine to the postsynaptic
  receptors.
• They produce their maximum effects on dopamine
  about 1 hour after someone takes a pill, and 1
  hour is also the time of maximum behavioral
  benefit, so the drug effects behavior through
  altering dopamine activity.

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Treatment (cond)

• 2. Psychological techniques
• Behavioral techniques based on operant
  conditioning work well.
• Applied Behavior Analysis
• Programs have demonstrated at least short-term
  success in improving social academic behavior.

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Behavior therapy

• Kids are reinforced for behaving appropriately
  (e.g., remaining in seats working on
  assignments).
• Point systems star charts are useful kids earn
  points or stars for good behaviors that allow
  them to earn tangible rewards.
• Focus of therapy is on improving academic
  social functioning, less emphasis is applied to
  reducing unwanted behaviors (hyperactivity).