ADHD??!!!?!

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ADHD??!!!?!
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Relationship between ADHD and EF

• EF ? ADHD
• All ADHD have some EFD but
• All EFD not ADHD

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ADHD and EF

• The two are not the same stem from different
  descriptive systems
• ADHD is a diagnosis based on cluster of observed
  behaviors
• EF is a neuropsychological construct
• Both describe a regulatory phenomenon

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Provocative Question 1Is the traditional triad
of symptoms (Inattention, Impulsivity,
Hyperactivity) sufficient to describe the full
set of treatable symptomatology in the syndrome
currently known as ADHD?
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Provocative Question 2Should we
reconceptualize and redefine the syndrome now
known as ADHD in terms of the neuropsychological
construct of Executive Function?
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Provocative Question 3Should the executive
function deficits associated with ADHD be
addressed directly in educational programming?
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Attention-Deficit/Hyperactivity Disorder (ADHD)
DSM-IV Diagnostic Criteria

• A. Either (1) or (2)
• (1) 6 or more symptoms of Inattention have
  persisted for at least 6 months
• often fails to give close attention to details or
  makes careless mistakes in schoolwork, work, or
  other activities
• often has difficulty sustaining attention in
  tasks or play activities
• often does not seem to listen when spoken to
  directly

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• often does not follow-through on instructions and
  fails to finish schoolwork, chores, or duties in
  the workplace (not due to oppositional behavior
  or failure to understand the instructions)
• 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 (toys, school assignments)
• is often easily distracted by extraneous stimuli
• is often forgetful in daily activities

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Attention-Deficit/Hyperactivity Disorder (ADHD)
DSM-IV Diagnostic Criteria

• (2) 6 or more symptoms of hyperactivity-impulsiv
  ity
• Hyperactivity (6)
• often fidgets with hands or feet or 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
• is often on the go or acts as if driven by a
  motor
• often talks excessively

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• Impulsivity (3)
• often blurts out answers before questions have
  been completed
• often has difficulty awaiting turn
• often interrupts or intrudes on

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(Sub)types

• 1. ADHD, Combined Type A1 and A2 met for past
  6 months
• 2. ADHD, Predominantly Inattentive Type A1 met
  but not A2
• 3. ADHD, Predominantly Hyperactive-Impulsive
  Type A2 but not A1

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Rule Outs

• TBI
• Epilepsy
• Language processing disorders
• Anxiety disorders including PTSD
• Depression
• Chaotic environment
• Sleep disorders

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Clinical Symptoms of ADHD

• Beyond the traditional triad of not paying
  attention, not thinking before he acts and
  running all over the house constantly...

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Clinical Symptoms of ADHDCore or not?

• Reports of Disorganization, cant remember
  3-step instructions, poor planning, not checking
  his/ her work, difficulty accepting other
  strategies, getting stuck, overemotional, locker/
  notebook looks like a disaster...

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Clinical Symptoms of ADHDCore or not?

• Executive Function (EF) is largely implicit in
  the DSM-IV diagnosis of ADHD.
• Only Inhibit (Impulse Control) is explicit.
• Should EF be formally incorporated into theories
  and definitions of ADHD?
• Are formal assessment and treatment of these
  (core?) EF symptoms necessary?

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Evolution of Diagnosis of ADHD

• 1st clinical description British physician Still
  (1902) - deficit in volitional inhibition,
  defect in moral control
• Similarities to brain-injured child syndrome
  (Strauss Lehtinen, 1947) but without evidence
  of brain injury resulted in minimal brain
  damage
• Minimal brain dysfunction
• Hyperkinetic impulse disorder
• Hyperactive child syndrome

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Evolution of Diagnosis of ADHD

• Hyperkinetic reaction of childhood (DSM-II)
• first mention of inattention and distractibility
• Attention-deficit disorder (Douglas) (DSM-III)
• with and without hyperactivity
• Attention-Deficit/ Hyperactivity Disorder
  (DSM-III-R) (no with or without)
• Attention-Deficit/ Hyperactivity Disorder
  (DSM-IV) (3 subtypes)
• ???

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Recent Conceptualizations

• With a better understanding of brain-behavior
  relationships, particularly the frontal lobes
• ADHD is undergoing further redefinition in terms
  of a disorder of the executive functions (EF)
  (Barkley, 1997, 2000 Brown, 1999 Denckla, 1996
  Pennington Ozonoff, 1996)
• The primacy of attention is being questioned.

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Models of executive function in ADHD

• Pennington Ozonoff (1996)
• frontal metaphor deficits in inhibition and
  working memory tasks
• Barkley (1997, 2000)
• Inhibition as core, executive function as model
• Bayliss Roodenrys (2000)
• supervisory attentional system as executive
  function

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Barkley (Bronowski) EF Model
Behavioral Inhibition
Working Memory (nonverbal)
Self-regulation of affect/ motiv./ arousal
Internalization of speech (verbal working memory)
Reconstitution (analysis, synthesis,
goal-directed)
Motor control/ fluency/syntax
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Barkley (Bronowski) EF Model

• Nonverbal working memory - visual imagery and
  private audition internalized resensing.
• Verbal working memory - covert language that
  controls self rule-governed behavior.
• Internalized emotion/ motivation - with working
  memory, emotional control and motivation can
  occur. Covert affective states. Source of
  intrinsic motivation that drives future behavior.

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Barkley (Bronowski) EF Model

• Reconstitution - analysis combining with
  synthesis, allowing manipulation to synthesize
  new responses. Allows flexible, fluent,
  inventive goal-directed behaviors.

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General Conclusions

• Relationship between EF and ADHD hypothesized by
  Barkley (1997, 2000) and Pennington Ozonoff
  (1996) is given strong support by BRIEF findings
• Multidimensional construct of EF appears to
  define with greater specificity the symptoms of
  ADHD.

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General Conclusions

• Multidimensionality of Executive Function
  provides a more comprehensive yet more specific
  model of ADHD, incorporating a more full set of
  relevant symptom behaviors.

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Brain Basis for the Executive Functions
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Proportional size of prefrontal region

• Human 29
• Chimpanzee 17
• Gibbon/Macaque 11.5
• Lemur 8.5
• Dog 7
• Cat 3.5

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Neuroanatomic Organization

• Executive function neurological development
  are parallel
• Development of prefrontal cortex is central
• Frontal lobe damage can result in dysfunction of
  various executive subdomains
• BUT - Executive functions do not simply reside in
  the frontal lobes

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3 Neuroanatomic Axes andNeuropsychological
Function

• Anterior-Posterior Axis
• Anterior Systems ?-----? Posterior Systems
• Anticipates behavior - Receives information
• Selects Goals - Encodes
• Organizes/ Plans - Stores
• Orchestrates - Structure/ organization
• Monitors of Knowledge Base
• Modulates
• lt----gt Complimentary Relationship

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Lateral Axis

• Left Hemisphere Systems
• Preferentially involved with
• Building blocks of language
• Parts of complex materials
• Temporal processing
• Processing unimodal codable information
• Executive of discrete motor

• Right Hemisphere Systems
• Preferentially involved with
• Spatial information
• Relationship between parts
• Configuration of complex
• Processing multi-modal novel information
• Emotional tone in speech

lt--gt
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Cortical-Subcortical

• Cortical (Thinking) Systems
• Frontal System Modulation
• Inhibition and selection
• Subcortical Systems
• Retic. Activ Syst Motor Control
  Emotions/Drive
• -Arousal - Impulses
• -Alertness - Emotional/Social
• Drives

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Neuroanatomic Organization

• Frontal lobes are densely connected with other
  cortical and subcortical regions
• Prefrontal system is highly, reciprocally
  interconnected with the
• limbic (motivational) system,
• reticular activating (arousal) system
• posterior association cortex (perceptual/
  cognitive processes and knowledge base)
• motor (action) regions of the frontal lobes

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Central neuroanatomic position underlies
regulatory control over

• Perceptual coding in posterior/temporal isotypic
  regions
• Conceptual processes of the posterior association
  cortex
• Attentional functions supported by subcortex
  (reticular activating system)
• Emotional functions subserved by subcortex
  (limbic system)

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Frontal system versus frontal lobe

• Frontal system acknowledges incorporates
  interconnectedness
• A disorder within any component of the frontal
  system network can result in executive dysfunction

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Conditions that render the frontal systems
vulnerable include

• Connectivity disorders such as cranial radiation
  and white matter development (migration errors)
• Lead poisoning affecting synaptogenesis
• Direct prefrontal trauma in traumatic brain
  injury
• Dysfunctional neurotransmitters (e.g., dopamine
  in TS ADHD)
• Posterior cortex disorders including LD
• Arousal mechanism disorders in TBI (shearing),
  severe depression.

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• Executive dysfunction can arise from damage to
  the primary frontal regions as well as to the
  densely interconnected secondary posterior or
  subcortical areas. The associated cognitive
  partners and slave systems must be present in
  order for the executive regulatory functions to
  have any operational purpose.

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Neuroanatomy

• Executive Function is a convenient shorthand
  that captures the problems of a group of
  patients...The levels should be kept separate
  Executive function should not be confounded with
  prefrontal except at a hypothesis-generating
  level. (Denckla, 1996)