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prevalence and impact of ADHD

-prevalence rate: 6-10%
-male more than females


diagnostic criteria for inattention symptoms of ADHD

need at least 6 of the following:
-fails to give close attention to details/ makes careless mistakes
-difficulty sustaining attention
-doesn't seem to listen when spoken to directly
-doesn't follow through on instructions/fails to finish work
-difficulty organizing tasks and activities
-avoids tasks requiring sustained mental effort
-loses things necessary for tasks/activities
-easily distracted by extraneous stimuli
-forgetful in daily activities


diagnostic criteria for hyperactivity-impulsivity symptoms of ADHD

need at least 6 of the following:
-difficulty playing/engaging in activities quietly
-always on the go or acts as if driven by a 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 class/situations when expected to sit


general diagnostic criteria for ADHD

-symptoms present before age 12
-clinically significant impairment in social or academic/occupational functioning
-symptoms that cause impairment in 2 or more settings
-not due to another disorder


three subtypes of ADHD

-combined type
-predominantly inattentive subtype
-predominantly hyperactive/impulsive subtype


describe the combined type of ADHD

-clinical levels of both inattention and hyperactivity/impulsivity
-most common subtype


describe the predominantly inattentive type of ADHD

-clinical levels of inattention only
-often not identified until middle school
-sluggish cognitive tempo


describe the predominantly hyperactive/impulsive type of ADHD

-clinical levels of hyperactivity/impulsivity only
-more common among very young children prior to school entry


associated peer problems

-inattentive sx -> ignored
-hyperactive/impulsive sx -> actively rejected
-not deficient in social reasoning/understanding, but rather the execution of appropriate social behavior


associated family dysfunction/parental issues

-no clear causal relationship b/w family problems and ADHD
-family probs can impact the severity and developmental course/outcomes of ADHD


associated problems with self-esteem

-inflated: positive illusory bias (Hoza)
-low self esteem associated with co-morbid depression


developmental course of ADHD

-persistent across lifespan in most cases
-inattention remains stable
-hyperactivity declines with age
-adult outcomes including psychiatric comorbidity (conduct disorder or depression or anxiety)


etiological factors of ADHD: heritability

.80-.85 (extremely high)
-environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions


etiological factors of ADHD: prefrontal lobe dysfunction

-involved in inhibition, executive functions
-abnormal brain activation during attention and inhibition tasks


etiological factors of ADHD: genes involved in dopamine regulation

-dopamine transporter DAT1 gene implicated
-7 repeat of dopamine receptor gene DRD4 implicated
-gene x environment interactions


etiological factors of ADHD: possible differences in size of brain structures

-prefrontal cortex
-corpus callosum
-caudate nucleus


ADHD differences in brain structure and function

-diffs in brain maturation, structure, fxn - particularly in frontostriatal circuitry (prefrontal cortex, basal ganglia, cerebellum)
-these areas are associated with executive fxn abilities:
-attention, spatial working memory, short term memory
-response inhibition and set shifting


what neurotransmitters are different in ADHD?

*norepi (mostly a dopamine prob, but dopa makes norepi)

dopamine associated with approach and pleasure-seeking
norepi role in emotional/behavioral regulation


executive functioning deficits

deficits in cognitive processes which activate, integrate, and manage other brain functions (sx overlap with ADHD, but not all kids with ADHD have EF deficits)
-cognitive: working memory, planning, organizing strategies
-language: verbal fluency, communication
-motor: response inhibition, motor coordination
-emotional: self-regulation of emotion, frustration tolerance


what is the basis of executive functioning deficits in ADHD?

behavioral disinhibition - a performance, rather than knowledge, deficit


evidence-based assessment of ADHD

*teacher and parent-completed questionnaires (Connor scales)
-structured clinical interview with parent(s)
-IQ/achievement testing to screen for learning disabilities (50% comorbidity)
-behavioral observations at home and school
-no medical screen, cognitive test, or brain imaging technique can detect ADHD
-kids with ADHD can focus long enough to watch TV, play video games or sit still at doc's office


well-established ADHD treatments

-stimulant meds
-behavioral interventions
-behavioral parent training
-behavioral classroom management
-intensive summer treatment programs


what are the best known stimulant meds for ADHD?




how do these stimulant meds reduce ADHD symptoms (mechanism of action)?

-block reuptake of norepi, dopamine and facilitate their release
-enhances norepi, dopamine availability in certain brain regions: prefrontal cortex, basal ganglia


how do these stimulant meds reduce ADHD symptoms (visible behavior changes)?

-extremely effective short term
-decrease disruption in class
-increase academic productivity and on-task behavior
-improve teacher ratings of behavior


common side effects of ADHD stimulant meds

-decreased appetite


what is an alternative non-stimulant medication for ADHD?

-non-stimulant alternative
-could need 4-6 weeks to work
-hasn't been studied as long as the stimulants
-smaller effect size relative to stimulants


limitations of stimulant treatment

-individual differences in response (80% respond)
-limited impact on domains of fxnal impairment
-does not normalize behavior (managed, but not cured)
-family problems beyond scope of medication
-no long-term effects established
-long-term use rare
-limited parent/teacher satisfaction
-some families not willing to try meds


ADHD behavioral treatment components

-psychoeducation about ADHD
-clear rules/expectations
-planned ignoring
-effective commands
-time out/loss of privileges
-point/token systems
-daily school-home report card
-intensive summer treatment programs


multi-modal treatment study for ADHD (MTA) - describe the set up/parameters

-6 sites
-579 kids, 7-9 y/o
-ADHD, combined type
-assigned to 14 months of:
-med management
-intensive behavior therapy
-combined treatment
-treatment as usual in the community (TAU)


MTA results

-all groups showed reduced ADHD over time
-meds alone + combined therapy did better than behavior therapy alone and TAU
-combined tx was often not better than meds alone
-higher med doses were needed in meds alone group relative to combined tx group