ADHD Flashcards
(14 cards)
IS ADHD REAL?
Many have argued that ADHD is a product of Western cultureUnrealistic expectations concerning children’s behavior*Pharmaceutical industry
The prevalence of ADHD is similar worldwideUse of medication to treat ADHD 5x higher in N. America than rest of the worldThe presence of ADHD is associated with marked impairmentProblems with peersSchool failureMortality
DEFINITION: CORE CHARACTERISTICS OF ADHD
Inattention
*Inability to sustain attention, particularly for repetitive, structured, and less-enjoyable tasks
Hyperactivity/Impulsivity
Hyperactivity -Inability to voluntarily inhibit dominant or ongoing behaviorImpulsivity –inability to control immediate reactions or to think before acting
DMS-5 criteria
InattentionSymptoms include:➢Often fails to give close attention to details or makes careless mistakes in homework, work, or other activities➢Often has difficulties sustaining attention in tasks or play activities➢Often does not seem to listen to when spoken to directly➢Often has difficulties organizing tasks and activities➢Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, book
Hyperactivity/ImpulsivitySymptoms include: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 is often “on the go” or often acts as if “driven by a motor” often talks excessively often blurts out answers before questions have been completed often has difficulty awaiting turn
Subtypes:
.Primarily Inattentive –ADHD-PI2.Primarily Hyperactive –ADHD-HI3.Combined –ADHD-CAt least 6 inattentive and 6 hyperactive symptomsAge 17 and older –5 and 5
ADDITIONAL CRITERIASymptoms continue for more than 6 monthsPersistence, impairment, and non-normativeSeveral symptoms were present prior to age 12Several symptoms are present in at least 2 settings
ADHD-PI*Inattentive, drowsy, daydreamy, spacey, in a fog, and easily confusedADHD-HIPrimarily hyperactivePrimarily diagnosed among preschool-aged childrenADHD-CBoth inattention and hyperactivity/impulsivityMost often referred for treatment
Specify current severity: Mild, Moderate, or Severe
ADHD: CATEGORICAL OR DIMENSIONAL
DSM treats ADHD as categoricalResearch evidence suggests it’s dimensionalDSMcriteria shape our understanding of ADHDDSMcriteria are also shaped by, and in some instances lag behind, new research finding
ASSESSMENT OF ADHD
Rating scales and interviewsParent reportTeacher report is critical for diagnosis of ADHDOther reason to obtain report from teachers:Normative framework for placing children’s behaviorOften do NOT ask youth (especially younger kids)In young children, report is not reliable*Children tend to underreport their own symptom
Diagnostic interviewsSymptom rating scales*Strong focus on observable signs of inattention and hyperactivity/impulsivity
Kiddie SADS –semi-structured interviewDifficulty sustaining attention on tasks or play activities Has there ever been a time when your child had trouble paying attention in school? Did it affect his/her school work? Did he/she get in trouble because of this? When he/she was working on her homework, did her mind wander? What about when he/she is playing games? Did he/she forget to go when it was his/her turn?Difficulty remaining seatedHas there ever been a time when your child got out of his/her seat a lot at school? Did he/she get in trouble for this? Was it hard for him/her to stay in her seat at school? What about at dinner time
Items from the SNAP-IV ADHD rating scale (parent/teacher report version
COMBINING REPORTS FROM PARENTS AND TEACHERSCategorizing of children depends upon how reports from multiple informants is combinedWhen you look at parent or teacher alone, you see more diagnoses of PI and PH*When parent and teacher are combined using the “or” rule for symptoms (symptom present if identified by either informant) many of those cases become combined
SUMMARY so far
ADHD is characterized by difficulties with inattention and/or hyperactivity/impulsivityDSM-5 has three diagnoses: ADHD-PI, ADHD-HI, and ADHD-CWhen assessing ADHD, important to get report from parents and teachersADHD can be assessed with interviews and rating scales*When combining information from different informants, choice of and/or rule may lead to very different diagnoses
MIGHT ADHD BE MULTIPLE DISORDERS??
HETEROGENEITY IN ADHDPRESENTATIONMany different presentations of ADHD^ implies there are likely different causes*DSM5 shapes our thinking, but lags behind research findings
S L U G G I S H C O G N I T I V E T E M P O / C O G N I T I V E D I S E N G AG E M E N T S Y N D RO M Ehttps://youtu.be/3B4t2J_H9yE?si=OPBzs6h4quB0zNJf(2:11)
Symptoms (see slide, can’t copy)
Time will tell whether ADHD is broken into new disorders and distinct causes identifiedRDoCv. DSM5CURRENT CLINICAL PRACTICECognitive disengagement syndrome is NOT a DSM diagnosis^i.e., you cannot diagnose cognitive disengagement syndrome
EPIDEMIOLOGY OF ADHD
Prevalence of ADHD Point prevalence: 5-9% of school-age children in N. AmericaOntario Child Health Study -6-month prevalence: 10.5% of children aged 4-11 years*National Comorbidity Survey –Adolescents -Lifetime prevalence: 8.7%
See table
Cultural and contextual differencesChildren in many cultures and countries meet diagnostic criteria for ADHDSlightly more prevalent among children living in povertyRacial differences not clear (+ complicated by fact that minority groups overrepresented among low SES communitie
Dx rates vary by gender3 boys:1 girl ratio in community6 boys:1 girl ratio in clinics^Why the difference?Symptom presentation varies by genderIn community samples, boys are more likely than are girls to be diagnosed with all subtypes of ADHD, but the gap is wider for ADHD-C and ADHD-HI than it is for ADHD-PINote that you do not see the same differences in presentation between boys and girls in clinically referred samples
DEVELOPMENTAL COURSE
Infancy“Should” be present at birthBut, no reliable and valid measures to assess sxbelow age 3PreschoolIf symptoms last for about a year, child is likely to continue to have challengesElementary school Beyond, outward hyperactivity might continue to decline slightlyStill higher than most all people without ADHD
PROGNOSIS
*Previously thought that symptoms of ADHD resolved in adolescence *5+ prospective studies have shown that pre-adolescents who meet criteria for a diagnosis of ADHD have higher rates of ADHD symptoms in early adulthood (ages 21-27) compared to youth who do not have ADHD, after accounting for related factors
ADULT OUTCOMES OF ADHD (KLEIN ET AL. 2012 STUDY)1970 and 1978 recruited 207 boys btwn1970 & 1978 who were referred to a no-cost clinic in New York State for behavior problemsParticipants rated as hyperactive by psychiatrist or teacher+parentRecruitment prior to DSM-III (1stinclusion ADHD)When the boys (probands) were 18, they recruited comparison participantsFollowed up with probands and comparisons when they were 41 years oldAttrition: 135 probands and 136 comparisons participatedProbands who participated did not differ from probands who were lost on childhood characteristics (e.g., SES), nor on rates of ADHD or substance use at age 25Comparisons who participated tended to have higher SES and higher IQs
See table
CORRELATES OF ADHD
Comorbidity with other psychological disorders →Other areas of ImpairmentIntellectual/academicPhysical health & mortality*Social impairment
Up to 80% of children with ADHD have a co-occurring psychological disorderOppositional Defiant Disorder (ODD) and Conduct Disorder (CD)50% or more of children and adolescents with ADHD meet criteria for ODDEarly-onset ADHD is a strong predictor of later CD and ODDAnxiety disorders25-50% of children with ADHD experience excessive anxiety or an anxiety disorderDepression20% to 30% of youth with ADHD will experience major depressionTic Disorders20% of youth with ADHD meet criteria for tic disorder
Intellectual ability and academic functioningADHD is not associated with decreased intellectual abilityAcademic functioning isimpairedFormal speech and language disordersSymptoms of ADHD impact language abilitiesSpeech production errors
Deficits in interpersonal functioningWith family&With peersExacerbated by co-occurring ODD/CD and general conduct issues
ETIOLOGY OF ADHD
HeritabilityBased on twin studies, heritability estimates for inattentive and hyperactive/impulsivity are ~75%Environmental influencesFactors that compromise development of nervous system may be related to ADHDMostly caused by bio + genetics, then maintained, mitigated, and exacerbated by environmental influences
Summary again
At any time, between 5% and 9% of youth will meet diagnostic criteria for ADHDBoys are more likely to meet criteria for ADHD than are girlsGirls’ presentation may be primarily inattentive, and they may be less likely to be referred treatmentMany youth who meet criteria for ADHD will continue to experience significant challenges with inattention/hyperactivity as adultsYouth with ADHD are likely to have a comorbid psychological disorder, with ODD and CD being most commonYouth with ADHD experience significant challenges in other domains, including academically and socially*ADHD is highly heritable
TREATING ADHD
MedicationBehavioral TreatmentsParent management trainingBehavioral classroom management *Behavioral peer interventions
MEDICATIONStimulants have been used to treat ADHD since the 1930sAmong the most effective stimulants are dextroamphetamine(Dexedrine) and methylphenidate (Ritalin, Concerta)Increase activity in the prefrontal cortexSide effects
“stimulant medications have large, beneficial, acute effects on multiple key domains of functioning in ADHD” (Pelham, Wheeler, & Chronis, 1998)BUT20% of children may not improve (non-responders)May not help academic performance, peer relationships, or family functioning in all kidsBeneficial effects may not be maintained over time and will stop once medication is stopped*Tolerance may also occur, in large % of cases leading to reduced efficacy over time at the same dosage (Handlemanet al., 2022)
BEHAVIORAL TREATMENTS
Parent management trainingBehavioral classroom management *Behavioral peer intervention
PARENT TRAININGGoal: Supporting caregivers managing challenging child behaviour& promoting positive behavioursParent-focused programs
See the main types
Parent-focused program structure: 1. PsychoeducationProvide parents education about ADHD in children
2. Improve parent-child relationship: Emphasis on providing children with positive attention& affirmationSpecial time Parent thought and mood monitoring
PARENT CHILD RELATIONSHIP –SPECIAL TIMEEmphasis on providing child with positive attentionPraise child for positive behavioursIgnore minor misbehaviour(e.g., whining) *10 minutes a day
3. BehaviouralStrategies Behaviourcharts & rewards for positive behaviourRoutine and structure building *Time-outs and privilege removal
4. Communication Strategies *Encouraging firm and assertive communication when necessary
Big takeaways: *Programs focus on increasing positive attention and teaching communication + behavioral strategies
How effective are Parent Training Programs?
OVERALL, meta-analyses and systematic reviews point to benefits for children AND for parents
Coates et al. 2015 –meta-analytic and systematic review findings11 studies included *Significantly reduce ADHD symptoms in children
Dekkers et al. 2022 *Small to medium-positive effects on parent outcomes Meta-analysis of 29 Randomized Control TrialsParent-child relationship quality, parent mental health, parenting sense of competence
HOWEVER, these effects may not be sustained over time *Lee et al. 2012 *Moderate effect sizes at post-treatment, small effect sizes at follow up *More follow up sessions may be beneficial
OTHER INTERVENTIONSCognitive interventionsCognitive techniques that children can use to control attention and behavior(e.g., verbal self-instruction, problem solving)Insufficient scientific evidence of benefitOrganizational skills training –can help with impairment related to ADHD (e.g., school failure)*Benefits in academic domain
MULTIMODAL TREATMENT OF ADHD (MTA)Three key objectives:(1) Compare long-term medication and behavioral treatments for ADHD (2) Determine if there are additional benefits if meds and behavioral treatment are combined(3) Compare systematic administration of treatment to treatment as delivered in community settings
MTA STUDY: PARTICIPANTS6 sites579 youths enrolledSchools, pediatricians, mental health clinicsage 7 to 980% maleADHD-Cdiagnosisparent-reportedAll over dimensional thresholds on parent andteacher report
Random assignmentFour groupsTreated for 14 monthsAssessed for 2 yearsArnold et al., 1997
(1) Medication managementStimulant medication28 day titration period(2) Psychosocial treatmentParent training27 group sessions and 8 individual sessionsEducational interventions16 to 20 sessions of teacher consultation12 weeks of half-time classroom behavioral specialistSummer treatment program(3) Combination treatment (medication management + psychosocial)(4) Community treatment as usual (TAU)Could be nothing, could include any of the above (2/3rdgot meds)
1) Compare long term medication and behavioral treatments for ADHD Note that for improving ADHD symptoms (as rated by both parents and teachers), medication outperformed behavioral treatmentBut, this was not true for many other outcomes (e.g., observed classroom behavior, parent and teacher reported social skills)Also note that children who got behavioral treatment did improve on ADHD symptomsParents prefer behavioral treatments(2) Determine if there are additional benefits if meds and behavioral treatment are combinedCombined treatment and medication treatment did not differ for any outcomeNote that for parent-child conflict, combined was better than TAU, and medication was not better than TAU, but in a direct comparison, combined was not better than medication(3) Compare systematic administration of treatment to treatment as delivered in community settingsCombined treatment and meds outperformed TAU for most ADHD outcomesBehavioral treatment did not*Note that behavioral treatment and combined treatment both outperformed TAU when outcome was reducing parent-child conflict (meds did not)
ONG-TERM PATTERNS OF REMISSION FROM MTA STUDY (SIBLEY ET AL., 2022)*Several of follow-ups with MTA sample 2 years post-intervention (youth were ~10y.o) to 16 years post-baseline (when youth were ~25 on average)The interventions helped, but do symptoms and impairment return across time ?
ig takeaways:-Increases over time, but overall very little full and sustained recovery-Many people fluctuate in symptoms and impairment X time-Some symptoms and/or impairment through emerging adulthood is the norm
TREATMENT STUDIES –CHRONIS-TUSC ANO ET AL. 2013Mothers of Children with ADHDTargeting maternal depressive symptoms and parenting children with ADHDRandomized into two groups –standard parent training and anintegrated intervention
Behavioral Parent TrainingFocus on routine building, time-outs, privilege removal, managing misbehavior, etc. Integrated InterventionStandard behavioral parent training WITH relaxation techniques, mood monitoring activities, cognitive distortion targeting, etc.
Integrated Intervention post-treatment:Produced small to moderate impacts on maternal depressive symptoms, negative parenting, child disruptive behavior, and family functioning compared to behavioral parent training
However, this effect wasn’t sustained -At later follow ups, Parent training group had better “positive parenting” (coded observationally) compared to integrated intervention group
Main takeaways:-Integrated intervention –positive impacts post-treatment-Parent training –impacts on “positive parenting” at later follow ups
