Chapter 9 Attention-Deficit Hyperactivity Disorder Bilge Yağmurlu PSYC 330 Developmental Psychopathology

DSM Classification Attention Deficit Hyperactivity Disorder Inattentive Type (ADHD-I) Hyperactive-Impulsive (ADHD-HI) Combined Type (ADHD-C) Must have some symptoms before age 7 Hard to identify inattentive type Display symptoms for at least 6 months Impaired social, academic, occupational functioning Seen in at least 2 settings Table 9-1 has the symptoms of inattention an hyperactivity impulsivity

Inattention Can’t focus consistently (sustained attention) Child may play video games for hours Difficult tasks increase problems Has trouble managing simultaneous stimuli or switching from one task to another May focus on unimportant information Easily distracted Continuous Performance Tests- used to evaluate attention

Hyperactivity Impulsivity Always on the run Restless Fidgety Can’t sit still Accident-prone Disorganized More apparent in structured situations Uninhibited Acts without thinking Interrupts others Cuts in line Engages in dangerous behaviors Careless Irresponsible Immature Rude

Secondary Features Motor problems Intelligence and academics Clumsiness, delays, complex movement and sequencing the most affected Intelligence and academics May perform somewhat lower on IQ tests, but a range is possible Academic failure is common 56% need tutoring 30% repeat a grade 30-40% receive special education placement 10-35% fail to graduate high school

Secondary Features Executive dysfunction These are the processes needed for goal-directed behavior. Involved in planning, organizing, and self regulating. Include: working memory, verbal self-regulation, self-monitoring, inhibition of behavior, emotional regulation, and motor control

Secondary Features Adaptive functioning Immature Deficits in communication and social skills Social behavior and relationships Social problems are very common due to loud, disruptive, aggressive, and impulsive behaviors Deficits in processing social cues Easily irritated, tantrums ADHD-C may not have insight into these problems Deficit of doing rather than knowing, i.e., may know what to do but have difficulty executing

Secondary Features Social behavior and relationships Research indicates ADHD children are at higher risk for peer rejection (HI type). Those with ADHD-I may be neglected by peers. Teachers directive and controlling toward children with ADHD Parents are observed to be more negative, directive, and intrusive Social Behavior and Relationships Research indicates ADHD children are at higher risk for peer rejection (HI type). Those with ADHD-I may be neglected by peers. Parents are observed to be more negative, directive and intrusive. Likely stems from the child’s behavior. High conflict in familial relationships. Parenting stress, lower sense of parenting competence, decreased contact with extended family, increased alcohol use by parent, increased marital conflict, separation and divorce can make the situation worse.

Secondary Features Sleep and accident risk Sleep problems common Falling asleep, waking up, involuntary movements May be due to medications or anxiety Higher risk for accidents See Accent on Teens with ADHD and auto accidents

Subtypes Most research on combined type Inattentive type may be missed Characterized by “sluggish cognitive tempo” Lethargic Daydreamy Confused Socially withdrawn Debate about subtypes Is ADHD I just a milder form of C or a separate type?

Co-occurring Disorders ADHD-C often coexists with other disorders Learning disorders 15-40% May be due to cognitive deficits associated with ADHD May be due to behavioral difficulties Externalizing disorders 35-70% ODD 30-50% CD When ADHD is comorbid with ODD or CD, there is a higher rate of coercive child-parent interactions, parent pathology and substance abuse, and lower SES Internalizing disorders OCD up to 30% Anxiety 25-30% Depression 25-30% Bipolar 10-20% Relationship between depression and ADHD is complex-See Figure 9-2

Epidemiology 3-7% of school age children In clinical studies, ADHD-C most common Boys diagnosed at a 3:1 ratio to girls May be referral bias problems Girls may be more likely to have ADHD-I ADHD occurs in all social classes, may be more prevalent in lower SES Cultural differences in diagnosis Based only on parent and teacher ratings, as many as 20% of kids could be diagnosed as ADHD.

Developmental Course Adolescence and adulthood Infancy and pre-school Disorder persists in 40-80% of youth Symptoms may diminish or change Can have long-term social and occupational problems Lots of variation Longer-term problems may be associated with co-occurring diagnoses Infancy and pre-school Difficult temperament High activity level Distractibility Less cooperative Poor emotional regulation Childhood Most ADHD cases diagnosed during elementary school Self-regulation and organization deficits Peer rejection ODD onset Figure 9-3 shows the trajectories of hyperactivity/attention problems. Table 9-2 shows the variables that can predict outcome

Theories of ADHD Arousal level Sensitivity to reward Aversion to delay Low arousal Sensitivity to reward High preference for immediate reward Do poorly in situations with low incentive Aversion to delay Make significant efforts to avoid or escape delay Working memory Deficits lead to disorganized behavior Misdirection of attention Rapid shifts in attention (that are inappropriate)

Theories of ADHD Inhibition and executive functions Barkley’s Model Behavioral inhibition Inhibit prepotent responses Interrupt prepotent responses Protect from interference 4 executive functions

Theories of ADHD Figure 9-4 depicts Barkley’s model

Theories of ADHD Dual Pathway Model Executive functions related to inattention Delay aversion tied hyperactivity-impulsivity

Etiology Brain structure Reduction in volume Temporal lobe Corpus callosum Cerebellum Frontal lobe and connections to striatal region Smaller than average Right frontal area Caudate nucleus Globus pallidus Figure 9-5 Some areas of brain hypothesized to be effected by ADHD from Youdin & Riederer, 1997

Etiology Brain activity Genetics Decreased blood flow and decreased glucose utilization in the frontal areas Deficiencies in dopamine and norepinephrine Likely a heterogeneous disorder Genetics Runs in families Twin studies average heritability rate of .80 DRD4, DAT1 Stimulant medication blocks the reuptake of dopamine and norepinephrine.

Etiology Prenatal influences and birth complications Some indication that maternal smoking and alcohol use linked to ADHD Birth complications linked to higher rates Diet does not play a strong role in ADHD Exposure to lead linked to ADHD and lower IQ Dangerous levels may be lower than those identified by CDC Maternal depression