Attention-Deficit/ Hyperactivity Disorder

ADHD subtypes Attention-Deficit/Hyperactivity Disorder specifiers Combined presentation Predominantly inattentive presentation Predominantly hyperactive/impulsive Notes: Notice that there are 3 subtypes. Combined type, Inattentive (also called ADD), and Hyperactive/impulsive. Combined and hyperactive/impulsive are probably the most commonly diagnosed. There is more research on these two categories and may be “easier” to detect.

Epidemiology Prevalence 2:1 for inattentive 5% children More prevalent in boys 2:1 for inattentive 5:1 for hyperactive-impulsive

Note. Increase in diagnosis rate over time Note. Increase in diagnosis rate over time. There may be a number of reasons for this. Could misdiagnosis/overdiagnosis be one of them? Probably.

Related characteristics & functional impairment Motor skills deficits & accidents Peer & teacher relations Family relations Academic achievement Sleep problems Notes: Perhaps we think of ADHD as problem only with grades. However, “true” accurately diagnosed ADHD is associated with a whole variety of problems. They have more injuries (probably due inattention and less developed motor skills), problems with family, problems with peers and teachers. Bottom line, this disorder can have a major impact on their development, and self-esteem.

A couple of important points here A couple of important points here. You may ask, “how would you diagnose ADHD when most children are very active, impulsive (at least sometimes), and have limited attention spans?” First, they show much more activity, impulsivity, and much poorer of an attention when compared to same-aged peers. This is why standardized rating scales are often important (e.g., a child may score in the 99th percentile for impulsivity and inattention when rated by parents and teachers). Second, peer status is an important marker. Although not essential for diagnosis, children with ADHD are often much more impulsive and hyperactive than their same-aged peers, their same-aged peers often reject them. Children with ADHD may come across as intrusive and overwhelming even to same-aged peers.

Developmental Course & Prognosis Preschool- excessive motor activity, emotional regulation problems, difficult to assess before 4. Childhood- most common time for referral Adolescence- many still meet diagnostic criteria Subclinical symptoms & comorbidity (mood disorders & DBDs) common Less hyperactivity

Notes: example from text of developmental progression (as summarized in previous slide).

Developmental Course & Prognosis Adulthood (2.5% prevalence) Many adults continue to exhibit symptoms; although some become better able to manage or outgrow. Substance abuse, interpersonal problems, lower income, APD possible

Etiology Frontal lobe deficits (especially working memory) Neurological factors Deficits in executive functions Blood flow to prefrontal cortex EEG patterns- increased theta & beta activity (under-arousal & under-activity) Other factors: pregnancy & birth complications, genetics (strong influence), environmental toxins (some cases) See following slides. Frontal lobe deficits are typically present, which control executive functioning (including working memory and impulse control). This is a very very neurobiolgical disorder. See following slides for more on this.

Behavioral Disinhibition Inattention, Hyperactivity & Impulsivity Working Memory Creative Problem Solving Emotion Regulation Internalized Speech ADHD: Inattention, Hyperactivity & Impulsivity

Treatment Medication Ritalin, Concerta (Methylphenidates) Stimulants Ritalin, Concerta (Methylphenidates) Adderall, Focalin (Dextroamphetamines) Nonstimulants Strattera Intunive Notes: Medication (usually stimulants) is the most effective, front line treatment for ADHD. So how is a stimulant helpful for individuals with ADHD. These medications stimulate the frontal lobe (which is typically overactive) by increasing Dopamine and Norepinephrine activity.

Notes: These medications have a short half-life, meaning that they start working quickly, but they leave the system quickly (see curve above). This is why some take a dose at lunch after an initial dose a breakfast. Another point, the idea only children with ADHD will respond to this medication does not seem to be accurate. These drugs may enhance performance in most people.

ADHD: Psychosocial Intervention Psychosocial intervention is also important and seems to improve outcome. This includes behavioral management Social skills training Psychoeducation about symptoms.