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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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?

11. 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 %
Bipolar 10-20%
Relationship between depression and ADHD is complex-See Figure 9-2

12. 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.

13. 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

14. 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)

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

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

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

18. 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

19. 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.

20. 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