Chapter 8: Attention-Deficit/Hyperactivity Disorder
Description and Epidemiology (1 of 18)
Attention-deficit/hyperactivity disorder (ADHD): Not a new disorder:
1. A German pediatrician more than 150 years ago in his poems Johnny Head-In-Air and
Fidgety Phillip describes children with significant inattention and hyperactivity–
impulsivity the core dimensions of the disorder.
2. In the fast-paced world where distractions are everywhere with smartphones, social
media, and multitasking, it is probably no surprise that 8% of children and adolescents
have significant problems with hyperactivity, impulsivity, or inattention.
Descriptions by DSM: ADHD was named as “hyperkinetic reaction of childhood” in DSM-II, then
as attention-deficit disorder (ADD) in DSM –III and finally as attention-deficit/hyperactivity
disorder in DSM-III-R and DSM-5.
What Is Attention-Deficit/Hyperactivity Disorder?: Description
Neurodevelopmental disorder: ADHD is a neurodevelopmental disorder characterized by
significant symptoms of inattention and/or hyperactivity–impulsivity.
Behavioral symptoms listed by DSM-5:
1. Attention problems: Persistent and developmentally unexpected difficulties with paying
attention to detail, sustaining attention over time, listening to others and following
through with assignments, organizing tasks, staying focused, and remembering
information and the location of important objects.
2. Hyperactivity problems: Difficulty remaining seated and staying still when expected,
problems playing quietly, talkative, and “on the go.”
3. Impulsivity problems: Acting without forethought; Problems delaying gratification in
order to achieve long-term goals.
Diagnostic criteria: Children must show at least six out of a possible nine symptoms of either
inattention or hyperactivity–impulsivity.
Heterogeneity in diagnosis: Two children diagnosed with ADHD can manifest the disorder in
very different ways. The diagnostic label ADHD reflects a heterogeneous mix of children .
Persistent pattern of problems: People with ADHD show a persistent pattern of inattention
and/or hyperactivity–impulsivity that lasts for at least 6 months.
Symptoms in multiple settings: People with ADHD show symptoms in multiple settings such as
home, school, and in other settings. Symptoms may be less noticeable or impairing during some
activities than others, but they are present.
Norm-referenced rating scales: Used to compare a person suspected of having ADHD with
other individuals of the same age and gender.
Impairment in academic/social activities:
1. Children’s symptoms must also interfere with their everyday functioning.
2. To be diagnosed with ADHD, children must show clear impairment in academic or social
activities.
Symptoms before age 12:
1. DSM-5 conceptualizes ADHD as a disorder that emerges in childhood.
2. To be diagnosed with ADHD, individuals must have at least some symptoms of
inattention or hyperactivity–impulsivity before age 12.
Severity of ADHD:
1. Severe symptoms: Exceeds the minimum criteria and marked impairment in functioning.
What Is Attention-Deficit/Hyperactivity Disorder?: Presentations
ADHD, predominantly hyperactive–impulsive presentation:
1. Children show hyperactive and impulsive symptoms but only subthreshold problems
with inattention and are usually described as “driven by a motor” or “constantly on the
go”.
2. Symptoms tend to emerge between 3 and 4 years of age, disproportionately in boys and
interfere with their interactions with caregivers, family members, and peers.
3. Between the ages of 6 and 12, most of these children will transition from hyperactive–
impulsive presentation to combined presentation.
ADHD, combined presentation:
1. Children experience significant inattentive and significant hyperactive–impulsive
symptoms.
2. They also have underlying problems with behavioral inhibition, the ability to control or
regulate immediate impulses to achieve long-term goals.
3. Disinhibition causes them to have difficulty with sustained attention and to show
overactivity and impulsiveness at school and home.
ADHD, predominantly inattentive presentation:
1. Children show significant problems with inattention but subthreshold symptoms of
hyperactivity and impulsivity.
2. They are often overlooked by parents and teachers, despite their higher frequency in
the general population.
3. Predominantly inattentive presentation is usually seen in older children and adolescents
and is disproportionately diagnosed in girls.
4. The inattentive symptoms usually emerge between the ages of 8 and 12 years.
What Is Attention-Deficit/Hyperactivity Disorder?: Symptoms Across Development
Symptoms in children:
1. Children might display hyperactive–impulsive symptoms by leaving their seat in class or
blurting out answers.
2. They might display inattention by not listening to parents or being easily distractible in
school.
Symptoms in college students:
1. College students are more likely to experience subjective feelings of restlessness during
lectures or have difficulty waiting their turn while in line at bookstore.
2. They might show inattention by daydreaming during lectures, forgetting to keep
appointments, or submitting late assignments.
Symptoms in older adolescents and adults:
1. DSM-5 requires older adolescents and adults (17 years of age) to show only five
symptoms of either inattention or hyperactivity–impulsivity to be diagnosed with the
disorder.
2. The reduced symptom count is allowed because, on average, adults with significant
impairments due to ADHD often endorse fewer symptoms than children with the
disorder.
3. Adults who exhibit only five symptoms tend to have equal levels of impairment in tasks
requiring attention or behavioral control as adults who meet six or more symptoms.
• Core Symptoms for Children, Adolescents, and Adults:
Inattention:
1. Preschool: Child plays for short periods of time (<3 min).
2. School-Age: Activities are brief (<10 min); forgetful, disorganized, easily distracted.
3. Adolescence: Less persistent in tasks than peers (<20–30 min); doesn’t focus on details;
forgets assignments.
4. College: Forgets appointments or assignments; doesn’t plan ahead for long-term
projects.
Hyperactivity:
1. Preschool: Overactive; can’t be settled; acts like a “whirlwind.”
2. School-Age: Restless; excessive movement; leaving seat in school.
3. Adolescence: Fidgets with object; squirms in seat; movement of legs and limbs.
4. College: Subjective sense of restlessness.
Impulsiveness:
1. Preschool: Doesn’t listen to adults’ warnings; no sense of danger
2. School-Age: Blurts out answers in class; interrupts others; gets into many accidents
3. Adolescence: Speaks or acts before thinking; doesn’t plan ahead; risk-taking
4. College: Quick and unwise decision-making; impatient; reckless driving
What Problems Are Associated With ADHD?: Conduct and Substance Use Problems
• Conduct problems:
Oppositional defiant disorder (ODD):
1. A condition characterized by persistent stubbornness and noncompliance toward adults.
2. Children with ODD refuse to obey, talk back, throw tantrums, and are otherwise spiteful
or argumentative toward caregivers.
Conduct disorder (CD):
1. A behavioral disturbance characterized by a persistent disregard for the rules of society.
2. Youths with CD show a wide range of disruptive and destructive behaviors, including
physical fighting, theft, vandalism, and truancy.
Antisocial personality disorder (ASPD):
1. A serious personality disturbance defined by a persistent disregard for the rights and
dignity of others.
2. Adults with ASPD often have histories of aggression and illegal behavior.
3. Overall, the presence of ADHD in childhood increases the likelihood of developing ODD,
CD, and/or ASPD tenfold
ADHD: Underlying problems: Problems with emotion regulation (e.g., excessive anger and
irritability); emotional dysregulation, in turn, contributes to arguments with caregivers and
other adults, peer problems, aggression, and antisocial behavior.
Warning for clinicians:
1. ADHD symptoms are not solely a manifestation of oppositional, defiant, or antisocial
behaviors.
2. Most children are hyperactive, impulsive, and/or inattentive but do not talk back to
parents, fight with classmates, or skip school.
3. Other children and adolescents show serious patterns of defiant and aggressive
behavior toward family and peers but show no problems with hyperactivity or
inattention.
• Substance abuse problems:
Probability of problems:
1. Children with ADHD are 6 times more likely than their peers without ADHD to misuse
nicotine, alcohol, or other drugs later in life.
Reasons for link with ADHD:
1. Comorbid conduct problems such as ODD, CD.
2. Peer rejection because of their high-rate, aversive behavior.
Smoking and vaping and nicotine:
1. ADHD is a specific, unique predictor for smoking and vaping.
2. Even after controlling for comorbid conduct problems, adolescents with ADHD
approximately twice as likely to use nicotine as their typically developing peers.
3. They have more difficulty quitting the habit, and have higher relapse rates.
4. The more symptoms, the greater the risk of smoking or vaping.
5. They report that nicotine improves their concentration and behavioral inhibition and
regulate their attention and behavior.
Stimulant medication:
1. It might predispose children with the disorder to substance use problems later in life.
2. It is also shown to protect children with ADHD from future substance use problems.
What Problems Are Associated With ADHD?: Academic Problems
Learning difficulties: Children with ADHD encounter problems in reading and math and show
lower academic achievement scores and school performance.
Statistics of academic problems:
1. 56% of youths require special tutoring.
2. 45% of youths are referred for special education because of a learning disability.
3. 30% of youths repeat a grade.
4. 10% of youths do not complete high school.
Cognitive processing problems:
1. These interfere with Children’s ability to learn in traditional academic settings.
2. Children may miss information presented by teachers and opportunities to practice
newly learned academic skills.
Memory problem:
1. Deficits in working memory interfere with children’s ability to perform multistep
academic tasks.
2. Children may have problems holding information in working memory long enough to
use this information effectively to solve academic problems.
3. They may also have difficulty organizing information and relaying it to others
4. These deficits interfere with their ability to learn new skills and to perform well on
homework and exams.
What Problems Are Associated With ADHD?: Problems With Parents and Peers
• Parent–Child Interactions:
Characteristics of children:
1. More talkative, negative, and defiant; less compliant and cooperative; and more
demanding of their parents’.
2. Engage in more disruptive behavior because of their parents’ punitive discipline.
Characteristics of parents:
1. More hostile and less sensitive and responsive.
2. Engage in more hostile–intrusive parenting tactics because they are frustrated by their
children’s high-rate behavior.
Negative interactions: It may lead to oppositional behavior and conduct problems through
adolescence.
Problematic interactions:
1. Parents of children with both ADHD and conduct problems report high levels of
parenting stress, low confidence in their abilities to control their children’s behavior,
and less positive interactions with their children and family.
2. They are more likely to have high levels of couple or marital conflict.
3. Some parents, particularly those with a genetic diathesis toward alcohol use problems,
may use alcohol to cope with their children’s misbehavior.
• Peer Rejection and Peer Neglect:
Peer rejection:
1. The hyperactive and impulsive behavior of children with ADHD interferes with their
ability to behave appropriately during peer interactions.
2. ADHD symptoms often cause peer rejection.
3. Once children are rejected by some of their peers, they often develop negative
reputations among the rest of the peer group.
4. Peer rejection can exacerbate children’s ADHD symptoms and lead to the development
of conduct problems.
Peer neglect:
1. Children with ADHD, predominantly inattentive presentation are at risk for peer neglect.
2. Since they are passive and withdrawn in social situations, they may be overlooked by
peers as potential playmates or friends
Stimulant medication:
1. It is associated with improvements in the social interactions of children with ADHD.
2. It does not seem to improve children’s social skills or positive interactions with peers.
What Problems Are Associated With ADHD?: Sleep Problems
Three categories of problems:
1. Dyssomnias: Refusing to go to sleep, problems falling asleep, or difficulty waking in the
morning.
2. Movement disorders: Sleep talking, teeth grinding, and excessive tossing and turning.
3. Parasomnias: Night wakings, recurrent nightmares, or night terrors.
Sleep problems as a cause of ADHD:
1. Reduced sleep increases the problems with attention and hyperactivity–impulsiveness.
2. Early sleep problems subsided show fewer ADHD symptoms in later childhood.
Low-quality sleep:
1. Children with ADHD exhibit more restless, low-quality sleep characterized by greater
physical movement of the torso and limbs.
2. Children with hyperactive–impulsive symptoms often experience problems settling into
bed and may have delayed sleep onset or refusal to go to bed.
How Common Is ADHD?: Prevalence
Statistics with respect to age: ADHD affects approximately 5% to 8% of children and adolescents
and from 3% to 5% of adults, worldwide.
Statistics with respect to location:
1. Prevalence appears to be highest in South America and Africa and lowest in the Middle
East.
2. Prevalence among children and adolescents in North American and Europe is
approximately equal, ranging from 5% to 8% of youths
Prevalence in the United States:
1. The prevalence of ADHD in the United States is significantly higher based on caregiver
reports.
2. The largest increase in ADHD has been seen in African American children and youths
from lower-socioeconomic status (SES) backgrounds.
Explanations for the increase in ADHD:
1. The Individuals With Disabilities Education Improvement Act (IDEIA),began recognizing
ADHD as a potential disability in 1990 which led parents to seek diagnoses for their
children in order to gain educational accommodations and services.
2. The number of school-based health clinics increased during this time period, giving lowincome children greater access to mental health services.
3. Advances in the assessment of ADHD, leading to better identification of children with
the disorder.
4. A general increase in public awareness of the disorder and, perhaps, a decrease in
stigma.
How Common Is ADHD?: Gender
Gender ratio:
1. ADHD is more common in boys than in girls.
The differences in boys and girls:
1. Boys with ADHD are more likely than girls to have co-occurring conduct problems and
more likely to be referred for treatment.
2. Girls with ADHD are less likely to show oppositional and defiant symptoms than boys
and are often overlooked by parents, teachers, and other adults.
3. Girls with ADHD show fewer hyperactive–impulsive symptoms and more inattentive
symptoms than boys.
4. Girls are more likely to be diagnosed with ADHD at a later age and to be classified with
predominantly inattentive presentation.
5. Boys are more likely than girls to develop conduct problems and girls are more likely
than boys to experience academic difficulties.
School-related problems:
1. Boys and girls show similar impairment in behavior and social functioning.
2. Whereas boys are more likely than girls to develop conduct problems, girls are more
likely than boys to experience academic difficulties.
3. These problems are often attributable to underlying problems with executive
functioning and working memory.
Causes (1 of 8)
Is ADHD Heritable?: Behavioral Genetics
Genetic factors: Explain 70% to 90% of the variance in ADHD symptoms among children with
the disorder.
Concordance between twins:
1. Concordance between monozygotic (MZ) twins is 50% to 80%, whereas concordance
between dizygotic (DZ) twins is only 33%.
2. Concordance is higher for hyperactivity–impulsivity symptoms than for symptoms of
inattention.
Biological factors:
1. Children with ADHD are more likely to have a biological parent with the disorder (18%)
than children without ADHD (3%).
2. Adults with ADHD have a 57% chance of having at least one child with the disorder.
3. Siblings of children with ADHD are 3 to 5 times more likely to have the disorder
compared to controls.
Is ADHD Heritable?: Molecular Genetics
Neurotransmitter systems and ADHD development:
1. Dopamine and serotonin receptors are especially prevalent in brain regions responsible
for regulating attention and inhibiting behavior, especially the striatum and prefrontal
cortex.
2. People with lesions to these areas (and presumably damage to the dopamine and
serotonin systems) often show ADHD symptoms.
3. Medications used to treat ADHD stimulate the dopamine system and enhance attention.
4. Mice lacking genes that code for dopamine receptors in the brain show hyperactivity
and impulse-control problems.
Dopamine D4 and D5 receptor genes:
1. These genes code for proteins that act as receptors for dopamine in postsynaptic
neurons.
2. Some children with ADHD show mutations in these genes.
Is ADHD Heritable?: Genes and Early Environment
Three risk factors to developing ADHD:
1. Prenatally, fetuses exposed to cigarette smoke are significantly more likely to develop
ADHD, lower intelligence, and other neuropsychological problems later in life.
2. Perinatal risks include premature birth, low birth weight, and complications with
delivery involving hypoxia.
3. Postnatally, children with breathing problems during sleep are at elevated risk for
ADHD.
How Do Deficits in Executive Functioning Underlie ADHD?: The Development of Executive
Functions
ADHD and deficits in executive functions:
1. Children with ADHD are forgetful, do not listen to others or learn from past experiences,
and do not consider the consequences of their behaviors before they act.
2. Children with ADHD have difficulty organizing and directing their behavior, following
rules, and obeying others’ instructions. Instead of being motivated by internalized
speech and thoughts, their surroundings largely dictate their actions.
3. Children with ADHD have difficulty regulating their moods, show reduced ability to
maintain their motivation on tasks that require sustained effort, and appear heavily
dependent on immediate reinforcement from the environment to direct their behavior.
4. Children with ADHD, however, show difficulty with organization, planning, and problemsolving.
Evidence-based Treatment (1 of 8)
What Medications Are Effective for ADHD?: Psychostimulants
Psychostimulants: The most commonly prescribed medications for ADHD that affect the
neurotransmitters dopamine and norepinephrine and cause increased attention and behavioral
inhibition.
Classes: amphetamine; methylphenidate:
1. Amphetamine: Increases the release of dopamine from presynaptic storage vesicles,
resulting in more dopamine output to the cleft
1. Most frequently prescribed amphetamines: Adderall, Dexedrine, and Vyvanse.
Misuse of stimulant medication:
1. Low doses of stimulant medication reduce impulsivity and increase attention in
individuals with and without ADHD.
2. Adolescents without ADHD may use these medications as “study enhancers” by orally
ingesting other people’s medications. These medications improve students’ attention
and concentration while studying.
3. Immediate-release medications can be crushed and inhaled, producing a short-lasting
euphoric effect.
What Psychosocial Treatments Are Effective for ADHD?: Clinical Behavior Therapy
Clinical behavior therapy:
1. Most frequently used nonpharmacological treatment for ADHD.
2. Gets its name because mental health professionals typically administer treatment in
clinics and hospitals.
Three components of the therapy:
1. Parent consultation: Involves helping the caregivers of children with ADHD learn more
effective ways to manage their children’s behavior.
2. School consultation: Involves helping teachers change the environment to reduce
disruptive behavior and encourage on-task activities..
3. A combined home–school reward system: Involves consulting with teachers and other
school personnel.
Daily report card: A card that keeps children’s appropriate behavior at school, which can be
monitored and rewarded by parents at home.
Limitations of clinical behavior therapy:
1. The efficacy of behavior therapy is strongly related to parents’ involvement in the
program.
2. Parent training is typically effective only as long as parents actively implement strategies
and tactics learned in therapy.
3. Parent training does not always normalize their child’s behavior.
4. Behavior therapy programs are less effective for adolescents than for younger children
What Psychosocial Treatments Are Effective for ADHD?: Summer Treatment Programs
Direct contingency management:
1. Used in schools and other structured settings in which therapists have a great deal of
control over children’s surroundings.
2. Therapists alter children’s environments to maximize the frequency of desired actions.
3. They rely heavily on systematic rewards and punishments to shape behavior.
Supplements of behavioral interventions:
1. All children participate in 10 minutes of formal social skills training each day and they
are encouraged to practice the skill during role-play.
2. Caregivers participate in weekly group parent-training sessions designed to teach them
how to use behavioral principles at home.
3. Children in the STP are assessed to determine the appropriateness of medication to
treat their ADHD symptoms.
Which Is More Effective: Medication or Psychosocial Treatment?: Behavioral Classroom
Management
Behavioral classroom management:
1. A school-based, psychosocial treatment for children with ADHD.
2. Unique characteristic: It is administered by school psychologists, teachers, and other
education specialists in classroom settings.
3. Interventions rely heavily on monitoring appropriate child behavior, administering
frequent positive reinforcement contingent on appropriate behavior, structuring the
classroom environment to elicit appropriate behavior, and developing a daily report
card so that parents can reinforce appropriate behavior at home.
Which Is More Effective: Medication or Psychosocial Treatment?: Multimodal Treatment
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Multimodal Treatment Study of Children With ADHD (MTA): The largest study
examining the relative effects of medication and behavior therapy on ADHD.
Medication alone: Youths in this group received 14 months of medication, usually
methylphenidate, which was carefully administered by researchers.
Behavior therapy alone. Youths in this group participated in 8 months of clinical
behavior therapy during part of the academic year and an STP during the summer.
These youths did not receive medication.
Combined treatment. Youths in this group received both medication and behavior
therapy, both administered by the researchers.
Community care. Youths in this group were referred to mental health professionals in
their communities. They were free to receive any treatment recommended by these
professionals, but they did not receive treatment from the researchers. Most children
who received community care were prescribed medication. Youths in this group served
as a “treatment as usual” control condition.
Which Is More Effective: Medication or Psychosocial Treatment?: Best Practices
Preschool-age children:
1. They should receive behavior therapy as a first-line treatment for ADHD.
2. Preschoolers who do not respond to behavior therapy may be prescribed medication
with consent of their caregivers.
School-age children and adolescent:
1. They should receive a combination of behavior therapy and medication as a first-line
treatment.
2. Behavior therapy can be administered either in a clinic, school, or across settings.
3. Medication should only be used with the consent of caregivers and assent of youths.
Adults: They should consider medication and participate in a behavior therapy program to help
them manage symptoms in everyday life.