8
Attention-Deficit/Hyperactivity
Disorder (ADHD)
Eric J. Mash
A. Wolfe
©David
Cengage Learning
2016
© Cengage Learning 2016
Description
• Attention-deficit/hyperactivity disorder
(ADHD) is exhibited as persistent ageinappropriate symptoms of inattention,
hyperactivity, and impulsivity that are
sufficient to cause impairment in major life
activities
– Characteristic behaviors vary considerably
from child to child
– Different behavior patterns may have different
causes
© Cengage Learning 2016
History
• Early 1900s
– Children who lacked self-control and showed
symptoms of overactivity/inattention in school
were said to have poor “inhibitory volition” and
“defective moral control”
• Following the worldwide influenza
epidemic from 1917-1926
– “Brain-injured child syndrome”
• 1940s-1950s: “minimal brain damage” and
“minimal brain dysfunction”
© Cengage Learning 2016
Historical Example
© Cengage Learning 2016
History (cont’d.)
• Late 1950s
– ADHD was called hyperkinesis
• Led to definition of hyperactive child syndrome, in
• By the 1970s
– Deficits in attention and impulse control, in
addition to hyperactivity, were seen as the
primary symptoms
• 1980s saw increased interest in ADHD
– Rise in stimulant use generated controversy
© Cengage Learning 2016
Core Characteristics
• Key symptoms fall under two welldocumented categories
– Inattention
– Hyperactivity-impulsivity
• Using these dimensions to define ADHD
oversimplifies the disorder
– Attention and impulse control are closely
connected developmentally
© Cengage Learning 2016
DSM-V Diagnostic Criteria for ADHD
© Cengage Learning 2016
DSM-V Diagnostic Criteria for ADHD
(cont’d.)
© Cengage Learning 2016
DSM-V Diagnostic Criteria for ADHD
(cont’d.)
© Cengage Learning 2016
Inattention
• Inability to sustain attention, particularly for
repetitive, structured, and less enjoyable
tasks
• Deficits may be seen in one or more types
of attention
– Attentional capacity
– Selective attention
– Distractibility
– Sustained attention/vigilance (a core feature)
© Cengage Learning 2016
Hyperactivity-Impulsivity
• Inability to voluntarily inhibit dominant or
ongoing behavior
• Hyperactive behaviors include
– Fidgeting and difficulty staying seated
– Moving, running, touching everything in sight,
excessive talking, and pencil tapping
– Excessively energetic, intense, inappropriate,
and not goal-directed
© Cengage Learning 2016
Hyperactivity-Impulsivity (cont’d.)
• Impulsivity
– Inability to control immediate reactions or to
think before acting
– Cognitive impulsivity includes disorganization,
hurried thinking, and need for supervision
– Behavioral impulsivity includes difficulty
inhibiting responses when situations require it
– Emotional impulsivity includes impatience, low
frustration tolerance, hot temper, quickness to
anger, and irritability
© Cengage Learning 2016
ADHD Presentation Types
• Predominantly inattentive presentation
(ADHD-PI)
• Predominantly hyperactive–impulsive
presentation (ADHD-HI)
• Combined presentation (ADHD-C)
© Cengage Learning 2016
Predominantly Inattentive Type (ADHD-PI)
• Inattentive, drowsy, daydreamy, spacey, in
a fog, and easily confused
• May have learning disability, process
information slowly, have trouble
remembering things, and display low
academic achievement
• Often anxious, apprehensive, socially
withdrawn, and may display mood
disorders
© Cengage Learning 2016
Predominantly Hyperactive-Impulsive Type
(ADHD-HI)
• Primarily symptoms of hyperactivityimpulsivity (rarest group)
• Primarily includes preschoolers and may
have limited validity for older children
• May be a distinct subtype of ADHD-C
© Cengage Learning 2016
Combined Type (ADHD-C)
• Children who have symptoms of both
inattention and hyperactivity-impulsivity
• Most often referred for treatment
© Cengage Learning 2016
Additional DSM Criteria
• Appears prior to age 12
• Persists more than 6 months
• Occurs more often and with greater
severity than in:
– Other children of the same age and sex
• Occur across two or more settings
• Interferes with social or academic
performance
• Not explained by another disorder
© Cengage Learning 2016
What DSM Criteria Don’t Tell Us
• Limitations of DSM criteria for ADHD
– Developmentally insensitive
– Categorical view of ADHD
• DSM criteria shape our understanding of
ADHD
– DSM criteria are also shaped by, and in some
instances lag behind, new research findings
© Cengage Learning 2016
Associated Characteristics
• Children with ADHD often display other
problems in addition to their primary
difficulties
– Cognitive deficits
– Speech and language impairments
– Developmental coordination and tic disorders
– Medical and physical concerns
– Social problems
© Cengage Learning 2016
Cognitive Deficits: Executive Functions
•
•
•
•
Cognitive processes
Language processes
Motor processes
Emotional processes
© Cengage Learning 2016
Examples of Impaired Executive Functions
© Cengage Learning 2016
Cognitive Deficits: Intellectual and
Academic
• Intellectual deficits
– Most children with ADHD have at least normal
intelligence - the difficulty lies in applying
intelligence to everyday life situations
• Impaired academic functioning
– Children with ADHD frequently have lower
productivity, grades, and scores on
achievement tests
© Cengage Learning 2016
Cognitive Deficits: Learning Disorders and
Self-Perceptions
• Learning disorders are common for
children with ADHD
– Problem areas: reading, spelling, and math
• Distorted self-perceptions
– Positive bias: exaggeration of one’s
competence
– Self-esteem in children with ADHD may vary
with the subtype of ADHD
– Distortions in perceptions of quality of life
© Cengage Learning 2016
Speech and Language Impairments
•
•
•
•
Formal speech and language disorders
Difficulty understanding others’ speech
Excessive and loud talking
Frequent shifts and interruptions in
conversation
• Inability to listen
• Inappropriate conversations
• Speech production errors
© Cengage Learning 2016
Developmental Coordination and Tic
Disorders
• As many as 30-50% of children with ADHD
display motor coordination difficulties
– Clumsiness, poor performance in sports, or
poor handwriting
• Overlap exists between ADHD and
developmental coordination disorder
(DCD)
– Marked motor incoordination and delays in
achieving motor milestones
© Cengage Learning 2016
Developmental Coordination and Tic
Disorders (cont’d.)
• Tic disorders occur in 20% of children with
ADHD
– Sudden, repetitive, nonrhythmic motor
movements or sounds such as eye blinking,
facial grimacing, throat clearing, and grunting
© Cengage Learning 2016
Medical and Physical Concerns
• Health-related problems
– Higher rates of asthma and bedwetting
• Studies’ findings are inconsistent
– Sleep disturbances may be related to use of
stimulant medications and/or co-occurring
conduct or anxiety disorders
© Cengage Learning 2016
Medical and Physical Concerns (cont’d.)
• Accident-proneness and risk taking
– Over 50% are described as being accidentprone
– At higher risk for traffic accidents
– At risk for early initiation of cigarette smoking,
substance use disorders, and risky sexual
behaviors
– Reduced life expectancy
– Higher medical costs
© Cengage Learning 2016
Social Problems
• Family problems include:
– Negativity, child noncompliance, excessive
parental control, sibling conflict, maternal
depression, paternal antisocial behavior, and
marital conflict
• Family difficulties may be due to cooccurring conduct problems
© Cengage Learning 2016
Social Problems (cont’d.)
• Peer problems
– ADHD children can be bothersome, stubborn,
socially awkward, and socially insensitive
• They are often disliked and uniformly rejected by
peers, have few friends
• They are unable to apply their social
understanding in social situations
• Positive friendships may buffer negative
outcomes
© Cengage Learning 2016
Accompanying Psychological Disorders and
Symptoms
• Up to 80% of children with ADHD have a
co-occurring psychological disorder
• Oppositional Defiant Disorder (ODD) and
Conduct Disorder (CD)
– Role of COMT gene
– A common genetic contribution for ADHD,
ODD, and CD
– Family connections – there is evidence for a
contribution from a shared environment
© Cengage Learning 2016
Accompanying Psychological Disorders and
Symptoms Anxiety Disorders
• Anxiety disorders
– About 25% of children with ADHD experience
excessive anxiety
– Co-occurring anxiety worsens symptoms or
severity of ADHD
• Findings are inconsistent
– Children with co-occurring ADHD and anxiety:
• Display social and academic difficulties
• Experience greater long-term impairment and
mental health problems
© Cengage Learning 2016
Accompanying Psychological Disorders and
Symptoms Mood Disorders
• Mood disorders
– ADHD at 4-6 years is a risk factor for future
depression and suicidal behavior
– 20-30% of children with ADHD experience
depression
• Family risk for one disorder may increase the risk
for the other
• Controversy regarding relationship between ADHD
and pediatric bipolar disorder (BP)
© Cengage Learning 2016
Prevalence and Course
• Prevalence rates vary widely with
sampling methods
– Estimates: 6-7% of school-age children and
adolescents in North America and 5%
worldwide have ADHD
– ADHD is one of the most common referral
problems seen at clinics
© Cengage Learning 2016
Gender
• ADHD occurs more frequently in boys
• Overall rates decrease in adolescence for
both sexes - ratio remains the same
• Ratio in clinical samples is 6:1 with boys
being referred more often than girls
– ADHD in girls may go unrecognized and
unreported
• DSM criteria (cutoffs and symptoms) may
be more appropriate to boys than girls
© Cengage Learning 2016
Gender (cont’d.)
• Girls with ADHD may be more likely to
display inattentive/disorganized symptoms
• Clinic-referred school-age children with
ADHD display similar symptoms
• Girls with ADHD who display impulsivehyperactive behaviors
– More likely to develop eating disorder
symptoms
© Cengage Learning 2016
Socioeconomic Status and Culture
• ADHD affects children from all social
classes
– Slightly more prevalent among lower SES
groups
• Findings are inconsistent regarding
relationships among ADHD, race, and
ethnicity
• ADHS is found in all countries and cultures
– Rates vary
© Cengage Learning 2016
Socioeconomic Status and Culture (cont’d.)
• Cultural differences may reflect cultural
norms and tolerance for ADHD symptoms
• ADHD is a universal phenomenon that is
diagnosed more often in boys than girls in
all cultures
– Expression, associated features, impairments,
and outcomes are quite similar wherever it
occurs
© Cengage Learning 2016
Course and Outcome
• Infancy
– Signs of ADHD may be present at birth - no
reliable or valid methods exist to identify it
• Preschool
– Hyperactivity-impulsivity symptoms become
more visible and significant at ages 3-4
– Children with symptoms for at least 1 year are
likely to continue to have difficulties later in
middle childhood and adolescence
© Cengage Learning 2016
Course and Outcome Elementary School
• Symptoms are especially evident when the
child starts school
• Oppositional defiant behaviors may
increase or develop
– By age 8-12, defiance and hostility may take
the form of serious problems
– Increased problems may encompass selfcare, personal responsibility, chores,
trustworthiness, independence, social
relationships, and academic performance
© Cengage Learning 2016
Course and Outcome Adolescence and
Adulthood
• Many children with ADHD do not outgrow
problems and some can get much worse
• At least 50% of clinic-referred elementary
school children continue to suffer from
ADHD into adolescence
• Adult challenges
– Some individuals either outgrow or learn to
cope with their disorder by adulthood
– ADHD is established as an adult disorder
© Cengage Learning 2016
Theories and Causes
• Explanations for ADHD
– Trait from evolutionary past as hunters
– ADHD is a myth fabricated because society
needs it
– Some theories
• Cognitive functioning deficits
• Reward/motivation deficits
• Arousal level deficits
• Self-regulation deficits
© Cengage Learning 2016
A Possible Developmental Pathway for
ADHD
© Cengage Learning 2016
Genetic Influences
• ADHD runs in families
• Adoption studies
• Twin studies
– 75% heritability estimates for hyperactiveimpulsive and inattentive behaviors
• Specific gene studies
– Genes may contribute to the expression of
ADHD – focus on dopamine regulation
© Cengage Learning 2016
Pregnancy, Birth, and Early Development
• Factors that compromise development of
the nervous system before and after birth
may be related to ADHD
• Mother’s use of cigarettes, alcohol, or
other drugs during pregnancy are
associated with ADHD
– Contributing factors, rather than a causal
association
– It is difficult to disentangle substance abuse
influence and other environmental factors
© Cengage Learning 2016
Neurobiological Factors
• Research shows differences on:
– Psychophysiological measures
• Diminished arousal or arousability
– Measures of brain activity during vigilance
tests
• Under-responsiveness to stimuli/deficits in
response inhibition
– Blood flow to prefrontal regions and pathways
connecting them to limbic system
• Decreased blood flow to these regions
© Cengage Learning 2016
Brain Abnormalities
• Abnormalities primarily in the frontostriatal
circuitry are implicated
– This region includes the prefrontal cortex and
the basal ganglia
– ADHD children have smaller total and right
cerebral volumes (by 3-4%), smaller
cerebellum, and delayed brain maturation
• Specific regions of the thalamus may also
be involved
© Cengage Learning 2016
Neurophysiological and Neurochemical
Associations
• No consistent differences have been found
between children with and without ADHD
– Some neurotransmitters may be involved
• Dopamine, norepinephrine, epinephrine, and
serotonin may be involved
• Most evidence suggests a selective deficiency in
availability of dopamine and norepinephrine
– Using medication for effective treatment of
ADHD symptoms does not prove that deficits
are the cause of symptoms
© Cengage Learning 2016
Diet, Allergy, and Lead
• Sugar is not the cause of hyperactivity
• Allergic reactions and diet
– Possible moderating role of genetic factors
may explain why food additives affect the
behavior of some children
• Low levels of lead may be associated with
ADHD symptoms
• The role of diet, allergy, and lead as
primary causes of ADHD is minimal to
nonexistent
© Cengage Learning 2016
Family Influences
• Importance of family influences
– Family influences may lead to ADHD
symptoms or to a greater severity of
symptoms
– Family problems may result from interacting
with a child who is difficult to manage
– Family conflict is likely related to the
presence, persistence, or later emergence of
associated oppositional and conduct disorder
© Cengage Learning 2016
Treatment
• Less than half of the children with ADHD
receive treatment
– Of those who receive treatment, many
discontinue prematurely
• The primary treatment approach
combines:
– Stimulant medication
– Parent management training
– Educational intervention
© Cengage Learning 2016
Treatments for Children with ADHD
© Cengage Learning 2016
Medication
• Stimulants have been used to treat ADHD
since the 1930s
– Among the most effective stimulants are
dextroamphetamine and methylphenidate
• May help normalize frontostriatal structural
abnormalities and functional connections
– Effects are temporary and occur only while
medication is taken; beneficial in short-term
• Questions surround long-term benefits and later
adjustment
© Cengage Learning 2016
Parent Management Training (PMT)
• Provides parents with a variety of skills
– Managing the child’s oppositional and
noncompliant behaviors
– Coping with emotional demands of raising a
child with ADHD
– Containing the problem so it does not worsen
– Keeping the problem from adversely affecting
other family members
© Cengage Learning 2016
Parent Management Training (PMT)
(cont’d.)
• Parents are:
– Taught to understand biological basis of
ADHD
– Given set of guiding principles
– Taught behavior management principles and
techniques
– Encouraged to spend time each day sharing
enjoyable activity with their child
– Taught how to reduce their own levels of
arousal
© Cengage Learning 2016
Educational Intervention
• Teacher and child must set realistic goals
and objectives
• Response-cost procedures are used to
reduce disruptive or off-task behaviors
• Many strategies are basic good teaching
methods
• School-based interventions for ADHD
have received considerable support
© Cengage Learning 2016
Intensive Interventions
• Summer treatment programs
– Maximize opportunities to build effective peer
relations in normal settings and provides
continuity with academic work so gains from
school year aren’t lost
– Are coordinated with stimulant medication
trials, PMT, social skills training, and
educational interventions
© Cengage Learning 2016
Additional Interventions
• Family counseling and support groups
– Help family members develop new skills,
attitudes, and ability to relate more effectively
• Individual counseling
– Helps children with ADHD deal with their
problems and feelings of isolation and
abnormality
– Helps build their sense of self-competence
© Cengage Learning 2016
Keeping Things in Perspective
• Children with ADHD have problems that
should not be minimized
• Each child is unique and has assets and
resources that need to be recognized and
supported
© Cengage Learning 2016