ADHD: Symptoms and Overview

ADHD Overview

• ADHD is an externalizing behavior disorder
• ADHD has a high heritability rate of about 60%, the highest among all disorders
• Individuals with ADHD exhibit under-controlled, impulsive, or aggressive behaviors
• ADHD is a neurodevelopmental condition characterized by differences in brain functions, including impulsivity and hyperactivity
• ADHD symptoms include persistent and age-inappropriate behaviors, such as inattention, hyperactivity, and impulsivity

Symptoms of ADHD

• Inattention involves difficulty maintaining focus, paying attention, and avoiding distractions
• Hyperactivity includes the inability to stay still and displaying excessive energy
• Over-activity is difficult to diagnose in children because it is normal, but is present by frequently switching activities
• Hyperactivity is often seen in school settings, where children are expected to sit still for extended periods
• Impulsivity involves difficulty with self-control and acting without thinking, leading to blurting out responses
• Impulsivity also manifests as invading personal space or interrupting conversations
• Quick responses to negative events and difficulty regulating strong emotions
• ADHD is similar to ODD and CD; these are more related to aggressive behaviors
• ADHD is a blanket term for a series of symptoms, with behavior patterns varying from child to child
• Subtypes on ADHD are used to classify the symptom severity
• There is no evidence of a causal relationship between diet and ADHD

History of ADHD

• The history of ADHD has included many name changes
• In the early 1900s, it was seen as "defective moral control"
• George Still found that some children had difficulty controlling their behavior
• Defective moral control was thought of to be related to ADHD, but with normal or above average intelligence
• Children with ADHD drew attention because there was an increased demand to display self-regulation
• From 1917-1925, following a worldwide influenza epidemic, some children suffered encephalitis, leading to brain trauma and the "brain-injured child syndrome"
• Then from 1940-1950 was called minimal brain damage and minimal brain dysfunction
• The brain damage theory was rejected as it failed to explain most cases of uncontrollable behavior
• In the late 1950s, the term "hyperkinesis" emerged, emphasizing hyperactivity as a core symptom
• In the 1970s, deficits in hyperactivity, attention, and impulse control were recognized
• Hyperactivity was not the only symptom; other primary symptoms were added to characterize the behavior
• The criteria used for ADHD began shaping at this point
• In the 1980s, interest in ADHD rose, with a rise in stimulant use
• ADHD was referred to as ADD initially, but the name was changed to ADHD in 1987 to reflect the components of hyperactivity and attention
• The DSM combined hyperactivity and impulsivity into one dimension

ADHD Characteristics

• ADHD is a neurodevelopmental disorder with an early onset, with symptoms appearing before age 12, and can be diagnosed early as 3 years old
• ADHD typically follows a persistent course and is a lifelong disorder, and the presentation of the disorder varies
• Shifts or reductions or increases in symptoms are seen over time, and neural development differences
• Delayed brain maturation, differences in activity in brain regions involved in thinking, behavior, and emotion regulation, as well as lowered Dopamine occurs
• Stimulants act to increase dopamine levels
• ADHD overlaps with other neurodevelopmental disorders and difficulties in language, motor coordination, and social development
• Inattention is an inability to engage and sustain attention, along with difficulty planning, organizing, and cognitive impairments
• Sustained attention and vigilance enable maintaining attention over a period, especially during repetitive tasks
• ADHD is associated with impaired altering, which involves reacting appropriately to stimuli; difficulty in planning and organization, often strongly impacting academics
• Hyperactivity-Impulsivity includes difficulty controlling motor behavior, inhibiting impulses, and delaying gratification
• Linked to aggressive behaviors and risk for social behavior challenges
• Hyperactivity is excessive activity that is not goal-directed, such as fidgeting and difficulty staying seated, sometimes during sleep
• Impulsivity involves cognitive, behavioral, and emotional components, but does not cause difficulty in school
• The DSM-5 criteria require the presence of either inattention or hyperactivity and impulsivity symptoms for an ADHD diagnosis
• DSM criteria are adjusted to fit older children as they grow into adolescents

Specifiers and Presentations

• Incorporates a dimensional approach by integrating other aspects of behavior
• Sub aspects include if there is a partial remission of symptoms
• It is important to note the severity of symptoms
• Presentation types:
  • Predominantly inattentive presentation (ADHD-PI) is characterized by forgetfulness, slow information processing, sluggish cognitive tempo, inattentiveness, distractibility, confusion, and disorganization
  • Social withdrawal and anxiety are more present compared to the other presentation types
  • Harder to diagnose than an impulsive or hyperactive type of ADHD
  • Predominantly hyperactive-impulsive presentation (ADHD-HI) involves hyperactivity, fidgeting, excessive talking, impulsivity, argumentativeness, difficulty following rules, difficulty showing difficulties in attention, and difficulty with self-control
  • Is rarest, diagnosed predominantly in young kids
  • Combined presentation (ADHD-C) shows both inattention and hyperactivity with impulsivity, restless, disorganized, and is commonly seen in clinical environments

Limitations of DSM for ADHD

• It can be difficult to categorize the subtypes of ADHD because there is a lot of variation.
• ADHD symptoms presentation can vary significantly, not only between subtypes but also within the same individual over time, making it hard to categorize and predict long-term outcomes effectively
• The children within the same ADHD subtype can vary greatly
• The changes in classification of the child can change as they grow, causing instability of the classification system
• Clinical judgment is needed to determine whether or not symptoms are typical based on development
• Attributing symptoms to different age/developmental stages can be hard and clinical judgment becomes critical in determining a child's behavior
• Symptoms adjustments for older populations are necessary because their symptoms are present differently

The Categorical View of ADHD

• ADHD is viewed under the binary lens that one either has ADHD or does not
• The DSM takes a categorical approach, diagnosing a child as either having ADHD or not, which overlooks the continuum of varied ADHD symptoms
• There are people just below the cut-off who are just above the cut-off, which is how different are they
• Where do we draw the line as well, knowing that others who are just below the line also be faced with challenges that accompany ADHD

Associated Characteristics of ADHD

• ADHD is like an iceberg, where the symptoms are just the tip and the the real problems that interfere with day-to-day life are hidden
• Children with ADHD have additional challenges with cognitive deficits, executive functions, time management, and planning
• They have emotional difficulties like mood swings and irritation
• They have self-concept and motivational challenges which result in reduced confidence and social and educational challenges
• Social challenges and difficulties communicating
• Medical difficulties such as difficulty sleeping and deficiency in dopamine

Links Between ADHD and Intelligence

• Inattention has a link to impaired academic function
• Children with ADHD have average or above intelligence for the most part
• They have difficulty connecting in the correct settings
• Connection between higher ADHD symptoms and low applying of intelligence in various settings
• It doesn't diminish intelligence, it impacts how smartness can be shown, cannot properly apply their intelligence in correct settings
• Children are often low in self-esteem and can suffer from distorted self perceptions

Co-morbidities of ADHD

• 80% of children with ADHD have other psychological disorders
• 50% have 2 or more disorders
• This makes treating ADHD difficulty as it is hard to isolate the symptoms accurately
• Oppositional Defiant Disorder (ODD) can also be present - 50%
• Conduct Disorder (CD) can also be present - 30-50%
• The combination of ADHD + ODD + CD can run in families due to:
  • Neurobiological causes
  • Shared environmental factors
• Anxiety disorders are also seen - 24-50%
  • It may cause a reduction in aggressive behaviors but result in challenges in social situations and education
• Mood disorders are also typical - 20-30%
• Depression is often seen, as well as motor coordination and tic disorders

Prevalence of ADHD

• Globally there is a ~5% of the world that suffers from ADHD
• Most commonly is a problem seen in clinics
• Symptoms can start in early childhood and develop over time
• As the individual goes through education, hyperactivity has been shown to decrease and impulsivity to increase
• Adolescents tend to see hyperactivity tendencies decrease
• Adulthood = Difficulty in work and functioning
• Gender plays a role. More frequently is is diagnosed in boys rather than girls
• This may be because ADHD tends to be ignored by families in girls and it is harder to diagnose
• ~2-4% for girls
• ~6-9% for boys

Theories and Causes of ADHD

• There is not a single cause of ADHD
• There are however many biological, environmental and psychological factors that may contribute to the development of ADHD

Biological Factors

• There are genetic links such as adoption studies show higher rates of ADHD
• Twin studies have shown there can be a 65% similarity between twins with ADHD
• Specific genetic variations related to dopamine regulation are linked to ADHD symptoms, which effects impulse control
• A brain with ADHD may show smaller or delays to the prefrontal cortext and also earlier maturation of the motor cortex

Environmental Factors

• Can be smoking, alcohol and lead intake which has been shown to be harmful to an unborn child
• There are theories to suggest that those factors may develop behavioral defects in the newborn
• They make a malleable state that can be combined with other factors to increase the risk for ADHD
• Parenting does not cause ADHD. It may affect how intense the symptoms of ADHD present in a family which has some level of conflict

Cognitive and Psychological Factors

• There are 4 main factors that lead to ADHD development
  • Cognitive function deficits
  • Motor difficulty
  • Cognitive language and communication
  • Difficulties with executive control and planning
• Reward and motivation deficits
  • Prefer immediate rewards over delayed ones
  • Inability to be successful in motivation when rewards are hard to obtain
  • Differences in sensitivity towards rewards
• Arousal level deficits
  • Differences in alternes and arousal
• There are self-regulation deficits which effect how people regulate their behavior based on difficult thought processes

Understanding Treatment for ADHD

• The main approach towards treating ADHD combines 3 approaches
  • Stimulant medication is a stimulant drug with the aim to normalize the levels of neurotransmitters in the brain
  • These are designed to normalize the levels of neurotransmitters + structural abnormalities
  • This has been used since the 1930s
  • It is reported that these medications are safe and can be helpful
  • They are usually adjusted by dosage
  • Non-addictive for most children
  • Does not cause an increased risk for substance abuse
• However stimulant treatments can have side effects
  • It may not be a long term solution
  • Can cause a reliance on meds
  • Addictive if misused
• Furthermore, medication alone wont address the underlying problems that has led to the development of ADHD
• Parent Management training is used as an intervention for parents so that there is an improvement in parent and child communication, creating a healthy relationship
• Help the parents to learn about ADHD so that they can reduce parenting stress in cases where their children have the condition.
• They will be taught behavior management techniques and how to handle and reward good behavior and encourage more positive interactions

Education intervention which is a collaboration between the teacher and the parent to create a collaborative school setting

• A plan will be developed that sets achievable goals. Support will be provided to help the children improve in education
• An effective reward system will be put in place to encourage better performance. Monitoring must also be implemented to make sure the child is on the right path
  • Punishment will be set for disruptive behaviour
• This type of intervention creates a good teaching method and provides positive acommodations for all parties

Intensive Interventions

• This leads to success not only at home but also in the classroom
• Summer programs provide an opportunity to improve peer relations
• Continuity is provided with academic support

Treatments and Studies

• The Multimodal Treatment Study tested the differences from different solutions
  • The treatment plans included medication, behavioral and combined options
  • What this found was that if the treatments plans were combined they were significantly more effective.
  • However there weren't too many difference 3 years later