Lecture 6: ADHD - PDF Notes

Lecture 6: ADHD ADHD ⇒ Externalizing behavior disorder It has about a 60% heritability → highest among all disorders Under controlled or impulsive or aggressive behaviors Neurodevelopment condition that is categorize...

Lecture 6: ADHD ADHD ⇒ Externalizing behavior disorder It has about a 60% heritability → highest among all disorders Under controlled or impulsive or aggressive behaviors Neurodevelopment condition that is categorized by differences in brain functions ⇒ Impulsivity + hyperactivity ADHD = Persistent (continuous), age-inappropriate symptoms of: 1. Inattention Difficulty maintaining focus when needed and sustaining focus during work or play Hard to pay attention (lapses in attention) Easily distracted Might not be able to pick up on mistakes that they or another person made during work or some other activity 2. Hyperactivity Cannot stay still Displays excessive energy Difficult to diagnose or recognize in children since they are naturally active Present as frequently switching between activities Seen more often in school settings ⇒ Children are expected to sit still for long periods of time in school 3. Impulsivity Difficulty with self-control Acting immediately without thinking Ex ⇒ Blurting out responses Lecture 6: ADHD 1  Invade personal space or interrupt conversations Ask personal questions frequently at inappropriate times Response to negative events are quick Difficulty regulating strong emotions Similar/related to ODD and CD (but these are more on aggressive behaviors) ADHD = Persistent + Age-inappropriate symptom of inattention, hyperactivity and impulsivity ADHD = Blanket term for series of symptoms ⇒ Pattern of these behaviors vary from child-to-child There are subtypes on ADHD to specify the symptom severity No causal relationship between diet and ADHD History of ADHD Has gone through multiple name changes throughout the years Early 1900’s ⇒ Defective moral control George Still ⇒ Found that some children in his practice had difficulty controlling their behavior Defective moral control These children were still intelligent Children with ADHD were drawing attention because there was an increased demand of displaying self-regulation 1917-1925 ⇒ Encephalitis and brain-injured child syndrome Following worldwide influenza epidemic ⇒ Some children who suffered Encephalitis suffered brain trauma which led to the Brain-injured child syndrome Some sort of brain trauma led to this syndrome Lecture 6: ADHD 2  1940-1950 ⇒ Minimal brain damage and minimal brain dysfunction Brain damage theory was rejected ⇒ failed to explain most cases of this uncontrollable behavior problem Similar signs (ADHD) were observed in children without brain damage Trying to attribute the symptoms to physical cause did not work Late 1950s ⇒ Hyperkinesis Moving away from the physical causes Describing the core features of ADHD Hyperkinesis = Emphasized perceptions of hyperactivity as the core symptom within the category Motor hyperactivity = Key feature in the defects in children 1970s ⇒ Deficits in = Hyperactivity + Attention + impulse control Began to see that hyperactivity was not the only symptom They added other primary symptoms to characterize the uncontrollable behavior Shaping the criteria for ADHD today 1980’s ⇒ Interest in ADHD rose and rise in stimulant use Referred to as ADD ⇒ Attention deficient disorder Did not include hyperactivity Name was changed to ADHD in 1987 Reflected the components of hyperactivity and attention DSM combines hyperactivity and impulsivity into one dimension ADHD overview ADHD = Neurodevelopmental disorder Lecture 6: ADHD 3  Early onset Symptoms need to have started before 12 y/o Early as 3 y/o can be diagnosed Persistent course ⇒ Lifelong disorder Childhood → Adulthood Presentation of disorder varies Shifts or reductions or increases in symptoms over time could be seen Differences in neural development Delayed brain maturation Differences in activity of certain brain regions involved in thinking, behavior, and emotion regulation Lower levels of Dopamine is detected in these brain regions Stimulants act to increase dopamine in these regions Overlaps with other neurodevelopmental disorders People with ADHD also experience difficulties in language + motor coordination + Social development Seen in ASD and other specific learning disorders Core characteristics Key symptoms fall under 2 categories ⇒ Inattention and Hyperactivity- impulsivity 1. Inattention ⇒ Inability to engage and sustain attention and follow through on directions or rules while resisting distractions Difficulties with planning and organization Can result from a failure in one or more cognitive processes Attention capacity is not affected ⇒ Temporary storage and recall of information Lecture 6: ADHD 4  The total amount of information a person can remember and sustain is not affected Ability to store and recall information of children with ADHD is comparable to other normal children Selective attention and distractibility ⇒ ability to focus on relevant information and avoid distractions ADHD ⇒ Children are more likely to be distracted by highly salient stimuli (Anything that stands out) or appealing stimuli Ex ⇒ Flashing lights, bright colors Sustained attention/Vigilance ⇒ Ability to maintain attention over a extended period of time Especially during repetitive + uninteresting tasks Core features of ADHD = Deficits in sustained attention ADHD ⇒ Perform more poorly than peers Altering ⇒ ADHD = Difficulty with altering Altering = Reacting appropriately to some sort of stimuli and preparing for what’s about to happen Ex ⇒ Fight or flight system Reacting too quickly or too slowly (Not incongruence with the situational needs) Reacting too slowly when a faster reaction is needed Reacting too quickly when a slower reaction is needed Strongly linked to academic difficulties Difficulty in planning and organization 2. Hyperactivity-Impulsivity ⇒ Under control of motor behavior + challenge inhibiting behavior + inability to delay a response or defer gratification Lecture 6: ADHD 5  Linked with aggressive behaviors and risk for social behavior (ie. peer rejection) Both of them are combined into a single dimension because they frequently co-occur Hyperactivity ⇒ Excessive + intense + Inappropriate activity that is not goal-directed Fidgeting + difficulty staying seated Could occur even while sleeping ⇒ Children with ADHD show greater movements compared to peers even while sleeping Children who are allowed to move and fidget more perform better during academic tasks Impulsivity ⇒ Cognitive + Behavior + emotional impulsivity Cognitive = Impulsive decision making + hurried thinking Ex ⇒ Forgetting to hand in completed homework assignment Emotional = Difficulty regulating emotions Ex ⇒ Child immediately yelling when making a small mistake Quick to respond in anger or frustration Behavior = Difficulty inhibiting responses when self-control is needed Ex ⇒ Calling out in class without being called on ADHD ⇒ increased motor activity (Even while sleeping) DSM-5 Criteria Either the symptoms of inattention need to be present or the symptoms of hyperactivity and impulsivity or both for it to be ADHD Lecture 6: ADHD 6  Adjustments are make for older children ⇒ Adolescents B + C + D + E criteria need to be met as well Specifiers ⇒ integrate more dimensional approach: 1. In partial remission 2. Symptoms severity 3. Presentation types a. Predominantly inattentive presentation (ADHD-PI) ⇒ Forgetful + Process information more slowly + Sluggish cognitive tempo (Ex: Daydreaming) + Inattentive + Easily distracted and confused + Careless + forgetful + disorganized + struggle with memory Lecture 6: ADHD 7  i. Social withdrawal and anxiety symptoms are also sometimes experienced ⇒ Anxiety and mood disorders comorbid ii. Most prevalent/common presentation iii. Less flaggable ⇒ Lower referral rates because they are less disruptive behaviors and thus harder to detect 1. Reason people with it are less frequently referred to clinics compared to combined presentation b. Predominantly hyperactive-impulsive presentation (ADHD-HI) i. Hyperactivity + Fidgeting + Excessive and fast talking + impulsivity + argumentative ii. Difficulty following rules/instructions iii. Argumentative iv. Do not show difficulties in attention v. Difficulty in self-control (inhibiting behavior) vi. Acting without thinking vii. Rarest presentation type viii. Diagnosed more in preschoolers 1. But later on (years later) ⇒ Do not fall into the category c. Combined presentation (ADHD-C) i. Both inattention and hyperactivity ii. Hyperactive + restless + disorganized + inattentive + impulsive iii. Most commonly seen in clinical environment 1. More likely to be flagged Lecture 6: ADHD 8  Limitations of DSM for ADHD 1. Use of subtypes is difficult ⇒ Even with specific subtypes there is a lot of variability (the children within them are different) a. Presentation can vary between subtypes and it is not highly stable i. ADHD symptoms presentation can vary significantly, not only between subtypes but also within the same individual over time ⇒ These subtypes are not highly stable, making it challenging to categorize and predict long-term outcomes effectively b. The children within the same ADHD subtype ⇒ when compared can be very different from one another i. Ex ⇒ two children classified as "inattentive" may exhibit very different behaviors and challenges 2. Limitations in developmental stability Classification is not stable ⇒ Changes in classification of the child as they grow The classification of the child may change as they grow ⇒ Makes the classification system developmentally unstable Lecture 6: ADHD 9  Ex ⇒ a child might meet the criteria for one subtype at a young age but shift to another or no longer meet diagnostic criteria in later years Clinical judgement is needed on whether or not symptoms are typical based on development Attributing symptoms to different age/developmental stages ranges is hard Clinical judgment becomes critical in determining whether a child's behavior is developmentally appropriate or indicative of ADHD Symptoms adjustments for older populations is be needed since their presentation of symptoms is different 3. Categorical view of ADHD Child either has ADHD or does not The DSM takes a categorical approach, diagnosing a child as either having ADHD or not ⇒ classification overlooks the continuum on which ADHD symptoms often exist Children just below the cut-off ⇒ How different are they from the people just above the cut-off Where do we draw the line ⇒ Will others who are just below the line also be faced with challenges that accompany ADHD ADHD exists on a continuum Associated characteristics Iceberg analogy = Obvious symptoms floating float above the disorder (Tip of the iceberg) but below the surface = other symptoms and problems that can interfere with daily life children with ADHD often have additional challenges: cognitive deficits Executive functions + Time management + planning Lecture 6: ADHD 10  emotional difficulties Mood swings Prone to frustration self-concept/motivational challenges Low self-esteem and feelings of self-doubt Challenges in academic or social settings social difficulties Difficulties in communication and reading social cues + maintaining social relationships difficulty medical and physical concerns Difficulty falling asleep and staying asleep Sleep disturbances Deficiency in dopamine ADHD = Dysregulation of Dopamine (regulate sleep-wake cycle) Higher risk for physical injuries ⇒ More accident prone Traffic accidents Serious injuries ⇒ broken bones or brain damage Risk for substance use disorder in later life stages Lecture 6: ADHD 11  Note on the links between ADHD and intelligence inattention → impaired academic functioning Children with ADHD have average or above average intelligence for the most part Difficulties = engaging in the correct settings Connection between higher ADHD symptoms and applying intelligence to situations ADHD does not affect intelligence, it affects how they are able show their intelligence ⇒ cannot apply their intelligence properly in correct settings ADHD Children: Low self-esteem ⇒ Children who show more inattentive symptoms + comorbid anxious symptoms Distorted self-perceptions ⇒ Think of themselves worse than they are Positive illusionary bias ⇒ More positive views of themself and Thinking that they are smarter than they are Overestimation of their social or academic or behavioral competence self-protective mechanism Lecture 6: ADHD 12  Reflects underlying deficits in executive functioning Comorbidity up to 80% of children with ADHD have a co-occurring psychological disorder and up to 50% have 2 or more disorders Makes treating ADHD more difficult ODD - oppositional defiant disorder ⇒ 50% Taking back or defiance Symptoms ⇒ Impulsivity and hyperactivity CD - conduct disorder ⇒ 30-50% overlap More severe than ODD Violation of societal rules Fighting + stealing + setting stuff on fire + destroying property ADHD + ODD + CD ⇒ Runs in families Neurobiological causes Shared environmental factors can also be involved Anxiety disorders ⇒ 25-50% Children with both ADHD and anxiety disorder tend to display less aggressive behaviors and show more social and academic difficulties Higher inattentive symptoms Mood disorders ⇒ 20-30% Lecture 6: ADHD 13  Depression Motor coordination and tic disorders ⇒ 30-50% Motor and coordination or tic disorder display Prevalence prevalence ~5% worldwide Most commonly referred problems seen in clinics course: symptoms emerge in early childhood and evolve over time Emerge as showing excessive energy or difficulty following rules Early and middle childhood = inattentive behaviors are more common with increasing academic and social demands Developing progression in general ⇒ Hyperactivity decreases + Inattention and impulsivity persist Symptoms before 12 and early as 3y/o Hyperactivity in adolescence tends to decrease As we age the symptoms vary and symptom severity as well Adulthood = Difficulty in work and functioning gender and prevalence ⇒ More frequently diagnosed in boys than girls May reflect the fact that the girls are more ignored for the disorder or are considered to be more inattentive than boys in general ⇒ harder to diagnose ~2-4% for girls ~6-9% for boys Lecture 6: ADHD 14  Theories and causes on the emergence of ADHD ⇒ No single cause of ADHD biological factors environmental factors cognitive and psychological factors Biological factors ADHD runs in families Genetic basis for ADHD Adoption studies and twin studies point towards genetics ⇒ 3x higher rates of ADHD with biological parents compared to adoptive parents Twin studies = 65% similarity 60% heritability specific gene variations related to dopamine regulation ⇒ Linked to ADHD symptoms Dopamine roles = Movement and motivation + reward processing + Alternes ADHD ⇒ Lower Dopamine levels are seen in regions where it is needed for impulse control or reward processing Stimulants that treat ADHD increase the Dopamine in the brain brain abnormalities and developmental delays: smaller right prefrontal cortex ⇒ Important for self-control and executive functioning brain maturation delayed in prefrontal regions ⇒ Developmental delay → delayed prefrontal cortex maturation earlier maturation of motor cortex ⇒ plans and controls movements Some research ⇒ Early maturation is reached in certain regions Ex: motor cortex ⇒ Fidget behaviors Lecture 6: ADHD 15  May account for restless behavior (symptom) Environmental factors pregnancy complications (low birth weight, preterm birth) and exposure to prenatal toxins (smoking, alcohol, lead) Contributing factors Not a causal association They make a malleable state that can be combined with other factors (i.e. genetic) to increase the risk for ADHD Parenting behaviors do not cause ADHD but they affect how symptoms manifest and the child’s ability to cope with the symptoms Families with conflicts may increase/worsen ADHD symptoms Structured routines and positive reinforcement can help children manage challenges more effectively Cognitive and Psychological 4 Causes: Cognitive functioning deficits Motor difficulty Cognitive language Executive functioning or planning Reward and motivation deficits Prefer more immediate rewards over delayed ones Lead to difficulty motivating self when rewards are delayed Differences in sensitivity towards rewards Arousal level deficits Tend to have differences in alternes and arousal ADHD = Under aroused Lecture 6: ADHD 16  Leads hyperactivity and impulsivity to get the optimal level of alternes Self-regulation deficits integrates all 3 deficits Understand how people with ADHD regulate their behavior based on the many concepts Underlying deficits in self-regulation which leads to impulsivity and difficulty sustaining focus Treatment Primary treatment approach combines 3 approaches: Stimulant Medication ⇒ Stimulant drug that the child takes Most widely used and studied Help manage symptoms of hyperactivity and inattention They help to normalize the levels of neurotransmitters (dopamine in the brain) and the structural abnormalities in children with ADHD Done by increasing the availability of dopamine Improves functional connectivity in the brain Treated ADHD since the 1930s Ex: Dexedrine, Dextrostat, Adderall, Ritalin Function by: Altering Activity in the frontostriatal region by affecting neurotransmitters (dopamine) May help normalize frontostriatal structural abnormalities and functional connections Pros: Effective for most children 80% experience symptoms improvement Lecture 6: ADHD 17  Positive experiences reported about the stimulant When used correctly and with proper supervision: Stimulant = safe Most side effects = Benign Adjusted and managed by adjusting dosage Not addictive for most children Not associated with increased risk for substance abuse Cons: Effects are temporary and only occur while medication is taken Reliance on meds No long-lasting effects after discontinuation Addictive if misused Do not address potential underlying and broader challenges contributing to the disorder Not addressing many of the associated individual, family, academic, etc. concerns experienced by children Parent Management training ⇒ Intervention for the parents Improving parent skills and parent-child relationship Reduces parenting stress + developing effective strategies to deal with children with ADHD Parents are: Taught about ADHD and its biological causes Helps alleviate any potential guilt about “ADHD is caused by parenting” Given a set of guiding principles for raising kids with ADHD Using rewards and punishments Staying consistent in activation Lecture 6: ADHD 18  Practicing forgiveness Taught behavior management techniques Rewards and punishment for target behavior Daily behavioral chart Identify goals of target behavior and point system Identifying behaviors that parents want to encourage or discourage Recognizing where the child performs these behaviors and providing some immediate reward Encouraged to share enjoyable activity with their child each day Daily one on one time with child ⇒ Positive parent-child relationship Taught how to reduce their own levels of arousal Parents taught to reduce their own levels of stress so that they can responds more effectively to the child’s behaviors Education intervention ⇒ Collaborative effort between teacher and parent (School setting) Teacher and child set realistic goals and objectives Supporting child at school level to improve academic performance Mutually agreed upon reward system ⇒ Careful monitoring of performance and reward the child for meeting goals Disruptive or off-task behaviors = Punishment with response-cost procedures (Loss of privileges, activities, points, or tokens) Promote good teaching methods Use of accommodations ⇒ Ex → Positioning the child where the he/she would be least distracted Setting them up to succeed Lecture 6: ADHD 19  Intensive Interventions At home and future success at school Summer treatment programs ⇒ 8W program with 360 hours Maximizes opportunities to build effective peer relations in natural setting Provides continuity with academic work Multimodal Treatment study of children with ADHD ⇒ MTA study Large scale + randomized clinical trial ⇒ Goal was to find the best treatment approach Uses the medication + behavioral + combined (meds and behavioral) treatments in different groups to test which one is best Control group = Routine community treatment Most effective = Combined treatment Combined > Medication > Behavior therapy > control 3 years later ⇒ No group differences Lecture 6: ADHD 20