Introduction to Abnormal Child and Adolescent Psychology PDF

Introduction to Abnormal Child and Adolescent Psychology 3 Edition 2 Introduction to Abnormal Child and Adolescent Psychology 3 Edition Robert Weis Denison University 3 FOR INFORMATION: SAGE Publications, Inc. 2455 Teller Road Thousand Oaks, California 91320 E-mail: [email protected] SAGE Publica...

Introduction to Abnormal Child and Adolescent Psychology 3 Edition 2 Introduction to Abnormal Child and Adolescent Psychology 3 Edition Robert Weis Denison University 3 FOR INFORMATION: SAGE Publications, Inc. 2455 Teller Road Thousand Oaks, California 91320 E-mail: [email protected] SAGE Publications Ltd. 1 Oliver’s Yard 55 City Road London EC1Y 1SP United Kingdom SAGE Publications India Pvt. Ltd. B 1/I 1 Mohan Cooperative Industrial Area Mathura Road, New Delhi 110 044 India SAGE Publications Asia-Pacific Pte. Ltd. 3 Church Street #10-04 Samsung Hub Singapore 049483 Copyright © 2018 by SAGE Publications, Inc. All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Printed in the United States of America Library of Congress Cataloging-in-Publication Data Names: Weis, Robert, 1973- author. Title: Introduction to abnormal child and adolescent psychology / Robert Weis, Denison University. Description: Third edition. | Los Angeles : SAGE, | Includes bibliographical references and index. Identifiers: LCCN 2016044641 | ISBN 9781506339764 (hardcover : alk. paper) Subjects: LCSH: Child psychopathology. | Adolescent psychopathology. Classification: LCC RJ499.W3925 2018 | DDC 618.92/89—dc23LC record available at 4 https://lccn.loc.gov/2016044641 This book is printed on acid-free paper. Acquisitions Editor: Abbie Rickard eLearning Editor: Morgan Shannon Editorial Assistant: Alexander Louis Helmintoller Production Editor: Libby Larson Copy Editor: Megan Markanich Typesetter: C&M Digitals (P) Ltd. Proofreader: Dennis Webb Indexer: Will Ragsdale Cover Designer: Candice Harman Marketing Manager: Katherine Hepburn 5 Brief Contents 1. Preface 2. About the Author 3. PART I: EVIDENCE-BASED RESEARCH AND PRACTICE 1. 1. The Science and Practice of Abnormal Child Psychology 1. 1.1 The Prevalence of Childhood Disorders 2. 1.2 What Is a “Mental Disorder”? 3. 1.3 An Introduction to Developmental Psychopathology 4. 1.4 Integrating Science and Practice 2. 2. The Causes of Childhood Disorders: A Levels of Analysis Approach 1. 2.1 Genetic and Epigenetic Influences on Development 2. 2.2 The Brain and Neurotransmitters 3. 2.3 Learning Theory 4. 2.4 Cognition and Emotion Regulation 5. 2.5 Parents, Families, and Friends 6. 2.6 Culture and Society 3. 3. Assessment and Diagnosis 1. 3.1 Psychological Assessment 2. 3.2 DSM-5 Diagnosis 4. 4. Treating Children, Adolescents, and Families 1. 4.1 Medication 2. 4.2 Systems of Psychotherapy 3. 4.3 Psychotherapy Efficacy and Effectiveness 4. 4.4 Professional Practice and Ethics 4. PART II: DEVELOPMENTAL DISORDERS AND DISABILITIES 1. 5. Intellectual Disability and Developmental Disorders 1. 5.1 Description and Epidemiology 2. 5.2 Causes 3. 5.3 Prevention and Treatment 2. 6. Autism Spectrum Disorder 1. 6.1 Description and Epidemiology 2. 6.2 Causes 3. 6.3 Identification, Prevention, and Treatment 3. 7. Communication and Learning Disorders 1. 7.1 Communication Disorders 2. 7.2 Learning Disabilities and Specific Learning Disorder 5. PART III: DISRUPTIVE DISORDERS AND SUBSTANCE USE PROBLEMS 1. 8. Attention-Deficit/Hyperactivity Disorder 1. 8.1 Description and Epidemiology 2. 8.2 Causes 6 6. 7. 8. 9. 10. 3. 8.3 Evidence-Based Treatment 2. 9. Conduct Problems in Children and Adolescents 1. 9.1 Oppositional Defiant Disorder and Conduct Disorder 2. 9.2 Causes 3. 9.3 Evidence-Based Treatment 3. 10. Substance Use Disorders in Adolescents 1. 10.1 Substance Use and Substance Use Disorders 2. 10.2 Causes 3. 10.3 Evidence-Based Treatment PART IV: EMOTION AND THOUGHT DISORDERS 1. 11. Anxiety Disorders and Obsessive–Compulsive Disorder 1. 11.1 Anxiety Disorders in Childhood and Adolescence 2. 11.2 Obsessive–Compulsive and Related Disorders 3. 11.3 Evidence-Based Treatment 2. 12. Trauma-Related Disorders and Child Maltreatment 1. 12.1 Posttraumatic Stress Disorder 2. 12.2 Social–Emotional Deprivation in Infancy 3. 12.3 Child Abuse and Neglect 3. 13. Depressive Disorders and Suicide 1. 13.1 Disruptive Mood Dysregulation Disorder 2. 13.2 Major Depressive Disorder and Dysthymia 3. 13.3 Suicide 4. 14. Pediatric Bipolar Disorders and Schizophrenia 1. 14.1 Bipolar Disorders in Children and Adolescents 2. 14.2 Pediatric Schizophrenia PART V: HEALTH-RELATED DISORDERS 1. 15. Feeding and Eating Disorders 1. 15.1 Feeding Disorders in Young Children 2. 15.2 Eating Disorders in Older Children and Adolescents 3. 15.3 Evidence-Based Treatment for Eating Disorders 2. 16. Health-Related Disorders and Pediatric Psychology 1. 16.1 Elimination Disorders 2. 16.2 Sleep–Wake Disorders in Children 3. 16.3 Pediatric Psychology Appendix: A Primer on Research Methods in Abnormal Child Psychology References Index 7 Detailed Case Studies Chapter 1 Culture Matters Cultural Context A Pathway to Trouble Developmental Pathways Diverging Developmental Paths Risk and Protective Factors Malala Yousafzai A Portrait of Resilience Chapter 2 Kirby Gene–Environment Correlation Chapter 3 Stubborn Sara Psychological Assessment Chapter 4 Anna’s Secret Systems of Psychotherapy Well-Intentioned Dr. Williams Professional Ethics: Competence Resentful Rachel Professional Ethics: Consent Risky Renae Professional Ethics: Confidentiality Margaret’s Mournful Mother Professional Ethics: Conflicts of Interest Chapter 5 The Family Who Got Rid of the “R-Word” Intellectual Disability (Down Syndrome) Silent Sam Global Developmental Delay Obsessed With Food Intellectual Disability (Prader-Willi Syndrome) Tough Love Fetal Alcohol Spectrum Disorder Chapter 6 Kylie and Thomas Autism Spectrum Disorder Alex Autism Spectrum Disorder With Intellectual Disability Benji Autism Spectrum Disorder Without Intellectual Disability Chapter 7 Cody’s Problems With Language Acquisition Language Disorder (Late Language Emergence) Bernadette’s Problems With Expression Language Disorder (Specific Language Impairment) Same Disorder, Different Problems Speech Sound Disorder Davis’s Stuttering Childhood-Onset Fluency Disorder Willem’s One-Sided Conversation Social (Pragmatic) Communication Disorder Waiting to Fail Specific Learning Disorder Rafe, Ricky, and RTI Response to Intervention Chapter 8 The Energizer Bunny Attention-Deficit/Hyperactivity Disorder, Combined Presentation 8 Well-Behaved Brandy Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation Chapter 9 Davidson’s Escape Oppositional Defiant Disorder Making Mom Miserable Conduct Disorder Callous Cade Conduct Disorder With Limited Prosocial Emotions Chapter 10 Erica’s Emerging Alcohol Problem Alcohol Use Disorder Erica’s Treatment Alcohol Use Disorder Chapter 11 Concerned About Dad Separation Anxiety Disorder Reticent Russell Selective Mutism Mary and Man’s Best Friend Specific Phobia Erin’s Social Anxiety Social Anxiety Disorder Heart Attack at Age 16 Panic Disorder Planning for an Emergency Agoraphobia (With Panic Disorder) Tammie’s Sleepless Nights Generalized Anxiety Disorder Doing Things “Just Right” Obsessive–Compulsive Disorder Chapter 12 Survivor’s Guilt Posttraumatic Stress Disorder Fleeing Syria Posttraumatic Stress Disorder in a Preschool-Age Child Anaclitic Depression Reactive Attachment Disorder Kayla’s Story Physical Abuse Unhappy Family Sexual Abuse Words Can Hurt, Too Psychological Abuse Lost Boy Child Neglect Chapter 13 Mood Problems and Meltdowns Disruptive Mood Dysregulation Disorder Hannah Misunderstood Major Depressive Disorder Bad Genes Persistent Depressive Disorder (Dysthymia) Chapter 14 Energetic Emily Bipolar I Disorder Mixed Mood Max Bipolar I Disorder With Mixed Features Mina’s Macabre Visions Schizophrenia (Adolescent-Onset) Caroline’s Conversations Schizophrenia (Childhood-Onset) Chapter 15 Perfectly Normal Anorexia Nervosa Ants! Binge Eating Disorder Eye of the Beholder Bulimia Nervosa and Culture Chapter 16 No Sleepovers Enuresis 9 Additional case studies and discussion questions are available to instructors. Visit abnormalchildpsychology.org. 10 Detailed Contents Preface About the Author PART I: EVIDENCE-BASED RESEARCH AND PRACTICE 1. The Science and Practice of Abnormal Child Psychology 1.1 The Prevalence of Childhood Disorders How Common Are Mental Disorders in Children? Overall Prevalence Use of Medication What Factors Influence the Prevalence of Childhood Disorders? Age Gender Socioeconomic Status Ethnicity Do Most Youths With Mental Disorders Receive Treatment? Access to Treatment Barriers to Treatment 1.2 What Is a “Mental Disorder”? How Do We Identify “Abnormal” Behavior in Children? How Does DSM-5 Define a Mental Disorder? How Does Culture Affect the Identification of Childhood Disorders? 1.3 An Introduction to Developmental Psychopathology What Is Developmental Psychopathology? Development Over Time Adaptive vs. Maladaptive Development Are Childhood Disorders Stable Over Time? Developmental Pathways Continuity vs. Change What Determines the Course of Children’s Development? 1.4 Integrating Science and Practice What Is Evidence-Based Practice? Definition Importance How Can Students Help Children in an Evidence-Based Manner? 2. The Causes of Childhood Disorders: A Levels of Analysis Approach 2.1 Genetic and Epigenetic Influences on Development How Do Genes Affect Development? Genes, Chromosomes, and Alleles Behavioral Genetics 11 Molecular Genetics How Do Genes Interact With the Environment to Shape Development? The Diathesis–Stress Model Gene–Environment Correlation How Can Epigenetics Help Explain Children’s Development? 2.2 The Brain and Neurotransmitters How Is Neuroimaging Used to Study Childhood Disorders? How Does the Brain Change Across Childhood and Adolescence? How Can Experience Affect Brain Development? 2.3 Learning Theory How Is Classical Conditioning Important to Understanding Childhood Disorders? How Is Operant Conditioning Important to Understanding Childhood Disorders? How Is Social Learning Important to Understanding Childhood Disorders? 2.4 Cognition and Emotion Regulation How Does Cognition Change Across Development? How Do Children’s Emotion-Regulation Skills Change Across Development? 2.5 Parents, Families, and Friends What Is Temperament? How Can Parents and Families Influence Children’s Development? Parent–Child Attachment Parenting Behavior How Do Peers Influence Children’s Development? Interpersonal Theory Peer Acceptance and Psychopathology 2.6 Culture and Society How Can Culture and Society Shape Children’s Development? What Is Bronfenbrenner’s Bioecological Systems Theory? 3. Assessment and Diagnosis 3.1 Psychological Assessment What Is Psychological Assessment? Purpose Principles What Is a Diagnostic Interview and Mental Status Exam? How Do Psychologists Assess Children’s Behavior? Observation Methods Functional Analysis 12 How Do Psychologists Assess Children’s Cognitive Functioning? Intelligence Academic Achievement How Do Psychologists Assess Children’s Personality and Social– Emotional Functioning? Personality Testing Parent and Teacher Rating Scales Specific Symptom Inventories What Makes a Good Psychological Test? Standardization Reliability Validity 3.2 DSM-5 Diagnosis What Is the DSM-5 Approach to Diagnosis? Categorical Classification Prototypical Classification Dimensional Classification How Is DSM-5 Different Than Its Predecessors? What Are the Advantages and Disadvantages of Diagnosing Children? Possible Benefits Potential Limitations Research Domain Criteria 4. Treating Children, Adolescents, and Families 4.1 Medication How Is Medication Used to Treat Children and Adolescents? What Medications Are Most Frequently Prescribed to Children? Stimulants and Nonstimulants for AttentionDeficit/Hyperactivity Disorder Anxiolytics Antidepressants Mood Stabilizers and Anticonvulsants Antipsychotics 4.2 Systems of Psychotherapy What Is Psychotherapy? Description Common Factors What Are the Major Systems of Psychotherapy? Behavior Therapy Cognitive Therapy Interpersonal Therapy Family Systems Therapy 13 Psychodynamic Therapy 4.3 Psychotherapy Efficacy and Effectiveness How Does Child Psychotherapy Differ From Adult Psychotherapy? Does Child Psychotherapy Work? What Therapies Work Best? Efficacy Effectiveness 4.4 Professional Practice and Ethics Who Treats Children and Families? What Is the APA Ethics Code? What Are the Four Cs of Child/Family Ethics? Competence Consent Confidentiality Conflicts of Interest PART II: DEVELOPMENTAL DISORDERS AND DISABILITIES 5. Intellectual Disability and Developmental Disorders 5.1 Description and Epidemiology What Is Intellectual Disability? How Does Intellectual Disability Differ Based on Severity? Mild Intellectual Disability (Adaptive Functioning Scores 55–70) Moderate Intellectual Disability (Adaptive Functioning Scores 40–55) Severe Intellectual Disability (Adaptive Functioning Scores 35–40) Profound Intellectual Disability (Adaptive Functioning Scores 60 or adaptive scores 60 and adaptive scores C; Xu & Spelke, 2000). By the time most children begin school, their ability to discriminate small quantities is greatly refined. Sixyear-olds can easily tell that a basket containing 25 pieces of candy has more candy than another basket containing only 20 pieces of candy. By late childhood, this capacity for numerosity is similar to that of adults (Geary, 2013). Number sense permits the development of all other math abilities (Geary, 2010). It allows very young children to subitize—that is, to estimate the number of objects in a small group, rapidly and accurately, without counting them. For example, young children can quickly differentiate between a plate with three cookies and a plate with five cookies. Number sense also allows them to mentally represent quantities. For example, young children learn the correspondence between Arabic numerals and discrete quantities (e.g., 3 = ). At about the same time, children also begin to mentally represent quantities along a number line. Young children easily understand that numbers are positioned in ordinal fashion—that is, first, second, third, and so on. Over time, children also learn that the intervals between numbers are equal. The capacity to mentally represent quantities permits basic math calculation in early elementary school, like addition and subtraction. Children with mathematics disabilities tend to show delays in the development of number sense. The Number Sets Test (see Figure 7.7) is a brief test of number sense that consists of a series of numerals (e.g., 1, 3) or groups of objects (e.g., , ◆◆◆) that children must group to match a target number presented at the top of the page. Children can use subitizing, counting, or a combination of both strategies to group the stimuli as fast and as accurately as possible. Typically developing children show improvement on this test from first through fourth grade. However, children with mathematics disabilities perform more slowly and make more errors than their classmates. On average, they lag approximately three years behind their peers (Geary, Bailey, & Hoard, 2009). Furthermore, children’s performance on the Number Sets Test at the beginning of first grade (before most children 569 even know how to add and subtract) predicts their likelihood of developing mathematics disability by the time they reach third grade. In fact, first graders’ scores on the Number Sets Test predict later math skills better than their intelligence, memory, and baseline knowledge of math! Figure 7.6 Effects of SRSD on Children’s Writing Source: Based on Graham and Harris (2003). Note: Children who participate in SRSD show improvements in four areas of writing compared to youths who receive traditional writing instruction. SRSD is associated with improvements in both typical readers and children with learning disabilities. Figure 7.7 The Numbers Sets Test 570 Source: Based on Geary and colleagues (2011). Note: This test can be used to predict mathematics disorder in young children. Children with mathematics disorder are 3 years behind their typically developing classmates in their capacity for numerosity. Figure 7.8 Children with math disability lag behind their classmates throughout elementary school. Source: Based on Geary and colleagues (2012). Note: In this longitudinal study, children with math disabilities used direct retrieval or decomposition less frequently than did typically achieving children and low-achieving children. Instead, youths with math disability relied heavily on immature (i.e., counting) strategies. Counting and Calculation Errors Children’s ability to count develops between the ages of 2 and 5. Young children obey certain principles of counting that follow a fixed sequence (Gelman & Gallistel, 1978). One-to-one correspondence: One number is assigned to each object. Stable order: Numbers are counted in a specific order. Cardinality: The last number stated reflects the quantity of the items counted. Abstraction: Objects of any kind can be grouped and counted. Order irrelevance: Objects can be counted in any order. 571 Preschoolers later diagnosed with math disability make two types of counting errors not often shown by their classmates (Geary, Hoard, & Bailey, 2011; Geary, Hoard, Nugent, & Bailey, 2012). To study these errors, researchers ask children to help a puppet learn to count objects. On some counts, the puppet deliberately makes mistakes. The researchers record whether the child detects the mistake and corrects the puppet. First, children with math disability often become confused when counting occurs from right to left, rather than in the typical left-to-right order. They do not seem to understand the principle of order irrelevance. Second, they often fail to detect errors when the puppet double-counts the first object in the row (e.g., the puppet points to the first object and counts “one, two” and then points to the second object and counts “three”). It seems that these children have difficulty remembering one-to-one correspondence. Beginning in elementary school, children’s math skills become more complex, as children transition from counting to arithmetic. Addition depends greatly on children’s counting abilities. For example, young children use fairly immature strategies to add numbers. Initially, they might count on their fingers to solve addition problems. Later, addition is performed verbally or mentally. Young children also use less efficient strategies to add. For example, very young children use the counting-all strategy; when asked to add 7 + 4, they first count from 1 to 7 and then count four more numbers until they arrive at the correct answer. In contrast, older children use the counting-on strategy; they begin with the larger number (i.e., 7) and then count four more digits until they arrive at the answer. Similar shortcuts are used for subtraction and other mathematical operations (Augustyniak, Murphy, & Phillips, 2006). With experience, children learn to store math facts in long-term memory. For example, children begin to use direct retrieval to recall that 7 + 6 = 13; they no longer need to count to arrive at the correct answer. Alternatively, they may use a process called decomposition to solve the same problem; they might break up the problem into smaller components that are more easily remembered. For example, children might directly recall that 6 + 6 = 12 and then add one to this partial sum to obtain the correct answer. Direct retrieval and decomposition permit more rapid and automatic math computation. Children can direct their attention to conceptualizing arithmetic problems rather than to counting. Direct retrieval and decomposition also free short-term memory, allowing children to perform more complex calculations in their heads (Geary, 2011). Children with math disabilities show deficits in math calculation skills. They calculate more slowly and make more errors than their typically developing classmates (see Figure 7.8). Several studies indicate that memory deficits underlie many of their difficulties with math calculations (Geary et al., 2011). Specifically these children have trouble remembering math facts (Geary et al., 2012). Whereas most fourth graders can effortlessly recall 4 + 5 = 9, children with mathematics disability often need to count to recall the correct answer. Consequently, they spend greater cognitive resources performing basic calculations and fewer resources conceptualizing the problem itself (Andersson, 2010). 572 Youths with mathematics disabilities also have difficulty remembering math procedures. For example, when presented with a problem such as 41 – 29 = ?, children with disabilities may forget how to “borrow” and, consequently, they provide an incorrect answer (Temple & Sherwood, 2002). Because of their difficulty retrieving math facts and procedures from long-term memory, children with mathematics disabilities often rely on immature strategies to solve math problems. For example, many first graders count on their fingers to solve addition problems. However, children with mathematics disabilities often continue to rely on this immature tactic into the third and fourth grades. Furthermore, when young children with disabilities count, they often count all digits rather than rely on more advanced “add-on” strategy. These immature strategies result in slow, error-prone calculations (Swanson, 2015; Swanson, Lussier, & Orosco, 2015). Deficits in Math Reasoning By late childhood, children begin to develop more complex math problem-solving skills. These skills include the ability to solve story problems, to interpret charts and graphs, and to perform mathematical operations with complex sets of numbers (i.e., borrowing, long division, fractions). Children’s ability to solve higher order math problems depends on their capacity for working memory (Toll, van der Ven, Kroesbergen, & van Luit, 2011). Many children with mathematics disabilities have problems with verbal or phonological working memory. Some children have reading disabilities that interfere with their ability to comprehend math story problems. Other children have difficulty with auditory working memory, attention, and concentration; they are unable to hold mathematical information in short-term memory long enough to process it and arrive at the correct answer. For example, they may forget important bits of information at the beginning of story problems, become distracted by extraneous information, or transpose digits when converting a story problem to a math calculation (Toll et al., 2011). Other children with mathematics disorder have problems with visual–spatial working memory. Poor visual–spatial working memory can lead to difficulty interpreting charts and graphs. Many complex math calculations, like adding three-digit numbers or performing long division, also depend on visual–spatial skills. Deficits in visual–spatial working memory can cause children to misalign numbers, leading them to use the wrong digits for their calculations (Geary et al., 2015). Review: Deficits in number sense that persist into first grade predict math disabilities. 573 Youths later diagnosed with math disabilities often show characteristic mistakes in counting and math calculation skills. They often rely on immature strategies to perform math computations. Some youths have deficits in math reasoning because of poor verbal working memory, which causes them to forget important information in story problems. Other children have deficits in visual–spatial working memory, which leads to mistakes interpreting graphs and figures. 574 What Treatments Are Effective for Children With Math Disabilities? Clinicians generally rely on one of three methods for math instruction: (1) direct instruction, (2) self-instruction, or (3) mediated/assisted instruction (Steedly, Dragoo, Arafeh, & Luke, 2008; see Table 7.10). Direct instruction in mathematics, like direct instruction for other skills, involves the systematic presentation of math calculation and problem-solving strategies. The teacher introduces and demonstrates the skill following a carefully designed script. Then, the skill is broken down into specific steps, which children perform. Teachers provide help and feedback regarding children’s performance, correcting children’s mistakes. Gradually, assistance is faded as children gain mastery of the skill. Children are given repeated opportunities to practice the skill and extend it to new problems. Direct instruction tends to be most effective in improving basic math computation skills in younger children. Self-instruction is a second method to improve children’s math skills. In self-instruction, teachers systematically present a series of verbal prompts that children can use to solve math problems. Teachers model the use of these prompts as they complete problems. Then, children are encouraged to use the prompts when solving their own problems, while the teacher monitors their use. Initially, teachers provide careful assistance to children in using the prompts. Eventually, assistance is faded until children can use the prompts to solve problems on their own. Self-instruction tends to be most effective for higher order math problem-solving. Teachers who use mediated or assisted instruction begin with the child’s understanding of the mathematical problem. Then, they offer assistance and guidance to help the child solve the problem correctly. Mediated or assisted instruction does not involve the use of a script (as direct instruction) or a series of prompts (as self-instruction). Instead, the teacher offers increasingly detailed hints until the child is able to complete the problem successfully. In this way, children are encouraged to derive their own way of solving problems, rather than rely on a formal set of rules. Table 7.10 Three Methods for Teaching Mathematics Skills Problem: Anne had 9 apples. She gave 4 apples to her friend. How many apples does Anne have left? Direct Instructiona Step A Read the problem with me. Teacher reads the problem. 575 What kind of problem is it? Answer: Subtraction Step B Good. It’s subtraction. Is the big number given? Answer: yes Step C Let’s read the problem again. Teacher reads the problem again. Is 9 the big number or the small number? Answer: The big number. What kind of number is 4? Answer: the small number. Step D Good. Now let’s take 9 and subtract 4. Watch me. Nine minus four is five. Now you say “Nine minus four is five.” Child repeats. Good. What is the answer? Answer: Five Step E Good. Now let’s read the next problem. Self-Instructionb Teacher introduces and demonstrates the following steps to solve story problems. Teacher encourages children to use the steps (first aloud, then silently) as she monitors. What are you asked? How many apples does Anne have left? What numbers do you have? 9 and 4 What number(s) do you need to know? How many left? What must you do? Subtract, 9 − 4 What is the answer? 5 Check your answer. 4 + 5 = 9, so it checks out! Mediated/Assisted Instructionc Teacher provides a structured sequence of hints to help the child complete the 576 problem. Hints become gradually more specific and content-related until the child is able to arrive at the correct answer. Hint Strategy Example Simple negative feedback: Teacher asks child to check answer. Your answer is not quite right. Try again. Working memory refresher: Teacher reminds child of important parts of the problem. Remember, she has 9 and gives away 4. Numerals as memory aids: Teacher asks child to write down important parts of problem. Let’s write it down in numbers: 9 − 4. Enumeration: Teacher uses a series of verbal instructions and numbers to guide child. Nine apples [points to nine] minus four apples [points to four] is what? Complete demonstration: Teacher completes problems for child, giving rationale. See. Nine minus four is five. a. Based on DISTAR Arithmetic (Engelmann & Carnine, 1975). b. Based on Fleischner and Manheimer (1997). c. Based on Goldman (1989). Meta-analyses support the use of all three strategies for children with and without math disabilities (Gersten et al., 2009). Children with disabilities who receive direct instruction or self-instruction show large improvements in calculation and reasoning skills compared to controls. Mediated or assisted instruction is associated with moderate improvement in math reasoning, especially for older children and adolescents. Review: Three effective treatments for math disabilities are direct instruction, self-instruction, 577 and mediated or assisted instruction. These strategies also improve math skills in youths without disabilities. Direct and self-instruction are most effective with younger children whereas mediated or assisted instruction is recommended for older children. 578 Key terms Anticipatory-struggle theory of stuttering: A theory used to explain stuttering; suggests that children expect speaking to be anxiety-provoking; these cognitions interfere with speech production Auditory perception: The ability to accurately identify and differentiate sounds Childhood-onset fluency disorder: A DSM-5 disorder characterized by a persistent problem with the normal rate, efficiency, and timing pattern of speech; causes anxiety and/or interferes with communication Comprehensive assessment: A method of learning disability assessment in which children are classified when they show (a) normative deficits in academic skills, (b) underlying cognitive processing problems that might explain these deficits, and (c) otherwise average intelligence Conversational recast training: A therapy for SLI, the therapist structures the child’s environment to elicit verbal behavior; then, the therapist prompts the child to practice the behavior, correcting mistakes and reinforcing appropriate use Conversational repair skills: Techniques used to help listeners regain an understanding of information conveyed during discourse; examples include providing additional background information or context Covert-repair hypothesis: An explanation for stuttering; children who stutter show frequent disruptions in language formulation; their stuttering occurs when they try to correct these formulations while speaking Curriculum-based assessment: A technique use in schools to measure children’s academic progress in terms of their ability to reach academic goals or “benchmarks” Decomposition: A technique used to solve math calculation problems in which the problem is broken into smaller steps that are more easily recalled and performed. In math calculation, to break up complex problems into smaller components which are more easily remembered or solved Digitally assisted reading: A technique to improve fluency using technology; children read text on a tablet or computer as a voice models fluent reading Direct instruction: The systematic introduction, modeling, practice, and reinforcement of appropriate skills Direct retrieval: In math calculation, the immediate recall of math facts (e.g., 3 x 3 = 9) Double-deficit model: A model that indicates that children can have problems with (a) basic word reading, (b) reading fluency and comprehension, or (c) both Dyslexia: A term used by some clinicians to refer to deficits in basic word reading and reading fluency Expressive language: The ability to share beliefs, knowledge, and skills with others Guided oral reading: A technique to improve fluency in which children read aloud and teachers provide assistance and feedback regarding mistakes 579 Grammar: The rules that govern the use of morphemes and the order of words (syntax) in a sentence Immature speech: Developmentally less sophisticated speech production that might be adaptive at early ages but is considered inarticulate and maladaptive at later ages Individuals With Disabilities Education Improvement Act (IDEIA): A federal law that entitles children with disabilities to free, appropriate public education Language: Spoken, signed, or written communication in which beliefs, knowledge, and skills are experienced, expressed, or shared; involves the manipulation and organization of auditory or visual symbols according to a system of rules that is determined by one’s culture Language disorder: A DSM-5 disorder characterized by persistent difficulties with the acquisition or use of language that include (a) reduced vocabulary, (b) limited sentence structure, or (c) impairments in discourse Late language emergence: A subtype of language disorder characterized by significant delays in receptive or expressive language; usually identified between 18 and 36 months Lateral sulcus: Also known as the sylvian fissure, a large gyrus (groove) in the left hemisphere of the brain; near important areas for language Mands: A term used by speech-language therapists to refer to requests Mediated or assisted instruction: A technique to improve math reasoning in which teachers help students comprehend math problems and offer assistance as children work through the problems themselves Milieu training: A treatment for SLI; uses behavioral techniques to encourage children’s language use in real-life environments and experiences Morphology: The structure of words; usually the combination of several phonemes; can be fixed or free Narrative skills: Communication skills used to tell stories or relate personal experiences; often deficient in youths with social communication disorder Number sense: An early awareness that a group of stimuli can be understood in terms of their quantity Number Sets Test: A test of number sense in which children must match numerals or objects with a target number; predicts math disabilities in young children Phonemic awareness: The ability to hear, identify, and manipulate these phonemes (i.e., the sounds of a language) Phonemic mediation: The ability to use phonemic awareness and phonics skills to sound out novel words Phonological short-term memory: The ability to hold auditory material in memory for short periods of time Phonological theory of SSD: Asserts that children develop SSD when they develop incorrect mental representations for phonemes during the first few years of life Phonology: The sounds of a language and the rules for combining these sounds Processing speed: The ability to quickly and accurately perform relatively simple 580 cognitive tasks without expending a high degree of effort Psycholinguistics: The study of the psychological and neurocognitive underpinnings of language Rapid automatized naming (RAN): The ability to recall the names of a series of familiar items as quickly as possible Rapid temporal processing: The ability to quickly and accurately process sensory information RAVE-O: A program to improve reading fluency; involves instruction in retrieval, automaticity, vocabulary, elaboration, and orthography Reading comprehension: The ability to read text for meaning, to remember information from the text, and to use information to solve problems or share with others Reading fluency: The ability to read rapidly, accurately, and with proper expression Receptive language: The ability to listen to and understand communication Response to intervention (RTI): A method of learning disability identification in which children are classified when they persistently fail to respond to scientific, research-based educational interventions Scripts: Detailed descriptions of social interactions in which people routinely engage; can be used to practice social communication skills Self-instruction (in mathematics): Teachers systematically present a series of verbal steps or “prompts” that children can use to solve math problems by themselves Self-regulated strategy development (SRSD): A technique to improve written expression; involves introducing, modeling, and reinforcing writing strategies for specific types of assignments Semantics: The meaning of individual words (lexical) or sentences (sentential) in a sentence Social (pragmatic) communication disorder: A DSM-5 disorder characterized by persistent difficulties in the use of verbal and nonverbal communication in social contexts; interferes with communication and/or social functioning Specific language impairment (SLI): A subtype of language disorder characterized by significant deficits in morphology, syntax, and/or grammar that are not better explained by ID or another medical or mental disorder Speech: The modulation of one’s voice to produce specific, discernible sounds that have meaning in a particular language Speech fluency: The ease and automaticity of speech; includes rate, duration, rhythm, and sequence Speech sound disorder (SSD): A DSM-5 disorder characterized by persistent difficulty with clear and articulate speech production; include sound omissions, substitutions, distortions, and lisps Skillstreaming: A social skills training program that systematically introduces, models, practices, and reinforces social skills; useful in teaching social communication Specific learning disability: A legal term usually used in educational settings to 581 describe problems in the basic psychological processes involved in spoken or written language; causes impairment in reading, math, spelling, writing, or oral language Specific learning disorder: A DSM-5 disorder characterized by difficulties learning or using reading, math, or writing skills; emerges in childhood or adolescence; skill deficits are significantly low, compared to other people of the same age, and cause impairment in school or daily activities Story grammar: Knowledge of the components and structure of stories (e.g., characters, setting, plot); often deficient in children with poor reading comprehension Tacts: A term used by speech-language therapists to refer to a comment or description Text enhancements: Visual aids or routines that assist students in identifying, organizing, understanding, and recalling important information; important to nonfiction reading comprehension Two-factor theory of stuttering: Posits that stuttering arises because of classical conditioning and is maintained through operant conditioning Working memory: The ability to simultaneously hold and manipulate multiple pieces of information in short-term memory to solve problems 582 Critical thinking exercises 1. Tom and Kelly are parents of a 2-year-old girl with late language emergence. At 24 months, their daughter is able to say only a handful of words and communicates mostly through gestures. Tom and Kelly are wondering if their daughter will eventually catch up to other children her age or if her language delays are a sign of a more serious problem. How might you respond to their concerns? What other information might you need? 2. Children’s language problems are sometimes associated with impoverished parent–child interactions. Why can’t we conclude that the quality of parent–child interactions causes these language problems? 3. Some adults try to help children who stutter by encouraging them to “relax” during conversations. Why isn’t this strategy usually effective? What might be a more effective intervention for older children and adolescents who stutter? 4. Why aren’t children who meet diagnostic criteria for ASD also diagnosed with social communication disorder? How might these two disorders be differentiated? 5. Children from low-SES families are at disproportionate risk for being classified with a learning disability. How might school psychologists and other professionals avoid misdiagnosing these children? 583 Test yourself and extend your learning Videos, flash cards, and links to online resources for this chapter are available to students online. Teachers also have access to PowerPoint slides to guide lectures, case studies to prompt classroom discussions, and exam questions. Visit www.abnormalchildpsychology.org. 584 Part III Disruptive Disorders and Substance Use Problems 8. Attention-Deficit/Hyperactivity Disorder 232 9. Conduct Problems in Children and Adolescents 265 10. Substance Use Disorders in Adolescents 301 585 Chapter 8 Attention-Deficit/Hyperactivity Disorder iStockphoto.com/Liderina 586 Learning Objectives After reading this chapter, you should be able to do the following: 8.1. Describe the key features of attention-deficit/hyperactivity disorder (ADHD) and how the signs and symptoms of this disorder vary from early childhood through adulthood. Identify problems associated with ADHD and how these problems vary as a function of children’s age and gender. 8.2. Discuss some of the main causes of ADHD and differentiate among the three neural pathways that underlie the disorder. Summarize Barkley’s neurodevelopmental model for ADHD. 8.3. Evaluate the relative strengths and weaknesses of medication and psychosocial therapy for the treatment of ADHD in children, adolescents, and young adults. 587 8.1 Description and Epidemiology We might think of attention-deficit/hyperactivity disorder (ADHD) as a truly “modern” illness, a by-product of 21st-century life. In the age of smartphones, social media, and multitasking, it is probably no surprise that 8% of children and adolescents have significant problems with hyperactivity, impulsivity, or inattention and approximately 7% of American youths are taking medication to manage these symptoms. We live in a fast-paced world where distractions are everywhere (Pliszka, 2015). ADHD is not a new disorder, however. Read the poems Johnny Head-In-Air and Fidgety Phillip, written by a German pediatrician more than 150 years ago (see Figure 8.1). They describe children with significant inattention and hyperactivity–impulsivity, respectively— the two core dimensions of the disorder we now call ADHD. In the 1800s, problems with attention and impulse control were attributed to poor upbringing. By 1902, however, the British physician George Still provided the first scientific description of 20 children with a deficit in “volitional inhibition.” He believed that these problems with inattention and impulse control were caused by subtle brain abnormalities; consequently, the disorder was initially labeled “minimal brain damage” and later “minimal brain dysfunction.” One generation later, and almost by accident, the American psychiatrist Charles Bradley (1937) discovered that stimulant medication could reduce hyperactivity and improve attention in boys with histories of disruptive behavior (Strohl, 2011). He wrote the following: The most striking change in behavior occurred in the school activities of many of these patients. There appeared a definite “drive” to accomplish as much as possible. Fifteen of the 30 children responded to (medication) by becoming distinctly subdued in their emotional responses. Clinically in all cases, this was an improvement. Figure 8.1 Inattention and hyperactivity–impulsivity are not new childhood problems. These pictures and poems are from a 19th century book for children. 588 Source: From Hoffmann (1845). Images courtesy of Project Gutenberg and Wikipedia commons. Although Bradley’s observations were not noticed by the medical community for several decades, stimulant medication continues to be a first-line treatment for ADHD today. The disorder now known as ADHD first appeared in DSM-II (1968) as “hyperkinetic reaction of childhood.” In DSM-III (1980), it was renamed attention-deficit disorder (ADD) a term still used by some people today. Subsequent research showed that problems with inattention and hyperactivity–impulsivity were both important features of the disorder; consequently, the disorder received its current name in a revised version of DSM-III-R (1987): attention-deficit/hyperactivity disorder. As we will see, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) has continued to refine our conceptualization of ADHD and influence the way mental health professionals think about this condition (Nigg & Barkley, 2014). 589 What Is Attention-Deficit/Hyperactivity Disorder? Description ADHD is a neurodevelopmental disorder characterized by significant symptoms of inattention and/or hyperactivity–impulsivity (American Psychiatric Association, 2013). DSM-5 lists behavioral symptoms that define problems in each of these domains (see Table 8.1). Children with significant attention problems show persistent and developmentally unexpected difficulties with 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. Children who have significant problems with hyperactivity fidget and squirm, have difficulty remaining seated and staying still when expected, show problems playing quietly, are talkative, and are “on the go.” They often exhaust others’ patience with their high-rate behavior or annoy others with their restlessness. Children who have significant problems with impulsivity act without forethought; they may blurt out answers in class, have trouble waiting their turn in line, and intrude into others’ conversations or activities. They often have problems delaying gratification in order to achieve long-term goals. Older children and adolescents may also make decisions or begin tasks without first considering the long-term consequences of their actions (Taylor & Sonuga-Barke, 2010). Table 8.1 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities1: a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy readings). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses 590 focus and is easily sidetracked). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). h. Is easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:1 a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace). c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) d. Often unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or is uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficulty [sic] to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). 591 i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of Schizophrenia or another psychotic disorder and are not better explained by another mental disorder. Specify whether: Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months. Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months. Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met but Criterion A1 (inattention) is not met for the past 6 months. Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. 1 The symptoms of inattention and/or hyperactivity-impulsivity are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. Children can be diagnosed with ADHD if they show significant symptoms of inattention or hyperactivity–impulsivity. By definition, children must show at least six out of a possible nine symptoms of either inattention or hyperactivity–impulsivity to be diagnosed with the disorder. The fact that children can be diagnosed with ADHD if they show either significant hyperactivity–impulsivity or significant inattention means that two children diagnosed with 592 ADHD can have qualitatively different symptoms. A fourth grader with predominantly hyperactive–impulsive symptoms might wander about the classroom, talk excessively with peers, interrupt the teacher, and disrupt learning. In contrast, his classmate with predominantly inattentive symptoms might sit quietly at her desk, look out the classroom window, think about events occurring in the hallway, and daydream. The diagnostic label ADHD reflects a mix of children (Nigg & Barkley, 2014). After reading the diagnostic criteria for ADHD, you may think, “Maybe I have ADHD?” Don’t all students sometimes have difficulty attending to lectures, experience time management problems, forget appointments or assignments, and dislike long and complex tasks? In fact, nearly all of the symptoms of ADHD are also seen in typically developing individuals from time to time. However, people with ADHD can be differentiated from their peers without ADHD in three ways. First, people with ADHD show a persistent pattern of inattention and/or hyperactivity– impulsivity that lasts for at least 6 months. The signs and symptoms of ADHD are relatively enduring; they are not occasional problems with distractibility or transient feelings of restlessness. Second, people with ADHD show symptoms in multiple settings. Typically, individuals with ADHD have problems with inattention and/or hyperactivity–impulsivity at home, at school, and in other settings (e.g., work, with friends). Symptoms may be less noticeable or impairing during some activities (e.g., playing sports) than others (e.g., attending class), but they are present. By definition, a child cannot be diagnosed with ADHD if he shows symptoms only in one setting. Third, people with ADHD show inattention and/or hyperactivity–impulsivity that is inconsistent with their developmental level. All children show problems with inattention and hyperactivity–impulsivity from time to time. Younger children generally have more frequent problems than older children. To qualify for a diagnosis of ADHD, individuals must show symptoms that greatly exceed the inattention and/or hyperactivity and impulsivity shown by people of the same age. Psychologists can compare a person suspected of having ADHD with other individuals of the same age by using norm-referenced rating scales. For example, a psychologist might administer an ADHD rating scale, like the Conners 3, to a child’s parents and teachers to assess the child’s behavior at home and school, respectively. The rating scale would ask informants to evaluate the severity of the child’s DSM-5 ADHD symptoms. If the parents’ and teacher’s ratings indicate that the child’s symptoms exceed 95% or 97% of children his age in the norm group, the child might qualify for a diagnosis of ADHD (Taylor & Sonuga-Barke, 2010). Children’s symptoms must also interfere with their everyday functioning. To be diagnosed 593 with ADHD, children must show clear impairment in academic, social, or occupational activities. For example, inattentive symptoms might interfere with their ability to pay attention in class and do well in school. Alternatively, hyperactive–impulsive symptoms might lead to peer rejection. Adolescents might get into trouble at work because of careless mistakes, rushing through activities, or forgetting important tasks. Finally, DSM-5 conceptualizes ADHD as a disorder that emerges in childhood. In order to be diagnosed with ADHD, individuals must have at least some symptoms of inattention or hyperactivity–impulsivity before age 12 (American Psychiatric Association, 2013). DSM-5 instructs clinicians to specify the severity of ADHD symptoms. Individuals with “mild” ADHD have few, if any, symptoms in excess of the required number for the ADHD diagnosis and only minor impairment in social, academic, or occupational functioning. In contrast, people with “severe” ADHD have many more symptoms beyond the number required for the ADHD diagnosis and marked impairment in functioning. Clinicians can also rate severity as “moderate”—that is, severity between mild and severe (American Psychiatric Association, 2013). Presentations When clinicians diagnose ADHD, they specify children’s current symptom presentation in one of three ways: (1) predominantly hyperactive–impulsive presentation, (2) combined presentation, or (3) predominantly inattentive presentation (Coghill & Seth, 2011; Tannock, 2013). Children with ADHD, predominantly hyperactive–impulsive presentation show significant hyperactive and impulsive symptoms but only subthreshold problems with inattention. These children may have problems with attention and concentration, but their inattention is not severe enough to merit a combined specification. These children are usually described as “driven by a motor” or “constantly on the go” (van Ewijk & Oosterlaan, 2015). Children with predominantly hyperactive–impulsive symptoms tend to be younger children and are disproportionately boys. Their symptoms tend to emerge between 3 and 4 years of age and interfere with their interactions with caregivers, family members, and peers. Most young children with predominantly hyperactive–impulsive symptoms will eventually develop attention problems as well. Between the ages of 6 and 12, most of these children will transition form hyperactive–impulsive presentation to combined presentation. Indeed, hyperactive–impulsive presentation is so rare among older children and adolescents, some experts believe it should be viewed as a developmental precursor for combined presentation (Nigg & Barkley, 2014). 594 Case Study: Attention-Deficit/Hyperactivity Disorder, Combined Presentation 595 The Energizer Bunny Source: ©iStockphoto.com/unguryanu Corey was an 8-year-old boy who was referred to our clinic by his mother. Corey showed significant problems with hyperactivity and impulsiveness at home. “Most second-grade boys are active, but Corey is always on the go,” his mother reported. “Watching him tires me out.” According to his mother, Corey had difficulty remaining seated during meals, constantly fidgeted with objects around the house, talked incessantly, and engaged in highrate behavior. “He’s very impulsive,” she added. “As soon as I let him out of the car, I know he’ll run into the parking lot. He’s constantly doing dangerous stunts with his bike. He just doesn’t think things through.” Corey also had difficulty sustaining his attention on any activity that required concentration or effort. “He can’t focus on his homework for more than a few minutes at a time,” his mother said. “I tried to reward him for completing his work, but then he rushes through it sloppily.” Corey was also extremely forgetful. He often neglected his chores, forgot to complete school assignments, and lost belongings. His mother said, “This is the third schoolbag he’s had this year. He’d forget to put on his underwear if I didn’t remind him.” Corey showed similar problems with hyperactivity, impulsivity, and inattention at school. Corey completed assignments quickly, making careless mistakes. His work was often difficult to read. His grades were slightly below average because he often forgot to turn in assignments, lost his work, or rushed through tests without reading directions. “When I remind him to obey the class rules, he’s always apologetic,” his teacher said. “He wants to be good, but he just can’t follow through.” A psychologist in our clinic interviewed Corey in her office. “You have a hard time doing what you’re supposed to do at home and in school?” she asked. “Yeah,” admitted Corey, “I’m always getting into trouble because I’m so hyper. My mom calls me her ‘Energizer Bunny.’” Children with ADHD, combined presentation show significant inattentive and significant hyperactive–impulsive symptoms for the past six months. When most people think of 596 ADHD, they probably envision a child with combined presentation. Parents and teachers describe these children as careless, forgetful, sloppy, distractible, rushed, irresponsible, or restless (Barkley, 2013c). Children with combined presentation have underlying problems with behavioral inhibition—that is, the ability to control or regulate immediate impulses to achieve long-term goals. Disinhibition causes them to have difficulty with sustained attention and to show over-activity and impulsiveness at school and home. Most children diagnosed with ADHD in clinics and hospitals display combined symptoms. Consider Corey, a boy with combined presentation. Children with ADHD, predominantly inattentive presentation show significant problems with inattention but subthreshold symptoms of hyperactivity and impulsivity. These children are typically described as “distractible, forgetful, and disorganized.” They may not pay attention to teachers at school or parents at home and may get into trouble because of their distractibility and lack of focus. Although predominantly inattentive presentation is the second most common presentation in clinical settings, it is the most common presentation in the community. Children with predominantly hyperactive–impulsive symptoms are more likely than children with predominantly inattentive symptoms to be referred for treatment because of their high-rate, overactive behavior. In contrast, children with predominantly inattentive symptoms are often overlooked by parents and teachers, despite their higher frequency in the general population. Consider Brandy, a well-behaved girl with serious inattentive symptoms. Predominantly inattentive presentation is usually seen in older children and adolescents and is disproportionately diagnosed in girls. Youths diagnosed with ADHD, predominantly inattentive presentation usually do not have a history of significant hyperactive–impulsive symptoms in early childhood. Their inattentive symptoms usually emerge between the ages or 8 and 12 years and are noticed by others when they interfere with daily activities, especially schoolwork. 597 Case Study: Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation Source: ©iStockphoto.com/princigalli 598 Well-Behaved Brandy Brandy was a 10-year-old girl with a history of low academic achievement. She was referred to our clinic for psychological testing by her pediatrician, who suggested that she might have a learning disability. Brandy’s academic problems emerged 2 years earlier, when she was in the third grade. She began making careless mistakes on homework and often asked teachers to repeat instructions on assignments. In class, Brandy had difficulty listening and often daydreamed. “Brandy always seems to be off in her own little world,” her teacher reported. “She seems more interested in doodling or staring out the window than in listening to me. I called her mother to make sure that Brandy was getting enough sleep, but she assured me that wasn’t the problem.” Brandy’s mother reported similar trouble with inattention at home: “She never listens to me. It’s not that she’s being disrespectful; it’s just that I have to remind her a thousand times to do something.” Brandy’s mother also remarked about her daughter’s forgetfulness: “She’s always asking, ‘Where’s my shoes, where’s my homework?’” Brandy was generally compliant, except during homework time. Her mother explained, “I’ll tell her to go upstairs and to do her homework, but when I check on her, she’s listening to music or drawing. She says she’ll get to work, but she never does.” A psychologist at our clinic administered an IQ and academic achievement test. Brandy’s scores indicated average intelligence and academic skills. The psychologist shared his findings with Brandy’s mother: “I don’t think your daughter has a learning disability. I need a little more information, but I think that she might have ADHD.” Her mother replied, “ADHD? That can’t be. She’s such a quiet, well-behaved girl.” Symptoms Across Development The diagnostic criteria for ADHD were developed for young children. Consequently, many of these criteria seem inapplicable to adolescents and adults. It is hard to envision a college student with ADHD who “blurts out answers” in class, “has difficulty sustaining attention on play activities,” or “runs about or climbs” in a lecture hall. For these reasons, DSM-5 describes several ways that older children, adolescents, and adults might manifest these symptoms. For example, whereas children might display hyperactive–impulsive symptoms by leaving their seat in class or blurting out answers, college students are more likely to experience subjective feelings of restlessness during lectures or have difficulty waiting their turn while in line at the registrar’s office. Whereas children might display inattention by not listening to parents or being easily distractible in school, college students might show inattention by daydreaming during lectures, forgetting to keep appointments, or submitting late assignments (Tannock, 2013). Clinicians can also consult tables, like Table 8.2, which show the way inattentive, hyperactive, and impulsive symptoms might manifest themselves across development. The diagnostic criteria for ADHD are slightly modified for older adolescents and adults. DSM-5 requires older adolescents and adults (>17 years of age) to show only five, rather than six, symptoms of either inattention or hyperactivity–impulsivity to be diagnosed with the disorder. The reduced symptom count is allowed because, on average, adults with significant impairments due to ADHD often endorse fewer symptoms than children with 599 the disorder. Indeed, as many as 50% of adults with persistent problems with inattention and hyperactivity–impulsivity fall short of the six-symptom criterion established for children. 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 (Solanto, Wasserstein, Marks, & Mitchell, 2013). Review: ADHD is a DSM-5 neurodevelopmental disorder characterized by significant inattention and/or hyperactivity–impulsivity that emerges prior to age 12 years, is present in two or more settings, and interferes with academic or social functioning. ADHD can be differentiated from normal functioning because ADHD is persistent over time and has signs and symptoms that are present across multiple settings. In addition, people with ADHD show behavior that is developmentally atypical. Individuals can be diagnosed with ADHD, predominantly hyperactive–impulsive presentation, predominantly inattentive presentation, or combined presentation. Presentations differ across age and gender. 600 What Problems Are Associated With AttentionDeficit/Hyperactivity Disorder? Conduct and Substance Use Problems Comorbid psychiatric disorders are common among children with ADHD. In communitybased samples, 44% of children with ADHD have at least one other mental disorder. Among youths referred to mental health clinics, approximately 85% have a comorbid condition (Willcutt et al., 2012). Table 8.2 The core symptoms of ADHD are the same for children, adolescents, and adults. However, these symptoms manifest themselves differently across development. Preschool School-Age Adolescence College Inattention Child plays for short periods of time (