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Transcript
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AttentionDeficit/Hyperactivity
Disorder
Presented by Keith Radley
University of Utah
Department of Educational Psychology
School Psychology Program
US Office of Education 84.325K
H325K080308
+
ADHD in the DSM-IV TR

ADHD has three subtypes: Predominately Inattentive Type,
Predominately Hyperactive-Impulsive Type, and Combined
Type

To meet criteria for Inattentive Type, six or more of the
following symptoms must be present for at least six months,
and to a degree that is maladaptive:









Fails to give close attention to detail
Has difficulty sustaining attention in tasks or play
Often does not seem to listen when spoken to
Often does not follow through on instructions and fails to finish
work
Has difficulty organizing tasks and activities
Often avoids tasks that require sustained mental effort
Often loses things necessary for tasks or activities
Is easily distracted by extraneous stimuli
Is often forgetful in daily activities
+
ADHD in the DSM-IV TR

To meet criteria for Hyperactive-Impulsive Type, six or more
of the following symptoms must be present for at least six
months, and to a degree that is maladaptive:

Hyperactivity







Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or other situation in which
remaining seated is expected
Often runs or climbs excessively
Often has difficulty playing quietly
Is often “on the go” or often acts as if “driven by a motor”
Often talks excessively
Impulsivity



Often blurts out answers before questions have been finished
Often has difficulty awaiting their turn
Often interrupts or intrudes on others
+
ADHD in the DSM-IV TR

To meet criteria for Combined Type, criteria for both
Inattentive and Hyperactive-Impulsive types must be met for
the past six months

Some hyperactive-impulsive symptoms or inattentive
symptoms must have been present before age 7

Some impairment must be present in two or more settings
(e.g., at school and at home)
+
ADHD in the DSM-IV TR

A diagnosis of Attention-Deficit/Hyperactivity Disorder Not
Otherwise Specified is available for individuals who:

meet the criteria for Attention-Deficit/Hyperactivity Disorder,
Predominately Inattentive Type, but whose onset of symptoms is 7
years or after

Have clinically significant impairment who present with
inattention and whose symptom pattern does not meet the full
criteria for the disorder, but have a behavioral pattern of
sluggishness, daydreaming, and hypoactivity
+
Other common characteristics

About half of individuals with ADHD also have Oppositional
Defiant Disorder or Conduct Disorder

Most common in individuals with Hyperactive-Impulsive and
combined subtypes

Other associated disorders include mood disorders, anxiety
disorders, learning disorders, and communication disorders

Approximately 50% of individuals with Tourette’s Disorder
meet criteria for ADHD
+
History of ADHD

First clinical description presented by George Still in 1902, who
observed children with aggressive, deviant, highly emotional,
and poorly inhibited behavior



Strauss and Lehtien (1942) argued that restless and inattentive
behavior were evidence of brain damage


Still hypothesized that these children had a deficiency in moral
control, which resulted from the surrounding environment and
internal factors
Also hypothesized about possible hereditary factors
Term “minimal brain damage” used to describe such children, and
special educational guidelines were proposed
Focus began to shift to deficit in filtering of stimuli in CNS
(Laufer, Denhoff, & Solomons, 1957)
+
History of ADHD

Terms associated with brain damage or dysfunction were
eventually dropped

Associations between hyperactivity and decreased attention and
impulse control (Douglas, 1972)

Impairments in investment, organization, maintenance of attention,
inhibition, control of arousal levels, and desire for immediate
reinforcement

Labeled ADD in 1980 by American Psychiatric Association,
ADHD in 1987

Focus returned to poor executive functioning and self-regulation
(1981-present)

Continuing questions of whether inattentive individuals
represent a completely different disorder
+
Causes and contributory factors


Neurology

Brain damage to prefrontal cortex associated with ADHD-like
symptoms

Low birth weight linked to risk for ADHD through relationship to
abnormal brain development

Neurotransmitter dysfunctions have also been proposed, but little
evidence exists

Reduced regions of prefrontal cortex as measured by MRI
(Baumgardner et al., 1996)
Diet and nutrition

Proposed to cause ADHD, but little evidence supports this claim
+
Causes and contributory factors

Genetics




10-35% of immediate family members of children with ADHD likely
have the disorder, with 32% of siblings having ADHD (Biederman et
al., 1992)
If parent has ADHD, risk of child having ADHD increases to 57%
(Biederman, Faraone, et al., 1995)
Twin studies provide strongest evidence for genetic basis: if one MZ
twin is diagnosed, risk is 81%; DZ twin, 29%
Social


Theories propose increased cultural tempo is a cause of ADHD
Twin studies have shown that the shared environment minimally
contributes to individual differences—essentially disproving social
basis theories
+
Assessment of ADHD

Broadband Scales

BASC correctly identified 97.7% of ADHD cases in Parent Report
(Boyle et al., 1993)

CBCL Attention subscale highly effective in identifying ADHD
(Chen, Faraone, Beiderman, & Tsuang, 1994)

Conners Rating Scale also well validated (Shaffer et al., 2000)

Overall, empirically-derived scales are accurate and reliable
in identifying individuals with ADHD

Also sensitive to pharmacological effects
+
Assessment of ADHD


Structured Interviews

Reliability of parent versions of Diagnostic Interview for Children
and Adolescents-Revised are high (Boyle et al., 1993)

Parent agreement is low (.01-.34)
Measures of Impairment

Highly effective in dividing clinical and nonclinical cases
(Pelham, Fabiano, & Massetti, 2005)

Substantial evidence for validity of Vanderbilt, Impairment Rating
Scale, Columbia Impairment Rating, and Child and Adolescent
Functional Assessment Rating Scale (Wolraich et al., 2003; Fabiano
et al., 2005; Bird et al.,1993,1996)
+
Assessment of ADHD


Observation

Able to discriminate between ADHD and comparison children,
and sensitive to treatment effects (Fabiano et al., 2004; Klein &
Abikoff,1997; Chronis et al., 2004)

Example of observation system: Individualized Target Behavior
Evaluation (ITBE)
Functional Behavior Assessment

Should be used to operational presenting problems, gather
information about the problems, and determine treatment options

Other than pharmacological interventions, no evidence-based
treatment for ADHD can be developed without a FBA (Pelham,
Fabiano, & Massetti, 2005)
+
Evidence-based reviews

Mash and Barkley-Treatment of childhood disorders, (pp. 55110)

Barkley-Adolescents with Attention-Deficit/Hyperactivity
Disorder: An Overview of Empirically Based Treatments
+
Treatment approaches

Pharmacological therapies

Stimulant medication-improvements in attention, impulsivity, and
irrelevant behavior


Increase in academic productivity, but not long-term achievement
Antidepressants


May be useful for individuals unable to use stimulants—however,
they have more serious side effects
Behavior management

First treatment option

Self-monitoring—beep tapes, MotivAtor

Repetition of instructions

Reminder cards
+
Treatment approaches

Parent and teacher training

Contingency management

Positive reinforcement

Response-cost



Superior effect to methylphenidate (Rapport et al., 1993)
Reducing task length
Combined treatment

Optimally, treatment plans consist of a combination of evidencebased treatments
+
Fads and non-EBP

Biofeedback

Relaxation training

Vitamins, minerals, and other health foods

Running

Vestibular stimulation

Social skills training

Especially for children with high levels of aggression
+
Recent ADHD research

IMPROVING HOMEWORK IN ADOLESCENTS WITH ADHD:
COMPARING TRAINING IN SELF- VS. PARENT-MONITORING OF
HOMEWORK AND STUDY SKILLS COMPLETION (Meyer, 2005)

Objective: Comparison of self-monitoring and parentmonitoring effects on homework completion and test
preparation

Participants: 42 6-8th grade students, all of whom were previously
diagnosed with ADHD

Assessment: Diagnoses of ADHD were confirmed through the
Conners Rating Scale for parents and teachers. Mean scores
were 73.62 and 73.52. The ADHD Rating Scale-IV and a semistructured interview werealso conducted.
+
Recent ADHD research

Design: A between groups designed was utilized. Three
groups were compared: 1)No treatment; 2) Parentmonitoring; and 3) Self-monitoring. Participants were
randomly assigned to a treatment group.

Steps to intervention:

Parent-Monitoring: Checklists were constructed using the SQ4R
study method. Participants and their parents were trained on how
to use the checklist to monitor homework completion. Parents
were instructed to review the accuracy of the checklist each night,
and to reward participants based on checklist completion (80%).
+
Recent ADHD research

Steps to intervention


Data analysis:



Self-monitoring: The same checklist was utilized for this group. Participants
were instructed on how to develop a proper homework routine. Parents were
encouraged to reward their student for checklist completion (80%), but told
not to complete the checklist themselves or review the checklist for accuracy.
Measured by the Homework Problem Checklist (HPC) and Classroom
Performance Survey (CPS)
A split-plot ANOVA was used to determine treatment differences in HPC and
CPS scores
Results


No-treatment participants were statistically different than treatment
participants, but no statistically significant differences were found between
self- and parent-monitoring.
Received high parental and student satisfaction
+
Conclusions

ADHD is one of the most common disorders seen by school
psychologists—school psychologists can be especially helpful
in helping teachers develop classroom interventions

Pharmaceutical interventions have been proven to be highly
effective, but some behavioral interventions (response-cost)
have been shown to have stronger effects

Behavioral interventions should be the first interventions
implemented

Combined treatments (those incorporating elements of parent
training, classroom modification, behavioral interventions, and
pharmaceutical interventions) show the greatest promise
+
References

Baumgardner, T., Singer, H. S., Denkla, M., Rubin, M., Abrams, M., Colli, M., & Reiss, A. (1996). Corpus callosum morphology in children with Tourette’s syndrome and Attention Deficit
Hyperactivity Disorder. Neurology, 47, 477-482.

Barkley, R. (2004). Adolescents with Attention-Deficit/Hyperactivity Disorder:An Overview of Empirically Based Treatments. Journal of Psychiatric Practice, 10, 39-56.

Biederman, J., Faraone, S., & Lapey, K. (1992). Comorbidity of diagnosis in Attention-Deficit Hyperactivity Disorder. Child and Adolescent Psychiatric Clinics of North America, 1(2), 335-360.

Biederman, J., Faraone, S., Mick, E., Spencer, T., Wilens, T., Kiely, K., Guite, J., Ablon, J., Reed, E., & Warburton, R. (1995). High risk for Attention Deficit Hyperactivity Disorder among
children of parents with childhood onset of the disorder: A pilot study. American Journal of Psychiatry, 152, 431-435.

Bird, H.R., Andrews, H., Schwab-Stone, M., Goodman, S., Dulcan, M., Richters, J., et al. (1996). Global measures of impairment for epidemiologic and clinical usewith children and
adolescents. International Journal of Methods in Psychiatric Research, 6, 295–307.

Bird, H. R., Shaffer, D., Fisher, P., Gould, M. S., Staghezza, B., Chen, J. Y., et al. (1993). The Columbia Impairment Scale (CIS): Pilot findings on a measure of global impairment for children and
adolescents. International Journal of Methods in Psychiatric Research, 3, 167–176.

Boyle, M. H., Offord, D. R., Racine, Y., Sanford, M., Szatmari, P., Fleming, J. E., et al (1993). Evaluation of the Diagnostic Interview for Children and Adolescents for use in general population
samples. Journal of Abnormal Child Psychology, 21, 663–681.

Chen,W.J.,Faraone,S.V.,Biederman,J.,&Tsuang,M.T.(1994). Diagnostic accuracy of the Child Behavior Checklist scales for attention-deficit hyperactivity disorder: Areceiver-operating
characteristic analysis. Journal of Consulting and Clinical Psychology, 62, 1017–1025.

Chronis, A.M., Fabiano, G.A., Gnagy, E.M., Onyango, A.N., Pel[ham, W. E., Williams, A., et al. (2004). An evaluation of the Summer Treatment Program for children with attentiondeficit/hyperactivity disorder using a treatment withdrawal design. Behavior Therapy, 35, 561–585.

Douglas, V. (1972). Stop, look, think, listen: The problem of sustained attention and impulse control in hyperactive and normal children. Canadian Journal of Behavioural Science, 4, 259-282.

Fabiano, G. A., Pelham, W. E., Manos, M., Gnagy, E. M., Chronis, A. M., Onyango, A. N., et al. (2004). An evaluation of three timeout procedures for children with attentiondeficit/hyperactivity disorder. Behavior Therapy, 35, 449–469.
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References

Klein, R. G., &Abikoff, H. (1997). Behavior therapy and methylphenidate treatment of children with ADHD. Journal of Attention Disorders, 2, 89–114.

Laufer, M., Denhoff, E., & Solomons, G. (1957). Hyperkenetic impulse disorder in children’s behavior problems. Psychosomatic Medicine, 19, 38-49.

Mash, E. & Barkley, R (1998). Treatment of childhood disorders, (pp. 55-110). New York, NY: Guilford Press.

Meyer, K. (2005). Improving homework in adolescents with ADHD: Comparing training in self- vs. parent-monitoring of homework and study skills completion.
Unpublished thesis.

Pelham, W., Fabiano, G., & Massetti, G. (2005). Evidence-based assessment of Attention-Deficit Hyperactivity Disorder in children and adolescents. Journal of Clinical Child
and Adolescent Psychology, 34, 449-476.

Pelham, W. E., Lahey, B., Gnagy, E., Kipp, H., &Roy, A. (2005, June). Predictive validity of ADHD symptoms. Impairment on functional outcomes. Poster to be presented at the
annual meeting of the International Society for Research on Child and Adolescent Psychopathology, New York.

Rapport, M., & Kelly, K. (1993). Psychostimulant effects on learning and cognitive function. In J. L. Matson (Ed.) Handbook of hyperactivity in children, (pp. 97-135).
Needham Heights, MA: Allyn & Bacon.

Shaffer, D., Fisher, P., Lucas, C.P., Dulcan, M.K., & Schwab-Stone, M. E. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIM HDISC–IV): Description,
differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 28–38.:

Still, G. (1902). Some abnormal psychical conditions in children. Lencet, I, 1008-1012, 1077-1082, 1163-1169.

Strauss, A., & Lehtinen, J. (1947) Psychopathology and education of the brain-injured child. New York: Grune & Stratton

Wolraich, M. L., Lambert, W., Doffing, M. A., Bickman, L., Simmons,T.,&Worley,K.(2003).Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a
referred population. Journal of Pediatric Psychology, 28, 559–568.