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Chapter 5
Attention-Deficit/Hyperactivity Disorder
(ADHD)
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Description and History
 Description
 Attention-deficit/hyperactivity disorder (ADHD) describes
children who display persistent age-inappropriate
symptoms of inattention, hyperactivity, and impulsivity
that are sufficient to cause impairment in major life
activities.
 New name, not new disorder
 No distinct physical signs: identified through characteristic
patterns of behavior
 These characteristic patterns vary from child to child
 Different patterns of behavior may have different causes
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Description and History (cont.)
 History
 Early 1900s: children who lacked self-control and showed
symptoms of overactivity/inattention in school were said to have
poor “inhibitory volition” and “defective moral control” (English
physician George Still, 1902)
 Worldwide influenza epidemic of 1917-1926
 “Brain injured child syndrome” (often associated with mental
retardation): children who developed and survived encephalitis
during epidemic, and those who suffered birth trauma, head
injury, or exposure to toxins
 Concept evolved to “minimal brain damage” and “minimal brain
dysfunction” in the 1940s and 1950s because some children
displayed similar behaviors with no evidence of brain damage
or mental retardation
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Description and History (cont.)
 History (cont.)
 In late 1950s: called hyperkinesis and was attributed to
poor filtering of stimuli entering the brain
 Led to definition of hyperactive child syndrome; motor
overactivity was seen as main feature of ADHD
 Soon recognized another problem: child’s failure to
regulate motor activity in relation to situational
demands
 By 1970s, deficits in attention and impulse control, in addition
to hyperactivity, were seen as the primary symptoms
 Most recently, there’s a focus on problems in self-regulation,
behavioral inhibition, and motivational deficits
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Core Characteritics
 Core Characteristics
 Key symptoms fall under two well-documented
categories: inattention and hyperactivity-impulsivity
 Using these two dimensions to define ADHD
oversimplifies the disorder
 Each dimension includes many distinct processes
 Although discussed separately, attention and impulse
control are closely connected developmentally
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Core Characteristics (cont.)
 Inattention (IA)
 Difficulty, during work or play, to focus on one task or to
follow through on requests or instructions
 Inability to sustain attention, particularly for repetitive,
structured, and less enjoyable tasks
 Deficits may be seen in one or more types of attention
 attentional capacity
 selective attention/distractibility
 sustained attention/vigilance (a core feature of
ADHD)
 may be a problem in alerting (the ability to
prepare for what is about to happen)
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Core Characteristics (cont.)
 Hyperactivity-Impulsivity (HI)
 Strong link between hyperactivity and impulsivity,
suggesting both are fundamental deficits in regulating
behavior
 Hyperactivity (HI): Primary impairment in HI is inability to
voluntarily inhibit dominant or ongoing behavior
 Hyperactive behaviors include:
 fidgeting, difficulty staying seated when required
 moving, running, climbing about, touching everything
in sight
 excessive talking and pencil tapping
 accomplishing little despite extreme activity
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Core Characteristics (cont.)
 Hyperactivity-Impulsivity (cont.)
 Impulsivity (IA): unable to control immediate reactions or
think before acting
 Cognitive impulsivity: disorganization, hurried thinking,
need for supervision
 Behavioral impulsivity: difficulty inhibiting responses
when situations require it
 The primary attention deficit in ADHD is an inability to
engage and sustain attention and to follow through on
directions or rules while resisting salient distractions
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Core Characteristics (cont.)
 Subtypes
 Predominantly Inattentive Type (ADHD-PI): primarily
symptoms of inattention
 inattentive, drowsy, daydreamy, spacey, in a fog,
easily confused
 may have learning disability, process information
slowly, have trouble remembering things, have low
academic achievement
 often anxious, apprehensive, socially withdrawn, with
mood disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Core Characteristics (cont.)
 Subtypes (cont.)
 Predominantly Hyperactive-Impulsive Type (ADHD-HI):
primarily symptoms of hyperactivity-impulsivity (rarest group)
 preschoolers; limited validity for older children
 may be a distinct subtype of ADHD-C
 Combined Type (ADHD-C): children who have symptoms of
both inattention and hyperactivity-impulsivity; most often
referred for treatment
 Children with ADHD-HI and ADHD-C are more likely to display:
 problems inhibiting behavior
 problems with behavioral persistence
 aggressiveness, defiance, peer rejection, suspension from
school, and placement in special education classes
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Core Characteristics (cont.)
 Additional DSM Criteria
 Behaviors appear prior to age 7
 Occur more often/with greater severity than in other
children of the same age and sex
 Continue for more than 6 months
 Behaviors occur across several settings
 Produce significant impairments in child’s social or
academic performance
 Behaviors not due to another disorder or serious life
stressor
 Important to assess both symptoms and impairment
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Core Characteristics (cont.)
 What DSM Criteria Don’t Tell Us
 Developmentally Insensitive
 Categorical view of ADHD
 Requirement of an onset before age 7 uncertain
 Requirement of persistence for 6 months may be too brief
for young children
 Requirement that symptoms must be demonstrated
across at least two environments confounds settings
(home, school) with informants (parent, teacher)
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Associated Characteristics
 Cognitive Deficits
 Executive functions
 cognitive processes: working memory, mental
computation, planning and anticipation, flexibility of
thinking, use of organizational strategies
 language processes: verbal fluency, communication,
use of self-directed speech
 motor processes: allocation of effort, following
prohibitive instructions, response inhibition, motor
coordination and sequencing
 emotional processes: self-regulation of arousal level,
tolerating frustration, mature moral reasoning
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Associated Characteristics (cont.)
 Cognitive Deficits (cont.)
 Intellectual deficits: Since most children with ADHD have
at least normal intelligence, the difficulty may be in
applying intelligence to everyday life situations
 Impaired academic functioning
 Learning disorders common for children with ADHD
 Problem areas: reading, spelling, math
 different pathways may underlie the link between
ADHD and learning disorders
 Distorted self-perceptions
 positive illusory bias
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Associated Characteristics (cont.)
 Speech and Language Impairments
 About 30-60% of children with ADHD have impairments in
speech and language
 formal speech and language disorders
 difficulty comprehending others’ speech
 difficulty using appropriate language in everyday
situations
 excessive and loud talking
 frequent shifts/interruptions in conversation
 inability to listen
 speech production errors
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Associated Characteristics (cont.)
 Medical and Physical Concerns
 Health Related Problems
 higher rates of asthma and bedwetting
 sleep disturbances, which may be related to use of
stimulant medications and/or co-occurring conduct or
anxiety disorders
 motor coordination difficulties; overlap with
developmental coordination disorder (DCD)
 20% have tic disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Associated Characteristics (cont.)
 Medical and Physical Concerns (cont.)
 Accident-Proneness and Risk Taking
 Over 50% are accident-prone and at higher risk for
traffic accidents
 At risk for early initiation of cigarette smoking
 Reduced life expectancy
 Social Problems
 Family problems include negativity, child noncompliance,
high parental control, sibling conflict, maternal
depression, paternal antisocial behavior, marital conflict
 Peer problems: disliked and uniformly rejected by peers,
have few friends, receive low social support from peers,
can’t apply their social understanding in social situations
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Accompanying Psychological Disorders and Symptoms
 As many as 80% of children with ADHD have a co-occurring
psychological disorder
 Oppositional Defiant Disorder (ODD) and Conduct Disorder
(CD)
 About 50% of children with ADHD meet criteria for ODD
by age 7 or later
 About 30-50% of children with ADHD develop CD
 A common predisposing cause for ADHD, ODD, and CD
 genetics and shared environment
 Anxiety Disorders
 About 25% of children with ADHD experience excessive
anxiety, although relationship between ADHD and anxiety
disorders is reduced or eliminated during adolescence
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Accompanying Psychological Disorders and Symptoms
(cont.)
 Mood Disorders
 As many as 20-30% of children with ADHD experience
depression
 More will develop depression or another mood disorder
by early adulthood
 may be that family risk for one disorder increases risk
for the other
 controversy regarding relationship between ADHD and
bipolar disorder (BP)
 diagnosis of childhood BP increases risk for
ADHD, but diagnosis of ADHD does not increase
risk for BP
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Prevalence and Course
 4-8% of school-age children in North America
 Gender - Diagnosed more frequently in boys (2.5:1)
 2-4% for girls, 6-9% for boys age 6-12
 Rates decrease in adolescence, ratio remains the same
 Ratio in clinical samples is 6:1 with boys being referred
more often than girls since boys tend to be more defiant
and aggressive and girls more inattentive
 DSM criteria may be more common in boys
 In community samples girls are less impaired; few gender
differences in clinic-referred samples, but when found,
boys’ symptoms are more externalized, girls’ are more
internalized
 A significant disorder with many of the same features and
outcomes for boys and girls
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Prevalence and Course (cont.)
 SES and Culture
 Slightly more prevalent among lower SES groups
 Found in all countries and cultures, although rates vary
 Estimated worldwide prevalence rate of 5.2%
 Highest rates in South America and Africa (8-12%)
 Lowest rates in Japan and China (2-5%)
 European and North American rates in middle (4-6%)
 Cultural differences may reflect cultural norms and
tolerance for ADHD symptoms
 Occurs more often in boys than girls in all cultures
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Prevalence and Course (cont.)
 Infancy: Likely that signs of ADHD are present at birth, but no
reliable/valid methods to identify
 Preschool: Hyperactivity-impulsivity symptoms become more
visible and significant at ages 3-4
 act suddenly without thinking, dash from activity to
activity, grab immediate rewards, easily bored, strong
negative reaction to routine events
 those with persistent pattern of hyperactive-impulsive and
oppositional behavior for at least 1 year are likely to
continue to have difficulties later in childhood
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Prevalence and Course (cont.)
 Elementary School:
 Symptoms are especially evident when the child starts school
and continue through grade school
 Oppositional defiant behaviors may increase or develop
 By age 8-12 defiance and hostility may become serious
problems (e.g., lying, aggression)
 Increased problems with self-care, personal responsibility,
chores, trustworthiness, independence, social relationships,
academic performance
 Adolescence: Some outgrow the problems, at least 50% of clinicreferred elementary school children don’t, sometimes the problems
get worse; significant impairments continue in emotional,
behavioral, and social functioning
 Adult Challenges: Some individuals learn to cope by adulthood; for
others, problems continue throughout life
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories and Causes
 Many explanations, some controversial
 Trait from evolutionary past as hunters
 ADHD is a myth fabricated because society needs it
 Some theories:
 Motivation deficits
 Arousal level deficits
 Self-regulation deficits
 Response inhibition deficits
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories and Causes (cont.)
 Genetic Influences
 Some suggested genetic influences from different types
of studies
 ADHD runs in families: about one-third of biological
relatives of children with ADHD have the disorder
 Adoption studies: ADHD rates are about three times
higher in biological versus adoptive parents of children
with ADHD
 Twin studies: About 80% heritability estimates for HI
and IA behaviors
 Specific gene studies, particularly dopamine regulation
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories and Causes (cont.)
 Pregnancy, Birth, and Early Development
 Factors that compromise development of the nervous
system before and after birth may be related to, elevate
risk for, or predict later ADHD symptoms, but none have
been shown to be specific to ADHD
 Mother’s use of cigarettes, alcohol, or other drugs during
pregnancy can damage her unborn child and are
associated with ADHD
 Difficult to disentangle influence of substance abuse
and other environmental factors
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories and Causes (cont.)
 Neurobiological Factors
 Substantial support for neurobiological causal factors show
differences on
 psychophysiological measures: diminished arousal or
arousability
 measures of brain activity during vigilance tests:
underresponsiveness to stimuli/deficits in response
inhibition
 blood flow to prefrontal regions and pathways connecting
them to limbic system: decreased blood flow to these
regions
 Brain abnormalities in frontostriatal circuitry of the brain
associated with attention, executive functions, delayed
responding, response organization
 ADHD children have smaller right cerebral volumes and smaller
cerebellum and delayed brain maturation
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories and Causes (cont.)
 Neurobiological Factors (cont.)
 Neurophysiological and Neurochemical Findings
 no consistent differences between children with and
without ADHD
 some neurotransmitters may be involved: dopamine,
norepinephrine, epinephrine, and serotonin with
selective deficiency in availability of dopamine and
norepinhephrine
 Diet, Allergy, and Lead
 The role of diet, allergy, and lead as primary causes of
ADHD is minimal to nonexistent
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories and Causes (cont.)
 Family Influences
 Little support for explanations based exclusively on
negative family influences, but they are important for
understanding ADHD:
 family influences may lead to ADHD symptoms or to a
greater severity of symptoms
 family problems may result from interacting with a
child who is impulsive and difficult to manage
 family conflict is likely related to the presence,
maintenance, and later emergence of associated
oppositional and conduct disorder symptoms
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment
 Medication and Behavior Therapy
 Rates of outpatient treatment for ADHD have more than
tripled from 1987 to 1997, from .9 to 3.4/100 children
 Fewer than half of the children with ADHD receive
treatment
 Of those who receive treatment, many discontinue
prematurely
 There are many treatments, but no known cure for ADHD
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment (cont.)
 Medication and Behavior Therapy (cont.)
 Medication
 Stimulants used since the 1930s; two most effective used
are dextroamphetamine and methylphenidate
 alter activity in the frontostriatal brain region by affecting
important neurotransmitters
 Other drugs include noradrenergic drugs, tricyclic
antidepressants, and antihypertensives
 Effects are temporary and occur only while medication is
taken; beneficial in short-term, questions about long-term
benefits on later adjustment
 Controversy about potential misuse
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment (cont.)
 Parent Management Training (PMT)
 provides parents with skills to help them
 manage child’s oppositional and noncompliant behaviors
 cope with emotional demands of raising a child with ADHD
 contain the problem so it doesn’t worsen
 keep the problem from adversely affecting other family
members
 taught to understand biological basis of ADHD
 given set of guiding principles
 taught behavior management principles and techniques
 encouraged to spend time each day sharing enjoyable activity
with their child
 learn to reduce their own levels of arousal
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment (cont.)
 Educational intervention focuses on managing IA and HI behaviors
that interfere with learning, providing classroom environment that
capitalizes on child’s strengths and improves academic performance
 Response-cost procedures are used to reduce disruptive or offtask behaviors
 Many strategies are basic good teaching methods
 Intensive Interventions
 Summer treatment program maximizes opportunities to build
effective peer relations in normal settings and provides continuity
with academic work so gains from school year aren’t lost
 coordinated with stimulant medication trials, PMT, social skills
training, and educational interventions
 The Multimodal Treatment Study of Children with ADHD (MTA
Study): Combination of medication and behavioral treatments
works best
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment (cont.)
 Additional Interventions
 Family Counseling and Support Groups
 Family counseling helps family members develop new skills,
attitudes, and ability to relate more effectively
 Many types of support groups for parents: local and
national, online bulletin boards and discussion groups
 Individual Counseling
 Helps children with ADHD deal with their problems and
feelings of isolation and abnormality; helps build their sense
of self-competence
 A Comment on Controversial Treatments
 Restricted diets, allergy treatments, medication to correct
inner ear problems, vestibular stimulation, running, etc.
 Expensive, provide false hope for quick cure, delay use of
beneficial evidence-based treatments
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning