Download Developmental Psychopathology

Attention Deficit Hyperactivity
Disorder
What is ADHD?
A disorder characterized by:
 attention deficits (difficulty sustaining attention/poor oncentration)
 hyperactivity
 Impulsivity
 mood swings
 short temper, aggressiveness
 high sensitivity to stress
 impaired ability to make & follow plans
 Fidgeting, constant motion or activity
 Disorganization.
 Difficulty getting along with others
 Have difficulty reading social cues
DSM-IV Criteria for ADHD
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Either A or B:
A. 6 or more manifestations of inattention present for at least 6 mos.
To a maladaptive degree & greater than what would be expected,
given person’s developmental level (e.g., careless mistakes, not
listening well, not following instructions, easily distracted).
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B. 6 or more manifestations of hyperactivity-impulsivity present for at
least 6 mos. To a maladaptive degree & greater than what would be
expected, given person’s developmental level (e.g., squirming in seat,
running about inappropriately).
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Some of the above present before age 7.
Present in 2 or more settings (e.g., at home & at school or work)
Significant impairment in social, academic, or occupational
functioning
Not part of other disorders such as schizophrenia, an anxiety disorder,
a mood disorder.
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What distinguishes ADHD from normal
“hyperactivity?”
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All kids have some level of hyperactivity, so what makes
ADHD unique??
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A diagnosis of ADHD is appropriate if maladaptive behaviors
are extreme for a particular developmental period, persistent
across different situations, & linked to significant impairments in
functioning. The diagnosis is reserved for truly extreme cases!!!
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The diagnosis does not apply to children who are rambunctious,
active, or slightly distractible, in the early schools years (this is
normal for this age).
Recent Hot Issue in the dramatic increase
of diagnosed cases of ADHD--
Has ADHD become a “designer diagnosis” for children
who are more active & difficult to control??
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Possibly!! Active behavior that would have been
considered “normal” years ago, is now considered
aberrant.
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The Result: A push to medicate kids who may be difficult
to control or deal with in classroom settings.
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ABA could be used here, in place of drugs!!!!
General Examples of problem behaviors that are
affected by ADHD:
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Academic difficulties-may do poorly in school due to
impulsivity & inattentiveness.
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Social behaviors-may be tactless, obstinate, bossy,
aggressive, have difficulty getting along with peers.
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Occupational difficulties-may have difficulty taking
orders from others, difficulty dealing with coworkers, struggle to be productive, etc.
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Antisocial behaviors – being aggressive, having
difficulty relating to others.
Specific problem behaviors of ADHD:
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Kids can’t sit still during classroom activities & at
mealtimes.
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Can’t stop talking at times when required to be quiet.
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Activities & movements are haphazard & constant.
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They quickly wear out shoes & clothing, smash their
toys, exhaust family members & teachers.
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Have difficulty getting alone with peers & establishing
friendships.
Specific problem behaviors (contd.)
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They may misinterpret others’ intentions, such as
acting aggressively because they assume that a
neutral action by a peer was meant to be aggressive.
They may know correct social behavior in situations,
but have difficulty transforming the information into
appropriate behavior in real-life social interactions.
****About 15-30% of kids with ADHD have a learning
disability. Half of kids with ADHD are placed in
special ed classrooms.
When does ADHD usually become a
problem?
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During the preschool years, when children have
difficulty controlling their activity & interacting
with their peers.
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However, ADHD may also become a problem in
adolescence.
65 - 80% of kids with ADHD still meet criteria in
adolescence & adulthood.
Prevalence of symptoms in ADHD &
normal adolescents (Barkley, 1990)
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Symptom
Fidgets
Easily distracted
Difficulty remaining
Seated
Blurts out answers
Difficulty (attention)
Interrupts others
Talks excessively
ADHD%
73.2
82.1
Normal%
10.6
15.2
60.2
65.0
79.7
65.9
43.9
3.0
10.6
16.7
10.6
6.1
Three types of ADHD:
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1. Predominantly Inattentive type: Children
with problems primarily of poor attention (ADD).
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2. Predominantly Hyperactive-Impulsive type:
Children whose difficulties result primarily from
hyperactive-impulsive behavior.
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3. Combined type: Children who have both sets
of problems. This type makes up the majority of
diagnosed cases. Most at risk for conduct disorder
as well.
Recent thoughts on the classification of
ADHD:
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Evidence suggests ---it may be best to think
of ADHD as two separate disorders:
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1. One of inattention
2. One of hyperactive/impulsive behavior
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Most theory & research does not make a
distinction.
ADHD & Comorbility
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ADHD is often comorbid with:
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Anxiety
Depression (unipolar depression)
Conduct Disorder
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What is the prevalence of ADHD?
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Difficult to determine--due to the varied
definitions of the disorder & # of
populations sampled.
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Estimates—2- 7% in the US
3 –7% worldwide
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Who is affected more: Males or
Females??
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Males are 2-3 times more likely to be diagnosed
with ADHD than are females.
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Figures change depending on sample (those
referred to a clinic vs. general pop.).
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Clinic samples show greater percentage of males,
since they were referred to the clinics because of
antisocial & aggressive behaviors.
Girls & ADHD:
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1. Like boys with ADHD, girls diagnosed with combined type
were more likely to have a comorbid diagnosis of conduct
disorder or oppositional defiant disorder than girls without
ADHD.
2. Girls with combined type have more disruptive behavior
symptoms than girls with inattentive type.
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3. Girls with combined type were viewed more negatively by
peers than girls with the inattentive type and girls without
ADHD. Girls with inattentive type were also viewed more
negatively than the comparison girls.
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4. Girls with ADHD had a # of neuropsychological deficits
such as executive functioning (planning, problem solving),
compared with girls without ADHD.
What causes ADHD?
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Theories:
• Genetics
• Prenatal/perinatal factors
• Environmental Toxins
• Psychological factors
• Neurological factors
Genetics & ADHD:
•There is a genetic predisposition for ADHD.
• When parents have ADHD, 50% of their
child do too.
Adoption & a # of identical twin studies show
a genetic link. MZ concordance rates are as
high as .70 - .80 (Tannock, 1998).
Prenatal/Perinatal Factors:
Factors predictive of ADHD:
•Low birth weight (perinatal)
• Maternal smoking (prenatal) – increases dopamine
release in baby’s brain—leading to hyperactivity &
behavioral disinhibition.
--Millberger et al., (1996) reported that 22% of
mothers of kids with ADHD smoked a pack of
cigarettes per day during pregnancy, compared with
8 % of mothers whose kids did not develop ADHD.
• Alcohol (prenatal)
Environmental toxins & ADHD:
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A. Dietary factors:
In 1970s Feingold argued that food additives upset the
CNS of hyperactive children. He proposed a diet free
of artificial additives (flavors/colors).
Well controlled studies do not support the efficacy of
the Feingold diet (Goyette & Conners, 1977).
Refined sugar also not found to be liked to ADHD.
B. Non-food related substances:
Although it was theorized that lead poisoning may be
linked with hyperactivity & attentional problems, kids
with ADHD don’t have higher lead-levels than agematched controls.
Psychological Theories
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1. Bettelheim’s (1970s) Diathesis-Stress theory
of ADHD.
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This view argues that kids with predisposition for
ADHD coupled with authoritarian parenting
develop the disorder.
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As parent becomes more impatient & negative
with the child, the parent-child interactions
become battles & a disruptive-disobedient pattern
is formed. This generalizes to other settings
besides the home (e.g., school, social settings,
etc.).
2. Learning theories
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Hyperactivity could be reinforced by the
attention it elicits, leading to increases in
the frequency of the negative behaviors.
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Ross & Ross (1982) argue that
hyperactivity may be modeled on the
behavior of parents & siblings. However,
research has not supported this.
Neurological factors
Brain function & structure differs for children with
& without ADHD.
•The Frontal lobes of kids with ADHD are under
responsive to stimulation & cerebral blood flow
is reduced.
• The frontal lobes, caudate nucleus, & globus
pallidus of kids with ADHD are smaller than
normal.
• Kids with ADHD show poorer performance on
neuropsychological tests of frontal lobe
function (such as inhibiting behavioral
responses).
Neurological Factors (contd.)
Kids with ADHD also have a smaller than average
right prefrontal cortex. The right prefrontal cortex
is thought to be associated with “behavioral
withdrawal.” (Left prefrontal-behavioral approach).
The cerebellum is also smaller than usual. Note that
cerebellar dysfunction is associated with difficulty
switching attention.
Its unclear whether brains were different to begin with
or developed differently based on their experience.
Measuring ADHD behavior:
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1. Choice-Delay Task- Ss are given a choice
between an immediate reward of a lesser value or
a delayed reward of a greater value and asked to
pick one.
E.g., Which would you prefer, $5 now or $6
tomorrow? Or which would you prefer, a cookie
now or a slightly larger cookie in 15 min.?
People w/ADHD—more likely than others to
choose the smaller, but more immediate
reward. This is used to index impulsivity or
difficulty inhibiting a behavior.
2. The Stop Signal Task
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Ss are asked to watch a screen or listen for a
sound. When they hear it, they are to press a
button as fast as possible.
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On some occasions, another stimulus is presented
a split sec after the first stimulus & is used to
indicate the Ss must not press the button. Thus, Ss
have to learn to inhibit their button pressing.
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With the intermediate delays, people with ADHD
are more likely than controls to press the button.
3. The Attentional Blink Task
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Ss watch a series of black letters flashed on a screen,
a new one every 90 ms. In each set, one of the
letters is blue. Another letter, designated as the
“probe” letter, might or might not appear after the
blue letter. The task is first to name the blue letter &
the to say whether or not the probe letter appeared
after the blue letter.
Most people miss the probe letter (they say “no” even
though it was present) if it appears about two 2 – 7
letters after the blue letter. This is called the
attentional blink; you pay attention to the blue letter
for about 200-600 ms after seeing it, so you have
trouble paying attention to anything else.
Attentional blink (contd.)
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The same is more evident for people with
ADHD, they usually miss the probe letter
even if it arrives almost a second after the
blue letter.
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Interpretation—people with ADHD have
trouble controlling their attention; they
can’t shift it when they need to.
ADHD: Treatment
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1. Medication- stimulants prescribed since
1960s (Ritalin).
Stimulant effects-paradoxical –improve
ability to concentrate/reduce disruptions.
In double-blind designed studies, 75% of
kids with ADHD showed dramatic
improvements with stimulants.
How does Ritalin work?
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Amphetamine & methylphenidate stimulate the
release of dopamine to the postsynaptic receptors.
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They produce their maximum effects on dopamine
about 1 hour after someone takes a pill, and 1 hour
is also the time of maximum behavioral benefit, so
the drug effects behavior through altering
dopamine activity.
Treatment (cond)
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2. Psychological techniques—
Behavioral techniques based on operant
conditioning work well.
Applied Behavior Analysis
Programs have demonstrated at least shortterm success in improving social &
academic behavior.
Behavior therapy
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Kids are reinforced for behaving appropriately
(e.g., remaining in seats & working on
assignments).
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Point systems & star charts are useful; kids earn
points or stars for good behaviors that allow them
to earn tangible rewards.
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Focus of therapy is on improving academic &
social functioning, less emphasis is applied to
reducing unwanted behaviors (hyperactivity).