Attention-Deficit

Hyperactivity Disorder
Melissa Stern, M.S.
mkstern@phhp.ufl.edu
A Day in the life of….
 Attention-Deficit/Hyperactivity
Disorder
 ADHD is a neurodevelopmental
disorder of childhood that is
characterized by developmentally
inappropriate levels of:
 Hyperactivity
 Impulsivity
 Inattention
 ADHD: Prevalence
 3-9% of the elementary school
population
 more often in males than females, with
the sex ratio being about 3:1 to 9:1
 most common disorders of childhood
accounting for a large number of
referrals to pediatricians, family
physicians and child mental health
professionals
 ADHD Risk Factors
 Maternal cigarette use
 Maternal alcohol use
 Unusually long or short labor
 Forceps delivery
 Toxemia
 Meconium staining
 Birth during the month of September
 Minor physical anomalies
 History of ADHD
 Characteristics of this disorder have been
recognized for at least a century
 The disorder has been referred to by a variety of
labels:
 Minimal Brain Dysfunction (MBD)

 Hyperkinetic Reaction of Childhood

 Attention Deficit Disorder (ADD)

 Attention Deficit Hyperactivity Disorder (ADHD)

 History of ADHD
 Characteristics of this disorder have been
recognized for at least a century
 The disorder has been referred to by a variety of
labels:
 Minimal Brain Dysfunction (MBD)

 Hyperkinetic Reaction of Childhood

 Attention Deficit Disorder (ADD)

 Attention Deficit Hyperactivity Disorder (ADHD)

 History of ADHD
 1980’s:
 DSM III & DSM III-R stimulates ADHD research
 development of new assessment methods
 new treatment methods
 increased focus on biological factors.
 1990’s:
 Neuroimaging
 genetics
 reevaluation of DSM
 DSM-IV:
Hyperactivity
 Often fidgets with hands or feet,
squirms in seat
 Often leaves seat in classroom or in
other situations in which remaining
seated is expected
 Often runs about or climbs excessively
in situations in which it is inappropriate
 Often has difficulty playing or engaging
in leisure activities quietly
 DSM-IV
Hyperactivity
 Is often "on the go" or often acts as
if "driven by a motor”

 Often talks excessively when

inappropriate to the situation

 6 or more of hyperactive and/or impulsive

symptoms required for diagnosis
 More on Hyperactivity
 Children with ADHD are more active,
restless, and fidgety than normal
children during the day and during sleep
 There are different types of
hyperactivity:
 Gross Motor Activity
 Restless/Squirmy
 Verbal hyperactivity
 Hyperactivity often varies according to
situation
 Degree of hyperactivity may vary with
age
 DSM-IV:
Impulsivity
 Often blurts out answers before
questions have been completed
 Often has difficulty awaiting turn
 Often interrupts or intrudes on others

Six symptoms of hyperactivity and

impulsivity are required for diagnosis
 DSM-IV:
Inattention
 Often fails to give close attention to details
or makes careless mistakes
 Often has difficulties sustaining attention in
tasks or play activities
 Often does not seem to listen when spoken
to directly
 Often does not follow through on
instructions and fails to finish homework,
chores, or duties in the workplace
 DSM-IV:
Inattention
 Often has difficulty organizing tasks and
activities
 Often avoids, dislikes, or is reluctant to engage
in tasks that require sustained mental effort
 Often loses things necessary for tasks or
activities
 Is often easily distracted by extraneous stimuli.
 Is often forgetful in daily activities

 6 or more symptoms needed for diagnosis

 More on Inattention
 “Attentional" problems may be
most obvious on specific types of
attentional tasks:
 sustained attention: responding to
tasks, being vigilant
 situations requiring the child to attend
over time to dull, boring, and
repetitive tasks
 Diagnostic Criteria Overview
 Symptom Criteria - Core Symptoms of
Hyperactivity & Impulsivity and/or Inattention
(Six or More Symptoms of either category)
 Duration Criterion - Symptoms have
Persisted for at Least 6 Months
 Developmental Criterion - Symptoms are
Inconsistent with Developmental Level
 Impairment Criterion - Clear Evidence of
Clinically Significant Impairment in Social,
Academic, or Occupational Functioning
 Diagnostic Criteria
 Age Criterion - Some Symptoms that
Cause Impairment Were Present Before
Age 7
 Situation Criterion - Some Impairment
from Symptoms is Present in Two or
More Settings
 Types of ADHD
 Combined Type
 Symptoms of hyperactivity, impulsivity and
inattention
 Hyperactive/Impulsive Type
 Symptoms of hyperactivity and impulsivity
 Predominately Inattentive Type
 Symptoms of inattention
 Impairment in ADHD
 Social Impairment – What does it look
like?
 Academic Impairment – Long term
outcomes for children with ADHD not so
good
 Family Impairment
 Occupational Impairment
 Driving Impairment
 ADHD Across the Lifespan
 ADHD is a chronic disorder
 60%-80% of children continue to meet
diagnostic criteria in Adolescence
 50%-70% of children will continue to meet
diagnostic criteria in Adulthood

 ADHD in childhood is different from

adolescence and different from adulthood
 Presentation of ADHD in
Adolescence
 Gross motor activity tends to disappear
 Predominance of Inattention,
Restlessness (rather than hyperactivity)
and impulsivity
 What is a developmentally appropriate
level of impulsivity in adolescence?
 ADHD in Adults
 More similar to adolescent presentation
 Mainly problems with inattention and
impulsivity
 How much inattention and impulsivity
affect an adult male? A father? A store
clerk?

 Impairment is key
 Occupational Impairment
 Similar problems to those seen in the
academic environment
 Often unprepared, untimely, easily
distracted
 “Under Achievers”
 Social Impairment
 Still there in adolescence and adulthood!
 If you don’t attend when people talk, they
often think you aren’t interested
Sensation Seeking/Substance Use
 Adolescents and adults with ADHD are
more likely than those with out to engage
in risky behavior including:
 Marijuana use
 Alcohol Use
 Drunk Driving

 This is true even when accounting for the

presence of oppositional defiant disorder
and/or conduct disorder
 Driving impairment
 Leading cause of death in 15-24 year olds
are motor vehicle accidents
 Adolescents and adults with ADHD are
more likely to have an accident, to have
more accidents, to speed, to receive traffic
citations, to receive more traffic citations,
to have their licenses suspended/revoked,
to drive without a license, to drive under
the influence
 Driving Impairment
 One of the most common causes of MVAs
is plain old inattention
 Adolescents in particularl are more likely
to speed, to not use a seatbelt, and to
drink and drive

 Hmm….what does this mean for people

with ADHD
 Virtual Reality
Researchers are using virtual reality to
simulate driving situations and assess
performance
Here at UF we have a high tech simulator

http://driving.phhp.ufl.edu/
 Shameless Plug
 Driving Impairment in ADHD is my area of
research
 I am going to need an RA or two to help
with my dissertation starting in the Spring
or next fall
 If you are a sophomore or junior and are
interested in getting into research, EMAIL
ME!  mkstern@phhp.ufl.edu
 But What About Cognitive
Impairment
 It’s a NEUROdevelopmental disorder,
right?
 So why hasn’t this lady mentioned
cognitive problems?
 ADHD & Neuropsychological
Deficits
 Results from research involving
neuropsychological testing has often
suggested that children with ADHD have
problems:
 inhibiting behavioral responses
 with working memory
 with planning and organization
 with verbal fluency
 with perserveration
 in motor sequencing
 with other frontal lobe functions
 Neurological Findings
 Siblings of children with ADHD who
do not have ADHD, have milder yet
significant impairments in
executive functions
 This suggests a possible genetic
risk for executive function deficits
in families
 Other Neurological Findings
 Differences in cerebral blood flow
 Differences in cerebral metabolism
 Differences in the corpus collosum
 Neurotransmitter Deficits
 Neurotransmitter dysfunction in children
with ADHD has been suggested for many
years
 Originated from observations of the
response of children with ADHD to
different type of stimulant drugs
 The fact that stimulant drugs have an
impact on ADHD and that they increase
dopamine has contributed to the
neurotransmitter dysfunction
hypothesis
 Comorbidity & ADHD
 Why is it essential to consider the
possibility of comorbid conditions in
assessing children with ADHD?
 Importance of distinguishing between
comorbid conditions and mimicry
 What is the frequency of comorbidities in
children with ADHD?
 Comorbidities
 Learning Disabilities - 19 to 26%
 Oppositional Defiant Disorder - 40%
 Conduct Disorder - 25% children; 45-50%
adolescents
 Anxiety Disorders - 30%
 Depressive Disorder - 10 - 30%
 Bipolar Disorder – up to 20%
 Tics and Tourette’s Disorder – 7% of children
with ADHD have a tic disorder
 40 to 50% of those with Tourette’s disorder have
ADHD
Onto Assessment and Diagnosis!
 American Academy of Pediatrics
Guidelines
 Only governing organization with
guidelines for ADHD assessment
 Designed for pediatricians
 Move toward guidelines in APA
 The Interview
 Structured or semi-structured
 Gold Standard is “The Barkley”
 Parent and Self-Report versions
 Mostly used in research
 Goal is to assess for the three main
symptom areas and evidence of
impairment which meets DSM criteria
 Behavioral Observations
 This isn’t technically recommended by
AAP
 However, if a child is literally climbing the
walls, it might be good to note that
 Always remember that children may be
inclined to be on their “best behavior” in
new situations
 Coding systems available for looking at
hyperactive and inattentive behaviors
 Parent-Report Rating Scales
 Shorter measures which ask parents
about frequency, severity, etc. of various
behaviors
 Recommended by AAP but not required
 Conners’ Parent Rating scale the “Gold
Standard” form
 Assesses various aspects of inattention,
hyperactivity, impulsivity
 CPRS
 Items are rated on a four-point scale from “Not at
all true” to “Very much true”
 87 questions
 Each question is part of one or more subscales
 The parents’ rating on a given question
corresponds to a number 0-3
 You sum the numbers for that scale
 You plot subscale sums on the profile chart
 Scores in the red area are indicative of greater
problems
 Parent-Report “Broadband”
Measure
 Broadband measures assess a wide array
of social, emotional, and behavioral
problems
 They are not recommended for AAP for
ADHD diagnosis
 However, they are USEFUL for identifying
comorbid areas of concern
(aggression/conduct problems,
depression)
 Teacher Reports
 These are essential in assessing for
ADHD
 Need to identify impairment in MULTIPLE
SETTINGS
 Most children with ADHD will have
academic impairment
 Teachers may have the best knowledge of
“developmentally appropriate” levels
because they work with so many children
 Teacher Reports
 There is a teacher version of the CPRS,
called the Conners’ Teacher Rating Scale
(CTRS)
 Modified for the classroom setting but
scored the same way
 There are also teacher equivalents of
broadband measures
Problems with Parent and Teacher
Report
 Always the issue of informant bias
(wanting to look like a good parent, like a
teacher who can “handle” kids)
 Sometimes difficult to get in contact with
teachers and they often don’t return forms
 CPRS and BASC may be biased towards
non-European-American Children
 Detour: Multicultural Issues in
ADHD
 ADHD is not limited to the U.S.
 It is seen cross-culturally
 However, there is concern it is over-diagnosed in
Low SES and minority children
 Compared to parents of Caucasian children,
parents of African-American and Hispanic
children have reported significantly more often
feeling as though their children are over-
diagnosed and over-medicated
 Detour: Multicultural Issues In
ADHD
 Parents of African-American children less
likely to associate school problems with
ADHD and are less likely to request
behavioral interventions compared to
parents of Caucasian children
 Parents of African-American children more
likely to report not knowing the etiology of
ADHD and where to go to receive
treatment for the disorder compared to
parents of Caucasian children
 Detour: Multicultural Issues In
ADHD
 In studies looking at cross-cultural validity of
several ADHD assessments, found that parents
of African-American children had significantly
higher scores compared to parents of Caucasian
children. Similar findings for teacher ratings
 Unclear as to whether this is due to informant
biases, cultural biases of the measure, or actual
ethnic differences
 This continues to be an area needing research
 Detour: Multicultural Issues In
ADHD
 What we do know:
 African-American Children respond equally
well to medication treatment compared to
Caucasian children
 Generally no differences in doses of
medication
 Multimodal treatment superiority effect for
minority children (we will get back to this in a
moment)
 Cognitive Measures
 Not recommended for use in diagnosis
 Most evaluators use them in combination
with many other measures.
 These are lab measures that directly
assess impulsivity, inattention, and
executive function
 The CPT
 Measures attention and impulsivity
 Various ways to administer it, but here we
use the “everything but X paradigm”

 Let’s see what this looks like

TREATMENT
ADHD treatment
 Treatment of ADHD
 Stimulant Medications
 Other Medications
 Psychosocial Treatments
 Educational Accommodations
 Stimulant Medications
 Ritalin
 Dexadrine
 Adderall
 Concerta
 70-80 % of children with ADHD respond well to
stimulant drugs
 Stimulant drugs represent an empirically
supported treatment for core symptoms of ADHD
 Stimulants are a trial and error method
 Stimulant Side Effects
 loss of appetite, weight loss, sleeping
problems, irritability
 restlessness, stomachache, headache, rapid
heart rate, elevated blood pressure, sudden
deterioration of behavior
 symptoms of depression with sadness,
crying, and withdrawn behavior
 intensification of tics (muscle twitches of the
face and other parts of the body), possible
Tourette’s, and growth suppression
 Long term effects?
 Stimulant Side Effects
 Side effects are often:
 transient in nature
 result of inappropriate medication levels
 If one medication results in side effects,
another might be used without side effects
 Other medications are used to minimize
side effects
 Good clinical judgment by the clinician
may help to minimize side effects
 Non-stimulant Medications
 Non-Stimulant ADHD Medication
 Straterra - a norepinephrine reuptake inhibitor-
selectively blocks the reuptake of norepinephrine,
which increases its availability
 Other Non Stimulant Drugs
 Anti-depressants (e.g., Tofranil, Wellbutrin)
 Anti-hypertensives (Clonidine)
 Psychosocial Treatments
 Parent Training
 Social Skills Training
 Cognitive Behavioral Treatments
 Psychotherapy for comorbid conditions

NEED FOR MULTIMODAL TREATMENT!

 Educational Interventions
 Special Education Services for existing
learning problems
 Classroom accommodations
 Classroom behavior modification
programs
 504 Plan
 The Daily Report Card
 Specific set of behaviors relevant to the
specific child
 Everyday teacher marks how the child did
on these behaviors
 Child is rewarded (or not) based on
performance at school
 Integrates the classroom and home
 ADHD Treatment:
Conclusions
 It is essential to treat the full range of difficulties
that impact on child and family functioning
 Treatment of ADHD needs to be “multimodal”
 Findings from the Multimodal Treatment Study
suggest that:
 Stimulant medication is effective in reducing core
symptoms
 Psychosocial treatments are of value in addressing
associated comorbidities