ADHD

Is a neurodevelopmental Disorders in DSM

Central Features of ADHD

Hyperactive/Impulsive
• Excessive activity restlessness acting without though

Inattentive

Inattentive Symptoms

• Fails to give close attention to detail/makes careless mistakes

• Difficulty sustaining attention in tasks/play

• Does not seem to listen when spoken to directly

• Does not follow through on instructions and fails to finish schoolwork or other tasks

• Difficulty organizing tasks or activities

• Dislikes or avoids tasks requiring sustained mental effort

◦Reading

• Often loses things necessary for tasks or activities

◦Adults: Wallets keys phones
◦Kids: Lunchbox

• Easily distracted by extraneous stimuli

◦Thinking about what you will have for dinner

• Often forgetful in daily activities

◦Bills, keeping appointments, X

Hyperactive/Impulsive Symptoms

• Fidgets with hands or feet or squirms in seat

• Leaves seat in situations where remaining seated is expected

• Runs about or climbs in situations where it is inappropriate (adolts/adults: restless

feelings)

• Unable to play or engage in leisure activities quietly

• “On the go” or acting like they are driven by a motor

• Talks excessively

• Blurts out answers before the question is completed

• Has difficulty waiting his/her turn

• Interrupts or intrudes on others

◦Budding into conversations

◦Taking over what someone else is doing without permission

DSM Criteria

• Children: school or at home

• Adults: work or at home

• Symptoms needs to be impairing

• Specify presentation:
◦Predominantly inattentive
‣ 6 or more attention symptoms not 6 or more in hyperactive symptoms
‣ xXX

◦Predominantly hyperactive/impulsive
‣ Would be 6 or more hyperactive/impulsive symptoms X

‣ Seen in preschoolers and will later age into a combined presentation of ADHD

◦Combined (most common)

‣ Have both 6 or more of both sets of symptoms

‣ Most common presentation

Prevalence & Course of ADHD

• 7.2% worldwide prevalence children <18 (Thomas et al 2015)

• 4% among children ?? (Stats Canada, 2017)

• Onset around 3-4 years old

• Predominantly inattentive presentation usually identified later
◦because it is easy to miss

• 3:1 male to female ratio in childhood

• Sex difference in diagnosis disappear in adults

• Comorbidities -80% w ADHD have another disorder

◦Oppositional Defiant Disorder

◦Conduct/antisocial problems

◦Specific learning disorders

◦Mood disorders

◦Substance use & risky sexual behavior for adolescents + adults

Myths vs. Facts

Myth: People with ADHD need to just try harder

• “Telling people with ADHD to “just focus” is like asking someone who’s nearsighted to
just see farther”
◦They need support and strategies, not just needing motivation

• People with ADHD struggle with attention and focusing because of differences in brain
functions

Myth: Kids who can play video games for hours can’t have ADHD
• Kids will hyperfocus on things they are interested in

• Hard to figuring out when to focus and when to tune out

• Kids with ADHD aren’t paying better attention than those without ADHD.

Myth: Only boys have ADHD

• Girls are likely to be overlooked and undiagnosed

Myth: Kids will grow out of ADHD

• Symptoms will change over time and kids can learn ways to manage them
◦Not the same as outgrowing it

• Many people with untreated ADHD continues to be impaired in in adolescence and

adulthood

Myth: Children who take ADHD medication are more likely to abuse drugs
• It’s the opposite! Having untreated ADHD increases the risk of substance use.
Treatment for ADHD decreases the risk
ADHD: Etiology

• Biological
◦Genetics – account for about 75-80% of variance

◦Up to 90% concordance rates in MZ twins

◦If parent has ADHD, child has more than 50% chance of having ADHD

• Brain structure & function

◦Smaller overall brain volume and smaller cerebellum

◦Dysfunctions in neurotransmitter systems (dopamine & norepinephrine)

• Environmental
◦Allergens and food additives ?
‣ No evidence

◦Maternal smoking
‣ Increases risk by 2.4x

‣ Interacts with genetic predisposition

• Overall, environmental factors may increase risk for some cases, but not considered to
be specific causal factors for ADHD

ADHD: Evidence-Based Treatment

• Biological intervention (medication)

• Psychological/psychosocial intervention
◦Behavioral therapy

◦Organizational skills training

◦CBT for adults

These treatments need parental and teacher involvedX

Medications

•Stimulants- well studied

◦Ritalin (methylphenidate) most common
‣ Goal to reduce symptoms of hyperactive and inattention

◦Highly effective short-term treatment

◦Reinforce ability to pay attention

◦Improve on-task behaviors

 ◦Decrease negative behaviors (disruption in classroom)

◦Side effects: insomnia, decreased appetite, sleep disturbance

• Non-stimulant (e.g., Strattera)

◦Works well for some children X%

◦Has not been studied as long or as intensively as the stimulants

Psychological Interventions

• Goals
◦Decrease disruptive behavior

◦Improve academic performance

◦Improve social skills

• Behavioral Therapy- Recommended as 1st treatment for young children

◦Behavioral parent training/parent management

◦Behavioral classroom management

◦Intensive summer treatment programs

• Organizational skills training

• CBT for adults with ADHD

Psychological Interventions: Behavioral Therapy

Parent Training/ Parent Management

• Focus on behavior and family relationships

• Parent implemented
◦Clinician will work with parent to teach them the skills
‣ How do you give praise
‣ How do you give commands
‣ How do you set up routines

• Warm, responsive parenting promote positive development outcomes for preschoolers

with ADHD

Classroom Management
• Focus on classroom behavior, academic performance, and peer relationships

• Teacher implemented
n
• Focusing on skills to help child regulate attention, improve academic performance, and
improve peer relationships

Psychological Interventions: Summer Treatment Program (STP)

• All day for 5-8 weeks (200-400 hrs of tx)

• Group based academic and recreational activities

◦Teaches sports and team membership skills as well

• Parents attend weekly group parent training

Psychological Interventions: Behavioral Therapy

• Fabiano et al 2009 meta analysis:

◦Behavioral treatments are highly effective for ADHD

◦Large effects compared to control at reducing symptoms + improving functional

impairment

Stimulant vs. Psychological Treatment

• MTA (Multimodal Treatment for ADHD) Study

• Assigned to 14 months of:

◦Med Management (MM)

◦Intensive Behavior Therapy (Beh)

◦Combined Treatment (Comb)

◦Community Care
(CC)

• All groups experienced

reductions in symptoms
over time

• On primary outcome
(ADHD symptoms): MM
> Beh; MM = Comb but
Comb required lower
dose

• Combined treatment did better at improving general functioning (family and peer
relationships, academic functioning), parent and teacher satisfaction

Treatment Sequencing (Pelham et al 2017)

Beginning with behavioral intervention associated with better outcomes

Treatment Sequencing (Pelham et al 2017)

Better parent attendance for behavioral intervention first

Organizational Skills Training (OST)

• Goal: overcome academic difficulties

• Teach organizational, time management, and planning skills

• Langberg et al 2008- relative to control, those who received OST improved on

organization and homework management skills, maintained at 8 week follow up
◦Gains in GPA

• LaCount et al 2018 -found it was also effective for college students

CBT for Adult ADHD

• Strategies and skills to cope with core symptoms of ADHD

◦Organization, planning, time management, problem solving

•Cognitive reframing around situations causing distress

• 2020 meta analysis (Young et al 2020)

◦CBT > waitlist with large effects

◦CBT > active control with small to moderate effects

◦Improve symptoms & functioning

Treatments without Research Support

• Biofeedback (might work)

• Individual therapy with child

• Diet changes

• Occupational therapy

• Cognitive training