ATTENTION-DEFICIT/HYPERACTIVITY

DISORDER (ADHD)
CLINICAL DESCRIPTION AND ASSOCIATED FEATURES

1 2 3
1. Primarily Inattentive 2. Primarily Hyperactive- 3. Combined Presentation
Presentation Impulsive Presentation
Diagnostic Criteria changes from DSM IV

+ (a) Symptoms must now be evident prior to 12 years of age

(rather than 7 years as noted previously);
+ (b) only five symptoms are required for individuals 17 years
of age and over, instead of the six symptoms required for
children and youth younger than 17 years of age.
Predominantly Inattentive Presentation

+ Careless attention to details

+ Problems sustaining attention over time
+ Does not appear to listen
+ Poor follow-through (schoolwork, homework, chores)
+ Poorly organized
+ Poor ability to sustain mental attention (e.g., homework, independent seatwork at school)
+ Loses necessary materials (e.g., pencils, notebooks, assignment sheets, homework)
+ Easily distracted
+ Forgetful
 In addition to children and youth having six of
the nine symptoms listed here, the DSM also
stipulates that a diagnosis requires that

(a) the symptoms are pervasive across situations

(two or more settings);
Diagnostic
(b) they interfere with performance (academic
criteria social, work-related);

and (c) they have been evident prior to 12 years

of age.
 Consequences

+ children with the inattentive presentation of ADHD are often misunderstood and
undiagnosed;
+ they often suffer painful consequences of internalizing disorders and have
academic problems (Weiss, Worling, & Wasdell).
+ One of the major developmental tasks of the school-aged child is to develop a
sense of competence, mastery, and efficacy.
+ However, children with ADHD face significant challenges in meeting increased
academic and social demands.
Barkley (1998)

+ children with predominantly inattentive symptoms may be characterized by a “sluggish”

information-processing style (slow to process information) and problems with focused or
selective attention.
+ Therefore, against the backdrop of “academic noise,” these children are unable to filter
essential from nonessential details.
+ Lack of attention to details often results from information overload and an inability to
selectively limit the focus of attention.
 Fidgety or squirmy behavior
Problems remaining seated
Excessive motion
Predominantly
Problems engaging in quiet play
Hyperactive- Constantly being on the go
Impulsive Incessant talking
Presentation The following are the symptoms of impulsivity:
Blurts out answers, comments
Is impatient, has problems with turn taking
Is intrusive to others
 Diagnostic criteria

+ The DSM requires six of a possible nine symptoms for a diagnosis of ADHD Hyperactive-Impulsive
Presentation, in children and adolescents (under 17 years of age).
+ The nine symptoms include six hyperactive and three impulsive symptoms.
+ Combined Presentation
+ Individuals who meet criteria for the combined presentation must meet criteria for both the
predominantly inattentive presentation and the predominantly hyperactive-impulsive presentation,
which means that children and youth prior to age 17 would require at least 12 symptoms (six from
each presentation), and those older than 17 would require a total of 10 symptoms (five from each
presentation).
Etiology
 structural regions of the brain,

Biological and genetic transmission,

Neurological
Features
neurotransmitter functions,

and neurocognitive processing.

Brain Structures

Frontal Lobe

+ Executive functions (EFs; also called

executive control or cognitive control)
refer to a family of top-down mental
processes needed when you have to
concentrate and pay attention, when
going on automatic or relying on instinct
or intuition would be ill-advised,
insufficient, or impossible (
Burgess & Simons 2005, Espy 2004,
Miller & Cohen 2001
Individuals with ADHD

+ working memory,
+ sense of time,
+ sustained effort
+ Problems with prospective memory (remembering to remember) can
result in poor follow-through and incomplete tasks (Barkley &
Gordon).
Basal ganglia
 Neurotransmitter and ADHD

+ Swanson in 2007 noted that the caudate nucleus and globus pallidus,
parts of the basal ganglia which both contain a high density of
dopamine receptors, are smaller in ADHD. [Swanson et al., 2007]
+ A reduction in dopamine synaptic markers associated with symptoms
of inattention was shown in the dopamine reward pathway of
participants with ADHD.
Neurotransmitters and ADHD

+ Research has identified low levels of catecholamines (dopamine, norepinephrine,

epinephrine) in children with ADHD.
+ The catecholamines are associated with attention and motor activity.
+ Medications prescribed for ADHD, such as Dexedrine (dexamphetamine), Ritalin
(methylphenidate), and Cylert (pemoline), increase the number of catecholamines
in the brain (Barkley).
Neuropsychogenetics of ADHD
+ In one study individuals with ADHD were found to have abnormal brain wave
patterns (Lubar 1991).
+ Their beta waves (brain waves associated with concentration) are low, and their
theta waves (associated with relaxation) are high, suggesting a state of drowsiness
and daydreaming.
+ It is not surprising, therefore, that activities associated with beta waves, eg,
watchful anticipation and problem solving, are difficult for individuals with ADHD
to sustain. They like activities that permit them to stay in a theta state with a
minimum of outside stimulation (Lubar 1991).
Douglas's Model of Cognitive
Deficits
+ Virginia Douglas (1972)
+ pattern of deficits -cognitive impairments
1) poor investment and maintenance of effort,
(2) deficient modulation of arousal to meet situational demands
(3) a strong inclination to seek immediate reinforcement,
(4) the originally proposed difficulties with impulse control
+ impairment in self regulation
resulted in difficulties with planning
organization
executive functions
metacognition
adapting cognitive sets (flexibility)
self-monitoring,
self-correction
+ Criticized for lack of evidence
The Quay/Gray Theory of
Behavioral Inhibition
+ Herbert Quay adopted Jeffrey Gray's neuropsychological model
of anxiety (1994) to explain the origin of the poor inhibition
evident in ADHD
+ behavioral inhibition system and a behavioral activation system
signals of reward Behavioral
Active avoidance and escape from activation
aversive consequences (negative system (BAS),
reinforcement) (dopaminergic
reward circuitry)

Approach behavior and the maintenance of

such behavior.
Signals
of impending punishment (particularly Behavioral
conditioned inhibition system
punishment) as well as frustrative (BIS) (septo-
nonreward hippocampal
system,
with connections to
the frontal cortex)

Avoidance behaviour
 Underactive
behavioral
inhibition system
(BIS).

ImpulsivenessADHD

Quay (1988; 1997)

+ function of the BIS,
+ it 'responds to conditioned stimuli for punishment and nonrewarded as
well as novelty and innate fear stimuli,
+ to bring about passive avoidance and extinction.
+ Its output causes the cessation of ongoing behavior, an increase in
nonspecific arousal, and a focusing of attention on relevant
environmental cues'
Family-environmental factors

+ hyperactivity was associated with poor coping and expressed criticism

from parents
+ parenting difficulties would be a consequence of the child's difficult
behavior rather than a causal factor
+ family-environmental factors- not - etiology of
+ a role in the maintenance and course of the disorder
Assessment tools
BASC-2

ASEBA Dimensional Scales

Externalizing Problems:
DSM-Oriented Scales
CRS-3 aggression, hyperactivity,

Affective Problems and conduct problems

DSM Diagnostic
Anxiety Problems Categories Internalizing Problems:

Somatic Problems ADHD Inattentive Type depression, anxiety,

somatization
Attention-Deficit/ ADHD Hyperactive-
School Problems:
Hyperactivity Problems Impulsive Type attention, learning
ADHD Total (Combined
Oppositional Defiant Adaptive Behaviours: social
Type) skills, leadership, study
Problems
skills
Conduct Problems
Other Behaviours:

withdrawal, atypicality