Children developing. AHDH - Outline. Evidence of ADHD as a valid medical diagnosis. Emotional and behavioural problems; co-morbidities

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1 Children developing Attention-deficit Hyperactivity Disorder Dr. Ceri Sims Psy2014, Psy4022 seminar AHDH - Outline 1. What is ADHD? Evidence of ADHD as a valid medical diagnosis Emotional and behavioural problems; co-morbidities 2. Theories Cognitive, Biological, Environmental ADHD C.Sims 2

2 Fidgety Phil He won t sit still He wriggles And giggles The naughty restless child Growing still more rude and wild (Heinrich Hoffman, 1845) ADHD C.Sims 3 Attention-deficit Hyperactivity Disorder (ADHD) Neurodevelopmental disorder and one of the most common childhood behavioural disorders Disruptive behaviour marked by over activity, excessive difficulty sustaining attention, distractibility and impulsiveness Dr. Heinrich Hoffman The story of fidgety Philip Sir G. Still - lectures to Royal College of physicians, England - described group of impulsive children with significant behavioural problems ADHD C.Sims 4

3 ADHD C.Sims 5 3 main symptoms are Inattention, Impulse control difficulties and Hyperactivity An externalising disorder: behaviour a result of internal difficulties Approx. 85 % manifest all of these symptoms Few manifest predominantly attention difficulties (ADD) more in community surveys/harder to detect (R. Barclay argued underresearched - ADD children tend to be underactive and dreamy) Most believe difficulties in directing and sustaining attention represent the fundamental problem some become calmer and less active as develop, but disorder persists throughout adolescence (70-80%) and adulthood (50-65%) ADHD C.Sims 6

4 ADHD C.Sims 7 Who identifies the problem? Often detected first by parent - many teachers diagnose the problem because they are familiar with norms of behaviour such as normal friendships and expected levels of achievement. Questionniares used by parents or teachers to assist diagnosis: Conners teacher and parent rating scale, Achenbach child-br checklists, Edelbrock child attention problems rating scale, Barley and DuPaul ADHD rating scale. ADHD C.Sims 8

5 Example questions from Child Behaviour Checklist (Achenbach. 1991, 1992) ADHD C.Sims 9 DIAGNOSIS OF ADHD continued Formal diagnosis by specialist - Paediatrician and or Educational psychologist: compare child s behaviour against medical criteria (DSM- IV-R) - at least 6 inattention and 6 Hyperactive/ Impulsive Is the problem continuous and situation general and excessive compared with peers of the same age? Wide range of situational observations as child may sit still in a clinicians consulting room Need to rule out other problems or disabilities that are not classified as ADHD ADHD C.Sims 10

6 Expression of core symptoms INATTENTION Does not pay attention when being spoken to Difficulty directing and sustaining attention in tasks and activities Easily distracted by extraneous stimuli and activities Failure to initiate or complete assignments/school work and homework Careless mistakes, forgetful in daily activities, often loses things Daydreaming, wandering off and generally having trouble focusing on present situation General difficulty organising tasks and activities (One criticism of the current behavioural criteria for inattention is that they are inappropriate for assessing problems for very young pre-school children) ADHD C.Sims 11 Expression of core symptoms IMPULSIVENESS Rushes into an activity without thinking Blurts out answers before questions completed Difficulty awaiting his/her turn Interrupts others conversations Intrudes on others activities and sabotages games Moves from one unfinished task to another ADHD C.Sims 12

7 Expression of core symptoms HYPERACTIVITY Fidgety and restless Difficulty remaining seated for manual activities and lessons Talks excessively Excessive physical activity in inappropriate environments: climbing, running, tumbling Displacement behaviours when seated: finger drumming, feet tapping, fiddling with objects Accident prone (Motor difficulties some ADHD also have these problems: handwriting, coordination, movement planning, accident prone often appear clumsy/dyspraxic) ADHD C.Sims 13 ADHD C.Sims 14

8 Specialists need to use various sources of information to rule out the following: Sudden change in child s life (family crisis or bereavement) Chaotic family life and home environment Undetected seizures (petit mal, temporal lobe) Ear problems (glue ear, hearing problems, infections) Medical disorders Conduct disorders without ADHD Other learning disabilities or psychiatric problems (Reading disorders; Dyspraxia, Autism; Obsessive-compulsive disorder; Tourettes) Anxiety or Depression ADHD C.Sims 15 Conduct Disorders with ADHD ADHD often found to show oppositional defiant behavioursmost common category referred to mental health practitioners. Only between 10-20% of ADHD children reach adulthood free of any psychiatric diagnosis. Restlessness at age 3 predicts conduct disorders at age 8 (Stevenson and Graham, 1975). Hyperactivity and Impulsivity among the most important factors that predict later delinquency and juvenile convictions; Cambridge study of Delinquent development (Farrington, 1991, 1995). Other attributes of ADHD related to delinquency: poor concentration, sensation seeking and risk taking. ADHD C.Sims 16

9 ADHD C.Sims 17 Social and Emotional consequences of ADHD Academic difficulties, Health and Life-style implications: Studies also show that these problems can persist into adolescence and adulthood (Hallowell and Ratey 1994; Wender 1995). injuries, anti-social behaviour, alcohol and substance abuse (Molina and Pelham, 2003), personality and emotional disturbances, risky driving/traffic accidents, marital disruptions more job changes legal infractions ADHD C.Sims 18

10 Is ADHD a social adaptational problem? Jensen et al ADHD diagnoses increasing as ADHD is an adaptational problem - changing expectations of behaviour in Western societies Popular press and TV have debunked the existence of ADHD - no laboratory test for ADHD Blaming children for educational shortcomings - e.g. not enough physical activity in school Doctors pushing medication However: Increasing evidence of Biological causes and understanding of ADHD as universal across societies recent research showing high prevalence in China and South Africa. ADHD C.Sims 19 ADHD C.Sims 20

11 ADHD C.Sims 21 ADHD C.Sims 22

12 ADHD C.Sims 23 ENVIRONMENTAL FACTORS ASSOCIATED WITH ADHD: Perinatal Environment: Evidence that prenatal exposure to alcohol (Oesterheld and Wilson, 1987); cigarettes (Thapar et al, 2003) or other drugs can lead to attention problems. Maternal smoking 3 times the risk, no direct causative link but effects remain when SES factors controlled for (Sadowski and Parish, 2005) Pregnant mothers with Rubella (German measles) at increased risk of having child with attention disorder. Prenatal exposure to high levels of lead, or oxygen deprivation in the womb are risk factors ADHD C.Sims 24

13 RESEARCH ON ATTENTION DEFICIT OF ADHD: Hypothesis: distractibility - cannot be selective when confronted with numerous stimuli that compete for their attention Landou, Larch and Milich (1992): 6-12 year old ADHD boys compared with same aged non-adhd boys - watch TV programme under two conditions: a) Toys present in room b) No toys - Test memory of details of TV programme - When toys present, ADHD sample remembered significantly less (half as much) about the programme compared with the non- ADHD group of boys ADHD C.Sims 25 Working Memory (Badderley, 1981, 1986) Central Executive Long-term memory Phonological loop controls the processing of information in working Memory: ability to focus attention on appropriate information and to divide attention between tasks Visuo-spatial scratchpad Implicated in cognitive deficit theories of ADHD (Barkley et al. 2001) ADHD C.Sims 26

14 RESEARCH IN ADHD AND IMPULSE CONTROL : HYPOTHESIS: ADHD are able to inhibit motor responses under highly motivating conditions Jennings et al. (1997): ADHD and non-adhd boys - participated in a computer game that required them to move an arrow to different parts of the screen - When a horn was heard the task was simply to stop moving as quickly as possible - Rewards and penalties given for success The ADHD group took significantly longer to respond but they were able to do this task successfully especially the older ADHD children (over 10 years) ADHD C.Sims 27 Research on ADHD and working memory Working memory deficits in ADHD: The contribution of age, learning/language difficulties and task parameters Sowerby et al. 2011, Journal of Attention disorders What is this study about? Rationale for the research? Aims and hypotheses? Choice of methodology? Who are the participants? How recruited? What measures are used? Do results support the hypotheses? Were appropriate controls used? How could future research build on this study? ADHD C.Sims 28

15 Additional references Lopez-Williams et al. (2005) Athletic performance and social behaviour as predictors or ppr acceptance in children diagnosed with ADHD. Journal of Emotional and Behavioural Disorders, 13,3 Loe et al. (2008) Early histories of school-aged children with ADHD. Child Development 79(6) Bailey, U.L et al (2009) Developmental changes in Attention and Comprehension among children with ADHD. Child Development, 80(6) ADHD C.Sims 29