ADHD and Comorbid Conditions in Children and Adults

Transcription

1 ADHD and Comorbid Conditions in Children and Adults DSM-5: the Shape of Things to Come Presented by George B. Haarman, Psy.D., LMFT Licensed Clinical Psychologist Licensed Marriage and Family Therapist Copyright 2013 All Rights Reserved

2 ADHD and Comorbid Conditions in Children and Adults: DSM-5, the Shape of Things to Come Chapter One Myths AND MISCONCEPTIONS ABOUT ADHD Attention Deficit Hyperactivity Disorder has been identified by a wide variety of descriptions in the professional literature. It was first described in 1902, as Minimal Brain Dysfunction and a variety of names have been employed over the years, including Hyperkinetic Reaction of Childhood. ADHD is one of the most commonly diagnosed disorders of childhood and is a composite disorder involving inattention and impulsivity /hyperactivity. Many individuals with this disorder have been very successful in life. However, without identification and proper treatment, ADHD may have serious consequences, including school failure, family stress and disruption, depression, problems with relationships, substance abuse, delinquency, risk of accidental injuries, and job failure. ADHD is a disorder that has generated significant controversy and discussion over the years. Some individuals have taken the position that ADHD is not real, but is actually acting out and misbehavior on the part of children. Other myths and misconceptions hold that ADHD is purely a disorder of childhood or is a normal part of a developmental maturation process and is going through a phase. In recent times, there has been significant controversy, particularly in minority communities that ADHD is overly diagnosed and that ADHD and accompanying medications are a way of controlling undesired behavior in minority children. Other individuals, inappropriately, have identified ADHD as a result of poor parenting. All of these options and opinions do not concur with the current understanding of the research regarding ADHD.

3 Over the years, a number of inaccurate stereotypes regarding ADHD children have developed. Some of the stereotypes portray ADHD as a disorder that only applies to young males and is rarely observed in younger or adolescent females. Another common stereotype is that ADHD children are always hyperactive, as opposed to recognizing that many children, especially females do not necessarily display hyperactivity, but their symptomatic presentation is dominated by the inattention aspect of the disorder. Another inappropriate stereotype is that ADHD children are unable to focus or attend. Even the most severely symptomatic ADHD children can focus given sufficiently high levels of stimulation. There are times when ADHD children can not only be focused, but are actually hyperfocused. Another common stereotype has been that ADHD children lack intellectual ability and are consistent low achievers. The reality is, that although many ADHD children perform poorly in school (typically in written language or formalized testing as a result of the interference of their disorder), ADHD, children's IQ scores are typically within the normal range. For many years it was commonly believed that the symptoms displayed by ADHD children ended with adolescence; however, it is now recognized that for many of these children, symptoms persist well into adulthood. ADHD Key Points ADHD is a disorder that is not suddenly acquired. Criteria call for symptoms to have occurred prior to age seven. In addition, many mothers of ADHD children report higher levels of intrauterine activity, excessive crying as an infant, and disruptions in a normal sleep cycle. Although any individual s symptoms may lessen in adolescence, many continue to experience the symptoms, even into adulthood. There is a significant correlation between first degree family members and individuals diagnosed with ADHD. A family history of mood disorders, learning disabilities, substance abuse, and antisocial behaviors are also frequently observed. ADHD impacts many domains of an individual's life, including school performance, family functioning, social activities, peer relationships, and self esteem. ADHD is not a disorder that is categorical, but rather appears to display itself in a two-dimensional fashion with some individuals displaying extremely

4 significant symptoms and other individuals displaying a much more moderated symptom presentation. ADHD is viewed as impairment in executive functioning and an inability of the brain to make appropriate decisions based on cognitive control. ADHD is also implicated in many other disorders and is extremely co-morbid with many other disorders. Given appropriate medical intervention and psychosocial interventions, ADHD is extremely treatable. Barkley (1988 and 2006) provides a significant statistical picture of ADHD. His studies indicate that 3 to 7% of children and adolescents have symptoms that are sufficient to justify a diagnosis, while 3 to 4% of adults display a significant number of symptoms to justify the diagnosis. Males are more likely to be diagnosed with ADHD than females, although a variety of studies indicate that females are also very likely be diagnosed with ADHD, particularly ADHD, Predominately Inattentive Type. In his review of the literature, Barkley (2006) has found that all levels of intelligence are represented in the ADHD population. ADHD appears to be a significantly genetically based disorder and studies have indicated genetic transmission rates from.30 to.90. Other studies indicate that siblings are 2 to 3 times at greater risk be diagnosed with ADHD. Twin studies have revealed a moderate to high degree of inheritability for ADHD. Causes of ADHD BRAIN INJURY AND FRONTAL LOBE DYSFUNCTION Several authors have advocated a position that ADHD is a result of brain injury, and many ADHD behaviors are similar to behaviors found in individuals and animals that have experienced frontal lobe injuries. While behavioral displays are very similar, studies indicate that only 10 to 15% of ADHD children have any history of brain trauma. Other authors have proposed that ADHD is a result of a frontal lobe dysfunction, specifically, nonverbal rule governed behavior. Many ADHD individuals are observed to lack the ability to generalize from one situation to another and display excessive rigidity in problem solving. ADHD behaviors are excessively repetitive and redundant, and it would often appear that these individuals fail to learn from past experiences. These individuals, even as adults, are

5 governed more by the immediate consequences of their actions, rather than by any underlying principles of behavior or an organized approach to obtain rewards and solve problems. BRAIN CHEMISTRY Another proposed cause of ADHD has been hypothesized to be the result of differences in brain chemistry. Studies have indicated that certain neurotransmitters appear to be deficient in the brains of animals who display ADHD symptoms. What has been observed directly and indirectly is that there are certain stimulant and non-stimulant drugs that impact these neural transmitters and improve symptoms of ADHD. Stimulants have been demonstrated to increase dopamine and norepinephrine levels in the brains of animals and dopamine and norepinephrine appear to be particularly involved in ADHD. An experimental study where dopamine has been eliminated or destroyed in the brains of animals has been shown to produce hyperactivity; whereas injection of stimulants has restored normal behavior. Genes that regulate dopamine, and possibly norepinephrine, have also been associated with ADHD. While the research and brain chemistry of ADHD has been very promising, it has not reached the level of conclusiveness yet (Swanson and Castellanos, 2002). BRAIN ACTIVITY A number of studies have observed differences in brain activity of ADHD children versus neurotypical children and adults. Studies have indicated overall lower levels of electrical activity in the frontal lobe of ADHD individuals. Positron emission tomography (PET Scans) has indicated less blood flow to the frontal lobe and may also be a promising area for investigation of the gross brain activity as it relates to ADHD (Brown, 2000). Electroencephalographic studies have shown lower levels of fast wave activity (beta waves) typically associated with concentration and attention and have shown higher levels of slow wave activity (theta waves) typically associated with immaturity and drowsiness. The results of these studies have significant implications for biofeedback training as a treatment for ADHD.