ADHD - Overview

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Attention-Deficit / Hyperactivity Disorder:

Attention-Deficit / Hyperactivity Disorder Overview Presentation of ADHD James Walls Amy Turner

Outline of Presentation:

Outline of Presentation I. History of ADHD A. Classifications of ADHD in History B. Modern Classifications of ADHD II. Diagnosis and Associative Features III. Statistics IV. Etiology A. Environmental Theories B. Biogenic Theories V. Treatment VI. Prognosis

Historical Background:

Historical Background Few reports documented before 1900 First Described by George Still in 1902 He first noted symptoms including: aggressiveness, defiant, overly emotional, and cruelty towards others Exempted cases of poor child rearing environments Still and Tredgold in the early 1900’s were instrumental in determining characteristics that are still valid today ADHD was referred to as “postencephalitic behavior disorder” after the many children who survived the 1917-1918 encephalitis epidemic and showed symptoms which are diagnosed as ADHD today

Classification of ADHD throughout History :

Classification of ADHD throughout History In the 1950’s these children were classified as having “hyperkinetic impulse disorder” Hyperactivity was accepted as a brain damage syndrome The “Hyperactive Child Syndrome” was described by Stella Chess in 1960 she emphasized activity as the defining feature the concept of a syndrome of hyperactivity was separated from that of a brain damage syndrome DSM-II first recognized this disorder as Hyperkinetic Reaction of Childhood disorder in 1980 In the 1970’s attention deficits in children with hyperkinesis were argued to be more a factor than hyperactivity

Modern Classifications of ADHD:

Modern Classifications of ADHD Not classified in Europe until ICD-9 First identified as ADD (with or without Hyperactivity) in DSM-III this contradicted ICD-9’s emphasis on hyperactivity DSM-III emphasized inattention and impulsivity DSM-III-R further changed criteria (i.e. symptoms, single cut off scores) for this disorder and changed its name to ADHD In DSM-IV the essential features of ADHD are patterns of inattention and/or hyperactivity-impulsivity ( * material from “History” and these last slides adapted from Barkley, 1990)

Diagnosis:

Diagnosis Six or more symptoms of inattention must be present for at least 6 months frequent mistakes or failure to pay close attention to details difficulty sustaining attention often does not listen when spoken to directly fails to finish work and does not follow instructions lacks organizational skills avoids sustained mental effort misplaces items easily distracted forgetful

Diagnosis (cont.’d):

Diagnosis (cont.’d) frequently fidgets or squirms frequently leaves his expected seating area frequently acts inappropriately has difficulty being quiet while in leisure activities frequently “on the go” talks excessively shouts answers out-of-turn impatient interrupts or intrudes on others Six symptoms of hyperactivity-impulsivity must be present for at least 6 months

Diagnosing ADHD:

Diagnosing ADHD Thorough clinical examinations are also important (interviewing and questionnaires) because of the many controversial diagnosis of ADHD (Jackson & Farrugia, 1997) thorough medical and family history physical examination interviews with parents, the child, and child’s teacher behavior rating scales by parents and teacher observation of the child psychological tests (IQ, social and emotional adjustment, and indication of learning disabilities) DSM-IV (1994) allows for adult diagnosis as long as the following associative characteristics are met...

Associative Features in ADHD:

Associative Features in ADHD Some symptoms must have been present before age 7 Symptoms must occur in at least 2 of the following settings- home school work Clear evidence of interference with social, academic, or occupational functioning must be observed 20-25% have learning disabilities (Davidson & Neale, 1998) Disturbances cannot occur during any other mental disorder; ADHD must be diagnosed separately *Diagnosis slides from DSM-IV (1994, APA), unless cited different

Statistics:

Statistics Effects 3-5% of all school-aged children Most commonly diagnosed behavioral disorder in children 9-18% of school-aged children with mental retardation meet criteria for ADHD (comorbidity is high in ADHD) (Epstein et al, 1986) Males to female ratio ranges from 4:1 to 9:1 depending on the setting (clinic or general population) (DSM-IV, 1994) Studies do not support clear gender differences; diversity in behavior and situational variability are similar between genders (Breen and Altepeter, 1990) Arnold, 1996 says more research is needed on sex differences, especially on female manifestations Occurs in all cultures , with prevalent findings in Western cultures (due to diagnostic methods) (DSM-IV) Mood and Anxiety, Learning, Substance-related, and Antisocial Personality Disorders are more prevalent in family members of those with ADHD (high rate of comorbidity) (DSM-IV) 9.5 million adults are suffering from ADHD (Quinn, 1997)

Etiology:

Etiology Many theories concerning the causes of ADHD are attributed to environmental and biogenic theories

...Environmental Theories:

...Environmental Theories The social constructional theory states: knowledge is socially, historically, and culturally situational and these play a part in the etiology of ADHD (Levine, 1997) these could include environmental toxins like, nicotine, maternal smoking (Davidson and Neale, 1998) Constructivism says: we cannot know reality apart from our own experience consideration of over-crowded schools, poverty, sexism, and exposure to violence should also be accounted for in the etiology of ADHD (Levine, 1997) Despite these theories, ADHD is an environmentally dependent disability and difficulties will come and go in relation to their environment’s demands and expectations

Etiology:

Etiology Many theories concerning the causes of ADHD are attributed to environmental and biogenic theories The most common biogenic theory is that of a neurobiologically-based developmental disability

...Neurobiological Causes:

...Neurobiological Causes Results from a chemical imbalance or deficiency in certain neurotransmitters Lower glucose reuptake in brains of adults with ADHD (Zametkin et al, 1990) Essential fatty acid (EFA) deficiency (due to difficulty metabolizing, converting or transporting EFA’s (Quinn, 1997) EFA’s critical controlling proper brain function and neurotransmitters The correlation is evident though effective treatment is unknown

Other Biogenic Causes...:

Other Biogenic Causes... High genetic transmission (more common in first degree biological relatives of children with ADHD) Lead poisoning and food sensitivities

Etiology:

Etiology Many theories concerning the causes of ADHD are attributed to environmental and biogenic theories The most common biogenic theory is that of a neurobiologically-based developmental disability Parents and teachers do not cause ADHD The exact cause of ADHD still remains unknown; however, research shows evidence for a neurological-based cause

Treatment:

Treatment Stimulant drugs such as the amphetamine methylphenidate hydrochloride (Ritalin) have been used since 1960 (Davidson & Neale, 1998) calm ADHD children and improve concentration use sometimes continues through adolescence and even adulthood loss of appetite and sleep problems accompany these drugs medication should never be the only treatment used

…Medicinal Therapies:

…Medicinal Therapies Dexaphetamine (a stimulant also known as Dexedrine) is cheaper than Ritalin, though less effective Stimulants such as Ritalin and Dexedrine, can cause side effects such as: irritability, anxiousness, and sleep problems loss of appetite, dizziness stomach- and headaches marked crying Valerian, an herb, is shown to improve attention and calm hyperactivity without the side effects Ritalin has (especially insomnia) (Quinn, 1997) Anti-depressants (Clonidine) are used for children who cannot take stimulant drugs

Treatment:

Treatment Stimulant drugs such as methylphenidate (Ritalin) have been used since 1960 (Davidson & Neale, 1998) calms ADHD children and improves concentration use sometimes continues through adolescence and even adulthood loss of appetite and sleep problems accompany these drugs medication should never be the only treatment used In the 1970’s stimulant medication with special education and behavior modification began (Barkley, 1990) close observation allows a child to be positively reinforced point systems and star charts are frequently used

Treatment (cont.’d) :

Treatment (cont.’d) No single treatment strategy has been proven to be effective... …A multimodal approach is agreed to be the best treatment (DuPaul & Stoner, 1994) education about ADHD and educational interventions behavior management, and frequently medication Counseling modalities depend on the individual, these are reviewed by Jackson and Farrugia, 1997 individual, group, vocational, marital, and family counseling educating drug and alcohol treatment strategies include a variety of managem ent skills Peer group counseling may provide ways for children to learn social skills, self control and esteem building (Contugno, 1995)

Ritalin (Methylphenidate hydrochloride):

Ritalin (Methylphenidate hydrochloride) Ritalin increases dopamine levels which is deficient in those with ADHD It is the most prevalent medical treatment for ADHD; 729,000 prescriptions will be written this year (Quinn, 1997) A February 1996 report by the United Nations discovered that 10-12% of all male school children in the U.S. currently take Ritalin as … Overuse of Ritalin has been a concern, as diagnosis for and the label of ADHD is used without proper examination (Livingston, 1997) In a double-blind, placebo-controlled study boys given Ritalin and observed while playing baseball, Pelham et al (1990) determined that Ritalin increased attention and can be helpful during organized sports activities

Prognosis:

Prognosis Follow-up shows that 70% of children with ADHD still meet the criteria after adolescence, with only about 30% exhibiting full remission of symptoms by adolescence (Gittelman, 1985) School drop-out rate is high (Davidson & Neale, 1998) 30-50% of children diagnosed with ADHD will continue to exhibit symptoms through adulthood (cited in Jackson & Farrugia, 1997) ADHD’s chronic pattern of symptoms throughout adulthood may lead to broken marriages and friendships, incomplete college degrees, unsteady jobs, and daily frustrations; studies agree that ADHD is truly a chronic disorder (Barkley et al, 1990)

Prognosis (cont.’d):

Prognosis (cont.’d) The many stimulant drugs that are used only produce short-term behavioral improvements in social and academic settings Handen et al’s study (1997) supported the ineffectiveness of Ritalin in a double-blind experiment with children with both ADHD and mental retardation

References:

References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition. Washington, DC, American Psychiatric Association, 1994. Arnold, E.L. (1996). Sex differences in ADHD. Journal of Abnormal Child Psychology , 24, 5. Barkley, R.A., Fischer, M., Edelbrock, C.S., and Smallish, L. (1990). The adolescent outcome of hyperactive children diagnosed by research criteria: An 8 year follow up study. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 546-57. Barkley , Russell A. (1990). Attention deficit-hyperactivity disorder: A handbook for Diagnosis and treatment . NY: Guilford Press. Breen, M.J. and Altepeter, T.S. (1990). Situational variability in boys and girls identified as ADHD. Journal of Clinical Psychology , 46, 486-90. Contugno, A.J. (1995). Personality attributes of ADHD using the Rorschach inkblot test. Journal of Clinical Psychology , 51, 554-62. Davison, G.C., & Neale, J.M. (1998). Abnormal psychology , 7th edition. New York: Wiley. DuPaul, G.J. and Stoner, G. (1994). ADHD in the schools: Assessment and intervention strategies . New York: Guilford Press.

References (cont.’d):

References (cont.’d) Epstein, M.H., Cullinan, D., & Gadow, K. (1986). Teacher ratings of hyperactivity in learning disabled, emotionally disturbed, and mentally retarded children. Journal of Special Education , 22, 219-29. Gittelman, R., Mannuzza, S., Shenker, R., & Bonagura, N. (1985). Hyperactive boys almost grow up. Archives of General Psychiatry , 42, 937-47. Handen, B.L., Janosky, J., and McAuliffe, S. (1997). Long-term follow-up of children with mental retardation/borderline intellectual functioning and ADHD. Journal of Abnormal Child Psychology , 25, 287-95. Jackson, B., and Farrugia, D. (1997). Diagnosis and treatment of adults with attention deficit hyperactivity disorder. Journal of Counseling and Development, 75, 312-19. Levine, J.E. (1997). Re-visioning attention deficit hyperactivity disorder (ADHD). Clinical Social Work Journal , 25, 197-209. Livingston, K. (1997). Ritalin: Miracle drug or cop-out? Public Interest , 127, 3-18. Pelham, W.E., McBurnett, K., & Harper, G.W. (1990). Methylphenidate and baseball playing in ADHD children. Journal of Consulting and Clinical Psychology , 58, 130-3.

References (cont.’d):

References (cont.’d) Quinn, S. (1997). Natural support for attention deficit hyperactivity disorder. Better Nutrition , 59, 32. Zametkin, A., Mordahl, T.E., Gross, M., King, A.C., Semple, W.E., Rumsey, J., Hamburger, S., and Cohen, R.M. (1990). Cerebral glucose metabolism in adults with hyperactivity of childhood onset. New England Journal of Medicine , 323, 1361-66.

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