Attention-Deficit

Hyperactivity Disorder
 ADHD – Key Features
 A persistent pattern of inattention or hyperactivity-
impulsivity more frequently displayed and more
severely displayed than in typical individals
 Six symptoms of inattention
 And/Or
 Six symptoms of hyperactivity-impulsivyt
 Before
 Age 7
 “6-6-6”
 Diagnostic Features
 Inattention may manifest itself in academic,
occupational or social situations.
 Hyperactivity may manifest itself by
fidgetiness or squirming in one’s seat.
 Impulsivity may manifest itself as impatience,
difficulty in delaying responses, and blurting
out answers in class.
 Both symptom clusters impact academics and
socialization.
 ADHD – Dx Criteria
A. Either (1) or (2):
(1) inattention: six (or more) of the following symptoms of inattention have
persisted for at least 6 months to a degree that is maladaptive and
inconsistent with developmental level:

Inattention
(a) often fails to give close attention to details or makes careless mistakes in
schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish school work,
chores, or duties in the workplace (not due to oppositional behavior or failure to
understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
 ADHD – Dx Criteria
A. Either (1) or (2):
(2) hyperactivity-impulsivity: six (or more) of the
following symptoms of hyperactivity-impulsivity have
persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:

Impulsivity
(g) often blurts out answers before questions have been
completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into
conversations or games)
 ADHD
Either (1) or (2):
– Dx Criteria
(2) hyperactivity-impulsivity: six (or more) of the following
symptoms of hyperactivity-impulsivity have persisted for at
least 6 months to a degree that is maladaptive and inconsistent
with developmental level:
Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in
which remaining seated is expected
(c) often runs about or climbs excessively in situations in
which it is inappropriate (in adolescents or adults, may be
limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities
quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively
 ADHD – Dx Criteria
B. Some hyperactive-impulsive or inattentive symptoms that
caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more

settings (e.g., at school [or work] and at home).

D. There must be clear evidence of clinically significant

impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a

Pervasive Developmental Disorder, Schizophrenia, or other
Psychotic Disorder and are not better accounted for by another
mental disorder (e.g., Mood Disorder, Anxiety Disorder,
Dissociative Disorders, or a Personality Disorder).
 ADHD – Dx Criteria
Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both

Criteria A1 and A2 are met for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly

Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the
past 6 months

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly

Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not
met for the past 6 months

Coding note: For individuals (especially adolescents and adults) who

currently have symptoms that no longer meet full criteria, "In Partial
Remission" should be specified.
 Recording Procedures
 Subtypes may go on to develop the Combined Type
and vice versa.
 Subtype coding should use a “last 6 months” time
frame.
 If clinically-significant symptoms remain but
diagnostic criteria are no longer met for any of the
subtypes, can code ADHD, In Partial Remission.
 If current clinically-significant symptoms do not meet
full diagnostic criteria and it is unclear as to whether
the individual ever met diagnostic criteria, the
appropriate diagnosis is ADHD NOS.
 Associated Features
 Vary by age and developmental stage.
 May include:
 Low frustration tolerance
 Temper outbursts
 Bossiness
 Stubborness
 Excessive and frequent insistence that requests be met
 Mood lability
 Demoralization
 Dysphoria
 Peer rejection
 Poor self-esteem
 Associated Features
 Often, academic achievement is markedly impaired and
devalued.
 This frequently leads to conflict with family, teachers, and
school administrators.
 Since the symptom picture in ADHD is hallmarked by
variability, their behaviors may be incorrectly seen as willful
and disobedient.
 IQ is usually highly variable in individuals with ADHD.
 Scatter within tests and across tests
 IQ suppression during actively symptomatic phases is common.
 Inattention more frequently associated with poor academics
while hyperactivity-impulsivity more frequently associated
with peer rejection.
 Associated Features
 About 50% of clinic-referred children with ADHD
also have comorbid Oppositional Defiant Disorder or
Conduct Disorder.
 Disruptive behavior disorders are most frequently
comorbid with ADHD than with other mental
disorders.
 About 50% of clinic-referred children with Tourette’s
also present with ADHD; most children with ADHD
do NOT have comorbid Tourette’s.
 When Tourette’s and ADHD co-exist, a diagnosis of
ADHD usually precedes a diagnosis of Tourette’s.
 Associated Features
 May be a history of child abuse or neglect
 ADHD kids are at a higher risk for abuse
 Also seen in children with multiple foster placements,
neurotoxin exposure (e.g., lead poisoning), infections
(e.g., encephalitis), drug exposure in utero, or Mental
Retardation.
 Low birth weight (LBW) may be associated with
ADHD, but not all LBW children develop ADHD
and most children with ADHD do not have a history
of LBW.
 Assessment findings?
 No lab tests, neurological assessments, or
attentional assessments that have been
established as the “gold standard.”
 Tests that require effortful mental processing
have shown group differences; applicability to
individuals is questionable.
 Some tests have shown promise:
 TOVA, CPT-II
 Theoretical Underpinnings
 Dopamine
 Psychopharmacology & patterns of substance use
 Dopamine dysregultion

 Norepinephrine dysregulation

 Hypofrontality
 Arousal-seeking
 Executive dysfunction
 Causes
 Neurological : FMRI & PET studies indicate frontal &
prefrontal areas, cerebellum & basal ganglia are structurally
smaller & have reduced blood flow.
 Reduced activity in these areas & less gray matter
 Cognitive aspects of ADHD related to impairment in frontal
& prefrontal areas,
 Hyperactivity related to impairment in basal ganglia & /or
cerebellum
 Certain chemicals in the brain ( neurotransmitter) play a major
role in ADHD behavior, especially dopamine and
norepinephrine
 Genetic factors : more common in biol. Relatives of children
with ADHD. More likely in siblings of ADHD.
 Probability of ADHD much higher in identical T pair.
 ? Defective gene inherited. Dopamine transporter gene
Brain injury : encephalitis, epilepsy, fetal exposure, toxemia, &
preschoolers exposed to high levels of lead have a higher risk of
developing ADHD
Different EEG patterns occur in brains of kids with ADHD
Environmental factors : family pathology, parental personality
problems, either hysteria/personality disorder,
Constant friction b/w parents & child subsequent to child’s behavior
causes more problems for an ADHD .
Poor parenting, disruptive family life, poor schooling , defective
management by parent, teachers & others prolonged emotional
deprivation, stressful psychic events
Predisposing factors : temperament, demands of society to adhere to
routine way of behaving & performing
 The neurological basis of attention :
 Abnormalities of brain structure reported in ADHD
– Total brain volume 5% smaller, cerebellar
volumes smaller, caudate volumes smaller – Frontal
lobe, basal ganglia, cerebellum – Findings
inconsistent
 Functional studies – Abnormal function of the
fronto-cortical-striatal- thalamic circuitry – Major
components of this circuitry and other regions
implicated in ADHD, Activation of other areas not
seen in controls –(2005).
 Exec fxing of Frontal cortex : Response inhibition :
 Neurological disorders that impair attention:
 Damage to the neural pathways supporting attention –
 Traumatic Brain Injury (~20%) – 15% between 6-12 months
after injury – 21% more than 1 year after injury
 Stroke – Children with stroke have a significantly increased
risk of ADHD – 15/25 stroke vs 6/25 control
 Lesion volume not associated with ADHD traits. Small
lesions of the putamen associated with ADHD – ADHD: 6/7
with putamen lesion versus 2/6 with no putamen lesion
 Encephalitis – Spina-bifida with hydrocephalus (~30%)
 Functional impairment of attention networks – Epilepsy – ?
ADHD in 4% of children with epilepsy, ADHD in 70% of
children with severe epilepsy
 Tourette syndrome (>50% ADHD clinical groups)
 Associated Physical Findings
 No specific physical features associated with
ADHD.
 Some minor physical abnormalities:
 Hypertelorism (atypically long distance between
eyes)
 Highly arched palate

 Low-set ears

 Higher rates of accidental physical injury

 Cultural & Gender Features
 ADHD is known to occur in various cultures.
 Prevalence variations probably due to different
diagnostic practices.
 More frequent in males than in females
 Male-to-female ratio ranging from 2:1 to 9:1
 Inattentive type may be more “balanced”;
hyperactive-impulsive type less so.
 Clinic-referred children are more likely to be male.

 Why the gender/subtype differences?

 Assessment
 Thorough medical & physical history
 Medical exam for general health & neurological status
 Comprehensive interview with parents, teacher & child
 Standardized behavioral rating scales specific for ADHD
( Achenbach’s behavioral problem check list )
 Observation of the child in natural & controlled situatn
 A variety of psychological tests to measure IQ, attention,
memory & social & emotional adjustment ( to
determine the presence of specific learning disabilities,
emotional disturbances and social deviation etc. ( emotional
disturbances plays an important role in intelligence
assessment). In addition, factors responsible for initiating &
maintaining abn. beh. shd. also b elicitd.
 Developmental Presentations
 Infancy
 Infant evidences only fleeting attention (in and out)
and is unable to focus for more than 5 to 6 seconds
on a caregiver’s facial expressions, presentation of
a toy, or other interactive opportunity.
 Initially, attempts to increase attention require
tremendous effort on the part of the caregiver, such
as holding a toy for the infant to reach for.
 However, these behaviors are nonspecific and a
disorder diagnosis is extremely difficult to make
in this age group.
 Developmental Presentations
Early Childhood
 The child is
 unable to function and play appropriately,
 may appear immature,
 does not engage in any activity long enough,
 is easily distracted,
 is unable to complete activities,
 has a much shorter attention span than other children the
same age,
 often misses important aspects of an object or situation (e.g.,
the rules of a game),
 does persist in various self-care tasks (dressing or washing)
to the same extent as other children of comparable age.
 The child shows problems in many settings over a long period
of time and is affected functionally.
 Developmental Presentations
 Middle Childhood and Adolescence
 The child
 Has significant school and social problems
 Often shifts activities
 Does not complete tasks
 Is messy and careless about schoolwork
 Starts tasks prematurely and without appropriate review of
the instructions
 Appears as if his or her mind is elsewhere and as if he or she
were not listening
 Has difficulty organizing tasks
 Dislikes activities that require close concentration
 Is easily distracted and is often forgetful.
 Developmental Presentations
 Symptoms are usually most prominent during
elementary school years.
 As children mature, symptoms usually become
less conspicuous.
 Prevalence
 DSM-IV-TR
 3% to 7% of all school-age children

 American Academy of Pediatrics

 4% to 12% of school-age children

 9.2% of males, 2.9% of females in the general

population
 School samples: 6.9%

 Community samples: 10.3%

 Variability likely due to differences in diagnostic

criteria over time (DSM-III / IV).
 Course
 Most parents notice their kids are excessively active when
their children are toddlers.
 However, many overactive toddlers will not be diagnosed
with ADHD.
 Diagnosis prior to age 4 or 5 is exceedingly difficult owing
to normal and environmental variability in behavior.
 Usually first diagnosed in elementary school
 Inattentive subtype may not be diagnosed until late
childhood.
 In most individuals, symptoms tend to attenuate as they get
older.
 Familial Pattern
 ADHD has been found to be more common in first-degree
relatives of ADHD positive probands.
 Early studies - families
 Cantwell (1975)
 Interviewed parents of ADHD children.
 10% of the parents had been ADHD themselves.
 45% had “some type of psychiatric disturbance.”
 Alcoholism, sociopathy
 Other studies found similar results.
 Problems with these studies?
 Parents with “some type of psychiatric disturbance” may struggle
in providing an optimal home life for children.
 This may also contribute to the development of ADHD.
 Experimenter bias?
 Familial Pattern
 Adoption studies
 Comparisons of the parents of children in four groups
 BH: ADHD children raised by their biological parents
 AH: ADHD children raised by their adoptive parents
 BN: Non-ADHD children raised by their biological
parents
 AN: Non-ADHD children raised by their adoptive
parents
 Higher rates of ADHD in the BH parents and siblings
supports a genetic cause.
 Problems with these studies?
 Rarely, were researchers blind to the diagnostic categories
of the children.
 Adoptive parents are usually screened for
psychopathology.
 Familial Pattern

Goodman & Stevenson (1989) Concordance Rates

60
50
40
30
20
10
0
Monozygotic Dizygotic
 Familial Pattern
 Most studies have found greater concordance
rates (% matches) with MZ twins compared to
DZ twins.
 Problems?
 Environment of MZ twins more similar than
environment of DZ twins.
 Is it genetics?
 Familial Pattern
 Studies also suggest higher prevalence of
 Mood and anxiety disorders
 Learning Disorders

 Substance-Related Disorders

 Antisocial Personality Disorder

 In family members of individuals with ADHD.

 Differential Diagnosis
 Age-appropriate behaviors in active children (e.g., no
diagnosis)
 Mental retardation
 Inattention or hyperactivity-impulsivity needs to be beyond what
you would expect for the child’s mental age.
 Highly-intelligent children in under stimulating environments.
 Oppositional Defiant Disorder / Conduct Disorder
 Stereotypic Movement Disorder
 Usually, these individuals have focused and fixed behaviors; ADHD
have unfocused and variable behaviors.
 PDD
 Other Substance-Related Disorder Not Otherwise Specified
 e.g., older bronchodilators, neuroleptic-induced akathisia
 Attention-Deficit/Hyperactivity Disorder
Not Otherwise Specified (314.9)
This category is for disorders with prominent symptoms of
inattention or hyperactivity-impulsivity that do not meet
criteria for Attention-Deficit/Hyperactivity Disorder.
Examples include:
Individuals whose symptoms and impairment meet the
criteria for Attention-Deficit/Hyperactivity Disorder,
Predominantly Inattentive Type but whose age at onset is 7
years or after.
Individuals with clinically-significant impairment who
present with inattention and whose symptom pattern does
not meet full criteria for the disorder but have a behavioral
patter marked by sluggishness, daydreaming & hypoactivity
 Slow Cognitive Tempo (& elevated comorbid anxiety)
 Common difficulties & problems :
summary
1. difficulty in delaying gratification
2. difficulty or inability to work for long term goals
3. difficulty in resisting distraction
4. Inconsistency in term of their receptive & responsive beh.
5. Resistant , oppositional , & domineering social beh.
6. Difficulty in following instructions
7. Difficulty in exercising restraint over emotional out bursts
8. Difficulty in making inferences, taking rt. decision &
judgment. & difficulty in terms of fine motor coordination
9. Difficulty with regard to tolerance of frustration or
disappointment
10. Attention demanding beh. & Difficulty in feeling satisfied
 Intervention
 Very important to structure, modify & improve
environmtal conditions at home, school and educate
parents & teachers so as to help ADHD child reduce
severity of problems & learn necessary skills in life.
Medicine used to calm the child : Ritalin
(methylphenidate)to reduce over-activity & distractibility
& increase alertness
Psychl : Behl.Tech. : Behl. Modification
Selective reinforcement in class, fly. therapy, +ve
reinforcement & structuring of learning materials & tasks
in a way, so as to minimize errors & maximize immediate
feedback & success.
 Behl. methods very useful 4 short term
gains.
 a) Functional Behavioral Assessment
Technique : linking intervention directly to
function of the behavior
 b)contingency based self management
techniques.
 c) problem solving & good communication
techniques.
 Beh. Thy alone or with med. very useful in most cases
Educational provisions: placement alternatives :
integrated mainstream set up with non ADHD kids
 Curriculum considerations : segregated education.
When required, mainstreaming with normal Kids
 Education of ADHD child in mainstream set up

 Method of instruc., pre situation of the subj.matter,

classroom interaction & work envt. Shd. b changed.
 Content shd. b as rich, varied & stimulating as possibl.

 Instruc, methods & techniques adopted shd. b clear,

tasks broken into smaller units, principle of novelty.
 Indiv. Attn & Care : best edutl. Trt. 4 children c- ADD
 Behavioral treatments have been successfully applied
to children with ADHD to facilitate in the
management of disruptive behavior, inattention,
social skills building, academic performance
 Dr. William Pelham, an expert in behavioral
treatments for children with ADHD, describes five
categories of behavioral treatment:
 cognitive-behavioral interventions
 clinical behavior therapy
 direct contingency management
 intensive, packaged behavioral treatments
 combined behavioral and pharmacological treatments
 Cognitive-Behavioral Interventions (CBI)
 The goal of this form of behavioral treatment is to teach self-
control through verbal self-instructions, problem-solving
strategies, cognitive modeling, self-monitoring, self-
evaluation, self-reinforcement and other strategies.
 Clinical Behavior Therapy (CBT)
 The goal of this form of behavioral treatment is typically to
train parents, teachers or other caregivers to implement
contingency management programs with children .
 Therapists using CBT often work with teachers in a
consultation model to teach behavioral strategies for
application in the classroom. The use of a daily report card
system wherein the child receives tokens or points for certain
target behaviors in the classroom is a popular ex. of CBT .
 Contingency Management (CM)
 a behl. treatment involving a more intensive program
of behavior modification.
 Typically this program is implemented in a specialized
treatment facility or specialized classroom.
 techniques used include token economies set up to
encourage specific beh. through the use of rewards &
consequences earned by the child, time out, response
cost & precise teacher responses to beh. through
attention, reprimands & gain or loss of privileges.
 Intensive behavioral treatments : The focus is to combine
clinical behavior therapy and contingency management into an
intensive program to improve self-control and socialization
 Educational provisions: placement alternatives :
integrated mainstream set up with non ADHD kids
 Curriculum considerations : segregated education.
When required, mainstreaming with normal Ks
 Education of ADHD child in mainstream set up
 Method of instruc., pre situation of the subj.matter,
classroom interaction & work envt. Shd. b changed.
 Content shd. b as rich, varied & stimulating as possi.
 Instruc, methods & techniques adopted shd. b clear,
tasks broken into smaller units, principle of novelty.
 Indiv. Attn & Care : best edutl. Trt. 4 children c- ADD
 If children with ADHD continue to have academic problems
after their ADHD symptoms have been effectively treated,
they should undergo an educational and psychological
evaluation •
 The clinician should advise the parent to contact the child’s
school in order to request this evaluation. Clinician contact
with the school may also be needed to assist with this
process
 If learning disorders or academic problems are identified,
then a IEP needs to be developed which addresses both the
child’s learning disorders and the issues related to ADHD •
 The clinician can assist the child and family over time with
insuring that the child's IEP is targeting the areas of
concern and is appropriately implemented
 Children with comorbid ADHD and ODD or CD shd. be
provided with:
 – clear, structured behavioral expectations
 – reinforcement of appropriate behaviour
 – consistent consequences for negative, inappropriate beh.
 The development of a behavioral plan designed to extinguish
negative and antisocial behaviors is a central part of treatment
 Child ’s parents may also benefit from working with a
counselor who can provide parent guidance to assist them in
developing skills and strategies for managing their child’s beh.
Medication & BT may help in treating ADHD symptoms, but
if persistent, significant aggressive beh, continues; then a
revaluation to rule out additional disorders and determine if
additional medication needed to cut aggressive beh.
 The power of a positive attitude
 A positive attitude and common sense are the your
best assets for treating ADD/ADHD.
 Keep things in perspective. Remember that the beh.
is due to a disorder, & most of the time un intentional.
 Don’t sweat the small stuff. : don’t look at what is
not done, appreciate and look at what is done
 Believe in your child. Think about or make a written
list of everything that is positive, valuable, and unique
about the person with ADD/ADHD.
 Trust that this person can learn, change, and succeed.
 Regular exercise: a powerful ADD/ADHD treatmt
 Tips for parents
 1. Avoid harsh punishment because it may have
lasting and devastating effects
 Understand children as well as possible
 Use positive redirection
 Foster natural talents, abilities and strengths
 Show love and caring
 Discipline
 Seek professional advice and assistance
 Treatment for childhood ADHD starts at home
 Children with ADD/ADHD are more likely to succeed in
completing tasks when the tasks occur in predictable patterns
and in predictable places,
 Follow a routine. It is important to set a time and a place for
everything to help a child with ADHD understand & meet
expectations. Establish simple and predictable rituals for
meals, homework, play, and bed.
 Use clocks & timers. Allow plenty of time for work
 Simplify your child’s schedule.
 Create a quiet place. : Similar to time-out.
 Set an example for good organization.
 Use Praise often : especially important for children with
ADHD because they typically get so little of it.
 Medications for ADHD

 Stimulant medications can help increase a

child's attention span while controlling
hyperactivity and impulsive behavior. Studies
suggest these drugs work in 70% to 80% of
patients, although they may have some
troubling side effects. Non-stimulant
medications are also options for some
children.
 Counseling for ADHD
 Counseling can help a child with ADHD learn to
handle frustrations and build self-esteem. It can
also provide parents with supportive strategies. A
specific type of therapy, called social skills
training, can help kids improve at taking turns and
sharing. Studies show that long-term treatment
with a combination of drugs and behavioral
therapy is more effective than medication alone.
 Special Education for ADHD
 Most children with ADHD are educated in
standard classrooms, but some do better in a more
structured environment. Special education is a
type of schooling that is tailored to meet the
specific needs of children with learning disabilities
or behavioral disorders. Not all children with
ADHD qualify for special education.
 The Role of Routine
 Parents can give kids more structure at home by
laying out clear routines. Posting a daily schedule
will remind your child of what he or she is
supposed to be doing at any given time. This can
help a child with ADHD stay on task. The
schedule should include specific times for waking
up, eating, playing, homework, chores, activities,
and bedtime.
 ADHD Diets
 The jury is still out on whether diet may improve ADHD
symptoms. While studies on ADHD diets have produced
mixed results, some health experts believe foods that are
good for the brain could reduce symptoms of ADHD.
High-protein foods, including eggs, meat, beans, and
nuts, may improve concentration. It might also be
helpful to replace simple carbs, like candy and white
bread, with complex carbs, like pears and whole-grain
bread. Talk to your pediatrician before making any
dramatic changes to your child's diet.
 ADHD and Junk Food
 While many kids bounce off the walls after eating
junk food, there is no evidence that sugar is a
cause of ADHD. The role of food additives is less
certain. Some parents believe preservatives and
food colorings worsen the symptoms of ADHD,
and the American Academy of Pediatrics says it's
reasonable to avoid these substances. 
 ADHD and Television
 The link between television and ADHD is
unclear, but the American Academy of Pediatrics
suggests limiting young children's exposure. The
group discourages TV viewing for kids under 2
and recommends no more than two hours a day
for older kids. To help your child develop
attention skills, encourage activities like games,
blocks, puzzles, and reading.
 Preventing ADHD
 There is no surefire way to prevent ADHD in children, but
there are steps you can take to reduce the risk. You can
increase your chance of your child not having ADHD by
staying healthy during pregnancy. Start by avoiding alcohol,
drugs, and tobacco during pregnancy. Children whose
mothers smoked during pregnancy are twice as likely to
develop ADHD.

 Outlook for Children With ADHD

 With treatment, a large majority of children with ADHD
improve. They should continue to undergo regular follow-up
since many kids grow out of the disorder as they get older.
But more than half of patients continue experiencing
symptoms once they reach adulthood.