Attention-Deficit/Hyperactivity

Disorder (ADHD)
Andrea Chronis-Tuscano, Ph.D.
Associate Professor of Psychology
Director, Maryland ADHD Program
University of Maryland
 Maryland ADHD Program
Mission
To conduct clinical research that advances our
knowledge about the assessment and treatment
of ADHD
To provide comprehensive, evidence-based
assessment and treatment of ADHD and
associated problems to children and their families
To train the next generation of clinical
psychologists in evidence-based assessment and
treatment practices
To educate parents, schools, health professionals
and the community about evidence-based
assessment and treatment for ADHD
Overview
Definition & Features
Etiological Factors
Evidence-Based Assessment &
Treatment
Professional Practice Parameters
Prevalence & Impact
Prevalence rate of 6-10%
More prevalent in males than females
Male:female ratio is 3:1 in epidemiological
samples
Ranges from 3:1 - 9:1 in clinical samples
50% of children referred to mental health
clinics are referred for ADHD-related
problems
Annual societal cost of illness for ADHD
estimated to be between $36 - 52 billion
$12,005 -- $17,458 annually per individual
 www.cdc.gov
Definition & Features
DSM-IV Diagnostic Criteria
Inattention Symptoms (at least 6 symptoms
required)
Fails to give close attention to details or makes
careless mistakes in schoolwork, work, etc.
Difficulty sustaining attention
Does not seem to listen when spoken to
directly
Does not follow through on instructions and
fails to finish schoolwork, chores, etc.
Difficulty organizing tasks and activities
Avoids tasks requiring sustained mental effort
Loses things necessary for tasks or activities
Easily distracted by extraneous stimuli
Forgetful in daily activities

APA, 2000
ADHD Diagnostic Criteria
(cont.)
Hyperactivity-Impulsivity Symptoms (at least 6
symptoms required)
Difficulty playing or engaging in activities quietly
Always "on the go" or acts as if "driven by a
motor”
Talks excessively
Blurts out answers
Difficulty waiting in lines or awaiting turn
Interrupts or intrudes on others
Runs about or climbs inappropriately
Fidgets with hands or feet or squirms in seat
Leaves seat in classroom or in other situations in
which remaining seated is expected

APA, 2000
ADHD Diagnostic Criteria
(cont.)
Symptoms present before age 7
Clinically significant impairment in social
or academic/occupational functioning
Some symptoms that cause impairment
are present in 2 or more settings (e.g.,
school/work, home, recreational
settings)
Not due to another disorder (e.g.,
Autism, Mood Disorder, Anxiety
Disorder)

APA, 2000
Subtypes
Combined Type
Clinical levels of both inattention and
hyperactivity/impulsivity
Most common subtype
Predominantly Inattentive Subtype
Clinical levels of inattention only
Often not identified until middle school
Sluggish cognitive tempo
Predominantly Hyperactive/Impulsive Subtype
Clinical levels of hyperactivity/impulsivity only
More common among very young children prior to
school entry
Controversial Issues with
DSM-IV Criteria
Developmentally insensitive
Symptoms based on field trials conducted
with elementary school aged boys (Lahey et al.,
1994)
Categorical (not continuous) view
Requirement of onset before age 7
arbitrary
Requirement of 6 months duration too
brief
Requirement that symptoms be
demonstrated across 2 settings
Associated Problems
Peer problems
Inattentive symptoms  ignored
Hyperactive/impulsive symptoms  actively rejected
Not deficient in social reasoning/understanding, but
rather the execution of appropriate social behavior

Family dysfunction/parental issues

No clear causal relationship between family problems
and ADHD
Family problems can impact the severity and
developmental course/outcomes of ADHD

Self-esteem
Inflated: Positive illusory bias (Hoza)
Low self esteem associated with comorbid
depression
 Developmental Course
ADHD is persistent across lifespan in most cases
Methodological issues impact estimates of persistence
ADHD severity, psychiatric comorbidity, and parental
psychopathology predict persistence (Biederman et al., 2011)

Inattention remains stable; hyperactivity declines

with age
DSM-IV criteria may not capture adolescent/adult
manifestations of impulsivity

Adult outcomes including psychiatric comorbidity

When ADHD co-occurs with conduct disorder, chronic
criminality and serious substance use can result
When ADHD co-occurs with depression, risk of suicide
Etiological Factors
 Etiological Factors
Average heritability of .80 - .85
Environmental factors are not the cause, but may
contribute to the expression, severity, course, and
comorbid conditions
Dysfunction in prefrontal lobes
Involved in inhibition, executive functions
Genes involved in dopamine regulation
Dopamine transporter (DAT1) gene implicated
7 repeat of dopamine receptor gene (DRD4)
implicated
Gene x environment interactions
Possible differences in size of brain structures
Prefrontal cortex, Corpus callosum, caudate nucleus
Abnormal brain activation during attention &
inhibition tasks
Kieling, Gondaves. Tannock. & Castellanos. 2008; Mick &.
Brain Structure & Function
 Differences in brain maturation,
structure, function
(particularly abnormalities in
frontostriatal circuitry):

 Prefrontal cortex
 Basal ganglia
 Cerebellum

 These areas of the brain

are associated with
executive function abilities:
 Attention, spatial working memory, and short-term
memory
 Response inhibition and set shifting
 Neurotransmitters
 Neurotransmitter differences,
particularly in levels of:
Dopamine
Norepinephrine
Epinephrine
Serotonin

 Dopamine has been associated

with approach and pleasure-seeking behaviors

 Norepinephrine plays a role in

emotional/behavioral regulation
Executive Functioning
Deficits
Cognitive processes which activate, integrate,
and manage other brain functions

Examples:
Cognitive: working memory, planning, use of
organizational strategies
Language: verbal fluency, communication
Motor: response inhibition, motor coordination
Emotional: self-regulation of emotion, frustration
tolerance

But…
EF deficits overlap with ADHD symptoms
EF deficits are not unique to ADHD
Not all children with ADHD have EF deficits
Barkley’s Theory
“ADHD is not a problem with
knowing what to do; it is a problem
of doing what you know.”
-Barkley, 2006

Behavioral disinhibition is the basis of

executive functioning deficits in ADHD

A performance, rather than knowledge,

deficit
A Possible Developmental Pathway for ADHD

From Mash & Wolfe, 2007

Evidence-Based Assessment
& Treatment of ADHD
Evidence-Based
Assessment
Teacher- and parent-completed questionnaires
Structured clinical interview with parent(s)
IQ/Achievement testing to screen for learning
disabilities (50% comorbidity)
Behavioral observations at home and school

No medical screen, cognitive test, or brain

imaging technique can detect ADHD
Children with ADHD can focus long enough to
watch TV, play videogames or sit still at the
doctor’s office.

Pelham, Fabiano & Massetti,

Well-Established ADHD
Treatments
Stimulant Medications

Behavioral Interventions
Behavioral parent training
Behavioral classroom management
Intensive summer treatment programs

Pelham & Fabiano, 2008

 Medication: Stimulants
 Most well-researched, effective, and commonly
used medication treatment for ADHD.
 Methylphenidate (Ritalin, Concerta, and Metadate)
 Dextroamphetamine (Adderall)

 These medications
reduce ADHD symptoms by:
 Blocking the reuptake of
norepinephrine (NOR) and
dopamine (DOP) and facilitating
their release

 Enhances NOR and DOP

availability in in certain brain
regions: PFC and basal ganglia
 Stimulant Medications
Research has shown that stimulants:
Are highly effective in reducing ADHD symptoms in the
short term
Decrease disruption in the classroom
Increase academic productivity and on-task behavior
Improve teacher ratings of behavior

Different formulations work best for different children

Common side effects: insomnia, decreased appetite

Strattera (atomoxetine)
A non-stimulant alternative that works well for some
children
Has not been studied as long or as intensively as the
stimulants
Smaller effect size relative to the stimulants
Limitations of Stimulant
Treatment
Individual differences in response
Not all children respond (approximately 80%)
Limited impact on domains of functional
impairment
Primary reason for treatment seeking
Does not normalize behavior
Family problems beyond the scope of
medication
No long-term effects established
Long-term use rare
Limited parent/teacher satisfaction
Some families are not willing to try
medication
How do we identify evidence-
based, non-pharmacological
treatments?
“Evidence-based treatment” implies that
studies have been conducted with the
following features:
Careful specification of the target population
Diagnostic, demographic, recruitment, selection
Random assignment to conditions
Comparison could be to placebo but ideally to
established tx
Use of treatment manuals
Ensures reliability of administration and facilitates
replication
Multiple outcome measures with blind raters
Statistically significant differences between
the tx and comparison group at post-tx
Replication, ideally by independent
researchers
Chambless et al., 1996; Silverman &
Hinshaw, 2008
Well-Established
Non-Pharmacological
Treatments
Behavioral parent training
33 well-conducted studies

Behavioral classroom management

45 well-conducted studies

Pelham, Wheeler & Chronis, 1998; Pelham &

Behavioral Treatment
Components
• Psychoeducation about ADHD
• Structure/routines
• Clear rules/expectations
• Attending/rewards
• Planned ignoring
• Effective commands
• Time out/loss of privileges
• Point/token systems
• Daily school-home report card
• Intensive summer treatment programs
Behavioral Treatment
Considerations
Need to address cross-situational impairments
Poor generalization from treatment setting to real-
world
Implement treatments in all settings in which child
shows impairment
School behavior
504 Plan/Individualized Education Plan (IEP)
Academic interventions needed in addition to
behavioral interventions (Raggi & Chronis, 2006)
Environmental contingencies must be delivered
consistently, which is difficult to maintain
Parental psychopathology can interfere with
implementation
Multi-Modal Treatment Study
for ADHD (MTA)
6 sites
579 Children, 7-9 y/o
ADHD, Combined Type
Assigned to 14 months of:
Med management
Intensive Behavior Therapy
Combined treatment
Treatment as Usual in the Community
(TAU)
2/3 received medication
MTA Cooperative Group,
1999
Overall Results
All groups showed reductions in ADHD sx over time
On primary outcome measure (ADHD sx),
medication alone and combined tx did better than
behavioral tx alone and tx as usual (TAU) in the
community
On many measures, combined tx was not
significantly better than medication alone
Only combined tx was better than TAU on
oppositional symptoms, aggression,
depression/anxiety symptoms, social skills, parent-
child relationship, and reading achievement
Higher medication doses were needed in the
medication only group relative to the combined
treatment group

MTA Cooperative Group,

1999
Combined Treatment was
superior
in terms of:
Parent and teacher satisfaction with
treatment
Normalization of child behavior
Improvements in functional outcomes
Family interactions
Peer relationships
Academic functioning

Connors et al., 2001; Hinshaw et al.,

2000; Pelham et al., 2004; Swanson et
MTA 6-8 Year Follow-Up
Original treatment assignment not associated with any
of the 24 outcomes 6-8 yrs later
ADHD symptom trajectory in the first 3 years predicted
55% of the outcomes
Children with the best initial tx response and most favorable
clinical presentation at baseline fared best over time
Children with behavioral and sociodemographic advantage,
with the best response to any tx, had the best long-term
prognosis
As a group, children with combined-type ADHD exhibit
significant impairment in adolescence (on 9 of 21
measures)
This suggests a need for sustained treatment over the
long term

Molina et al., 2009

Practice Parameters
American Medical Association (AMA)
“encourages the use of individualized therapeutic
approaches…which may include pharmacotherapy,
psychoeducation, behavioral therapy, school-based and other
environmental interventions, and psychotherapy, as indicated
by clinical circumstances and family preferences.” (p.1106)”

American Academy of Pediatrics (AAP)

“the clinician should recommend medication (strength of
evidence: good) and/or behavior therapy (strength of
evidence: fair), as appropriate, to improve target outcomes in
children with ADHD (strength of recommendation: strong)”
(p. 1037)
American Academy of Child &
Adolescent Psychiatry (AACAP)
Treatment “may consist of pharmacological and/or
behavior therapy” but that “pharmacological
intervention for ADHD is more effective than a
behavioral treatment alone” and that “behavioral
intervention alone might be recommended as an initial
treatment if the patient’s ADHD symptoms are mild
with minimal impairment…or parents reject
medication” (p.902)…”if a child has a robust response
and shows normative functioning…then
psychopharmacological treatment alone is
satisfactory” (p. 912)…
If the child does not show a robust response to all FDA-
approved medications, the clinician should “consider
behavior therapy and/or the use of medications not
approved by the FDA for treatment of ADHD” (p.907)
Summary
1. ADHD is a highly prevalent, brain-based disorder which
is associated with lifelong impairment in functioning
2. Environmental factors can contribute to the
expression, severity, course, and comorbid conditions
3. Long-term developmental outcomes for individuals
with ADHD can include serious substance abuse,
chronic criminality, depression and suicide
4. Stimulant medications and behavior therapy are
currently the only established evidence-based
treatments for ADHD
5. Combined behavioral-pharmacological treatment has
the greatest impact on functional outcomes, is
preferred by parents and teachers, and is most likely
to result in normalization of behavior