Overview
This lecture covers Attention-Deficit/Hyperactivity Disorder (ADHD, Aroreretini) in children: its three DSM-V presentations, diagnostic criteria, prevalence, risk factors, comorbidities and associated problems, sleep and physical health impacts, sex differences, assessment approach, and treatment (medication and parent training interventions), closing with five key take-home messages. Although the lecture title also names Oppositional Defiant Disorder and Conduct Disorder, this deck only mentions them as associated/comorbid challenging behaviours rather than covering their own criteria in detail.
ADHD: Presentation and Diagnostic Criteria
Three DSM-V presentations of ADHD:
- Inattentive
- Hyperactive-impulsive
- Combined
Core definition: a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.
Diagnostic criteria:
- Symptom count required varies with age: 6 or more symptoms in each category up to age 16; 5 or more from age 17
- Symptoms present for at least 6 months
- Symptoms inappropriate for developmental level
- Longitudinal criterion: hyperactive-impulsive or inattentive symptoms causing impairment before age 12 (previously age 7)
- Cross-situational criterion: impairment from symptoms present in two or more settings
- Pervasiveness and severity criterion: clear evidence of clinically significant impairment in social, academic, or occupational functioning
- Exclusion criterion: symptoms do not occur during Pervasive Developmental Disorder or psychotic disorders, and are not better accounted for by another disorder (e.g. mood, anxiety, dissociative disorder)
Inattention symptoms:
- Fails to attend to details, careless mistakes
- Difficulty sustaining attention in tasks or play
- Often doesn’t seem to be listening when spoken to
- Doesn’t follow through on instructions, fails to finish work/duties
- Difficulty organising tasks or activities
- Avoids/dislikes sustained mental effort
- Often loses things
- Easily distracted by irrelevant stimuli
- Often forgetful
Hyperactivity and impulsivity symptoms:
- Fidgets, squirms in seat
- Leaves seat in classroom
- Runs about, climbs excessively
- “On the go”, acts as if driven by a motor
- Unable to play quietly
- Talks excessively
- Blurts out answers, difficulty waiting turn
- Interrupts
Clinical illustrations:
- Teresa (10, inattentive presentation): previously kept up but now falling behind; slow to start and rarely finishes work; loses things and forgets equipment; messy/disorganised work with trouble checking it; misses instructions without asking for help; described as “away with the fairies”/“somewhere else”; new headaches and frequent sickness with missed school days; loses herself in reading and does not respond to her name.
- Thomas (10, hyperactive-impulsive presentation): frequent trouble at school and rule-breaking, including breaking things; calls out ahead of turn and rushes into tasks without understanding them; restless in his chair and on the mat, struggles to sit still, easily distracted and distracts others; little fear with a number of injuries; few friends, loud and boisterous; frequent playground arguments; feels unfairly picked on.
Prevalence and Risk Factors
Prevalence:
- Worldwide: 5%
- Adults: 2-3%
- New Zealand: 1 in 20 (roughly one child per classroom)
- Sex ratio: males:females 2:1 in childhood, narrowing to 1:1 in adulthood
- Cultural differences: diagnosis depends on the degree of difference from culturally accepted standards
Risk factors:
- Genetic: 60% risk of ADHD in a child if a parent has ADHD; 3x as likely if a biological (versus adoptive) parent has ADHD; involvement of dopamine regulation genes
- Pregnancy, birth and early development: birth complications, maternal stress, and toxin exposure create a general risk for the child developing later problems
- Family influences: family interactions may exacerbate symptoms; family problems may result from the difficulty of dealing with ADHD symptoms; family conflict is related to the presence of oppositional problems
The "Brain function" slide is a section-header image (a generic head/brain outline) with no labelled structures or specific claims; the transcript records no further content for it.
Comorbidities and Associated Problems
Comorbidity rates:
- ADHD only: 20%
- Anxiety: 25%
- Mood disorders: 20-30%
- Oppositional problems: 50%
- ASD: 50% of those with ASD also have ADHD
- Developmental coordination difficulties: 30-50%
Associated problems:
- Tourette’s disorder (uncontrollable motor and vocal tics); ADHD precedes Tourette’s
- Autism spectrum disorder (debated whether inherent to the ASD diagnosis or a true comorbidity)
- Trauma/maltreatment: cross-sectional and longitudinal studies predict relationships between maltreatment types and ADHD; open questions about the role of attachment, parenting, and stress
- Non-suicidal self-injury (NSSI)
- Suicide attempts
- Substance misuse
- Challenging behaviour: Conduct Disorder, Oppositional Defiant Disorder, Intermittent Explosive Disorder
Cognitive problems: academic underachievement, school failure, unemployment; substantially poorer language skill across expressive, receptive and pragmatic domains; effects on application of intelligence and executive function.
Emotional and social problems: difficulty reading others’ emotional cues and modulating responses; reduced emotion regulation (mood problems, irritability); peer rejection, which can occur quickly; family stress and discord; more likely to become hyperaroused in the presence of reward and frustrated when reward is absent.
Sleep and Physical Health
Sleep:
- Up to 70% of children with ADHD experience sleep problems, versus 20-30% in the general population
- Sleep problems are associated with worse ADHD symptoms, poorer quality of life, and other mental health problems
- Up to 20% of adolescents with ADHD report sleep problems (fewer than 7 hours/night), daytime sleepiness, and falling asleep in class, versus 10% of adolescents without ADHD
- Unclear whether treating sleep problems improves ADHD symptoms
Physical problems:
- Motor coordination and development difficulties can lead to accidental injury (falls, burns), driving accidents, and risk-taking behaviour, raising the risk of acquired brain injury
- Other health problems: smoking, obesity, hypertension
Females and ADHD
- More males than females are diagnosed, but the ratio narrows by adulthood
- Most research has been conducted with boys and men, but research with girls shows high levels of real-world problems across time
- Girls show worse outcomes than boys with respect to antisocial behaviour and peer rejection
- Heightened risk of eating disorders, interpartner violence, self-harm, suicidal behaviour, maltreatment, and unplanned pregnancy
Assessment
- Requires specialist assessment
- Consider strengths and difficulties, and fit with environment and expectations
- CBDS approach [slide does not fully elaborate the acronym]
- Consider common comorbidities and assess/screen for those
Fuller assessment components:
- Problem description: specific examples, frequency, contexts
- Functional analysis: antecedents, behaviour, consequences (the ABCs)
- Identifying reinforcers and their dynamics
- Family styles
- Identifying possible modelling/learning influences
- Child characteristics
- Caregiver characteristics
- Environmental/contextual factors
- Comorbidity
Treatment
General principles:
- Medication benefits cease once medication is not taken or is metabolised
- Medication benefits are not exclusive to ADHD, carrying a risk of misuse/abuse
- Important to build skills as well as control symptoms
- Finding the right dose and titration can take time
Ranked effectiveness (Hinshaw et al., 2015): Medication + Behavioural therapy > Medication alone > Behavioural therapy alone > Control (no treatment).
Effects of medication:
- Compliance with stimulant medication is quite poor, especially in adolescence
- Fewer than 10% of children with ADHD persist with long-term medication treatment
- Parents often prefer non-medication approaches
- Side effects: irritability, loss of appetite, insomnia
- Longer-term effects: social withdrawal, blunting, reduced weight and height gain, increased blood pressure and heart rate (reduced height persists longer term with medication use)
Common foci of effective parent training interventions: the parent-child relationship/child behaviour sits at the centre, shaped by three inputs: reinforcement processes (behavioural/systems), family structure (systems), and attributions (cognitive).
Summary: Five Key Messages
- ADHD is a genuine medical condition
- Only comprehensive assessment can distinguish ADHD from other mental health conditions, chaotic home environments, or after-effects of maltreatment; this is rarely done, and psychologists have an important role
- Medications are effective in reducing core symptoms in the short term; most genuine gains come from combining medication with skill-building approaches
- Rates of ADHD diagnosis and medication use vary dramatically, related to family and cultural values, demands for achievement, and other factors
- Misdiagnosis is common (both false positive and false negative)
The transcript flags that this slide's heading ("Five Key Messages") and bullet structure are ambiguous: the first bullet ("Genuine medical condition") reads as a heading for the second point, so it is unclear whether five or four distinct messages are intended. Listed above as it appears on the slide.
Self-test
- List the four DSM-V criterion categories used to diagnose ADHD, beyond the symptom-count and duration requirements.
- Distinguish the three DSM-V presentations of ADHD.
- Describe how the number of symptoms required for an ADHD diagnosis changes across the lifespan.
- List four symptoms of inattention.
- List four symptoms of hyperactivity-impulsivity.
- Teresa’s case vignette illustrates which ADHD presentation? Give three supporting features.
- Thomas’s case vignette illustrates which ADHD presentation? Give three supporting features.
- State the worldwide prevalence of ADHD and how it compares in adults and in New Zealand.
- Describe how the male:female ratio of ADHD changes from childhood to adulthood.
- List three genetic risk factors for ADHD.
- Distinguish two ways family influences can relate to ADHD.
- List four comorbidities of ADHD with their approximate rates.
- Describe the relationship between ADHD and sleep problems, including rates in children and adolescents.
- What physical health risks are associated with ADHD?
- Describe how outcomes differ for girls with ADHD compared to boys.
- Rank the four treatment approaches for ADHD by effectiveness, according to Hinshaw et al. (2015).
- List three side effects of stimulant medication for ADHD, distinguishing short-term from longer-term effects.
- Describe the three factors that, together with the parent-child relationship, form the foci of effective parent training interventions.
- Explain how ADHD could plausibly account for a child presenting with poor school performance, sleep problems, and peer rejection, drawing on the risk factor, sleep and associated-problems content.
Answers
Reveal answers
- Longitudinal criterion (impairment before age 12), cross-situational criterion (impairment in two or more settings), pervasiveness and severity criterion (clinically significant impairment in social, academic or occupational functioning), and exclusion criterion (not better accounted for by PDD, psychotic disorders, or another disorder such as mood, anxiety or dissociative disorder).
- Inattentive (attention/organisation difficulties without marked hyperactivity), hyperactive-impulsive (motor restlessness and impulsive behaviour without marked inattention), and combined (both symptom sets present).
- Six or more symptoms in each category are required up to age 16; from age 17, five or more are required in each category.
- Any four of: fails to attend to details/careless mistakes, difficulty sustaining attention, doesn’t seem to listen, doesn’t follow through/finish tasks, difficulty organising, avoids sustained mental effort, often loses things, easily distracted, often forgetful.
- Any four of: fidgets/squirms, leaves seat in classroom, runs/climbs excessively, “on the go”/driven by a motor, unable to play quietly, talks excessively, blurts out answers/difficulty waiting turn, interrupts.
- Inattentive presentation. Supporting features include: falling behind despite previously keeping up, slow to start and rarely finishing work, losing things/forgetting equipment, messy/disorganised work, missing instructions, being “away with the fairies”, or losing herself in reading and not responding to her name.
- Hyperactive-impulsive presentation. Supporting features include: calling out ahead of turn, rushing into tasks without understanding them, restlessness and difficulty sitting still, being easily distracted and distracting others, little fear with frequent injuries, or frequent rule-breaking/trouble at school.
- Worldwide prevalence is 5%; in adults it is 2-3%; in New Zealand it is 1 in 20 (about one child per classroom).
- The male:female ratio is 2:1 in childhood, narrowing to 1:1 in adulthood.
- Any three of: 60% risk to a child if a parent has ADHD, 3x greater likelihood if a biological (versus adoptive) parent has ADHD, involvement of dopamine regulation genes.
- Family interactions may exacerbate ADHD symptoms (family as a contributing factor), and family problems may instead result from the difficulty of dealing with ADHD symptoms (family difficulty as a consequence); family conflict is also related to the presence of oppositional problems.
- Any four of: ADHD only 20%, anxiety 25%, mood disorders 20-30%, oppositional problems 50%, ASD (50% of those with ASD have ADHD), developmental coordination difficulties 30-50%.
- Up to 70% of children with ADHD have sleep problems versus 20-30% of the general population, and this is associated with worse ADHD symptoms, poorer quality of life and other mental health problems. Up to 20% of adolescents with ADHD report sleep problems (<7 hours/night), daytime sleepiness and falling asleep in class, versus 10% of adolescents without ADHD. It is unclear whether treating sleep improves ADHD symptoms.
- Motor coordination and development difficulties raising the risk of accidental injury (falls, burns), driving accidents and risk-taking behaviour (with greater risk of acquired brain injury), plus other health problems such as smoking, obesity and hypertension.
- Girls have worse outcomes than boys with respect to antisocial behaviour and peer rejection, and face heightened risk of eating disorders, interpartner violence, self-harm, suicidal behaviour, maltreatment, and unplanned pregnancy, despite most research historically being conducted on boys and men.
- Medication + Behavioural therapy > Medication alone > Behavioural therapy alone > Control (no treatment).
- Short-term: irritability, loss of appetite, insomnia. Longer-term: social withdrawal, blunting, reduced weight and height gain, increased blood pressure and heart rate (with reduced height persisting longer term).
- Reinforcement processes (behavioural/systems), family structure (systems), and attributions (cognitive) - all feeding into the central parent-child relationship/child behaviour.
- Poor school performance can arise from ADHD’s core inattentive/organisational symptoms and associated cognitive problems (academic underachievement, poorer language skill, executive function difficulties); sleep problems occur in up to 70% of children with ADHD and are linked to worse symptoms and quality of life, which could further impair school functioning; peer rejection is a documented emotional/social associated problem of ADHD, arising quickly and linked to difficulty reading others’ emotional cues and modulating responses. Together these reflect the multi-domain impact (cognitive, emotional/social, physical) that ADHD can have beyond core symptoms.