CU ADHD

Attention deficit hyperactivity disorder – ADHDAttention deficit hyperactivity disorder – ADHD
Dr Elspeth Webb
Attention deficit hyperactivity disorder
ADHD

 Over-activity & Impulsiveness
&/or
 Inattentiveness/distractibility
Pervasive: in all contexts
Early onset
What is ADHD?

 A condition comprising a degree of impulsivity & hyperactivity and/or inattention
to a point that is disruptive and inappropriate for developmental level
 Pervasive & present for at least 6 months
 Two sub types: Inattentive and Hyperactive/impulsive
 Hyperactive/impulsive subtype also referred to as hyperactivity or hyperkinetic
disorder
But what is “inappropriate”? - this is a condition that is, in part,But what is “inappropriate”? - this is a condition that is, in part, sociallysocially
constructed.constructed.
p.s. DSM-V -- which is currently in the planning stages and is expected to be published in 2013 -- will bring
changes, perhaps by treating these as two separate disorders, rather than subtypes of the same condition
Definitions: ADHD (DSM-IV TR)

 1/10
 1/20
 1/50
 1/100
 1/200
Have a guess
Prevalence: – how common is it?

 UK/USA/Australia/Scandinavia
• 5% for total (mixed or just hyperactive/impulsive or just inattentive)
• About 3% for hyperactivity ( i.e. mixed or just hyperactive impulsive
• 1% for mixed ICD10 (hyperactive & inattentive)
Politics: Administrative vs. real prevalence
USA : administrative prevalence greater than real (Driven by litigation)
UK: real prevalence less than administrative
2001
administrative = 20,000
real = 70,000
Prevalence

 Highly heritable.
• ? evolutionary advantage
 neurological damage
Not bad parents:- c.f. Kanner’s original
description of autism, (will return to this)
Aetiology:- what causes it?

Attention
Executive function
Neuro-psychological basis

 detecting a stimulus
 encoding or processing information
 sustaining attention to relevant stimulus whilst
filtering out others
 shifting attention when appropriate
 inhibiting involuntary shifting (distractibility)
 organising a response to incoming information
Attention

 Studies suggest that the attentional problem is not at the level of
“going in”, but at the level of stimuli processing
 So children with ADHD do not have difficulties with receiving
information, but with subsequent processing and selection of
appropriate response
 i.e. it’s not that they don’t pay attention, but they act as if they
don’t pay attention, because they do not respond appropriately.
Attention in ADHD

 A set of brain functions unique to humans, concerned with self
regulation, sequencing of behaviour, flexibility, response inhibition,
planning and organisation of behaviour
 Allows us to think about ourselves, what may happen in the future, and
how we can influence it
Executive function

3 components are limited:
– working memory - ‘open file’ on the hard drive
• non-verbal working memory
• verbal working memory
– self-regulation
– reconstitution; using working memory to plan and organise and
reflect
As children with ADHD get older and enter adolescence these are the areas of
function in which they get more different from their peers, precisely when we start
to ask more of them in these areas
Executive function in ADHD:
deficits in inhibition

 Any intellectual activity is much more difficult for these children
both in getting started and in sustaining that activity
 They have to put in far more effort for any particular task
compared to their peers – everything is at least twice as hard
 This is very tiring
 They will therefore do anything to avoid intellectual effort
because it is so hard
Effort avoidance

 Some diseases are “all-or-nothing”, e.g. influenza
 Others are “dimensional” in that the disorder or disease fades into normality
ADHD “normal”
For children on the cusp, it is difficult to distinguish disorder from personality.
To some extent it is a socially constructed diagnosis which is a disorder “here and
now” because it is hard to accept that 5% of all children are “abnormal”
ADHD as a dimensional disorder

 Clinical interview
 Rating scales
 Observation (preferably not in clinic)
 Cognitive assessment
– learning difficulties/unrecognised superior skills
 Psychological evaluation
Multidisciplinary/multiagency
Assessment - all

 hearing
 chromosomes if associated with dev. Delay
 EEG ( if suggestion of epilepsy)
 Occupational Therapy if child has associated co-ordination difficulties
 Speech and Language Assessment
Additional assessment

 Linked
 Co-ordination problems
 Speech and language disorder
 Autistic spectrum
 Tourette syndrome
 Coincidental
 Hearing impairment
 Pseudo link
 Oppositional/defiant disorder and Conduct disorder
Co-morbidity/overlap

abuse/violence/poor parenting
inappropriate classroom management
Contributory/exacerbating factors

 Genotype – our genetic inheritance and makeup – what our DNA says, which
genes we carry
 Phenotype – how our genotype is expressed . E.g. gene for cystic fibrosis results
in a phenotype that involves chest infections, digestive problems, infertility in
males. Benes for ADHD result in ADHD phenotype
 Phenocopy. – when another set of factors, usually environmental, result in a set
of signs symptoms and behaviours very similar to a genetic phenotype. Most
famous example – Romanian orphans and autism
 ADHD phenocopies – violence, abuse, and anxiety
Phenocopy of ADHD

 The infant human brain at birth is very immature in comparison to other mammals
 ++ growth, development, cellular interconnections and cell culling in the first year
or two
 Direction and pattern of these processes is partly genetically, partly
environmentally driven
 Our children’s brains are sculpted irreversibly by their early (and perhaps even
prenatal) life experiences
 Children exposed to violence are hard wired to be anxious, distractible, highly
aroused in situations of conflict, and impulsively aggressive – this is largely
irreversible
Impact of early violence on brain
development

 Children living with violence are anxious, highly aroused, and have
raised cortisone
 Although for older children this does not have the same long term
impact on brain structure, fearful highly aroused children are:
 distractible/inattentive/overactive/impulsive
 How? - Weinstein et al, 2000:
 difficulty concentrating caused by re-experiencing trauma (PTSD)
 hyperactivity caused by hyper-vigilance
Impact of current violence on behaviour

 Higher prevalence of violence in low income families,
including domestic abuse (DA) and child abuse
Poverty associated with other risk factors for “ADHD”
 LBW and prematurity
 Intrauterine exposure to illegal drugs and alcohol (itself
strongly linked to DA)
Demography of violence

Child health outcomes – reduction in health problems if all children had
outcomes of wealthiest 5th
(courtesy of Nick Spencer)
Child health outcomes % reduction
Birth weight*: <2500g
<1500g
Disability**:
Cerebral palsy
Intellectual disability
Psychological problems***:
Emotional disorders
Conduct disorders
Hyperkinetic disorders
Registration for Child Abuse**
30%
32%
30%
39%
34%
59%
54%
53%
* Based on 210,000 births in the West Midlands region of the UK, 1991-‘93
** Based on data on 150,000 births in the West Sussex region of the UK, 1983-2001
***Based on the UK survey of mental health among 5-15 year olds (Meltzer et al 2000)

Abuse
ADHD
1. Neurocognitive effects
2. Anxiety/disordered attachment
Overactivity
Distractability
Impulsivity
Increases
risk ?
exacerbates
Conduct
disorder
co-morbid with
In care
•? hard to place
•? breakdown of placement
mimics
causal
associated
with
Parent with
ADHD
In summary:
Relationshipbetween ADHD and child maltreatment

Problems for diagnosis,
management, and research
Maltreatment and ADHD phenocopies

 These children can be clinically indistinguishable from those with genetic
ADHD (although some differences from population studies)
 In both cases symptoms may be lessened by treatment with stimulants
 This poses not just a diagnostic dilemma but an ethical one too in
therapeutics
 It raises doubts about the validity of much research – what is being
studied?
Challenges

Medication
 Stimulants (short acting or slow release)
 Others
Behavioural
Psychological
Management of hyperactivity

Short term effects
- improves attention/decreases impulsivity/decreases over-
activity
Consistently shown in research
Effectiveness of stimulants

 Dose related: decreased appetite, insomnia, irritability, anxiety, abdominal pain,
headaches, mood disturbance.
 Tics
 Behavioural rebound
 Socialisation: some negative effects on pro-social behaviours
 Rare: psychosis, obsessive/compulsive disorder (OCD), cardiomyopathy, effects
on blood count.
“My friends say I’m boring on the tablet and I don’t have any ideas”
Adverse effects

The decision to put a child on stimulants is not an easy one for parents, clinicians,
or children.
Everyone must feel comfortable with the decision to treat or continue treatment
No child should be coerced to take stimulants
Medication must always be backed up by appropriate parenting and school
strategies.
Improvement on stimulants should not be used as an excuse to remove
recognition of special educational needs - their ADHD remains.

Behavioural
Psychological
 Depressingly there is a very poor evidence base for either in that
neither achieve much without stimulants
But parenting education helpful with stimulants – not
because “poor” parents, but because it’s much harder
to be a parent to a child with ADHD, and often requires
counter-intuitive responses.
Management approaches

3 groups
Group 1:- do well and not distinguishable from matched normal controls
in adulthood - 30%
Group 2:- continue to have significant problems with concentration,
impulsivity and social interaction - 50% (but can these be a strength –
stand up comics)
Group 3:- significant psychiatric or antisocial problems or both - 10%
(severe depression, bipolar affective disorder, suicide, drug/alcohol abuse;
delinquency leading to serious crime)
Overall an increased risk of school failure, unemployment, poverty,
imprisonment
Prognosis

Child
Family
Treatment
Schools
Factors predicting outcome

IQ - lower the IQ poorer the outcome
Inattention – underachieve academicallyacademically
Hyperactive - poor socialsocial outcome
Poor social skills - greater risk of CD and substance abuse
Co-morbidity - poorer outcome
Child

Poor parental mental health, poor mother /child relationship -
poor outcome
Parenting style
 consistency and firmness - good
 inconsistent/permissive/restrictive/punitive – bad
SE status - low SE status possibly associated with persistence of
ADHD into adolescence
Family

 Medication alone - no difference in outcome, but medication and ‘good
family’ - good outcome
 In general medication in childhood does not seem to affect adult
outcome except some evidence for improved social skills and self-esteem.
 But this research may be invalid in that more severely affected children
are medicated
Treatment

 There is very little research on looking at educational
interventions and long term outcomes, whether
1. Classroom strategies
2. Educational approaches
 Inclusion vs. specialised
 Adapting teaching to how these children learn
 How do they learn – not even much on that!
Schools

http://www.acer.edu.au/documents/Kos_Prim
aryTeachers-ADHAD.pdf
“The classroom may represent one of the most
difficult places for children with ADHD, most
probably because this setting requires children
to engage in behaviours that are contrary to the
core symptoms of the disorder”

 Increases anxiety
 Makes symptoms worse
 Pushes children further along the dimension
 Reduces self esteem
 Contributes in the longer term to alienation, conduct disorder,
delinquency
Poor school experience

“….programmes on television in the UK exploring ADHD ……..ignored
children’s rights in that they were exploitive, contravened a child’s right to
privacy, and were certainly not in the best interests of the children involved.
They provided inaccurate presentations of ADHD with most of the
cases presented being conduct disordered children in very disadvantaged
circumstances. ….(The programmes) had a focus on these children not as in
distress, but as ….. bad. ”
Webb E. Health services: who are the best advocates for children?
Archives of Disease in Childhood 2002;87:175-177
ADHD & the Media

-a badly behaved,
impulsively
aggressive, morally
deficient child
ADHD media stereotype
But children with ADHD can
be impulsively anything:-
brave, empathetic, witty,
cautious, clever, unkind,
generous, reserved,
oppositional, adventurous,
imaginative, energetic,
creative, destructive, etc..
Don’t stereotype or you
will miss cases
Don’t confuse personality
with disorder

Summary
 ADHD is common, but under-diagnosed in the UK
 1o
schools: a major role in recognising affected children
 Affected children form a highly heterogeneous population: each
child with ADHD requires a tailored strategy
 Stimulants are effective in management (but they are not
everything)
 The severity of ADHD, and adult outcomes, are strongly affected by
how a child is treated by the adults in his/her life
 Educational practice underpinned by poor research and
evidence base
 Educational research is possibly not asking the right questions

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