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ADHD PART 2

Correlates and Causes

Executive Functions: higher-order mental processes that underlie a child’s capacity to regulate thought, emotion, and behavior

 Cognitive: working memory, planning, organization

 Motor: response inhibition, response speed

 Emotion: self-regulation of emotional arousal

Executive Function Deficits

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Examples of Impaired Executive Functions in ADHD

Intellectual and Academic Deficits

 Most children with ADHD have at least normal intelligence  Score 5-9 points lower on IQ tests

 Difficulty lies in applying intelligence to tests and to everyday life situations

 Impaired academic functioning

 Children with ADHD frequently have lower productivity, grades, and scores on achievement tests

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 Learning disorders are common for children with ADHD  Problem areas: reading, spelling,

and math

 Distorted self-perceptions  Self-esteem in children with ADHD

may vary with the subtype of ADHD  ADHD-I: Low self-esteem

 ADHD-HI: Positive bias (exaggeration of one’s competence)

Cognitive Deficits: Learning Disorders and Self-Perceptions

 30-60% have speech or language problems

 Impairments in pragmatic language skills  Difficulty understanding others’

speech

 Excessive and loud talking

 Frequent shifts and interruptions in conversation

 Tangential stories

Speech and Language Impairments

Teacher: “How old was the boy?” Child: “Grade one…seven and…so she..um.. we went on it and he was… he got pushed a little bit on the swing you know and then…pow…down he falls and then we called his brother over…he was really really rough and…he was really light too and um he went on the swing and…and my friend you know she put it in again and we said come on and I don’t know I …forget the boy’s name…but we…told him to come over and sit on the swing and…so he came over and sat on the swing…”

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 30-50% of children with ADHD display motor coordination difficulties  Clumsiness, poor performance in sports,

or poor handwriting

 Tic disorders occur in 20% of children with ADHD

 Sudden, repetitive, non-rhythmic motor movements or sounds such as eye blinking, facial grimacing, throat clearing, and grunting

Developmental Coordination and Tic Disorders

 Physical health problems  Asthma, bedwetting, dental issues,

obesity, eating problems

 Sleep problems  High-rates of disordered sleep

 Sleep apnea and sleep reduction kids mimics ADHD

 Stimulants can interfere with sleep

 Reduced life expectancy/higher medical costs  Accident prone

 Cigarette smoking, substance use disorders, traffic accidents, risky sexual behaviors

Health Issues

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 Family problems include:  Negativity (parent and child)

 Sibling conflict

 Maternal depression

 Paternal antisocial behavior

 Marital conflict

 Transactional influence

 Many family problems may be driven by co-occurring conduct problems

Social Problems: Family

Social Problems: Peers

 Often unable to apply their social understanding in social situations  Can be bothersome, stubborn, socially awkward, and socially

insensitive; can have trouble following rules while playing games

 Often disliked and rejected by peers or have few friends

 Maintaining friends difficult

 Type Differences  ADHD-PI: experience peer neglect

 ADD-HI: experience peer rejection

 Positive friendships may buffer negative outcomes

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 Up to 80% have a co-occurring psychological disorder

 Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)

 About 50% (mostly boys) also meet criteria for ODD

 About 30% eventually develop conduct disorder (CD)

 Hyperactivity increases the odds of developing ODD/CD 10-fold

 Anxiety (about 25% of children with ADHD)

 Social and academic impairment

 Depression

 20-30% of children with ADHD experience depression

 Being diagnosed with ADHD between ages 4 to 6 is a risk factor for future depression and suicidal behavior

Comorbid Psychopathology

What Causes ADHD?

 We know what doesn't cause ADHD  Sugar, food additives

 Allergies

 Exposure to lead

 Bad parenting

 What does cause ADHD? ….  Different causal factors might exist for different ADHD

presentations

 Different causal factors might interact with each other

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 ADHD runs in families across generations

 Adoption studies: ADHD rates 3 times higher in biological than adoptive parents of kids with ADHD

 Twin studies: 75% heritability estimates for hyperactive-impulsive and inattentive behaviors

 65% concordance rates for identical twins (vs. < 34% for fraternal twins)

 Specific genes implicated

 Dopamine transporter gene (DAT1)

 Dopamine receptor gene (DRD4)  But only in the case of environmental risk

(i.e. maternal smoking)

Genetic Influences on ADHD

 Factors that compromise development of the nervous system before/after birth related to later development of ADHD  Pregnancy and birth complications

 Low birth weight

 Malnutrition

 Early neurological insult or trauma

 Maternal substance use

 Maternal smoking (especially in combination with genetic risk)

Pregnancy, Birth, and Early Development

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 Many children with ADHD show Executive Functioning (EF) deficits  Particularly in processes involved in regulating

one’s attention, behavior and emotions

 Could be related to alterations in PFC  Children with ADHD have smaller total and right

cerebral cortex volumes (by 3-4%)

 But not everyone with ADHD has EF deficits

Promising Theory 1: Executive Functioning Deficits

Promising Theory 2: Reward/Motivation Deficits

 Perform similarly to other children when continuous reward

 Difficulty motivating themselves and performing well when rewards are unavailable or delayed

 Related to abnormalities in the frontostriatal circuitry of the brain

 Includes prefrontal cortex and basal ganglia

 Areas rich in dopamine receptors

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 EEG shows under-activation of PFC in cognitive tasks

 fMRI studies of reward:  Increased striatal response

 Decreased activation of prefrontal regions and pathways connecting them to striatum in reward tasks

 How could this translate to behavioral need for higher reward?

Frontostriatal Circuitry and ADHD: Functional Abnormalities

green= cortex more active

Promising Theory 3: Arousal Level Deficits

 Diminished arousal on psychophysiology tests  Lower galvanic skin response

 Decreased heart-rate

 But not reliable enough for diagnosis

 Hyperactivity–impulsivity may reflect an effort to maintain an optimal level of arousal by excessive self-stimulation

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 Importance of family influences

 Family influences may exacerbate ADHD symptoms or lead to a greater severity of symptoms

 Parents may have ADHD themselves

 Family conflict is likely related to the presence, persistence, or later emergence of associated oppositional and conduct disorder

Family Influences

Where do we go from here?