Course:KIN366/ConceptLibrary/ADHD

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KIN 366
Section:
Instructor: DR. Shannon S.D. Bredin
Email: shannon.bredin@ubc.ca
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Important Course Pages
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Course Discussion


Attention Deficit Hyperactivity Disorder (ADHD) is a psychiatric disorder of the neurodevelopmental type characterized by a pattern of behavior, present in multiple settings (school and home), that can result in performance issues in social, educational, or work settings. The DSM-IV symptoms are divided into three categories of inattention, hyperactivity and impulsivity.[1] ADHD affects around 5.29% of the worldwide population[2] and are more likely to affect male than female.[3]

Diagnosis and Symptoms

ICD-10

The International Classification of Mental and Behavioral Disorders (ICD-10) talks about ADHD as hyperkinetic disorder (HKD), and is more widely used internationally by the World Health Organization and European clinical guidelines.[4]

DSM-V

The American Psychiatric Association's Diagnostic and Statistical Manual, Fifth edition (DSM-5) is the standard diagnostic method more frequently used in North America. To be diagnosed with ADHD under the DMS-V one must exhibit multiple symptoms in at least one of the two categories. The two categories are the Inattention category and the other being the Hyperactivity and impulsivity category. Details for both diagnostic criterions can be found here. Once diagnosed, subject will be placed in one of three kinds (presentations) of ADHD:[5]

  • Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
  • Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
  • Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

General Symptoms

Although the ICD-10 and DMS-V each have their own specific criteria for the diagnosis of ADHD/Hyperkinetic disorder, the general Symptoms include but are not limited to:[6][7]

  • Lack of attention for detail
  • Having trouble holding attention on tasks or activities
  • Easily distracted
  • Inability to listen when spoken to
  • Has trouble with organization
  • Often avoids dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
  • Excessive fidgeting
  • Often leaves seat in situations when remaining seated is expected
  • Has difficulty playing quietly
  • Often has trouble waiting his/her turn
  • Often interrupts of intrudes on others (e.g in conversations)
  • Onset at an early age as young as 4 years of age to as old as 12 years of age
  • Symptoms persists for over 6 months
  • IQ above 50

It is important to note that the above symptoms are only used for reference and does not enable one to diagnose ADHD on their own. Please consult a certified professional for an actual diagnosis

Possible Causes

The exact cause of ADHD has yet to be identified; however, studies have shown that prenatal exposure, environmental factors, genetic factors, and diet have all been correlated in the development of ADHD.[8][9]

Genetics

There is quite an abundance of research exploring the genetic contributions of ADHD. A study has shown that relatives of ADHD patients are more likely to have ADHD when compared to control group.[10][11] Twin studies showed heritability of attentional problems and hyperactive/impulsive behavior ranged from 80%-88%.[12][13]

Psychosocial Adversity

Low parental education, social class, poverty, bullying/peer victimization, negative parenting, maltreatment and family discord are associated with ADHD.[14]

  • Substance Abuse

Maternal smoking during pregnancy or environmental exposure to cigarette smoke has been found to be associated with increased risk of ADHD.[15] A recent review from case-controlled studies showed a twofold likelihood for ADHD in individuals whose mothers smoked during pregnancy.[16] Alcohol consumption during pregnancy has also been correlated with increased risk of ADHD.[17] Alcohol abuse also plays an environmental role as it increases the likelihood of family discord, maltreatment, and negative parenting.

Biological Adversity

A study have shown correlation between children exposed to lead with increased risk of ADHD.[18][19] Contradicting studies on lead exposure commented that the bulk of children with ADHD do not show lead contamination, and many children with high lead exposure do not exhibit symptoms of ADHD.[20] There is the idea that excessive sugar intake seems to be the culprit for hyperactivity, which was falsified in various systematic reviews.[21][22] A systematic review showed that food additives did not contribute to ADHD[23], however another study conducted on children 3 years and 8 to 9 years of age concluded that certain food additives (Artificial colours and/or a sodium benzoate preservative) in diet resulted in an increase in hyperactivity in this study group.[24]

Management and Treatments

Treatment for ADHD can be in the form of medication, psychotherapy (behavioural therapy) or a combination of the two. Jensen et al (2001) found that the “gold standard” treatment would be a combination of medication and behavioral therapy, but noted that the addition of behavioral therapy only reduced symptoms by a small but statistically significant amount. The reason for the seemingly lack of potency in behavioral therapy is attributed to the lack of measuring power and should not be seen as the impotency of the treatment method.[25] It is also noted that since up to 30% of children do not respond to stimulant therapy, the study of behavioral and psychosocial therapy will play an important role in treatment of that population.[26]

Medication

Stimulants are the most common pharmacological treatment for ADHD. Stimulants used for ADHD treatment include methylphenidate (Ritalin) amphetamine (Dexedrine, Adderall) methamphetamine (Desoxyn) and pemoline (Cylert), with methylphenidate and amphetamine being the most commonly prescribed. Although it may seem counterintuitive to treat hyperactivity with a stimulant, stimulants activate brain circuits that support attention and focused behavior, thus reducing hyperactivity.[27] Studies have shown that 70%-90% of respond to at least one type of stimulant without adverse response. It is also important to try out the different types of stimulant as some people respond better to certain types.[28]

  • Side Effects

The most commonly reported side effects are decreased appetite, sleep problems, anxiety, and irritability. Some children also report mild stomach aches or headaches. Most side effects are minor and disappear over time or if the dosage level is lowered. The effects of long term side effects are not as abundant, but a few long term studies have noted a loss of appetite coupled with at least one physiological side effect such as headaches or abdominal pain. It is noted in these studies that although side effects are present, the children continued with the medication suggesting the side effects to be mild.[29] Less common side effects include children developing sudden, repetitive movements or sounds called tics. Changing the medication dosage may make tics go away. Some children may also exhibit sudden personality change, such as appearing "flat" or without emotion. Rare side effects include increased cardiovascular parameters and psychological disturbances but were at clinically insignificant levels.[30]

Psychotherapy

Psychosocial approaches for treatment of ADHD include educational support, behaviorally based strategies, and parent skills training. Psychotherapy is another method of treatment for parents who are concerned with the long term effects of stimulant therapy. This approach also accommodates ADHD patients that are not responding well the medical treatment method.In addition, due to the shorter lasting effects of stimulant therapy, psychotherapy can be used to provide additional benefits on top of medication.

  • Parent skills training

Many parents with children diagnosed with ADHD exhibit a multitude of “less than optimal” parenting. Parents with children diagnosed with ADHD are more controlling, disapproving, gives more attention to overactive & impulsive behavior, less rewarding and responsive than parents whose child is not diagnosed with ADHD.[31] The effects of behavioral parenting training (BTP) are studied on the overall parenting style, self-efficacy of parents, and the treatment’s ability to reduce ADHD symptoms.

Studies have shown BTP to increase parent’s self-efficacy, reduce stress, and also reduced the child’s hyperactive, aggressive, and defiant behavior.[32] Barkley (1997) noted that children with ADHD are affected by their immediate environment, rather than previous experiences or future goals. It is important, then, for parents to treat an unwanted behavior immediately, as delayed intervention would yield less positive responses. Through parent training, parents will be more equipped and able to immediately deal with impulsive or hyperactive behavior in a manner which constitutes as treatment instead of negative parenting.[33]

Contemporary ADHD Literature and its Relation to Growth & Motor Development

Growth Development

Height and Weight

Multiple studies have concluded that neither ADHD nor stimulant therapy (regardless of type) causes stunting in height or weight in both male and female cohorts.[34][35][36][37] It was noted, however, ADHD girls with major depression were 7.6kg heavier than ADHD girls without depression.[38]

Motor Development

A Taiwanese study used the Movement Assessment Battery for Children (MABC) to assess manual dexterity, ball skills, and balance (static and dynamic). The study compared the three ADHD types (ADHD-PI, ADHD-HI, and ADHD-C) to a control group to examine the effects of ADHD on motor development. The study found that ADHD-PI and C group did poorer in manual dexterity and ball skill tasks compared to control and ADHD-HI had similar results to the control group. In terms of static and dynamic balance there were no significant differences across groups.[39]

Practical Application

Physical Activity

Executive function is an umbrella term for the management (regulation, control) of cognitive processes, including working memory, reasoning, task flexibility, and problem solving as well as planning and execution. Executive function is said to be impaired in those with ADHD.[40] A recent study concluded that 30minutes of physical exercise has shown to improve executive functions in ADHD children.[41]

Tips for Teachers/Coaches

Children with ADHD are often inefficient at planning and do not have the ability to quickly formulate or use strategies they have learned from coaches.The use of visual aid, auditory prompts, and peer collaboration drills will assist athlete's learning. Athletes with ADHD may also lack self confidence and are overly concerned with being judged, therefore it may be useful to use self regulatory techniques (goal-setting strategy, positive self talk, and self monitoring...etc) to allow the athlete to practice comfortably. The use of visual representations to measure the athlete's progress and success will help the athlete keep track of their goals.[42]

Reference

  1. ADHD. (n.d.). Retrieved February 27, 2015, from http://apa.org/topics/adhd/index.aspx
  2. Polanczyk, G., de Lima, M. S., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. The American journal of psychiatry, 164(6), 942-948
  3. Gershon, J., & Gershon, J. (2002). A meta-analytic review of gender differences in ADHD. Journal of attention disorders, 5(3), 143-154.
  4. ADHD Educational Institute. (2015, February 1). Retrieved February 26, 2015, from http://www.adhd-institute.com/assessment-diagnosis/diagnosis/icd-10/
  5. Symptoms and Diagnosis. (2014, September 29). Retrieved February 26, 2015, from http://www.cdc.gov/ncbddd/adhd/diagnosis.html
  6. Symptoms and Diagnosis. (2014, September 29). Retrieved February 26, 2015, from http://www.cdc.gov/ncbddd/adhd/diagnosis.html
  7. World Health Organization. (1993). The ICD-10 Classification of Mental and Behavioural Disorders Diagnostic criteria for research [PDF file]. Available from http://www.who.int/classifications/icd/en/GRNBOOK.pdf
  8. Neuman, R. J., Lobos, E., Reich, W., Henderson, C. A., Sun, L. W., & Todd, R. D. (2007). Prenatal smoking exposure and dopaminergic genotypes interact to cause a severe ADHD subtype. Biological psychiatry, 61(12), 1320-1328
  9. Thapar, A., Cooper, M., Eyre, O., & Langley, K. (2013). Practitioner review: what have we learnt about the causes of ADHD?. Journal of Child Psychology and Psychiatry, 54(1), 3-16.
  10. Faraone, S. V., & Biederman, J. (1998). Neurobiology of attention-deficit hyperactivity disorder. Biological psychiatry, 44(10), 951-958.
  11. Biederman, J., Faraone, S. V., Keenan, K., Benjamin, J., Krifcher, B., Moore, C., ... & Tsuang, M. T. (1992). Further evidence for family-genetic risk factors in attention deficit hyperactivity disorder: Patterns of comorbidity in probands and relatives in psychiatrically and pediatrically referred samples. Archives of general psychiatry, 49(9), 728-738
  12. Faraone, S. V., & Biederman, J. (1998). Neurobiology of attention-deficit hyperactivity disorder. Biological psychiatry, 44(10), 951-958
  13. Smalley, S. L. (1997). Genetic influences in childhood-onset psychiatric disorders: autism and attention-deficit/hyperactivity disorder. The American Journal of Human Genetics, 60(6), 1276-1282
  14. Thapar, A., Cooper, M., Jefferies, R., & Stergiakouli, E. (2012). What causes attention deficit hyperactivity disorder?. Archives of disease in childhood, 97(3), 260-265
  15. Kieling, C., Goncalves, R. R., Tannock, R., & Castellanos, F. X. (2008). Neurobiology of attention deficit hyperactivity disorder. Child and adolescent psychiatric clinics of North America, 17(2), 285-307
  16. Langley, K., Rice, F., Van den Bree, M. B., & Thapar, A. (2005). Maternal smoking during pregnancy as an environmental risk factor for attention deficit hyperactivity disorder behaviour. A review. Minerva pediatrica, 57(6), 359-371
  17. Knopik, V. S., Heath, A. C., Jacob, T., Slutske, W. S., Bucholz, K. K., Madden, P. A., ... & Martin, N. G. (2006). Maternal alcohol use disorder and offspring ADHD: disentangling genetic and environmental effects using a children-of-twins design. Psychological medicine, 36(10), 1461-1471
  18. Eubig, P. A., Aguiar, A., & Schantz, S. L. (2010). Lead and PCBs as risk factors for attention deficit/hyperactivity disorder. Environmental health perspectives, 118(2), 1654-1667
  19. Nigg, J. T., Nikolas, M., Mark Knottnerus, G., Cavanagh, K., & Friderici, K. (2010). Confirmation and extension of association of blood lead with attention‐deficit/hyperactivity disorder (ADHD) and ADHD symptom domains at population‐typical exposure levels. Journal of Child Psychology and Psychiatry, 51(1), 58-65
  20. Kieling, C., Goncalves, R. R., Tannock, R., & Castellanos, F. X. (2008). Neurobiology of attention deficit hyperactivity disorder. Child and adolescent psychiatric clinics of North America, 17(2), 285-307
  21. Kieling, C., Goncalves, R. R., Tannock, R., & Castellanos, F. X. (2008). Neurobiology of attention deficit hyperactivity disorder. Child and adolescent psychiatric clinics of North America, 17(2), 285-307
  22. Wolraich, M. L., Wilson, D. B., & White, J. W. (1995). The effect of sugar on behavior or cognition in children: a meta-analysis. Jama, 274(20), 1617-1621
  23. Conners, C. K. (1980). Food additives and hyperactive children. New York: Plenum Press
  24. McCann, D., Barrett, A., Cooper, A., Crumpler, D., Dalen, L., Grimshaw, K., ... & Stevenson, J. (2007). Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. The Lancet, 370(9598), 1560-1567
  25. Jensen, P. S., Hinshaw, S. P., Swanson, J. M., Greenhill, L. L., Conners, C. K., Arnold, L. E., ... & Wigal, T. (2001). Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. Journal of Developmental & Behavioral Pediatrics, 22(1), 60-73
  26. Chronis, A. M., Jones, H. A., & Raggi, V. L. (2006). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clinical Psychology Review, 26(4), 486-502
  27. Stimulant Medication and AD/HD - Northern County Psychiatric Associates. (n.d.). Retrieved February 27, 2015, from http://ncpamd.com/stimulants/
  28. Connor, D. F., & Steingard, R. J. (2004). New formulations of stimulants for attention-deficit hyperactivity disorder. CNS drugs, 18(14), 1011-1030
  29. Craig, S. G., Davies, G., Schibuk, L., Weiss, M. D., & Hechtman, L. (2015). Long-Term Effects of Stimulant Treatment for ADHD: What Can We Tell Our Patients?. Current Developmental Disorders Reports, 1-9
  30. Vitiello, B., Elliott, G. R., Swanson, J. M., Arnold, L. E., Hechtman, L., Abikoff, H., ... & Gibbons, R. (2012). Blood pressure and heart rate over 10 years in the multimodal treatment study of children with ADHD. American Journal of Psychiatry, 169(2), 167-177
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  32. Danforth, J. S., Harvey, E., Ulaszek, W. R., & McKee, T. E. (2006). The outcome of group parent training for families of children with attention-deficit hyperactivity disorder and defiant/aggressive behavior. Journal of Behavior Therapy and Experimental Psychiatry, 37(3), 188-205
  33. Barkley, R. A. (1997). Attention-deficit/hyperactivity disorder, self-regulation, and time: Toward a more comprehensive theory. Journal of Developmental & Behavioral Pediatrics, 18(4), 271-279
  34. Biederman, J., Faraone, S. V., Monuteaux, M. C., Plunkett, E. A., Gifford, J., & Spencer, T. (2003). Growth deficits and attention-deficit/hyperactivity disorder revisited: impact of gender, development, and treatment. Pediatrics, 111(5), 1010-1016
  35. Zachor, D. A., Roberts, A. W., Hodgens, J. B., Isaacs, J. S., & Merrick, J. (2006). Effects of long-term psychostimulant medication on growth of children with ADHD. Research in developmental disabilities, 27(2), 162-174
  36. Harstad, E. B., Weaver, A. L., Katusic, S. K., Colligan, R. C., Kumar, S., Chan, E., ... & Barbaresi, W. J. (2014). ADHD, Stimulant Treatment, and Growth: A Longitudinal Study. Pediatrics, 134(4), e935-e944
  37. Spencer, T. J., Faraone, S. V., Biederman, J., Lerner, M., Cooper, K. M., Zimmerman, B., & Concerta Study Group. (2006). Does prolonged therapy with a long-acting stimulant suppress growth in children with ADHD?. Journal of the American Academy of Child & Adolescent Psychiatry, 45(5), 527-537
  38. Biederman, J., Faraone, S. V., Monuteaux, M. C., Plunkett, E. A., Gifford, J., & Spencer, T. (2003). Growth deficits and attention-deficit/hyperactivity disorder revisited: impact of gender, development, and treatment. Pediatrics, 111(5), 1010-1016
  39. Pitcher, T. M., Piek, J. P., & Hay, D. A. (2003). Fine and gross motor ability in males with ADHD. Developmental Medicine & Child Neurology, 45(8), 525-535
  40. Thapar, A., Cooper, M., Eyre, O., & Langley, K. (2013). Practitioner review: what have we learnt about the causes of ADHD?. Journal of Child Psychology and Psychiatry, 54(1), 3-16
  41. Grassmann, V., Alves, M. V., Santos-Galduróz, R. F., & Galduróz, J. C. F. (2014). Possible Cognitive Benefits of Acute Physical Exercise in Children With ADHD A Systematic Review. Journal of attention disorders, 1087054714526041
  42. Braun, R., & Braun, B. (2015). Managing the Challenges of Hidden Disabilities in Youth Sport: A Look at SLD, ADHD, and ASD through the Sport Psychology Lens. Journal of Sport Psychology in Action, (ahead-of-print), 1-16.