ATTENTION DEFICIT HYPERACTIVITY DISORDER

Faculty: Dr. Jayshree C Shanbal

Presenters: [Link] & [Link] Rekha N

 Definition
• Inattention is characterized as wandering off task, difficulty
with sustained attention and being disorganized.
• Hyperactivity is referred as excessive motor activity including
not being able to sit still, or fidgeting; for adolescents and
adults this may be described as restlessness.
• Impulsivity refers to making a decision without considering
the consequences, inability to delay gratification, or
excessively interrupting
(APA, 2013)
 History
• Brain Damage, Hyperkinesis and Minimal Brain Damage
(MBD), and following this the label hyperactivity was applied.

• In 1980, adopted the term Attention Deficit Disorder (ADD)

and described in two forms
 Attention Deficit Disorder with Hyperactivity (ADDH)
 Attention Deficit Disorder without Hyperactivity (ADD without
H) , (American Psychiatric Association, APA)

In 1987, the distinction between these two was

dropped
 In 1994, 3 types of ADHD

DSM (4th ed): American Psychiatric Association

Combined type (ADHD C), which requires children to

display at least six of nine inattention and six of nine
hyperactivity- impulsivity symptoms

Predominantly inattentive type (ADHD,IA), which

requires at least six of nine inattention symptoms and
fewer than six hyperactivity- impulsivity symptoms

Hyperactivity- Impulsive type (ADHD, HI), which

requires at least six of nine hyperactivity- impulsivity
symptoms and fewer than six inattention symptoms
 Recent, Diagnosis
• A child must have at least 6 responses of “often” or “very
often” (scored 2 or 3) to either the 9 items- inattention (1-
9) or the hyperactivity- impulsive items (10-18), or both.
• For older adolescents and adults (17 and older), at least
five symptoms are required. The clinician might consider
ADHD as possible diagnosis if 5 or more symptoms are
scored 2 or 3 in either or both domains.
• In addition symptom must have occurred by age 12, they
must impair the individual functioning in two or more
settings, and they must not be primarily due to any other
factors or conditions.

Rating: “not at all, just a little, often and very often”

Cont…
• Depending on the domains affected
• ADHD, predominantly inattentive type;
• ADHD, predominantly hyperactivity- impulsivity type; or
• ADHD, combined type may be considered.

Source: Diagnostic and Statistical Manual of Mental Disorders,

DSM (5thed),2013 American Psychiatric Association.
 Prevelance

12.2%

Prevalence of attention deficit disorder among preschool age

children
BS Suvarna and AKamath, Nepal Med Coll J 2009; 11(1):
1-4
 Prevelance

Worldwide: 5.29% and 7.1%.

Indian scenario: range of 2% to 17%.

5.76% - 3.8% among girls and 1.9%

among boys
Prevalence of ADHD in Primary School Children in Belagavi City,
India
Himani Mahesh Joshi, MubashirAngolkar
Journal of Attention Disorder, June 21, 2018
 Etiology

Genetic

• Higher rates of ADHD in parents and siblings of

affected probands compared to relatives of
unaffected controls, and by higher cordance rates for
ADHD in monozygotic than in dizygotic twin pairs
(Thapar et al.,2012)
• Lichtenstein et al. (2010) reported concordance rates
for ADHD in monozygotic and dizygotic twin boys of
44% and 10% respectively.
Genes of the dopaminergic and serotonergic
system, including DRD4, SLC6A3 (DAT1),
GMR5 and DBH, were widely studied and
implicated to be associated with the
susceptibility of ADHD
 Cont..

Environmental factors

• Maternally related prenatal risks (e.g. alcohol

consumption, smoking and drug use in
pregnancy),
• Pregnancy and birth complications (e.g.
prematurity and low birth weight) and
• External agents (e.g. infections, exposure to
lead and other toxins) (Thaper et al 2012).
 Cont..
Neurobiological perspective
The frontal lobe
Cortex maturation, reach the peak of the
thickening of their cortex in their teenage
years rather than in their childhood years
(Castellanos, 2012; National Institute of
Mental Health, 2007)
Cerebellum and Basal Ganglia
Differentiating frontostriatal and fronto cerebellar circuits
in attention deficit hyperactivity disorder

Durston S, Van Belle J, de Zeeuw P

Biol Psychiatry, 2011 Jun 15;69(12):1178-84
 Circuits

• Dorsal frontostriatal circuitry

• Orbitofronto-striatal loops

• Fronto-cerebellar circuits
 Co- morbid
In the United States, Larsoon et al. (2011)
examined the co-morbidities of 5,028 children
with ADHD aged 6- 17 years.
• Learning Disability was reported in 46% of
these children.
• Other significant co-morbidities were conduct
disorder (27%), anxiety (18%), depression
(14%) and speech problem (12%).
 Co- morbidity
• Giacobini et al. (2016)
Reported significant psychiatric co-morbidity in
Swedish children, adolescents and adults with
ADHD.
Autism Spectrum Disorders were more common
in younger children, while substance abuse,
anxiety and personality disorder were the
most common co-morbidities in older
patients.
 Language skills
Impairment in number of receptive and
expressive language measures (such as
understanding spoken language, following
directions and understanding concepts and
understanding grammatical relationships).
They also had difficulty in formulating
sentences recalling words rapidly and
performing word association tasks.
DaParma et al. (2011)
Bruce et al (2006) used a parental questionnaire
to examine Language and Communication
skills in 76 children with ADHD.

• The majority of these children had, pragmatic

problems, which were associated with the
core aspects of ADHD symptoms, particularly
inattention and impulsiveness.
• Rumpf et al (2012) examined the organization of narrative
in children with ADHD. Only 1 of 9 children with ADHD
(11%) was able to verbalize the core aspects of story
adequately.

Children with: ADHD and TD children

In ADHD children poorer performances sentence imitation
and word articulation subtests, speaking quotient and
speech-language quotient. More inadequate pragmatic
behaviours.
Kim & Kaiser (2000)
• McInnes et al. (2003)
The ADHD patients comprehension was
impaired in listening to spoken expository
passages (inferences and monitoring of
instructions), poorer verbal working memory,
spatial span and spatial working memory.
• Increased response variability,
• Deficits in attention and in visuo-spatial short-
term memory
• Large errors on the time reproduction task
• Deficits in duration discrimination

Time perception, phonological skills and executive

function in children with dyslexia and/or ADHD
symptoms
Journal of Child Psychology and Psychiatry 52:2 (2011),
Debbie Gooch et al
ADHD progression
Preschool children with ADHD are at greater risk
for behavioral, academic, social and family
problems when compared to typical peers.

They are likely to have been expelled or

removed from preschool and daycare
placements due to behaviors that are
extremely disruptive.

Kratochvil (2012)
 Schooling
Same children may already be delayed in understanding
basic mathematical concepts, developing pre-
literacy skills and in developing fine motor skills.
The compounding difficulty of poor peer relationships
and pragmatic deficits are additional risk factors in
developing the antisocial behaviors especially as
children age up through elementary school.
Whereas over-activity may subside by adolescence or
adulthood, this characteristics is often replaced by
restlessness.
 Adulthood
25- 35 % of this group may displace antisocial
behavior or conduct disorder; problems
making and keeping friends due to deficits in
social comprehension and decreased problem
solving skills.

• Sibley et al., 2010

 Cont…
• Many adolescents display risk taking
behaviors experimenting with drugs and/ or
alcohol (Glass, Flory,Martin & Hankin,2011;
Harty, Miller, Newcom, & Halperin, 2009).

• Those who go onto college may experience

impairment in executive function as well as in
academic, psychological and social skills
(DuPaul, Weyandt, O’Dell & Varejao, 2009).
 The Disturbing Effect of Irrelevant Information
on Arithmetic Problem Solving in Inattentive
Children

Gian Marco Marzocchi , Daniela Lucangeli ,

Tiziana De Meo , Federica Fini & Cesare
Cornoldi
Developmental Psychology journal , Pages 73-92
Published online: 08 Jun 2010
Study 1 & study 2
4th and 5th grade
 Study 1
• 20 inattentive children, fourth and fifth
graders,
• 20 control children

Matched for IQ, gender, and schooling were

administered 12-word arithmetic problems
Four problems
• only essential information necessary for the
problem's solution,
• whereas the other problems included
 irrelevant information
 half at the beginning of the problem and half at the
end..
 Study 2
• The aim of the 2nd study was to extend the
observations of the previous one, concerning
the influence of irrelevant information on
word problem solving tasks.
The influence of numerical and verbal irrelevant
information
• 19 inattentive children, fourth and fifth
graders,
• 18 control children

Matched for IQ, gender, and schooling

6 with irrelevant numerical-arithmetic
information (data and arithmetic relations:
more than, less, equal to and so on)

6 with irrelevant verbal information (sentences

unnecessary to understand and solve the
problem but convening rich semantic
information)
• Both kinds of information produced a greater
number of procedural errors in the inattentive
group, but differences in calculation errors were
less evident

• Inattentive children were more disturbed when

the irrelevant information was verbal than when
it was numerical, suggesting that inattentive
children's difficulties in problem solving are
partially due to an inability to inhibit irrelevant
information, especially when it conveys a rich
semantic knowledge
 Summarize
• Understanding spoken language
• Following directions
• Understanding grammatical relationships
• Formulating sentences
• Narration- inferences and monitoring of instructions
• Pragmatic deficits
• Recalling words rapidly
• Verbal working memory
• Spatial span and spatial working memory
 Cont…

• Behavioral, academic, social and family

problems
• Poor peer relationships and
• Restlessness in adulthood.
• Inability to inhibit irrelevant information
• problems making and keeping friends
developing pre-literacy skills and in developing
fine motor skills.
Thank you
Irrelevant information in the beginning of the sentence

An example of an IIB arithmetic word problem is

the following:
In a box there are 9 candies and 7 licorices. In a
green box there are 25 chocolates, and in a
white box there are 8 chocolates more than in
the green box. A blue box has 12 chocolates
less than those contained in the green box.
Howmany chocolates are there in the blue,
green, and white boxes?