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Subject PSYCHOLOGY

Paper No and Title Paper No.15: Clinical psychology

Module No and Title Module No.11: Attention deficit Hyperactivity Disorder

Module Tag PSY_P15_M11

TABLE OF CONTENTS
1. Learning Outcomes
2. Introduction
3. Clinical Description, Prevalence of ADHD
3.1 DSM-IV-TR Criteria for ADHD
4. Causal Factors in ADHD
4.1 Genetic Factors
4.2 Neurobiological Factors
4.3 Pre-natal and Perinatal factors
4.4 Environmental Toxins
4.5 Psychological Factors in ADHD
5. Treatment of ADHD
5.1 Stimulant Medication
5.2 Psychological Treatment
6. Summary

PSYCHOLOGY PAPER No.15: Clinical Psychology

MODULE No.11: Attention Deficit Hyperactivity Disorder
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1. Learning outcomes

After studying this module , you will be able to:

- Know and understand the concept of Attention/Deficit/Hyperactivity Disorder
- Identify the clinical picture and causal factors of ADHD
- Evaluate the various methods of treatment

2. Introduction

Attention-Deficit Hyperactivity Disorder is often referred to as “hyperactivity” is characterized by

difficulties that interfere with effective task-oriented behaviour in children-particularly impulsivity,
excessive or exaggerated motor activity such as aimless or haphazard running or fidgeting, and difficulties
in sustaining attention (Brodeur &pond,2001) .When such problems are critical and tenacious enough, the
criteria for diagnosis of attention-deficit of these children are met. The primary characteristics of such
people include a pattern of inattention such as not paying attention to school-or-work-related tasks. These
deficits significantly disrupt academic efforts, as well as social relationship.

3. Clinical Description, Prevalence of ADHD

What distinguish the hyperactive behaviour from a identifiable disorder? The diagnosis of ADHD will be
appropriate when these behaviors show up for a particular time period, insistent across different situations
and are linked to significant impairment in functioning.(NIH Consensus statement,1998). ADHD children
have great deal of difficulty sustaining their attention on a task or activity (Barkley,2006). Their task are
often unfinished and they often seem not to be listening when someone else is speaking.. In addition to this
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serious disruption in attention, some children with ADHD display

motor hyperactivity. They are unable to sit at one place in a school
for more than a minutes. Their restlessness in a school is a considerable source of concern for their teacher
and peers. In –addition to hyperactivity and problem sustaining attention, impulsivity-acting apparently
without thinking – is a common complaint made about them.
DSM-1V-TR differentiate three types of symptoms. The first includes problem of in attention . They appear
not to listen to others, they may lose necessary school assignments, books, and they may not pay enough
attention to details. They make careless mistakes.

The second type of symptoms includes hyperactivity, which includes fidgeting ,having trouble sitting for
any length of time, always being on the go.

The third general symptom is impulsivity, which includes blurting out answers before questions have been
completed and having trouble waiting turns. Either the first or second and third (hyperactivity and
impulsivity) domains of symptoms must be present for someone to diagnosed with ADHD.
In-attention ,hyperactivity , and impulsivity often cause other problems that appear secondary to ADHD.
Academic performance tends to suffer, especially the child progresses in school. The cause of this
performance is not known. It could be a result of the problem with attention and impulsivity characteristic
of ADHD and in some children this can be made worse by factors such as concurrent learning disability,
which are common in boys with ADHD. ADHD children are rated to be unpopular and rejected by peers.
Evidence suggests that some children with ADHD actually have an inflated sense of their own competence
in area such as social acceptance, physical appearance, and self- worth.
Anxiety and depression , the internalizing disorders occur simultaneously with ADHD. Recent estimates
suggests that as many as 30% of children with ADHD may have comorbid internalizing
disorders.Approximately 15 to 30% of children suffering from ADHD face difficulty in math, reading, or
spelling (Barkley, Dupaul ,& Mc-Murray,1990), becaused of this difficulty of adjusting to a typical
classroom they are placed iin special educational programmes (Barkley et.al,1990).

Although having both ADHD and conduct disorder is associated with substance use and abuse, a
prospective study found that the hyperactive symptoms of ADHD predicted subsequent substance (nicotine,
alcohol, illicit drugs) use at the age 14 and abuse or dependence at age 18 even after controlling for
symptoms conduct disorder, and this was equally true for boys and girls

The consensus on prevalence estimates of ADHD is that 3 to 7% of school children worldwide currently
have ADHD are used across countries as diverse as the US ,Kenya and China. However ,one study reported
a much higher prevalence rate of 16.1% for ADHD (Wolrich,Hannah,et.al,1998) The disorder occurs most
frequently among pre-adolescent boys-it is 6 to 9 times more prevalent among boys than among girls,
ADHD occurs with the greatest frequency before age 8 and tends to become less frequent and to involve
briefer episodes thereafter, ADHD has also been found to be comorbid with other disorders such as
oppositional defiant disorder (Drabick, Gadow, et al, 2004).Some residual effects, such as attention
difficulties, may persist into adolescence or adulthood (Odell,Warren,et.al199 )
In India, The prevalence of ADHD among primary school children was found to be 11.32%.Prevalence was
found to be higher among the males (66.7%) as compared to that of females (33.3%). The prevalence
among lower socio-economic group was found to be 16.33% and that among middle socio-economic group
was 6.84%. The prevalence was highest in the age group 9 and 10 years. .

PSYCHOLOGY PAPER No.15: Clinical Psychology

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3.1 DSM-1V-TR Criteria for Attention-Deficit/ Hyperactivity disorder

3. Causal factors in Attention-Deficit/ Hyperactivity Disorder

It still remains unclear to what extent the disorder results from environmental or biological factors, and
recent research points to both genetic and environmental precursors (Hechtman,1996) Many researchers
believe that biological factors such as genetic inheritance will turn out to be important precursors to the
development of ADHD (Durson,2003). But firm conclusions regarding any biological basis for ADHD still
awaits further research.

4.1 Genetic Factors Substantial evidence indicates that a genetic predisposition towards ADHD plays
a role (Thaper et al; 2007) and numerous large scale studies indicate a genetic component to ADHD , with
heritability estimates as high as 70 to 80%. Most attention to date focuses on genes associated with the
neurochemical dopamine, although norepinephrine, serotonin, and gamma-amino butyric acid are also
implicated in the cause of ADHD .There is a strong evidence that ADHD is associated with D4 receptor
gene, the dopamine transporter gene (DAT1), and the dopamine D5 receptor gene. (DAT1) is of particular
interest because Ritalin is one of the most common treatments for ADHD – inhibit this gene and increase
the amount of dopamine available. Even with these promising findings , most investigators agree that a
single gene will not ultimately account for ADHD .Rather several genes interacting with environmental
factors will provide the most complex picture of the cause if ADHD .Additional gene-environment
interaction studies are underway and if these finding replicated .We have a clearer picture of how genes and
environment interact in ADHD.
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4.2 Neurobiological Factor

In children with and without ADHD brain structure and function differ, particularly in areas of the brain
linked to the neurotransmitter dopamine . For example studies of brain structure have found that
dopaminergic area of the brain such as caudate nucleus, frontal lobes, are smaller in children with ADHD
than without ADHD (castellanos et al;2002; swanson et al.2007)Studies of brain function have found that
children with ADHD exhibitless trigger in frontal areas of the brain while performing different tasks (Casey
& Durston,2006; Nigg& Casey2005). In neuropsychological tests children with ADHD perform poorly and
these tests rely on the frontal lobe providing further evidence for the theory that a basic deficit in this part
of the brain may be related to this disorder.

4.3 Prenatal and perinatal factors

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Pre natal and peri natal complications are other neurobiological

factors for ADHD. Low birth weight , for example , is a quite specific
predictor of the development of ADHD (Breslau et al; 1996; Whitaker et.al 1997) mothers use of substance
such as alcohol and tobacco are related with other complications are prognostic of ADHD symptoms.

4.4 Environmental Toxins

In 1970s environmental factors played a major important role in the development of
hyperactivity. Feingold proposed that additives and artificial colors in foods disturb the central nervous
system of the children who were hyperactive and he prescribed a diet which does not involve them.
However well controlled studies of the so-called Feingold diet have found very few children with ADHD
respond positively to it(Goyette &Conners,1977 ) Even though these early findings did not support
Feingold theory, Researchers continue to examine how different elements of the diet , particularly additives
may influence hyperactive behaviour. A recent study found a similarly small effect of food additives and
artificial coloring on hyperactive behaviour . Research didn’t supported the popular view that refined sugar
causes ADHD (Wolraich, Wilson & White, 1995)

Research suggests that small degree of symtoms of hyperactivity and attentional problems are may be
associated with lead poisoning. Researchers continue to whether lead exposure might play a role, however
a small , in the etiology of ADHD (Nigg,2006) Nicotine –specifically, maternal smoking- is an
environmental toxin that play a role , however small , in the etiology of ADHD .Several animal studies
indicate that chronic exposure to nicotine is associated with decreases in dopamine release in the brain and
causes hyperactivity. Dopaminergic system of fetus is affected by maternal smoking as shown by research
which results in behavioural dis inhibition and ADHD.

4.5 Psychological factors in ADHD

In the etiology of ADHD research results show that neurologic and psychological factors
play more important role as compared to psychological factors, relationship between parents
and child interact with these neurobiological factors in a complex way which contribute to ADHD. For
example, parents of children with ADHD may give them more commands and have negative interactions
with them (Anderson,Hinshaw,1994) It results in more negative interactions between. Certainly it becomes
difficult for parents to bring up a child who is impetous, hostile, non-complaint and and unable in following
the instructions. Hyperactivity and increase compliance in children can be reduced with the help of
stimulant medication. . Significantly when such medication is used, either alone or in combination with
behavioural treatment. It is also very important to note parents own history. Genetic component plays a
major role in ADHD. That’s why children of ADHD parents have a higher probability of acquiring the
disorder.

5 Treatment of ADHD

Although hyperactivity syndrome was described to be 100 years old, disagreement over the most effective
methods of treatment continues, especially regarding the most effective method of treatment like use of
drugs to calm down a hyperactive child.

5.1 Stimulant Medications

The first class of medication used for children with ADHD is the stimulants. Stimulant medications , such
as methylphenidate, or Ritalin, have been prescribed for ADHD since the early 1960s. Other medicines
approved by the FDA to treat ADHD include Adderall, Concerta, and Strattera. In 2006,an estimated 2.5
million children in the United States were taking stimulant medication (National survey on children s
health 2003) including almost 10% of all 10 year boys. These drugs have proved helpful for more than
70% of of cases in at least temporarily reducing hyperactivity and impulsivity and improving concentration
on tasks (connor,2006)Adderall, which is a longer acting version of these psycho-stimulants, reduces the
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need for multiple doses for children during the day but has similar
positive effects (connor,2006). Originally it seemed contrary to
expect that children would calm down after taking a stimulant . However ,on the same low doses , children
and adults with or without ADHD react in the same way. It appears that stimulant medication reinforce the
brains ability to focus attention during problem-solving tasks (connor 2006) Although the use of stimulant
medications remain controversial, especially for children , most clinician recommend them temporarily, in
combination with psycho-social interventions, to help improve children s social and academic skills.
Research suggest that other drugs, such as one of the antidepressants (bupropion, imipramine) and a drug
used for treating high blood pressure (clonidine), may have similar effects on people with ADHD
(spencer,2006). Not all children with ADHD have depression or high blood pressure (although depression
can be a problem in a portion of these children), but these drugs work on the same neurotransmitter systems
(norepinephrine and dopamine) involved in ADHD . All these drugs seem to improve compliance and
decrease negative behaviours in many children, and their effects do not usually last when the drugs are
discontinued.

5.2 Psychological Treatment

Some portion of the children with ADHD do not respond to medication and most children who do respond,
show improvement in ability to focus their attention but do not show gains in the important areas of
academic and social skills (Smith, Barkley & Shapiro, 2006). In addition, the medication often result in
unpleasant side effects, such as insomnia, drowsiness , or irritability (connor,2006) Because of these
findings researchers have applied various behavioural interventions to help these children at school and in
home. Reinforcement programs reward the child for improvements and, at times ,punish misbehaviour with
loss of rewards. Other programs incorporate parent training to teach families how to respond constructively
to their child’s behaviour and how to structure the child’s day to help prevent difficulties (Sonuga-
Barke,Daley, Thompson, Laver-Bradbury& Week, 2001)Social skills training for these children , which
includes teaching them how to interact appropriately with their peers, also seems to be an important
treatment component. For adults with ADHD , cognitive-behavioural interventions for the distractibility
and organizational skills problems appears quite helpful. Most clinicians typically recommend a
combination of approaches designed to individualize treatments for those with ADHD, targeting both short-
term management issues (decreasing hyperactivity and impulsivity ) and long term concerns (preventing
and reversing academic decline and improving social skills.

Training teachers so as to understand the needs of these children and and to apply operant techniques are
the considered school interventions(Welsch et al 1997). In academic skills giving peer giving peer tutoring
(Dupaul & Henningson, 1993) and giving reports daily to parents about the behavior of the child, which are
then rewarded at home.Certain classroom structures can help children with ADHD as shown in research.
Varying the format and materials used in presentation for tasks, giving concise assignments and providing
immediate feedback that whether it was done correctly or not, having an eager work oriented style, giving
breaks for physical exercise, computer assisted drill programs are used and planning academic work during
early hours of the day. Such environmental changes are designed to accommodate the limitations imposed
by this disorder rather than to change the disorder itself.

Some controversy surround the interpretation of these findings –specifically , whether or not the
combination of behavioural and medical treatments is superior to medication alone (Biederman, Spencer,
Wilens &Greene,2001) One of the concerns surrounding the study was that although medication continued
to be dispensed, the behavioural treatment was faded over time, which may account for the observed
differences. Practically, if there is no difference between these two treatment, most parents and therapists
would opt for simply providing medication for these children. Behavioural interventions have the added
benefit of improving aspects of the child and family that are not directly affected by medication. Despite
these advances, however , children with ADHD continue to pose a considerable challenge to their families
and to the educational system.

PSYCHOLOGY PAPER No.15: Clinical Psychology

MODULE No.11: Attention Deficit Hyperactivity Disorder
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Summary

 ADHD is one of the more common behaviour problem of childhood. In this disorder the child
shows impulsive, overactive, behaviour that interferes with his ability to accomplish tasks.
 This disorder is common in boys than girls.
 In ADHD genetic factors play a major role. Neurotransmitter Dopamine plays an important role in
ADHD and also areas of brain are involved.
 Genetic Vulnerabilities suggests that family and peer variables play a major role in etiology of the
disorder.
 Medication such as Ritalin and behavior therapy in combination is the most effective treatment for
ADHD.
 Behaviour therapy , cognitive behavioural methods had shown a great deal of promise in
modifying the behaviour of hyperactive.
 More longitudinal research is clearly needed before we can conclude that children with ADHD go
on to develop similar or other problem in adulthood Estimates of the number of children with
ADHD in adulthood are likely to vary considerably.

PSYCHOLOGY PAPER No.15: Clinical Psychology

MODULE No.11: Attention Deficit Hyperactivity Disorder