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History
Discovered mid-nineteenth century
Dr. George F. Still, credited as being one of the first authorities to being ADHD to attention
Behavioral inhibition is still one of the components of ADHD that is still discussed today
History
Still’s cases similar to today’s population Children had mild brain pathology Some had normal intelligence More prevalent in males than females Some basis as hereditary condition Some had comorbid disorders such as
depression Many of his cases would still be labeled with
ADHD or ADHD with conduct disorder
History
Goldstein’s Brain-Injured Soldiers of WWI Noticed symptoms such as
Disorganized behavior Hyperactivity Perseveration Forced responsiveness to stimuli Lack of ability to focus on figure, instead attention
was paid to ground Laid the work for Strauss and Werner in 1930s-40s
Strauss Syndrome Figure background task
History
William Cruickshank Children with CP more likely to respond to
background than figure in figure/background task
All children had normal intelligence Brought to light that distractibility and
hyperactivity could occur in “normal” children First to establish educational program for
children with ADHD
Progression of Terms
1950’s-1960’s-Minimal brain injury
1960’s-1970’s-Hyperactive child syndrome
1980’s-ADHD
Definition
American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) Fourth edition (DSM-IV) ADHD, Predominantly Inattentive Type ADHD, Predominantly Hyperactivity Type ADHD, Combined Type
Criteria on p. 229
Prevalence
Most frequent reason children are referred for behavior problems
3-7% of school-age population Hard to have accurate percentage since
ADHD is served under “other health impaired” (OHI)
3:1 males to females Males have hyperactivity or impulsive type Females have inattentive type
Identification of ADHD
4 main components Medical examination Clinical interview Teacher and parent rating scales
Conners Rating Scales-Revised ADHD Rating Scale-IV
Behavioral observations Continuous performance test (CPT) stimuli presented
one at a time on a screen rapidly, with child pressing button when a particular stimulus is shown
Causes
Strong evidence of neurological abnormalities Prefrontal lobes & Frontal Lobes
Executive functions
Basal ganglia (caudate & globus pallidus) & Cerebellum Coordination & control of motor behavior
Corpus callosum Communication between hemispheres
The size of these areas is smaller Suggested reduced metabolic activity in the frontal lobes
and basal ganglia
Hereditary Factors
Family studies indicate 32% chance if sibling has ADHD 57% chance if parent has ADHD 2-8 more times likely if parent has ADHD than a
parent that does not In identical twins, increased chance versus
fraternal twins No single gene cause of ADHD Possible link to gene that regulates dopamine
Medical Factors
Not as strong a link as heredity Exposure to lead Alcohol abuse during pregnancy Tobacco use during pregnancy Low birthweight Complications at birth
Barkley’s Model of ADHD
Behavioral inhibition is the critical element leads to problems with executive functioning
time awareness and management
Disrupts person’s ability to persist in goal-directed behavior Problem’s with wait for turn Refraining from interrupting conversations Inability to resist distractions Inability to delay immediate gratification In the classroom, problems with transitions/switching
tasks
Executive Functions
Ability to regulate one’s behavior Children with ADHD have problems with
Working memory Forgetfulness, lack of hindsight, time management
Delayed inner speech Following rules or instructions
Controlling emotions and arousal levels Overreact to negative/positive experiences Quick to show anger/frustration
Analyzing problems and communicating solutions to others
Responds impulsivity to the first solution that comes to mind
Other Areas of Deficits
Adaptive skills Usually discussed when talking about intellectual disabilities New research shows children with ADHD have difficulties with these
skills
Socializing with peers More often rejected by peers Fewer close friends Disliked by students who enjoy high social status Research indicates this could be a defining characteristic of ADHD Difficult to overcome and is long lasting Can lead to social isolation
Comorbid Conditions
Learning disabilities Overlap of 10-25 percent Suggest strongest link ADHD, predominately inattentive
type
Emotional or behavioral disorders 25-50% exhibit some form of EBD 25-35% anxiety is present
Substance abuse Adolescents are more likely to experiment Twice as likely to abuse alcohol or drugs
Educational Considerations
Classroom Structure Reduce irrelevant stimuli/distractions
Teacher Direction Clear breakdown of instructional day
Functional Behavior Assessment Identifies ABC-antecedent, behavior, consequence
Contingency-based self management Students keep track of own behavior, then receive
consequences
Introducing Lessons
Provide an advance organizer Review previous lessons Set learning expectations State needed materials Explain additional resources Simplify instructions, choices and scheduling
Conducting Lessons
Be predictable Support the student’s participation in class Check student performance Perform ongoing student evaluation Follow-up directions
Written oral
Divide work into smaller units Eliminate or reduce frequency of timed tests
Concluding Lessons
Provide advance warnings Can use overhead timer Visual timer
Check assignments Preview the next lesson Remember break the work into smaller
chunks helps the children focus and limit distractions
Medical Considerations
Controversial topic Psychostimulants
Stimulate or activate neurological functioning Ritalin
Takes about one hour to take effect Optimal effect in 2 hours Wears off in 4 hours
Adderall Stratera-non stimulant
What Research Says
Ritalin has positive effects in helping students have more normalized behavioral inhibition and executive functioning
Leads to increased results on parent-teacher rating scales and academic achievement
Increased classroom behaviors Better at taking notes On-task behavior Quiz scores Homework completion Written-langauge work
What the Research Says
Not effective for everyone Around 30% do not have favorable response Side effects
Insomnia, reduced appetite, abdominal pain, headaches, and irritability
Some reports can cause tics or increase tics that children already have
Can have rebound effect Some studies suggest taking Ritalin can decrease
adolescent use of drugs
Monitoring Progress
Curriculum-based measurement (CBM) Attention & Behavior
Momentary time sampling Allows the teacher to conduct brief observations and
collect data on a specific set of behaviors Observer determines length of observation & divides
it into intervals At beginning of interval, observer notes whether the
student is exhibiting the target behavior & then waits until the beginning of the next interval to document behavior
Testing Accommodations
Small-group or individual administration in a quiet location
Extended time Frequent breaks Presentation format Response format
Early Intervention
Diagnosis is difficult at an early age Most commonly will see a great deal of motor activity and a
lack of impulse control Stronger use of contingencies such as praise, points, and
tangible rewards Intensive, structured methods of applying behavioral
management can be successful in improving behavior and pre-academic skills
Symptoms such as strong aggression can not remediate completely the symptoms of ADHD, will need long-term programming
Transition into Adulthood
2/3 of children with ADHD will continue to have significant symptoms in adulthood 4-5%, similar to the rate in children
Person’s history is important in determining adult ADHD
Some adults also exhibit antisocial, anxiety, and depression disorders, including employment Comorbid conditions lead to poorer outcomes compared
to those who do not have them