Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Gordon Teichner

• Publisher: Momentum Press
• Year: 2017
• Print ISBN: 9781944749354
• eBook ISBN: 9781944749361
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Medical and mental health professionals who treat children and adolescents are frequently asked to evaluate and treat an Attention-Deficit/Hyperactivity Disorder (ADHD). This book presents information that will assist professionals in this process. The reader will learn about the causes of ADHD, how to accurately diagnose ADHD, and methods to evaluate potential coexisting disorders that often accompany this condition. Professionals reading this book will gain a thorough understanding of empirically based treatments that work for ADHD. A number of case studies illustrating the assessment and treatment of ADHD are presented. Mental health professionals who are looking to increase their revenue may be interested in this book given the growing need for qualified providers who can provide assessment and treatment services for this population.

CHAPTER 1

Description and Diagnosis of Attention-Deficit/Hyperactivity Disorder

DSM-5 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that is characterized by symptoms of inattention, impulsivity, and hyperactivity that are inconsistent with a child’s developmental level. Several symptoms must be displayed across two or more settings. Difficulties associated with ADHD must significantly interfere with, or reduce the quality of, the child’s functioning (e.g., at home, at school, in academic performance, in leisure activities, in relations with others, in managing daily responsibilities) in order to meet the criteria for this diagnosis.

Symptom onset has been changed in DSM-5 (American Psychiatric Association, 2013) to prior to the age of 12 years; several symptoms of inattention, hyperactivity, and impulsivity must have been present prior to this age in order to meet the DSM-5 diagnostic criteria. DSM-IV (American Psychiatric Association, 1994) and DSM-IV-TR (American Psychiatric Association, 2000) definitions required a symptom onset prior to the age of seven years in order to meet diagnostic criteria for ADHD.

ADHD is a neurodevelopmental condition that can result in a range of functional difficulties for the child. Males and females generally display equal levels of persistent academic, behavioral, and social problems (Hinshaw et al., 2012). Such difficulties may include academic underachievement, learning disorders, externalizing behavior problems, psychological difficulties, problems with peer relations, and substance usage. Such issues often precipitate a referral to evaluating and treating clinicians.

DSM-5 indicates that the prevalence of ADHD in children is about 5 percent across cultures. ADHD is more frequently demonstrated by boys, with a ratio of approximately 2:1 in children. Girls are more likely to primarily demonstrate symptoms comprising the ADHD symptom cluster of Inattention.

Listed in the following are the DSM-5 diagnostic criteria for ADHD (American Psychiatric Association, 2013).

Attention-Deficit/Hyperactivity Disorder—DSM-5 Diagnostic Criteria

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 years and older), at least five symptoms must be present.

a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details; work is inaccurate).

b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallet, keys, paperwork, eyeglasses, mobile phone).

h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, this may include unrelated thoughts).

i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 years and older), at least five symptoms must be present.

a. Often fidgets with or taps hands or feet or squirms in seat.

b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or workplace, or in other situations that require remaining in place).

c. Often runs about or climbs in situations where it is inappropriate. (In adolescents or adults, this may be limited to feeling restless).

d. Often unable to play or engage in leisure activities quietly.

e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or is uncomfortable being still for extended time, as in restaurants, meetings; the child may be experienced by others as being restless or difficult to keep up with).

f. Often talks excessively.

g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).

h. Often has difficulty waiting his or her turn (e.g., while waiting in line).

i. Often interrupts or intrudes on others (e.g., interrupts conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, at school, or at work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic/occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Specify Whether

1. 314.01 (F90.2) Combined presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for the past six months.

2. 314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met for the past six months.

3. 314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (Hyperactivity-Impulsivity) is met and Criterion A1 (Inattention) is not met for the past six months.

4. 314.01 (F90.8) Other Specified Attention-Deficit/Hyperactivity Disorder: This category applies to presentations in which symptoms characteristic of ADHD that cause significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for ADHD or any of the disorders in the neurodevelopmental disorders diagnostic class. The Other Specified ADHD category is used in situations in which the clinician chooses to communicate the specific reason for the presentation not meeting the criteria for ADHD or any specific neurodevelopmental disorder. This is done by recording “Other Specified Attention-deficit/hyperactivity Disorder” followed by the specific reason (e.g., “with insufficient inattentive symptoms”).

5. 314.01 (F90.9) Unspecified Attention-Deficit/Hyperactivity Disorder: This category applies to presentations in which symptoms characteristic of ADHD that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for ADHD or any of the disorders in the neurodevelopmental disorders diagnostic class. The Unspecified ADHD category is used in situations in which the clinician chooses not to specify the reason the criteria are not met for ADHD or for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis.

Specify Whether

1. In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past six months, and the symptoms still result in impairment in social, academic/occupational functioning.

Specify Current Severity

1. Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.

2. Moderate: Symptoms or functional impairment between “mild” and “severe” are present.

3. Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

Executive Dysfunction

ADHD is a neurobiological disorder that is characterized by executive deficits. In many ways, ADHD can be conceptualized as a spectrum disorder in the sense that its symptom presentation can differ greatly between individuals. The aforementioned symptoms of inattention, hyperactivity, and impulsivity comprise the core features of ADHD. However, it is common for many children and adolescents with ADHD to display a range of additional frontal systems challenges that can negatively impact their functioning.

ADHD is a biologically based condition that is primarily due to deficits associated with the frontal lobe and related frontal systems. The prefrontal cortex of the brain and its various neural pathways to different brain structures are involved in a range of neurocognitive and neurobehavioral functions over and above attention/concentration, activity level, and control on one’s impulses. These functions are known as executive abilities. Executive skills include planning, organization, applying logic, reasoning, problem solving, behavioral initiation, motivation, persistence, delaying gratification, information processing speed, self-management of time, judgment, insight, cognitive flexibility, and regulating one’s emotions. Children and adolescents with ADHD may potentially demonstrate some combination of such executive difficulties over and above symptoms of inattention, hyperactivity, and impulsivity. An understanding of such challenges can often be important in guiding specific interventions targeting specific areas of concern.

Differential Diagnosis

ADHD is somewhat of a complex neurodevelopmental disorder to assess when considering that some of its symptoms and behaviors may be a function of a competing condition and not ADHD itself. The evaluative process needs to take into consideration a range of other psychological, neurodevelopmental, and substance use disorders when determining if the child truly demonstrates ADHD, or if symptoms are better accounted for by an alternate condition.

Common rule-out diagnoses in the differential diagnosis process include Behavioral Disorders (e.g., Oppositional Defiant Disorder, Conduct Disorder), Anxiety Disorders (e.g., Generalized Anxiety Disorder), Mood Disorders (e.g., Major Depressive Disorder, Persistent Depressive Disorders, Bipolar Disorder, Disruptive Mood Dysregulation Disorder), Neurodevelopmental Disorders (e.g., Autism Spectrum Disorder, Tourette’s Disorder, Intellectual Disability), Reactive Attachment Disorder, Substance Use Disorders, Psychotic Disorders, and Specific Learning Disorders.

Comorbidity

Making matters more difficult is the fact that many children and adolescents with ADHD demonstrate comorbid DSM-5 disorders. ADHD is a condition where comorbidity is the rule rather than exception. It is estimated that at least 80 percent of children with ADHD concurrently display one or more comorbid disorders (Willcutt & Bidwell, 2011). Any of the aforementioned behavioral, psychological, substance use, learning, or neurodevelopmental conditions may accompany an ADHD diagnosis. An understanding of the gestalt of the child is paramount so that all pertinent issues can be appropriately addressed.

Precise comorbidity estimates in regard to how frequently specific disorders are demonstrated in conjunction with ADHD are difficult to determine given that results vary across studies. Willcutt and Bidwell (2011) reviewed the literature indicating a relatively high frequency of comorbid disorders that often accompany ADHD. For example, Oppositional Defiant Disorder is present for approximately 30 to 60 percent of children with ADHD, with close to 50 percent of children with the Combined Presentation of ADHD concurrently displaying this behavioral disorder. A more serious Conduct Disorder is displayed by 20 to 50 percent of children with ADHD Combined Presentation. Other conditions such as anxiety disorders (15 to 30 percent) and depressive disorders (15 to 30 percent) are common. Approximately 10 percent of children with ADHD have a tic disorder (MTA Cooperative Group, 1999), although 50 to 60 percent of children with tic disorders have ADHD (Rothenberger, Roessner, Banashewki, & Leckman, 2007). The prevalence rates of children with intellectual disabilities and comorbid ADHD are 18 to 40 percent, while children with Autism Spectrum Disorders demonstrate comorbid ADHD at rates of 18 to 40 percent (Murray, 2010). Disruptive Mood Dysregulation Disorder is a new condition that has been introduced into DSM-5. The majority of children and adolescents with a Disruptive Mood Dysregulation Disorder concurrently display ADHD. However, the prevalence of a Disruptive Mood Dysregulation Disorder among children and adolescents is estimated to fall in the 2 to 5 percent range (American Psychiatric Association, 2013). In reality only a smaller percentage of children and adolescents demonstrating ADHD concurrently display a Disruptive Mood Dysregulation Disorder.

Research indicates that children with ADHD are more likely to display a comorbid Specific Learning Disorder compared with their peers. A recent literature review by DuPaul, Gormley, and Larracy (2013) concluded that the comorbidity rate is as high as 45 percent. Further, it is not uncommon for children with ADHD to underachieve academically, receive poor grades, or be less productive compared with their peers. DuPaul and Stoner (2014) estimate that learning and/or academic achievement problems are prevalent for 50 to 80 percent of samples of children and adolescents with ADHD.

It is important for the evaluating psychologist, psychiatrist, or physician to perform a thorough exam when assessing for ADHD given this potentially complex differential picture and high comorbidity rates that accompany this condition. It is not uncommon for many children with ADHD to continue to struggle academically, psychologically, and/or socially even after ADHD has been correctly identified ...

Table of contents

• Cover
• Half-title Page
• Title Page
• Copyright
• Contents
• Acknowledgments
• Chapter 1 Description and Diagnosis of Attention-Deficit/Hyperactivity Disorder
• Chapter 2 Conceptualization of ADHD
• Chapter 3 Evaluation and Assessment of Attention-Deficit/Hyperactivity Disorder
• Chapter 4 Treatment of Attention-Deficit/Hyperactivity Disorders
• Chapter 5 Case Studies
• About the Author
• Bibliography
• Index
• Backcover