Case Analysis – Integrating Theoretical Orientations

10

Attention-Deficit/

Hyperactivity Disorders

REBECCA J. HAMBLIN AND ALAN M. GROSS

OVERVIEW

Attention-deficit/hyperactivity disorder (ADHD)

is one of the most well-studied child psycho-

pathologies, and a tremendous amount of

research has been published related to its

etiology, primary problems and impact,

demographic and contextual variability, and

treatment methods. The label has also received

heavy criticism as being an artificial U.S.

construct for labeling normally exuberant

children; however, early clinical descriptions

of attention impairments date to 1798 (Barkley,

2006; Palmer & Finger, 2001). Attention-

deficit/hyperactivity disorder symptoms are

reported to occur in all countries in which

ADHD has been studied (Polanczyk, de Lima,

Horta, Biederman, & Rohde, 2007). Despite

early conceptualization of the disorder as

resulting from poor character or wayward

parenting, ADHD is now seen as a neuro-

logically based disorder (Barkley, 2006).

ADHD is one of the most common dis-

orders of childhood, affecting an estimated

3% to 5% of children in the United States,

and is the most common reason for clinical

referral of children to psychiatric clinics

(American Psychiatric Association, 2000).

Children with ADHD display symptoms of

inattention, impulsivity, and hyperactivity

across multiple situations beginning at an

early age. The frequency of these behaviors

is out of bounds with respect to normal

development, and symptoms cause significant

impairments in family and peer relationships,

academic functioning, and emotional well-

being (Barkley, 2006).

This chapter will provide an overview of the

core symptoms and current diagnostic features

of the disorder, describe its prevalence and

epidemiology, impairments to daily life,

comorbid disorders, and long-term outcomes.

The next sections will describe various

psychosocial treatments that have been

empirically explored, and will review the most

current research on treatment efficacy. The

chapter concludes with a summary and list of

evidence-based treatments for ADHD.

CORE SYMPTOMS

Inattention

Relative to children without ADHD, those

with the disorder have difficulty maintaining

attention or vigilance in responding to envir-

onmental demands. That is, they have trouble

sustaining effort in tasks, particularly for

activities that are tedious, difficult, or with

little intrinsic appeal (Barkley, 2006). In the

classroom setting, impairment in attention and

task vigilance may be evident in inability to

c10 21 April 2012; 9:57:7

243 Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, child and adolescent disorders. Retrieved from http://ebookcentral.proquest.com Created from ashford-ebooks on 2019-11-03 14:16:24.

C op

yr ig

ht ©

2 01

2. J

oh n

W ile

y &

S on

s, In

co rp

or at

ed . A

ll rig

ht s

re se

rv ed

.

 

 

complete independent assignments or listen

to class instruction. In unstructured settings,

inattention may be apparent in frequent shifts

between play activities. Parents and teachers

report that these children have difficulty

focusing, are often forgetful, lose things, fre-

quently daydream, fail to complete chores and

schoolwork, and require more redirection

and supervision than others the same age.

Children with high levels of inattentive

symptoms in the absence of hyperactive or

impulsive symptoms may also have a different

kind of attention problem marked by sluggish

cognitive processing and deficiency in select-

ive attention (Barkley, 2003). Case Analysis – Integrating Theoretical Orientations

Hyperactivity and Impulsivity

Hyperactivity and impulsivity almost always

co-occur and are therefore considered a single

dimension of ADHD. The hyperactive-

impulsive dimension of the disorder is often

conceptualized as behavioral disinhibition.

Hyperactivity is displayed in fidgeting, rest-

lessness, loud and excessive talking, and

excessive levels of motor activity. Impulsive

behaviors include interrupting or intruding on

others, difficulty waiting and taking turns, and

blurting out without thinking. Children

and adolescents with hyperactive-impulsive

features are described by caregivers as reck-

less, irresponsible, rude, immature, squirmy,

and on the go (APA, 2000; Barkley, 2006).

Diagnostic Criteria and Subtypes

Diagnostic criteria for ADHD are defined by

theDiagnostic and StatisticalManual ofMental

Disorders, FourthEdition, Text Revision (DSM-

IV-TR) as presence of several symptoms in

inattention, hyperactivity-impulsivity, or both,

as seen in Table 10.1 (APA, 2000). Individuals

with symptoms in both domains are classified as

having ADHD, combined type (ADHD-C).

Those who manifest multiple symptoms of

inattention but no or few hyperactive-impulsive

characteristics are diagnosed with ADHD,

predominately inattentive type (ADHD-PI).

The ADHD, predominately hyperactive-

impulsive type (ADHD-PHI) describes indi-

viduals with behavioral disinhibition without

significant symptoms of inattention. Table 10.1

contains the complete diagnostic contained in

the DSM-IV-TR.

PREVALENCE AND DEMOGRAPHIC

VARIABLES

Nearly 5 million children in the United States

are diagnosed with ADHD (Centers for Dis-

ease Control and Prevention [CDC], 2005).

Prevalence rates of ADHD translate, on aver-

age, to one to two children in every classroom

in America (APA, 2000). The most commonly

diagnosed subtype is ADHD-C, representing

about 50% to 75% of children diagnosed.

Another 20% to 30% are classified with

ADHD-PI, while fewer than 15% are diag-

nosed with ADHD-PHI. It is thought that

ADHD-PHI may be a developmental precursor

to the combined type, seen in preschool-age

children who have not yet manifested symp-

toms of inattention.

Boys are 2 to 9 times more likely than girls to

be diagnosed with ADHD (APA, 2000). The

gender discrepancy is more pronounced in

clinic referred than in community samples.

Higher rates among males may be at least

partially attributable to a stronger tendency for

males to present ADHD-C and comorbid dis-

ruptive behavior disorders, which are more

likely to rise to the level of clinical attention.

Girls are more likely to have ADHD-PI and

comorbid disorders are more likely to be

internalizing disorders. Because symptoms of

ADHD-PI and emotional disorders are more

likely to go unnoticed, girls with ADHD

may be underindentified and undertreated

(Biederman, 2005).

ADHD is present among all socioeconomic

levels and ethnic groups within the United

States, though prevalence and symptoms vary

by gender, age, and ethnicity (Barkley, 2003;

244 Specific Disorders

c10 21 April 2012; 9:57:7

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, child and adolescent disorders. Retrieved from http://ebookcentral.proquest.com Created from ashford-ebooks on 2019-11-03 14:16:24. Case Analysis – Integrating Theoretical Orientations

C op

yr ig

ht ©

2 01

2. J

oh n

W ile

y &

S on

s, In

co rp

or at

ed . A

ll rig

ht s

re se

rv ed

.

 

 

TABLE 10.1 DSM-IV-TR Criteria for Attention-Deficit/Hyperactivity Disorder

I. Either A or B:

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is

inappropriate for developmental level:

Inattention

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other

activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the work-

place (not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time

(such as schoolwork or homework).

7. Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an

extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat when sitting still is expected.

2. Often gets up from seat when remaining in seat is expected.

3. Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel

very restless).

4. Often has trouble playing or doing leisure activities quietly.

5. Is often “on the go” or often acts as if “driven by a motor.”

6. Often talks excessively.

Impulsivity

7. Often blurts out answers before questions have been finished.

8. Often has trouble waiting one’s turn.

9. Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g., at school/work and at home).

IV. There must be clear evidence of clinically significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other

Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g., Mood Disorder,

Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Case Analysis – Integrating Theoretical Orientations