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No universal agreed upon definition of how adhd is operationalized 2
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*variation in the research - Differences between boys and girls is variable and complex. Mixed research findings. Other issues surround neurobiological differences between M and F, as well as other environmental factors (sampling basis). - 3:1 ratio is based upon clinical samples; contrast when looking at non-referred samples the gender differences range from 1:1 to 3:1 - Teachers given comparable fictional records (diff only in gender) were more likely to refer boys than girls for consideration of ADHD - Girls less likely to manifest comorbid types as well as other externalizing behaviors - Britain uses ICD criteria which is more restrictive, and they conceptualize ADHD from resulting from family dysfunction, social disadvantage - Social- those with ADHD can be intrusive, immature, bossy, aggressive; negative social interactions with peers may lead to rejection, poor reputations, etc 4
Slide from: http://www.psychcongress.com/sites/naccme.com/files/318%20Jain_Slides_1.pdf 5
Slide from: http://www.psychcongress.com/sites/naccme.com/files/318%20Jain_Slides_1.pdf 6
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In social sciences, concentration is referred to as the ability to pay selective attention to something while ignoring other things. Controlling ones attention is the ability that we call as concentration. We cannot concentrate on an object or an activity unless we pay selective attention to it. Attention is an on and off activity and we can choose to pay attention to something or not. On the other hand, concentration has levels or degrees though it is hard to measure these levels. Paying attention to something or activity is like focusing the spotlight of a torch in the dark. One can pay attention to several activities at any given time. 8
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ARTICLE in resources that outlines Mirsky model more detailed. Mirsky suggested that attentive functioning results from coordinated action of several elements including: Encode- can they even get the info in? look at working memory ability Sustain- how do they maintain their performance over time. Computer task (14 min) example Shift- go between different tasks (prefrontal cortex, anterior cingulate gyrus) Focus/execute- inferior parietal lobe, superior temporal lobe, stratium. Stability- look at response reaction time, errors, etc. 11
Attention plays a role in ALL tasks we do so we are always looking at attention Divided attention- talking on phone while cooking Alternative attention- have difficulty in moving from one task to another; eg. increase mistakes when switching from folding to writing task; people may continue to perform aspects of the original task. Going back and forth between cooking and helping kid with homework 12
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When we talk about brain development, it is a bottom up process with frontal lobe being last to mature in 20s. Executive function skills are often associated with frontal lobe but do not work in isolation, it is a series of processes and interacts with multiple brain regions. Very complex and also variation in how it is defined and described Research has demonstrated that Children with ADHD have smaller volume prefrontal cortex as compared to same age peers 14
Skills associated with higher level adult types of function that you need to utilize everyday. variety of higher order cognitive abilities involved in the control and regulation of lower-level cognitive processes . Though there are variations in definitions of which specific skills it entails, executive functioning is believed to include skills which help in the guidance, direction, and management of cognitive, emotional, and behavioral functioning in purposeful behavior. The regulatory and management functions include skills such as initiation, cognitive flexibility, inhibition, planning, organization, ability to shift, problem-solving, monitoring, working memory, sustained and selective attention, and emotional control, particularly in tasks involving non-habitual responses 15
Dr. Brown gives us a helpful visual image by comparing executive function to the conductor's role in an orchestra. The conductor organizes various instruments to begin playing singularly or in combination, integrates the music by bringing in and fading certain actions, and controls the pace and intensity of the music. 16
comparing executive function to the conductor's role in an orchestra. The conductor organizes various instruments to begin playing singularly or in combination, integrates the music by bringing in and fading certain actions, and controls the pace and intensity of the music. An orchestra is made up of many different types of instruments, and each of these instruments is played independently. It is the conductor's role to integrate and organize the different instruments from moment to moment to achieve his musical goal regarding the piece. The conductor may need to respond to unexpected changes – for example, depending on the acoustics in the concert hall, he may need to ask one section to play louder. 17
http://www.westport.k12.ct.us/media/parents/westport_powerpoint_- _executive_functioning_12.10.09.pdf From Perkins ppt in folder 18
When we talk about ADHD, executive function is an important factor. Though not implicitly stated in diagnostic criteria it is in there, subtly through the symptomology. 19
Barkely conceptualizes ADHD types as separate conditions. Combined and hyperactivity types are different than inattentive. 20
Core impairment = Response Inhibition which then leads to secondary impairments in four neuropsych abilities which then lead to decreased control of behavior and action Due to abnormalities in the prefrontal cortex and connections to other brain regions (striatum) Response Inhibition affects four intermediate executive functions (lighter blue) So, poor response inhibition + deficits in executive functions = poor control Barkley also asserts that individuals with ADHD don’t develop “future orientation and sense of self across time” 21
Behavioral inhibition refers to 3 interrelate processes (see above). Prepotent response: is that response for which immediate reinforcement is available or has been previously associated with that response. Executive function plays role in beginning- having to resist urge to act involves self- regulation– an Executive Function 22
These are the Efs involved Kids with ADHD struggle in complex WM tasks (Digit Span Backwards) and mental math, struggle to hold information active in mind Self-regulation- emotional self-control; ability to express emotions internally; intrinsic motivation. Kids with adhd more negative and emotional peer interactions, low persistence of effort Speech- self-directed speech; formulating rules and problem solving; internal reflection, questioning, instruction/ internal rules for governing behavior. Kids with ADHD are less compliant with verbal demands, immature self-directed speech, develop internal speech at later age Reconstitution- ability to create complex and novel behavior sequences in order to attain future goals (generativity or fluency); AKA creative problem solving (verbal fluency). Analysis involves taking old behavior patterns into smaller pieces and synthesis involves recombining behavior patterns into novel solutions. Finding alternative solutions/methods. 23
As described previously- the deficits in the inhibition and exec function thereby leads to deficits in various abilities including control, timing, persistence, flexibility, and goal- directed actions. Goal directed motor responses 24
No official diagnosis or criteria There is a cognitive-inattentive and behavioral-motor dimension similar to ADHD. Symptom dimensions are distinct from yet partially correlated with those forming ADHD Some scientists think that SCT and ADHD may differ in the kind of inattention that they produce: While those with ADHD can engage their attention but fail to sustain it over time, people with SCT seem to have difficulty with engaging their attention in the first place Proposes it represents a dysfunction in the focus/execute component of attention in Mirsky’s model According to Dr Russell Barkley, a leading proponent of the SCT theory – he calls the condition "the second attention disorder" – between a third and a half of all those diagnosed with the inattentive subtype of ADHD are, in fact, suffering from SCT, and about the same number again remain undiagnosed. Associated with increased risk for internalizing symptoms (especially anxiety and depression) Stimulants not found to be very helpful with inattention linked to CDD 25
Hopefully now are familiar with my stance that we never look at scores or solitary behaviors in isolation. So when looking at ADHD evaluation and consideration, must consider all possible factors. 26
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