Attention-Deficit/Hyperactivity

Disorder (ADHD)
Andrea Chronis-Tuscano, Ph.D.
Associate Professor of Psychology
Director, Maryland ADHD Program
University of Maryland

Maryland ADHD Program

Mission
To conduct clinical research that advances our

knowledge about the assessment and treatment

of ADHD
To provide comprehensive, evidence-based
assessment and treatment of ADHD and
associated problems to children and their families
To train the next generation of clinical
psychologists in evidence-based assessment and
treatment practices
To educate parents, schools, health professionals
and the community about evidence-based
assessment and treatment for ADHD

Overview
Definition & Features
Etiological Factors
Evidence-Based Assessment &

Treatment
Professional Practice Parameters

Prevalence & Impact

Prevalence rate of 6-10%
More prevalent in males than females
Male:female ratio is 3:1 in epidemiological
samples
Ranges from 3:1 - 9:1 in clinical samples
50% of children referred to mental health

clinics are referred for ADHD-related

problems
Annual societal cost of illness for ADHD
estimated to be between $36 - 52 billion
$12,005 -- $17,458 annually per individual
www.cdc.gov

Definition & Features

DSM-IV Diagnostic Criteria

Inattention Symptoms (at least 6 symptoms

required)

Fails to give close attention to details or makes

careless mistakes in schoolwork, work, etc.

Difficulty sustaining attention
Does not seem to listen when spoken to
directly
Does not follow through on instructions and
fails to finish schoolwork, chores, etc.
Difficulty organizing tasks and activities
Avoids tasks requiring sustained mental effort
Loses things necessary for tasks or activities
Easily distracted by extraneous stimuli
Forgetful in daily activities

APA, 2000

ADHD Diagnostic Criteria

(cont.)

Hyperactivity-Impulsivity Symptoms (at least 6

symptoms required)

Difficulty playing or engaging in activities quietly

Always "on the go" or acts as if "driven by a

motor
Talks excessively
Blurts out answers
Difficulty waiting in lines or awaiting turn
Interrupts or intrudes on others
Runs about or climbs inappropriately
Fidgets with hands or feet or squirms in seat
Leaves seat in classroom or in other situations in
which remaining seated is expected

APA, 2000

ADHD Diagnostic Criteria

(cont.)

Symptoms present before age 7

Clinically significant impairment in social

or academic/occupational functioning
Some symptoms that cause impairment
are present in 2 or more settings (e.g.,
school/work, home, recreational
settings)
Not due to another disorder (e.g.,
Autism, Mood Disorder, Anxiety
Disorder)

APA, 2000

Subtypes
Combined Type
Clinical levels of both inattention and

hyperactivity/impulsivity
Most common subtype
Predominantly Inattentive Subtype
Clinical levels of inattention only
Often not identified until middle school
Sluggish cognitive tempo

Predominantly Hyperactive/Impulsive Subtype

Clinical levels of hyperactivity/impulsivity only
More common among very young children prior to

school entry

Controversial Issues with

DSM-IV Criteria

Developmentally insensitive
Symptoms based on field trials conducted with
elementary school aged boys (Lahey et al., 1994)
Categorical (not continuous) view
Requirement of onset before age 7

arbitrary
Requirement of 6 months duration too
brief
Requirement that symptoms be
demonstrated across 2 settings

Associated Problems
Peer problems
Inattentive symptoms ignored
Hyperactive/impulsive symptoms actively rejected
Not deficient in social reasoning/understanding, but
rather the execution of appropriate social behavior
Family dysfunction/parental issues
No clear causal relationship between family problems
and ADHD
Family problems can impact the severity and
developmental course/outcomes of ADHD
Self-esteem
Inflated: Positive illusory bias (Hoza)
Low self esteem associated with comorbid depression

Developmental Course
ADHD is persistent across lifespan in most cases
Methodological issues impact estimates of persistence
ADHD severity, psychiatric comorbidity, and parental
psychopathology predict persistence (Biederman et al., 2011)
Inattention remains stable; hyperactivity declines with

age
DSM-IV criteria may not capture adolescent/adult

manifestations of impulsivity
Adult outcomes including psychiatric comorbidity
When ADHD co-occurs with conduct disorder, chronic
criminality and serious substance use can result
When ADHD co-occurs with depression, risk of suicide

Etiological Factors

Etiological Factors
Average heritability of .80 - .85
Environmental factors are not the cause, but may
contribute to the expression, severity, course, and
comorbid conditions
Dysfunction in prefrontal lobes
Involved in inhibition, executive functions
Genes involved in dopamine regulation
Dopamine transporter (DAT1) gene implicated
7 repeat of dopamine receptor gene (DRD4)
implicated
Gene x environment interactions
Possible differences in size of brain structures
Prefrontal cortex, Corpus callosum, caudate nucleus
Abnormal brain activation during attention &

inhibition tasks

Kieling, Gondaves. Tannock. & Castellanos. 2008; Mick &.

Brain Structure & Function

Differences in brain maturation,

structure, function
(particularly abnormalities in
frontostriatal circuitry):
Prefrontal cortex
Basal ganglia
Cerebellum

These areas of the brain

are associated with

executive function abilities:
Attention, spatial working memory, and short-term

memory

Response inhibition and set shifting

Neurotransmitters
Neurotransmitter differences,

particularly in levels of:

Dopamine
Norepinephrine
Epinephrine
Serotonin

Dopamine has been associated

with approach and pleasure-seeking behaviors

Norepinephrine plays a role in

emotional/behavioral regulation

Executive Functioning
Deficits

Cognitive processes which activate, integrate,

and manage other brain functions

Examples:
Cognitive: working memory, planning, use of
organizational strategies
Language: verbal fluency, communication
Motor: response inhibition, motor coordination
Emotional: self-regulation of emotion, frustration
tolerance
But
EF deficits overlap with ADHD symptoms
EF deficits are not unique to ADHD
Not all children with ADHD have EF deficits

Barkleys Theory
ADHD is not a problem with
knowing what to do; it is a problem
of doing what you know.
-Barkley, 2006
Behavioral disinhibition is the basis of

executive functioning deficits in ADHD

A performance, rather than knowledge,

deficit

A Possible Developmental Pathway for ADHD

From Mash & Wolfe, 2007

Evidence-Based Assessment
& Treatment of ADHD

Evidence-Based
Assessment
Teacher- and parent-completed questionnaires
Structured clinical interview with parent(s)
IQ/Achievement testing to screen for learning

disabilities (50% comorbidity)

Behavioral observations at home and school
No medical screen, cognitive test, or brain

imaging technique can detect ADHD

Children with ADHD can focus long enough to
watch TV, play videogames or sit still at the
doctors office.
Pelham, Fabiano & Massetti,

Well-Established ADHD
Treatments
Stimulant Medications
Behavioral Interventions
Behavioral parent training
Behavioral classroom management
Intensive summer treatment programs

Pelham & Fabiano, 2008

Medication: Stimulants
Most well-researched, effective, and commonly

used medication treatment for ADHD.

Methylphenidate (Ritalin, Concerta, and Metadate)

Dextroamphetamine (Adderall)

These medications

reduce ADHD symptoms by:

Blocking the reuptake of

norepinephrine (NOR) and

dopamine (DOP) and facilitating
their release
Enhances NOR and DOP
availability in in certain brain
regions: PFC and basal ganglia

Stimulant Medications
Research has shown that stimulants:

Are highly effective in reducing ADHD symptoms in the short

term
Decrease disruption in the classroom
Increase academic productivity and on-task behavior
Improve teacher ratings of behavior

Different formulations work best for different children

Common side effects: insomnia, decreased appetite
Strattera (atomoxetine)

A non-stimulant alternative that works well for some children

Has not been studied as long or as intensively as the

stimulants
Smaller effect size relative to the stimulants

Limitations of Stimulant
Treatment
Individual differences in response
Not all children respond (approximately 80%)
Limited impact on domains of functional

impairment

Primary reason for treatment seeking

Does not normalize behavior

Family problems beyond the scope of

medication
No long-term effects established
Long-term use rare
Limited parent/teacher satisfaction
Some families are not willing to try
medication

How do we identify evidencebased, non-pharmacological

treatments?

Evidence-based treatment implies that

studies have been conducted with the
following features:
Careful specification of the target population
Diagnostic, demographic, recruitment, selection
Random assignment to conditions
Comparison could be to placebo but ideally to
established tx
Use of treatment manuals
Ensures reliability of administration and facilitates
replication
Multiple outcome measures with blind raters

Statistically significant differences between the

tx and comparison group at post-tx

Replication, ideally by independent researchers
Chambless et al., 1996; Silverman &
Hinshaw, 2008

Well-Established
Non-Pharmacological

Treatments
Behavioral parent training
33 well-conducted studies

Behavioral classroom management

45 well-conducted studies

Pelham, Wheeler & Chronis, 1998; Pelham &

Behavioral Treatment
Components

Psychoeducation about ADHD

Structure/routines
Clear rules/expectations
Attending/rewards
Planned ignoring
Effective commands
Time out/loss of privileges
Point/token systems
Daily school-home report card
Intensive summer treatment programs

Behavioral Treatment
Considerations

Need to address cross-situational impairments

Poor generalization from treatment setting to realworld
Implement treatments in all settings in which child
shows impairment
School behavior
504 Plan/Individualized Education Plan (IEP)
Academic interventions needed in addition to

behavioral interventions

(Raggi & Chronis, 2006)

Environmental contingencies must be delivered

consistently, which is difficult to maintain

Parental psychopathology can interfere with

implementation

Multi-Modal Treatment Study

for ADHD (MTA)
6 sites
579 Children, 7-9 y/o
ADHD, Combined Type

Assigned to 14 months of:

Med management
Intensive Behavior Therapy
Combined treatment
Treatment as Usual in the Community

(TAU)
2/3 received medication
MTA Cooperative Group,
1999

Overall Results
All groups showed reductions in ADHD sx over time
On primary outcome measure (ADHD sx),

medication alone and combined tx did better than

behavioral tx alone and tx as usual (TAU) in the
community
On many measures, combined tx was not
significantly better than medication alone
Only combined tx was better than TAU on
oppositional symptoms, aggression,
depression/anxiety symptoms, social skills, parentchild relationship, and reading achievement
Higher medication doses were needed in the
medication only group relative to the combined
treatment group

MTA Cooperative Group,

1999

Combined Treatment was

superior
Parent and teacher satisfaction with
intreatment
terms of:
Normalization of child behavior
Improvements in functional outcomes
Family interactions
Peer relationships
Academic functioning

Connors et al., 2001; Hinshaw et al.,

2000; Pelham et al., 2004; Swanson et

MTA 6-8 Year Follow-Up

Original treatment assignment not associated with any

of the 24 outcomes 6-8 yrs later

ADHD symptom trajectory in the first 3 years predicted
55% of the outcomes
Children with the best initial tx response and most favorable

clinical presentation at baseline fared best over time

Children with behavioral and sociodemographic advantage,
with the best response to any tx, had the best long-term
prognosis
As a group, children with combined-type ADHD exhibit

significant impairment in adolescence (on 9 of 21

measures)
This suggests a need for sustained treatment over the
long term
Molina et al., 2009

Practice Parameters

American Medical Association (AMA)

encourages the use of individualized therapeutic

approacheswhich may include pharmacotherapy,

psychoeducation, behavioral therapy, school-based and other
environmental interventions, and psychotherapy, as indicated
by clinical circumstances and family preferences. (p.1106)

American Academy of Pediatrics (AAP)

the clinician should recommend medication (strength of

evidence: good) and/or behavior therapy (strength of

evidence: fair), as appropriate, to improve target outcomes in
children with ADHD (strength of recommendation: strong) (p.
1037)

American Academy of Child &

Adolescent Psychiatry (AACAP)

Treatment may consist of pharmacological and/or

behavior therapy but that pharmacological

intervention for ADHD is more effective than a
behavioral treatment alone and that behavioral
intervention alone might be recommended as an initial
treatment if the patients ADHD symptoms are mild with
minimal impairmentor parents reject medication
(p.902)if a child has a robust response and shows
normative functioningthen psychopharmacological
treatment alone is satisfactory (p. 912)
If the child does not show a robust response to all FDAapproved medications, the clinician should consider
behavior therapy and/or the use of medications not
approved by the FDA for treatment of ADHD (p.907)

Summary
1. ADHD is a highly prevalent, brain-based disorder which
2.
3.

4.

5.

is associated with lifelong impairment in functioning

Environmental factors can contribute to the expression,
severity, course, and comorbid conditions
Long-term developmental outcomes for individuals with
ADHD can include serious substance abuse, chronic
criminality, depression and suicide
Stimulant medications and behavior therapy are
currently the only established evidence-based
treatments for ADHD
Combined behavioral-pharmacological treatment has
the greatest impact on functional outcomes, is preferred
by parents and teachers, and is most likely to result in
normalization of behavior