ADHD - ADHD: a historical neuropsychological perspective
11 important questions on ADHD - ADHD: a historical neuropsychological perspective
International classification system
- The WHO has the ICD, but used the term "hyperkinetic disorder" until recently
- ICD-10-CM is now more in line with the DSM-V
- ICD-10-CM has an age of onset of 7, and ADHD cannot be accompanied by other disorders
- this gives the ICD-10-CM lower diagnostic rates
Consensus statements and practical guidelines
- the disorder remained controversial tilll the 1990s, even after the start of medication
- there is remaining beliefs that the disorder does not exist
- the AACAP, NICE, and AAP created guidelines
- medication is a second line of treatment in children with mild to moderate symptoms
ADHD and executive functions
- failure of exucutive functioning, secondary to presumed anomalies in the (pre)frontalstratial brain circuitry, modulated by the expression of catecholamines
- Barkley: a failure of self-control systems with behavioral inhibition as the core
- four functions: working memory, self-regulation of affect-motivation-arrousal, internalization of speech, and reconstruction
- inhibition was a primary deficit
- secundary EF impairments led to motor deficits
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Cognitive energetic models
- based on the information processing model of joseph sergeant and colleagues
- ADHD is a product of energetic (bottom-up) systems involving arousal, activation and effort, and cognitive (Top-down) executive control systems that limit the expression of energetic stated like an inverted U, allowing for other EF functions to moderate output
- in contrast to Barkleys model, the cognitive energetic model alows for subxortical anomalies to be the primary manifestation of ADHD
Motivation and delay aversion
- based on the influence of reward systems in the brain
- preference for "smaller sooner" over "larger later" rewards
- incorporates EF and dorsal-frontostratial circuitry
- dual-pathway model recognises influence from a second reward system, and sensitivity to rewards
- a third pathway is suggested, involving temporal processing deficits manifested in difficulties with time and timing, reproduction and motor synchronization
Sluggish cognitive tempo
- sluggish cognitive tempo (SCT)
- lethargy, daydreaming, confusion, drowsiness
- three core symptoms: lethargy, underactivity, slowness
- these core symptoms are different from inattention associated with ADHD and are hypnothesized to be a function of earlier selective attention processes
Multimodal treatment study of children with ADHD (MTA)
- four treatment strategies: medication, psychosocial treatment, combined (medication and psychosocial treatment), and community control
- medication and combined showed greatest improvement
- psychosocial treatment and community control showed less improvement but showed the same improvement (more intense psychosocial treatment may have been necessary)
- after 24 months, the combined treatment showed better effects compared to the medication, and showed growth-related side effects in comorbidities and family related processes
Preschool ADHD treatment study (PATS)
- large trial to study the effects of MPH on preschoolers
- side effects were less than in the MTA and side-effects like a slower growth rate were more common
- a 6 year follow up showed stability of the symptoms despite the ongoing medication
Genes environment and ADHD
- genetic component with a heritability of 70-80%
- first degree relatives have a 5-10 fold risk of developing the symptoms
- most likely deficits in the dopamine or other neurotransmitters
- COMT gene - associated with degradation of prefrontal dopamine
- ADHD is associated with multiple genes
ADHD and learning disabilities
- comorbidity with dyslexia
- high rate of learning disorders
- more problems arise when children go from "learning to read" to "reading to learn" because this increases demands for Ef
ADHD and motor control
- overflow movements - unconsiously produced concomitant movements
- exists in children, but symptoms diminish till disappearance during the first decade of life in healthy children
- overflow movements persist in children with ADHD
- difficulty to meet normal movement milestones in children with ADHD (ability to hop on 1 foot is a predictor at age 4 for hyperactivity at age 7)
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