THE MANY FACES OF ADHD

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THE MANY FACES OF ADHD

• Francis M. Crinella, Ph.D.
• Clinical Professor of Pediatrics, Psychiatry
  Human Behavior,
• and Physical Medicine Rehabilitation
• Director, Neuropsychology Laboratory
• Child Development Center
• University of California, Irvine
• 25 JAN 10

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WHAT IS ATTENTION?

• A special mental function was instituted which
  had periodically to search the outer world in
  order that its data might be already familiar if
  an urgent inner need should arise This function
  was attention. Its activity meets the sense
  impressions half way, instead of awaiting their
  appearance. At the same time, there was probably
  introduced a system of notation, whose task was
  to deposit the result of this periodic activity
  of consciousnessa part of which we call memory.
• Sigmund Freud Formulations regarding the two
  principles of mental functioning, 1911

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WHAT IS ATTENTION?

• Everyone knows what attention is. It is the
  taking possession in the mind, in clear and vivid
  form, of one out of what seem several
  simultaneous object or trains of
  thought. William James The Principles of
  Psychology, 1890

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CONSIDER YOUR LIFE WITHOUT ATTENTION--SOME
IMPORTANT FEATURES OF ATTENTION
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ATTENTION HELPS US TO MANAGE CONFLICTING
PERCEPTUAL INPUTS
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ATTENTION ALLOWS US TO PERSIST IN TASK PERFORMANCE
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ATTENTION HELPS US FOCUS ON THE TASK AT HAND
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ATTENTION ENABLES US TO PERFORM TASKS THAT
REQUIRE PLANNING AND WORKING MEMORY
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ATTENTION ENABLES US TO MAINTAIN VIGILANCE WHEN
MONITORING SIGNALS
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ATTENTION ENABLES US TO AVOID COSTLY ERRORS
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HOWEVER ATTENTION ITSELF IS ONE OF THE MOST
FRAGILE OF ALL MENTAL FUNCTIONS

• IT CAN BE ADVERSELY AFFECTED BY ANY NUMBER OF
  INFLUENCES
• ALMOST EVERY NEUROPSYCHIATRIC DISORDER IS
  ACCOMPANIED BY SOME KINDS OF ATTENTION DEFICITS
• ADHD IS BUT ONE OF THE PSYCHIATRIC DISORDERS IN
  WHICH ATTENTION IF AFFECTED
• ADHD MAY AFFECT SEVERAL DIFFERENT COMBINATIONS
  OF ATTENTIONAL COMPONENTS

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DSM-IV SYMPTOMS OF ADHD

• INATTENTION
• CANT ATTEND TO DETAILS
• CANT SUSTAIN ATTENTION
• DOESNT LISTEN
• FAILS TO FINISH
• CANT ORGANIZE TASKS
• AVOIDS SCHOOLWORK
• LOSES THINGS
• EASILY DISTRACTED
• FORGETFUL

• HYPERACTIVITY/IMPULSIVITY
• FIDGETS
• CANT STAY SEATED
• RUN ABOUT AND CLIMBS
• CANT PLAY QUIETLY
• IS OFTEN ON THE GO
• TALKS TOO MUCH
• BLURTS OUT ANSWERS
• CANT WAIT TURN
• INTERRUPTS OR INTRUDES

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CONFIGURATION OF DSM-IV SYMPTOMS OF ADHD IN
PATIENT 1
INATTENTION HYPERACTIVITY/IMPULSIVITY
1 CANT ATTEND TO DETAILS YES FIDGETS YES
2 CANT SUSTAIN ATTENTION NO CANT STAY SEATED YES
3 DOESNT LISTEN NO RUN ABOUT AND CLIMBS YES
4 FAILS TO FINISH YES CANT PLAY QUIETLY YES
5 CANT ORGANIZE TASKS YES IS OFTEN ON THE GO YES
6 AVOIDS SCHOOLWORK NO TALKS TOO MUCH NO
7 LOSES THINGS EASILY NO BLURTS OUT ANSWERS NO
8 DISTRACTED NO CANT WAIT TURN YES
9 FORGETFUL YES INTERRUPTS OR INTRUDES YES
NUMBER OF INATTENTION SYMPTOMS 4 NUMBER OF HYPERACTIVITY SYMPTOMS 7

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SYMPTOM CHECKLISTS FOR TWO PATIENTS WHO MEET
CRITERIA FOR ADHD, HYPERACTIVE/IMPULSIVE SUBTYPE
HYPERACTIVITY/ IMPULSIVITY PATIENT 1 PATIENT 2
1 FIDGETS YES NO
2 CANT STAY SEATED YES NO
3 RUNS ABOUT AND CLIMBS YES NO
4 CANT PLAY QUIETLY YES YES
5 IS OFTEN ON THE GO YES YES
6 TALKS TOO MUCH YES YES
7 BLURTS OUT ANSWERS NO YES
8 CANT WAIT TURN NO YES
9 INTERRUPTS OR INTRUDES NO YES
TOTALYES 6 6

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NUMBER OF POSSIBLE OF DSM-IV SYMPTOM
CONFIGURATIONS THAT MEET CRITERIA FOR DIAGNOSIS
OF ADHD

• FOR HYPERACTIVE SUBTYPE ONLY
• NUMBER OF VARIATIONS ON 9 CRITERIA
• 9/6 84
• 9/7 36
• 9/8 9
• 9/9 1
• ? 130

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NUMBER OF POSSIBLE OF DSM-IV SYMPTOM
CONFIGURATIONS THAT MEET CRITERIA FOR DIAGNOSIS
OF ADHDALL SUBTYPES

• HYPERACTIVE SUBTYPE 130
• INATTENTIVE SUBTYPE 130
• COMBINED SUBTYPE 260
• SUM OF POSSIBLE CONFIGURATIONS 520

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DOMAIN OF ADHD SYMPTOMS
7
8
13
2
1
14
12
4
18
3
9
15
6
5
16
11
17
10
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ADHD SYMPTOMS AS SUBDOMAIN OF MORE INCLUSIVE
DOMAIN OF ALL SYMPTOMS OF NEUROPSYCHIATRIC
DISORDER
1
11
8
12
2
10
3
7
14
6
13
9
4
17
5
15
18
16
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INDIVIDUAL WITH PUREADHD, REPRESENTED AS SUBSET
OF SYMPTOMS IN ADHD SUB-DOMAIN, EXCLUSIVE OF ALL
NON-ADHD SYMPTOMS IN LARGER DOMAIN OF ALL
MALADAPTIVE BEHAVIORS
1
11
8
12
2
10
3
7
6
14
13
4
5
9
17
18
15
16
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MORE COMMON CASE INDIVIDUAL WHO MEETS DSM-IV
DIAGNOSTIC CRITERIA FOR ADHD, BUT ALSO PRESENTS
WITH SYMPTOMS NOT CONSIDERED DIAGNOSTIC OF ADHD
1
11
2
10
12
8
7
3
13
14
6
4
9
17
5
18
15
16
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IS THIS ADHD? INDIVIDUAL STILL MEETS DSM-IV
DIAGNOSTIC CRITERIA FOR ADHD, BUT ALSO PRESENTS
WITH MANY MORE SYMPTOMS NOT CONSIDERED DIAGNOSTIC
CRITERIA FOR ADHD
1
11
8
2
12
7
3
10
6
14
13
4
5
17
9
18
16
15
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PROBLEM MANY CONFIGURATIONS OF MALADAPTIVE
BEHAVIOR ARE LABELED ADHD

• Should the label, ADHD, be assigned to a
  potpourri of disorders with only some features in
  common?
• Are there core features of true ADHD?
• What are the most common non-core accompaniments
  of ADHD?
• When do these non-core features signify that a
  diagnosis other than ADHD is more appropriate?

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BIOLOGICAL EVIDENCE FOR A CORE ADHD SYNDROME

1. NEUROCHEMICAL
2. GENETIC
3. ELECTROPHYSIOLOGICAL
4. FUNCTIONAL IMAGING
5. NEUROPSYCHOLOGICAL

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• NEUROCHEMICAL
• MOST EFFECTIVE TREATMENT--CNS STIMULANTS
• DEXTROAMPHETAMINES
• METHYLPHENIDATES
• EFFECTS
• Improved classroom behavior
• Improved academic productivity
• Improved peer/adult interactions
• Less frequent oppositional conduct
• Reduced aggression

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• GENETIC
• BEFORE MOLECULAR BIOLOGY
• Catecholamine hypothesisgenetic variations in
  brain neurochemistry (Wender, 1971)
• Family genetic studies (e.g., Faroane, Biederman,
  Chen et al., 1992)
• AFTER MOLECULAR BIOLOGY
• Subsensitive dopamine receptor hypothesis DRD4
  gene (LaHoste, Swanson, Wigal, et al., 1996)
• Dopamine transporter gene (Cook, Stein,
  Krasowski, et al., 1995)

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• FUNCTIONAL BRAIN IMAGING
• Evidence before modern imaging methods
• MBD hypothesis (Clements et al, 1963)
• Neuropsychology of MBD (Crinella, 1972)
• Evidence from modern imaging methods
• Methods used PET SPECT fMRI
• Results Variations in size and symmetry of
  brain structures (e.g., Swanson Castellanos,
  1997)
• Structures involved
• FRONTO-STRIATAL NETWORK
• CAUDATE NUCLEUS
• BASAL GANGLIA

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RECENT BRAIN IMAGING STUDIES IN ADHD
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• ELECTROPHYSIOLOGY
• Early studies of analog EEG
• Satterfield, J.H., Schell, A.M. (1984).
  Childhood brain function differences in
  delinquent and non-delinquent hyperactive boys.
  Electroencephalography and Clinical
  Neurophysiology, 57, 199-207.
• Finding Abnormal maturational effects of
  auditory event- related potential differentiated
  ADHD from non-ADHD subjects
• Recent brain mapping studies
• Pliszka, S.R., Liotti, M., Woldorff, M.G.
  (2000). Inhibitory control in children with
  attention-deficit/hyperactivity disorder.
  Biological Psychiatry, 48,238-46.
• Finding Event related potentials identify the
  processing component and timing of an impaired
  right-frontal response- inhibition mechanism.

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• COGNITIVE NEUROPSYCHOLOGY
• BASED ON TRADITIONAL APPROACH TO STUDYING
  BRAIN-BEHAVIOR RELATIONSHIPS
• Experimental removal of brain structures
• Observation of effect on specific behavioral
  functions
• Identification of brain structures/networks that
  are correlated with ADHD-like behavior

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DISTINCT ANATOMICAL NETWORKS CARRY OUT SPECIFIC
ASPECTS OF ATTENTION

• ALERTING NETWORK
• LOCATION ARAS, ETC.
• FUNCTION ACHIEVE AND MAINTAIN STATE OF READINESS
• ORIENTING NETWORK
• LOCATIONS PARIETAL LOBE, SUPERIOR COLLICULUS
  PULVINAR
• FUNCTION REACT TO SENSORY STIMULI
• EXECUTIVE NETWORK
• LOCATION ANTERIOR CINGULATE DORSOLATERAL
  FRONTAL CORTEX BASAL GANGLIA
• FUNCTIONS
• CONTROL NEURAL RESPONSES TO STIMULI
• GENERATE NEW INFORMATION FROM LONG TERM MEMORY
• PRIORITIZE OPERATION OF OTHER BRAIN AREAS

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ADHD IS A DISORDER THAT PRIMARILY AFFECTS THE
EXECUTIVE NETWORK
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SOME FEATURES OF EXECUTIVE FUNCTIONSTERNBERG
(1985)

• Decision as to just what the problem is that
  needs to be solved
• Selection of lower-order components
• Selection of one or more representations of
  organizations for information
• Selection of a strategy for combining lower order
  components
• Decision regarding tradeoffs in the speed and
  accuracies with which various components are
  executed
• Solution monitoring

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TESTS OF EXECUTIVE FUNCTION IN THE HUMAN
NEUROPSYCHOLOGY LABORATORY

• By definition, no test can be performed in the
  absence of executive control
• Executive functions must be differentiated from
  other cognitive
• abstract reasoning
• crystallized problem solving
• long term memory
• sensory-perceptual processing
• motor control systems
• Motivational states
• Which tests do this best?

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SPECIFIC NEUROPSYCHOLOGICAL APPROACHES TO
IDENTIFICATION OF ADHD

• EXAMPLE OF LABORATORY MEASURE OF EXECUTIVE
  FUNCTION--CONTINUOUS PERFORMANCE TEST (CPT)
• FOCUSES ON SPECIFIC AREAS OF EXECUTIVE FUNCTION
• TASK PERSISTENCE
• VIGILANCE
• IMPULSE CONTROL
• REGULATION OF AROUSAL LEVEL

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PRESS BUTTON EVERY TIME A LETTER APPEARS
A
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EXCEPT WHEN THE LETTER X APPEARS
X
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CONTINUOUS PERFORMANCE TEST

• SCORING CATEGORIES
• Omissions
• Commissions
• Overall Processing Speed
• Overall Attentional Variability
• Perceptual Sensitivity
• Risk Taking
• Perseverations
• Speed Decrement Over time
• Variability Over time
• Activation/arousal
  

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HIT REACTION TIME
700
675
650
4 SEC
625
600
2 SEC
575
550
MILLISECONDS
525
TYPICAL
500
1 SEC
ADHD
475
450
425
400
375
350
325
300
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STANDARD ERROR OF HIT REACTION TIME
100
4 SEC
90
80
2 SEC
70
1 SEC
60
MILLISECONDS
TYPICAL
50
ADHD
40
30
20
10
0
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COMMISSION ERRORS
1.8
1.6
1.4
1.2
1
MILLISECONDS
CONTROLS
ADHD
0.8
0.6
2 SEC
4 SEC
1 SEC
0.4
0.2
0
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• NON-ADHD CONDITIONS THAT CAN AFFECT SCORES ON
  CPT
• Commissions anxiety toxic irritability
• Omissions depression dyspraxia schizophrenia
• Overall Processing Speed depression anxiety
  metabolic conditions (e.g., hypoglycemia)
• Perceptual Sensitivity Visual acuity dyseidetic
  dyslexia cataracts
• Risk Taking psychopathy anxiety bipolar
  disorder
• Perseverations psychomotor retardation frontal
  lobe damage frank mental retardation
• Speed Decrement Over time depression diabetes
  hypothyroidism
• Activation/arousal schizotypal conditions
  (blocking) obsessional states malnutrition
  
  

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CPT AND DSM-IV COMMONALITIES FOR INDIVIDUALS WITH
ADHD AND INDIVIDUALS WITH ANXIETY
CPT
DSM-IV
UNDERAROUSED
RESTLESS AND ON EDGE
IMPERSISTENT
DIFFICULTY CONCENTRATING
IMPULSIVE
IRRITABLE
RECKLESS
TENSE
PERSEVERATIVE
DISTURBED SLEEP
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CPT AND DSM-IV COMMONALITIES FORINDIVIDUALS WITH
ADHD AND INDIVDUALS WITH DEPRESSION
CPT
DSM-IV
LOW ENERGY OR FATIGUE
IMPULSIVE
IMPERSISTENT
POOR CONCENTRATION
UNDERAROUSED
INSOMNIA/HYPERSOMNIA
RECKLESS
HOPELESSNESS
POOR APPETITE
PERSEVERATIVE
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CONCLUSIONS REGARDING THE DIAGNOSTIC SPECIFICITY
OF TESTS OF EXECUTIVE FUNCTION

• The capacity to maintain attention is fragile,
  and may be affected by virtually any psychiatric
  and/or neurological condition
• Even on tests of executive function, thought to
  be quite specific for the core deficits found
  in ADHD, problems other than ADHD will affect
  performance

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CONCLUSIONS

• Many individuals thought to have ADHD may have
  behavioral deficits that are commonly found among
  individuals with ADHD, but these deficits are
  also found in individuals with a host of other
  psychiatric disorders
• The incidence and prevalence of persons who have
  true ADHD, a hereditarily-transmitted disorder of
  the brains dopaminergic networks is probably
  much less than claimed by ADHD professionals and
  advocates
• Nevertheless Those whose attentional processes
  are affected by neuropsychiatric conditions other
  than ADHD are as deserving of treatment and
  accommodations for their attentional deficits as
  are those with true ADHD