Chapter 8 – Attention-Deficit/Hyperactivity Disorder (ADHD)
Description and history
Attention-deficit/hyperactivity disorder (ADHD): a disorder in which the individual consistently
and repeatedly shows age-inappropriate behaviors in 2 general categories of inattention and
hyperactivity-impulsivity, resulting in significant impairment in life functioning.
Inattentive: lacking the ability to focus or sustain one’s attention. Children who are inattentive
find it difficult to sustain mental effort during work or play and behave carelessly, as if they are
not listening.
Hyperactive: displaying an unusually high level of energy and an inability to remain still or quiet.
Impulsive: prone to acting with little or no consideration of possible consequences. This term is
frequently used to describe children who suffer from ADHD.
Description and History – Section Summary
- Attention-deficit/hyperactivity disorder (ADHD) is manifested in children who display persistent
age-inappropriate symptoms of inattention, hyperactivity and impulsivity that cause impairment
in major life activities.
- ADHD can only be identified by characteristic patterns of behavior, which vary quite a bit from
child to child.
- The behavior of children with ADHD is a constant source of stress and frustration for the child
and parents, siblings, teachers and classmates; it also has high costs to society.
- The disorder that we now call ADHD has had many different names, primary symptoms, and
presumed causes, and views of the disorder are still evolving.
Core characteristics
ADHD is included in DSM-5 as a neurodevelopmental disorder, because it has an early onset and
persistent course, is associated with lasting alterations in neural development, and is often
accompanied by subtle delays and problems in language, motor, and social development that
overlap with other neurodevelopmental disorders like autism spectrum disorder (ASD) and
specific learning disorder.
2 lists of key symptoms that were identified for defining ADHD and distinguishing it from related
problems:
1. First list includes symptoms of inattention
2. The second list includes symptoms of hyperactivity-impulsivity
The 2 dimensions of inattention and hyperactivity-impulsivity are highly correlated, but they do
predict different behavioral and cognitive impairments and likely have different neural
correlates.
• E.g. inattention tend to predict academic problems and peer neglect
• E.g. hyperactivity-impulsivity tend to predict aggressive behavior and peer rejection
Inattention
Inattention: an inability to sustain attention or stick to tasks or play activities, to remember and
follow through on instructions or rules, and to resist distractions.
Attentional capacity: the amount of information in short-term memory to which one can attend.
• Children with ADHD do not have a deficit in their attentional capacity. They can
remember just as much as any other children.
,Selective attention: the ability to concentrate exclusively on relevant stimuli and ignore task-
irrelevant stimuli in the environment.
• Distractibility: a term used to describe deficits in selective attention.
• Children with ADHD are much more likely than others to be distracted by stimuli that
are highly salient and appealing.
Sustained attention: the ability to maintain a persistent focus of attention over time on
unchallenging, uninteresting tasks or activities or when fatigued.
• Seems to be the primary attention deficit in ADHD.
• Deficits in sustained attention is one of the core features of ADHD.
Alerting: refers to an initial reaction to a stimulus and involves the ability to prepare for what is
about to happen.
• A child with an alerting deficit may respond too quickly in situations requiring a slow
and careful approach and too slowly in situations requiring a quick response.
• Thus, one view is that the deficit in sustained attention may be partly related to the
difficulty in alerting.
Hyperactivity-Impulsivity
Hyperactivity-impulsivity: a core feature of ADHD that involves the undercontrol of motor
behavior, poor sustained inhibition of behavior, the inability to delay a response or defer
gratification, or an inability to inhibit dominant responses in relation to ongoing situational
demands.
• A strong link between hyperactivity and impulsivity suggests a deficit in regulating
behavior.
Hyperactivity:
• Children with ADHD have more motor activity than other children, even when they
sleep. The amount of activity depends on environmental demands, with the largest
differences found in situations requiring the child to inhibit motor activity.
Impulsivity:
• Cognitive impulsivity is reflected in disorganization, hurried thinking and the need for
supervision. It may also involve impulsive decision making. It predicts problems with
academic achievement, especially reading.
• Behavioral impulsivity includes impulsively calling out in class or acting without
considering the consequences. They have difficulty inhibiting their response when the
situation requires it and are insensitive to the negative consequences of their behavior.
Behavioral impulsivity predicts rule-breaking behavior and may be a specific sign of
increased risk for conduct problems. It also predicts problems with academic
achievement, especially reading.
• Emotional impulsivity is demonstrated by impatience, low frustration tolerance, hot
temper, quickness to anger and irritability.
Primary attention deficit in ADHD is an inability to engage and sustain attention and to follow
through on directions or rules while resisting salient distractions.
The primary impairment in hyperactivity-impulsivity involves undercontrol of motor behavior,
poor sustained inhibition of behavior, the inability to delay a response or defer gratification, and
an inability to voluntarily inhibit dominant responses in relation to situational demands.
, Presentation type
Presentation type: a term used to describe a group of individuals with something in common -
symptoms, etiology, problem severity, or likely outcome – that makes them distinct from other
groups.
DSM specifies 3 presentation types of ADHD based on the individual’s primary symptoms:
1. Predominantly inattentive presentation (ADHD-PI): characterized by predominantly
inattentive symptoms.
a. Inattentive to details, easily distracted, careless, not listening, unfocused,
disorganized, unable to sustain effort and forgetful.
b. Often described as anxious and apprehensive and socially withdrawn and may
display anxiety and mood disorders.
c. These children represent the most common presentation in the general
population, but are less often referred to clinic than those with ADHD-C.
2. Predominantly hyperactive-impulsive presentation (ADHD-HI): characterized by
predominantly hyperactive-impulsive symptoms.
a. Rarest presentation and includes primarily preschoolers.
3. Combined presentation (ADHD-C): characterized by a combination of inattentive
symptoms and hyperactive-impulsive symptoms.
a. Most often referred for treatment.
3 subgroups of ADHD-PI:
1. Children who display both clinically significant symptoms of inattention and subclinical,
but still substantial, levels of hyperactivity-impulsivity.
2. Children whose inattentive symptoms are linked to problems with arousal and sluggish
cognitive tempo (SCT): a cluster of symptoms that includes daydreams, sleepy/drowsy,
underactive/slow moving, tired/lethargic, easily confused, stares blankly, lost in
thoughts, in a fog, slow thinking and responding, spacey/alertness changes from moment
to moment, apathetic, unmotivated, or low initiative and persistence.
3. Children who originally met criteria for the ADHD-C presentation but experience an age-
related reduction in symptoms of hyperactivity-impulsivity and thus no longer meet
criteria for the ADHD-C presentation.
ADHD-HI and ADHD-C:
• More likely to display problems in inhibiting behavior and in behavioral persistence.
• More likely to be aggressive, defiant, rejective by peers, and suspended from school or
placed in special education classes.
Additional DSM criteria
• Appears before age 12
• Persist for more than 6 months
• Occur more often and with greater severity than in other children of the same age and
sex
• Occur across 2 or more settings (e.g., home, school, etc.)
• Interfere with or reduce the quality of social, academic, or occupational functioning
• Not be better explained by another mental disorder
Limitations of DSM-5 for ADHD
• Developmentally insensitive: it applies the same symptoms to individuals of all ages.
• Categorical view of ADHD: according to DSM, ADHD is a disorder that a child either has or
doesn’t have. But research support the idea that ADHD is a dimensional rather than a
Description and history
Attention-deficit/hyperactivity disorder (ADHD): a disorder in which the individual consistently
and repeatedly shows age-inappropriate behaviors in 2 general categories of inattention and
hyperactivity-impulsivity, resulting in significant impairment in life functioning.
Inattentive: lacking the ability to focus or sustain one’s attention. Children who are inattentive
find it difficult to sustain mental effort during work or play and behave carelessly, as if they are
not listening.
Hyperactive: displaying an unusually high level of energy and an inability to remain still or quiet.
Impulsive: prone to acting with little or no consideration of possible consequences. This term is
frequently used to describe children who suffer from ADHD.
Description and History – Section Summary
- Attention-deficit/hyperactivity disorder (ADHD) is manifested in children who display persistent
age-inappropriate symptoms of inattention, hyperactivity and impulsivity that cause impairment
in major life activities.
- ADHD can only be identified by characteristic patterns of behavior, which vary quite a bit from
child to child.
- The behavior of children with ADHD is a constant source of stress and frustration for the child
and parents, siblings, teachers and classmates; it also has high costs to society.
- The disorder that we now call ADHD has had many different names, primary symptoms, and
presumed causes, and views of the disorder are still evolving.
Core characteristics
ADHD is included in DSM-5 as a neurodevelopmental disorder, because it has an early onset and
persistent course, is associated with lasting alterations in neural development, and is often
accompanied by subtle delays and problems in language, motor, and social development that
overlap with other neurodevelopmental disorders like autism spectrum disorder (ASD) and
specific learning disorder.
2 lists of key symptoms that were identified for defining ADHD and distinguishing it from related
problems:
1. First list includes symptoms of inattention
2. The second list includes symptoms of hyperactivity-impulsivity
The 2 dimensions of inattention and hyperactivity-impulsivity are highly correlated, but they do
predict different behavioral and cognitive impairments and likely have different neural
correlates.
• E.g. inattention tend to predict academic problems and peer neglect
• E.g. hyperactivity-impulsivity tend to predict aggressive behavior and peer rejection
Inattention
Inattention: an inability to sustain attention or stick to tasks or play activities, to remember and
follow through on instructions or rules, and to resist distractions.
Attentional capacity: the amount of information in short-term memory to which one can attend.
• Children with ADHD do not have a deficit in their attentional capacity. They can
remember just as much as any other children.
,Selective attention: the ability to concentrate exclusively on relevant stimuli and ignore task-
irrelevant stimuli in the environment.
• Distractibility: a term used to describe deficits in selective attention.
• Children with ADHD are much more likely than others to be distracted by stimuli that
are highly salient and appealing.
Sustained attention: the ability to maintain a persistent focus of attention over time on
unchallenging, uninteresting tasks or activities or when fatigued.
• Seems to be the primary attention deficit in ADHD.
• Deficits in sustained attention is one of the core features of ADHD.
Alerting: refers to an initial reaction to a stimulus and involves the ability to prepare for what is
about to happen.
• A child with an alerting deficit may respond too quickly in situations requiring a slow
and careful approach and too slowly in situations requiring a quick response.
• Thus, one view is that the deficit in sustained attention may be partly related to the
difficulty in alerting.
Hyperactivity-Impulsivity
Hyperactivity-impulsivity: a core feature of ADHD that involves the undercontrol of motor
behavior, poor sustained inhibition of behavior, the inability to delay a response or defer
gratification, or an inability to inhibit dominant responses in relation to ongoing situational
demands.
• A strong link between hyperactivity and impulsivity suggests a deficit in regulating
behavior.
Hyperactivity:
• Children with ADHD have more motor activity than other children, even when they
sleep. The amount of activity depends on environmental demands, with the largest
differences found in situations requiring the child to inhibit motor activity.
Impulsivity:
• Cognitive impulsivity is reflected in disorganization, hurried thinking and the need for
supervision. It may also involve impulsive decision making. It predicts problems with
academic achievement, especially reading.
• Behavioral impulsivity includes impulsively calling out in class or acting without
considering the consequences. They have difficulty inhibiting their response when the
situation requires it and are insensitive to the negative consequences of their behavior.
Behavioral impulsivity predicts rule-breaking behavior and may be a specific sign of
increased risk for conduct problems. It also predicts problems with academic
achievement, especially reading.
• Emotional impulsivity is demonstrated by impatience, low frustration tolerance, hot
temper, quickness to anger and irritability.
Primary attention deficit in ADHD is an inability to engage and sustain attention and to follow
through on directions or rules while resisting salient distractions.
The primary impairment in hyperactivity-impulsivity involves undercontrol of motor behavior,
poor sustained inhibition of behavior, the inability to delay a response or defer gratification, and
an inability to voluntarily inhibit dominant responses in relation to situational demands.
, Presentation type
Presentation type: a term used to describe a group of individuals with something in common -
symptoms, etiology, problem severity, or likely outcome – that makes them distinct from other
groups.
DSM specifies 3 presentation types of ADHD based on the individual’s primary symptoms:
1. Predominantly inattentive presentation (ADHD-PI): characterized by predominantly
inattentive symptoms.
a. Inattentive to details, easily distracted, careless, not listening, unfocused,
disorganized, unable to sustain effort and forgetful.
b. Often described as anxious and apprehensive and socially withdrawn and may
display anxiety and mood disorders.
c. These children represent the most common presentation in the general
population, but are less often referred to clinic than those with ADHD-C.
2. Predominantly hyperactive-impulsive presentation (ADHD-HI): characterized by
predominantly hyperactive-impulsive symptoms.
a. Rarest presentation and includes primarily preschoolers.
3. Combined presentation (ADHD-C): characterized by a combination of inattentive
symptoms and hyperactive-impulsive symptoms.
a. Most often referred for treatment.
3 subgroups of ADHD-PI:
1. Children who display both clinically significant symptoms of inattention and subclinical,
but still substantial, levels of hyperactivity-impulsivity.
2. Children whose inattentive symptoms are linked to problems with arousal and sluggish
cognitive tempo (SCT): a cluster of symptoms that includes daydreams, sleepy/drowsy,
underactive/slow moving, tired/lethargic, easily confused, stares blankly, lost in
thoughts, in a fog, slow thinking and responding, spacey/alertness changes from moment
to moment, apathetic, unmotivated, or low initiative and persistence.
3. Children who originally met criteria for the ADHD-C presentation but experience an age-
related reduction in symptoms of hyperactivity-impulsivity and thus no longer meet
criteria for the ADHD-C presentation.
ADHD-HI and ADHD-C:
• More likely to display problems in inhibiting behavior and in behavioral persistence.
• More likely to be aggressive, defiant, rejective by peers, and suspended from school or
placed in special education classes.
Additional DSM criteria
• Appears before age 12
• Persist for more than 6 months
• Occur more often and with greater severity than in other children of the same age and
sex
• Occur across 2 or more settings (e.g., home, school, etc.)
• Interfere with or reduce the quality of social, academic, or occupational functioning
• Not be better explained by another mental disorder
Limitations of DSM-5 for ADHD
• Developmentally insensitive: it applies the same symptoms to individuals of all ages.
• Categorical view of ADHD: according to DSM, ADHD is a disorder that a child either has or
doesn’t have. But research support the idea that ADHD is a dimensional rather than a
