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Externalising Disorders 6 Notes

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= problem behaviours that includes several clinically recognised disorders eg attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD)
Mullin & Hinshaw, 2007: By grouping ADHD, CD and ODD under 1 label, the communalities of these disorders are highlighted, however some of their important differences are usually de-emphasised

Characteristics  definitions and symptoms
Characterised by pervasive behave symptoms of hyperactivity, impulsivity and inattention, starting in childhood
Alexander Chrichton (1763-1856): earliest recorded feature in 1978: 'mental restlessness'
Nigg et al., 2005: impulsive, excessive/ exaggerated motor activity, difficulties in sustaining attention
Wender, 2000: highly distractible and fail to follow instructions or respond to demand placed on them
Barkley, 1997: Lower in intelligence - usually 7-15 IQ points below average talk incessantly, socially intrusive and immature.
Biederman et al., 2004: children with ADHD show deficits on neuropsych testing that are related to poor academic functioning
Generally have many social problems due to their impulsivity and overactivity
Hyperactive children have issues in getting along with their parents as they do not follow rules
In general, they are not anxious, even though overactivity and distractibility may suggest they are
Ryan-Krause et al., 2010: hyperactivity is the most frequently diagnosed mental health condition in the US
More frequently among preadolescent boys  6-9x more prevalent in boys than girls
ADHD occurs with the greatest frequency before age 8, and becomes less frequent thereafter
Staller, 2006: comorbid with other disorders eg ODD
Odell et al., 1997: residual effects may persist into adulthood
Bauermeister et al., 2010: found across cultures  one study found that ADHD symptoms are similarly recognised across 10 European countries

Prevalence rate - gender differences
Planczyk et al., 2007; 2014: a Neurodevelopmental disorder affecting 5-7% of children worldwide
Alloway et al., 2010: in the UK 8% are diagnosed with ADHD
The disorder commonly occurs amongst boys more than girls  boys 6-9% more likely to have ADHD
Male-female ratio - 6:1, 3:1, 1:1

4.4% adults Conceptualising ADHD
1968: Hyperkinetic Disorder of childhood 1980: Attention Deficit Disorder  with or without hyperactivity, residual type recognised 1987: ADHD (only combined symptoms)
1994: AD/HD - 3 types 2000: AD/HD (impaired executive function)

3 subtypes in DSM-IV-TR:

1. Inattentive (IA)

2. Hyperactive-impulsive (HI)

3. Combined (C)

Differential diagnosis
 ADHD - more off-task behaviour, cognitive and achievement deficits
 Conduct Disorder - more aggressive, act out in most settings, antisocial behaviours, family hostility

DSM-V (2013)
Adults and teenagers can be officially diagnosed
Earliest symptoms identified at age 12 years (rather than 7)
Subtypes now referred to as 'presentations'
Mild, moderate and sever levels of ADHD, depending on symptoms
Main difference from DSM-IV-TR  can be diagnosed with ASD

DSM-V Diagnostic Criteria:
 Inattentive presentation
 Hyperactive/impulsive presentation
 Combined presentation
Moderat e


Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in only minor functional impairments
Symptoms or functional impairment between 'mild' and 'severe' are present
Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities

2. Often has difficulty sustaining attention in tasks or play activities

3. Often does not seem to listen when spoken to directly Hyperactivit y and impulsivity

4. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

7. Often loses things necessary for tasks or activities

8. Is often easily distracted by extraneous stimuli

9. Is often forgetful in daily activities

1. Often fidgets with or taps hands or feet or squirms in seat

2. Often leaves seat in situations when remaining seated is expected

3. Often runs about or climbs in situations where it is inappropriate
(Note: In adolescents or adults, may be limited to feeling restless)

4. Often unable to play or engage in leisure activities quietly

5. Is often "on the go," acting as if "driven by a motor"

6. Often talks excessively

7. Often blurts out an answer before a question has been completed

8. Often has difficulty waiting his or her turn (eg while waiting in line)

9. Often interrupts or intrudes on others

ADHD: Cognitive deficits
Impairments in all aspects of executive function  Martinussen et al., 2005; Willcutt et al., 2005
Executive process are:
 Inhibition
 Working memory
 Cognitive flexibility
 Planning
Barkley (1997, 2000,2005)
Nature of inattentiveness  failure to inhibit response - central impairment
Behavioural inhibition  links to emotional to self-regulation
Not related to Sluggish Cognitive Tempo  SCT children tend to have problems with attention, LTM,
socially withdrawn
Biederman et al., 2004: ADHD linked with EF deficits  poor acadmic achievement
Clark et al., 2000: those with ADHD performed worse on EF tasks whether they had comorbid CD/ODD or not

ADHD: Neurological deficits Shaw et al., 2007:
Both control and ADHD groups showed a similar development process of cortical thickness, but the ADHD
group showed considerable delay in reaching this developmental marker
Neuroanatomical Correlates:
Reduced activity in:
Castellanos et al., 1996
Frontal cortex
Hill et al., 2003
Basal ganglia

Prefrontal subregions
Reduced volume including the caudate nucleus and putamen, both serve as entry points of basal ganglia
Reduced volume by 6% compared to controls

ADHD Genetics: Heritability Coefficient
Doyle et al., 2005: 76% heritability - meta-analysis of twin studies
Larsson, 2013: correlation of innatentive and hyperactive-impulsive symptoms:
 52% genetic influence
 48% environmental influence
Biederman et al., 2012: rates of ADHD are sig higher between biological relatives compared with adoptive relatives
Noradrenergic system: altered peripheral levels  assoc with neuropsych tasks and brain function

ADHD: Risk Factors and Aeitology
= much debated  likely to be a combination
Genetic risk factors:
Rietveld et al., 2004: measured maternal ratings of CBCL of twins at 4 age points (3, 7, 10, 12 years)  75%
heritability at all ages = high
Genome studies:
Gizer et al., 2009: ADHD is known to respond to medications of NT reuptakes
Target genes implicated:
 Dopamine receptors - DRD4, DRD5
 Dopamine transporters - DAT1
 Serotonin receptors - 5HTTPLR
Other genes involved in noradrenergic and nicotinergic pathways
 Individually tested - likelihood of false positives
 Single genes identified - may not always be causal
 Different genetic risk assoc - harder to identify single risk factor in large populations
Environmental factors:
Low birth weight
Breslau & Chilcoat, 2000: <2500g Maternal smoking/drugs

Prenatal alcohol consumption
Family pathology
Lead exposure

BUT this was accounted for by maternal smoking
Also more ADHD in urban than suburban areas
Bada et al., 2007; Milberger et al., 1996
 Exposure to tobacco in utero is assoc with ADHD symptoms
 May damage dopaminergic system resulting in behavioural disinhibition  Kring et al., 2006
Jacobson et al., 2002
Goos et al., 2007: parental personality  transmitted to children
Lead is one of the sig heavy metals related to having detrimental health effects  Dietrich et al., 2001
Related to low IQ and hyperactive-impulsive traits  Nigg et al., 2008

Whatever the causes, the underlying mechanisms need to be better understood
Nigg, 2001: general agreement that processes operating in the brain are disinhibiting the child's behaviour
Barry et al., 2003: different EEG patterns in children with and without ADHD  BUT theorists do not agree what those CNS processes are

ADHD: Treatment
= disagreement over the most effective methods
Medications and behaviour therapy
Medications eg amphetamines = controversial
Behaviour therapy, particular cognitive = great deal of promise in modifying the behaviour of children with hyperactivity
Stimulant medications
 Reduce disruptive behaviour
 Improve interactions with parents, teachers, peers
 Improve goal-directed behaviour and concentration
 Reduce aggression
 Konrad et al., 2004: stimulants decreased overactivity and distractibility, and increase alertness
 allows them to function much better at school



Fava, 1997: Ritalin can lower aggressiveness
Charach et al., 2004: can make behaviour relatively normal

greater improvement in teacherreported symptoms

Side effects
Decreased blood flow to the brain 
 Impaired thinking ability and memory loss
 Disruption of growth hormone

suppression of growth
 Insomnia
 Psychotic symptoms

Exerts beneficial effects on classroom behaviour by enhancing cognitive

Less adverse side effects than

Do not cure ADHD but reduce behavioural symptoms in 50-67% of cases where medication was warranted Strattera


FDA-approved nonstimulant medication reduces symptoms but mode of operation is not understood
Combination of amphetamine and dextroamphetamine

Vomiting, fatigue, jaundice, liver damage

Miller-Horn et al., 2008:
no advantage or improvement over Ritalin or Strattera

ST pharmacological effects of stimulants are established, but LT effects are not well known
Volkow et al., 1995: pharmacological similarity of Ritalin and cocaine = concerns
Chutko etal., 2010: college students share prescription with friends to get high

Psychological treatments
= used in conjunction with medications
DuPaul et al., 1998
Everett & Everett, 2001

Frazier & Merril, 1998

Selective reinforcement in the classroom
Family therapy
Effects the whole family eg other children wondering why the ADHD child gets more attention
In order to reduce ADHD, must reduce family dysfunction
 highly successful method
Positive reinforcement and structuring of learning materials/tasks in ways to minimise error and maximise feedback and success
 effective with those with ADHD with different levels of the disorder - most effective for lower/intermediate levels

Multimodal treatment of ADHD (MTA) study: Jensen et al., 2001:
 Slightly better than medication alone
 Improved social skills whereas medication alone did not
 No difference in groups at 3 year follow-up
 Stimulant medication more effective for some children than others
Major Co-occurring disorders
Pliszka, 2006:
45-84% Conduct disorders and oppositional defiant disorder 25% Anxiety (including OCD)
Holtman et al., 2007: 14-75% ASD
= a repetitive and persistent violation of rules and a disregard of others
 aggressive or antisocial behaviours
Children with CD shows a deficit in social behaviour

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