ATTENTIONDEFICIT HYPERACTIVITY DISORDER Oppositional Defiant Disorder Conduct Disorder

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER & Oppositional Defiant Disorder, Conduct Disorder, and Juvenile Delinquency Child and Adolescent Psychopathology

Three types 1) Inattentive-disorganized (314. 00) 2) Hyperactive-impulsive (314. 01) 3) Combined type (314. 01) Ø Controversy over whether impulsivity should belong to hyperactive-impulsive type or separate category

Assessment of ADHD ü Careful history ü Data from multiple informants (e. g. , parents, teachers) ü Not normal developmental variation (e. g. , toddlerhood) ü Rule-out diagnoses (e. g. , anxiety and mood disorders, sleep and health-related disorders, some learning disorders) ü Direct observations ü Functional impairments (e. g. , at home and school, with peers)

Prevalence In U. S. population: 6. 8% between ages 6 -11 (although half also received diagnosis of LD) 4. 4% of adults diagnosed *Percent of Youth 4 -17 ever diagnosed with Attention. Deficit/Hyperactivity Disorder: National Survey of Children's Health, 2003 5. 3% of worldwide prevalence estimate

Etiological formulations ① Genetic influences on liability to ADHD: Ø Heritability estimated between. 6 and. 9 Ø Nonshared environmental effects are modest to small Ø Shared environmental effects are negligible Ø Genome-wide scans: focus on chromosome 5 (where DA transporter gene has been mapped) Ø Candidate gene studies: DA receptor genes (e. g. DA beta-hydroxylase gene)

Etiological Formulations ② Environmental Risks and Triggers a) Gene-environment correlations: Ø Parents who pass on ADHD genes and also provide chaotic home environment Ø Child contributes to counterproductive socialization experiences Ø Caregiver behavior also impacts ADHD sx Ø Transactional model: but child effects are greater (e. g. , medication reduced mothers' negative/controlling behaviors)

Environmental Risks and Triggers b) Gene-environment interactions Inflated heritability term in twin studies: experiential effects might differentially activate genetic risk Ø Unknown effect size of these experiential effects Ø

Environmental Risks and Triggers c) Environmental risk factors: ü Low birth weight (<2, 500 grams) ü Prenatal teratogens: o o Maternal alcohol exposure Maternal smoking ü Postnatal exposure to toxins (e. g. , lead exposure) ü Dietary insufficiencies (Uganda experience)

Neural imaging findings v 5% reduction in overall brain volume v 12% reduction in volume of key frontal and subcortical structures *UQ neuroscientist, Dr Ross Cunnington of Queensland Brain Institute (QBI) said there appears to be a biological difference in the brain that makes some children more susceptible to attention deficit hyperactivity disorder, combined type (ADHD-CT) (2007) *Neuroanatomical and functional model of attention-deficit hyperactivity disorder developed by Arnsten et al. (1996). Lateral view of the brain with a section of the cortex removed. Red lines represent noradrenergic pathways and black lines indicate cortical pathways mediated primarily by excitatory amino acids.

Neuropsychological and cognitive abilities Attention: ability to filter information is compromised ② Cognitive control: strategic allocation of attention and response is compromised ①

Cognitive control a) Working memory: Limited capacity system for keep something in mind while doing something else is compromised, especially spatial working memory weaknesses b) Response suppression: Ability to interrupt a response during dynamic moment-to-moment behavior (e. g. check-swing) is compromised

Cognitive control c) Set shifting: shifting one’s mental focus within a task is compromised (e. g. sorting by color or number) *Wisconsin Card Sorting task

Cognitive control d) Task switching: alternating tasks is compromised (e. g. counting or naming objects)

Neuropsychological and cognitive abilities ③ Motivation, approach, and reinforcement response a) ADHD not related to low reactive control as in psychopathy b) ADHD related to weakened reinforcement - delay gradient - lose interest in reward earlier than others c) Positive response to high intensity reinforcement d) Lack of physiological response to potential rewards

Neuropsychological and cognitive abilities ④ Temporal informational processing and motor control a) Faulty time perception for behavioral control b) Poor time estimation c) Poor time reproduction

Developmental Progression v Diagnosis as young as age 3 v Motoric hyperactivity more pronounced in preschool v Inattention more pronounced with age v Criteria for adolescents and adults are lacking

Comorbidity: ODD, CD, anxiety disorders, learning disorders v Sex differences: Ø Male preponderance: 2. 5: 1 in childhood, 1. 6: 1 in adulthood Ø Girls are less likely to show comorbid externalizing problems Ø Some impaired girls are missed by current diagnostic criteria Ø Girls might have greater resistance to etiological factors of ADHD

Cultural differences u ADHD informant ratings differ cross-culturally u ADHD might consist of different systems cross-culturally u Differences in treatment crossculturally (stimulants for minorities)

Protective factors Birth weight × lack of parental warmth ADHD (moderational model) Effectiveness in neuropsychological response inhibition Protective factors for ADHD children: Ø Ø reading ability absence of aggressive behavior positive peer relations effective parenting

Future directions v Specification of heterogeneity of ADHD v Specification of etiologies of ADHD subgroups v Specification of key moderators of ADHD behaviors v Specification of long-term treatment

Oppositional Defiant Disorder, Conduct Disorder, Juvenile Delinquency Juvenile delinquency: Children who have broken a law Conduct Disorder: 3 out of 15 antisocial behaviors within 12 months Oppositional Defiant Disorder: 4 out of 9 disruptive interpersonal behaviors

Comorbidity ODD, CD, ADHD all co-occur ODD and CD cooccur with depression

Developmental trajectories of conduct problems ① Childhood-onset (life-course persistent) trajectory: (5 -14%) • • Early neurodevelopmental deficits Inadequate parenting and adverse social influences ② Adolescent-onset (adolescence-limited) trajectory: (10 -21%) • Few conduct problems in childhood First law breaking in adolescence Desist from offending in early adulthood • •

Developmental trajectories of conduct problems ③ 3: 1 Ratio of males to females for childhood onset, but 1: 1 ratio for adolescent onset ④ Not two distinct trajectories but rather a continuum for children ⑤ CD children mostly childhood onset and met criteria of ODD

Age, sex, and prevalence ① ODD more prevalent than CD during early childhood ② ODD and CD have equal prevalence through adolescence ③ CD increase is greater in males than females ④ ODD more prevalent in males at all ages ⑤ Rates of delinquency peak at 16 or 17 and then decline sharply (age-crime curve)

Child characteristics that predict CD and delinquency ① Temperament: resists control, responds to threats with negative emotions, daring sensation-seeking, low prosocial behaviors, impulsivity, lack of persistence ② ODD CD ③ ADHD × CD APD (moderational model)

Child characteristics that predict CD and delinquency ④ Early shyness and anxiety conduct problems ⑤ Childhood cognitive skills and language conduct problems ⑥ Lower verbal intelligence conduct problems because affect more likely to be expressed behaviorally, more frustrating for parents

Adolescent and Adult outcomes of childhood ODD and CD ① Likelihood of other serious mental Dx in adulthood ② Majority of CD children (60 -70%) do not progress to ③ ④ ⑤ ⑥ APD Likelihood of depression (CD stressful life events depression) (mediational model) Adolescent suicide with CD, depression, and substance abuse Adult males: criminal behavior, work problems, substance abuse Adult females: depression, suicidal behavior, poor physical health

Environmental risk factors for conduct problems ü Birth weight and birth complications ü Maternal cigarette smoking and substance use during pregnancy ü SES + lower parental education (mostly childhood onset) ü Parental characteristics, family characteristics, and parenting Ø Ø Parental antisocial behavior and substance abuse Low maternal IQ Young mothers Mother’s multiple partners and discordant relationships

Environmental risk factors for conduct problems ü Deviant peer influence and gang membership • • Almost all adolescent crime is committed with peers Association with delinquent peers is highly correlated with delinquency ü Neighborhood and urbanicity: poverty and social disorganization

Molecular Genetics v Maltreatment × low-activity MAO-A genotype Conduct problems v Birth weight × high-risk COMT genotype Conduct problems

Summarizing dispositions to conduct problems ü Prosociality vs. callousness ü During sensation-seeking vs. fearful inhibition ü Negative emotionality vs. emotional stability ü Slowly developing cognitive skills and language (interferes with socialization experiences)

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