3/14/2011

What are the Earliest Signs of ADHD?

Jerilyn Ninowski, PhD March 9, 2011

Learning Objectives 1. Discuss how ADHD may manifest prior to the school age period. 2 Review 2. R i the th literature lit t off infants i f t att familial f ili l risk for ADHD. 3. Brief discussion on how parenting behaviours may play a role in ADHD developmental pathways.

Challenges • Normative behaviours for young children • Challenge of linking early behaviours with l t diagnoses later di • Lack of developmental sensitivity • No consensus on underlying deficit or single etiology

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• Retrospectively, parents report differences in their children as early as infancy – More M squirmy i – Less interested in cuddling – Impatient, easily frustrated – Require more attention – Sleep/nap less

• Toddler years – Inability to sustain attention for even a few minutes – Constantly distracted by sights and sounds – Difficulty sustaining eye contact – Better B tt attention tt ti for f high hi h interest i t t things thi such h as a favorite f it video id game or playing outside when high energy levels are required – Excessively hyperactive, always in motion – Lack of interest in cuddling or quiet activities – Difficulty calming down after becoming excited – Highly impulsive: will jump off of decks, slides or out of windows, will run into the street more often – Accident-prone – Difficulty sleeping, may have a hard time falling asleep and may be up at 5:00 AM each morning

• Preschool years – – – – – – – – – – – –

Inability to sit still Lack of interest in quiet activities or in listening to stories Changes activities every few minutes Inconsistency in attention skills, skills may be able to hold attention when an activity is interesting, but not able to keep attention for other activities Always in motion, sometimes running without looking, may run into street or fall often Can be very talkative Poor social skills Behavioral problems, not listening, disobeying or consistent unsafe behaviors Can be clumsy or have underdeveloped coordination May grab toys from classmates, siblings or friends Difficulty waiting for their turn May be aggressive, causing fights or hitting other children

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Preschoolers • Prevalence – 2-6 % meet DSM criteria – 5.1 % based on PAPA • Validity – Criteria are not developmentally sensitive • Preschool Age Psychiatric Assessment (PAPA)

Preschoolers • Recent increase in diagnoses – BUT, are we over-identifying? • Less than 100% persistence – 25 -50 % of preschoolers diagnosed with ADHD will no longer meet criteria in childhood or adolescence

Preschoolers • Inattention – Difficulty sustaining attention in tasks or play activities – Difficulty controlling attention to rules in one-to-one play activities • Hyperactivity – Talks excessively – Difficulty controlling talking when remaining quiet is expected (e.g., story time) • Impulsivity – Interrupts & intrudes on others – Difficulty refraining from interrupting when provided with structure and support to participate in engaging activities

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Sonuga-Barke et al. (2005)

Wh t about What b t prior i to t preschool? h l?

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What have we looked at? Regulatory disturbances – Crying – Sleep – Feeding • Temperament – Negativity – Activity level – Attention • Emotion regulation

Regulatory Disturbances • Wolke et al. (2002); Rao et al. (2004) – ↑ infant crying → ↑ child hyperactivity • Thunstrom (2002) – Infant sleep disturbance → ADHD • Becker et al. (2009) – DRD4 moderates the relationship between regulatory disturbances and ADHD

Temperament • Sanson et al. (1993) – ↑ activity & reactivity → ↑ activity, reactivity, behaviour problems @ 3 & ↑ hyperactivity @ 8 • Rende (1993) – ↑ infant emotionality → childhood attention problems – boys only • Goldsmith et al. (2004) – ↑ infant irritability & anger → ADHD sx

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Temperament cont’d • Auerbach et al. (2004, 2005, & 2008) – Atrisk infants – Neonates: irritability and difficulties with state lability & self-soothing – 7 months: less interest in block play & more anger reactivity – 12 months: increased activity & anger – 25 months: lower inhibitory control & effortful control

Emotion Regulation • Less data available – Theoretically: • ADHD can be viewed as a disorder of self-regulation • Regulation starts very early –Physiological, emotion, attention, behaviour

Ninowski (2010) • 78 mothers – varied on ADHD symptomatology and their 8-12 month old infants • Questionnaire and observational data • Goal to identify indicators of risk for ADHD in infancy based on maternal familial risk (FR)

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Key Findings • Was FR for ADHD related to infant temperament and emotion regulation? – FR → ↑ negative temperament, temperament activity, activity distress to limitations, ↓ duration of orienting and sustained attention – FR → ↑ negative reactivity, avoidant behaviours, ↓ focused orientation strategies

Summary • Infant temperament variables related to ADHD differ from the temperament variables related to other disorders. • BUT, BUT – Is any one variable necessary or sufficient? – How specific are these variables to ADHD compared to externalizing behaviours in general? – Is there a threshold of risk that must be met? – What role do other non-temperament variables play in the developmental pathway?

The role of parenting • Olsen et al. (2002) – ↑ object stimulation & ↓ restrictiveness →↓ ↓ impulsivity i l i it @ 8 yrs • Jacobvitz et al. (2004) – ↑ hostility →↑ ADHD symptoms @ 7 yrs

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Parenting cont’d • Carlson et al. (1995) – Intrusive parenting → distractibility @ 3 5 yrs, 3.5 yrs hyperactivity @ 6, 6 8, 8 & 11 yrs • Gaertner et al. (2008) – Maternal praise, warmth, & positive affect →↑ sustained attention – Maternal over-control →↓ sustained attention

Ninowski (2010) • Maternal insensitivity/intrusiveness partially mediated the relationship between familial risk and infant attention

Why is it important? • Early Identification • Early Intervention • Possibility of altering developmental trajectory

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References Auerbach, J. G., Atzaba-Poria, N., Berger, A., & Landau, R. (2004). Emerging developmental pathways to ADHD: Possible path markers in early infancy. Neural Plasticity, 11, 29-43. Auerbach, J. G., Berger, A., Atzaba-Poria, N., Arbelle, S., Cypin, N., Friedman, A., & Landau, R. (2008). Temperament at 7, 12, and 25 months in children at familial risk for ADHD. Infant and Child Development, 17, 321-338. Auerbach, J. G., Landau, R., Berger, A., Arbelle, S., Faroy, M., & Karplus, M. (2005). Neonatal behavior of infants at familial risk for ADHD. Infant f Behavior and Development, p , 28,, 220-224. Becker, K., Blomeyer, D., El-Faddagh, M., Esser, G., Schmidt, M. H., Banaschewski, T., & Laucht, M. (2010). From regulatory problems in infancy to attention-defict/hyperactivity disorder in childhood: A moderating role for the dopamine D4 receptor gene. Journal of Pediatrics, 156, 798-803. Carlson, E. A., Jacobvitz, D., & Sroufe, L. A. (1995). A developmental investigation of inattentiveness and hyperactivity. Child Development, 66, 37-54. Gaertner, B. M., Spinrad, T. L., & Eisenberg, N. (2008). Focused attention in toddlers: Measurement, stability, and relations to negative emotion and parenting. Infant and Child Development, 17, 339363. Goldsmith, H. H., Lemery, K. S., & Essex, M. J. (2004). Temperament as a liability factor for childhood behavioral disorders: The concept of liability. In L. F. DiLalla (Ed.), Behavior genetics principles: Perspectives in development, personality, and psychopathology (pp. 119-39). Washington, DC: American Psychological Association. Jacobvitz, D., Hazen, N., Curran, M., & Hitchens, K. (2004). Observations of early triadic family interactions: Boundary disturbances in the family predict symptoms of depression, anxiety, and attention-deficit/hyperactivity disorder in middle childhood. Development and Psychopathology, 16, 577-592.

Olson, S. L., Bates, J., E., Sandy, J. M., & Schilling, E. M. (2002). Early developmental precursors of impulsive and inattentive behavior: From infancy to middle childhood. Journal of Child Psychology and Psychiatry, 43, 435-447. Rao, M. R., Brenner, R. A., Schisterman, E. F., Vik, T., & Mills, J. L. (2004). Long-term cognitive development in children with prolonged crying. Archives of Disease in Children, 89, 989-992. Rende, R. D. (1993). Longitudinal relations between temperament traits and behavioral syndromes in middle childhood. Journal off the American Academyy off Child and Adolescent Psychiatry, y y, 32,, 287290. Sanson, A., Smart, D., Prior, M., & Oberklaid, F. (1993). Precursors of hyperactivity and aggression. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 1207-1216. Sonuga-Barke, E. J. S., Auerbach, J., Campbell, S. B., Daley, D., & Thompson, M. (2005). Varieties of preschool hyperactivity: Multiple pathways from risk to disorder. Developmental Science, 8, 141150. Thunstrom, M. (2002). Severe sleep problems in infancy associated with subsequent development of attention-deficit/hyperactivity disorder at 5.5 years of age. Acta Pediatrica, 91, 584-592. Wolke, D., Rizzo, P., & Woods, S. (2002). Persistent infant crying and hyperactivity problems in middle childhood. Pediatrics, 109, 1054-1060

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