IntroductionAttention Deficit-Hyperactivity Disorder (ADHD) has been one of the most talked about and controversial disorders of children. The controversy that surrounds this disorder is in part due to contradictory information available to the public. On one hand, there is a significant concern about over-diagnosis of ADHD and, as a result, overmedication of children. On the other hand, data shows that while between 3-13% of children have symptoms of ADHD, only 2-3% are receiving treatment. The purpose of this article is to dispel some of the misconceptions about ADHD as well as to provide definition and diagnostic guidelines that are used by doctors and therapists.
Symptoms and DiagnosisFor ADHD, the name says it all. It is a disorder related to attention (or inattention) and hyperactivity. Even though this disorder has a deceptively easy name, it is one of the most difficult to diagnose. There are several reasons for this difficulty. First, the person who makes the diagnosis has to be able to differentiate between the normal activity level and normal attention span of a child as opposed to overactivity and attentional deficits that are considered excessive. We all have seen children who are at times very active, get distracted easily, and are unable to focus on their tasks or follow directions. Most children, however, are able to return to their normal functioning after a short period. A child with ADHD has chronic problems with inattention and hyperactivity. These children are inattentive, unable to follow directions, and unable to stay on task most of the time. A second issue related to the diagnosis of ADHD is that the behavioral problems must occur in more than one setting. If a child shows problems in school but does not exhibit similar behavior in any other setting (such as at home, or in team sports), other diagnoses should be considered. The third issue relates to the ability of the clinician to distinguish between symptoms of ADHD and other symptoms-such as overactivity, restlessness, and inattention-that result from disorders such as childhood anxiety, depression, or conduct disorder. The fourth factor relates to the age of onset of ADHD and duration of time a child has shown deficit behaviors. In a child with ADHD, symptoms should be present before age seven, and some symptoms must be present continuously for six months. As these factors indicate, diagnosis of ADHD requires extensive investigation and history taking. The clinician should obtain information from multiple sources, such as the child, his/her parents, teachers, and others who may be familiar with the child’s behavior.
Diagnosis of ADHDAttention Deficit-Hyperactivity Disorder can be diagnosed under three types. First is the "combined" type, in which both criteria for inattention and hyperactivity are met for six consecutive months. Second is the predominantly "inattentive" type, in which only inattentive criteria are met for the six months. The third diagnosis is predominantly "hyperactive-impulsive" type, in which criteria for hyperactivity are met for six months, but the criteria for impulsivity are not met.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) sets the criteria for diagnosis of different types of ADHD. For the inattentive type, six or more of the following symptoms must be present. The child:
- fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
- has difficulty sustaining attention during tasks or play activities.
- fails to listen when spoken to directly.
- fails to follow through on instructions and to finish schoolwork, chores, or duties in the workplace.
- has difficulty organizing tasks and activities.
- avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as homework).
- loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools).
- is easily distracted by outside stimuli.
- is frequently forgetful in daily activities.
The symptoms of hyperactivity and impulsivity should also be excessive and inconsistent with developmental level. To make this type of ADHD diagnosis, the child should demonstrate six or more of the following behaviors for six consecutive months. The child:
- fidgets with hands or feet or squirms in his/her seat.
- leaves his/her seat in the classroom or in other situations in which remaining seated is expected.
- runs around or climbs excessively in situations in which these behaviors are inappropriate. (In adolescents or adults, these behaviors may be limited to subjective feelings of restlessness.)
- has difficulty playing or engaging in leisure activities quietly.
- is often "on the go" or acts as if he/she is "driven by a motor".
- talks excessively.
- blurts out answers before questions have been completed.
- has difficulty awaiting his/her turn.
- often interrupts or intrudes on others, butting into conversations or games, for example.
Associated features and symptomsAttention Deficit-Hyperactivity Disorder is four- to nine times more frequent in boys than in girls. Children with ADHD also experience associated learning disabilities. Some research has shown that up to 30% of ADHD children have disabilities in reading or mathematics, which worsen their already poor performance in school. According to a report by U.S. Surgeon’s General office, most children with ADHD are not diagnosed formally until they start school. The main reason for this late diagnosis is that up until they are in school, most of these children do not have to deal with the demands of a highly structured environment. Furthermore, their overactivity, restlessness and inattention begin to set them apart from other students. Furthermore, because of their unusual level of activity, ADHD children tend to be unpopular with their schoolmates, which in turn exacerbates their isolation and the negative psychological impact of the disorder. The worst outcome of Attention Deficit-Hyperactivity Disorder is for children who have conduct or oppositional defiant (disagreeable) disorder. As they grow up, these children tend to develop depression and anxiety and have severe behavioral difficulties.
Adult ADHDAlthough the main focus of this article is on children, adult ADHD must also be mentioned. For many ADHD children, behavioral problems begin to decrease as they age. However, for some, the deficits continue until adulthood and can have significant impacts on their lives. Common signs of adult ADHD include disorganization, the inability to hold jobs, and chronic underachievement. Furthermore, since individuals with ADHD are susceptible to self-medication, problems with drugs and alcohol might continue into adulthood.
Causes of ADHDSimilar to many other psychiatric disorders, the exact cause of ADHD is not known. Some studies of twins have pointed to genetic causes as the main culprit. In addition, since ADHD children respond well to a group of medications called psychostimulants, which increase the level of the brain chemical dopamine, the so called "dopamine hypothesis" (deficient brain dopamine) has been put forth as the cause of the disorder. However, other studies have shown that stimulants increase attention spans both in people with ADHD and in those who do not have the disorder. Therefore, the dopamine hypothesis does not seem to be the sole explanation for development of ADHD. Other studies using brain imaging have shown differences between people with and without ADHD in an area of the brain called the pre-frontal lobe . This area of the brain is responsible for the so-called "executive functioning", which is responsible for decision-making, goal setting, and behavior directing. Another possible cause relates to exposure to toxins, such as lead. Other studies have examined the behavior of the parents of ADHD children, examining overly controlling- and overly intrusive parents. However, a closer look appears to indicate that such parenting style is a response to the ADHD children rather that the actual cause of the disorder.
ADHD TreatmentAccording to the American Academy of Child and Adolescent Psychiatry (AACAP), treatment of ADHD should include medication, support and education of parents, and appropriate school placement. As mentioned previously, the most common type of medications for treatment of ADHD are psychostimulants. The most commonly known drugs in this class are Ritalin (methylphenidate hydrochloride) and Dexedrine (dextroamphetamine Sulfate). These drugs work by increasing brain arousal, which in turn increases attention and lowers impulsivity. Of course, these medications have associated side effects, including insomnia, decreased appetite, stomachaches, and headaches. In most cases, lowering of the dosage will adequately relieve side effects. For children who do not respond well to psychostimulants, other types of medications-such as antidepressants or antipsychotic-have been shown to improve the symptoms occasionally. You can also buy strattera. It is primarily used to treat children who have ADHD.
Since medications alone do not seem to improve social functioning and personal relationships of ADHD children, treatment must be supplemented with behavioral therapy for the children, parents, and teachers. In fact, a recent study by the National Institute of Mental Health (NIMH) showed that combined medication and behavioral treatment has the best outcome. Behavioral treatment becomes even more important for children who do not respond well to any type of medication. Among other techniques, behavioral treatment should enhance a child’s ability to tell between behavior that is expected versus behavior that is not expected or is inappropriate. For example, a teacher should say, "Johnny, this is not the time to talk," (what is not expected) "but is time to do your homework" (what is expected). A parent should say, "Alice, stop running," (what is not expected) "and listen to me" (what is expected). With adequate support and appropriate reinforcement (such as praise or attention), an ADHD child should be able eventually to control his/her behavior without supervision. The most important aspect, however, is that such behavioral techniques are most effective if applied in all situations (such as home and school). Likewise, as was mentioned previously, ADHD children often have learning disabilities. Therefore, school accommodations, appropriate school settings, and psychological referrals are also needed.