Attention Deficit/Hyperactivi... Health Article

Attention Deficit/Hyperactivity Disorder

Disorder characterized by attentional deficit and/or hyperactivity—impulsivity more severe than expected for a developmental age.

Attention Deficit/Hyperactivity Disorder (ADHD), which affects 3-5% of school-age children in the United States, refers to a combination of excessive motor restlessness, difficulty in controlling or maintaining attention to relevant events, and impulsive responding that is not adaptive.

For some children hyperactivity is the primary feature of their ADHD diagnosis. These children may be unable to sit quietly in class. They may fidget in their chairs, sharpen their pencils multiple times, flip the corners of the pages back and forth, or talk to a neighbor. On the way up to the teacher's desk they may take several detours.

Most children with ADHD have both attentional and hyperactivity-impulsivity components, and so they may experience difficulties regulating both attention and activity. Although many children who do not have ADHD seem periodically inattentive or highly active, children with ADHD experience these difficulties more severely than others at their same developmental level. Moreover, these difficulties interfere with age-appropriate behavioral expectations across settings such as home, playground, and school.

Psychologists have not always used the label ADHD to describe this constellation of behaviors. In the 1950s and 60s, children exhibiting these symptoms were either diagnosed as minimally brain damaged or labelled as behavior problems. The fourth edition of the Diagnostic and Statistical Manual (DSM-IV), which is used to classify psychiatric disorders, describes ADHD as a pattern of inattention and/or impulsivity-hyperactivity more severe than expected for the child's developmental level. The symptoms must be present before age seven, although diagnosis is frequently made only following interference with school activities. Symptoms must be present in at least two settings, and there must be clear evidence of interference with academic, social, or occupational functioning. Finally, the symptoms must not be due to other neuropsychiatric disorders such as pervasive developmental disorder, schizophrenia or other psychoses, or anxiety disorder or other neuroses.

Inattention may be evident in (a) failing to attend closely to tasks or making careless errors, (b) having difficulty in persisting with tasks until they are completed, (c) appearing not to be listening, (d) frequently shifting tasks or activities, (e) appearing disorganized, (f) avoiding activities that require close or sustained attention, (g) losing or damaging items by not handling them with sufficient care, (h) being distracted by background noises or events, or (i) being forgetful in daily activities. According to the DSM-IV, six or more of these symptoms must persist for six months or more for a diagnosis of ADHD with inattention as a major component.

Hyperactivity may be seen as (a) fidgety behavior or difficulty sitting still, (b) excessive running or climbing when not appropriate, (c) not remaining seated when asked to, (d) having difficulty enjoying quiet activities, (e) appearing to be "constantly on the go," or (f) excessive talking. Impulsivity may be related to hyperactive behavior and may be manifest as (a) impatience or blurting out answers before the question has been finished, (b) difficulty in waiting for one's turn, and (c) frequent interruptions or intrusions. Impulsive children frequently talk out of turn or ask questions seemingly "out of the blue." Their impulsivity may also lead to accidents or engaging in high risk behavior without consideration of the consequences. According to the DSM-IV, six or more of these symptoms must persist for six months or more for a diagnosis of ADHD with hyperactivity-impulsivity as a major component.

The DSM-IV recognizes subtypes of ADHD. The most prevalent type is the Combined Type in which individuals show at least six of the symptoms of inattention as well as of hyperactivity or impulsivity. The Predominantly Inattentive Type and the Predominantly Hyperactive-Impulsive type are distinguished by which of the major pattern of symptoms predominate.

It is important that a careful diagnosis be made before proceeding with treatment, especially with medication. Often symptoms of inattention or hyperactivity may cause parents to seek professional help, but these symptoms may not necessarily indicate the presence of ADHD. Paul Dworkin, a physician with special interests in school failure, reports that out of 245 children referred for evaluation due to parental or school concerns about inattention, impulsivity, or overactivity, only 38% received a diagnosis of ADHD, although almost all (91%) were diagnosed with some kind of academic problem.

Who gets ADHD? Boys outnumber girls by at least a factor of four; studies have found prevalence ranging from four to nine times as many boys with ADHD compared to girls. The family members (first degree relatives) of children with ADHD are more likely to have the disorder, as well as a higher prevalence of mood and anxiety disorders, learning disabilities, and substance abuse problems. Children who have a history of abuse or neglect, multiple foster placements, infections, prenatal drug exposure, or low birth weight are also more likely to have ADHD. Although there is no definitive laboratory test for ADHD nor a distinctive biological marker, children with ADHD do have a higher rate of minor physical anomalies than the general population.

Children may develop problems because of the consequences of ADHD. If the causes of a child's disruptive or inattentive behavior are not understood, the child may be punished, ridiculed, or rejected, leading to potential reactions in the areas of self-esteem, conduct, academic performance, and family and social relations. A child who feels that he or she is unable to perform to expectations no matter what type of effort is put forth may begin to feel helpless or depressed. Often, the reaction can exacerbate the inattention or hyperactivity or diminish the child's capacity to compensate, and a vicious cycle can develop.

The course of the disorder may vary. For many ADHD children, symptoms remain relatively stable into the early teen years and abate during later adolescence and adulthood. About 30-40% of cases persist into the late teens. Some individuals continue to experience all of their symptoms into adulthood and others retain only some.

What causes ADHD? The exact cause of ADHD is not known. The increased incidence of the disorder in families suggests a genetic component in some cases. Brain chemistry is implicated by the actions of the medications that reduce ADHD symptoms, suggesting that there may be a dysfunction of the norepinephrine and dopamine systems. Brain imagining techniques have been used with mixed success. Positron emission tomography (PET) scans show some reduced metabolism in certain areas (prefrontal and premotor cortex) in ADHD adults, but findings on younger patients are less clear. One complication in conducting these imagining studies is the necessity for patients to remain still for a period of time, something that is, of course, difficult for ADHD children to do.

What can be done? Treatment for ADHD takes two major forms: treating the child and treating the environment. Pharmacological treatment can be effective in many cases. Stimulant medications (Ritalin/methylphenidate, Dexedrine/dextroamphetimine, and Cylert/magnesium pemoline) have positive effect in 60-80% of cases and are the most common type of drugs used for ADHD. The benefits include enhancement of attention span, decrease in impulsivity and irrelevant behavior, and decreased activity. Vigilance and discrimination increase and handwriting and math skills frequently improve. These gains are most striking when pharmacological treatment is combined with educational and behavioral interventions.

Stimulant medications, however, may have side effects in some children that may make them inappropriate choices. These side effects include loss of appetite, insomnia, mood disturbance, headache, and gastro-intestinal distress. Tics may also appear and should be monitored carefully. Psychotic reactions are among the more severe side effects. There is some evidence that long-term use of stimulant medication may interfere with physical growth and weight gain. These effects are thought to be ameliorated by "medication breaks" over school vacations and weekends, and the like.

When stimulant medications are not an appropriate choice, non-stimulants or tricyclic antidepressants may be prescribed. The use of tricyclic antidepressants, especially, has to be monitored carefully due to possible cardiac side effects. Combined pharmacologic treatment is used for patients who have ADHD in addition to another psychiatric disorder.

It is important that drug treatment not be used exclusively in the management of ADHD. Each child should have an individual educational plan that outlines modifications to the regular mode of instruction that will facilitate the child's academic performance. Teachers need to consider the needs of the ADHD child when giving instructions, making sure that they are well paced with cues to remind the child of each one. They must also understand the origins of impulsive behavior—that the child is not deliberately trying to ruin a lesson or activity by acting unruly. Teachers should be structured, comfortable with the remedial services the child may need, and able to maintain good lines of communication with the parent.

Specialists should devise a series of compensatory strategies that will enable the child to cope with his or her attentional or activity challenges. These strategies might include simple things like checklists of things to do before handing in assignments (name on top, check spelling, etc.), putting a clock on the child's desk to help structure time for activities, or covering the pictures on a page until the child has read the words so that he is not distracted.

Special assistance may not be limited to educational settings. Families frequently need help in coping with the demands and challenges of the ADHD child. Inattention, shifting activites every five minutes, difficulty completing homework and household tasks, losing things, interrupting, not listening, breaking rules, constant talking, boredom, and irritability can take a toll on any family.

Parents may not understand how attention regulation or impulsivity affect daily functioning, and they might not be trained in the kind of techniques that help ADHD children manage their behavior. Siblings may be resentful of what the ADHD child seems to "get away with" or the inordinate amount of attention he or she receives. The ADHD child may be resentful of the younger sibling who is more accomplished at school or never seems to get in any trouble. Family interaction patterns may set up vicious cycles that become destructive and difficult to break.

Support groups for families with any ADHD member are increasingly available through school districts and health care providers. Community colleges frequently offer courses in discipline and behavior management. Counselling services are available to complement any type of pharmacological treatment that the family obtains for its member. There are also a number of popular books that are informative and helpful. Some of these are listed below.