attention deficit hyperactivity disorder

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Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder

Definition

Attention deficit hyperactivity disorder (ADHD) is not a clinically definable illness or disease. Rather, as of December 2003, ADHD is a diagnosis that is made for children and adults who display certain behaviors over an extended period of time. The most common of these behavioral criteria are inattention, hyperactivity, and marked impulsiveness.

In the American description, there are three types of ADHD, depending on which diagnostic criteria have been met. These are: ADHD that is characterized by inattention, ADHD characterized by impulsive behavior, and ADHD that has both behaviors.

The European description of ADHD places the disorder in a subgroup of what are termed hyperkinetic disorders (hallmarks are inattention and over-activity).

Description

ADHD is also known as attention deficit disorder (ADD), attention deficit disorder with and without hyperactivity, hyperkinesis, hyperkinetic impulse disorder, hyperactive syndrome, hyperkinetic reaction of childhood, minimal brain damage, minimal brain dysfunction, and undifferentiated deficit disorder.

The term attention deficit is inexact, as the disorder is not thought to involve a lack of attention. Rather, there appears to be difficulty in regulating attention, so that attention is simultaneously given to many stimuli. The result is an unfocused reaction to the world. As well, people with ADHD can have difficulty in disregarding stimuli that are not relevant to the present task. They can also pay so much attention to one stimulus that they cannot absorb another stimulus that is more relevant at that particular time.

For many people with ADHD, life is a never-ending shift from one activity to another. Focus cannot be kept on any one topic long enough for a detailed assessment. The constant processing of information can also be distracting, making it difficult for an ADHD individual to direct his or her attention to someone who is talking to him or her. Personally, this struggle for focus can cause great chaos that can be disruptive and diminish self-esteem.

The neurological manifestations of ADHD are disturbances of what are known as executive functions. Specifically, the six executive functions that are affected include:

  • the ability to organize thinking
  • the ability to shift thought patterns
  • short-term memory
  • the ability to distinguish between emotional and logical responses
  • the ability to make a reasoned decision
  • the ability to set a goal and plan how to approach that goal

About half or more of those people with ADHD meet criteria set out by the American Psychiatric Association (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) for at least one of the following other illnesses:

  • learning disorder
  • restless leg syndrome
  • depression
  • anxiety disorder
  • antisocial behavior
  • substance abuse
  • obsessive-compulsive behavior

Demographics

ADHD is a common childhood disorder. It is estimated to affect 37% of all children in the United States, representing up to two million children. The percentage may in fact be even higher, with up to 15% of boys in grades one through five being afflicted. On average, at least one child in each public and private classroom in the United States has ADHD. In countries such as Canada, New Zealand, and Germany, the prevalence rates are estimated to be 510% of the population.

The traditional view of ADHD is that boys are affected more often than girls. Community-based samples have found an incidence rate in boys that is double that of girls. In fact, statistics gathered from patient populations have reported male-to-female ratios of up to 4:1. However, as the understanding of ADHD has grown since the early 1990s and as the symptoms have been better recognized, the actual number of females who are affected by ADHD may be more similar to males than previously thought.

Causes and symptoms

The cause of ADHD is unknown. However, evidence is consistent with a biological cause rather than an environmental cause (e.g., home life). Not all children from dysfunctional homes or families have ADHD.

For many years, it was thought that ADHD developed following a physical blow to the head, or from an early childhood infection, leading to the terms "minimum brain damage" and "minimum brain dysfunction." However, these definitions apply to only a very small number of people diagnosed with ADHD, and so have been rejected as the main cause.

Another once-favored theory was that eating refined sugar or chemical additives in food produced hyperactivity and inattention. While sugar can produce changes in behavior, evidence does not support this proposed association. Indeed, in 1982, the results presented at a conference sponsored by the U.S. National Institutes of Health conclusively demonstrated that a sugar- and additive-restricted diet only benefits about 5% of children with ADHD, mostly young children and those with food allergies.

The biological roots of ADHD may involve certain areas of the brain, specifically the frontal cortex and nearby regions. One explanation is that the executive functions are controlled by the frontal lobes of the brain. Magnetic resonance imaging (MRI) examination of subjects who are exposed to a sensory cue has identified decreased activity of regions of the brain that are involved in tasks that require attention. Another MRI-based study published in November 2003 also implicates a region of the brain that controls impulsive behavior. Finally, a study conducted by the U.S. National Institute of Mental Health (NIMH) documented that the brains of children and adolescents with ADHD are 34% smaller than those of their ADHD-free counterparts. Additionally, the decreased brain size is not due to the use of drugs in ADHD treatment, the researchers concluded in a paper published in October 2002.

ADHD symptoms can sometimes be relieved by the use of stimulants that increase a chemical called dopamine. This chemical functions in the transmission of impulses from one neuron to another. Too little dopamine can produce decreased motivation and alertness. These observations led to the popular "dopamine hypothesis" for ADHD, which proposed that ADHD results from the inadequate supply of dopamine in the central nervous system .

The observations that ADHD runs in families (1035% of children with ADHD have a direct relative with the disorder) point to an underlying genetic origin. Studies with twins have shown that the occurrence of ADHD in one twin is more likely to be mirrored in an identical twin (who has the same genetic make-up) than in a fraternal twin (whose genetic make-up is similar but not identical).

The genetic studies have implicated the binding, transport, and enzymatic conversion of dopamine. Two genes in particular have been implicated: a dopamine receptor (DRD) gene on chromosome 11 and the dopamine transporter gene (DAT1) on chromosome 5.

There may be environmental factors that influence the development of ADHD. Complications during pregnancy and birth, excessive use of marijuana, cocaine, and/or alcohol (especially by pregnant women), ingestion of lead-based paint, family or marital tension, and poverty have been associated with ADHD in some people. However, many other ADHD sufferers do not display any of these associations.

Heavy use of alcohol by a pregnant woman can lead to malformation of developing nerve cells in the fetus, which can result in a baby of lower than normal birth weight with impaired intelligence. This condition, called fetal alcohol syndrome, can also be evident as ADHD-like hyperactivity, inattention, and impulsive behavior.

Diagnosis

ADHD is sometimes difficult to diagnose. Unlike the flu or a limb fracture, ADHD lacks symptoms that can be detected in a physical examination or via a chemical test. Rather, the diagnosis of ADHD relies on the presence of a number of characteristic behaviors over an extended period of time. Often the specialist will observe the child during high-stimuli periods such as a birthday party and during quieter periods of focused concentration. Diagnosis uses the DSM-IV criteria, originally published in 1994, in combination with an interview and assessment of daily activity by a qualified clinician. (As of December 2003, revised DSM criteria are pending. These revisions will reflect the increased awareness of the greater-than-perceived prevalence of ADHD in girls and women.)

The benchmarks for either inattention or for hyperactivity/impulsive behavior must be met. These benchmarks typically occur by the age of seven and are not exclusive to one particular social setting such as school. These benchmarks must have been present for an extended period of time, at least six months or more. There are nine separate criteria for each category. For diagnosis, six of the nine criteria must be met. Examples of diagnostic signs of inattention include difficulty in maintaining concentration on a task, failure to follow instructions, difficulty in organizing approaches to tasks, repeated misplacement of tools necessary for tasks, and tendency to become easily distracted. Examples of hyperactivity or impulsive behavior include fidgeting with hands or feet, restlessness, difficulty in being able to play quietly, excessive talk, and tendency to verbally or physically interrupt.

Because ADHD can be associated with the use of certain medications or supplements, diagnosis involves screening for the past or present use of medications such as anticonvulsant or antihypertensive agents, and caffeinecontaining drugs.

Diagnosis of ADHD can also be complicated by the simultaneous presence of another illness. Diagnosis involves screening for bipolar disorder, depression, eating disorder, learning disability, panic disorder (including agoraphobia), sleep disorder, substance abuse, or Tourette's syndrome. Almost half of all children (mostly boys) with ADHD display what has been termed "oppositional defiant behavior." These children tend to be stubborn, temperamental, belligerent, and can lash out at others over a minor provocation. Without intervention, such children could progress to more serious difficulties such as destruction of property, theft, arson, and unsafe driving.

Other, nonclinical information such as legal infractions (arrests, tickets, vehicle accidents), school reports, and interviews with family members can be valuable, as ADHD can be perceived as antisocial, erratic, or uncommon behavior.

A complete physical examination is recommended as part of the diagnosis. The examination offers the clinician an opportunity to observe the behavior of the person. More specific tests can also be performed. Children can be assessed using the Conner's Parent and Teacher Rating Scale. Adolescent and adult assessment can utilize the Brown Attention Deficit Disorder Scale. Impulsive and inattentive behavior can be assessed using the Conner's Continuous Performance Test (CPT) or the Integrated Visual and Auditory CPT. Girls can be specifically assessed using the Nadeau/Quinn/Littman ADHD Self-Rating Scale.

Treatment team

The treatment team involves behavioral and medical specialists. Concerning behavior, teachers play a very important role. Their daily observation of the child and the use of standard evaluation tests can help in the diagnosis and treatment of ADHD. More specialized consultants within the school system, such as psychometrists, may also be available. Outside of the school setting, psychologists, social workers , and family therapists can also be involved in treatment.

The use of medications involves physicians, nurses, and pharmacists.

Treatment

Behavior treatment can consist of the monitoring of school performance and the use of standard evaluation tests. For older children, adolescents, and adults, support groups can be valuable. As well, ADHD patients can learn behavioral techniques that are useful in self-monitoring their behavior and making the appropriate modifications (such as a time out). Behavior treatment is useful in combination with drug therapy or as a stand-alone treatment in those cases in which the use of medication is not tolerated or is not preferred.

Medical treatment can consist of the use of drugs such as Ritalin that are intended to modify over-exuberant behavior, or other drugs that have differing targets of activity. Psychostimulant medications like Ritalin, Cylert, and Dexedrine increase brain activity by increasing the brain concentration of chemicals such as dopamine, which are involved in the transmission of impulses or by stimulating the receptors to which the chemicals bind. Psychostimulant medications can sometimes disrupt sleep, depress appetite, cause stomachaches and headaches , and trigger feelings of anger and anxiousness, particularly in people afflicted with psychiatric illnesses such as bipolar disorder or depression. For many people, the side effects are mild and can become even milder with long-term use of the drugs.

Antidepressant medications such as imipramine act by slowing down the absorption of chemicals that function in the transmission of impulses. Central alpha agonists are particularly used in the treatment of hyperactivity. By restricting the presence of neurotransmitter chemicals in the gap between neurons, drugs such as clonidine and guanfacine restrict the flow of information from one neuron to the next. There have been four reported cases of sudden death in people taking clonidine in combination with the drug methylphenidate (Ritalin), and reports of nonfatal heart disturbances in people taking clonidine alone.

Finally, medications known as selective norepinephrine reuptake inhibitors restrict the production of norepinephrine between neurons, which inhibits the sudden and often hyperactive "fight or flight" response.

Recovery and rehabilitation

After a patient has been stabilized, typically using medication, follow-up visits to the physician are recommended every few months for the first year. Then, follow-ups every three or four months may be sufficient. The use of medications may continue for months or years.

Recovery and rehabilitation are not terms that apply to ADHD. Rather, a child with ADHD can be assisted to an optimum functionality. Assistance can take the form of special education in the case of those who prove too hyperactive to function in a normal classroom; the child may be seated in a quieter area of the class; or by using a system of rules and rewards for appropriate behavior. Children and adults can also learn strategies to maximize concentration (such as list making) and strategies to monitor and control their behavior.

Clinical trials

Beginning in 1996, the U.S. National Institute of Mental Health (NIMH) and the Department of Education began a clinical trial that included nearly 600 elementary school children ages seven to nine. The study, which compared the effects of medication alone, behavior management alone, or a combination of the two, found the combination to produce the most marked improvement in concentration and attention. Additionally, the involvement of teachers and other school personnel was more beneficial than if the child was examined only a few times a year by their family physician.

As of January 2004, a number of clinical studies were recruiting patients, including:

  • Behavioral and functional neuroimaging study of inhibitory motor control. The basis of the inability to control behavior in ADHD was assessed using behavioral tests and the technique of magnetic resonance imaging (MRI ).
  • Brain imaging in children with ADHD. MRI was used to compare the connections between brain regions in children with and without ADHD.
  • Brain imaging of childhood onset psychiatric disorders, endocrine disorders, and healthy children. MRI was used to investigate the structure and activity in the brains of healthy people and those with childhood onset psychiatric disorders, including ADHD.
  • Genetic analysis of ADHD. Blood samples from a child with ADHD and his or her immediate family members were collected and analyzed to determine the genetic differences between ADHD and non-ADHD family members.
  • Biological markers in ADHD. People with ADHD, their family members, and a control group of healthy people who had previously undergone magnetic resonance examination were assessed using psychiatric interviews, neuropsychological tests, and genetic analysis.
  • Study of ADHD using transcranial magnetic stimulation. The technique, in which a magnetic signal is used to stimulate a region of the brain that controls several muscles, was used to investigate whether ADHD patients have a delayed maturation of areas of their nervous system responsible for such activity. Detectable differences could be useful in diagnosing ADHD.
  • Clonidine in ADHD Children. The trial evaluated the benefits and side effects of two drugs (clonidine and methylphenidate) used individually or together to treat childhood ADHD.
  • Nutrient intake in children with ADHD. The study determined if children with ADHD have a different eating pattern, such as intake of less food or a craving for carbohydrates, than children without ADHD. The information from the study would be used in probing the origins of ADHD and in devising treatment strategies.
  • Preventing behavior problems in children with ADHD. The study was designed to gauge the effectiveness of a number of treatment combinations in preventing behavior that is characteristic of ADHD in children.
  • Psychosocial treatment for ADHD Type I. The study focused on ADHD that is characterized by inattention. The aim of the study was to develop effective treatment strategies for Type I ADHD.
  • Treatment of adolescents with comorbid alcohol use and ADHD. The effectiveness of a drug (bupropion) that is designed to be released at a constant rate over time was evaluated in the treatment of ADHD adolescents (1418 years) who are also alcohol abusers.
  • Behavioral treatment, drug treatment, and combined treatment for ADHD. The effectiveness of the three treatment approaches was compared, and the interactions between different levels of the behavioral and drug treatments were examined.
  • Attention deficit disorder and exposure to lead. The effect of past exposure to lead was studied in children with ADHD.

Prognosis

The outlook for a patient with ADHD can be excellent, if the treatment regimen is followed and other existing conditions and disabilities have been identified and are treated. Methylphenidate, the major psychostimulant used in the treatment of ADHD, has been prescribed since the 1960s. The experience gained over this time has established the drug as being one of the safest pharmaceuticals for children. Indeed, intervention can be beneficial. Researchers from the Massachusetts General Hospital reported in 1999 that drug treatment of children diagnosed with ADHD could dramatically reduce the future risk of substance abuse.

Special concerns

The diagnosis of ADHD continues to be controversial. While some children do benefit from the use of medicines, other children who behave differently than is the norm may be needlessly medicated. The inattention, hyperactivity, and impulsive behavior that are the hallmarks of ADHD can be produced by many other conditions. The death of a parent, the discomfort of a chronic ear infection, and living in a dysfunctional household are all situations that can cause a child to become hyperactive, uncooperative, and distracted.

Evidence since the 1960s has led to the consensus that the medications used to treat ADHD, particularly methylphenidate (Ritalin), pose no long-term hazards. However, research published in December 2003 documented that rats exposed to the drug tended to avoid rewarding stimuli and instead became more anxious. More research on the effects of long-term drug treatment in ADHD is scheduled.

Resources

BOOKS

National Institutes of Health. Attention Deficit Hyperactivity Disorder. NIH Publication No. 963572, 1996.

PERIODICALS

Bolaños, Carlos A., Michel Barrot, Oliver Berton, Deanna Wallace-Black, and Eric J. Nestler. "Methylphenidate Treatment During Pre- and Periadolescence Alters Behavioral Responses to Emotional Stimuli at Adulthood." Biological Psychiatry (December 2003).

Castellanos, F. Xavier, Patti P. Lee, Wendy Sharp, et al. "Developmental Trajectories of Brain Volume Abnormalities in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder." Journal of the American Medical Association (October 9, 2002) 288: 17401748.

Rowland, Andrew S., David M. Umbach, Lil Stallone, A. Jack Naftel, E. Michael Bohlig, and Dale P. Sandler. "Prevalence of Medication Treatment for Attention Deficit-Hyperactivity Disorder among Elementary School Children in Johnston County, North Carolina." American Journal of Public Health (February 2002) 92: 231234.

Sowell, Elizabeth R., Paul M. Thompson, Suzanne E. Welcome, Amy L. Henkenius, Arthur W. Toga, and Bradley S. Peterson. "Cortical Abnormalities in Children and Adolescents with Attention-Deficit Hyperactivity Disorder." Lancet (November 2003) 362: 16991702.

OTHER

National Institute of Neurological Disorders and Stroke. NINDS Attention Deficit-Hyperactivity Disorder Information Page. December 9, 2003 (February 18, 2004). <http://www.ninds.nih.gov/health_and_medical/disorders/adhd.htm>.

ORGANIZATIONS

Attention Deficit Disorder Association (ADDA). PO Box 543, Pottstown, PA 19464. (484) 945-2101; Fax: (610) 970-7520. mail@add.org. <http://www.add.org>.

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). 8181 Professional Place, Suite 150, Bethesda, MD 20785. (301) 306-7070 or (800) 233-4050; Fax: (301) 306-7090. <http://www.chadd.org>.

National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Bethesda, MD 20892-9663. (301) 443-4513 or (866) 615-6464; Fax: (301) 443-4279. nimhinfor@nih.gov. <http://www.nimh.nih.gov>.

National Institute of Neurological Disorders and Stroke. 6001 Executive Boulevard, Bethesda, MD 20892-9663. (301) 446-5751 or (800) 352-9424. <http://www.ninds.nih.gov>.

Brian Douglas Hoyle

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Attention-Deficit/Hyperactivity Disorder (AD/HD)

Attention-deficit/Hyperactivity disorder (AD/HD)

Definition

Attention-deficit/hyperactivity disorder (AD/HD) is a neurobiological disorder characterized by hyperactivity, impulsive behavior, and the inability to remain focused on tasks or activities.

Description

AD/HD, also known as hyperkinetic disorder (HKD) outside of the United States, is estimated to affect 37 percent of school-aged children, and seems to afflict boys more often than girls. However, the prevalence in boys may be cited because often girls are not diagnosed until later in age. Although difficult to assess in infancy and toddlerhood, signs of AD/HD may begin to appear as early as age two or three, but visible symptoms change as adolescence approaches. Many symptoms, particularly hyperactivity, diminish in early adulthood, while impulsivity and inattention problems often continue.

First documented in 1902, AD/HD has been called minimal brain dysfunction, hyperkinetic reaction, and attention-deficit disorder (ADD). The name AD/HD reflects the various behaviors of inattention, hyperactivity, and impulsiveness that characterize the disorder. Its more precise classification is a result of the Diagnostic and Statistical Manual, fourth edition (DSM-IV) system for characterizing and diagnosing mental and behavioral disorders.

Children with AD/HD have difficulties with inattention that can be manifest as a lack of concentration, an easily distracted focus, and an inability to know when and how long to focus. The characteristics of inattention vary with each AD/HD child; however, all most often translate into poor grades and difficulties in school and other social arenas. AD/HD children act impulsively, taking action first and thinking later. They are constantly moving, running, climbing, squirming, and fidgeting. Yet, they often have trouble with gross and fine motor skills and, as a result, they may be physically clumsy and awkward. Their clumsiness may also extend to their social skills. They are sometimes shunned by peers due to their impulsive and intrusive behavior.

Demographics

Of the 37 percent of school-aged children with AD/HD, some will have a reduction of symptoms as they reach adulthood. However, 65 percent of AD/HD children will continue to display characteristics of AD/HD through adulthood. Until recently, it was believed that boys were three times more likely to have AD/HD; however, that gap has been narrowed. It is more likely that the presence of AD/HD is distributed equally between boys and girls. The reason for the discrepancy was, in part, because young boys tend to more readily and overtly manifest the characteristics of AD/HD, making diagnosis easier. In addition, the inattentive form affects girls more than the hyperactive form; as a result, girls may be less likely to be diagnosed.

Causes and symptoms

The causes of AD/HD are not specifically known. However, it is a neurologically based disease that may be genetic. Children with an AD/HD parent or sibling are more likely to develop the disorder themselves. Although the exact cause of AD/HD is not known, an imbalance or deficiency of certain neurotransmittersthe chemicals in the brain that transmit messages between nerve cellsis believed to be the mechanism behind AD/HD symptoms.

A widely publicized study conducted by Dr. Ben Feingold in the early 1970s suggested that allergies to certain foods and food additives caused the characteristic hyperactivity of AD/HD children. By eliminating the food allergen, the premise was that AD/HD characteristics would disappear. Although some children may have adverse reactions to certain foods and food additives that can affect their behavior, carefully controlled follow-up studies have uncovered no link between food allergies and AD/HD. Another popularly held misconception about food and AD/HD is that the consumption of sugar causes the hyperactive behavior in an AD/HD child. Again, studies have shown no link between sugar intake and AD/HD. (In a recent study conducted by the National Institute of Mental Health, the level of glucose use in the brain was actually lower in individuals with AD/HD. Since glucose is the main source of fuel for the brain, this is a significant finding.) Finally, parenting style is not a cause for AD/HD. While certain parenting skills and/or deficiencies can affect the environment of an AD/HD child and, as a result, exasperate or help manage the characteristics of AD/HD, it appears that neurological issues are the primary causal agents at play.

In order to diagnose AD/HD, psychologists and other mental health professionals typically use the criteria listed in the DSM-IV. DSM-IV requires the presence of at least six of the following symptoms of inattention, or six or more symptoms of hyperactivity and impulsivity combined.

Inattention:

  • fails to pay close attention to detail or makes careless mistakes in schoolwork or other activities
  • has difficulty sustaining attention in tasks or activities
  • does not appear to listen when spoken to
  • does not follow through on instructions and does not finish tasks
  • has difficulty organizing tasks and activities
  • avoids or dislikes tasks that require sustained mental effort (e.g., homework)
  • is easily distracted
  • is forgetful in daily activities

Hyperactivity:

  • fidgets with hands or feet or squirms in seat
  • does not remain seated when expected to
  • runs or climbs excessively when inappropriate (in adolescence and adults, feelings of restlessness)
  • has difficulty playing quietly
  • is constantly on the move
  • talks excessively

Impulsivity:

  • blurts out answers before the question has been completed
  • has difficulty waiting for his or her turn
  • interrupts and/or intrudes on others

Of those symptoms, AD/HD can be categorized further by three subtypes. Each subtype exhibits particular behaviors that make up the general symptoms of a child with AD/HD. They are:

AD/HD predominantly inattentive type (AD/HD-I)

  • is disorganized
  • is easily distracted
  • is forgetful
  • has unsustained attention
  • has difficulty following instructions
  • appears to have poor listening skills
  • makes careless mistakes

AD/HD predominantly hyperactive-impulsive type (AD/HD-HI)

  • fidgets
  • is unable to engage in quiet activity
  • is interruptive or intrusive
  • cannot remain seated
  • speaks out of turn
  • climbs or runs about inappropriately
  • talks excessively

AD/HD combined type (AD/HD-C) is a combination of the symptoms exhibited by the other two subtypes (inattentive type and hyperactive-impulsive type). Also, for a complete diagnosis, DSM-IV requires that some symptoms develop before age seven, and that they significantly impair functioning in two or more settings (e.g., home and school) for a period of at least six months.

Diagnosis

AD/HD cannot be diagnosed with a laboratory test. Diagnosis is difficult and it takes into consideration many aspects of the child's behavior. Often the child's teacher is the one to bring the first signs to the attention of the parents. However, the first step in determining if a child has AD/HD is to consult with a pediatrician. The pediatrician can make an initial evaluation of the child's developmental maturity compared to other children in his or her age group. The physician should also perform a comprehensive physical examination to rule out any organic causes of AD/HD symptoms, such as an overactive thyroid or vision or hearing problems.

If no organic problem can be found, a psychologist, psychiatrist, neurologist, neuropsychologist, or learning specialist is typically consulted to perform a comprehensive AD/HD assessment . A complete medical, family , social, psychiatric, and educational history is compiled from existing medical and school records and from interviews with parents and teachers. Interviews may also be conducted with the child, depending on his or her age. Along with these interviews, several clinical inventories may also be used, such as the Conners' Rating Scales (Teacher's Questionnaire and Parent's Questionnaire), Child Behavior Checklist (CBCL), and the Achenbach Child Behavior Rating Scales. These inventories provide valuable information on the child's behavior in different settings and situations.

Other disorders such as depression, anxiety disorder, and learning disorders can cause symptoms similar to AD/HD. A complete and comprehensive psychiatric assessment is critical to differentiate AD/HD from other possible mood and behavioral disorders. Bipolar disorder , for example, may be misdiagnosed as AD/HD.

Public schools are required by federal law to offer free AD/HD testing upon request. A pediatrician can also provide a referral to a psychologist or pediatric specialist for AD/HD assessment. Parents should check with their insurance plans to see if these services are covered.

Treatment

Despite similar behavioral characteristics, AD/HD must be treated individually by developing an approach combining various types of treatment. The use of medication in combination with behavioral interventions, classroom accommodations, and proactive parents provide the best treatment option.

Psychostimulants and their effects have been studied in approximately 6,000 children and the positive results of their use have been documented. Such psychostimulants as dextroamphetamine (Dexedrine, Dextrostat), pemoline (Cylert), methylphenidate (Ritalin, Concerta, Metadate, Focalin), and mixed salts of a single-entity amphetamine product (Adderall, Adderall XR) are commonly prescribed to control hyperactive and impulsive behavior as well as to increase attention. They work by stimulating the production of certain neurotransmitters in the brain. Generally, short-acting medication lasts for four hours, while long-lasting preparations will last for six to eight hours. Some medication is effective for 1012 hours. Specific dosages depend upon the patient and that is determined by trial and error in conjunction with close monitoring by a physician in order to find the most beneficial strength. Possible side effects of stimulants include nervous tics , irregular heartbeat, loss of appetite, and insomnia. However, the medications are usually tolerated and safe in most cases. In fact, 7080 percent of AD/HD children respond well to psychostimulants.

In children who do not respond well to stimulant therapy, nonstimulant medications are prescribed. In 2002, the Food and Drug Administration (FDA)approved atomoxetine (Strattera) for the treatment of AD/HD. Unlike the stimulant medications, atomoxetine is not a controlled substance and can be prescribed with refills. (With the use of stimulant medication, the physician must write prescriptions each month of treatment.) Atomoxetine usually takes three to four weeks of use until its effect is evident. In January 2005 the FDA warned that evidence of atleast two cases of liver problems in an adult and teenage patient taking atomoxetine were reported. In both cases, the individuals fully recovered. The manufacturer of atomoxetine (Strattera) planned to notify users of the new FDA warning; however, the company, Eli Lilly & Co., believed that the risk-benefit analysis during trials of the drug was still positive. Such tricyclic antidepressants as desipramine (Norpramin, Pertofane) and amitriptyline (Elavil) are frequently recommended as well. Reported side effects of these drugs include persistent dry mouth, sedation, disorientation, and cardiac arrhythmia (particularly with desipramine).

Other medications prescribed for AD/HD therapy include buproprion (Wellbutrin), an antidepressant; fluoxetine (Prozac), an SSRI antidepressant; and carbamazepine (Tegretol, Atretol), an anticonvulsant drug. Clonidine (Catapres), an antihypertensive medication, has also been used to control aggression and hyperactivity in some AD/HD children, although it should not be used in combination with Ritalin.

A child's response to medication will change with age and maturation, so AD/HD symptoms should be monitored closely and prescriptions adjusted accordingly.

Behavior interventions are also crucial to AD/HD treatment. In a Nation Institute of Mental Health (NIMH) study conducted on 579 children over the course of 14 months it was observed that the children receiving AD/HD medication or both medication and behavioral interventions were more likely to see the most relief from their symptoms than those children that only received community aid. The use of a reward system to reinforce good behavior and task completion can be implemented both in the classroom and at home. A chart system may be used to visually illustrate the child's progress and encourage continued success with the use of larger rewards after a certain number of daily rewards are achieved. The reward system stays in place until the appropriate behavior becomes second nature to the child.

A variation of this technique, cognitive-behavioral therapy, works to decrease impulsive behavior by getting the child to recognize the connection between thoughts and behavior, and to change behavior by changing negative thinking patterns.

Individual psychotherapy can help an AD/HD child build self-esteem , give them a place to discuss their worries and anxieties, and help them gain insight into their behavior and feelings. Family therapy may also be beneficial in helping family members develop coping skills and in working through feelings of guilt or anger parents may be experiencing.

AD/HD children perform better within a familiar, consistent, and structured routine with an emphasis on positive reinforcements for good behavior and minimal use of punishments. When a negative behavior must be acknowledged and corrected, "time outs" give the child with AD/HD an opportunity to regroup without negative reinforcement. Family, friends, and caretakers should all be educated on the special needs and behaviors of the AD/HD child.

Alternative treatment

A number of alternative treatments exist for AD/HD; however, there are very few studies to prove their efficacy. When choosing a treatment option, it is important to investigate authoritative sources that provide a basis through documented studies for the validity of the treatment. AD/HD is not a disorder that can be cured but rather it is one that is managed by a variety of treatment options. Some of the more popular alternative treatments include:

  • EEG (electroencephalograph) biofeedback. By measuring brainwave activity and teaching the AD/HD patient which type of brainwave is associated with attention, EEG biofeedback attempts to train patients to generate the desired brainwave activity. This treatment has been in use for over 25 years and it has had positive response from parents. However, no consistent medical studies are available.
  • Chelation therapy focuses on removing excess lead within the body. This treatment is based on the idea that excessive lead in animals causes hyperactivity; yet, not enough medical studies have been done. A physician should be consulted when this approach is considered.
  • Intractive metronome training uses a similar instrument as the metronome used by musicians to keep time in order to train individuals to develop their motor and timing skills through repetitively tapping the beat.
  • Nutritional supplements claiming to be a cure for AD/HD are not regulated by the Food and Drug Administration (FDA) and should not be considered a treatment option without consultation with a medical doctor.

There are many advertised alternative and complementary treatment options for AD/HD. Only a few are listed here; however, it is always necessary to consult a physician to develop a fine-tuned treatment plan specific to each child's needs.

Nutritional concerns

As mentioned, links between nutrition and AD/HD have not been confirmed through medical studies. However, it is important to note that a nutritionally balanced diet is important for normal development in all children.

Prognosis

Untreated, AD/HD negatively affects a child's social and educational performance and can seriously damage his or her self-esteem. Children with AD/HD have impaired relationships with their peers, and may be looked upon as social outcasts. They may be perceived as slow learners or troublemakers in the classroom. Siblings and even parents may develop resentful feelings towards the AD/HD child.

Some AD/HD children also develop a conduct disorder . For those adolescents who have both AD/HD and a conduct disorder, up to 25 percent go on to develop antisocial personality disorder and the criminal behavior, substance abuse, and high rate of suicide attempts that are symptomatic of it. Children diagnosed with AD/HD are also more likely to have a learning disorder, a mood disorder such as depression, or an anxiety disorder.

Approximately 7080 percent of AD/HD patients treated with stimulant medication experience significant relief from symptoms, at least in the short-term. Approximately half of AD/HD children seem to "outgrow" the disorder in adolescence or early adulthood; the other half will retain some or all symptoms of AD/HD as adults. With early identification and intervention, careful compliance with a treatment program, and a supportive and nurturing home and school environment, children with AD/HD can flourish socially and academically.

Parental concerns

Because AD/HD is often indicated when the AD/HD child is in school, parents are extremely concerned about their child's academic progress. Communication between parents and teachers is especially critical to ensure an AD/HD child has an appropriate learning environment. Educational interventions under Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 mandate that AD/HD children will be served within the public school system. This means that upon request the public school is required to test the child for AD/HD as well as other learning disabilities if they are suspected. In addition, special education services are mandated for those children with AD/HD that need extra help and accommodation. It is important that parents assume a positive relationship with their child's educator and school in order to develop the best possible teaching strategies and learning environment for their AD/HD child.

Development of self-esteem is another particular concern for parents of AD/HD children. Because they often have difficulty in school and in social relationships, low self-esteem can be a factor that leads the school aged children toward dangerous or destructive behaviors as they reach adolescence. Finding one activity that the child excels at is essential in fostering a positive self-image. Often parents look to sports as an appropriate outlet. Individual sports such as karate, swimming, tennis, etc. are less socially demanding than team sports; yet they provide an opportunity for the child to thrive in a competitive activity.

AD/HD is a chronic condition. Parents can feel overwhelmed when they have to deal with AD/HD characteristics on a daily basis. Parent should face the issues honestly and directly while fostering a positive relationship with their AD/HD child. The best advocate the AD/HD child has is a parent so it is important that parents be proactive and keep up to date on the latest research. Learning about AD/HD and the various treatment options helps parents cope with their own concerns at the same time they are helping their child.

KEY TERMS

Conduct disorder A behavioral and emotional disorder of childhood and adolescence. Children with a conduct disorder act inappropriately, infringe on the rights of others, and violate societal norms.

Nervous tic A repetitive, involuntary action, such as the twitching of a muscle or repeated blinking.

Oppositional defiant disorder An emotional and behavioral disorder of children and adolescents characterized by hostile, deliberately argumentative, and defiant behavior towards authority figures that lasts for longer than six months.

Resources

BOOKS

Alexander-Roberts, Colleen. The ADHD Parenting Handbook: Practical Advice for Parents from Parents. Dallas: Taylor Publishing Co., 1994.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.

Barkley, Russell A. Taking Charge of ADHD. Revised Edition. New York: Guilford Press, 2000.

Hallowell, Edward M., and John J. Ratey. Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood. New York: Touchstone, 1995.

Osman, Betty B. Learning Disabilities and ADHD: A Family Guide to Living and Learning Together. New York: John Wiley & Sons, 1997.

PERIODICALS

Foley, Kevin. "Experiencing Nature May Quell ADHD in Kids." Pediatric News 38 (Nov. 2004).

Franklin, Deeanna. "FDA Issues Warning for ADHD Drug." Pediatric News 39 (Jan. 2005):42.

Glicken, Anita D. "Attention Deficit Disorder and the Pediatric Patient: A Review." Physician Assistant 21, no. 4 (Apr. 1997):101-11.

Hallowell, Edward M. "What I've Learned from A.D.D." Psychology Today 30, no. 3 (May/June 1997): 40-6.

Swanson, J. M., et al. "Attention-deficit Hyperactivity Disorder and Hyperkinetic Disorder." The Lancet 351 (7 Feb. 1997): 429-33.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. (AACAP). 3615 Wisconsin Ave. NW, Washington, DC 20016. (202) 966-7300. Web site: <http://www.aacap.org>

Children and Adults with Attention Deficit Disorder (CH.A.D.D.). 8181 Professional Place, Ste. 150, Landover, MD 20785. (800) 233-4050. (305) 306-7070.

National Attention Deficit Disorder Association. (ADDA). 9930 Johnnycake Ridge Road, Suite 3E, Mentor, OH 44060. (800) 487-2282. Web site: <http://www.add.org>

WEB SITES

Schwablearning.org: A Parent's Guide to Helping Kids with Learning Difficulties. (cited March 8, 2005). Available online at: <www.schwablearning.org>.

Jacqueline L. Longe Paula A. Ford-Martin

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Longe, Jacqueline; Ford-Martin, Paula. "Attention-Deficit/Hyperactivity Disorder (AD/HD)." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Encyclopedia.com. 27 Jul. 2016 <http://www.encyclopedia.com>.

Longe, Jacqueline; Ford-Martin, Paula. "Attention-Deficit/Hyperactivity Disorder (AD/HD)." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Encyclopedia.com. (July 27, 2016). http://www.encyclopedia.com/doc/1G2-3447200071.html

Longe, Jacqueline; Ford-Martin, Paula. "Attention-Deficit/Hyperactivity Disorder (AD/HD)." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Retrieved July 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3447200071.html

Attention Deficit/Hyperactivity Disorder (ADHD)

Attention Deficit/Hyperactivity Disorder (ADHD)

Attention Deficit/Hyperactivity Disorder (ADHD) is the diagnostic term used to describe patterns of behavior, beginning in childhood, related to deficient self-regulation. In the course of the twentieth century, ADHD has been called minimal brain dysfunction, hyperkinesis, or attention deficit disorder. The core symptoms include (a) difficulties in paying attention, particularly in situations that demand concentration, like school classes and homework sessions; (b) impulsivity or poor impulse control— in other words, "acting before thinking"—and behavior that ranges from the annoying to the physically dangerous; and (c) hyperactivity, including fidgetiness, motor restlessness, and actions such as running through a classroom. Given that close attention is demanded from students, ADHD became an important issue with the advent of compulsory education. Considerable notoriety currently surrounds ADHD; there is an ongoing debate over its status as a legitimate diagnosis as opposed to an excuse for the overzealous use of pharmacological treatments or a "medicalized" label for problems that actually result from discordant family interactions, poor schooling, or increasing societal demands for educational attainment (DeGrandpre and Hinshaw 2000).

Part of the reason for the intensity of this debate is that the constituent behaviors are part of normal development. Indeed, inattention, impulsivity, and overactivity are ubiquitous in children— particularly boys—during the preschool or early elementary years, when the frontal lobes of the brain have not fully matured yet demands for compliance and socialization increase markedly. To make an accurate diagnosis, clinicians must document that the behavior patterns are (a) developmentally extreme (i.e., statistically rare for children of the same age); (b) of early onset (aged 6 years or younger); (c) present in both home and school situations (or, for adults, in home and work settings); and (d) impairing with respect to family interactions, educational achievement, friendships, and the attainment of independence (American Psychiatric Association 1994).

In fact, despite the contention that ADHD is a mythical condition, children who meet stringent diagnostic criteria are often severely impaired. School failure is common, despite average or above-average intelligence; discordant parent-child relationships are commonplace; rejection from the peer group is common, as youth with ADHD are almost universally disliked by their peers; selfconcept and self-esteem suffer, particularly as development progresses; and the risk of serious accidental injury—ranging from burns and falls in childhood to serious automobile accidents in adolescence and adulthood—is striking (Hinshaw 1999). Thus, despite allegations that ADHD is a convenient diagnostic term for children who are simply exuberant or bothersome to adults, careful assessment can warn of significant developmental failures and impairments.

A brief office visit is insufficient for a proper diagnostic work-up. A complete evaluation must include parent and teacher ratings of the constituent behaviors (with scales that are carefully normed), a careful history gathered from caregivers, conversations with teachers (and classroom observations), a physical examination (to rule out various medical and neurological conditions that can mimic ADHD), and appraisal of the presence of co-occurring learning and behavioral difficulties. In fact, there are many reasons why a child or adolescent could display symptoms related to ADHD, including life stress, child abuse, depression or various neurological conditions, unstructured family configurations, or grossly disorganized classroom settings (Barkley 1998). Thus, assessment must use multiple sources of information and transcend brief observations of the child in the office, where the novelty of the situation may temporarily suppress the ongoing behavior patterns.


Demographics, Developmental Course, and Etiology

ADHD occurs in about 3 to 7 percent of the general population. As is the case with nearly all developmental disorders, it is more common in boys than girls, with a male to female ratio of about 3:1 in community settings and even higher in clinical settings. An exception is that individuals displaying the Inattentive type of ADHD—formerly termed attention deficit disorder without hyperactivity and distinguished by inattention but without noteworthy hyperactivity and impulsivity—has a male to female ratio closer to 1.5:1 or 2:1.

Longitudinal studies demonstrate that ADHD almost always persists into adolescence, and in a plurality of cases impairment lasts into adulthood (Mannuzza and Klein 1999). Although the motor overactivity per se dissipates with time, inattention, disorganization, impulsivity, and academic and social difficulties are likely to persist well beyond childhood.

Regarding etiology, ADHD is one of the most heritable conditions in all of psychopathology. Seventy to 80 percent of the individual differences in ADHD-related symptoms are attributed to genetic rather than environmental factors. Thus, ADHD's genetic liability is higher than that for depression or schizophrenia, and roughly equal to that for bipolar disorder or autistic disorder (Tannock 1998). Although ADHD is not a simple, single-gene condition, recent discoveries at the molecular genetic level implicate genes related to dopamine neurotransmission. Note that, because ADHD persists throughout development and because it is strongly familial, a high proportion (30–40%) of the biological parents of children with ADHD will have clinically significant symptoms themselves, whether or not formally diagnosed. Thus, the new generation often suffers from both genetic and psychosocial risk, the latter related to being raised by parents who are themselves not fully self-regulated.

Other biological (but non-genetic) risk factors for ADHD include low birthweight, several types of prenatal and perinatal complications, and maternal use of substances such as nicotine, alcohol, or illicit drugs during pregnancy (Tannock 1998). Although these risk factors are not inevitable causes of ADHD—and most cases of ADHD do not show associations with these risks—they do play a role in many individuals with the disorder. Overall, ADHD has strong psychobiological origins.

Can ineffective parenting cause ADHD? Most experts say no, because (a) many discordant family characteristics appear to result from (rather than predispose to) having a child with the difficult behavioral pattern demarcated by ADHD and (b) children with ADHD do not show higher than expected rates of insecure attachment in infancy and toddlerhood (Hinshaw 1999). Nevertheless, there some evidence for family "causation" with respect to children from impoverished backgrounds: In a high-risk sample, Elizabeth Carlson and colleagues (1995) found that unresponsive and overly stimulating parenting styles during the first two years of life could be used to predict ADHD-related symptomatology years later, over and above indicators of early temperament and biological dysfunction. In most cases, however, parenting may serve to accentuate or exacerbate difficult temperament or other signs of early biological risk.


Family Processes and ADHD

As reviewed by Johnston and Mash (2001), families of children and adolescents with ADHD experience a number of difficulties, in contrast to families who do not have offspring with this diagnosis. First, caregivers report higher levels of family conflict and stress and lower levels of perceived competence in the parenting role. They also report lower rates of authoritative parenting, a style blending warmth, limit setting, and autonomy encouragement typically associated with the child's attainment of social and academic competence (Hinshaw et al. 1997). Second, parents of children with ADHD experience greater marital conflict and less marital satisfaction than families of comparison children. Third, direct observations of parent-child interaction (an important area of research, given the potential for biases in self-reports from parents) have reported high levels of parental negativity and harsh/directive parenting to characterize family interchanges, particularly for mothers interacting with their sons who have ADHD. Fourth, children with ADHD are overrepresented in the population of children who have been adopted (Simmel et al. 2001). As in all aspects of research regarding ADHD, however, far more is known about boys than girls; more is known about mothers than fathers; more is known about majority than ethnic minority children (because of a dearth of research on the latter group); and more is known about youth in middle childhood than in adolescence. Nonetheless, this disorder is clearly characterized by family stress and distress and negative parent-child interactions.

Two issues require comment. First, the family variables noted above may pertain as much to aggressive behavior patterns that frequently accompany ADHD as to the core symptoms of ADHD itself. Harsh and unresponsive parenting, in particular, is causally related to the development of aggressive behavior in children (Patterson, Reid, and Dishion 1992); negative parenting and family variables may therefore pertain more to noncompliance, aggression, and covert antisocial behaviors like stealing than to inattention, impulsivity, and hyperactivity per se ( Johnston and Mash 2001). Insecure attachment in early development predicts subsequent aggression but not ADHD. Second, the processes and mechanisms responsible for the associations between family distress and ADHD remain elusive. Indeed, instead of the usual supposition that negative parenting influences difficult child behavior, it is conceivable (given ADHD's strong heritability) that the same genes are responsible for (a) impulsive, harsh parenting behaviors and (b) noncompliant and negative behaviors in the child. In addition, many of the negative behaviors displayed by parents could be a reaction to, rather than a cause of, the child's noncompliant, difficult temperamental and behavioral style. The chains of risk and causation are likely to be reciprocal (with negative parenting triggered by child impulsivity and defiance but also fueling further difficulty in the child) and transactional (with reciprocal chains of influence proceeding through development). Thus, the picture is of a child with early temperamental difficulties and behavior problems, with less-than-optimal parenting serving to amplify problem behavior and set the stage for further negativity and even aggression.

Culture and Ethnicity

Research indicates that ADHD exists in multiple cultures, societies, and nations. Not only has ADHD been diagnosed in various ethnic groups within the United States, but it has been documented in China, South America, Europe, India, and Japan, as well as other regions (Hinshaw and Park 1999). Thus, ADHD is not simply a product of Western industrialized societies, although its visibility and detection are bound to be far greater in cultures and societies with compulsory education. Considerably more research is needed if we are to understand whether the prevalence of ADHD is equal across nations and cultures or whether, as might be predicted, different styles of child temperament (known to display differing rates in different nations) or different childrearing styles (also known to vary across nations and cultures) could influence symptoms (Hinshaw and Park 1999). In other words, ADHD appears to be a universal— rather than culturally specific—disorder, but we still have much to learn about the influence of culture, schooling practices, and nationality on its prevalence and presentation.


Treatment

Only two intervention strategies have shown research-based evidence for the treatment of ADHD: (a) stimulant medications, such as methylphenidate or dextroamphetamine, which regulate dopamine neurotransmission and (b) behavioral strategies such as parent management training, school consultation, and direct contingency management in classroom or special educational settings (Pelham, Wheeler, and Chronis 1998). Indeed, individual therapies that do not directly target the child's social, behavioral, and academic problems have not yielded clear support regarding intervention for ADHD. Medication typically yields stronger effects than behavioral interventions in terms of improving core symptomatology, but (a) psychosocial treatments may be preferable for some families (who may be philosophically opposed to medication); (b) perhaps as many as 20 percent of the youths with ADHD either do not respond optimally to medication or show prohibitive side effects; (c) medication alone is typically insufficient for helping the child learn new academic or social skills or for the family to learn and practice new management skills; and (d) combining well-delivered pharmacological intervention with systematic behavioral family and school treatment is most likely to yield normalization of behavioral, social, and academic targets (Pelham, Wheeler, and Chronis 1998). It is important to note that both pharmacological and behavioral treatments for ADHD share a common limitation: their benefits tend to persist only as long as the intervention is delivered. ADHD is a chronic condition and may well require chronic treatment.

Unfortunately, in light of the strongly heritable nature of ADHD and the documented success of pharmacological interventions, it could be concluded that family and school environments are not particularly important and that psychosocial interventions have limited potential for success. Such thinking fails to take into account the demonstrated facts that (a) conditions with clear psychosocial etiology may respond to biological treatment regimens and (b) conditions with strong psychobiological underpinnings may respond to treatments emphasizing skill enhancement or environmental manipulation. In fact, recent evidence suggests that even for a condition as heritable as ADHD a combination of treatments may be the answer: when combined pharmacological and behavioral treatments produce optimal benefits for youth with ADHD, a key explanatory factor is the family's reduction of harsh and ineffective discipline strategies at home (Hinshaw et al. 2000). Thus, the family's learning of more productive management strategies at home and their coordination of intervention efforts with the school are necessary components of a viable treatment plan for ADHD. The development of self-regulation requires active teaching by parents and teachers, often in concert with pharmacological interventions to enhance attention and regulate impulse control. Such consistent intervention from families appears necessary to break the intergenerational cycle that is often found with ADHD.


See also:Chronic Illness; Conduct Disorder; Developmental Psychopathology; Parenting Styles; School; Temperament


Bibliography

american psychiatric association. (1994). diagnostic andstatistical manual of mental disorders, 4th edition. washington, dc: american psychiatric press.

barkley, r. a. (1998). attention deficit hyperactivity disorder: a handbook for diagnosis and treatment, 2nd edition. new york: guilford.

carlson, e. a.; jacobvitz, d.; and sroufe, l. a. (1995). "adevelopmental investigation of inattentiveness and hyperactivity." child development 66:37–54.

degrandpre, r., and hinshaw, s. p. (2000). "attention-deficit hyperactivity disorder: psychiatric problem or american cop-out?" cerebrum 2:12–38.

hinshaw, s. p. (1999). "psychosocial intervention forchildhood adhd: etiologic and developmental themes, comorbidity, and integration with pharmacotherapy." in rochester symposium on developmental psychopathology, vol. 9: developmental approaches to prevention and intervention, ed. d. ciccehetti and s. l. toth. rochester, ny: university of rochester press.

hinshaw, s. p.; owens, e. b.; wells, k. c.; kraemer, h. c.;abikoff, h. b.; arnold, l. e.; conners, c. k.; elliott, g.; greenhill, l. l.; hechtman, l.; hoza, b.; jensen, p. s.; march, j. s.; newcorn, j.; pelham, w. e.; swanson, j. m.; vitiello, b.; and wigal, t. (2000). "family processes and treatment outcome in the mta: negative/ineffective parenting practices in relation to multimodal treatment." journal of abnormal child psychology 28:555–568.


hinshaw, s. p., and park, t. (1999). "research issues andproblems: toward a more definitive science of disruptive behavior disorders." in handbook of disruptive behavior disorders, ed. h. c. quay and a. e. hogan. new york: plenum.

hinshaw, s. p.; zupan, b. a.; simmel, c.; nigg, j. t.; andmelnick, s. m. (1997). "peer status in boys with and without attention-deficit hyperactivity disorder: predictions from overt and covert antisocial behavior, social isolation, and authoritative parenting beliefs." child development 64:880–896.

johnston, c., and mash, e. j. (2001). "families of children with attention-deficit/hyperactivity disorder: review and recommendations for future research." clinical child and family psychology review 4:183–207.

mannuzza, s., and klein, r. g. (1999). "adolescent andadult outcomes in attention-deficit/hyperactivity disorder." in handbook of disruptive behavior disorders, ed. h. c. quay and a. e. hogan. new york: plenum.

patterson, g. r.; reid, j.; and dishion, t. (1992). antisocial boys. eugene, or: castalia.


pelham, w. e.; wheeler, t.; and chronis, a. (1998). "empirically supported psychosocial treatments for adhd." journal of clinical child psychology 27:189–204.

simmel, c.; brooks, d.; barth, r. p.; and hinshaw, s. p.(2001). "externalizing symptomatology among adoptive youth: prevalence and preadoption risk factors." journal of abnormal child psychology 29:57–69.


tannock, r. (1998). "attention deficit hyperactivity disorder: advances in cognitive, neurobiological, and genetic research." journal of child psychology and psychiatry 39:65–99.

stephen p. hinshaw

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"Attention Deficit/Hyperactivity Disorder (ADHD)." International Encyclopedia of Marriage and Family. 2003. Encyclopedia.com. 27 Jul. 2016 <http://www.encyclopedia.com>.

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Attention-Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder

Definition

Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or activities.

Description

ADHD, also known as hyperkinetic disorder (HKD) outside the United States, is estimated to affect 7% of children ages six to 11, or about 1.6 million children in the United States. It also affects about 4% of adults. The disorder affects boys more often than girls. Although difficult to assess in infancy and toddlerhood, signs of ADHD may begin to appear as early as age two or three, but the symptom picture changes as adolescence approaches. Many symptoms, particularly hyperactivity, diminish in early adulthood. However, impulsivity and inattention problems remain with up to 50% of ADHD individuals throughout their adult life.

Children with ADHD have short attention spans and are easily bored and/or frustrated with tasks. Although they may be quite intelligent, their lack of focus frequently results in poor grades and difficulties in school. ADHD children act impulsively, taking action first and thinking later. They are constantly moving, running, climbing, squirming, and fidgeting, but often have trouble with gross and fine motor skills. As a result, they may be physically clumsy and awkward. Their clumsiness may extend to the social arena, where they are sometimes shunned due to their impulsive and intrusive behavior. Some critics argue that ADHD is a condition created and diagnosed in the Western world, particular to the environment of highly developed countries, since it is not diagnosed in other cultures. These critics of the ADHD diagnosis feel that medicating a child does not address the true underlying problem. They also note that there may not be a problem at all because children are naturally active and impulsive.

Causes & symptoms

The causes of ADHD are not known. However, it appears that heredity plays a major role in the development of ADHD. Children with an ADHD parent or sibling are more likely to develop the disorder. Before birth, ADHD children may have been exposed to poor maternal nutrition , viral infections , or maternal substance abuse. In early childhood, exposure to lead or other toxins can cause ADHD-like symptoms. Traumatic brain injury or neurological disorders also may trigger ADHD symptoms. Although the exact cause of ADHD is not known, an imbalance of certain neurotransmitters (the chemicals in the brain that send messages between nerve cells) is believed to be the mechanism behind ADHD symptoms.

A widely publicized study conducted by Ben Fein-gold in the early 1970s suggested that allergies to certain foods and food additives caused the characteristic hyperactivity of ADHD children. Although some children may have adverse reactions to certain foods that can affect their behavior (for example, a rash might temporarily cause a child to be distracted from other tasks), carefully controlled follow-up studies have uncovered no link between food allergies and ADHD. Another popularly held misconception about food and ADHD is that eating sugar causes hyperactive behavior. Again, studies have shown no link between sugar intake and ADHD. It is important to note, however, that a nutritionally balanced diet is important for normal development in all children.

People with ADHD suffer from a variety of symptoms. These symptoms include such things as distraction, not paying attention, inconsistency, forgetfulness of even simple tasks, fidgeting, verbal impulsivity, and so on. It is interesting to note that everyone suffers from these symptoms at times, but an individual with ADHD will have more of these symptoms more of the time.

Some doctors indicated immature symmetric tonic neck reflex (STNR) as a possible cause of certain symptoms. Other studies in 1993 and 1994 showed a link between the disorder and diet, dyes, and preservatives. In another study in 1996, ADHD was linked to maternal smoking during pregnancy .

Psychologists and other mental health professionals typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a guideline for determining the presence of ADHD. For a diagnosis of ADHD, DSM-IV requires the presence of at least six of the following symptoms of inattention, or six or more symptoms of hyperactivity and impulsivity combined.

Inattention

  • fails to pay close attention to detail or makes careless mistakes in schoolwork or other activities
  • has difficulty sustaining attention in tasks or activities
  • does not appear to listen when spoken to
  • does not follow through on instructions and does not finish tasks
  • has difficulty organizing tasks and activities
  • avoids or dislikes tasks that require sustained mental effort (like homework)
  • is easily distracted
  • is forgetful in daily activities

Hyperactivity

  • fidgets with hands or feet or squirms in seat
  • does not remain seated when expected to
  • runs or climbs excessively when inappropriate (in adolescents and adults, feelings of restlessness)
  • has difficulty playing quietly
  • is constantly on the move
  • talks excessively

Impulsivity

  • blurts out answers before the question has been completed
  • has difficulty waiting for his or her turn
  • interrupts and/or intrudes on others

DSM-IV also requires that some symptoms develop before age seven, and that they significantly impair functioning in two or more settings (e.g., home and school) for at least six months. Children who meet the symptom criteria for inattention, but not for hyperactivity/impulsivity are diagnosed with Attention-deficit/hyperactivity disorder, predominantly inattentive type, commonly called ADD. (Young girls with ADHD may not be diagnosed because they have mainly this subtype of the disorder.)

Diagnosis

The first step in determining if a child has ADHD is to consult with a pediatrician, a doctor who treats children. The pediatrician can make an initial evaluation of the child's developmental maturity compared to other children in his or her age group. The doctor also should perform a comprehensive physical examination to rule out any organic causes of ADHD symptoms, such as an overactive thyroid or vision or hearing problems.

If no organic problem can be found, a psychologist, psychiatrist, neurologist, neuropsychologist, or learning specialist typically is consulted to perform a comprehensive ADHD assessment. A complete medical, family, social, psychiatric, and educational history is compiled from existing medical and school records and from interviews with parents and teachers. Interviews also may be conducted with the child, depending on his or her age. Along with these interviews, several clinical inventories also may be used, such as the Conners Rating Scales (Teacher's Questionnaire and Parent's Questionnaire), Child Behavior Checklist (CBCL), and the Achenbach Child Behavior Rating Scales. These inventories provide valuable information on the child's behavior in different settings and situations. In addition, the Wender Utah Rating Scale has been adapted for use in diagnosing ADHD in adults.

It is important to note that mental disorders such as depression and anxiety disorder can cause symptoms similar to ADHD. A complete and comprehensive psychiatric assessment is critical to differentiate ADHD from other possible mood and behavioral disorders. Bipolar disorder , for example, may be misdiagnosed as ADHD.

Public schools are required by federal law to offer free ADHD testing upon request. A pediatrician also can provide a referral to a psychologist or pediatric specialist for ADHD assessment. Parents should check with their insurance plans to see if these services are covered.

Treatment

A 2003 survey showed that approximately 54% of parents reported using complementary or alternative medicine treatments for their children in the previous year. Some parents reported turning to these therapies because doctors don't always agree on the ADHD diagnosis and cannot adequately explain how allopathic drug treatments calm people and improve mental focus. Behavior modification therapy uses a reward system to reinforce good behavior as well as task completion and can be used both in the classroom and at home. A tangible reward such as a sticker may be given to the child every time he completes a task or behaves in an acceptable manner. A chart system may be used to display the stickers and visually illustrate the child's progress. When a certain number of stickers are collected, the child may trade them in for a bigger reward such as a trip to the zoo or a day at the beach. The reward system stays in place until the good behavior becomes ingrained.

A variation of this technique, cognitive-behavioral therapy, works to decrease impulsive behavior by getting the child to recognize the connection between thoughts and behavior, and to change behavior by changing negative thinking patterns.

Individual psychotherapy can help ADHD children build self-esteem, give them a place to discuss their worries and anxieties, and help them gain insight into their behavior and feelings. Family therapy also may be beneficial in helping family members develop coping skills and work through feelings of guilt or anger they may be experiencing.

ADHD children perform better within a familiar, consistent, and structured routine with positive reinforcements for good behavior and real consequences for bad. Family, friends, and caretakers should be educated on the special needs and behaviors of the ADHD child. Communication between parents and teachers is especially critical to ensuring an ADHD child has an appropriate learning environment.

A number of alternative treatments exist for ADHD. Although there is a lack of controlled studies to prove their efficacy, proponents report that they are successful in controlling symptoms in some ADHD patients. Some of the more popular alternative treatments are listed.

  • Electroencephalograph (EEG) biofeedback . By measuring brain wave activity and teaching the ADHD patient which type of brain wave is associated with attention, EEG biofeedback attempts to train patients to generate the desired brain wave activity.
  • Dietary therapy. Based in part on the Feingold food allergy diet, dietary therapy focuses on a nutritional plan that is high in protein and complex carbohydrates and free of white sugar and salicylate-containing foods such as strawberries, tomatoes, and grapes.
  • Herbal therapy. Herbal therapy uses a variety of natural remedies to address the symptoms of ADHD. Ginkgo (Gingko biloba ) is used for memory and mental sharpness and chamomile (Matricaria recutita ) extract is used for calming. The safety of herbal remedies has not been demonstrated in controlled studies. For example, it is known that gingko may affect blood coagulation, but controlled studies have not yet evaluated the risk of the effect.
  • Vitamin and mineral supplements. Some vitamin and mineral supplements that are thought to be effective by some alternative practitioners include calcium, zinc, magnesium, iron , inositol, trace minerals, blue-green algae. Also recommended are the combined amino acids GABA, glycine, taurine, L-glutamine, L-phenylalanine, and L-tyrosine. In 2003, a study reported that a combination of omega-3 and omega-6 fatty acids supplements may help with cognitive and behavioral symptoms of ADHD.
  • Homeopathic medicine. This is probably the most effective alternative therapy for ADD and ADHD because it treats the whole person at a core level. Constitutional homeopathic care is most appropriate and requires consulting with a well-trained homeopath who has experience working with ADD and ADHD individuals.
  • Auricular acupuncture . A small study in 1997 indicated that this type of acupuncture therapy might be effective in some children.

Allopathic treatment

Psychosocial therapy, usually combined with medications, is the treatment approach of choice to alleviate ADHD symptoms. Psychostimulants, such as dextroamphetamine (Dexedrine), pemoline (Cylert), and methylphenidate (Ritalin) commonly are prescribed to control hyperactive and impulsive behavior and increase attention span. They work by stimulating the production of certain neurotransmitters in the brain. Possible side effects of stimulants include nervous tics, irregular heartbeat, loss of appetite, and insomnia . However, the medications usually are well-tolerated and safe in most cases. But according to Carolyn Chambers Clark, R.N., Ed.D., 25% of the children with ADHD do not respond to stimulant drugs.

In children who don't respond well to stimulant therapy, tricyclic antidepressants such as desipramine (Norpramin, Pertofane) and amitriptyline (Elavil) are frequently recommended. Reported side effects of these drugs include persistent dry mouth , sedation, disorientation, and irregular heartbeat (particularly with desipramine). Other medications prescribed for ADHD therapy include buproprion (Wellbutrin), an antidepressant; fluoxetine (Prozac), an antidepressant; and carbamazepine (Tegretol, Atretol), an anticonvulsant drug. Clonidine (Catapres), a medication for high blood pressure, also has been used to control aggression and hyperactivity in some ADHD children, although it should not be used with Ritalin. A child's response to medication will change with age and maturation, so ADHD symptoms should be monitored closely and prescriptions adjusted accordingly.

In mid-2003, the first new drug for treating ADHD was about to become available. Called atomoxetine (Strattera), it was planned to offer several advantages over standard stimulants. First, atomoxetine is not a controlled substance, so physicians can write prescriptions for a larger number of pills and refills. Further, it doesn't have the potential for abuse that the stimulant drugs pose.

Expected results

Untreated, ADHD negatively affects a child's social and educational performance and can seriously damage his or her sense of self-esteem. ADHD children have impaired relationships with their peers and may be looked upon as social outcasts. They may be seen as slow learners or troublemakers in the classroom. Siblings and even parents may develop resentful feelings toward the ADHD child.

Some ADHD children also develop a conduct disorder problem. For those adolescents who have both ADHD and a conduct disorder, up to 25% go on to develop anti-social personality disorder and the criminal behavior, substance abuse, and high rate of suicide attempts that are symptomatic of it. Children diagnosed with ADHD also are more likely to have a learning disorder, a mood disorder such as depression, or an anxiety disorder.

Approximately 70-80% of ADHD patients treated with stimulant medication experience significant relief from symptoms, at least in the short-term. Approximately half of ADHD children seem to "outgrow" the disorder in adolescence or early adulthood. The other half will retain some or all symptoms of ADHD as adults. With early identification and intervention, careful compliance with a treatment program, and a supportive and nurturing home and school environment, ADHD children can flourish socially and academically.

Resources

BOOKS

Alexander-Roberts, Colleen. The ADHD Parenting Handbook: Practical Advice for Parents from Parents. Dallas: Taylor Publishing Co., 1994.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Press Inc., 1994.

Diller, Laurence H. Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill. New York: Bantam Books, 1998.

Hallowell, Edward M., and John J. Ratey. Driven to Distraction. New York: Pantheon Books, 1994.

Kennedy, Patricia, Leif Terdal, and Lydia Fusetti. The Hyperactive Child Book. New York: St. Martin's Press, 1993.

Maxmen, Jerrold S., and Nicholas G. Ward. "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence." In Essential Psychopathology and Its Treatment, 2nd ed. New York: W.W. Norton, 1995, 419-457.

Osman, Betty B. Learning Disabilities and ADHD: A Family Guide to Living and Learning Together. New York: John Wiley & Sons, 1997.

PERIODICAL

"Complementary, Alternative Medicine Being Used by Parents for ADHD." The Brown University Child and Adolescent Psychopharmacology Update (August 2003):1-3.

Gaby, Alan R. "Essential Fatty Acids for ADHD." Townsend Letter for Doctors and Patients (April 2003):43.

Glicken, Anita D. "Attention Deficit Disorder and the Pediatric Patient: A Review." Physician Assistant 21, no. 4 (April 1997): 101-111.

Hallowell, Edward M. "What I've Learned from A.D.D." Psychology Today 30, no. 3 (May-June 1997): 40-46.

Monaco, John E. "New Drug for ADHD." Pediatrics for Parents (June 2003):7-11.

"New National ADHD Resource Center Opens in Maryland." Special Education Report (June 2003):12.

"Parents Increasingly Seek Alternative ADHD Treatments." Mental Health Weekly (September 22, 2003):7.

Swanson, J.M., et al. "Attention-deficit Hyperactivity Disorder and Hyperkinetic Disorder." The Lancet 351 (February 7, 1997): 429-433.

ORGANIZATION

Children and Adults with Attention Deficit Disorder. (CH.A.D.D.). 499 Northwest 70th Ave., Suite 101, Plantation, FL 33317. (800) 233-4050. <http://www.chadd.org/.>

The National Attention Deficit Disorder Association. (ADDA). 9930 Johnnycake Ridge Rd., Suite 3E, Mentor, OH 44060. (800) 487-2282. <http://www.add.org/.>

The National Resource Center of ADHD. (800) 233-4050. <http://www.help4adhd.org/.>

Kim Sharp

Teresa G. Odle

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Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder

Definition

Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or activities.

Description

ADHD, also known as hyperkinetic disorder (HKD) outside of the United States, is estimated to affect 3%-9% of children, and afflicts boys more often than girls. Although difficult to assess in infancy and toddlerhood, signs of ADHD may begin to appear as early as age two or three, but the symptom picture changes as adolescence approaches. Many symptoms, particularly hyperactivity, diminish in early adulthood, but impulsivity and problems focusing attention remain with up to 50% of individuals with ADHD throughout their adult life.

Children with ADHD have short attention spans, becoming easily bored and/or frustrated with tasks. Although they may be quite intelligent, their lack of focus frequently results in poor grades and difficulties in school. Children with ADHD act impulsively, taking action first and thinking later. They are constantly moving, running, climbing, squirming, and fidgeting, but often have trouble with gross and fine motor skills and, as a result, may be physically clumsy and awkward. In social settings, they are sometimes shunned due to their impulsive and intrusive behavior.

Causes and symptoms

Causes

The causes of ADHD are not known. However, it appears that heredity plays a major role in the development of ADHD. Children with an ADHD parent or sibling are more likely to develop the disorder themselves. Before birth, ADHD children may have been exposed to poor maternal nutrition, viral infections, or maternal substance abuse. In early childhood, exposure to lead or other toxins can cause ADHD-like symptoms. Traumatic brain injury or neurological disorders may also trigger ADHD symptoms. Although the exact cause of ADHD is not known, an imbalance of certain neurotransmitters (the chemicals in the brain that transmit messages between nerve cells) is believed to be the mechanism behind ADHD symptoms.

Symptoms

The diagnosis of ADHD requires the presence of at least six of the following symptoms of inattention, or six or more symptoms of hyperactivity and impulsivity combined:

Inattention:

  • fails to pay close attention to detail or makes careless mistakes in schoolwork or other activities
  • has difficulty sustaining attention in tasks or activities
  • does not appear to listen when spoken to
  • does not follow through on instructions and does not finish tasks
  • has difficulty organizing tasks and activities
  • avoids or dislikes tasks that require sustained mental effort (such as homework)
  • is easily distracted
  • is forgetful in daily activities

Hyperactivity:

  • fidgets with hands or feet or squirms in seat
  • does not remain seated when expected to
  • runs or climbs excessively when inappropriate (in adolescents and adults, feelings of restlessness)
  • has difficulty playing quietly
  • is constantly on the move
  • talks excessively

Impulsivity:

  • blurts out answers before the question has been completed
  • has difficulty waiting for his or her turn
  • interrupts and/or intrudes on others

Further criteria to establish a diagnosis also require that some symptoms develop before age seven, and that they significantly impair functioning in two or more settings (home and school, for example) for a period of at least six months.

Many individuals with ADHD have symptoms from all three of the above categories. Some children, however, have behavior patterns in which inattention dominates, or hyperactivity and impulsivity dominate. For this reason, ADHD can be further categorized, or subdivided, into three subtypes. Children who have at least six symptoms from both of the inattention and hyperactivity-impulsivity categories above may be diagnosed with ADHD, combined type. Children who meet the symptom criteria for inattention, but not for hyperactivity/impulsivity are diagnosed with attention-deficit/hyperactivity disorder, predominantly inattentive type, commonly called ADD. Children who experience more symptoms from the hyperactivity and impulsivity categories, but fewer than six symptoms of inattention may be diagnosed with ADHD, predominantly hyperactive-impulsive type.

Diagnosis

The first step in determining if a child has ADHD is to consult with a pediatrician. The pediatrician can make an initial evaluation of the child's developmental maturity compared to other children in his or her age group. The physician should also perform a comprehensive physical examination to rule out any organic causes of ADHD symptoms, such as an overactive thyroid or vision or hearing problems.

If no organic problem can be found, a psychologist , psychiatrist , neurologist, neuropsychologist, or learning specialist is typically consulted to perform a comprehensive ADHD assessment. A complete medical, family, social, psychiatric, and educational history is compiled from existing medical and school records and from interviews with parents and teachers. Interviews may also be conducted with the child, depending on his or her age. Along with these interviews, several clinical questionnaires may also be used, such as the Conners Rating Scales (Teacher's Questionnaire and Parent's Questionnaire), Child Behavior Checklist (CBCL), and the Achenbach Child Behavior Rating Scales. These inventories provide valuable information on the child's behavior in different settings and situations. In addition, the Wender Utah Rating Scale has been adapted for use in diagnosing ADHD in adults.

It is important to note that mental disorders such as depression and anxiety disorder can cause symptoms similar to ADHD. (Depression can cause attention problems, and anxiety can cause symptoms similar to hyperactivity.) A complete and comprehensive psychological assessment is critical to differentiate ADHD from other possible mood and behavioral disorders. Bipolar disorder , for example, may be misdiagnosed as ADHD.

Public schools are required by federal law to offer free ADHD testing upon request. A pediatrician can also provide a referral to a psychologist or pediatric specialist for ADHD assessment. Parents should check with their insurance plans to see if these services are covered.

Treatment

Therapy that addresses both psychological and social issues (called psychosocial therapy), usually combined with medications, is the treatment approach of choice to alleviate ADHD symptoms.

Medications

Medications known as psychostimulants, such as dextroamphetamine (Dexedrine), pemoline (Cylert), and methylphenidate (Ritalin), are commonly prescribed to control hyperactive and impulsive behavior and increase attention span. These medications work by stimulating the production of certain neurotransmitters in the brain. These medications are usually well-tolerated and safe in most cases, but possible side effects of stimulants include nervous tics, irregular heartbeat, loss of appetite, and insomnia .

For children who do not respond well to stimulant therapy, and for children who clearly suffer from depression as well as ADHD, tricyclic antidepressants (a group of drugs used to treat depression) may be recommended. Examples of these antidepressants include desipramine (Norpramin, Pertofane) and amitriptyline (Elavil). Reported side effects of these drugs include persistent dry mouth, sedation, disorientation, and cardiac arrhythmia (an abnormal heart rate), particularly with desipramine. Other medications prescribed for ADHD therapy include buproprion (Wellbutrin), an antidepressant; fluoxetine (Prozac), an SSRI antidepressant (a group of medications used to treat depression by directing the flow of a neurotransmitter called serotonin); and carbamazepine (Tegretol, Atretol), an antiseizure drug. Clonidine (Catapres), a medication used to treat high blood pressure, has also been used to control aggression and hyperactivity in some ADHD children, although it should not be used with Ritalin. Because a child's response to medication will change with age and maturation, ADHD symptoms should be monitored closely and prescriptions adjusted accordingly.

Psychosocial therapies

Behavior modification therapy uses a reward system to reinforce good behavior and task completion and can be implemented both in the classroom and at home. A tangible reward such as a sticker may be given to the child every time he completes a task or behaves in an acceptable manner. A chart may be used to display the stickers and visually illustrate the child's progress. When a certain number of stickers are collected, the child may trade them in for a bigger reward such as a trip to the zoo or a day at the beach. The reward system stays in place until the good behavior becomes ingrained.

A variation of this technique, cognitive-behavioral therapy , may work for some children to decrease impulsive behavior by getting the child to recognize the connection between thoughts and behavior, and to change behavior by changing negative thinking patterns.

Individual psychotherapy can help an ADHD child build self-esteem, provide a place to discuss worries and anxieties, and help him or her to gain insight into behavior and feelings.

Family therapy may also be beneficial in helping family members develop coping skills and in working through feelings of guilt or anger parents may be experiencing.

ADHD children perform better within a familiar, consistent, and structured routine with positive reinforcements for good behavior and real consequences for bad behavior. Family, friends, and caretakers should all be educated on the special needs and behaviors of the ADHD child so that they can act consistently. Communication between parents and teachers is especially critical to ensuring an ADHD child has an appropriate learning environment.

Alternative treatment

A number of alternative treatments exist for ADHD. Although there is a lack of controlled studies to prove their efficacy, proponents report that they are successful in controlling symptoms in some ADHD patients. Some of the more popular alternative treatments include:

  • EEG (electroencephalograph) biofeedback . By measuring brainwave activity and teaching the ADHD patient which type of brainwave is associated with attention, EEG biofeedback attempts to train patients to generate the desired brainwave activity.
  • Limited sugar intake. However, data indicate that this method does not actually reduce symptoms.
  • Relaxation training.

Prognosis

Untreated, ADHD negatively affects a child's social and educational performance and can seriously damage his or her sense of self-esteem. ADHD children have impaired relationships with their peers, and may be looked upon as social outcasts. They may be perceived as slow learners or troublemakers in the classroom. Siblings and even parents may develop resentful feelings towards a child with ADHD.

Some ADHD children also develop a conduct disorder problem. For those adolescents who have both ADHD and a conduct disorder, up to 25% go on to develop antisocial personality disorder and the criminal behavior, substance abuse, and high rate of suicide attempts that can be symptomatic of that disorder. Children diagnosed with ADHD are also more likely to have a learning disorder, a mood disorder such as depression, or an anxiety disorder.

Approximately 70%-80% of ADHD patients treated with stimulant medication experience significant relief from symptoms, at least in the short term. Approximately half of ADHD children seem to "outgrow" the disorder in adolescence or early adulthood; the other half will retain some or all symptoms of ADHD as adults. With early identification and intervention , careful compliance with a treatment program, and a supportive and nurturing home and school environment, children with ADHD can flourish socially and academically.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revised. Washington, DC: American Psychiatric Press, Inc., 2000.

Arnold, L. Eugene. Contemporary Diagnosis and Management of Attention Deficit/ Hyperactivity Disorder. Newtown: Handbooks in Health Care Company, 2000.

Boyles, Nancy S. Parenting a Child with Attention Deficit/Hyperactivity Disorder. New York: Contemporary Books, 1999.

Fowler, Rick, and Jerilyn Fowler. Honey, Are You Listening? Attention Deficit/ Hyperacitivity Disorder and Your Marriage. Gainsville: Fair Havens Publications, 2002.

Goldman, Lee, J. Claude Bennett, eds. Cecil Textbook of Medicine. 21st ed. Saint Louis: Harcourt Health Sciences Group, 2000.

Jones, Clare B. Sourcebook for Children with Attention Deficit Disorder. San Antonio: Communication Skill Builders/ Therapy Skill Builders, 1998.

Morrison, Jaydene. Coping with ADD-ADHD: Attention- Deficit Disorder- Attention Deficit Hyperactivity Disorder. New York: Rosen Publishing Group, 2000.

Munden, Alison. ADHD Handbook: A Guide for Parents and Professionals. Philadelphia: Taylor and Francis, Inc., 1999.

Noble, John. Textbook of Primary Care Medicine. Saint Louis: Mosby, Incorporated, 2001.

Osman, Betty B. Learning Disabilities and ADHD: A Family Guide to Living and Learning Together. New York: John Wiley and Sons, 1997.

Tasman, Allan, Jerald Kay, MD, Jeffrey A. Lieberman, MD,eds. Psychiatry. 1st ed. W. B. Saunders Company, 1997.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. (AACAP). 3615 Wisconsin Ave. NW, Washington, DC 20016. (202) 966-7300. <http://www.aacap.org>.

Attention Deficit Disorder Association (ADDA). 1788 Second Street, Suite 200, Highland Park, IL 60035. Telephone: (847) 432-ADDA. <http://www.add.org>.

Children and Adults with Attention Deficit Disorder (CH.A.D.D.). 8181 Professional Place, Suite 201, Landover, MD 20785. CHADD National Call Center (800) 233-4050. Web site: <http://chadd.org>.

Paula Anne Ford-Martin, M.A.

Laith Farid Gulli, M.D.

Nicole Mallory ,M.S.,PA-C

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Ford-Martin, Paula Anne; Gulli, Laith Farid; Mallory , Nicole. "Attention-deficit/hyperactivity disorder." Gale Encyclopedia of Mental Disorders. 2003. Encyclopedia.com. 27 Jul. 2016 <http://www.encyclopedia.com>.

Ford-Martin, Paula Anne; Gulli, Laith Farid; Mallory , Nicole. "Attention-deficit/hyperactivity disorder." Gale Encyclopedia of Mental Disorders. 2003. Encyclopedia.com. (July 27, 2016). http://www.encyclopedia.com/doc/1G2-3405700041.html

Ford-Martin, Paula Anne; Gulli, Laith Farid; Mallory , Nicole. "Attention-deficit/hyperactivity disorder." Gale Encyclopedia of Mental Disorders. 2003. Retrieved July 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3405700041.html

Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (ADHD)

Definition

Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or activities.

Description

ADHD, also known as hyperkinetic disorder (HKD) outside of the United States, is estimated to affect 3-9% of children, and afflicts boys more often than girls. Although difficult to assess in infancy and toddlerhood, signs of ADHD may begin to appear as early as age two or three, but the symptom picture changes as adolescence approaches. Many symptoms, particularly hyperactivity, diminish in early adulthood, but impulsivity and inattention problems remain with up to 50% of ADHD individuals throughout their adult life.

Children with ADHD have short attention spans, becoming easily bored and/or frustrated with tasks. Although they may be quite intelligent, their lack of focus frequently results in poor grades and difficulties in school. ADHD children act impulsively, taking action first and thinking later. They are constantly moving, running, climbing, squirming, and fidgeting, but often have trouble with gross and fine motor skills and, as a result, may be physically clumsy and awkward. Their clumsiness may extend to the social arena, where they are sometimes shunned due to their impulsive and intrusive behavior.

Causes and symptoms

The causes of ADHD are not known. However, it appears that heredity plays a major role in the development of ADHD. Children with an ADHD parent or sibling are more likely to develop the disorder themselves. In 2004, scientists reported at least 20 candidate genes that might contribute to ADHD, but no single gene stood out as the gene causing the condition. Before birth, ADHD children may have been exposed to poor maternal nutrition, viral infections, or maternal substance abuse. In early childhood, exposure to lead or other toxins can cause ADHD-like symptoms. Traumatic brain injury or neurological disorders may also trigger ADHD symptoms. Although the exact cause of ADHD is not known, an imbalance of certain neurotransmitters, the chemicals in the brain that transmit messages between nerve cells, is believed to be the mechanism behind ADHD symptoms.

Drugs Used To Treat ADHD
Brand Name (Generic Name) Possible Common Side Effects
Include:
Cylert (pemoline) Insomnia
Dexedrine (dextroamphetamine
sulfate)
Excessive stimulation, restlessness
Ritalin (methylphenidate
hydrochloride)
Insomnia, nervousness, loss of
appetite

A widely publicized study conducted by Dr. Ben Feingold in the early 1970s suggested that allergies to certain foods and food additives caused the characteristic hyperactivity of ADHD children. Although some children may have adverse reactions to certain foods that can affect their behavior (for example, a rash might temporarily cause a child to be distracted from other tasks), carefully controlled follow-up studies have uncovered no link between food allergies and ADHD. Another popularly held misconception about food and ADHD is that the consumption of sugar causes hyperactive behavior. Again, studies have shown no link between sugar intake and ADHD. It is important to note, however, that a nutritionally balanced diet is important for normal development in all children.

KEY TERMS

Conduct disorder A behavioral and emotional disorder of childhood and adolescence. Children with a conduct disorder act inappropriately, infringe on the rights of others, and violate societal norms.

Nervous tic A repetitive, involuntary action, such as the twitching of a muscle or repeated blinking.

Oppositional defiant disorder A disorder characterized by hostile, deliberately argumentative, and defiant behavior toward authority figures.

Psychologists and other mental health professionals typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a guideline for determining the presence of ADHD. For a diagnosis of ADHD, DSM-IV requires the presence of at least six of the following symptoms of inattention, or six or more symptoms of hyperactivity and impulsivity combined:

Inattention:

  • fails to pay close attention to detail or makes careless mistakes in schoolwork or other activities
  • has difficulty sustaining attention in tasks or activities
  • does not appear to listen when spoken to
  • does not follow through on instructions and does not finish tasks
  • has difficulty organizing tasks and activities
  • avoids or dislikes tasks that require sustained mental effort (e.g., homework)
  • is easily distracted
  • is forgetful in daily activities

Hyperactivity:

  • fidgets with hands or feet or squirms in seat
  • does not remain seated when expected to
  • runs or climbs excessively when inappropriate (in adolescents and adults, feelings of restlessness)
  • has difficulty playing quietly
  • is constantly on the move
  • talks excessively

Impulsivity:

  • blurts out answers before the question has been completed
  • has difficulty waiting for his or her turn
  • interrupts and/or intrudes on others

Diagnosis

The first step in determining if a child has ADHD is to consult with a pediatrician. The pediatrician can make an initial evaluation of the child's developmental maturity compared to other children in his or her age group. The physician should also perform a comprehensive physical examination to rule out any organic causes of ADHD symptoms, such as an overactive thyroid or vision or hearing problems.

If no organic problem can be found, a psychologist, psychiatrist, neurologist, neuropsychologist, or learning specialist is typically consulted to perform a comprehensive ADHD assessment. A complete medical, family, social, psychiatric, and educational history is compiled from existing medical and school records and from interviews with parents and teachers. Interviews may also be conducted with the child, depending on his or her age. Along with these interviews, several clinical inventories may also be used, such as the Conners Rating Scales (Teacher's Questionnaire and Parent's Questionnaire), Child Behavior Checklist (CBCL), and the Achenbach Child Behavior Rating Scales. These inventories provide valuable information on the child's behavior in different settings and situations. In addition, the Wender Utah Rating Scale has been adapted for use in diagnosing ADHD in adults.

It is important to note that mental disorders such as depression and anxiety disorder can cause symptoms similar to ADHD. A complete and comprehensive psychiatric assessment is critical to differentiate ADHD from other possible mood and behavioral disorders. Bipolar disorder, for example, may be misdiagnosed as ADHD.

Public schools are required by federal law to offer free ADHD testing upon request. A pediatrician can also provide a referral to a psychologist or pediatric specialist for ADHD assessment. Parents should check with their insurance plans to see if these services are covered.

Treatment

Psychosocial therapy, usually combined with medications, is the treatment approach of choice to alleviate ADHD symptoms. Psychostimulants, such as dextroamphetamine (Dexedrine), pemoline (Cylert), and methylphenidate (Ritalin) are commonly prescribed to control hyperactive and impulsive behavior and increase attention span. They work by stimulating the production of certain neurotransmitters in the brain. Possible side effects of stimulants include nervous tics, irregular heartbeat, loss of appetite, and insomnia. However, the medications are usually well-tolerated and safe in most cases. In 2004, longer-acting stimulants had been released to treat adult ADHD.

In 2004, the American Academy of Child and Adolescent Psychiatry listed the first nonstimulant as a first-line therapy for ADHD. Called atomoxetine HCI (Strattera), it is a norepinephrine reuptake inhibitor.

In children who do not respond well to stimulant therapy, tricyclic antidepressants such as desipramine (Norpramin, Pertofane) and amitriptyline (Elavil) are sometimes recommended. Reported side effects of these drugs include persistent dry mouth, sedation, disorientation, and cardiac arrhythmia (particularly with desipramine). Other medications prescribed for ADHD therapy include buproprion (Wellbutrin), an antidepressant; fluoxetine (Prozac), an SSRI antidepressant; and carbamazepine (Tegretol, Atretol), an anticonvulsant drug. Clonidine (Catapres), an antihypertensive medication, has also been used to control aggression and hyperactivity in some ADHD children, although it should not be used with Ritalin. A child's response to medication will change with age and maturation, so ADHD symptoms should be monitored closely and prescriptions adjusted accordingly.

Behavior modification therapy uses a reward system to reinforce good behavior and task completion and can be implemented both in the classroom and at home. A tangible reward such as a sticker may be given to the child every time he completes a task or behaves in an acceptable manner. A chart system may be used to display the stickers and visually illustrate the child's progress. When a certain number of stickers are collected, the child may trade them in for a bigger reward such as a trip to the zoo or a day at the beach. The reward system stays in place until the good behavior becomes ingrained.

A variation of this technique, cognitive-behavioral therapy, works to decrease impulsive behavior by getting the child to recognize the connection between thoughts and behavior, and to change behavior by changing negative thinking patterns.

Individual psychotherapy can help an ADHD child build self-esteem, give them a place to discuss their worries and anxieties, and help them gain insight into their behavior and feelings. Family therapy may also be beneficial in helping family members develop coping skills and in working through feelings of guilt or anger parents may be experiencing.

ADHD children perform better within a familiar, consistent, and structured routine with positive reinforcements for good behavior and real consequences for bad. Family, friends, and caretakers should all be educated on the special needs and behaviors of the ADHD child. Communication between parents and teachers is especially critical to ensuring an ADHD child has an appropriate learning environment.

Alternative treatment

A number of alternative treatments exist for ADHD. Although there is a lack of controlled studies to prove their efficacy, proponents report that they are successful in controlling symptoms in some ADHD patients. Some of the more popular alternative treatments include:

  • EEG (electroencephalograph) biofeedback. By measuring brainwave activity and teaching the ADHD patient which type of brainwave is associated with attention, EEG biofeedback attempts to train patients to generate the desired brainwave activity.
  • Dietary therapy. Based in part on the Feingold food allergy diet, dietary therapy focuses on a nutritional plan that is high in protein and complex carbohydrates and free of white sugar and salicylate-containing foods such as strawberries, tomatoes, and grapes.
  • Herbal therapy. Herbal therapy uses a variety of natural remedies to address the symptoms of ADHD, such as ginkgo (Gingko biloba ) for memory and mental sharpness and chamomile (Matricaria recutita ) extract for calming. The safety of herbal remedies has not been demonstrated in controlled studies. For example, it is known that gingko may affect blood coagulation, but controlled studies have not yet evaluated the risk of the effect.
  • Homeopathic medicine. The theory of homeopathic medicine is to treat the whole person at a core level. Constitutional homeopathic care requires consulting with a well-trained homeopath who has experience working with ADD and ADHD individuals.

Prognosis

Untreated, ADHD negatively affects a child's social and educational performance and can seriously damage his or her sense of self-esteem. ADHD children have impaired relationships with their peers, and may be looked upon as social outcasts. They may be perceived as slow learners or troublemakers in the classroom. Siblings and even parents may develop resentful feelings towards the ADHD child.

Some ADHD children also develop a conduct disorder problem. For those adolescents who have both ADHD and a conduct disorder, as many as 25% go on to develop antisocial personality disorder and the criminal behavior, substance abuse, and high rate of suicide attempts that are symptomatic of it. Children diagnosed with ADHD are also more likely to have a learning disorder, a mood disorder such as depression, or an anxiety disorder.

Approximately 70-80% of ADHD patients treated with stimulant medication experience significant relief from symptoms, at least in the short-term. Approximately one-half of ADHD children seem to "outgrow" the disorder in adolescence or early adulthood; the other half will retain some or all symptoms of ADHD as adults. With early identification and intervention, careful compliance with a treatment program, and a supportive and nurturing home and school environment, ADHD children can flourish socially and academically.

Resources

PERIODICALS

"AACAP Guidelines Include Strattera as a First-line ADHD Therapy Option." Drug Week (May 28, 2004): 54.

"More Long-acting Stimulants to Treat Adult ADHD." SCRIP World Pharmaceutical News (May 14, 2004): 101-23.

"Study Updates Genetics of ADHD." Drug Week (May 21, 2004): 55.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. (AACAP). 3615 Wisconsin Ave. NW, Washington, DC 20016. (202) 966-7300. http://www.aacap.org.

Children and Adults with Attention Deficit Disorder (CH.A.D.D.). 8181 Professional Place, Suite 201.

National Attention Deficit Disorder Association. (ADDA). 9930 Johnnycake Ridge Road, Suite 3E, Mentor, OH 44060. (800) 487-2282. http://www.add.org.

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Ford-Martin, Paula; Odle, Teresa. "Attention-Deficit/Hyperactivity Disorder (ADHD)." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. 27 Jul. 2016 <http://www.encyclopedia.com>.

Ford-Martin, Paula; Odle, Teresa. "Attention-Deficit/Hyperactivity Disorder (ADHD)." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. (July 27, 2016). http://www.encyclopedia.com/doc/1G2-3451600202.html

Ford-Martin, Paula; Odle, Teresa. "Attention-Deficit/Hyperactivity Disorder (ADHD)." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved July 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451600202.html

Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder

DIAGNOSIS

COURSE, IMPACT, AND COMORBIDITY

HISTORY OF THE DISORDER AND ITS TREATMENT

BIBLIOGRAPHY

Attention-deficit/hyperactivity disorder (ADHD) is a diagnostic label describing children and adults who demonstrate developmentally inappropriate levels of inattention, hyperactivity, and impulsivity. This disorder has been identified by many different names in the past, including attention-deficit disorder (ADD) with and without hyperactivity. It is one of the most commonly diagnosed disorders of childhood and accounts for a significant percentage of referrals to mental health and primary care clinics. Once considered a childhood disorder that one would grow out of, it is now recognized that symptoms and impairment persist across the lifespan for many individuals, with an increasing number of adults seeking treatment. Although prevalence rates vary as a function of diagnostic method, it is estimated that 5 to 8 percent of children and 1 to 3 percent of adults meet criteria for ADHD as outlined by the American Psychiatric Association (1994). ADHD is more often diagnosed in boys, but prevalence rates are fairly consistent across diverse geographic and racial populations.

DIAGNOSIS

The Diagnostic and Statistical Manual of Mental Disorders (DSM -IV), the primary reference for mental health professionals in the United States (APA 1994), identifies three subtypes of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Atleast six of nine inattentive or hyperactive-impulsive symptoms must be present for at least six months for diagnosis, with the subtype determined by which symptoms are predominant. Inattentive symptoms include inattention to details or making careless mistakes, difficulty sustaining attention, not listening, not following through and completing tasks, avoiding or disliking tasks requiring sustained mental effort, disorganization, forgetfulness, losing things, and distractibility. Hyperactive symptoms include fidgeting, difficulty remaining seated, being on the go, running or climbing excessively (feelings of restlessness in adults), difficulty playing quietly, and talking excessively. Impulsive symptoms include blurting out, difficulty waiting, and interrupting or intruding on others. These symptoms must be sufficiently maladaptive and developmentally inappropriate to warrant diagnosis.

DSM -IV criteria also require that at least some of the symptoms must have caused impairment for the individual before the age of seven. Although symptoms may be overlooked in some children when they are younger, particularly those who are higher functioning, the developmental nature of the disorder requires a chronic and pervasive pattern of difficulties across time. Thus, one cannot develop adult onset ADHD. When symptoms present in adulthood for the first time, there is often an alternative explanation for them, such as anxiety, depression, or another medical condition. Because inattention and hyperactivity-impulsivity can have numerous causes, diagnosis actually requires that symptoms are not better accounted for by another psychiatric disorder and that they do not occur solely in the context of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. Finally, ADHD-related impairments must occur across settings (i.e., in the home, during social activities, and at school or work) and there must be evidence of clinically significant impairment in social, academic, or occupational functioning. That is, the symptom severity is more than mild and interferes in individuals daily lives and activities. Although these criteria have limitations, notably their appropriateness for different ages and subtypes, they are the most rigorous and empirically derived in the history of ADHD.

When the DSM -IV criteria are carefully followed using well-defined practice parameters for children (AACAP 1997; AAP 2000), ADHD can be reliably diagnosed. The parent interview lies at the core of the assessment process and covers questions regarding symptoms, impairment, history (medical, developmental, psychiatric, and family), and alternative explanations for the childs behavior. Developmental history forms, symptom screening checklists, and diagnostic interviews are useful tools in collecting this information. Standardized parent and teacher rating scales that include ADHD-specific items aid in documenting developmental deviance and pervasiveness of symptoms. Additional feedback from the childs school, including testing reports and observations, may also be obtained. Although medical and cognitive tests are not routinely indicated, they may help identify coexisting conditions. Assessment of ADHD in adults includes the same basic components, with age-appropriate interviewing tools and the use of rating scales completed by the adult and another informant, such as a spouse or coworker (Weiss and Murray 2003). The reliability and validity of these measures are less well established, however.

Despite concerns about large-scale overdiagnosis, epi-demiological studies have found little evidence of this. According to the 2003 National Survey of Childrens Health that assessed over 100,000 U.S. children through parent phone interviews, approximately 7.8 percent of 4-17 year olds were reported to have been identified by a professional as having ADHD (Centers for Disease Control 2005). Similarly, William J. Barbaresi, Slavica K. Katusic, Robert C. Colligan, et al. (2002) found that 7.5 percent of children in a birth cohort of over 5,000 in Minnesota had received clinical diagnoses of ADHD according to medical record documentation. These numbers closely resemble prevalence rates found in carefully conducted diagnostic studies (Barkley 2006), suggesting that there is not substantial over-identification in practice. The American Medical Association came to a similar conclusion after reviewing over 20 years of literature using a National Library of Medicine database (Goldman et al. 1998). Rather, more children, particularly girls and adolescents, are being identified than in the past, particularly with recently changed and expanded diagnostic criteria. Nonetheless, some practitioners who do not conduct thorough evaluations using validated diagnostic criteria may be inappropriately diagnosing and treating children. Dramatically increasing prescription rates for medications to treat ADHD are also believed to represent more effective treatment patterns, although concerns of misuse and diversion are recognized.

COURSE, IMPACT, AND COMORBIDITY

Children with ADHD experience frequent learning difficulties and are more likely than others to be placed in special education, retained, and suspended; they are also more likely to fail to graduate. Furthermore, they are at higher risk for peer rejection, physical injury, delinquency, and substance use (Barkley 2006). Adults with ADHD are also at higher risk for smoking, drug abuse, driving citations and accidents, and poorer physical and mental health. They often experience higher levels of anxiety and depression, more job-related turmoil, and relationship difficulties (Wender 1995).

Outcomes for children with ADHD vary based on risk factors and the presence of coexisting psychiatric conditions, which commonly include oppositional behavior and conduct problems, anxiety, depression, tic disorders, and learning disorders. Overall, 15 to 20 percent of children with ADHD appear normalized as adults; 20 to 30 percent experience marked impairments in occupational, relational, and mental health functioning, and the remainder exhibit persistent symptoms with mild to moderate difficulties (Biederman et al. 1998). Factors predicting a worse outcome include psychosocial adversity, a family history of ADHD, and the presence of oppositional behavior (Biederman et al. 1996).

HISTORY OF THE DISORDER AND ITS TREATMENT

First described in the early 1900s, thousands of studies on ADHD were conducted in the latter half of the twentieth century, making this the most well-researched childhood disorder. Significant advances have been made in our understanding of the nature of ADHD, resulting in changes to diagnostic criteria and ongoing exploration of risk factors and prognosis. Once attributed to brain injuries or environmental maladjustment, the neurobio-logical nature of the disorder is now well established (Barkley 2006). Research suggests that the causes of ADHD are complex, although most cases can be accounted for by heredity. Neuroimaging research has identified frontal lobe functioning deficits and structural brain abnormalities associated with ADHD, and molecular genetics studies are investigating specific genes that may be implicated, with a goal of developing more sophisticated treatment strategies (Biederman 2005).

A wide range of treatments for ADHD has been developed, with many having little or no empirical basis (e.g., dietary interventions, biofeedback, and optometric training). Proven treatments for ADHD include parent-management training, direct behavior modification in schools and specialty camps, and stimulant medications, primarily methylphenidate products (AACAP 1997; Pelham et al. 1998). More recently, efficacy has been demonstrated for specific norepinepherine reuptake inhibitors such as atomoxetine. A multimodal treatment approach is generally considered the best practice, although knowledge of long-term benefits and methods for individualizing treatments is limited. There is also a lack of information on the availability and effectiveness of typical community and school services for ADHD. Use of stimulant medications remains controversial, although there is considerable evidence of short-term benefit for core symptoms in children (MTA Cooperative Group 1999) and growing support for the use of these medications in adults. Psychosocial treatments for adults that incorporate behavioral compensation skills and cognitive-behavioral modification are being developed but have not yet been well evaluated.

SEE ALSO Anxiety; Disability

BIBLIOGRAPHY

American Academy of Child and Adolescent Psychiatry (AACAP). 1997. Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 36 (10) Suppl.: 85S121S.

American Academy of Pediatrics (AAP). 2000. Clinical Practice Guideline: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity Disorder. Pediatrics 105 (5): 1158-1170.

American Psychiatric Association (APA). 1994. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: Author.

Barbaresi, William J., Slavica K. Katusic, Robert C. Colligan, et al. 2002. How Common Is Attention-Deficit/Hyperactivity Disorder? Incidence in a Population-Based Birth Cohort in Rochester, MN. Archives of Pediatrics and Adolescent Medicine 156: 217-224.

Barkley, Russell. 2006. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 3rd ed. New York: Guilford.

Biederman, Joseph. 2005. Attention-Deficit/Hyperactivity Disorder: A Selective Overview. Biological Psychiatry 57 (11): 1215-1220.

Biederman, Joseph, et al. 1996. Predictors of Persistence and Remission of ADHD into Adolescence: Results from a Four-Year Prospective Follow-up Study. Journal of the American Academy of Child and Adolescent Psychiatry 35 (3): 343-351.

Biederman, Joseph, Eric Mick, and Stephen Faraone. 1998. Normalized Functioning in Youths with Persistent Attention-Deficit/Hyperactivity Disorder. Journal of Pediatrics 133 (4): 544-551.

Centers for Disease Control and Prevention. 2005. Mental Health in the United States: Prevalence of Diagnosis and Medication Treatment for Attention-Deficit/Hyperactivity DisorderUnited States, 2003. Morbidity and Mortality Weekly Report 54 (34): 842-847.

Goldman, Larry S., Myron Genel, Rebecca J. Bezman, and Priscilla J. Slanetz. 1998. Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Journal of the American Medical Association 279 (14): 1100-1107.

MTA Cooperative Group. 1999. A 14-month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry 56: 1073-1086.

Pelham, William, Trilby Wheeler, and Andrea Chronis. 1998. Empirically Supported Psychosocial Treatments for Attention Deficit Hyperactivity Disorder. Journal of Clinical Child Psychology 27 (2): 190-205.

Weiss, Margaret, and Candice Murray. 2003. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults. Canadian Medical Association Journal 168 (6): 715-722.

Wender, Paul. 1995. Attention-Deficit Hyperactivity Disorder in Adults. New York: Oxford University Press.

Desiree W. Murray

Rachel E. Baden

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"Attention-Deficit/Hyperactivity Disorder." International Encyclopedia of the Social Sciences. 2008. Encyclopedia.com. 27 Jul. 2016 <http://www.encyclopedia.com>.

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Attention Deficit/Hyperactivity Disorder (ADHD)

Attention deficit/hyperactivity disorder (ADHD)

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

Attention deficit/hyperactivity disorder (ADHD) refers to a combination of excessive motor restlessness, difficulty in controlling or maintaining attention to relevant events, and impulsive responding that is not adaptive. Children and adults experience the symptoms of ADHD in most areas of their life. It affects their performance in school or at work, depending on their age, and it affects them socially. In some cases, however, ADHD sufferers experience the disorder in only one arena, such as a child who may be hyperactive only in school, or an adult who finds it impossible to concentrate during meetings or while socializing with friends after work. Particularly stressful situations, or those requiring the sufferer to concentrate for prolonged periods of time, often will exacerbate a symptom or a series of symptoms.

Studies indicate that ADHD affects 3-5% of all children. 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 the 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 labeled 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 after the disorder

interferes 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.

Treatment

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 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 behaviorthat 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.

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 activities 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.

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. Counseling 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.

Doreen Arcus, Ph.D.

Further Reading

Barkley, R.A. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: Guildord Press, 1990.

Hallowell, E.M. and J.J. Ratey. Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood. New York: Simon and Schuster, 1994.

Manuzza, S., R.G. Klein, A. Bessler, P. Malloy, and M. La-Padula. "Adult Outcome of Hyperactive Boys: Educational Achievement, Occupational Rank, and Psychiatric Status." Archives of General Psychiatry, 50, (1993): 565-76.

Weiss, G. Attention Deficit Hyperactivity Disorder. Philadelphia: W.B. Saunders, 1992.

Wender, P. The Hyperactive Child, Adolescent, and Adult: Attention Deficit Disorder through the Lifespan. New York: Oxford University Press, 1987.

Wilens, T.E. and J. Biederman. "The Stimulants." Psychiatric Clinics of North America. D. Shafer, ed. Philadelphia: W.B. Saunders, 1992.

Zametkin, A.J. and J.L. Rappaport. "Neurobiology of Attention Deficit Disorder with Hyperactivity: Where Have We Come in 50 Years?" Journal of the American Academy of Child and Adolescent Psychiatry 26, (1987): 676-86.

Further Information

Attention Deficit Disorder Association. P.O. Box 972, Mentor, OH 44061, (800) 4872282.

CHADD (Children and Adults with Attention Deficit Disorder). 499 NW 70th Ave., Suite 308, Plantation, FL 33317,(305) 5873700 (A national and international non-profit organization for children and adults with ADHD).

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Arcus, Doreen. "Attention Deficit/Hyperactivity Disorder (ADHD)." Gale Encyclopedia of Psychology. 2001. Encyclopedia.com. 27 Jul. 2016 <http://www.encyclopedia.com>.

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Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder

Attention deficit/hyperactivity disorder (ADHD) is a condition characterized by inattention and/or impulsivity and hyperactivity that begins in children prior to the age of seven. Their inattention leads to daydreaming, distractibility, and difficulties sustaining effort on a single task for a prolonged period of time. Their impulsivity disrupts classrooms and creates problems with peers, as they blurt out answers, interrupt others, or shift from schoolwork to inappropriate activities. Their hyperactivity is frustrating to those around them and poorly tolerated at school. Children with ADHD show academic underachievement and conduct problems. As they grow older, they are at risk for low self-esteem, poor peer relationships, conflict with parents, delinquency, smoking, and substance abuse.

Course, Prevalence, and Treatment

Although the longitudinal course of this condition and its prevalence in adulthood have been sources of controversy, a growing literature has documented the persistence of ADHD into adulthood, with about two-thirds of ADHD children continuing to experience impairing symptoms of the disorder though adulthood. Over time, symptoms of hyperactivity and impulsivity are more likely to diminish compared with symptoms of inattention.

Prevalence studies from North America, Europe, and Asia show that ADHD affects about 5 percent of the population. The impact of the disorder on society, in terms of financial cost, stress to families, and disruption in schools and workplaces, is enormous. Although current treatments for the disorder are not 100 percent effective, clinical trials have shown that stimulant medications, such as methylphenidate and amphetamine, relieve symptoms and lessen adverse outcomes, while showing few adverse side effects. Because these medicines increase the availability of the neurotransmitter dopamine in the brain, dysregulation of dopamine systems has been a primary candidate for the pathophysiology of ADHD. But drugs like desipramine and alomoxeline, which have their effects on other brain systems, also exert strong anti-ADHD effects. This suggests that dysregulation of dopamine systems cannot completely explain the pathophysiology of ADHD.

Neuropsychological and neuroimaging studies provide converging evidence for the hypothesis that brain dysfunction causes the symptoms of ADHD. Neuropsychological tests show many ADHD patients to have deficits in the executive functions needed for organizing, planning, sequencing, and inhibiting behaviors. These performance deficits are similar to, albeit milder than, the deficits seen among patients with frontal lobe disorders. Several structural and functional neuroimaging studies implicate networks of regions throughout the brain, not just in the frontal lobes.

The Genetic Epidemiology of ADHD

Family, twin, and adoption studies provide strong support for the idea that genes influence the etiology of ADHD. Family studies find the parents and siblings of ADHD children to have a five-fold increase in the risk for ADHD. Children of ADHD adults have a ten-fold increase in risk, which has led to the idea that persistent cases of ADHD may have a stronger genetic component. Consistent with a genetic theory of ADHD, second-degree relatives (such as cousins) are at increased risk for the disorder but their risk is lower than that seen in first-degree relatives.

Family studies have provided evidence for the genetic heterogeneity of ADHD. Studies that systematically assess other psychiatric disorders suggest that ADHD and major depression often occur together in families; that ADHD children with conduct and/or bipolar disorders might be a distinct familial subtype of ADHD; and that ADHD is familially independent from anxiety disorders and learning disabilities. It may therefore be appropriate to divide ADH children into those with and those without conduct and bipolar disorders, thus forming more familially homogeneous subgroups. In contrast, major depression may be a nonspecific manifestation of different ADHD subforms.

Several twin studies have provided evidence of genetic influence on hyperactive and inattentive symptoms. An early study found the heritability of hyperactivity to be 64 percent. A study of ADHD in twins who also had reading disabilities reported the heritability of attention-related behaviors to be 98 percent. All twin studies considered together suggest that the heritability of ADHD is about 70 percent, which makes it one of the most heritable of psychiatric disorders.

Adoption studies also implicate genes in the etiology of ADHD. Two early studies found that the adoptive relatives of hyperactive children were less likely to be hyperactive or have associated conditions than the biological relatives. Biological relatives of hyperactive children also performed more poorly on standardized measures of attention than did adoptive relatives. A study using the contemporary definition of ADHD found that biological, not adoptive, relationships account for the transmission of ADHD.

The Molecular Genetics of ADHD

Molecular genetic studies have already implicated several genes as mediating the susceptibility to ADHD. Researchers have examined candidate genes in dopamine pathways because animal models, theoretical considerations, and the effectiveness of stimulant treatment implicate dopaminergic dysfunction in the pathophysiology of this disorder. Dopamine is a neural trans-Dopamine mitter in the brain used in both movement control and pleasure/reward systems. In its simplest form, the dopamine hypothesis holds that excess clearance of dopamine between neurons may contribute to ADHD.

Many studies have focused on the D4 dopamine receptor gene (DRD4) which encodes a protein receptor that mediates the post-synaptic action of dopamine. A meta-analysis of these studies showed a small but statistically significant association, which could not be accounted for by any single study or by publication biases. Although the nature of the mutations in DRD4 have not been conclusively described, a version of the gene known as the 7repeat allele has generated much interest because this allele causes a blunted response to dopamine and has been implicated in novelty seeking, a personality trait of many ADHD patients.

Several authors have reported an association between ADHD and a particular allele of the dopamine transporter (DAT) gene. This finding has been replicated by some, but not all studies. The link between the DAT gene and ADHD is further supported by a study that relates this gene to poor methylphenidate response in humans, a "knockout" mouse study showing that its elimination leads to hyperactivity in mice, and two molecular neuroimaging studies that found elevated DAT density in the striatum of ADHD adults.

Molecular genetics studies of ADHD have also targeted other genes that are related to the dopamine system. Four studies have examined the Catechol-O-Methyltransferase (COMT) gene, whose protein product breaks down dopamine and norepinephrine. Although one study found ADHD was associated with the high-activity form of COMT, three others could not replicate the finding. Other candidate genes that show promising results for ADHD are the D5 dopamine receptor gene and the serotonin 1B receptor. This latter finding is intriguing because, although serotonergic medicines do not help ADHD symptoms, these systems have been implicated in animal models of the disorder.

see also Behavior; Disease, Genetics of; Psychiatric Disorders; Twins.

Stephen V. Faraone

Bibliography

Faraone, S. V., D. Tsuang, and M. T. Tsuang. Genetics of Mental Disorders: A Guide for Students, Clinicians, and Researchers. New York: Guilford, 1999.

Faraone, S. V., and A. Doyle. "The Nature and Heritability of Attention Deficit Hyperactivity Disorder." Child and Adolescent Psychiatric Clinics of North America 10 (2001): 299-316.

Faraone, S. V., and J. Biederman. "Neurobiology of Attention Deficit Hyperactivity Disorder." Biological Psychiatry 44 (1998): 951-958.

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Attention Deficit Hyperactivity Disorder

ATTENTION DEFICIT HYPERACTIVITY DISORDER


The most common reason that children are referred to child-guidance clinics is for attention deficit hyperactivity disorder (ADHD). ADHD is a behavioral disorder with a strong hereditary component, which likely results from neurological dysfunction. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), there are three diagnostic categories of ADHD: (1) ADHD, Predominantly Inattentive Type; (2) ADHD, Predominantly Hyperactive-Impulsive Type; and (3) ADHD, Combined Type. ADHD often occurs simultaneously with other behavioral and learning problems, such as learning disabilities, emotional or behavioral disabilities, or Tourette's syndrome.

A 1998 study by Russell A. Barkley stated that ADHD is a deficit in behavior inhibition, which sets the stage for problems in regulating behavior. Students with ADHD may experience problems in working memory (remembering things while performing other cognitive operations), delayed inner speech (self-talk that allows people to solve problems), problems controlling emotions and arousal, and difficulty analyzing problems and communicating solutions to others. Hence, students with ADHD may find it difficult to stay focused on tasks such as schoolworktasks that require sustained attention and concentration, yet are not intrinsically interesting. In addition, the majority of individuals with ADHD experience significant problems in peer relations and demonstrate a higher incidence of substance abuse than that of the general population.

Although professionals did not recognize ADHD as a diagnostic category until the 1980s, evidence of the disorder dates from the beginning of the twentieth century. The physician George F. Still is credited with being one of the first authors to bring those with "defective moral control" to the attention of the medical profession in 1902. In the 1930s and 1940s Heinz Werner and Alfred Strauss were able to identify children who were hyperactive and distractiblechildren who exhibited the Strauss syndrome. Later, in the middle of the twentieth century, the term minimal brain injury was used to refer to children of normal intelligence who were inattentive, impulsive, and/or hyperactive. This term fell out of favor and was replaced by hyperactive child syndrome. Professionals eventually rejected this term, as inattention, not hyperactivity, was recognized as the major behavior problem associated with the disorder.

Students with ADHD are eligible for special education services under the category "other health impaired (OHI)." This category has dramatically increased in size; however, the number of students served in this category remains well below the estimated prevalence rate of 3 to 5 percent of the school-age population. From discrepancies such as this, researchers have estimated that fewer than half of all students with ADHD are receiving special education services.

As Barkley noted in his 1998 study, the effective diagnosis of ADHD requires a medical exam, a clinical interview, and teacher and parent rating scales. During the medical exam the physician must rule out other possible causes of the behavior problem, and through the clinical interview, the clinician obtains information from both parents and child about the child's physical and psychological characteristics. Finally, parents, teachers, and in some cases children themselves, complete behavioral rating scales, such as the Connors scales and the ADHD Rating ScaleIV in order to quantify observed behavior patterns.

Frequently students with ADHD are treated with psychostimulants, such as methylphenidate (Ritalin), which stimulate areas of the brain responsible for inhibition. Despite some negative publicity in the media, most authorities in the area of ADHD are in favor of Ritalin's use. In addition to medication, students with ADHD also benefit from carefully designed educational programming. In the early 1960s William Cruickshank was one of the first to establish an educational program for students who would meet what has become the criteria for ADHD. This program, proposing a degree of classroom structure rarely seen in the early twenty-first century, advocated: (1) a reduction of stimuli irrelevant to learning and enhancement of material important for learning and (2) a structured program with a strong emphasis on teacher direction. In addition to educational programs that emphasize and provide structure, a 1997 study by Robert H. Horner and Edward G. Carr indicated that students with ADHD benefited from instructional approaches examining the consequences, antecedents, and setting events that maintain inappropriate behaviors. Other researchers' findings indicated that they also profited from behavior management systems in which the student with ADHD learns to monitor his or her own behavior. These strategies, although effective, are not generally powerful enough to completely remedy the symptoms of children with ADHD. The majority of children diagnosed with ADHD continue to demonstrate symptoms in adulthood.

See also: Special Education, subentries on Current Trends, History of.

bibliography

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, Text Revision, 4th edition. Washington, DC: American Psychiatric Association.

Barkley, Russell. A. 1998. Attention-Deficit Hyperactive Disorder: A Handbook for Diagnosis and Treatment. New York: Guilford Press.

Connors, C. Keith. 1989. Connors Teacher Rating Scale-28. Tonawanda, NY: Multi-Health Systems.

Dupaul, George J.; Power, Thomas J.; Anastopolous, Arthur D.; and Reid, Robert. 1998. ADHD Rating ScaleIV: Checklists, Norms, and Clinical Interpretations. New York: Guilford Press.

Hallahan, Daniel P., and Cottone, E. A. 1997. "Attention Deficit Hyperactivity Disorder." In Advances in Learning and Behavioral Disabilities, Vol. 11, ed. Thomas E. Scruggs and Margo A. Mastropieri. Greenwich, CT: JAI Press.

Horner, Robert H., and Carr, Edward G. 1997. "Behavioral Support for Students with Severe Disabilities: Functional Assessment and Comprehensive Intervention." Journal of Special Education 31:111.

Shapiro, Edward S.; Dupaul, George J.; and Bradley-Klug, Kathy L. 1998. "Self-Management as a Strategy to Improve the Classroom Behavior of Adolescents with ADHD." Journal of Learning Disabilities 31:545555.

Devery R. Mock

Daniel P. Hallahan

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Attention-Deficit Hyperactivity Disorder (ADHD)

Attention-deficit hyperactivity disorder (ADHD)

Attention-deficit hyperactivity disorder (ADHD) is a condition that is characterized by a person's inability to focus attention. The condition is present at birth and is usually evident by early childhood, although some persons are not diagnosed until adulthood. ADHD is thought to be a disorder of the functioning of the brain that may be caused by hereditary factors or exposure of the developing fetus to harmful substances.

ADHD is estimated to occur in 3 to 5 percent of school-age children in the United States; boys with the disorder outnumber girls who have it. ADHD is a major cause of poor school performance.

Symptoms of ADHD

For purposes of diagnosis, the symptoms of ADHD are divided into two categories: one describes symptoms related to a person's inability to pay attention; the other describes symptoms related to a person's level of hyperactivity and impulsiveness.

Symptoms of inattentiveness include a child's (1) failure to pay attention to detail, (2) tendency to make careless errors in schoolwork, (3) inability to follow instructions or complete tasks with ease, (4) seeming not to listen when spoken to, (5) having apparent difficulty keeping attention on the subject at hand, (6) frequently losing things necessary for schoolwork or play, and (7) being easily distracted by sights or sounds.

Symptoms of hyperactivity include a child's (1) inability to sit still,(2) running around or climbing when expected to remain seated, (3) excessive talking, and (4) difficulty playing or performing activities quietly. Symptoms of impulsive behavior in social situations include (1) blurting out answers before questions are completed, (2) difficulty waiting for one's turn, and (3) interrupting others.

Effect of ADHD on learning

ADHD is not a learning disability, but it often has a serious effect on learning because of a child's inability to pay attention, follow instructions, remember information, or complete a task. Many people who have this disorder are highly intelligent but may do poorly in school because of the regimentation of traditional classroom settings. In addition, children with ADHD may have problems making friends because of their tendency to take over activities or talk too much, their inability to follow the rules of games or activities, or other inappropriate behavior.

Treatment of ADHD

In order to effectively treat a child with ADHD, the child, his parents, and his teachers must be educated as to the nature of the disorder and how it affects the child's functioning. Treatment usually involves psychological counseling, behavior modification, providing structured settings and controls, and giving the child frequent praise and rewards for completing tasks and controlling behavior.

Words to Know

Behavior modification: A type of therapy that uses learning techniques in an attempt to substitute inappropriate behavior with appropriate behavior.

Hyperactivity: A condition of being overly or abnormally active.

Impulsiveness: Spontaneous action without prior thought.

Treatment with medication is sometimes effective in relieving symptoms of ADHD. The drugs Ritalin and Dexedrine, which are stimulants, have shown remarkable success in temporarily improving a child or an adult's ability to focus in up to 90 percent of cases. These drugs are only effective in the short-term, however. Once the drug leaves the body or is stopped, symptoms of ADHD return. Other drugs, including certain antidepressants, are also sometimes used to control symptoms.

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attention deficit hyperactivity disorder

attention deficit hyperactivity disorder (ADHD), formerly called hyperkinesis or minimal brain dysfunction, a chronic, neurologically based syndrome characterized by any or all of three types of behavior: hyperactivity, distractibility, and impulsivity. Hyperactivity refers to feelings of restlessness, fidgeting, or inappropriate activity (running, wandering) when one is expected to be quiet; distractibility to heightened distraction by irrelevant sights and sounds or carelessness and inability to carry simple tasks to completion; and impulsivity to socially inappropriate speech (e.g., blurting out something without thinking) or striking out. Unlike similar behaviors caused by emotional problems or anxiety, ADHD does not fluctuate with emotional states; sleep deprivation may also cause symptoms in children that resemble those of ADHD. While the three typical behaviors occur in nearly everyone from time to time, in those with ADHD they are excessive, long-term, and pervasive and create difficulties in school, at home, or at work. ADHD is usually diagnosed before age seven. It is often accompanied by a learning disability.

The cause of ADHD is unknown, although there appears to be a genetic component in some cases. Intake of sugars is no longer considered to be a factor. Some studies suggest that although food additives, such as colorings, do not cause symptoms in the general population, they may aggravate hyperactivity in some susceptible individuals. It has been shown that people with ADHD have less activity in areas of the brain that control attention. Treatment usually includes behavioral therapy and emotional counseling combined with medications such as methylphenidate hydrochloride (Ritalin) or dextroamphetamine (Dexedrine) that correct neurochemical imbalances in the brain; over the long term, however, such medications do not appear to offer any benefits. Symptoms may decrease after adolescence, although they often persist into adulthood.

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Attention-Deficit/Hyperactivity Disorder

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

DEFINITION


Attention-deficit/hyperactivity disorder (ADHD) is a condition that shows up most commonly in boys and girls after puberty begins. Puberty is the period in life when a person's sex hormones become active. ADHD is characterized by an inability to concentrate on tasks, hyperactivity (an abnormally high level of physical activity), and unpredictable behavior. ADHD is known as hyperkinetic disorder (HKD) outside of the United States.

DESCRIPTION


ADHD is thought to affect 3 to 9 percent of all children and is more common in boys than in girls. The signs of ADHD may first appear as early as the age of two or three. In most cases, however, the disorder is not diagnosed until adolescence. Some symptoms of ADHD, such as hyperactivity, tend to disappear in early adulthood. But others, such as inattention to details, remain with up to half of all ADHD individuals throughout their lives.

Children with ADHD have short attention spans. They may become bored or frustrated with tasks. They may be intelligent, but they receive poor grades in school because they do not focus on their work. They tend to be overly active, constantly moving, running, climbing, squirming, and fidgeting. They often have trouble controlling their muscles, which makes them clumsy and physically awkward. Such problems can cause social difficulties as well. Other children may avoid youngsters with ADHD because they may be noisy or bothersome.

CAUSES


The causes of ADHD are not known. Some people believe that an imbalance in neurotransmitters causes the disorder. Neurotransmitters are chemicals that carry messages from one part of the brain to another. Damage to neurotransmitters can be caused by a number of factors. For example, a head injury can damage the brain cells that produce neurotransmitters. Children who are exposed to toxins (poisons) early in life may experience similar brain cell damage.

Heredity also seems to play a role in ADHD. Studies show that children born to people who have the disorder tend to inherit the disorder.

Some medical authorities have suggested that diet may be a factor in causing ADHD. For example, a high intake of sugar was once thought to be a possible cause of the disorder. Today, that explanation for ADHD is no longer accepted. Dietary factors do not seem to be responsible for ADHD.

Attention-Deficit/Hyperactivity Disorder: Words to Know

Conduct disorder:
A behavioral and emotional disorder of childhood and adolescence. Children with a conduct disorder act inappropriately, infringe on the rights of others, and violate social rules.
Nervous tic:
An involuntary action, continually repeated, such as the twitching of a muscle or repeated blinking.

SYMPTOMS


Doctors use a standard reference book called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to diagnose ADHD. A patient must show some combination of the following symptoms to be diagnosed with ADHD.

  • Fails to pay close attention to detail or makes careless mistakes in schoolwork and other activities
  • Has difficulty paying attention to tasks or activities
  • Does not seem to listen when spoken to
  • Does not follow through on instruction and does not finish tasks
  • Has difficulty in organizing tasks and activities
  • Avoids or dislikes tasks that require sustained mental effort, such as homework
  • Is easily distracted
  • Is forgetful in daily activities
  • Fidgets with hands or feet or squirms in seat
  • Does not remain seated when expected to
  • Runs or climbs when inappropriate
  • Has difficulty playing quietly
  • Is constantly on the move
  • Talks excessively
  • Blurts out answers before questions have been completed
  • Has difficulty waiting for his or her turn
  • Interrupts and/or intrudes on others

Doctors also make use of other information in diagnosing ADHD. For example, some symptoms have to show up before the age of seven. In addition, there must be evidence that a child cannot function normally in at least two settings, such as home and school.

DIAGNOSIS


The first step in diagnosing ADHD is to have the child see a pediatrician. A pediatrician is a medical doctor who specializes in the diseases and disorders of children. Because many of the symptoms of ADHD are normal and common in all children, the pediatrician is careful to determine whether the child is behaving normally compared with other children of the same age. The pediatrician may also conduct a physical examination to make sure that there is nothing physically wrong with the patient, which may be causing the inadequate behaviors.

If the pediatrician finds no problems during the physical examination, the child may be referred to someone who works with mental disorders, such as a psychologist or a psychiatrist. The specialist then conducts his or her own examination, which may include a medical, family, educational, social, and psychological history. The specialist is likely to hold interviews with the child and to have the child take certain standard tests. The Achenbach Child Behavior Rating Scales, for example, attempts to provide information about a child's behavior in different settings.

Diagnosis of ADHD can be difficult because its symptoms are similar to those of other disorders. For example, depression (see depressive disorders entry) and anxiety disorders can cause symptoms similar to those of ADHD. Federal law now requires all public schools to offer free ADHD testing upon request.

TREATMENT


ADHD is usually treated with one of two approaches: drugs or behavior modification. Drugs tend to be the more popular therapy because they are easy to use and seem to have more dependable results. Prescribing drugs for children, however, is not without controversy.

One group of drugs used to treat ADHD is psychostimulants. These drugs work by stimulating the production of neurotransmitters. One of the best known of these drugs is methylphenidate (pronounced meth-uhl-FEN-uh-date, trade name Ritalin). For children who do not respond to psychostimulants, a variety of other drugs are available. These include desipramine (pronounced dez-uh-PRAM-uhn, trade names Norpramin, Pertofane) and fluoxetine (pronounced floo-AHK-suh-teen, trade name Prozac), which are antidepressants, and carbamazepine, (pronounced KAHR-buh-MAZ-uh-peen, trade names Tegretol, Atretol), an anticonvulsant. The most effective drug for any one child may change as that child grows and becomes more mature.

ARE WE "DRUGGING" PROBLEM CHILDREN?

Not all experts agree that ADHD is a disease or a disorder. According to some, many children have a lot of energy when they are growing up. A normal, healthy child is naturally curious and full of activity, so should parents and teachers really be surprised when some students have trouble sitting still in classes for six or more hours a day? Some experts think this behavior is perfectly normal.

These experts argue that giving children drugs is the wrong answer to a perceived problem. They agree that the drugs work in the short-term: drugs help children settle down and focus on their school work. But they argue that parents and doctors should also deal with the emotional or psychological problems that may have contributed to the child's behavior. Some researchers are concerned over whether children are being helped in the long-term.

Another issue has arisen about the use of drugs to control ADHD. Some young men and women have now been taking Ritalin for more then ten years. They started taking the drug during elementary or high school and continue to take the drug in college. They find that Ritalin helps them to concentrate on their class assignments. Some students report that they take up to twenty-five pills a day to get the effect they need. Such doses can have harmful effects on users. These effects include sleeplessness, loss of appetite, and fatigue.

Most authorities agree that drugs can solve ADHD problems for some children. How frequently drugs are prescribed and just how to properly diagnosis ADHD is still being debated.

All drugs used to treat ADHD have side effects, some of which can be serious. For example, methylphenidate may cause insomnia, nervousness, and loss of appetite; desipramine can cause dry mouth, disorientation, and irregular heartbeat.

Behavior modification therapy is a set of techniques designed to change the way people behave. Rewards are provided for good or correct behavior, while punishment may be given for bad or inappropriate behavior. For example, a child may be given a token each time he or she behaves in an approved manner. When the child has collected enough tokens, he or she may redeem the tokens for some kind of prize or reward.

One form of behavior modification is called cognitive-behavioral therapy. In this form of therapy, the child is taught to recognize the connection between thought and action. He or she is then shown how to change behavior by changing his or her negative thoughts.

Individual and family counseling can also help ADHD patients. Patients and their families can be helped to understand possible causes for the inappropriate behavior and how to deal with and eventually change that behavior.

Alternative Treatment

A number of alternative treatments for ADHD exist. In many cases, there is little or no scientific evidence that these treatments are effective. Many people believe strongly in them, however, and recommend their use with ADHD children. These treatments include:

  • EEG biofeedback. During EEG (electroencephalograph; pronounced ih-LEK-tro-in-SEH-fuh-lo-graf) biofeedback, an ADHD child watches the brain waves produced when he or she is behaving correctly or incorrectly. The child is then trained to adjust that behavior to produce correct brain waves.
  • Dietary therapy. This therapy is based on the theory that ADHD is caused by incorrect diet. Patients are taught to eat foods high in protein and complex carbohydrates (such as starches like potatoes and pasta), and to avoid white sugar and other types of foods.
  • Herbal therapy. Herbal therapy uses a variety of natural products to relieve the symptoms of ADHD. Some examples include ginkgo, to improve memory and mental sharpness, and chamomile, to help calm the patient. Although herbs like these are popular with some doctors, their effectiveness and safety have not been proved scientifically.
  • Homeopathic medicine. This approach has perhaps the best chance of success of all alternative treatments. It treats the person as a whole, seeking to discover the fundamental problems that have led to ADHD in the first place.

PROGNOSIS


Children who have been properly diagnosed with ADHD and who do not receive treatment may experience serious problems. They tend to develop low self-esteem and often have problems relating to other children. Their education may also suffer because of teachers who think of them as slow learners or troublemakers. Parents and siblings (brothers and sisters) may also develop negative feelings toward the ADHD child. Over time, ADHD children are also likely to develop learning disorders or emotional problems, such as depression or anxiety disorders.

ADHD can also lead to an even more serous problem known as conduct disorder. Among adolescents diagnosed with both ADHD and conduct disorder, up to 25 percent go on to become criminals, drug abusers, or suicide victims.

Approximately 70 to 80 percent of ADHD patients who receive drug treatment experience significant improvement in their condition, at least on a short-term basis. About half of all ADHD children seem to outgrow the disorder by the end of adolescence. The other half seem to retain some or all symptoms of ADHD as adults.

PREVENTION


Researchers have not yet determined if ADHD is preventable.

FOR MORE INFORMATION


Books

Alexander-Roberts, Colleen. The ADHD Parenting Handbook: Practical Advice for Parents from Parents. Dallas: Taylor Publishing Co., 1994.

Barkley, Russell A. Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. New York: Guilford Press, 1995.

Hallowell, Edward M., and John J. Ratey. Driven to Distraction. New York: Pantheon Books, 1994.

Kennedy, Patricia, Leif Terdal, and Lydia Fusetti. The Hyperactive Child Book. New York: St.Martin's Press, 1993.

Osman, Betty B. Learning Disabilities and ADHD: A Family Guide to Living and Learning Together. New York: John Wiley & Sons, 1997.

Stein, David B. Ritalin Is Not the Answer: A Drug-Free, Practical Program for Children Diagnosed with ADD or ADHD. New York: Jossey-Bass, Inc., 1999.

Periodicals

Hallowell, Edward M. "What I've Learned from A.D.D." Psychology Today (MayJune 1997): pp. 4046.

Organizations

American Academy of Child and Adolescent Psychiatry (AACAP). 3615 Wisconsin Avenue NW, Washington, DC 20016. (202) 9667300. http://www.aacap.org.

Children and Adults with Attention Deficit Disorder (CHADD). 499 Northwest 70th Avenue, Suite 101. Plantation, FL 33317. (800) 2334050. http://www.chadd.org.

The National Attention Deficit Disorder Association. (ADDA). 9930 Johnny-cake Ridge Road, Suite 3E, Mentor, OH 44060. (800) 4872282. http://www.add.org.

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Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder

Kevins Story

How Is Attention Deficit Hyperactivity Disorder Diagnosed?

What Causes ADHD?

How Is ADHD Treated?

Why Is ADHD Diagnosed More Often Than in the Past?

Living with ADHD

Resources

Attention Deficit Hyperactivity (DEF-ih-sit hy-per-ak-TIV-ih-tee) Disorder, or ADHD, is a common developmental disorder that affects both children and adults, although it is usually diagnosed in childhood. ADHD affects a persons ability to study, learn, work, play, and even socialize with others. People with ADHD are less able to sit still, plan ahead, organize and finish tasks, and tune in fully to what is going on around them than are people without the disorder.

KEYWORDS

for searching the Internet and other reference sources

Attention deficit disorder (ADD)

Hyperactivity

Impulsivity

Psychostimulant drugs

Ritalin

Kevins Story

As a sixth-grader at a new middle school, Kevin was having a much harder time than he expected. Then again, school had never been easy for him. He often had trouble staying focused and controlling his impulse to talk out loud in class. Homework had always been a nightmare, too; he knew he had assignments to complete, but he forgot to write them down, often brought home the wrong books, and just could not sit still long enough to get anything done. Fortunately, Kevins grade school teachers knew him well and worked with him on ways to stay focused and organized. From first through fifth grade, he always had one teacher for most of his subjects, one desk where he kept his books, and small classes. His parents and teachers were in constant communication, too. That had gotten him through most of the rough spots.

In the sixth grade, though, Kevin had a different teacher for every subject, a locker for his books and supplies, and a couple study periods during the day. He felt constantly overwhelmed and disorganized. Several of his teachers had already sent notes home expressing concern about disruptive behaviors such as calling out, walking around the room, and interrupting others. He could not keep track of his assignments and always felt like he was jumping from task to task.

After two bad report cards and many calls from concerned teachers, Kevins parents took him to see his pediatrician. After examining Kevin and hearing about his problems in school, the pediatrician recommended that Kevin see a psychologist* for an evaluation. After meeting with Kevins parents a few times, surveying his teachers and coaches, performing some special psychological tests, reading school reports, and even watching Kevin in the classroom, the psychologist confirmed what some of Kevins teachers and his pediatrician suspected: Kevin had Attention Deficit Hyperactivity Disorder-Combined Type (or ADHD-Combined Type, meaning that he had problems with both inattention and hyperactivity). Because Kevin had learned ways to cope pretty well in grade school, the psychologist suggested that they all work together to develop new strategies that might help him deal with the more challenging environment of middle

* psychologist
(sy-KOL-uh-jist) is a mental health professional who has specialized training in the diagnosis and treatment of emotional and behavioral conditions. Psychologists administer special tests to help them arrive at a diagnosis. Psychologists, like other mental health experts, also provide counseling services.

school. If those were not effective enough, then Kevin could try taking some medication that might help him stay more focused and attentive.

Just about every classroom in the United States has a student like Kevin. Experts believe that about 5 percent of students, or 1 in 20, have a form of ADHD. Boys are three to four times more likely than girls to be affected by ADHD. Of course, everyone has a hard time paying attention and staying focused now and then, but students with ADHD feel this way most of the time.

How Is Attention Deficit Hyperactivity Disorder Diagnosed?

Diagnosing ADHD is difficult because symptoms vary and there is no simple test that can determine whether someone has ADHD. In most cases, parents notice early on that their child is much less attentive or has less control over his behavior than other children. However, the disorder usually is not diagnosed until the child enters school and is expected to follow directions, cooperate with others, and be quiet at certain times.

To make the diagnosis, a psychologist or psychiatrist* looks for patterns of certain behaviors that have lasted for more than six months and interfere with two or more areas of a persons life (such as school and play, school and home, or home and work). In addition to interviewing the child and family members, the specialist may need to speak with others who know the child well, such as teachers and coaches. Former teachers may be asked to fill out an evaluation. Special tests may also be administered to clarify the diagnosis.

* psychiatrist
(sy-KY-uh-trist) refers to a medical doctor who has completed specialized training in the diagnosis and treatment of mental illness. Psychiatrists diagnose and treat mental illnesses, prescribe medications, and provide mental health counseling.

The behaviors that experts look for fall into three categories: inattention, hyperactivity, and impulsivity. Signs of inattention in a child include:

  • failure to pay close attention to details
  • finding it difficult to sustain attention in work and play
  • not seeming to listen when spoken to directly
  • not following through on instructions and failing to finish tasks
  • having difficulty organizing tasks and activities
  • avoiding, disliking, or seeming reluctant to engage in tasks that require concentration
  • being easily distracted by unimportant sights and sounds
  • losing things
  • forgetting things

Hyperactivity refers to overly active behavior. Children experiencing hyperactivity might:

  • fidget with their hands or feet
  • squirm while seated
  • leave their seat in the classroom and elsewhere
  • run about or climb excessively
  • have difficulty playing or engaging in leisure activities quietly
  • seem on the go or act as if driven by a motor
  • talk excessively

A mother gives her hyperactive son medication to help his behavior. Stock Boston

An impulsive child might:

  • blurt out answers before questions have been completed
  • interrupt or intrude on others
  • have difficulty waiting his or her turn

Not everyone with ADHD has all of the above symptoms. There are three kinds of ADHD that are commonly recognized. People who have significant problems with attention but are not really hyperactive or impulsive are diagnosed with ADHD-Inattentive Type. Other children have problems mainly with hyperactivity and impulsivity. These individuals are diagnosed as having ADHD-Impulsive Hyperactive Type. Individuals with significant problems with impulsivity, hyperactivity, and attention are diagnosed with ADHD-Combined Type.

Children with ADHD may have other behavioral disorders as well. These may include oppositional defiant disorder*, depression*, anxiety*, and delays in learning speech and language.

* oppositional defiant disorder
(op-uh-ZIH-shun-ul de-FY-unt dis-OR-der) is a disruptive behavior disorder that can be diagnosed in children as young as preschoolers who demonstrate hostile or aggressive behavior and who refuse to follow rules.
* depression
(de-PRESH-un) is a mental state characterized by feelings of sadness, despair, and discouragement.
* anxiety
(ang-ZY-e-tee) can be experienced as a troubled feeling, a sense of dread, fear of the future, or distress over a possible threat to a persons physical or mental well-being.

What Causes ADHD?

Doctors and researchers are not sure why certain people have ADHD. There have been theories involving many possible causes, such as diet, head injuries, exposure to drugs before birth, and even family and home environment. However, none of these theories offers a satisfactory explanation for most cases of ADHD.

Researchers interested in learning about possible biological (by-uh-LOJih-kul) causes of ADHD are looking at how the brains of people with ADHD might actually function differently than other peoples brains. For example, using a special scanning test called a PET scan, positron emission tomography (POZ-ih-tron e-MISH-un tuh-MOG-ruh-fee), researchers can watch the brain as it works. The test lets them see how much glucose (GLOO-cose), a type of sugar, is used by the areas of the brain that inhibit impulses and control attention (glucose is the brains main source of energy). Some studies have found that the areas of the brain that control attention use less glucose in people with ADHD; this means that these areas of the brain appear to be working less hard. Other researchers believe that ADHD has something to do with differences in the neurotransmitters* that deliver signals to the brain areas that control attention. Still, researchers are not sure why certain peoples brains might function differently in this way. It does appear that children may inherit a tendency to develop ADHD. For example, children who have ADHD usually have at least one close relative

* neurotransmitters
(NUR-o-tranzmit-erz) are brain chemicals that let brain cells communicate with each other and therefore allow the brain to function normally.

with ADHD. In addition, if one of a pair of identical twins is diagnosed with ADHD, the other twin likely has ADHD as well.

Can Food Cause Hyperactivity?

Anyone who drinks too much cola or coffee is likely to have a hard time concentrating, because caffeine can over-stimulate the brain. At one time, mental health specialists believed that sugar and other food additives actually contributed to ADHD. As a result, parents were encouraged to stop serving children foods containing artificial flavorings, preservatives, and sugars. It was thought that this restricted diet could actually prevent or cure the symptoms of the condition. Researchers no longer believe that this is the case.

In the 1980s, the National Institutes of Health, the Federal agency responsible for biomedical research, held a major scientific conference to discuss the issue of diet and ADHD. After studying the data, the scientists concluded that the restricted diet seemed to help only a very small number of children with ADHD (mostly either young children or children with confirmed food allergies). Many books and websites still promote restricted diets and even vitamins as a cure for ADHD, but they are not backed by scientific evidence.

How Is ADHD Treated?

Usually, ADHD is first treated with behavioral (be-HAY-vyor-ul) therapy. This involves working with a psychologist or psychotherapist* to learn ways of coping with the condition. The therapist can help people become more aware of their behavior, develop strategies for controlling it, and even help them practice how to deal with situations that caused problems in the past. A person also might find it helpful to participate in a support group with others in the same situation.

* psychotherapist
(sy-ko-THER-apist) is any mental health professional who works with people to help them change thoughts, actions, or relationships that play a part in their emotional or behavioral problems.

Parents and teachers are part of the treatment plan as well. Parents can learn how to establish more structure for the child, define limits more clearly, and be consistent with discipline, all of which are especially important for a child with ADHD. Teachers can provide predictable routines and structure in the classroom and try to keep the student away from distractions. Both parents and teachers can establish certain penalties and rewards to help the child make progress with behavior.

If these strategies are not effective enough in controlling the condition on their own, then a psychostimulant (SY-ko-STIM-yoo-lint) medication such as methylphenidate (meth-il-PHEN-uh-date; Ritalin, Concerta, Methylin, Metadate), dextroamphetamine (dex-tro-am-PHET-uh-meen; Dexedrine, Dextrastat), or mixed amphetamine salts (Adderall) might be prescribed. It may seem strange that an inattentive, overly active person would be treated with a stimulant (a drug that increases energy). However, these medications work by stimulating certain areas of the brain that make it possible for many people with ADHD to concentrate, behave more consistently, and take part in activities that were impossible before.

Why Is ADHD Diagnosed More Often Than in the Past?

More children than ever before are being diagnosed with ADHD-Predominantly Impulsive Hyperactive Type or ADHD-Predominantly Inattentive Type. In addition, the use of stimulant medications increased dramatically during the 1990s; according to one estimate, production of these medications increased by 700 percent between 1990 and 1997. There is some disagreement over why this is the case. Some people think that greater awareness of the condition is leading more parents to seek help for their children. Others believe that some cases of what is simply bad behavior are being misdiagnosed as ADHD. Some argue that parents may find it easier to accept that their child has a mental disorder rather than learn how to deal with unruly behavior or poor school performance due to other reasons. The debate continues, but experts agree that ADHD is a real condition that can have serious consequences if it is not diagnosed and managed appropriately.

Living with ADHD

Living with ADHD can be difficult. Children and adults with ADHD may have a hard time keeping friends and performing well at school or work. While many individuals live well with ADHD, many may become lonely, depressed, and even use drugs or alcohol as an escape.

A boy with ADHD receives one-on-one instruction with his teacher. The method of teaching a child according to his or her own special way of learning is an effective way of managing ADHD. Photo Researchers, Inc.

People with ADHD do not outgrow the condition. While they often become less hyperactive when they get older, people with ADHD may still have problems with restlessness and short attention span.

By using certain coping strategies, many people with ADHD learn to deal with the condition successfully and can achieve in school and thrive in rewarding careers. Many people are able to find the right kind of job for their strengths and abilities. For example, a person might be better suited for a position that offers variety and constant change rather than one that requires long periods at a desk.

The U.S. National Institute for Mental Health, the Federal agency for research on mental disorders, recommends the following strategies for living with ADHD:

  • When necessary, ask the teacher or boss to repeat instructions instead of guessing about what was said.
  • Break large assignments or job tasks into small, simple tasks. Set a deadline for each task and provide rewards for each completed task. Each day, make a list of what needs to be done. Plan the best order for doing each task, then make a schedule for doing them. Use a calendar or daily planner.
  • Work in a quiet area. Do one thing at a time. Take short breaks.
  • Write things down in a notebook with dividers. Write different kinds of information, like assignments, appointments, and phone numbers, in different sections. Keep the book on hand.
  • Post reminders of things that need to be done.
  • Store similar things together.
  • Create a routine. Get ready for school or work at the same time, in the same way, every day.
  • Exercise, eat a balanced diet, and get enough sleep.

See also

Attention

Brain Chemistry (Neurochemistry)

Impulsivity

Learning Disabilities

Oppositional Defiant Disorder

Resources

Books

Barkley, Russell A. Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. New York: Guilford Publications, Inc., 2000.

Quinn, Patricia O., and Judith M. Stern (eds.). The Best of BRAKES: An Activity Book for Kids with ADD and ADHD. Washington, DC: American Psychological Association, 2000. This book provides a collection of tips, activities, games, puzzles, and other resources designed to help kids deal with ADD. This book is especially targeted at those between the ages of 8 and 13.

Organizations

CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder), 8181 Professional Place, Suite 201, Landover, MD 20785. CHADD is a national organization for education, advocacy and support of people with ADHD. http://www.chadd.org

Nemours Center for Childrens Health Media, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803. This organization is dedicated to issues of childrens health and produces the KidsHealth website. Its website has articles about ADHD. http://www.KidsHealth.org

United States National Institute of Mental Health (NIMH), 6001 Executive Blvd., Rm. 8184, MSC 9663, Bethesda, MD 20892-9663. The NIMH provides a booklet of information about ADHD at its website. http://www.nimh.nih.gov

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attention-deficit/hyperactivity disorder

attention-deficit/hyperactivity disorder (ADHD, hyperkinetic disorder) (ă-ten-shŏn def-i-sit dis-or-der) n. a mental disorder, usually of children, characterized by a grossly excessive level of activity and a marked impairment of the ability to attend, resulting in aggressive disruptive behaviour. Treatment can involve drugs (such as methylphenidate) and behaviour therapy.

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