attention deficit hyperactivity disorder

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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. [email protected] <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. [email protected] <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)

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

views updated

Attention-deficit/hyperactivity disorder (ADHD)

Causes and symptoms

Diagnosis

Treatment

Alternative treatment

Prognosis

Resources

Attention deficit/hyperactivity disorder (ADHD), also known as hyperkinetic disorder (HKD) outside of the United States, is estimated to affect 3-9% of children, afflicting 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 symptoms change 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 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

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 its symptoms. In 1990 a brain imaging study by researchers at the National Institute for Mental Health documented the neurobiological effects of ADHD. The results showed that the rate at which the brain uses glucose, its main energy source, was lower in persons with ADHD, especially in the portion of the brain that is responsible for attention, handwriting, motor control, and inhibition responses. Heredity appears to play a major role in the disorder, with children of an ADHD parent or sibling more likely to develop the disorder themselves. Scientists also speculate that ADHD children may have been exposed to poor maternal nutrition, viral infections, or maternal substance abuse in the womb. In early childhood, exposure to lead or other toxins as well as traumatic brain injury or neurological disorders may trigger ADHD-like symptoms.

A widely publicized study conducted 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.

Diagnosis is based on a collaborative process that involves the child, psychiatrists or other physicians, the childs family, and school. Deciding what treatment will best benefit the child requires a careful diagnostic assessment after a comprehensive evaluation of psychiatric, social, cognitive, educational, family, and medical/neurological factors. A thorough evaluation can take several hours and may require more than one visit to a physician. Treatment begins only after the evaluation is made.

Psychologists and other mental health professionals typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as a guideline for diagnosing ADHD. DSM-IV-TR 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.

DSM-IV-TR 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 a period of 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 mainly have this subtype of the disorder.)

Diagnosis

The first step in determining if a child has ADHD is to consult a pediatrician, who can evaluate the childs developmental maturity compared to other children in the same 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, familial, social, psychiatric, and educational history is compiled from existing medical and school records and from interviews with parents and teachers. The child may also be interviewed, depending on his or her age. Along with these interviews, several clinical inventories may also be used, such as the Connerss Rating Scales (Teachers Questionnaire and Parents Questionnaire), Child Behavior Checklist (CBCL), and the Achenbach Child Behavior Rating Scales. These inventories provide valuable information on the childs 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 misdiag-nosed 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 include nervous tics, irregular heartbeat, loss of appetite, and insomnia. However, the medications are usually well-tolerated and safe in most cases.

In children who dont 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 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. 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 childs 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 variation on this is cognitive-behavioral therapy. This decreases 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 a child with ADHD 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 know the childs special needs and behaviors. Communication between parents and teachers is especially critical to ensuring that the child has an appropriate learning environment.

Alternative treatment

A number of alternative treatments exist. 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. This treatment uses a variety of natural remedies to address ADHD symptoms, 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. 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.

Prognosis

Untreated, ADHD can negatively affect a childs 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 social outcasts, 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, up to 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

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.

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.

See also Nervous system; Neuroscience; Psychiatry; Psychoanalysis; Psychology.

Resources

BOOKS

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

Hallowell, Edward M., and John J. Ratey. Driven to Distraction. New York: Pantheon Books, 1995.

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

Wender, Paul H. ADHD: Attention-Deficit Hyperactivity Disorder in Children and Adults. Oxford: Oxford University Press, 2001.

PERIODICALS

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

Swanson, J. M., et al. Attention-Deficit Hyperactivity Disorder and Hyperkinetic Disorder. Lancet 351 (Feb 7, 1997): 429-433.

OTHER

National Institutes of Mental Health. Attention-Deficit Hyperactivity Disorder <http://www.nimh.nih.gov/publicat/adhd.cfm> (accessed October 29, 2006).

Centers for Disease Control and Prevention. Attention-Deficit/Hyperactivity Disorder (ADHD) <http://www.cdc.gov/ncbddd/adhd> (accessed October 29, 2006).

Paula Anne Ford-Martin

views updated

Attention deficit hyperactivity disorder

Definition

Attention deficit hyperactivity disorder (ADHD) is a neurological disorder that presents in various forms, with no two ADHD disorders having exactly the same characteristics. ADHD is classified as a disruptive behavior disorder characterized by ongoing difficulty with attention span, hyperactivity, and/or impulsivity. These difficulties occur more frequently and severely than is typical for individuals in the same stage of development.

Description

ADHD is a neurological condition, frequently familial, that affects specific types of brain functioning. The term ADHD is further divided into subcategories that describe the type of ADHD. The three categories recognized by the scientific community are ADHD inattentive type, ADHD impulsive-hyperactive type, or ADHD combined type. Some individuals, including many professionals, still refer to the condition as ADD (attention deficit disorder). However, this term is no longer in widespread use. For individuals who have been diagnosed with ADD in the past, the corresponding current terminology is most likely to be predominantly ADHD, inattentive type.

It is possible to meet the accepted diagnostic criteria for ADHD without displaying any symptoms of hyperactivity or impulsivity. Each ADHD individual will display a unique combination of symptoms. They will not necessarily have all of the symptoms associated with ADHD, and the levels of severity or impairment are varied from individual to individual. There are mild forms of ADHD in addition to the severe forms that result in significant impairment. Symptoms of ADHD usually begin before seven years of age, and can cause problems in school, jobs and careers, family life, and other relationships. ADHD can be managed through behavioral or medical interventions, or a combination of the two. Despite public controversy over the legitimacy of the disorder's existence, the National Institutes of Health (NIH), the Surgeon General of the United States, and the international community of clinical researchers and physicians have affirmed that ADHD is a valid disorder that may result in severe, lifelong consequences if left untreated. The Senate of the United States designated September 7, 2004, as National Attention Deficit Disorder Awareness Day.

Genetic profile

The exact cause of ADHD is unknown, although abnormal neurotransmitter levels, genetics, and complications occurring around the time of birth have been implicated. According to the National Resource Center on ADHD, heredity makes the largest contribution to the prevalence of ADHD in the population. ADHD occurs frequently in families, and inheritance is an important risk factor. Between 10–35% of children diagnosed with ADHD have a first-degree relative with ADHD. Approximately 50% of parents who have ADHD have a child with the disorder. ADHD is significantly more likely to be present in an identical (monozyogotic) twin than in a fraternal (dizygotic) twin.

ADHD is not a form of gross brain damage. Because the symptoms of ADHD respond well to treatment with stimulants that increase the availability of the neuro-transmitter dopamine, the dopamine hypothesis has gained acceptance. The dopamine hypothesis suggests that ADHD is due to inadequate availability of dopamine in the central nervous system. Dopamine plays a key role in initiating focused movement, increasing motivation and alertness, and preventing sleepiness in response to boredom. Multiple genes have been implicated in ADHD, including genes affecting dopamine usage by the brain.

The male to female ratio is 8:1. Despite the strong genetic linkage, research also suggests that non-genetic factors may play a role in ADHD. Hyperactivity and inattention are more common in children who have had exposure to toxins such as lead, alcohol, or cigarette smoke, or episodes of fetal oxygen deprivation during complications of pregnancy. These factors may adversely affect dopamine-rich areas of the brain.

In addition to dopamine, research has shown that glucose usage may also be involved in ADHD. Brain-imaging studies, using a technique called magnetic resonance imaging (MRI), have demonstrated differences between the brains of children with and without ADHD. A link has been established between an individual's ability to pay continued attention and the brain's use of glucose as a fuel. In adults with ADHD, the brain areas that control attention span may use less glucose and be less active, suggesting that a lower level of activity in this part of the brain may cause the inattention symptoms associated with ADHD.

By 2002, the NIMH Child Psychiatry Branch had performed a decade-long controlled study that demonstrated ADHD children having 3–4% smaller brain volumes in multiple critical brain regions affecting the types of behaviors associated with ADHD. The study also demonstrated that ADHD children receiving medication had developed volume of white matter that was the same as normal children. Individuals who had ADHD but were never medicated had an abnormally small volume of white matter. Whether or not genetic differences are responsible remains to be determined. As of 2004, the NIMH is conducting clinical trials examining the MRI of identical twins with ADHD.

Demographics

ADHD is the most commonly diagnosed behavioral disorder of childhood, affecting an estimated 3–5% of children, approximately two million in the United States. Males are considered up to eight times more likely to have ADHD than females. While it has been proven that males are more likely than females to develop ADHD, the difference in the numbers of male versus female may be due, in part, to males having a higher rate of hyperactivity symptoms that are easier to detect and diagnose. ADHD often occurs in conjunction with other problems such as depressive and anxiety disorders, conduct disorders, drug abuse, and antisocial behaviors. Children with untreated ADHD have increased rates of injury and co-morbid psychiatric disorders. Approximately 70–80% of children with ADHD exhibit significant symptoms into adolescence and adulthood. It is estimated that 2–6% of adolescents and 2–4% of adults have ADHD. Adults who had untreated ADHD in childhood have more severe symptoms and adverse risk factors later in life. Adverse factors both influence the expression of ADHD and increase the risk for associated disorders that reduce overall adjustment throughout life. ADHD is considered a lifelong disorder that requires appropriate diagnosis and treatment.

Signs and symptoms

Symptoms of ADHD often become apparent by the age of seven, but many adults remain undiagnosed. The three subtypes of ADHD recognized by the scientific community are a predominantly hyperactive-impulsive type that does not display significant symptoms of inattention, a predominantly inattentive type that does not display significant symptoms of hyperactive-impulsive behavior, and a combined type that displays both the inattentive and hyperactive-impulsive symptoms associated with ADHD. The predominantly inattentive type is sometimes still referred to as ADD, but this is an outdated term for the disorder.

Symptoms of inattention tend to persist through childhood into adulthood. The symptoms of inattention may include difficulty in paying attention to details, easy distractability and inability to concentrate, procrastination of tasks requiring sustained mental effort, frequent careless mistakes, disorganization, difficulty maintaining conversations, and difficulty completing appointed tasks. The symptoms of hyperactivity and impulsivity are nearly always present before the seventh year and tend to diminish with age. Hyperactivity symptoms may include restlessness, the perceived need to frequently walk or run during periods of prolonged sitting, excessive verbosity, and frequent inappropriate or uninhibited social interactions such as interrupting conversations or games. Hyperactive behavior is often associated with the development of other disruptive behavior disorders. It has been proposed that the impulsivity and inattention associated with ADHD may interfere with social learning in a way that predisposes the individual to the development of these disorders.

While many of these symptoms may sometimes occur in normal children, children with ADHD experience these behaviors more intensely and across several settings. Both children and adults with ADHD may experience these symptoms to a degree that interferes with normal functioning. Some individuals with moderate to severe ADHD may also experience periods of anxiety or depression . Individuals whose predominant symptom is inattention are most prone to depression. It follows that ADHD rarely occurs alone. It has been demonstrated that many people with ADHD also are subject to one or more co-morbid conditions such as depression, anxiety disorders, learning disabilities, or substance abuse disorders. Many conditions may have symptoms similar to, and be mistaken for, ADHD. It is critical that co-morbid disorders are diagnosed and treated or efforts to treat the ADHD may fail. When ADHD symptoms are present as a secondary to some other psychiatric disorder, the individual may be incorrectly treated for ADHD. However, when ADHD is the primary disorder, treating it often eliminates other dysfunctions.

There are many ADHD Internet sites available to the public. Many of these sites offer various questionnaires and descriptions of symptoms on the subject of ADHD. These Internet sites are not standardized or scientifically validated and should never be used to diagnose ADHD. A valid diagnosis can only be provided by a qualified, licensed medical professional.

Diagnosis

Well-established and research-validated clinical guidelines for the diagnosis of ADHD are provided in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The DSM-IV criteria for diagnosis include multiple symptoms of inattention or hyperactivity-impulsivity that persist for at least six months across multiple settings such as school or work and home. These symptoms must exist to a degree that is inconsistent with other individuals at the same developmental level. Some of the hyperactive-impulsive or inattentive symptoms must have been present before the age of seven years. The symptoms must not occur exclusively during the course of another developmental disorder, schizophrenia , or psychotic disorder and should not be better accounted for by any other mental disorder. Although fidgeting and inattentiveness are common childhood behaviors, the DSM-IV criteria indicate a diagnosis of ADHD for children in whom such behavior occurs so frequently that it produces continuing, pervasive dysfunction. A diagnostic evaluation requires histories from multiple sources, a medical evaluation of general and neurological health, and a full cognitive assessment. In practice, the diagnosis is often made in individuals who meet only some of the criteria established by the DSM-IV.

Treatment and management

The American Academy of Child and Adolescent Psychiatry (AACAP) established treatment as the support and education of family members, appropriate school placement, and pharmacology. Both pharmacological treatment and psychosocial treatment such as behavioral modification may be used.

Pharmacological treatment

Pharmacological treatment with psychostimulants is the most widely researched treatment for ADHD. This treatment has been used for childhood behavioral disorders since the 1930s. Psychostimulants are highly effective for approximately 75–90% of children with ADHD. There are four psychostimulant treatments that have been demonstrated by hundreds of randomized controlled trials to consistently reduce the primary symptoms of ADHD: methylphenidate, dextroamphetamine, pemoline, and a mixture of amphetamine salts. These medications are only effective for one to four hours and so must be administered with the individual's school or work schedule. The medications are most effective for symptoms of hyperactivity, impulsivity, inattention, and the associated features of rebelliousness, aggression, and argumentativeness. They promote improved overall performance. Individuals who do not respond to one stimulant may respond to another. Individuals in whom psychostimulant treatment has been indicated require an assessment to determine which, if any, psychostimulant may improve their symptoms with the least side effects. According to guidelines established by the AACAP, stimulants are usually started at a low dose and adjusted weekly. According to the NIMH, the stimulants most commonly prescribed for ADHD include methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and amphetamine (Adderall).

In December 1999, the National Institutes of Mental Health (NIMH) began an ongoing Multimodal Treatment Study of Children with ADHD (MTA) that was one of the largest clinical studies ever conducted by the National Institutes of Health. The MTA utilized 18 nationally recognized authorities in ADHD at six different university medical centers and hospitals to evaluate the leading psychosocial and pharmacological treatments for ADHD. The MTA indicated that long-term combination treatments and pharmacological treatment alone are both significantly superior to intensive behavioral treatments and routine community care in reducing most ADHD symptoms. Combined treatment was equal in efficacy to medication alone in modifying the core ADHD symptoms of inattention, hyperactivity, impulsivity, and aggression. Combined treatment was superior to medication alone in treating anxiety symptoms and in improving academic performance and social skills. Combined treatment also allowed children to be successfully treated with lower doses of medication. The NIH ADHD Consensus Conference of 1998 reported that several decades of research have proven behavioral therapies to be very effective. However, the NIMH MTA study demonstrated that carefully monitored medication management is even more effective for the treatment of ADHD symptoms.

Some common side effects of psychostimulant therapy include insomnia, decreased appetite, stomachaches, headaches, and jitteriness. There may be rebound activation (a sudden increase in attention deficit and hyperactivity) after medication levels drop. Most side effects are mild, diminish over time, and respond to changes in dosage. There is no evidence that height or weight is affected by psychostimulant treatment, but precautionary monitoring of growth for children taking stimulants is still recommended. Atomoxetine (Strattera) is the only nonstimulant medication approved for the treatment of ADHD. Atomoxetine has effects on the neurotransmitter norepinephrine, which may also play a role in ADHD. Research contrasting atomoxetine with psychostimulants is being implemented. As of 2004, more than 70% of children with ADHD given Strattera have significant improvement in their symptoms.

Between 10–30% of individuals with ADHD do not respond to stimulant medication. For such non-responders and those who cannot tolerate the side effects, there are other useful medications. The antidepressant bupropion has been shown to be effective in a lower percentage of patients than stimulant medication. Certain types of antidepressants are sometimes used to augment psychostimulant treatment.

Psychosocial treatment

Psychosocial treatments may be used alone or in conjunction with pharmacological treatment to manage ADHD symptoms. Behavioral treatment for children typically involves using time-out, point systems, and contingent attention (adults reinforcing appropriate behavior by paying attention to it).

Children with ADHD can present a challenge that puts significant stress on the family. Skills training in psychosocial treatment for parents can help reduce this stress on the family. Systematic programs conducted in specialized classrooms or summer camps by highly trained individuals may be highly effective for some children. Adults may need treatment designed to train them in coping skills for management of ADHD symptoms. These skills may include list-making systems or other such reminders to assist in the completion of important tasks. Psychosocial treatment of ADHD symptoms has been proven to be less effective than pharmacological treatment when used alone, and needs to be consistently implemented in multiple settings to be fully effective. Behavioral interventions focus on improving targeted behaviors or skills, but are not as useful in reducing the core symptoms of inattention, hyperactivity, or impulsivity.

Educational accommodations for children with ADHD are federally mandated. Two federal laws that impact ADHD individuals are the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, which prohibit discrimination against individuals with disabilities in higher education and the workplace. Adults with ADHD are sometimes eligible for both protection and accommodation in higher education and the workplace under these laws. Organizations such as Children and Adults with Attention Deficit Disorder (CHADD) and the National Attention Deficit Disorder Association can provide information and support for individuals with ADHD.

Treatment controversies

Antidepressants known as selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, are not effective treatments for ADHD. Dietary manipulation has also been proven to be ineffective. In line with dietary research, controlled studies failed to demonstrate that sugar exacerbates the symptoms of children with ADHD. It is clear that research does not support the popularly held views that ADHD can be caused from excessive sugar intake, food additives, excessive television, poor parenting, or social and environmental factors such as poverty.

A highly controversial issue is whether there is over-diagnosis of ADHD and resultant over-prescription of stimulant medications. Special education legislation in the early 1990s increased general awareness of ADHD as a handicapping condition and provided the legal basis for accommodating ADHD-impaired students in the

school setting. These legal mandates have increased the awareness of ADHD within the school system and may have inadvertently led to the inaccurate conclusion that ADHD is a new disorder or that it is over-diagnosed. Despite the increased awareness, the Executive Summary on Mental Health, a supplement to the Surgeon General's Report in 2001, indicated that 75–80% of youths with mental health illnesses do not receive the needed treatments. Any increased use of stimulants in the 1990s is thought to reflect better diagnosis and more effective treatment of this prevalent disorder, which is still under-diagnosed. Most under-diagnosis is thought to be due to inadequate information supplied to the health care provider.

Prognosis

When properly diagnosed and treated, ADHD can be well managed. Treatment often leads to increased satisfaction in life and significant improvement in daily functioning. Many individuals with ADHD lead highly successful and happy lives. With proper treatment, the prognosis for ADHD can be very good. However, medications do not cure ADHD; they only temporarily control the symptoms. Although medications improve the prognosis and assist with symptom control, they cannot improve academic skills. The medications only help individuals to use those skills they already possess. Behavioral therapy and emotional counseling help individuals with ADHD to cope with their disorder.

Treatment may also mitigate risk factors for ADHD. A review of all long-term studies on stimulant medication and substance abuse, conducted by Researchers at Massachusetts General Hospital and Harvard Medical School, determined that teenagers with ADHD who remain on their medication have a lower probability of substance abuse than those who do not remain on medication. Medications used properly where indicated at a young age may prevent additional later-onset emotional problems. ADHD individuals who do not receive any form of treatment, pharmacological or psychosocial, have a much poorer prognosis.

Resources

ORGANIZATIONS

Children and Adults with Attention/Hyperactivity Deficit Disorder. 8181 Professional Place, Suite 150, Landover, MD 20785. Toll-free: (800) 233-4050. <http://www.chadd.org>.

National Attention Deficit Disorder Association. P.O. Box 543 Pottstown, PA 19464. (484) 945-2101. <http://www.add.org>.

National Institutes of Health. 9000 Rockville PikeBethesda, Maryland 20892. (301) 496-4000. <http://www.nih.gov>.

OTHER

About AD/HD. National Resource Center on AD/HD. <http://www.help4adhd.org/en/about>.

Attention Deficit Hyperactivity Disorder. NIMH publication, 2003.

Attention Deficit Hyperactivity Disorder. Online Mendelian Inheritance in Man. <http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=143465>.

Attention Deficit Hyperactivity Disorder (ADHD). <http://www.nimh.nih.gov/healthinformation/adhdmenu.cfm>.

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. National Institutes of HealthConsensus Development Conference Statement, November 16–18, 1998. <http://odp.od.nih.gov/consensus/cons/110/110_statement.htm>.

Mental Health: A Report of the Surgeon General. <http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec4.html>.

National Institute of Mental Health. <http://www.nimh.nih.gov/nimhhome/index.cfm>.

Maria Basile, PhD

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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

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

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 (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)

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.

views updated

Attention-deficit/hyperactivity disorder (ADHD)

Attention deficit/hyperactivity disorder (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 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, with many researchers assuming that ADHD is due to a genetic defect that results in altered brain biochemistry . 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. In 1990, a study by researchers at the National Institute for Mental Health documented the neurobiological effects of ADHD through brain imaging. The results showed that the rate at which the brain uses glucose, its main energy source, was shown to be lower in persons with ADHD, especially in the portion of the brain that is responsible for attention, handwriting, motor control and inhibition responses.

A widely publicized study conducted 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.

Diagnosis is based on a collaborative process that involves affected children, psychiatrists or other physicians, the child's family and school. Deciding what treatment will best benefit the affected child requires a careful diagnostic assessment after a comprehensive evaluation of psychiatric, social, cognitive, educational, family and medical/neurological factors. A thorough evaluation can take several hours and may require more than one visit to a physician. Treatment follows only after the evaluation is made.

Psychologists and other mental health professionals typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as a guideline for determining the presence of ADHD. For a diagnosis of ADHD, DSM-IVTR 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.

DSM-IV-TR 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 a period of 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. 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 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 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 variation on this is cognitive-behavioral therapy. This decreases 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. 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.

Prognosis

Untreated, ADHD can negatively affect 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, up to 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 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.

See also Nervous system; Neuroscience; Psychiatry; Psychoanalysis; Psychology.


Resources

books

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

Hallowell, Edward M. and John J. Ratey. Driven to Distraction. New York: Pantheon Books, 1995.

Wender, Paul H. ADHD: Attention-Deficit Hyperactivity Disorder in Children and Adults. Oxford: Oxford University Press, 2001.

periodicals

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

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

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

other

National Institutes of Mental Health. "Attention-Deficit Hyperactivity Disorder" [cited January, 10, 2003]. <http://www.nimh.nih.gov/publicat/adhd.cfm>.


Paula Anne Ford-Martin

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 towards authority figures.