Attention Deficit/Hyperactivity Disorder
Attention Deficit/Hyperactivity Disorder (ADHD) is a genetically determined hereditary disorder. It is a syndrome characterized by chronic behavior patterns of inattentiveness, lack of impulse control and excess energy (hyperactivity). The symptoms may be mild or severe and are associated with functional deviations of the central nervous system without signs of major neurologic or psychiatric disturbance.
Inattentiveness is when the child is easily distracted and has difficulty focusing or concentrating on a task.
Lack of impulse control is when the child may get into frequent fights or act aggressively toward others with little cause.
Hyperactivity is when the child seems to fidget, squirm and move about constantly and can't sit still for any length of time.
It is important for parents, teachers and caregivers to understand that ADHD is not caused by poor parenting or a chaotic home environment. ADHD affects approximately 3 to 5 percent of all American children. The syndrome is 4 to 6 times more likely to occur in males than in females. In about half the cases, the age of onset occurs before age 4.
A single biologic model to explain the syndrome has not been established. Some researchers believe that ADHD is due to a genetic defect that results in altered brain biochemistry. Differences in biochemistry are considered to be the cause of poor regulation of attention, impulsivity and motor activity.
In 1990, the New England Journal of Medicine published a landmark study by researchers at the National Institute for Mental Health which documented the neurobiological effects of ADHD through brain imaging. 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.
Additionally, some researchers suggest that prenatal conditions such as maternal alcohol or drug abuse and birth complications may contribute in some cases.
ADHD characteristics often arise in early childhood. The Diagnostic and Statistical Manual, 4th Edition (DSM-IV) lists the following symptoms for Childhood ADHD:
- often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
- often has difficulty sustaining attention in tasks or play activities
- often does not seem to listen when spoken to directly
- often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
- often has difficulty organizing tasks and activities
- often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
- often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books or tools)
- often easily distracted by extraneous stimuli
- often forgetful in daily activities
- often fidgets with hands or feet or squirms in seat
- often leaves seat in classroom or in other situations in which remaining seated is expected
- often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
- often has difficulty playing or engaging in leisure activities quietly
- is often "on the go" or often acts as "driven by a motor"
- often talks excessively
- often blurts out answers before questions have been completed
- often has difficulty awaiting turn
- often interrupts or intrudes on others
The fact that the child exhibits ADHD-like behaviors does not prove that they are suffering from this disorder. It is quite possible that some other problem is causing these symptoms. In order to correctly diagnose ADHD, the doctor must first rule out these "look-alike" factors by conducting a thorough physical examination and administering laboratory and other diagnostic tests:
Medical conditions. Allergy and effects of allergy medication, hearing loss, thyroid disorders, visual disturbances, genetic disorders (such as Fragile X syndrome), seizure disorders and chronic medical conditions.
Behavioral and neurologic conditions. Articulation problems, coordination problems, encopresis (a type of soiling problem whereby children defecate in inappropriate places), enuresis (bed-wetting), night terrors and sleep difficulties.
Learning and language disabilities. Difficulties with listening, speaking, thinking, reading, writing, reasoning and performing mathematical calculations.
Additionally, the doctor will take a thorough medical history and consult rating scales to confirm ADHD. The history should include a family, birth and general medical history gathered from family as well as school and day-care (if applicable) workers.
Children suspected of having ADHD can be evaluated at the school’s expense and, if found to be eligible, provided services under either of two federal laws: (1) the Individuals with Disabilities Education Act (IDEA), or (2) Section 504 of the Rehabilitation Act of 1973.
Most ADHD therapy today involves a "biopsychosocial" approach - "bio" refers to medication, "psycho" refers to counseling and psychotherapy and "social" refers to instruction in self-management and training in social skills.
For decades, medications have been used to treat the symptoms of ADD. Medications in the class of drugs known as stimulants seem to be the most effective in both children and adults. These are methylphenidate (Ritalin, Methlyn), mixed salts of single entity amphetamine product (Adderall), and dextroamphetamine (Dexedrine or Dextrostat), and pemoline (Cylert). Cylert may cause serious liver damage.
For many people, these medicines dramatically reduce the hyperactivity and improve their ability to focus, work and learn. The medications may also improve physical coordination, such as handwriting and ability in sports.
Stimulants are not appropriate for every child with attention disorder. For instance, they are not intended for anyone with a primary psychiatric illness (such as schizophrenia, in which the person loses touch with reality) because they can worsen the disturbances. They can aggravate emotional problems, such as anxiety. They can bring out tics (involuntary movements) in a patient with a family history of tics.
Even a correctly administered stimulant can cause adverse effects, for no drug is completely without risk. The side effects most frequently reported are decreased appetite and insomnia. Less common are drowsiness, hypersensitivity, weight loss, headache, nausea, and blood pressure changes.
Whether a child should be given stimulants is a case-by-case decision in which the benefits are weighed against the risks. In the past, most stimulant treatments for ADHD were prescribed only for two to three years and only for children. But today, treatment may extend over longer periods and may be given to adolescents and adults. Stimulants clearly are not intended to be the sole treatment.
Other medications prescribed for symptoms of ADHD include clonidine (Catapres) and tricyclic antidepressants.
Parents and children can be instructed in positive reinforcement techniques for rewarding desirable behavior and reducing negative behavior. Here are some strategies:
- Discipline can best be maintained by establishing a few consistent rules with immediate consequences whenever each rule is broken. Rules should be phrased positively in terms of what the child should do. Praise the child and reward him or her for good behavior.
- Structure a system of rewards for good behavior. This system encourages the child to work to earn privileges or rewards he or she wants by accumulating points for desired behaviors and removing points for undesirable behaviors.
- Make a written agreement (a contract) with the child in which the child agrees to do his or her homework every night or to demonstrate other desired behavior in return for a privilege.
- Provide a specified time-out location for when the child is out of control. This should not be seen as a place of punishment but as a "calm down" spot.
- Set up a study area away from distractions and establish a specific time each day to do homework.
- Have the teacher make a checklist of homework to be done.
- Put up a calendar of long-term assignments and other tasks.
- Avoid emotional reactions such as anger, sarcasm and ridicule.
Counseling and Psychotherapy
There are three different types of psychotherapy available: individual psychotherapy, cognitive behavioral therapy and family therapy.
Individual therapy helps children with anxiety, difficulties with self-esteem, depression and other emotional problems. Cognitive behavioral therapy teaches children to modify their behavior by correcting the way they think about it. Family therapy assists the child and his or her family in understanding the condition.
Close communication between the physician and school personnel is essential.
Self-management and training in social skills helps children curb aggressive, impulsive and socially maladaptive behaviors.
Can my child have ADHD and not be hyperactive?
How do you diagnose a hyperactive child?
How do you know the child's disorder is caused by deviations of the central nervous system versus just environmental discipline problems?
Would you prescribe a medication for part of the treatment?
What are the side effects?
How should I expect the child's behavior to change after starting the medication?
How long will the medication have to be taken?
Are there any drug-free treatments for ADHD?
What can be done to prevent social and emotional problems?
Does eliminating sugar and caffeine products help reduce hyperactivity?
What kind of behavior therapy will be planned? And will someone be able to work with the family and teachers to follow the behavioral plan?
Does my child qualify for special education or other assistance from his/her school?
With medications and behavior-modification techniques, when should we start to see a change in the child's behavior and learning problems?
There is no evidence to support the use of dietary management. Megavitamins, restriction of sugar, and supplementary trace minerals do not appear effective. Diets low in food additives or coloring are not effective.