Attention-Deficit/Hyperactivity Disorder (AD/HD)
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.
AD/HD, also known as hyperkinetic disorder (HKD) outside of the United States, is estimated to affect 3–7 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.
Of the 3–7 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 neurotransmitters—the chemicals in the brain that transmit messages between nerve cells—is 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.
- 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
- 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
- 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)
- 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.
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.
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 10–12 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, 70–80 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
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.
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.
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 70–80 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.
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.
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.
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.
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Jacqueline L. Longe Paula A. Ford-Martin