Attention Deficit-Hyperactivity Disorder (ADHD) is a behavioral syndrome that is estimated to affect 3-6% of elementary and high school students It usually becomes apparent in the first few years of school, but it may go undiagnosed until adulthood.
A good description of a child with ADHD is as follows: The “ADHDer” has a million thoughts racing through his mind, forgets chores and assignments, doesn’t listen, alienates his peers, behaves impulsively, is disorganized, and drives his family crazy. Beneath it all, however, is an intelligent, creative, and well-intentioned kid (from Zipper: The Kid with ADHD).
ADHD can be more clinically and scientifically defined as a persistent pattern of inattention and/or hyperactivity – impulsivity that is more frequent and severe than is typical for others at a similar level of development.
ADHD is not a new disorder. The syndrome of hyperactivity was first described in 1900. In 1960, hyperactivity was thought to be due to subtle changes in the area of the brain that control behavior. At that time, this syndrome was called “Minimal Brain Damage Syndrome”. By the 1970’s, the syndrome was no longer felt to be the result of a physical brain abnormality, but rather a behavioral problem. In the 1980’s, attentional deficits were added to the diagnosis of hyperactivity.
There is no single lab test, finding on physical exam, or psychological test that proves or disproves the diagnosis of ADHD. Rather, the diagnosis must be made as a collaborative effort between parents, physicians, teachers, and other caregivers. To make the diagnosis, physicians will often perform some combination of the following tests:
” Medical Evaluation, which may include lab tests, x-rays, or other studies ” Having parents and teachers fill out ADHD rating forms ” Comprehensive interviews with patients, family, and teachers ” Mental Status Examination ” Assessment of cognitive ability and IQ ” Reviewing school performance reports, speech, and language evaluation
The painting entitled, Child Psychology, was done by Norman Rockwell and appeared on the November 25, 1933 cover of the Saturday Evening Post.
SIGNS & SYMPTOMS
ADHD can be defined as a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typical for others at a similar level of development.
There are three subtypes of ADHD: The predominantly inattentive type, the predominantly hyperactive and impulsive type, and a combination of these two. In actuality, most people have a combination of these two forms. The following is the official diagnostic criteria from the American Psychiatric Association’s DSM – IV:
” The symptoms must be present and cause difficulty before age 7 ” The symptoms must cause problems in two or more settings (home, school, or work ” There must be clear evidence of significant impairment in social, academic, or occupational functioning ” The symptoms may not occur exclusively during the course of another disorder, such as schizophrenia, depression, anxiety, or a personality disorder
” Often fails to give close attention to details or makes careless mistakes ” 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 does not finish tasks ” Often has difficulty organizing tasks and activities ” Often avoids engaging in tasks that require sustained mental effort ” Often loses things necessary for tasks and activities ” 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 being seated is expected ” Often runs about or climbs excessively when it is inappropriate (in adolescents and adults, this may be limited to feelings of restlessness) ” Often has difficulty playing or engaging in leisure activities quietly ” Often “on the go” or acts as if “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 treatment of ADHD is based on medication and behavioral modification. Some doctors liken medication treatment to eyeglasses: they help the patient focus the world, but the rest is up to the patient themselves. Medication alone, however, cannot improve all of the symptoms. Medications must be combined with behavioral therapy at home and at school. Limitations and rule setting must be consistent to improve behavior in people with ADHD. The person with ADHD must learn new ways to relate to his/her family and the world. Group or family therapy may be helpful. Stimulant medications, such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert) have been unequivocally shown to improve the symptoms of ADHD. It is useful to think of their seemingly paradoxical mechanism as the brake in a car. When the brake is stimulated, the car slows down. Seventy-five percent of children with ADHD will respond to stimulants. The doctor will usually start with a low dose, and then gradually increases it until the dose is found that works the best with the least side effects. Medication dosage can vary between children based on body weight, diet, and other factors. The medications are usually given 2-3 times per day, depending on the patient. Some patients need only take the medication on school days; others require the medication every day. Many physicians suggest that the patient have an annual “drug holiday”, in which the medication is stopped, in order to assess the severity of remaining symptoms. These usually occur during school vacations.
Certain antidepressants, such as amitriptyline (Elavil), desipramine (Norpramin), buproprion (Wellbutrin), fluoxetine (Prozac), and sertraline (Zoloft), have also been found to be effective in ADHD, especially when ADHD is accompanied by depressive symptoms.
Clonidine (Catapres) is another class of medication sometimes used in the treatment of ADHD. Clonidine acts on the central nervous system and is especially helpful if the symptoms are primarily hyperactivity, aggression, or if tics are present. It is available as a pill or as a patch.
Side Effects All of the stimulants have the potential to cause insomnia, decreased appetite, stomach ache, headache, and jitteriness. Often, a slight decrease in dose can eliminate the side effects. Giving the medication after meals can reduce the effects of decreased appetite. Growth appears to be affected only as a result of decreased appetite. Your physician will monitor the child’s growth while on the medication. Pemoline (Cylert) has been found to cause rare cases of liver failure, so it is usually not used unless other treatments have failed.
The antidepressants have different side effects depending on their class. Serotonin Specific Reuptake Inhibitors (SSRI) antidepressants, such as Prozac and Zoloft, have few serious side effects. Minor side effects include dry mouth, blurry vision, and sexual dysfunction. Tricyclic antidepressants, such as amitriptyline and desipramine, can cause blurry vision, dry mouth, constipation, and difficulty voiding. These medications should not be used in patients with a certain cardiac condition (long or prolonged QT syndrome). An EKG is often performed before starting treatment with a tricyclic antidepressant.
Clonidine can cause fatigue
Isn’t it normal for children to be hyperactive and easily distractible? What makes this a disease? It’s true that young children are more hyperactive, more easily distractible, and misbehave more frequently than older children or adults. This is a normal part of growing up. As the ADHD criteria state, a disorder may be present when the behaviors are significantly different from other children of the same age.
Are these medications a “chemical straitjacket” for normally exuberant children? Some have argued that these medications amount to a “chemical straitjacket”, and that ADHD medications interferes with normal aspects of childhood. These medications should only be used when the criteria of ADHD are met, not just when a child is normally boisterous. “When needed, however, the medications improve classroom behavior and academic performance and diminish oppositional and aggressive behaviors” (Council on Scientific Affairs, American Medical Association).
How do I know if all of my child’s behavioral problems are caused by ADHD? Could he/she have other problems as well? This is an important question. Up to 65% of children with ADHD may have another disorder as well. Forty percent may have Oppositional Defiant Disorder, a syndrome in which a child is resistant to authority. Twenty percent may have a mood disorder, such as depression, anxiety, or bipolar disorder (manic-depression). Another twenty percent may have Conduct Disorder, a syndrome in which a child disregards the law. Seven to ten percent may have Tourette’s syndrome, a disorder in which a child has “tics” in which he/she involuntarily moves or speaks. If another disorder is present, the treatment of ADHD may be different. For example, many medications used for ADHD can actually make Tourette’s syndrome worse.
What is the course of ADHD? Will my child have ADHD forever? It is thought that the severity of the symptoms of ADHD diminishes with age. One rough rule-of-thumb is that the symptoms of ADHD diminish by half every five years. Between 10 and 60% of children may still have ADHD as adults, but the symptoms may not be as severe. Many children no longer need treatment for ADHD by the time they finish high school or college. The severe inattention and hyperactivity of ADHD is typically worst during early schooling. It is important to treat the syndrome when first diagnosed so that your child can have the best education possible.
Can adults have ADHD? Should they be treated with medication? Yes. Up to 2% of adults may have ADHD. Most of these adults probably had some degree of ADHD as children whether or not they were ever diagnosed or treated. Over 75% of adults with ADHD will benefit from medication.
For a more detailed and comprehensive look at ADHD, we recommend the following books:
- Dr. Larry Silver’s Advice to Parents on Attention Deficit Hyperactivity Disorder (by Larry Silver M. D)
- The ADHD e-Book (Dr. Kutcher’s free online discussion on ADHD as well as other important pediatric conditions including Asperger’s and Autism.)
- Zipper : The Kid With ADHD (by Caroline Janover) – an excellent book geared for elementary and junior high school children
Finally, here is a list of some excellent websites and other resources through which additional ADHD information can be obtained.
” CHADD: Children with Attention Deficit Disorders ” ADDA: Attention Deficit Disorders Association (geared more for adults with ADHD). ” A site that looks at some of the controversy surrounding ADHD ” The National Institute of Health (NIH) consensus statement on ADHD ” MiningCo.com has a good list of additional links on ADHD ” A personal home page that takes a look into the mind of the person with ADHD ” The World Health Organization (WHO) slightly different ADHD criteria
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, or DSM – IV for short, is a textbook put out by the American Psychiatric Association. It is based on the most current mental health clinical research and written by over a 1000 mental health workers, including physicians, nurses, researchers, social workers, and others. The DSM – IV essentially summarizes the current accepted diagnostic criteria (i.e., the common signs & symptoms) of psychiatric and mental illness. The behavioral signs & symptoms of depression, schizophrenia, bipolar disorder, anxiety, panic disorder, and ADHD, to name only a few, are summarized in this extensive book. Health care professionals can use these classifications to help give a name to the constellation of behaviors a patient exhibits. In addition, treatment can be offered that has been shown to benefit others who have had the same, or similar, behaviors. In the case of ADHD, the DSM -IV allows us to differentiate between normal hyperactive behavior often seen in children and that which is considered abnormal. Of course the DSM – IV is not necessarily right, and each successive edition updates and modifies the diagnostic criteria of mental illness based on recent clinical studies and our current beliefs. The DSM – IV essentially summarizes our current understanding of the signs & symptoms of mental illness.