ATTENTION-DEFICIT/HYPERACTIVITY DISORDER


DEFINITION

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

DESCRIPTION

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

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

CAUSES

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

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

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

Attention-Deficit/Hyperactivity Disorder: Words to Know

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

SYMPTOMS

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

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

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

DIAGNOSIS

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

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

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

TREATMENT

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

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

ARE WE "DRUGGING" PROBLEM CHILDREN?

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

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

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

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

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

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

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

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

Alternative Treatment

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

Ritalin is a drug commonly given to children with ADHD. (Reproduced by permission of AP/Wide World Photos)
Ritalin is a drug commonly given to children with ADHD. (Reproduced by permission of
AP/Wide World Photos
)

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

PROGNOSIS

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

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

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

PREVENTION

Researchers have not yet determined if ADHD is preventable.

FOR MORE INFORMATION

Books

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

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

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

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

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

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

Periodicals

Hallowell, Edward M. "What I've Learned from A.D.D." Psychology Today (May–June 1997): pp. 40–46.

Organizations

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

Children and Adults with Attention Deficit Disorder (CHADD). 499 Northwest 70th Avenue, Suite 101. Plantation, FL 33317. (800) 233–4050. http://www.chadd.org.

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