Attention-deficit disorder and Attention deficient hyperactivity disorder

Attention-deficit/Hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and theinability to remain focused on tasks. The National Institutes of Health (NIH)regards ADHD as the most commonly diagnosed behavioral disorder of childhoodand thus, a major public health problem.

ADHD is also known as hyperkinetic disorder (HKD) outside of the United States. Studies done in Japan, China, Germany, France, Holland, Sweden and North America suggest that 3-9% of children are affected. In the United States, thistranslates to an estimated 2 million children with ADHD. The condition afflicts boys more often than girls. Some children suffer primarily from inattentiveness rather than from hyperactivity and are classified as having AttentionDeficit Disorder (ADD).

Although difficult to assess in infancy and toddlerhood, signs of ADHD may begin to appear as early as age 2 or 3. Children with ADHD have short attentionspans, becoming easily bored or frustrated with tasks. Although they may bequite intelligent, their lack of focus frequently results in poor grades anddifficulties in school. ADHD children act impulsively, taking action first and thinking later. They constantly move, run, climb, squirm, and fidget, but often have trouble with gross and fine motor skills. Their clumsiness may extend to the social arena, where they are sometimes shunned due to their impulsive and intrusive behavior. Many symptoms, particularly hyperactivity, diminish in early adulthood, but impulsivity and inattention problems remain with upto 50% of ADHD individuals throughout their adult life.

The causes of ADHD are not known. It appears that heredity plays a major role, since 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 a 1999 consensus statement on ADHD, the National Institutes of Health acknowledged that years of clinical research had yielded only speculation about the causes of the condition. Since the causes are not known, there is no definitive program for preventing ADHD. However, psychologists have experimented with early intervention for ADHD children. Using the theory that speech and motor functioning are linked to the ability to pay attention and concentrate, child psychologists set up an early intervention program that offered occupational therapy and speech therapy to preschoolers. The children were reevaluated when they were 8 to 10 years old and there was a small difference between ADHD and non-ADHD children, but it was not statistically significant. However,when psychologists factored in a family history of ADHD, the early intervention did make a difference. Although the research is still in the early stages, it gives scientists a promising direction for additional study.

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 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 performa comprehensive ADHD assessment. Public schools are required by federal lawto offer free ADHD testing upon request. Some advocacy groups encourage parents to consult with more than one physician for diagnosis and prescription ofmedication.

Psychosocial therapy, usually combined with medications, is the treatment ofchoice to alleviate ADHD symptoms. Psychostimulants, such as dextroamphetamine (Dexedrine), pemoline (Cylert), and methylphenidate (Ritalin) are commonlyprescribed to control hyperactive and impulsive behavior and increase attention span. They work by stimulating the production of certain neurotransmittersin the brain. Possible side effects of stimulants include nervous tics, irregular heartbeat, loss of appetite, and insomnia. The National Institutes of Health has received reports of hallucinogenic responses in a small percentageof children treated at high doses. However, the medications are usually well-tolerated and safe in most cases.

In children who do not 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. Other medications prescribed for ADHD therapy include buproprion (Wellbutrin), fluoxetine (Prozac), and carbamazepine (Tegretol, Atretol). Clonidine (Catapres), anantihypertensive 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, so symptoms shouldbe monitored and prescriptions adjusted accordingly.

In addition to drugs, behavior modification therapy, which uses a reward system to reinforce good behavior and task completion, can be implemented in theclassroom and at home. Behavior modification rewards good behavior until it becomes ingrained. A variation of this technique, cognitive-behavioral therapy, works to decrease impulsive behavior by getting the child to recognize theconnection between thoughts and behavior, and to change behavior by changingnegative thinking patterns.

Physicians prescribed controlled substances such as Ritalin for nearly half amillion children aged 3 to 6 in 1995. Production of Ritalin increased sevenfold during the 1990s, with 90% of the drug consumed in the United States. Most clinicians recommend trying behavioral techniques before using stimulants on very young children. Some insurance companies will not cover behavioral therapy and this reinforces the trend toward prescription medicines. In the United States in 1996, 75% of children diagnosed with ADHD received a prescription for a medicine such as Ritalin. In 1989, the figure was 55%. From 1989 to 1996, the use of psychotherapy for ADHD children dropped from 40% to 25%. TheNIH cautions that stimulant drugs alone will not help with the cluster of behavioral and developmental problems that constitute ADHD.

Teachers often work with families and physicians to help provide an atmosphere where the ADHD child can succeed. A teacher might increase the distance between desks, use concise instructions and use shorter assignments or work periods. An ADHD student might be seated in a quiet area close to a good role model or "study buddy". A teacher might ignore minor inappropriate behavior andpraise an ADHD student for raising his hand to answer a question. Frequentlya teacher will work with an ADHD student to develop a private signal to remind the student to stay on task.

A number of alternative treatments exist for ADHD. Although there is a lack of controlled studies to prove their efficacy, proponents of alternative treatments report that they are successful in controlling symptoms in some ADHD patients. Some of the more popular alternative treatments include: EEG (electroencephalography), biofeedback, dietary therapy, and herbal therapy. The safety of herbal remedies has not been demonstrated in controlled studies.Dietary therapy remains under debate, with some clinicians observing that 70percent of children who crave sweets have better control over their behaviorwhen following a diet that is low in added sugar. A clinical trial in Britainshowed that the majority of ADHD children in a London hospital suffered fromfood intolerance that was linked to hyperactive behavior. Children with ADHDwere most likely to be intolerant of or allergic to foods made with cow's milk, corn, wheat, soy and eggs. Some patients seek homeopathic medicine as analternative therapy for ADD and ADHD because it treats the whole person at acore level.

Some of the toughest ethical issues center not on the children who are most severely ill but on those with borderline diagnoses. Diagnosis is usually madeby subjective observations of behavior at home and in the classroom. Criticscharge that some of the yardsticks for ADHD, such as "fidgety, distracted, talking out of turn," apply to all children at times and are thus meaningless.There is some preliminary research at Stanford University on using magneticresonance imaging (MRI) to diagnose boys with ADHD, but much more research will be needed before there is a definitive method of diagnosis. For the studies to be scientifically valid, researchers will need to compare the findings on ADHD children against data on children with disorders that are similar to ADHD, and children on Ritalin will need to be compared with children who are taking a placebo.

Doctors caution that many children may improve if given stimulants such as Ritalin and clinical improvement does not, in itself, show that a child has ADHD. While studies show that Ritalin-like drugs work over the short term, it isnot known why they work, and there are no long-term studies on this group ofdrugs. These variables make it almost impossible for clinicians to determinewhether the drug is being overprescribed.

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 socialoutcasts. They may be perceived as slow learners or troublemakers in the classroom. Siblings and even parents may develop resentful feelings toward the ADHD child. Children with ADHD use a large portion of the resources of the health care system, the school system, the criminal justice system and other social service agencies.

Some ADHD children also develop a conduct disorder problem. For those adolescents who have both ADHD and a conduct disorder, up to 25% develop antisocialpersonality 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. It is not unusual for children with ADHD to suffer from obsessive-compulsive disorder (OCD) or Tourette's syndrome.

According to one developmental theory, ADHD is a disorder of self-regulationin which there is a lag in social development. The child is not able to learnfrom mistakes and apply new strategies. Frequently the child with ADHD appears to be disorganized and chaotic, acting without any sense of direction. Often the child can see only the present moment and is not able to plan for thefuture. Even when the child with ADHD is improving, he continues to lag behind his peers in development.

There are some positive aspects of ADHD brain functioning, in that the childmay have superb intuitive powers and may excel in creative activities that require spontaneity. Some development specialists who work with ADHD children use many yardsticks to measure intelligence. For example, a test of verbal andlinguistic skills might include humor, jokes and storytelling. Visual and spatial skills might be tested by asking a child to draw, paint, pretend or otherwise use the imagination. An ADHD child who has trouble sitting still mighthave his kinesthetic skills tested with dance, drama, sports or martial arts. Child development specialists caution against heavy dependence on traditional intelligence tests that focus solely on verbal and mathematical skills.

Approximately 70-80% of ADHD patients treated with stimulant medication experience significant relief from symptoms, at least in the short-term. About 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. The best treatment for adults with ADHD is still under study. Preliminary research shows that antidepressants may help such adults and they may not requirestimulants such as Ritalin. Research on teenagers and adults who have been treated with Ritalin is contradictory as to whether Ritalin use predisposes patients to misuse stimulants, alcohol and other drugs as they get older. A small study of adult prisoners showed a much higher incidence of ADHD than in thegeneral public, but much more research is needed.

Often physicians do not recognize or treat ADHD in adults, so very little data is available. Many successful people have had symptoms consistent with ADHDor similar learning disorders as children, including Alexander Graham Bell,Thomas Edison, Henry Ford, Albert Einstein, John F. Kennedy, Robert Kennedy,John Lennon, Prince Charles, "Magic" Johnson and Sylvester Stallone.

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