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The Disorder Named AD/HD


By: CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder

Occasionally, we may all have difficulty sitting still, paying attention or controlling impulsive behavior. For some people, the problem is so pervasive and persistent that it interferes with their daily life, including home, academic, social, and work settings.

Attention-Deficit/Hyperactivity Disorder (AD/HD) is characterized by developmentally inappropriate impulsivity, attention, and in some cases, hyperactivity. AD/HD is a neurobiological disorder that affects three-to-five percent1,2,3 of school-age children. Until recent years, it was believed that children outgrew AD/HD in adolescence. Perhaps, this was because hyperactivity often diminishes during the teen years. However, it is now known that many symptoms continue into adulthood. In fact, current research reflects rates of roughly two to four percent among adults.4

Although individuals with this disorder can be very successful in life, without identification and proper treatment, AD/HD may have serious consequences, including school failure, depression, problems with relationships, conduct disorder, substance abuse, and job failure. Early identification and treatment are extremely important.

Medical science first documented children exhibiting inattentiveness, impulsivity and hyperactivity in 1902. Since that time, the disorder has been given numerous names, including Minimal Brain Dysfunction, Hyperkinetic Reaction of Childhood, and Attention-Deficit Disorder With or Without Hyperactivity. With the Diagnostic and Statistical Manual, 4th Edition (DSM-IV) classification system, the disorder has been renamed Attention-Deficit/Hyperactivity Disorder. The current name reflects the importance of the inattention characteristics of the disorder as well as hyperactivity and impulsivity.

The Symptoms

Typically, AD/HD symptoms arise in early childhood, unless associated with some type of brain injury later in life. Some symptoms persist into adulthood and may pose life-long challenges. Although the official diagnostic criteria state that the onset of symptoms must occur before age seven, leading researchers in the field of AD/HD argue that criterion should be broadened to include onset anytime during childhood.2 Criteria for the three primary subtypes are summarized as follows:

AD/HD predominately inattentive type: (AD/HD-I)5

  • Fails to give close attention to details or makes careless mistakes.
  • Has difficulty sustaining attention.
  • Does not appear to listen.
  • Struggles to follow through on instructions.
  • Has difficulty with organization.
  • Avoids or dislikes tasks requiring sustained mental effort.
  • Loses things.
  • Is easily distracted.
  • Is forgetful in daily activities.
  • AD/HD predominately hyperactive-impulsive type: (AD/HD-HI)5

  • Fidgets with hands or feet or squirms in chair.
  • Has difficulty remaining seated.
  • Runs about or climbs excessively.
  • Difficulty engaging in activities quietly.
  • Acts as if driven by a motor.
  • Talks excessively.
  • Blurts out answers before questions have been completed.
  • Difficulty waiting or taking turns.
  • Interrupts or intrudes upon others.
  • AD/HD combined type: (AD/HD-C)5

  • Individual meets both sets of inattention and hyperactive/impulsive criteria.
  • Youngsters with AD/HD often experience a two- to four-year developmental delay that makes them seem less mature and responsible than their peers. In addition, AD/HD frequently co-occurs with other conditions, such as depression, anxiety, or learning disabilities. For example, in 1999, NIMH research indicated that two thirds of children with AD/HD have a least one other coexisting condition.6 When coexisting conditions are present, academic and behavioral problems may be more complex.

    Teens with AD/HD present a special challenge. During these years, academic and organizational demands increase. In addition, these impulsive youngsters are facing typical adolescent issues: discovering their identity, establishing independence, dealing with peer pressure, exposure to illegal drugs, emerging sexuality, and the challenges of teen driving.

    Recently, deficits in executive function have emerged as key factors impacting academic and career success.2 Simply stated, executive function refers to the “variety of functions within the brain that activate, organize, integrate and manager other functions.”7 Critical concerns include deficits in working memory and the ability to plan for the future.

    The Diagnosis

    Because everyone shows signs of these behaviors at one time or another, the guidelines for determining whether a person has AD/HD are very specific. To be diagnosed with AD/HD, individuals must exhibit six of the nine characteristics in either or both DSM-IV categories listed above. In children and teenagers, the symptoms must be more frequent or severe than in other children the same age. In adults, the symptoms must affect the ability to function in daily life and persist from childhood. In addition, the behaviors must create significant difficulty in at least two areas of life, such as home, social settings, school, or work. Symptoms must be present for at least six months.

    Many adults with AD/HD were never properly diagnosed as children. As a result, they grew up struggling with a disability they did not even know they had. Others were diagnosed as “hyperkinetic” or “hyperactive” and were told their symptoms would disappear in adolescence. Consequently, many developed other problems that masked the underlying AD/HD.

    Adults with AD/HD may be easily distracted, have difficulty sustaining attention and concentrating, are often impulsive and impatient, may have mood swings and short tempers, may be disorganized and have difficulty planning ahead. They may also feel fidgety and restless internally.

    In addition, adults may also experience career difficulties. They may lose jobs due to poor job performance, attention and organizational problems, or interpersonal relationships. As a result, some adults experience periods of sadness or depression. On the other hand, adults who are diagnosed and treated adequately can thrive professionally. This is especially true once individuals find jobs that rely on their strengths rather than their deficits.

    The Evaluation

    Determining if a child has AD/HD is a multifaceted process. Many biological and psychological problems can contribute to symptoms similar to those exhibited by children with AD/HD. For example, anxiety, depression and certain types of learning disabilities may cause similar symptoms.

    There is no single test to diagnose AD/HD. Consequently, a comprehensive evaluation is necessary to establish a diagnosis, rule out other causes and determine the presence or absence of co-existing conditions. Such an evaluation should include a clinical assessment of the individual’s academic, social and emotional functioning and developmental level. A careful history should be taken from the parents, teachers and when appropriate, the child. Checklists for rating AD/HD symptoms and ruling out other disabilities are often used by clinicians.

    There are several types of professionals who can diagnose AD/HD, including school psychologists, private psychologists, social workers, nurse practitioners, neurologists, psychiatrists and other medical doctors. Regardless of who does the evaluation, the use of the Diagnostic and Statistical Manual IV criteria is necessary. A medical exam by a physician is important and should include a thorough physical examination, including hearing and vision tests, to rule out other medical problems that may be causing symptoms similar to AD/HD. In rare cases, persons with AD/HD also may have a thyroid dysfunction. Only medical doctors can prescribe medication if it is needed. Diagnosing AD/HD in an adult requires an examination of childhood academic and behavioral history as well as reviewing current symptoms.

    The Causes

    According to a June 1997 AMA study, “AD/HD is one of the best researched disorders in medicine, and the overall data on its validity are far more compelling than that for most mental disorders and even for many medical conditions.”8 Nonetheless, the exact causes of AD/HD remain illusive. Currently, most research suggests a neurobiological basis. Since AD/HD runs in families, inheritance appears to be an important factor.9 Even though a diagnostic test for AD/HD does not exist, the 1998 National Institute of Health Consensus Statement concludes, “there is evidence supporting the validity of the disorder.”10

    Multimodal Treatment

    There may be serious consequences for persons with AD/HD who do not receive treatment or receive inadequate treatment. These consequences may include low self-esteem, social and academic failure, career underachievement and a possible increase in the risk of later antisocial and criminal behavior. Treatment plans should be tailored to meet the specific needs of each individual and family. So treating AD/HD in children often requires medical, educational, behavioral, and psychological intervention. This comprehensive approach to treatment is called “multimodal” and often includes:

    Parent training

    Behavioral intervention strategies

    An appropriate educational program

    Education regarding AD/HD

    Individual and family counseling

    Medication, when required

     

    Research from the landmark NIMH Multimodal Treatment Study of AD/HD is very encouraging.6 Children who received medication, alone or in combination with behavioral treatment showed significant improvement in their behavior and academic work plus better relationships with their classmates and family.

    Psychostimulants are the most widely used class of medication for the management of AD/HD related symptoms. Approximately 70 to 80 percent11 of children with AD/HD respond positively to psychostimulant medications. Significant academic improvement is shown by students who take these medications: increased attention and concentration, compliance and effort on tasks, amount and accuracy of schoolwork produced and decreased activity levels, impulsivity, negative behaviors in social interactions and physical and verbal hostility12 Other medications that may decrease impulsivity, hyperactivity and aggression include some antidepressants and antihypertensives. However, each family must weigh the pros and cons of taking medication.

    Behavioral interventions are also a major component of treatment for children who have AD/HD. Important strategies include being consistent and using positive reinforcement, and teaching problem-solving, communication, and self-advocacy skills. Children, especially teenagers, should be actively involved as respected members of the school planning and treatment teams.

    School success may require a variety of classroom accommodations and behavioral interventions. Most children with AD/HD can be taught in the regular classroom with minor adjustments to the environment. Some children may require special education services if an educational need is indicated. These services may be provided within the regular education classroom or may require a special placement outside of the regular classroom that meets the child’s unique learning needs.

    Adults with AD/HD may benefit from learning to structure their environment. Plus, medications effective in childhood AD/HD also appear helpful for adults who have AD/HD. Vocational counseling is often an important intervention. Short-term psychotherapy can help adults identify how his or her disability might be associated with a history of problems at work and difficulties in personal relationships. Extended psychotherapy can help address mood swings, stabilize relationships and alleviate guilt and discouragement.

    The Prognosis

    Children with AD/HD are “at-risk” for potentially serious problems: academic underachievement, school failure, difficulty getting along with peers, and problems dealing with authority.2 Furthermore, up to 67 percent of children will continue to experience symptoms of AD/HD in adulthood.13 However, with early identification and treatment, children and adults can be successful. Studies show that children who receive adequate treatment for AD/HD have fewer problems with school, peers and substance abuse, and show improved overall functioning, compared to those who do not receive treatment.2, 6, 14 In adulthood, roughly one third of individuals with AD/HD lead fairly normal lives while half still have symptoms that may interfere with their family relationships or job performance.15 However, severe problems persist in about ten percent of adults.

     

     

    Suggested reading

    Barkley, R. (1998). Attention deficit hyperactivity disorders: A handbook for diagnosis and treatment. New York: Guilford Press.

    Brown, T.E. (2000) Attention-deficit disorders and comorbidities in children, adolescents, and adults. Washington, D.C.: American Psychiatric Press, Inc.

    Dendy, C.A.Z. (1995). Teenagers with ADD. Bethesda, MD: Woodbine House.

    Goldstein, S. (1999). The facts about AD/HD: An overview of attention-deficit hyperactivity disorder. CHADD 1999 Conference Book, Landover, MD: CHADD.

    Parker, H.C. (1988). The attention deficit disorder workbook for parents, teachers and kids. Plantation, FL: Impact Publications.

    Rief, S. (1993). How to reach and teach children with ADD/AD/HD. West Nyack, NY: The Center for Applied Research in Education.

    References

    1. American Psychiatric Association. (1994) Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: author.

    2. Barkley, RA. (1998). Attention deficit hyperactivity disorders: A handbook for diagnosis and treatment. New York: Guilford Press Barkley RA. (1998)

    3. Wolraich, M.L. Hannah, J.N. Pinnock, T.Y., Baumgaertel, Al, & Brown, J. (1996). Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample. Journal of the America Academy of Child and Adolescent Psychiatry, 35, 319-324.

    4. Murphy, K. R., & Barkley, R.A. (1996) The prevalence of DSM-IV symptoms of AD/HD in adult licensed drivers: Implications for clinical diagnosis. Comprehensive Psychiatry, 37, 393-401.

    5. Adapted from the American Psychiatric Association. (1994) Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.

    6. MTA Cooperative Group. (1999) A 14-month randomized clinical trial of treatment strategies for attention deficit hyperactivity disorder. Archives of General Psychiatry, 56, 12.

    7. Brown, T.E. (2000) Attention-deficit disorders and comorbidities in children, adolescents, and adults. Washington, D.C.: American Psychiatric Press, Inc.

    8. Goldman, L.S., Genel, M., Bezman, R, et.al. (1998) Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Journal of the American Medical Association. April 8, 1998-Vol 279, No. 14, pg. 1105 (1100-1107)

    9. U. S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General (Children and Mental Health). Rockville, MD: DHHR, SAMHSA, CMHS, NIH, NIMH.

    10National Institute of Health. (1998). Diagnosis and treatment of attention deficit hyperactivity disorder. Washington, D.C.: NIH Consensus Statement 1998 Nov 16-18; 16 (2): 1-37.

    11. Spencer, T., Wilens, T., Biederman, J., Faraone, S. V., Ablon, J. S., & Lapey, K. (1995). A double-blind, crossover comparison of methylphenidate and placebo in adults with childhood- onset attention-deficit hyperactivity disorder. Archives of General Psychiatry, 52, 434-443.

    12. Swanson, JM, McBurnett K, et al (1993) Effect of stimulant medication on children with attention deficit disorder: a “review of reviews.” Exceptional Children, 60, 154-162.

    13. Barkley, RA, Fischer, M., Fletcher, K., & Smallish, L. (2001) Young adult outcome of hyperactive children as a function of severity of childhood conduct problems, I: Psychiatric status and mental health treatment. Submitted for publication.

    14. Biederman J., Wilens T, et al (1999) Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics, 104, 2.

    15. Weiss G, Hechtman L., Milroy T, et al (1985) Psychiatric studies of hyperactives as adults: a controlled prospective 15-yr follow-up of 63 hyperactive children. Journal of the American Academy of Child Psychiatry, 23, 211-220.