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What is Attention Deficit Hyperactivity Disorder ?
Attention
Deficit Hyperactivity Disorder (ADHD) is a condition that becomes
apparent in some children in the preschool and early school years. It
is hard for these children to control their behavior and/or pay
attention. It is estimated that between 3 and 5 percent of children
have ADHD, or approximately 2 million children in the United States.
This means that in a classroom of 25 to 30 children, it is likely that
at least one will have ADHD.
ADHD was first described by Dr.
Heinrich Hoffman in 1845. A physician who wrote books on medicine and
psychiatry, Dr. Hoffman was also a poet who became interested in
writing for children when he couldn't find suitable materials to read
to his 3-year-old son. The result was a book of poems, complete with
illustrations, about children and their characteristics. "The Story of
Fidgety Philip" was an accurate description of a little boy who had
attention deficit hyperactivity disorder. Yet it was not until 1902
that Sir George F. Still published a series of lectures to the Royal
College of Physicians in England in which he described a group of
impulsive children with significant behavioral problems, caused by a
genetic dysfunction and not by poor child rearing—children who today
would be easily recognized as having ADHD. 1 Since then, several
thousand scientific papers on the disorder have been published,
providing information on its nature, course, causes, impairments, and
treatments.
A child with ADHD faces a difficult but not
insurmountable task ahead. In order to achieve his or her full
potential, he or she should receive help, guidance, and understanding
from parents, guidance counselors, and the public education system.
This document offers information on ADHD and its management, including
research on medications and behavioral interventions, as well as
helpful resources on educational options.
Because ADHD often continues into adulthood, this document contains a section on the diagnosis and treatment of ADHD in adults.
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Symptoms
The
principal characteristics of ADHD are inattention, hyperactivity, and
impulsivity. These symptoms appear early in a child's life. Because
many normal children may have these symptoms, but at a low level, or
the symptoms may be caused by another disorder, it is important that
the child receive a thorough examination and appropriate diagnosis by a
well-qualified professional.
Symptoms of ADHD will appear over
the course of many months, often with the symptoms of impulsiveness and
hyperactivity preceding those of inattention, which may not emerge for
a year or more. Different symptoms may appear in different settings,
depending on the demands the situation may pose for the child's
self-control. A child who "can't sit still" or is otherwise disruptive
will be noticeable in school, but the inattentive daydreamer may be
overlooked. The impulsive child who acts before thinking may be
considered just a "discipline problem," while the child who is passive
or sluggish may be viewed as merely unmotivated. Yet both may have
different types of ADHD. All children are sometimes restless, sometimes
act without thinking, sometimes daydream the time away. When the
child's hyperactivity, distractibility, poor concentration, or
impulsivity begin to affect performance in school, social relationships
with other children, or behavior at home, ADHD may be suspected. But
because the symptoms vary so much across settings, ADHD is not easy to
diagnose. This is especially true when inattentiveness is the primary
symptom.
According to the most recent version of the
Diagnostic and Statistical Manual of Mental Disorders 2 (DSM-IV-TR),
there are three patterns of behavior that indicate ADHD. People with
ADHD may show several signs of being consistently inattentive. They may
have a pattern of being hyperactive and impulsive far more than others
of their age. Or they may show all three types of behavior. This means
that there are three subtypes of ADHD recognized by professionals.
These are the predominantly hyperactive-impulsive type (that does not
show significant inattention); the predominantly inattentive type (that
does not show significant hyperactive-impulsive behavior) sometimes
called ADD—an outdated term for this entire disorder; and the combined
type (that displays both inattentive and hyperactive-impulsive
symptoms).
Hyperactivity-Impulsivity
Hyperactive children
always seem to be "on the go" or constantly in motion. They dash around
touching or playing with whatever is in sight, or talk incessantly.
Sitting still at dinner or during a school lesson or story can be a
difficult task. They squirm and fidget in their seats or roam around
the room. Or they may wiggle their feet, touch everything, or noisily
tap their pencil. Hyperactive teenagers or adults may feel internally
restless. They often report needing to stay busy and may try to do
several things at once.
Impulsive children seem unable to curb
their immediate reactions or think before they act. They will often
blurt out inappropriate comments, display their emotions without
restraint, and act without regard for the later consequences of their
conduct. Their impulsivity may make it hard for them to wait for things
they want or to take their turn in games. They may grab a toy from
another child or hit when they're upset. Even as teenagers or adults,
they may impulsively choose to do things that have an immediate but
small payoff rather than engage in activities that may take more effort
yet provide much greater but delayed rewards.
Some signs of hyperactivity-impulsivity are:
Feeling restless, often fidgeting with hands or feet, or squirming while seated
Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected
Blurting out answers before hearing the whole question
Having difficulty waiting in line or taking turns.
Inattention
Children
who are inattentive have a hard time keeping their minds on any one
thing and may get bored with a task after only a few minutes. If they
are doing something they really enjoy, they have no trouble paying
attention. But focusing deliberate, conscious attention to organizing
and completing a task or learning something new is difficult.
Homework
is particularly hard for these children. They will forget to write down
an assignment, or leave it at school. They will forget to bring a book
home, or bring the wrong one. The homework, if finally finished, is
full of errors and erasures. Homework is often accompanied by
frustration for both parent and child.
The DSM-IV-TR gives these signs of inattention:
Often becoming easily distracted by irrelevant sights and sounds
Often failing to pay attention to details and making careless mistakes
Rarely
following instructions carefully and completely losing or forgetting
things like toys, or pencils, books, and tools needed for a task
Often skipping from one uncompleted activity to another.
Children
diagnosed with the Predominantly Inattentive Type of ADHD are seldom
impulsive or hyperactive, yet they have significant problems paying
attention. They appear to be daydreaming, "spacey," easily confused,
slow moving, and lethargic. They may have difficulty processing
information as quickly and accurately as other children. When the
teacher gives oral or even written instructions, this child has a hard
time understanding what he or she is supposed to do and makes frequent
mistakes. Yet the child may sit quietly, unobtrusively, and even appear
to be working but not fully attending to or understanding the task and
the instructions.
These children don't show significant
problems with impulsivity and overactivity in the classroom, on the
school ground, or at home. They may get along better with other
children than the more impulsive and hyperactive types of ADHD, and
they may not have the same sorts of social problems so common with the
combined type of ADHD. So often their problems with inattention are
overlooked. But they need help just as much as children with other
types of ADHD, who cause more obvious problems in the classroom.
Is It Really ADHD?
Not
everyone who is overly hyperactive, inattentive, or impulsive has ADHD.
Since most people sometimes blurt out things they didn't mean to say,
or jump from one task to another, or become disorganized and forgetful,
how can specialists tell if the problem is ADHD?
Because
everyone shows some of these behaviors at times, the diagnosis requires
that such behavior be demonstrated to a degree that is inappropriate
for the person's age. The diagnostic guidelines also contain specific
requirements for determining when the symptoms indicate ADHD. The
behaviors must appear early in life, before age 7, and continue for at
least 6 months. Above all, the behaviors must create a real handicap in
at least two areas of a person's life such as in the schoolroom, on the
playground, at home, in the community, or in social settings. So
someone who shows some symptoms but whose schoolwork or friendships are
not impaired by these behaviors would not be diagnosed with ADHD. Nor
would a child who seems overly active on the playground but functions
well elsewhere receive an ADHD diagnosis.
To assess whether a
child has ADHD, specialists consider several critical questions: Are
these behaviors excessive, long-term, and pervasive? That is, do they
occur more often than in other children the same age? Are they a
continuous problem, not just a response to a temporary situation? Do
the behaviors occur in several settings or only in one specific place
like the playground or in the schoolroom? The person's pattern of
behavior is compared against a set of criteria and characteristics of
the disorder as listed in the DSM-IV-TR.
Diagnosis
Some
parents see signs of inattention, hyperactivity, and impulsivity in
their toddler long before the child enters school. The child may lose
interest in playing a game or watching a TV show, or may run around
completely out of control. But because children mature at different
rates and are very different in personality, temperament, and energy
levels, it's useful to get an expert's opinion of whether the behavior
is appropriate for the child's age. Parents can ask their child's
pediatrician, or a child psychologist or psychiatrist, to assess
whether their toddler has an attention deficit hyperactivity disorder
or is, more likely at this age, just immature or unusually exuberant.
ADHD
may be suspected by a parent or caretaker or may go unnoticed until the
child runs into problems at school. Given that ADHD tends to affect
functioning most strongly in school, sometimes the teacher is the first
to recognize that a child is hyperactive or inattentive and may point
it out to the parents and/or consult with the school psychologist.
Because teachers work with many children, they come to know how
"average" children behave in learning situations that require attention
and self-control. However, teachers sometimes fail to notice the needs
of children who may be more inattentive and passive yet who are quiet
and cooperative, such as those with the predominantly inattentive form
of ADHD.
Professionals Who Make the Diagnosis.
If ADHD is suspected, to whom can the family turn? What kinds of specialists do they need?
Ideally,
the diagnosis should be made by a professional in your area with
training in ADHD or in the diagnosis of mental disorders. Child
psychiatrists and psychologists, developmental/behavioral
pediatricians, or behavioral neurologists are those most often trained
in differential diagnosis. Clinical social workers may also have such
training.
The family can start by talking with the child's
pediatrician or their family doctor. Some pediatricians may do the
assessment themselves, but often they refer the family to an
appropriate mental health specialist they know and trust. In addition,
state and local agencies that serve families and children, as well as
some of the volunteer organizations listed at the end of this document,
can help identify appropriate specialists.
Specialty that Can
Diagnose ADHD: Psychiatrists; Pschologist,Pedatricians or Family
Physicians, Neurologist, and clinical Social Worker
Knowing
the differences in qualifications and services can help the family
choose someone who can best meet their needs. There are several types
of specialists qualified to diagnose and treat ADHD. Child
psychiatrists are doctors who specialize in diagnosing and treating
childhood mental and behavioral disorders. A psychiatrist can provide
therapy and prescribe any needed medications. Child psychologists are
also qualified to diagnose and treat ADHD. They can provide therapy for
the child and help the family develop ways to deal with the disorder.
But psychologists are not medical doctors and must rely on the child's
physician to do medical exams and prescribe medication. Neurologists,
doctors who work with disorders of the brain and nervous system, can
also diagnose ADHD and prescribe medicines. But unlike psychiatrists
and psychologists, neurologists usually do not provide therapy for the
emotional aspects of the disorder.
Within each specialty,
individual doctors and mental health professionals differ in their
experiences with ADHD. So in selecting a specialist, it's important to
find someone with specific training and experience in diagnosing and
treating the disorder.
Whatever the specialist's expertise,
his or her first task is to gather information that will rule out other
possible reasons for the child's behavior. Among possible causes of
ADHD-like behavior are the following:
A sudden change in the child's life—the death of a parent or grandparent; parents' divorce; a parent's job loss
Undetected seizures, such as in petit mal or temporal lobe seizures
A middle ear infection that causes intermittent hearing problems
Medical disorders that may affect brain functioning
Underachievement caused by learning disability
Anxiety or depression.
Ideally,
in ruling out other causes, the specialist checks the child's school
and medical records. There may be a school record of hearing or vision
problems, since most schools automatically screen for these. The
specialist tries to determine whether the home and classroom
environments are unusually stressful or chaotic, and how the child's
parents and teachers deal with the child.
Next the specialist
gathers information on the child's ongoing behavior in order to compare
these behaviors to the symptoms and diagnostic criteria listed in the
DSM-IV-TR. This also involves talking with the child and, if possible,
observing the child in class and other settings.
The child's
teachers, past and present, are asked to rate their observations of the
child's behavior on standardized evaluation forms, known as behavior
rating scales, to compare the child's behavior to that of other
children the same age. While rating scales might seem overly
subjective, teachers often get to know so many children that their
judgment of how a child compares to others is usually a reliable and
valid measure.
The specialist interviews the child's teachers
and parents, and may contact other people who know the child well, such
as coaches or baby-sitters. Parents are asked to describe their child's
behavior in a variety of situations. They may also fill out a rating
scale to indicate how severe and frequent the behaviors seem to be.
In
most cases, the child will be evaluated for social adjustment and
mental health. Tests of intelligence and learning achievement may be
given to see if the child has a learning disability and whether the
disability is in one or more subjects.
In looking at the
results of these various sources of information, the specialist pays
special attention to the child's behavior during situations that are
the most demanding of self-control, as well as noisy or unstructured
situations such as parties, or during tasks that require sustained
attention, like reading, working math problems, or playing a board
game. Behavior during free play or while getting individual attention
is given less importance in the evaluation. In such situations, most
children with ADHD are able to control their behavior and perform
better than in more restrictive situations.
The specialist
then pieces together a profile of the child's behavior. Which ADHD-like
behaviors listed in the most recent DSM does the child show? How often?
In what situations? How long has the child been doing them? How old was
the child when the problem started? Are the behavior problems
relatively chronic or enduring or are they periodic in nature? Are the
behaviors seriously interfering with the child's friendships, school
activities, home life, or participation in community activities? Does
the child have any other related problems? The answers to these
questions help identify whether the child's hyperactivity, impulsivity,
and inattention are significant and long-standing. If so, the child may
be diagnosed with ADHD.
A correct diagnosis often resolves
confusion about the reasons for the child's problems that lets parents
and child move forward in their lives with more accurate information on
what is wrong and what can be done to help. Once the disorder is
diagnosed, the child and family can begin to receive whatever
combination of educational, medical, and emotional help they need. This
may include providing recommendations to school staff, seeking out a
more appropriate classroom setting, selecting the right medication, and
helping parents to manage their child's behavior.
What Causes ADHD?
One
of the first questions a parent will have is "Why? What went wrong?"
"Did I do something to cause this?" There is little compelling evidence
at this time that ADHD can arise purely from social factors or
child-rearing methods. Most substantiated causes appear to fall in the
realm of neurobiology and genetics. This is not to say that
environmental factors may not influence the severity of the disorder,
and especially the degree of impairment and suffering the child may
experience, but that such factors do not seem to give rise to the
condition by themselves.
The parents' focus should be on
looking forward and finding the best possible way to help their child.
Scientists are studying causes in an effort to identify better ways to
treat, and perhaps someday, to prevent ADHD. They are finding more and
more evidence that ADHD does not stem from the home environment, but
from biological causes. Knowing this can remove a huge burden of guilt
from parents who might blame themselves for their child's behavior.
Over
the last few decades, scientists have come up with possible theories
about what causes ADHD. Some of these theories have led to dead ends,
some to exciting new avenues of investigation.
Environmental Agents.
Studies
have shown a possible correlation between the use of cigarettes and
alcohol during pregnancy and risk for ADHD in the offspring of that
pregnancy. As a precaution, it is best during pregnancy to refrain from
both cigarette and alcohol use.
Another environmental agent
that may be associated with a higher risk of ADHD is high levels of
lead in the bodies of young preschool children. Since lead is no longer
allowed in paint and is usually found only in older buildings, exposure
to toxic levels is not as prevalent as it once was. Children who live
in old buildings in which lead still exists in the plumbing or in lead
paint that has been painted over may be at risk.
Brain Injury.
One
early theory was that attention disorders were caused by brain injury.
Some children who have suffered accidents leading to brain injury may
show some signs of behavior similar to that of ADHD, but only a small
percentage of children with ADHD have been found to have suffered a
traumatic brain injury.
Food Additives and Sugar.
It has
been suggested that attention disorders are caused by refined sugar or
food additives, or that symptoms of ADHD are exacerbated by sugar or
food additives. In 1982, the National Institutes of Health held a
scientific consensus conference to discuss this issue. It was found
that diet restrictions helped about 5 percent of children with ADHD,
mostly young children who had food allergies. 3 A more recent study on
the effect of sugar on children, using sugar one day and a sugar
substitute on alternate days, without parents, staff, or children
knowing which substance was being used, showed no significant effects
of the sugar on behavior or learning. 4
In another study,
children whose mothers felt they were sugar-sensitive were given
aspartame as a substitute for sugar. Half the mothers were told their
children were given sugar, half that their children were given
aspartame. The mothers who thought their children had received sugar
rated them as more hyperactive than the other children and were more
critical of their behavior. 5
Genetics.
Attention
disorders often run in families, so there are likely to be genetic
influences. Studies indicate that 25 percent of the close relatives in
the families of ADHD children also have ADHD, whereas the rate is about
5 percent in the general population. 6 Many studies of twins now show
that a strong genetic influence exists in the disorder. 7
Researchers
continue to study the genetic contribution to ADHD and to identify the
genes that cause a person to be susceptible to ADHD. Since its
inception in 1999, the Attention-Deficit Hyperactivity Disorder
Molecular Genetics Network has served as a way for researchers to share
findings regarding possible genetic influences on ADHD. 8
Recent Studies on Causes of ADHD.
Some
knowledge of the structure of the brain is helpful in understanding the
research scientists are doing in searching for a physical basis for
attention deficit hyperactivity disorder. One part of the brain that
scientists have focused on in their search is the frontal lobes of the
cerebrum. The frontal lobes allow us to solve problems, plan ahead,
understand the behavior of others, and restrain our impulses. The two
frontal lobes, the right and the left, communicate with each other
through the corpus callosum, (nerve fibers that connect the right and
left frontal lobes).
The basal ganglia are the interconnected
gray masses deep in the cerebral hemisphere that serve as the
connection between the cerebrum and the cerebellum and, with the
cerebellum, are responsible for motor coordination. The cerebellum is
divided into three parts. The middle part is called the vermis.
All
of these parts of the brain have been studied through the use of
various methods for seeing into or imaging the brain. These methods
include functional magnetic resonance imaging (fMRI) positron emission
tomography (PET), and single photon emission computed tomography
(SPECT). The main or central psychological deficits in those with ADHD
have been linked through these studies. By 2002 the researchers in the
NIMH Child Psychiatry Branch had studied 152 boys and girls with ADHD,
matched with 139 age- and gender-matched controls without ADHD. The
children were scanned at least twice, some as many as four times over a
decade. As a group, the ADHD children showed 3-4 percent smaller brain
volumes in all regions—the frontal lobes, temporal gray matter, caudate
nucleus, and cerebellum.
This study also showed that the ADHD
children who were on medication had a white matter volume that did not
differ from that of controls. Those never-medicated patients had an
abnormally small volume of white matter. The white matter consists of
fibers that establish long-distance connections between brain regions.
It normally thickens as a child grows older and the brain matures. 9
Although
this long-term study used MRI to scan the children's brains, the
researchers stressed that MRI remains a research tool and cannot be
used to diagnose ADHD in any given child. This is true for other
neurological methods of evaluating the brain, such as PET and SPECT.
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