Health & Life® MedixNet® • Health and Medical Publications, November 8th, 2006
ADHD is a group of related disorders that interfere with the ability to control activity level, behavior and attention. Symptoms include an inability to sustain attention and concentration, levels of activity, distractibility, and impulsivity.
Children with this disorder have functional impairment across multiple settings including home, school, and peer relationships. This disorder has also been shown to have long term adverse effects on academic performance, vocational success, social and emotional development. Children experience an inability to sit still and pay attention in class and suffer the negative consequences of such behavior. They have higher injury rates and experience peer rejection, engaging in a broad array of disruptive behaviors; their academic and social problems have complex, long term consequences. As they grow, without treatment, they may experience drug abuse and antisocial behavior. Many untreated children will continue to suffer from this disorder into adulthood.
Children, and also adults, who are inattentive have a hard time keeping their mind on one thing and may become bored with a task after only a few minutes. Focusing conscious, deliberate attention to organizing and completing routine tasks may be difficult. Hyperactive individuals always seem to be in motion. They can not sit still, they may dash around or talk incessantly. Sitting still through a lesson can be an impossible task. They may roam around the room, squirm in their seats, wiggle their feet, touch everything, or noisily tap a pencil. They may also feel intensely restless.
Impulsivity is frequently present; they may seem unable to curb their immediate reactions or think before they act. As a result, they may blurt out answers to questions or inappropriate comments or run into the street without looking. 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 are upset.
The diagnosis of ADHD is made by the use of proven interviewing methods; it is also based on history and observable behaviors in the child's usual settings. A reliable diagnosis should be made including input from parents and teachers. Key elements include a thorough history covering the presenting symptoms, differential diagnosis with other disorders that might be present, medical, developmental, school, psychosocial and family histories. At this time there are no independent tests for this disorder; this is not unique for ADHD, but applies as well to most mental disorders, including schizophrenia and autism.
ADHD is the most commonly diagnosed disorder of childhood, estimated to affect approximately five percent of children, occurring three times more often in boys than in girls. On average, about one child in every classroom in the US needs help for this disorder.
Health care professionals and parents should be aware that schools must perform appropriate evaluations if children are suspected of having a disability that affects their academic progress. If these evaluations are inadequate or inappropriate, parents may request that an independent evaluation be conducted at the school's expense. Some children with ADHD may qualify for special education services within the public schools. Special education teachers, school psychologists and administrators, along with parents, must assess the child's strengths and weaknesses and design an individualized education program.
What Causes ADHD?
We do not know; research shows that it tends to run in families, so there are likely to be genetic influences. Children who have it usually have at least one close relative —including their parents, who also has the disorder.
The number of children identified with ADHD and who obtain treatment has risen over the past ten years. Some of this increased identification and increased treatment seeking is due in part to greater media interest, heightened consumer awareness, and the availability of effective treatments. A similar pattern is now being observed in other countries; whether the frequency of the disorder itself has increased remains unknown.
Research shows that the brains of children with ADHD differ fairly consistently from those of children without the disorder in that several brain regions and structures tend to be smaller. Overall brain size is generally five percent smaller in affected children than children without ADHD; although this average difference is observed consistently, it is not useful when making a correct diagnosis in a particular individual. In addition, there appears to be a link between the ability to pay continued attention and measures that reflect brain activity. Brain areas that control attention appear to be less active, suggesting that a lower level of activity in some parts of the brain may be related to difficulties sustaining attention.
The diagnosis of ADHD in the preschool child is possible, but can be difficult and should be made cautiously by experts well trained in childhood neurobehavioral disorders. Developmental problems, especially language delays, and adjustment problems can sometimes imitate this disorder. Treatment should focus on placement in a structured preschool with parent training and support. Stimulants can reduce oppositional behavior and improve mother-child interactions, but they are usually reserved for severe cases or when a child is unresponsive to environmental or behavioral interventions.
Living With ADHD
Life can be hard for children suffering from this disorder. They are the ones who get in trouble at school, can not finish a game and have difficulties making friends. They may spend agonizing hours each night struggling to keep their mind on their homework, then forget to bring it to school. It is not easy coping with these frustrations day after day for children or their families. Family conflicts can increase; in addition, problems with peers and friendships are often present.
In adolescence, these children are at increased risk for motor vehicle accidents, tobacco use, early pregnancy, and lower educational attainment. When a child receives a diagnosis of ADHD, parents need to think carefully about treatment choices. Also, when they pursue treatment for their children, families face high out-of-pocket expenses because treatment for this disorder and many other mental illnesses is often not covered by insurance policies, particularly under managed care coverage.
School programs that help children with problems often connected to this disorder are not available in many schools; not all children with ADHD qualify for special education services. This situation leads to children who do not receive proper and adequate treatment. To overcome these barriers, parents may want to look for school-based programs that have a team approach involving them, teachers, school psychologists and other mental health specialists.
Treating ADHD
Many parents have exhausted nutritional approaches, such as eliminating sugar from the diet, before they seek medical attention. However, there are no well established nutritional interventions that consistently demonstrate to be useful for assisting the great majority of children with ADHD. A small body of research has suggested that some children may benefit from these interventions, but delaying the implementation of effective treatments while engaged in the search for unknown, generally unproven allergens, is likely to be harmful for many children.
There are various forms of behavioral interventions used for children with ADHD, including psychotherapy, cognitive behavioral therapy, social skills training, support groups, and parent and educator skills training. Medications such as Ritalin and amphetamines are the most widely prescribed treatments for this disorder. Numerous studies have established the safety and efficacy of these and other medications, plus psychosocial treatments for alleviating the symptoms of ADHD.
Antidepressant medications may also be used as a second line of treatments for children who show poor response to stimulants, who have unacceptable side effects, or who have other conditions such as anxiety or mood disorders. Some antidepressants have shown good results in approximately sixty percent of children with ADHD. While the medications could be very beneficial to most children, they alone may not necessarily be the best strategy. The best results are obtained when anxiety and other problems accompany ADHD and when the dosage is carefully adjusted for every situation.
Stimulant drugs, when used with medical supervision, are usually considered quite safe. Although they can be addictive when abused by teenagers and adults, when taken as prescribed for ADHD these medications have not been shown to be addictive nor to lead to substance abuse problems. Although little information exists concerning the long-term effects of stimulants, there is no evidence that careful therapeutic use is harmful. When adverse drug reactions do occur, they are usually related to dosage and are always reversible. Effects associated with moderate doses are decreased appetite and insomnia; they occur early during treatment and may decrease with time.
An increased risk of drug abuse and cigarette smoking is associated with childhood ADHD; children who are treated with stimulants were significantly less likely to abuse drugs and alcohol when they got older. Caution is warranted, nonetheless, as the overall evidence suggests that individuals with this disorder, particularly when it is not treated, are indeed at greater risk for later alcohol or substance abuse. Because some studies have come to conflicting conclusions, more research is needed to understand these phenomena. Regardless, in view of the substantial, well established findings of the harmful effects of inadequate or no treatment for a child with ADHD, parents should not be dissuaded from seeking effective treatments because of misconstrued or exaggerated claims about substance abuse risks.
Other disorders occur in most children clinically treated for ADHD: learning disabilities, language and conduct disorders, oppositional defiant disorder, mood and anxiety disorders. Many children with tic disorders also have ADHD. Impairments in memory and sleep, cognitive processing, sequencing, motor skills, social skills, modulation of emotional response and response to discipline are common.
