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.
Prevelance and Course of AD/HD
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 percent 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.
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.
History of AD/HD
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. Criteria for the
three primary subtypes are summarized as follows:
AD/HD predominately inattentive type: (AD/HD-I)
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)
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)
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. 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.
Executive Function Deficits
Recently, deficits in executive function have emerged as
key factors impacting academic and career success. Simply stated, executive function refers to the “variety of functions
within the brain that activate, organize, integrate and manager other functions.” Critical concerns include deficits
in working memory and the ability to plan for the future.
Diagnostic Criteria
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.
Adults with AD/HD
Many 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.” 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. 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.”
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:
Research from the landmark NIMH Multimodal Treatment Study of AD/HD is very encouraging. 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.
Medication
Psychostimulants are the most widely used class of medication for the management of AD/HD related symptoms. Approximately 70 to 80 percent
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 hostility. 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
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 Interventions
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.
Adult Interventions
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. Furthermore, up to 67 percent of children will continue to experience symptoms of AD/HD in adulthood. 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. 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. However, severe problems persist
in about ten percent of adults.
**"ChADD Fact Sheet 1: The Disorder Named AD/HD,"
Publication of ChADD, the
national organization for Children and Adults with Attention Deficit Disorder:
http://www.chadd.org/webpage.cfm?cat_id=24
This link also includes a printer-friendly version of
this article.
