Attention-deficit disorder (ADD or ADHD, attention deficit hyperactivity disorder) is a common neurobehavioral disorder in children, particularly in the elementary/high school age. If untreated, it can cause a lot of social disturbance and can get the affected adolescents into trouble with the law.
The 4th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) states that ADHD is characterized by inattention, easy distractibility, difficulties sustaining attention and poor impulse control. There is also a decrease in the capacity for self-inhibition. Motor restlessness and motor overactivity are hallmark symptoms as well.
Symptoms of ADHD
As many of the symptoms are rather vague, the DMS-IV defines ADHD in the following way. Below are two lists of symptoms. The first list consists of inattention symptoms, the list underneath that consists of hyperactivity/impulsivity symptoms. The diagnosis is positive for ADHD, if the requirements outlined below are met.
Of the following list of 9 inattention symptoms 6 (or more) have to be present for more than 6 months to make a diagnosis of ADHD.
- Failing to pay close attention to detail or making careless mistakes with school work, work or other activities (attention deficit)
- Having difficulties with sustained attention during tasks or play activities
- Not following through on instructions or failing to finish school work, chores or work duties
- Does not seem to listen when spoken to directly
- Having difficulties organizing tasks or activities
- Disliking, avoiding and showing reluctance in doing mental effort tasks (completing school work or chores at home)
- Often looses things required to complete such tasks (pencils, books, toys, tools, school assignments etc.)
- Easily distractible by extraneous stimuli (background noises, passing cars etc.)
- Being forgetful in daily activities (forgetfulness)
Alternatively, if 6 (or more) symptoms of the following hyperactivity/impulsivity list of 9 symptoms are present, and these symptoms are present for 6 months or more, this would also qualify for the diagnosis of ADHD.
- Fidgeting with hands or feet and/ or squirming in seat
- Often leaves the seat in situations where the person is expected to be seated (classroom, church etc.)
- Running about or climbing excessively in situations where this is inappropriate (adolescents may feel an internal restlessness)
- Having difficulties playing or doing leisure activities quietly
- Often being “on the go” or behaving as “driven by a motor”
- Talking excessively (this is a measure for impulsivity)
- Having difficulties awaiting one’s turn
- Blurting out answers before questions have been completed
- Interrupting or intruding on others (butting into conversations or games)
In addition to the requirement regarding either one of these lists of symptoms, there is a requirement that the condition would have to be evident before the age of 7 years. Also, some of the impairment from the symptoms must be present in 2 or more settings (school, at home etc.). There must be evidence of impaired functioning in the setting of school, socially or at work. Finally, there is a requirement that the ADHD symptoms cannot just be present at the time of another psychiatric disorder (schizophrenia, developmental disorder, mood disorder, personality disorder, anxiety disorder or dissociative disorder). If this is the case, the other psychiatric diagnosis would be the primary diagnosis.
Diagnosis of ADHD
The diagnosis is made by using the diagnostic criteria involving the symptoms outlined above and is best done by a pediatrician or child psychiatrist with experience in treating ADHD patients. The tools used in the process of making the diagnosis are standardized behavior rating scales, clinical interviews, a neuropsychological evaluation and a physical examination. It may be best done in a clinic that specializes in ADHD diagnosis and treatment and where a team of experts in the field can evaluate the patient. Caution is required in that the patient may appear more normal in the unfamiliar surrounding of the doctor’s office or clinic setting and the symptoms may not be that obvious as they would be when in the familiar school setting or at home.
Treatment of ADHD
When other mental illnesses have been ruled out and the diagnosis of ADHD has been confirmed, treatment can begin. It consists of a combination of behavior management training, psychosocial intervention and medication. It would be a mistake to rely on medication alone as this would fail or end up in overdosing the patient in an attempt to maximize the effect. Much has been learnt from studying ADHD in detail over the years. What has been learnt is that positive reinforcements when desired behaviors are observed have a very beneficial effect. This is combined with negative enforcements for times when a goal has not been achieved. Courses for patients and care givers are usually given that would last in the order of 8 to 12 weeks. There are non profit organizations that help with information as well:
- “Children and Adults with Attention-Deficit/Hyperactivity Disorder” (CHADD, thanks to www.chadd.org for this link) is a non-profit organization with many local support groups.
- Attention Deficit Disorder Association (ADDA, thanks to www.add.org for this link) is also a non-profit organization providing a lot of links.
Psychological therapeutic intervention concentrates on improving learning, behavior, social skills, family functioning as well as self esteem and peer interaction. Medications that have been found to be beneficial over the past 60 years are the stimulants. Two main classes of medication are Ritalin (and similar derivatives of methylphenidate such as Concerta, Metadate CD, Methylin) and amphetamines and derivatives (Dexedrine, Adderall). These medications are considered to be the first-line medications (true and tested for a long time). Second-line medications are antidepressant medications such as tricyclics (Imipramine, Desipramine) and bupropion (Wellbutrin).
Prognosis and comments regarding ADHD
There is a popular misconception that the stimulants listed above would be addictive. Long-term studies have shown that this is not so as there is no development of tolerance (meaning that more and more drug would be required to achieve the same effect). There is also no withdrawal or craving upon termination of the medication. Studies also showed that patients who have been on stimulants do not get into drug addiction behavior later in life. To the contrary, it was found that adolescents who are treated a supervised stimulant treatment protocol in combination with the other treatments described above will have much less incidences of illicit drug use and alcohol abuse than patients who refuse treatment. Furthermore, patients on stimulants do not engage in aggressive behaviors (assaults etc.) and do not experience more seizures. All these are popular misconceptions and unfortunately are used by certain interest groups that do not understand the seriousness on this disorder and the seriousness of NOT treating it adequately. It needs to be said that about 80% of ADHD children will continue to have the condition even in adulthood. The earlier the above mentioned clinical and educational measures are taken and the children are put on appropriate medication for ADHD, the faster their lives will normalize. Studies have shown that it is the children/adolescents that have slipped through screening programs and whose ADHD was missed that will get into trouble with the law (more frequently involved in accidents, showing risky sexual behaviors, engaging in criminal behaviors etc.). Many inmates in prisons have undiagnosed and untreated ADHD. Society needs to rethink this scenario based on the reality of the findings mentioned above and realize that it is much better for everyone involved to diagnose ADHD early and to treat ADHD appropriately and for long enough.
1. Behrman: Nelson Textbook of Pediatrics, 17th ed., Copyright © 2004 Saunders, An Imprint of Elsevier
2. The Merck Manual , 18th edition, Merck Research Laboratories, © 2006. Chapter 299: Learning and developmental disorders.
3. Here is a link to the DMS-IV classification guidelines: http://en.wikipedia.org/wiki/DSM-IV_Codes