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Understanding Attention Deficit Hyperactivity Disorder Back to Course Index

         Attention Deficit Hyperactivity Disorder (ADHD)

 

Introduction

Imagine living in a fast-moving maze, where flashing exit signs and strange mirrors call your attention at every turn.  Sounds and thoughts are constantly flashing. Feeling easily bored, like you have been stuck in that same spot for days, powerless to keep your mind on the tasks you need to complete in order to move on. Distracted by unimportant sights and sounds, your mind drives you from one thought or activity to the next. Perhaps, you are so wrapped up in a collage of thoughts and images that you don’t notice when someone speaks to you.

This is what it is like for those who suffer from Attention Deficit Hyperactivity Disorder, or ADHD. Seemingly caught up in a whirlwind of activity, they may be unable to sit still, plan ahead, finish tasks, or be fully aware of what’s going on around them.  This disorganized, frenzied activity frequently causes negative consequences such as a failure to succeed at work or repeated correction at school.  As a result, the disorder can interfere with the relationships with others in addition to disrupting their daily life, consuming energy, and diminishing self-esteem.

ADHD, once called “hyperkinesias” or “minimal brain dysfunction”, is believed to affect 3-5% of the United States population and is one of the most common mental disorders among children. Two to three times more boys than girls are affected. On average, at least one child in every classroom in the US needs requires attention for the disorder. ADHD beginning in early childhood often continues into adolescence and adulthood, can cause a lifetime of frustration and emotional pain.

 

ADHD is currently considered to be chronic syndrome which no cure is available.  However, in the last decade, scientists have learned much about the course of the disorder and are now able to identify and treat those who have it. A variety of medications, behavior-changing therapies, and educational options are available to help people with ADHD focus their attention, build self-esteem, and function in new ways.

 

This course is based upon work done by the National Institute of Mental Health (NIMH), the Federal agency that supports research nationwide on the brain, mental illnesses, and mental health.

 

This course will explore information on attention deficit disorders, effective diagnosis and the role of research in discovering underlying causes and effective treatments.

 

Diagnosis

 

Identifying and diagnosing ADHD is a vital step towards effective treatment and expanded quality of life. Parents will usually be able to see signs of ADHD by the time the child enters school. If hyperactivity, inattention, and other symptoms are seen, parents should consult a pediatrician, psychologist, psychiatrist, or neurologist to see if the child’s disturbing behaviors could be a disorder.

 

In this era, it is not uncommon for parents to diagnose their children based on negative behavior alone.  Care should be taken to get an appropriate screening and assessment from a qualified professional before labeling a child as ADHD.

Many individuals exhibit signs and symptoms without meeting the requirements of a diagnosed disorder.  There are many factors that can cause symptoms that look like ADHD, including emotional problems, middle ear infections and learning disabilities. It is important to seek the opinion of a qualified physician to rule out biological and physical issues before any testing for ADHD begins.  The physician should check for any history of allergies, nutritional problems, poor vision or hearing, seizures, emotional disorders, or any other health reasons that might cause the patient to behave differently. Another factor is the patient’s environment.  Although environment has been disproved as a cause of ADHD, if the sufferer’s environment is stressful, neglectful or chaotic, which mimics the symptoms of ADHD, this could a measure of adaptation. 

There are several experiences common to persons with ADHD. Researcher Gabor Mat describes these characteristics of the beginning of ADHD with these main hallmarks:

Poor Attention Skills

  • an automatic, unwilled “tuning out,” a frustrating non-presence of mind (causes distractibility, short attention spans, and chaos)
  • lack of a mental model of how order comes about (may be able to visualize a tidy and organized room, but missing the mind-set to create it)
  • frequent fine motor control coordination difficulties (though some may have well developed mechanical skills)
  • inability to form three-dimensional mental representations or spatial relationships
  • inability to track a conversation or verbal directions
  • inconsistent distractibility (may be able to attend to activities of high interest and motivation)
  • hyper-focusing (compulsive, hyper-concentrated attention that excludes awareness of the environment)

Impulsiveness in Word and Deed

  • poorly-controlled emotional reactivity
  • difficulty restraining from interrupting others
  • torturous to wait for a turn
  • often act or speak impulsively, with no forethought

Hyperactivity

  • trouble keeping physically still (toes or fingers tapping, thighs pumping, nails being chewed, teeth biting the inside of the mouth)
  • excessive talking
  • the mind as a perpetual motion machine
  • intense aversion to boredom, and a need for constant activity, distraction, or attention
  • unremitting lack of internal stillness
  • inertia or procrastination for long periods, with restlessness, and bursts of adrenaline and activity when the threat of failure or the promise of reward is imminent
  • hyperactivity may occasionally be absent altogether, especially in girls

Overachievement and social disability

  • high achievers despite ADD (with wide variations)
  • workaholism and professional success (which can mask serious problems in other areas)
  • difficulty recognizing interpersonal boundaries
  • an almost insatiable desire for physical and emotional contact from adults
  • naive and unrequited openness in approaches to other children (often leading to rebuffs)
  • impaired ability to read social cues, often leading to ostracism by peers

Most attention deficit hyperactivity disorder “testing” consists of checklists of behavior observed at home and in the classroom and filled out by parents and teachers, respectively. The Connors is the most common. The Conners Continuous Performance Test is an attention test that is widely used in ADHD research and clinical assessments for respondents aged 6 or older. It is important to note that this and all other tests, rating scales, checklists, surveys and or questionnaires, although commonly used to diagnose ADHD, have yet to be validated and endorsed.

 

Common rating scales used to help differentiate between anxiety and ADHD, among other disorders, include the Behavioral Assessment Scale for Children (BASC) and the Child Behavior Checklist (CBCL). Both measures include a parent and teacher report which can be compared to one another, as well as a self report. However, caution is given with regard to administration of the CBCL for differential diagnostic purposes since it does not clearly define behaviors between disorders, but rather the scale clusters together similar behaviors which can be seen in a number of disorders (Reynolds & Kamphaus, 1990). For example, the scale does not separate behaviors related to anxiety and those related to depression; it also does not provide a distinct scale for hyperactivity. In addition, caution was raised regarding the insensitivity of the CBCL scale for diagnosing ADHD-Inattentive Type since such children may appear within normal limits due to items not reflective of attention difficulties which are included in the attentional dimension, such as cannot sit still, clumsy, and acts young (Dumas & Guevremont, 1994). On the other hand, the BASC provides a more accurate scale for differentiating between anxiety and ADHD because it includes more distinct behaviors related to a specific disorder, as well as distinguishes among the disorders so that there is a separate scale for anxiety, a scale for attention problems, and a scale for hyperactivity (scales for other disorders are also included). Another benefit of the BASC is the inclusion of a lie scale to detect invalid responses.

 

Specific behavior rating scales which are used to gain additional insight regarding each disorder include the Attention Deficit Disorders Evaluation Scale (ADDES) and the Reynolds manifest Anxiety Scale (RMAS). Such scales are generally administered following the more comprehensive behavioral scales, such as the BASC, when significant areas of concern have been detected. With regard to ADHD, the ADDES presents a list of behaviors linked to the DSM-IV criteria and provides both a Home Version and a School Version to determine if the child meets criteria and if so, to pinpoint for which subtype. A number of other scales such as the ACTers, the CAAS-H, and the Conners are also used to aid in diagnosing ADHD. However, the ADDES was rated as one of the most favorable tools because it uses specific descriptors and observable behaviors; whereas, other scales tend to be vague, require the rater to draw conclusions, and/or include items unrelated to ADHD (Sharp, 1993). With regard to anxiety disorders, the RMAS provides an overall score which is derived from three subscales: Physiological, Worry/Oversensitivity, and Social Concerns/Concentration. Thus, critical areas can be determined from the subscales with regard to the nature of the anxiety. A lie scale is incorporated to indicate the validity of responses.

 

 

Occasionally a more traditional battery of ability and personality tests can be suggested.

 

The symptoms of the said disorder have been distinguished by the Diagnostic and Statistical Manual of Mental Disorder, referred to as the DSM. The most common behaviors of someone suffering from ADHD are inattention, hyperactivity, and impulsivity. During the assessment process it is necessary to compare the client’s behavior to the Diagnostic and Statistical Manual of Mental Disorder (DSM), to the past and present behavior, and to the people similar to the patient’s age. These behaviors must be displayed for a period of time before a diagnosis of ADHD can be given. According to the DSM, “signs of inattention include: becoming easily distracted by irrelevant sights and sounds; failing to pay attention to details and making careless mistakes; rarely following instructions carefully and completely; and losing or forgetting things like toys, or pencils, books, and tools needed for a task. Some signs of hyperactivity and impulsivity are: feeling restless, often fidgeting with hands or feet, or squirming; 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 for a turn.” 

 

With this description, almost everyone will exhibit symptoms of ADHD at some point in their lives.  We cannot be dependent on the signs and symptoms alone. That is why DSM contains very specific guidelines for the diagnosis. These behaviors must be seen for at least six months and if possible detected during early life. Children with ADHD must be more rigid in inattention, hyperactivity, and impulsivity than other children their age. Most of all, the behaviors must be a hindrance in at least two different parts of a person’s life such as school or work and social settings. A person who shows symptoms of ADHD at home but acts differently at work cannot be diagnosed with ADHD. The same way with a child who does poorly in school but excels in other activities.

 

Co-morbidity is also frequently a factor in addressing a diagnosis of ADHD.  The following chart By Leigh Coriale Design & Illustration from a chart by Drs. Biederman and Faraone shows percentages of attention deficit hyperactivity disorder cases in which other disorders were also present.



A therapist or social worker can:

  • Evaluate a child at home and at school to determine how ADHD is affecting the child’s ability to perform assignments and participate at home.

 

  • Recommend and/or facilitate a program that addresses the physical, behavioral, and emotional effects of ADHD and identifies goals to help the child succeed.

 

  • Use the intervention of sensory integration to modify the environment to decrease noise and distractions caused by visual, auditory, and tactile stimulation.

 

The Causes of ADHD

 

Identifying, detecting and diagnosing ADHD is a challenging task. Tracing its causes has proven to be even more elusive.  It is virtually impossible to detect the exact cause of ADHD. The theories for a set of causes continue to develop and frequently get dispelled. Nevertheless, scientists continue to prioritize the study of the possible causes so they can find better ways of treating and even preventing ADHD. Evidence suggests that ADHD comes from biological causes rather than from the home environment. We will explore many of the purported theories below.

 

 

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.

 

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

 

Those concerned about diet and ADHD hypothesize a toxic or allergic effect by some foods. The most commonly targeted foods are milk, wheat, dyes, preservatives and sugars.  The National Institute of Mental Health’s summary stated that the data on nutrition and attention deficit hyperactivity disorder did indicate a limited positive association between defined [Feingold-type] diets and a decrease in hyperactivity.  That is, there is evidence that, for a small group of children, elimination of some food colorings and preservatives may be helpful, though seldom curative. It was found that diet restrictions helped about 5 percent of children with ADHD, mostly young children who had food allergies.  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.

 

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.  Many studies of twins show that a strong genetic influence exists in the disorder.

 

Approximately a third of every father who is an ADHD sufferer bears a child with ADHD. 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.

 

Thyroid Dysfunction

 


Scientists have also theorized that thyroid dysfunction may be related to ADHD. This is because the thyroid gland helps diversified cells to get their supply of oxygen for the brain and body metabolism. When one has a thyroid dysfunction, brain activity will be impaired causing inability to pay attention and less control in behavior. Recent studies show that up to 70% of children who are suffering from a thyroid dysfunction have shown symptoms of ADHD. Yet we still cannot be certain for this maybe just a coincidence.

 

 

 

 

Recent Studies on Causes of ADHD

 

 

More recent studies have been done through the use of various methods for seeing into or imaging the brain. These methods include functional magnetic resonance imaging (MRI), 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.

 

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.

 

 

 

Treatment

 

Life can be really arduous for individuals with ADHD. Children with this disorder typically have difficulty making and maintaining friendships.  Sufferers can spend tormenting hours every day completing work projects or schoolwork. Unfortunately, there are only a few schools that specialize in treating ADHD. it is best for the parents to place the child in a school where the environment and the relationship with the child’s teachers are conducive for the ADHD child to excel, although that is frequently difficult to find. The class should consist of a small number of students so that the child could be given more attention. The teacher should be aware of the condition of the child in order for him/her to adjust and understand the child’s behavior and learning limitations. The teacher should also be consistent about the expectations and proactive discipline he/she imposes to the child. He/she can also use interesting or exciting learning materials to get the child’s attention. Lastly, parents should work closely with the child’s teachers to be able to monitor the child’s development.

 

Choice of treatment for ADHD is frequently made on the basis of cost, availability, effectiveness and risk.  Getting the proper treatment will help the ADHD sufferer and his/her family better function and thrive. There are a wide variety of treatments utilized but medication with cognitive behavioral therapy is considered by the National Institute of Mental Health as the best treatment for ADHD.

 

After detecting the symptoms and diagnosing the patient, the next step is treating the mentioned disorder. There are a lot of medicines, which can treat the symptoms of ADHD. Ritalin, Dexedrine, and Cylert are the three medications in the class of drugs known as stimulants. These seem to be the most effective because it improves the patient’s ability to focus, work, and learn. They can also help improve physical coordination. The use of stimulant drugs must be used under medical supervision. These can be highly addictive to teenagers and adults when misused. Fortunately, it is not addictive to children. In fact, it helps the child control his/her behavior.

The stimulants are used in slightly different ways. It depends on the need of the child. The long-term dose is suitable for school days while short-term dose is used for church or other short activities. Not all stimulant drugs work for all persons. Adjustments and switching between drugs will help find out which really suits the patient. Other types of medications may be tried if stimulants do not work. Antidepressants, antihistamines, or even clonidine, a drug used to treat hypertension may be helpful in treating ADHD. The doctor should work closely with the patient to be able to find the most appropriate medication.

Stimulant drugs have been proved to be very helpful to the patient but they also have some side effects. Some of these side effects are weight loss, loss of appetite, temporary stunting of growth for children, sleeping problems, and possibly worsening the symptoms of Tourette’s syndrome. Some doctors feel that the benefits should be greater than the side effects before prescribing the drug. Other doctors say that by discreetly monitoring the child the child and reducing the dosage if there are any side effects, the medication will be very beneficial.

External factors such as adjustments or puberty worsen the symptoms of ADHD. It puts the child under stress. The same could be said for adults worsening their symptoms during times of stress. 

 

Another reason for worsening ADHD is non-compliance of medication, forgetting to take the drug or proper dosage.

Lastly, communication between the therapist, doctors and if the client is a child, teachers are very important. Some professionals advise that the patient be taken off a medication for a period of time to verify the patient still needs it. Unfortunately, when immediate improvement is seen because of the mentioned drugs, the patients often rely solely on the prescription. Numerous experts recommend that medication should be combined with other forms of treatment and support such as counseling. With this combination, lasting improvement will occur.


Medication can diminish some of the behavioral problems but usually there are conditions that medication cannot address.  The disorder has extensive emotional impacts. According to the National Institute of Mental Health, “Several intervention approaches are available and different therapists tend to prefer one approach or another. Knowing the various types of interventions will make it easier to choose a therapist that will suit the needs of the patient. Psychotherapy helps people with ADHD to like and accept themselves despite their disorder. In this approach, the therapist talks to the patient. The therapist helps the patient understand how he/she can change. Yet people with ADHD usually want to gain control of the symptomatic behaviors more directly. Cognitive behavioral therapy helps people work on immediate issues. It supports them in ways such as practical assistance and encouragement with the use of rewards or praises. This helps the patient to think first before doing anything and to control one’s feelings.


Education, caution, in-depth analysis and close supervision should be practiced in selecting the treatments the ADHD sufferer would undergo. There may be treatments that sound promising but they may not yet have a scientific evidence of effectiveness. There are also treatments that are not supported by evidence. These treatments risk the health of the patient as well as the efforts of the family. According to the National Institute of Mental Health, “some of the treatments that have not helped the majority of ADHD patients are: biofeedback, restricted diets, allergy treatments, medicines to correct problems in the inner ear, megavitamins, chiropractic adjustment and bone re-alignment, treatment for yeast infection, eye training, and special colored glasses”.

 

There are many treatments for ADHD. As mentioned earlier, the most acceptable and effective method is a combination of medication and cognitive behavioral therapy. However, continuous research and studies for alternative methods are still ongoing. Hopefully, in the near future, there will be a perfect formula to cure or at least more effectively help ADHD sufferers so they may live like other normal human beings.

 

Behavioral modification, direct negative or positive reinforcement of desired behavioral changes, can be utilized by the professional and taught to the family. For example, one intervention might be that a teacher rewards a child who has ADHD for taking small steps toward learning to raise a hand to be called on before talking in class, even if the child still blurts out a comment. The theory is that rewarding the struggle toward change encourages the full new behavior.

 

According to the American Academy of Pediatrics, there are three basic principles to any behavior therapy approach:

 

        *Set specific goals. Set clear goals for your child such as staying focused on homework for a certain time or sharing toys with friends.

 

        *Provide rewards and consequences. Give your child a specified reward (positive reinforcement) when he or she shows the desired behavior. Give your child a consequence (unwanted result or punishment) when he or she fails to meet a goal.

 

       * Keep using the rewards and consequences. Using the rewards and consequences consistently for a long time will shape your child’s behavior in a positive way.

 

Note that individuals with ADD / ADHD are notoriously variable in their symptoms. One day, the person may behave acceptably in one realm, and, the next day, may fall back into old, unacceptable patterns. This makes behavioral intervention difficult because it seems as if the training is not working. However, over time, reinforcement does improve behavior; the person with ADHD may simply have more off-days than do individuals who do not have ADD / ADHD.

 

Experts believe that problems in motor sequencing, rhythm, and timing are related to problems with behavioral self-control, such as paying attention, goal-setting, and impulse-control. In Interactive Metronome brain training, the person with ADHD learns to improve the rhythm and timing of motor responses through the use of a musical metronome and a computer-based training program. The computer produces a metronome beat heard through headphones. As the participant listens, he or she performs various hand and foot exercises to a rhythmic beat. Auditory tones provide immediate feedback, letting the participant know if the response was on time, early, or late. The difference between the participant’s response and the actual beat is measured in milliseconds, and the person receives a score. The IM training is physically interactive, so participants stay engaged and challenged. By keeping the beat, the person trains the brain to plan, sequence, and process information more effectively. This improved rhythm and timing appears to improve the symptoms of ADD / ADHD.  This treatment is usual done through an occupational therapist, speech therapist, or physical therapist for.

Adults in treatment have different needs.  They frequently need help in the areas of:

 

  • Time management (particularly procrastination and prioritizing)
  • Organization (de-cluttering)
  • Finances (especially the tendency to overspend)
  • Anger management
  • Releasing addictions (to substances, to sex, and to the Internet and TV)
  • Improving social skills and relationships
  • Work (how to use strengths, release the focus on weaknesses)
  • Expressing in a more organized manner (in writing and in speaking)

From time to time, practically every person can be a bit absent-minded, restless, fidgety, or impulsive. With ADHD these behaviors occur far more often and therefore are the rule and not the exception.  With continued research, accurate diagnosis and effective treatment the lives of ADHD sufferers can be greatly improved.

 

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