ADHD In A Nutshell
Attention Deficit/Hyperactivity Disorder (ADHD) has had many alternative labels, including attention deficit disorder (ADD), minimal brain dysfunction, hyperkinetic syndrome, and developmental hyperactivity. This syndrome appears in early childhood and may have a lifelong course. Research findings show a primary deficit in the ability to inhibit responding, to delay responding, or to tolerate externally imposed delays in behavior once a task is begun.
Students with ADHD do not see the value in working hard at school, and academic achievement is often below the student’s measured Intelligence. Sustained mental effort tends to be inherently punishing. Conflict with parents and teachers is common. Compared to most individuals of the same age there is more variability in the ADHD person’s behavior across situations and time. Classrooms and other group settings requiring sustained attention to task produce much more symptomatic behavior than one-to-one situations, novel settings, or situations in which the person receives frequent feedback or reinforcement.
As of 1994 the American Psychiatric Association recognized three types of ADHD: combined type, predominantly inattentive type, and predominantly hyperactive-impulsive type.
There are nine criteria for diagnosing the inattentive type. Six or more of these must have been often or very often true for at least six months in order to make a diagnosis of ADHD. These criteria are that the person fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities; has difficulty sustaining attention in tasks or play activities; does not seem to listen when spoken to directly; does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace; often has difficulty organizing tasks and activities; avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort; loses things necessary for tasks or activities, such as school assignments, pencils, books, or tools; is easily distracted by extraneous stimuli; and is forgetful in daily activities.
There are also nine criteria for the hyperactive-impulsive type. As with inattention, six or more of these must have been true often or very often for at least six months in order to make a diagnosis of ADHD. Six of these relate to hyperactivity: the person fidgets with hands or feet or squirms in seat; leaves seat in classroom or in other situations in which remaining seated is expected; runs about or climbs excessively in situations in which it is inappropriate or has subjective feelings of restlessness; has difficulty playing or engaging in leisure activities quietly; is on the go or acts as if driven by a motor; and talks excessively. The final three criteria in this set cover impulsivity: the person blurts out answers before questions have been completed, has difficulty waiting for his or her turn, and interrupts or intrudes on others.
The diagnosis of ADHD also requires that some of the symptoms appeared before age seven, that the symptoms impair functioning in at least two settings (e.g., school and home), that there must be impairment in social, academic, or occupational functioning that is clinically significant, and that the symptoms are not caused by another mental or physical disorder.
For children and adolescents at least six criteria within both sets of nine must be met to make the diagnosis of ADHD, combined. Experts on ADHD have not reached consensus on making the diagnosis in adults; however, evidence exists that suggests when an adult meets at least four of the criteria in a given set, making the ADHD diagnosis is appropriate. Gathering retrospective data on the adult’s behavior in childhood can be helpful in clarifying whether the diagnosis is appropriate.
Regardless of the age of the patient, personal history and current symptoms form the basis for making the diagnosis. Particularly for children and adolescents many questionnaires are available to help in determining whether ADHD is present. Common clinical practice calls for using multiple informants to fill out a variety of such measures. No medical laboratory tests are useful in diagnosing ADHD. Psychological tests are also of little value in making the diagnosis. Many computerized tests for measuring sustained attention to task are available, but most of these do not appear to be helpful in discriminating ADHD from other disorders.
Inattention, fidgeting, overactivity, and impulsivity are common in young children. They are also often present in children with lower intelligence who are placed in academic settings that do not match their ability or in intellectually gifted children who are understimulated. In addition the symptoms of inattention, hyperactivity, and impulsivity can appear in a number of other disorders. Although there is some overlap in some of the symptoms that define ADHD and these other disorders, the diagnostic criteria in use as of the mid-1990s are sufficiently clear to discriminate among these disorders.
Comorbidity refers to the phenomenon in which persons with one disorder have a greater-than-chance probability of having one or more other disorders. ADHD has a number of comorbidities. Up to 85% of ADHD children have at least one other diagnosable behavioral, emotional, or learning disability. They also have more minor physical anomalies, wet the bed more frequently, have more physical accidents, manifest greater sleep problems, and have more aches and pains than other children. They are most at risk for oppositional, defiant, and antisocial behavior problems. ADHD appears to raise the risk of substance abuse, job failure, marital discord, and divorce, but longitudinal studies suggest that it is comorbid oppositional, defiant, and aggressive behavior that places the child at high risk for serious problems in later life rather than the ADHD symptoms themselves.
ADHD is the most frequent referral problem to clinics and professionals that serve children and adolescents with behavioral or psychological problems in the United States. It occurs across cultures and socioeconomic levels. This disorder is diagnosed substantially more often in boys than in girls. There appears to be a significant hereditary contribution to the appearance of the disorder. If a child’s parent had ADHD, the child has more than a 50% chance of having the disorder. The basic problem does not seem to be a problem in attention; rather, it is an impairment in cortical regulation of response inhibition and impulse control.
The effective treatment of ADHD children is multifaceted. Drugs are typically one part of the treatment regimen. From 70% to 90% of ADHD children benefit from one of the psychostimulants: methylphenidate, amphetamine, and pemoline. Available evidence indicates that adolescents and adults also benefit from stimulant medication.
Although individual play therapy or psychotherapy has no demonstrated helpfulness in treating ADHD, other psychological interventions are recommended. Parent training is standard practice (see Parent Training Programs). This training covers many points. The child’s difficulties are not a result of faulty parenting. The symptoms will make parenting difficult, demanding, and complex. Parenting that includes writing and managing parent-child contingency contracts will be helpful. These contracts identify what the parents want the child to do and not to do as well as the specific consequences the child will receive for the desired behaviors. Catching the child being good, delivering rewards immediately and frequently after good behavior, and using mild punishments such as time out and response cost are some of the keys to success.
Psychological consultation with the child’s teacher is also important. The purpose of this consultation is to identify what educational services will benefit the student and to establish a contingency management program at school similar to the one used by the parents at home. The home and school programs are often linked by the teacher’s sending home a daily report on the child’s behavior and academic performance. This report allows the parents to reinforce good behavior that occurs at school. Academic tutoring by adults or peers is often helpful.
Direct therapeutic work by mental health professionals includes social skills training; coaching in goal setting, in self-monitoring of progress toward goals, in making plans to reach one’s goals, and in using timers, checklists, organizers, and other tools for self-management; and family therapy.
In dealing with ADHD in adolescents, all of the procedures outlined may be used, but there is value in emphasizing the self-control strategies, including cognitive-behavior therapy. When the patient is an adult, self-regulation approaches also are relevant. Marital therapy by a professional experienced in treating ADHD may be helpful.
Various experts have proposed the value of a number of other treatments without providing adequate scientific evidence of their effectiveness. Among these treatments that do not have empirical validity are eliminating food additives or sugar from the diet, the use of megavitamins and mineral supplements, taking anti-motion sickness medication, antifungal medication combined with a low-sugar diet, biofeedback targeting brain waves, sensory integration training, the chiropractic neural organization technique (applied kinesiology), and optometric training.