ADHD
stands for Attention
Deficit-Hyperactivity Disorder and is a
neurobiological disorder which is
characterized by age inappropriate
impulsiveness, hyperactivity and
difficulty sustaining attention.
Generally the symptoms must be present
for at least six months and appear
before the age of seven. ADHD was first
formally diagnosed in the 1940's; at
that time, children with these problems
were labeled as having Minimal Brain
Damage. This diagnostic name was later
changed to Minimal Brain Dysfunction and
referred to children who had problems
functioning in school due to a short
attention span, hyperactivity and
emotional problems. In the 1980's, the
name was changed again to Attention
Deficit Disorder (ADD) and this is the
label used most often today by the
general public.
People
have various talents, strengths and
weakness. These are what make us
different, special and unique. If I am
not a very good singer or artist, it is
not usually a problem. And I can assure
you that if I had to sing for my supper,
I would be broke. In fact, recently my
son was slow in getting to his homework
and did not respond to a suggestion to
get started. So, I started singing and
he exited quickly to start on his
homework. My un-talent worked for me.
It's
not critical that I sing to communicate
with others or earn a living, but being
able to pay attention is essential. In
order to accomplish almost anything you
must be able to focus on what is
important and relevant and to ignore and
not be distracted by the irrelevant.
Attention is the foundation for
learning, organizing, planning and
finishing the work we need to do. It is
critical to success in so many aspects
of life, and yet most people take it for
granted. It is interesting to realize
that mental abilities fall along a
scale. Some super computer programmers
can remember 200 items and some young
children with ADHD have a problem
remembering more than a one-step
command.
In
order to understand ADHD it is best to
conceive of it as a dimensional
disorder. From time to time, everybody
loses things, forgets to give a message,
becomes disorganized, buys something on
impulse, is too demanding, gets
impatient, gets upset or angry,
daydreams, makes a "stupid" mistake or
does not listen. Too many of these types
of problems lead to poor grades,
reprimands, social conflicts, financial
losses, divorces, getting fired and low
self-esteem. It is the frequency and
severity of self-control and attentional
problems that leads to the individual
wondering, "Why me? Why do I always seem
to have these problems?"
It is
easy to see or recognize if people have
severe deficits in hearing or vision,
which most everyone will acknowledge can
be significant impairments. The reason
why people wonder if ADHD is real is
that it is not so easy to "see" deficits
in attention or to realize that a
person's mental "hardware" (i.e., their
brain) does not function as well as most
other peoples. Often, skeptics tend to
attribute ADHD solely to a person's
mental attitude, or "software." Based on
the latest NIMH research, it would
appear that the symptoms of ADHD have a
neurobiological basis which lead to
feelings of frustration, low
self-esteem, negative feelings and low
motivation. In other words, it is much
harder for people with ADHD to pay
attention and control themselves, which
frequently leads to negative feelings
and a negative attitude towards
themselves. The problems of the brain
("hardware") and mental attitude
("software") interact.
This
brain dysfunction can also lead to
extreme denial and blaming of others for
ones difficulties "the teacher is
mean," " the work is too hard" or "I
don't understand, leave me alone." I had
a child with ADHD draw me a picture of
himself, and what he drew was a small
boy in the middle of what looked like a
tornado -- a blooming buzzing confusion!
Imagine yourself trying to think,
concentrate, learn and attend in the
middle of a tornado!
2. How many people have ADHD?
Research by the National Institute of
Mental Health (NIMH) has found that
about 5% of children have ADHD, a total
of 3.5 million. In addition, between 2-5
million adults have been found in
research to also have ADHD. It is the
most common neurobiological disorder in
children.
3. How can parents tell if their child
has ADHD?
ADHD
symptoms in children include:
excessive fidgetiness
frequent
out of seat behavior
frequent
problems following instructions
difficulty finishing tasks
difficulty listening well
acting
without thinking
often
interrupting conversations
difficulty concentrating
difficulty waiting their turn
excessive talkativeness
difficulty keeping track of homework,
papers or books
If the
child has these problems and they
persist, an evaluation by a health
professional is recommended.
4. What causes ADHD? Is it "real?"
The
causes of ADHD are not fully known.
Research indicates that there may be
multiple causes. Recent studies
conducted at NIMH have made a landmark
discovery -- the right cerebral
hemispheres of males with ADHD are about
5% smaller than a matched control group
without ADHD. This physiological
difference may account for at least some
of the symptoms of ADHD such as poor
judgment and impulse control. This
research also found evidence of genetic
causes of ADHD which predispose a fetus
to be more vulnerable to prenatal viral
infections. Some researchers believe
that ADHD is due to an imbalance in
brain biochemistry which involves a
lower level of the neurotransmitter,
dopamine. Studies based on brain imaging
techniques have found that the brains of
individuals with ADHD are less active in
the areas which control attention,
handwriting, motor control and
inhibition. Twin studies have found that
diet or poor parenting do not account
for problems of inattention. These twin
studies found that a genetic factor
appeared to account for about 50% of
attention problems. To sum it up, ADHD
may be due to:
the
structure of the brain
chemical imbalances in the brain
prenatal diseases
exposure to toxic substances in the womb
or in infancy or early childhood
genetic factors
5. Are there different types of ADHD?
DSM-IV
defines four sub-types of ADHD:
Predominantly Hyperactive/Impulsive
Predominantly Inattentive
Combined Type
Not
otherwise specified
I have
found clinically that some children are
only hyperactive and not impulsive.
Some
children primarily have problems
sustaining attention and "space out"
without any awareness that their minds
are focusing elsewhere. These children
have input processing
problems either visual, auditory or
both -- and often have difficulty
learning. This group tends to be under-diagnosed, because these do not cause
problems which disrupt a class.
The
Hyperactive/Impulsive type of ADHD child
constantly seeks new stimulation, hates
to wait and acts without thinking about
the consequences. These children often
know the social rules and how they
should behave if questioned, but they
don't internalize these rules and act on
what they know. The children who are the
Hyperactive/Impulsive type tend to "do
it now" and pay later. In other words,
they have output control
problems.
6.
Is ADHD over-diagnosed?
Many
people believe that ADHD is
over-diagnosed and has become a
"popular" diagnostic label for
undisciplined, lazy unmotivated
children. Poor parenting is often
thought to be the cause. The parents
themselves may even feel that they are
to blame for their children's problems
with misbehaving and underachieving in
school and in social settings. In some
cases, one parent blames the other. In
truth, research indicates that as many
as 50% of children with ADHD are never
diagnosed. In an informal survey I
conducted, it was the unanimous opinion
of Chesterfield County school
psychologists that girls are
under-diagnosed. This agrees with the
research literature.
7. Is
ADHD a "guy thing"?
Boys
are more likely than girls to be
diagnosed as ADHD, because they show
more hyperactive, impulsive and
inattentive behavior. Girls with ADHD
are likely to be more withdrawn, tend to
worry more and be less aggressive than
boys. As ADHD males become teenagers,
the research shows that they are more
likely to become defiant, aggressive and
develop a conduct disorder. Teenage
girls with ADHD are more likely to
develop somatic problems (i.e.,
headaches, stomach aches, fatigue).
8. Does sugar cause behavioral problems
and hyperactivity in children?
The
belief that sugar causes children to be
more hyperactive is not supported by
controlled research. A recent paper
published in the Journal of the
American Medical Association (1995)
which analyzed 23 controlled studies
found that sugar does not effect the
cognition or behavior of children.
Candy, cake and ice cream which are high
in sugar are often given under "party"
conditions and appear to lead parents to
conclude that they cause hyperactivity.
However, these findings do not rule out
that some children may become excited or
hyperactive when given foods high in
sugar.
9. Do food additives, vitamin
deficiencies, too much TV or excessive
yeast cause ADHD?
Research studies have not found food
additives to be a significant
contributing factor in causing or
exacerbating ADHD symptoms. There may be
some children who have food allergies
that cause them to appear to have ADHD
symptoms. A well-balanced diet will
generally help any child. In research,
high doses of vitamins or a reduction in
yeast intake have not been found to help
reduce ADHD symptoms.
10. How is it possible that my child can
have ADHD, yet he can focus on playing
video games or watching TV for hours?
This is
one of the most common questions asked
by parents. Think about video games.
What do most of them require to win?
Impulsive and rapid responding at a high
level! Poke, bounce, keep moving,
fiddle, experiment, try anything and you
are rewarded with gold coins or points.
These games constantly change and
display new stimuli. Thus, in some ways
many video games are "more of the same."
By this I mean that they reinforce
hyperactive, impulsive behavior and
satiate a desire for novelty. TV
programs are often stimulating in the
same way.
Many
children with ADHD will pay attention
for long periods of time doing
self-directed, fun, stimulating and
entertaining activities. It is the
other-directed, rote, skill-building,
repetitive practice and exercises that
are necessary to learn academic or work
related material that are resisted and
avoided. It's not fun in the moment and
it is difficult for these children with
ADHD to take the long-term view.
11. How does a clinician diagnose ADHD?
Most
clinicians will spend some time
observing the subject, then gather
clinical and behavioral data from
parents and teachers. These parental and
teacher rating scales are used to
quantify the severity of the problem and
to establish that the symptoms occur in
more than one environment. All children
have ADHD-type problems to some degree,
but it is the age inappropriateness,
severity and prevalence of these
problems, as well as their effect on the
childs functionality, which need to be
assessed. The clinician will also
consider other possible contributing
psychological problems.
To
counter the subjectivity of rating
scales, many clinicians are using a new
type of objective computerized test
called a Continuous Performance Test (CPT).
This type of test uses the computer to
provide non-biased measures of
impulsiveness, inattention, focus,
mental effort and stamina.
Contrary to what many people believe, a
positive response to Ritalin does not
confirm an ADHD diagnosis. Research in
the 1980's found that children with or
without ADHD were more attentive and
focused after taking Ritalin.
12. What typical treatments are
recommended for ADHD?
Typical
treatments for ADHD include one or more
of the following: medication, behavior
modification techniques, parental
training, psychotherapy and special
education and educational
accommodations.
13. Why is it important to diagnose and
treat ADHD at a young age?
If the
problem is treated when the child is
young, certain other problems may be
less likely to develop. These other
problems may include Depression,
Oppositional Defiant Disorder and
Conduct Disorder.
14. What challenges face a child with
ADHD?
ADHD
children as a group are more likely to
be physically abused at home and to be
unpopular with their peers at school or
in social situations. Parents often feel
very frustrated and stressed in dealing
with continual daily conflicts and
temper tantrums. Since these children
can be very manipulative and persistent
in trying to get their own way, parents
can easily fall into the trap of
randomly giving in to their demands when
they "act out" after being told "no."
This is done to buy some much-needed
peace, but ends up randomly reinforcing
the childs "acting out" behavior. The
result is that the next time the parent
says "no," the child has learned to just
"keep at it" until the parent to gives
in. Thus, making the child happy in the
short term often results in a great deal
of unhappiness in the long term.
In
school sometimes children who are ADHD
will get attention or avoid stress by
being the "class clown." They may also
have continual failure experiences and
become depressed or withdrawn. School
avoidance due to stomachaches or
headaches can also occur. Back-talking
and resistance towards school work often
occurs.
In
general, ADHD children do not pay
attention well to non-verbal social
cues. Their thinking tends to be
immature and egocentric. They are often
bossy and impatient. Fighting may occur
more frequently than with normal
children. Sometimes, they tend to choose
to play with younger children who are
more likely to do what they say.
15. How severe are the problems that
children with ADHD have in school?
30%-50% are retained in a grade at least
once
1 in
2 has been suspended from school at
least once
1 in
10 has been expelled
1 in
10 drops out of school
Only
1 in 20 finishes college
In
response to these problems, some parents
choose private schools with smaller
classes and special programs. There are
some private colleges and schools which
specialize in helping children with
ADHD.
16. Are there other disorders which look
like ADHD, but are not?
Some of
the other psychological disorders which
may be mistaken for ADHD are:
Learning Disabilities
Obsessive Compulsive Disorder
Dysthymia
Major
Depression
Generalized Anxiety Disorder
Oppositional Defiant Disorder
Conduct Disorder
Auditory Processing Disorder
Visual Processing Problems
Post
Traumatic Stress Disorder
Cognitive Disorders
Mild
Brain Injury
Bi-polar Disorder
Some of
these disorders may be co-morbid with
ADHD.
17. Do children with ADHD also have
learning problems?
Cognitive problems of subtle or gross
nature are reported to exist in 50 to
80% of the cases of ADHD.
18. Is there a cure for ADHD?
Medication treatment does not cure ADHD.
Once medication is stopped, the symptoms
usually return in a few days. The brain
continues to mature into early
adulthood, and about half of the time
the symptoms subside to the point where
they no longer have a significant impact
on the individuals life. It is usually
the less severe cases of ADHD for which
the symptoms of the disorder lessen to
the point where the person is no longer
significantly impaired.
19. Do
adults have ADHD?
Research studies have found that between
30% and 70% of individuals with ADHD do
not "outgrow" it, and the symptoms often
persist and effect their adult life.
Since ADHD was generally under-diagnosed
when many of today's adults were
children, these individuals may not
realize why they have problems
concentrating, learning or studying. As
many as 2-5 million adults continue to
have problems functioning due to ADHD
symptoms.
It does
need to be kept in mind that many
children with ADHD will not continue as
adults to have the severe symptoms which
warrant a diagnosis of ADHD. Thus, just
having ADHD symptoms as a child does not
automatically mean that a person will
meet the criteria for diagnosis of ADHD
as an adult. However, the consequences
of having ADHD as a child and the
failure experiences in ones academic and
social life can lead to other
psychological disorders, such as
depression and anxiety, which do
continue into adulthood.
20. What are the typical symptoms of
adult ADHD?
Most
adults with ADHD are restless, easily
distracted, act impulsively, are
impatient, get angry easily, are easily
frustrated, do not plan or organize
well, have difficulty sustaining
attention and may be described as moody.
ADHD adults are not typically
hyperactive. Many adults with the
disorder have learned to compensate or
have chosen jobs which are less complex,
give them the opportunity to move freely
and change environments, offer variety,
and allow them to set their own pace or
schedule.
21. How can an adult with ADHD cope with
this disability?
Adults
can compensate in a number of ways:
Use
organizational tools: Post-its,
computers, tape recorders and
appointment books
Utilize medication, either stimulants or
anti-depressants
Get
help and feedback from a therapist,
spouse or friend
Make
affirmative, positive statements and
avoid negative self-statements
Look at the "glass half-full" with a
sense of humor towards their
difficulties in functioning
Avoid alcohol
and illegal drug use
Practice
relaxation and anger control techniques
These techniques
are also very useful for ADHD teenagers
(and maybe the rest of us too!)
22. Is medication for ADHD
over-prescribed?
Prescription
practices for Ritalin in Michigan in
1995 were studied by the Federal Drug
Enforcement Agency because the state has
a very high rate of prescriptions
relative to the total population.
Ritalin was prescribed about 1% less
than the expected prevalence rate of
ADHD. Thus, no evidence of excessive
prescribing of Ritalin was found.
Besides
psychostimulants such as Ritalin, Cylert
and Dexedrine, there are two other types
of medications for ADHD which are
commonly prescribed Tricyclic
anti-depressants and high blood pressure
medications. Of these types of drugs
physicians typically prescribe
Imipramine, a Tricyclic, and Clonidine,
a high blood pressure medication. These
medications can work in cases in which
the psychostimulants do not help or have
adverse side-effects. They can also be
administered in conjunction with
Ritalin. There has been no concern about
these medications being over-prescribed,
as they do not have any potential for
substance abuse.
23. What are the side-effects of
Ritalin?
The most common
side-effects are some loss of appetite,
slower growth or difficulty falling
asleep. Usually within a week or so, the
person adjusts and the side-effects
dissipate. Adjustments in the time of
administration (e.g., after meals),
amount of medication or "medication
vacations" often control for these
side-effects.
Based on my
clinical experience and the research
literature, more serious side-effects
can occur which lead to the need to
discontinue Ritalin and try other
treatment techniques. These side-effects
are:
Increase in
heart rate or blood pressure
Greater
nervousness or anxiety
Increase in
angry and aggressive behavior
Social
withdrawal
Increase in
crying spells and moodiness
Development of
or increase in tics for some children
Increase in
frequency or severity of headaches
Occurrence of
stupor-like behavior
Rashes
24. Is Ritalin a "bad" or dangerous
medication?
Ritalin is
effective in significantly reducing the
symptoms of ADHD in about 70 to 80% of
cases for both children and adults. NIMH
reports that significant benefits are
achieved in 90% of cases where either
Ritalin or one of the two other typical
medications (Dexedrine and Cylert) are
tried. In other words, psychostimulant
medications do help individuals with
ADHD sit still, sustain attention, exert
more self-control, stay on-task and be
more tolerant of frustration. These
changes enable the ADHD person to learn
what is being taught and to get work
completed. When attention improves, so
does memory and the ability to process
and follow verbal and written
instructions.
Ritalin has been
used in the treatment of ADHD for over
30 years and no long-term side-effects
related to its continued use have been
identified. Research shows that, on the
average, most children stay on this type
of medication for about 2 to 3 years.
Periodically, it may be useful to
discontinue medication in order to see
if it is still needed.
25.
Is Ritalin addictive?
Contrary to
popular opinion, Ritalin does not
produce a "high." And research shows
that ADHD children treated with
psychostimulants are less likely later
to develop a substance abuse problem
than those with ADHD who do not receive
treatment. My clinical experience also
supports that the drug is not addictive,
as the discontinuation has never
resulted in any reported withdrawal
effects or cravings.
26. Are there any new or alternative
treatments other than medication that
have any scientific basis or have been
found by you to be clinically effective?
Neurofeedback
and cognitive training have been very
effective tools for me in my practice.
27. What can parents do to help their
child with ADHD?
Give
immediate, positive and negative
reinforcement
Avoid
spanking or other physical punishment.
Externalize the rules. (For example,
make a poster about the positive rules
and their negative correlates, and hang
it in a prominent place. You can number
these rules and then refer to them by
number.)
Let
your child know it is the behavior, not
the child, that you do not like.
Be
consistent and structured (Say what you
mean, mean what you say.)
Stay
calm--yelling and screaming is not
communication.
Choice or consequences (For
oppositional behavior, tell the child
that it is his choice to do what you are
asking him to do, and if he chooses not
to do it, what the consequences will be.
Then ask him to make a decision. )
Allow
for brief breaks and "chunking" of work
when doing homework.
Don't
forget the fun and special times.
Coordinate with the school, get feedback
from teachers and counselors, and
remember that "the squeaky wheel gets
the oil."
Help
your child to find at least one "buddy."
Explore ways -- a sport, game, etc.-- to
help your child develop an area of
self-esteem.
28. What can parents of an ADHD child do
for themselves to learn more and cope
with the problems that occur?
Remember,
raising children with ADHD can be very
stressful. Don't go it alone. Take care
of yourself--your children need you.
Practical tips
are:
Learn stress
management techniques.
Take time for
yourself, and take a break from having
to manage your ADHD child.
Share
experiences - talk with a friend or
relative
Read and learn
about ADHD - try new ideas. Remember,
nothing works forever, and no one thing
works for every child.
Join a support
group
Communicate
with the teacher, and ask for help.
29. How can my child's school or teacher
help him or her with ADHD?
Work with your
school to develop a "504 plan." This
plan can help by providing feedback to
the parent in order to better monitor
homework, make reasonable accommodations
for testing, reschedule more challenging
classes to morning times or provide more
individualized instruction. Long-term
assignments can be broken up into
smaller parts. An aide or second teacher
can come into the classroom to provide
more one-to-one instruction for subjects
the student is having difficulty
understanding or completing. More
structure and immediate consequences
with daily or weekly parental feedback
can often be helpful. Some teachers also
have special training which helps them
to better relate to and encourage
children with ADHD.
30. How can I learn more about ADHD?
There
are several national support groups and
many publications written about ADHD
available at your local library. A list
of these organizations can be obtained
directly on the Internet or through
America Online, Compuserve, or Prodigy.
The web site for the national ADHD group
called Ch.A.D.D. is
www.chadd.org.
