Hyperactivity Disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or activities.

ADHD, also known as hyperkinetic disorder (HKD) outside of the United States, is estimated to affect 3-9% of children, and afflicts boys more often than girls. Although difficult to assess in infancy and toddlerhood, signs of ADHD may begin to appear as early as age two or three, but the symptom picture changes as adolescence approaches. Many symptoms, particularly hyperactivity, diminish in early adulthood, but impulsivity and inattention problems remain with up to 50% of ADHD individuals throughout their adult life.

Children with ADHD have short attention spans, becoming easily bored and/or frustrated with tasks. Although they may be quite intelligent, their lack of focus frequently results in poor grades and difficulties in school. ADHD children act impulsively, taking action first and thinking later. They are constantly moving, running, climbing, squirming, and fidgeting, but often have trouble with gross and fine motor skills and, as a result, may be physically clumsy and awkward. Their clumsiness may extend to the social arena, where they are sometimes shunned due to their impulsive and intrusive behavior.

The causes of ADHD are not known. However, it appears that heredity plays a major role in the development of ADHD. Children with an ADHD parent or sibling are more likely to develop the disorder themselves. In 2004, scientists reported at least 20 candidate genes that might contribute to ADHD, but no single gene stood out as the gene causing the condition. Before birth, ADHD children may have been exposed to poor maternal nutrition, viral infections, or maternal substance abuse. In early childhood, exposure to lead or other toxins can cause ADHD-like symptoms. Traumatic brain injury or neurological disorders may also trigger ADHD symptoms. Although the exact cause of ADHD is not known, an imbalance of certain neurotransmitters, the chemicals in the brain that transmit messages between nerve cells, is believed to be the mechanism behind ADHD symptoms.

A widely publicized study conducted by Dr. Ben Feingold in the early 1970s suggested that allergies to certain foods and food additives caused the characteristic hyperactivity of ADHD children. Although some children may have adverse reactions to certain foods that can affect their behavior (for example, a rash might temporarily cause a child to be distracted from other tasks), carefully controlled follow-up studies have uncovered no link between food allergies and ADHD. Another popularly held misconception about food and ADHD is that the consumption of sugar causes hyperactive behavior. Again, studies have shown no link between sugar intake and ADHD. It is important to note, however, that a nutritionally balanced diet is important for normal development in all children.

Conduct disorder — A behavioral and emotional disorder of childhood and adolescence. Children with a conduct disorder act inappropriately, infringe on the rights of others, and violate societal norms.

Nervous tic — A repetitive, involuntary action, such as the twitching of a muscle or repeated blinking.

Oppositional defiant disorder — A disorder characterized by hostile, deliberately argumentative, and defiant behavior toward authority figures.

Psychologists and other mental health professionals typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a guideline for determining the presence of ADHD. For a diagnosis of ADHD, DSM-IV requires the presence of at least six of the following symptoms of inattention, or six or more symptoms of hyperactivity and impulsivity combined:

Inattention:

Hyperactivity:

Impulsivity:

The first step in determining if a child has ADHD is to consult with a pediatrician. The pediatrician can make an initial evaluation of the child's developmental maturity compared to other children in his or her age group. The physician should also perform a comprehensive physical examination to rule out any organic causes of ADHD symptoms, such as an overactive thyroid or vision or hearing problems.

If no organic problem can be found, a psychologist, psychiatrist, neurologist, neuropsychologist, or learning specialist is typically consulted to perform a comprehensive ADHD assessment. A complete medical, family, social, psychiatric, and educational history is compiled from existing medical and school records and from interviews with parents and teachers. Interviews may also be conducted with the child, depending on his or her age. Along with these interviews, several clinical inventories may also be used, such as the Conners Rating Scales (Teacher's Questionnaire and Parent's Questionnaire), Child Behavior Checklist (CBCL), and the Achenbach Child Behavior Rating Scales. These inventories provide valuable information on the child's behavior in different settings and situations. In addition, the Wender Utah Rating Scale has been adapted for use in diagnosing ADHD in adults.

It is important to note that mental disorders such as depression and anxiety disorder can cause symptoms similar to ADHD. A complete and comprehensive psychiatric assessment is critical to differentiate ADHD from other possible mood and behavioral disorders. Bipolar disorder, for example, may be misdiagnosed as ADHD.

Public schools are required by federal law to offer free ADHD testing upon request. A pediatrician can also provide a referral to a psychologist or pediatric specialist for ADHD assessment. Parents should check with their insurance plans to see if these services are covered.

Psychosocial therapy, usually combined with medications, is the treatment approach of choice to alleviate ADHD symptoms. Psychostimulants, such as dextroamphetamine (Dexedrine), pemoline (Cylert), and methylphenidate (Ritalin) are commonly prescribed to control hyperactive and impulsive behavior and increase attention span. They work by stimulating the production of certain neurotransmitters in the brain. Possible side effects of stimulants include nervous tics, irregular heartbeat, loss of appetite, and insomnia. However, the medications are usually well-tolerated and safe in most cases. In 2004, longer-acting stimulants had been released to treat adult ADHD.

In 2004, the American Academy of Child and Adolescent Psychiatry listed the first nonstimulant as a first-line therapy for ADHD. Called atomoxetine HCI (Strattera), it is a norepinephrine reuptake inhibitor.

In children who do not respond well to stimulant therapy, tricyclic antidepressants such as desipramine (Norpramin, Pertofane) and amitriptyline (Elavil) are sometimes recommended. Reported side effects of these drugs include persistent dry mouth, sedation, disorientation, and cardiac arrhythmia (particularly with desipramine). Other medications prescribed for ADHD therapy include buproprion (Wellbutrin), an antidepressant; fluoxetine (Prozac), an SSRI antidepressant; and carbamazepine (Tegretol, Atretol), an anticonvulsant drug. Clonidine (Catapres), an antihypertensive medication, has also been used to control aggression and hyperactivity in some ADHD children, although it should not be used with Ritalin. A child's response to medication will change with age and maturation, so ADHD symptoms should be monitored closely and prescriptions adjusted accordingly.

Behavior modification therapy uses a reward system to reinforce good behavior and task completion and can be implemented both in the classroom and at home. A tangible reward such as a sticker may be given to the child every time he completes a task or behaves in an acceptable manner. A chart system may be used to display the stickers and visually illustrate the child's progress. When a certain number of stickers are collected, the child may trade them in for a bigger reward such as a trip to the zoo or a day at the beach. The reward system stays in place until the good behavior becomes ingrained.

A variation of this technique, cognitive-behavioral therapy, works to decrease impulsive behavior by getting the child to recognize the connection between thoughts and behavior, and to change behavior by changing negative thinking patterns.

Individual psychotherapy can help an ADHD child build self-esteem, give them a place to discuss their worries and anxieties, and help them gain insight into their behavior and feelings. Family therapy may also be beneficial in helping family members develop coping skills and in working through feelings of guilt or anger parents may be experiencing.

ADHD children perform better within a familiar, consistent, and structured routine with positive reinforcements for good behavior and real consequences for bad. Family, friends, and caretakers should all be educated on the special needs and behaviors of the ADHD child. Communication between parents and teachers is especially critical to ensuring an ADHD child has an appropriate learning environment.

A number of alternative treatments exist for ADHD. Although there is a lack of controlled studies to prove their efficacy, proponents report that they are successful in controlling symptoms in some ADHD patients. Some of the more popular alternative treatments include:

Untreated, ADHD negatively affects a child's social and educational performance and can seriously damage his or her sense of self-esteem. ADHD children have impaired relationships with their peers, and may be looked upon as social outcasts. They may be perceived as slow learners or troublemakers in the classroom. Siblings and even parents may develop resentful feelings towards the ADHD child.

Some ADHD children also develop a conduct disorder problem. For those adolescents who have both ADHD and a conduct disorder, as many as 25% go on to develop antisocial personality disorder and the criminal behavior, substance abuse, and high rate of suicide attempts that are symptomatic of it. Children diagnosed with ADHD are also more likely to have a learning disorder, a mood disorder such as depression, or an anxiety disorder.

Approximately 70-80% of ADHD patients treated with stimulant medication experience significant relief from symptoms, at least in the short-term. Approximately one-half of ADHD children seem to "outgrow" the disorder in adolescence or early adulthood; the other half will retain some or all symptoms of ADHD as adults. With early identification and intervention, careful compliance with a treatment program, and a supportive and nurturing home and school environment, ADHD children can flourish socially and academically.

"AACAP Guidelines Include Strattera as a First-line ADHD Therapy Option." Drug Week (May 28, 2004): 54.

"More Long-acting Stimulants to Treat Adult ADHD." SCRIP World Pharmaceutical News (May 14, 2004): 101-23.

"Study Updates Genetics of ADHD." Drug Week (May 21, 2004): 55.

American Academy of Child and Adolescent Psychiatry. (AACAP). 3615 Wisconsin Ave. NW, Washington, DC 20016. (202) 966-7300. http://www.aacap.org.

Children and Adults with Attention Deficit Disorder (CH.A.D.D.). 8181 Professional Place, Suite 201.

National Attention Deficit Disorder Association. (ADDA). 9930 Johnnycake Ridge Road, Suite 3E, Mentor, OH 44060. (800) 487-2282. http://www.add.org.