This online course begins with an overview of ADHD, followed by several case examples. Current diagnoses from the Diagnostic and Statistical Manual of the American Psychiatric Association and the International Classification of Diseases are given. A working definition is also given, which places symptoms in an everyday context. Next, a discussion of important, relevant issues provides an understanding of the environment and context of ADHD symptoms.
A brief historical overview of ADHD is presented, including early historical citations and a developmental overview from infancy through adulthood. Cause is then addressed, including those causes for which there is minimal support. A discussion of genetics follows with a brief overview of brain functioning.
An overview of evaluation procedures is provided, including the role of the physician, assessment in the school and home, including the use of laboratory measures to assess ADHD. A thorough discussion of co-occurring psychiatric problems is followed by current conceptualizations of the multi-treatment model, including an overview of medication, parent training, and a discussion of effective educational strategies. Finally, controversial treatments are reviewed. The online course concludes with an in-depth bibliography of resources which can be provided to interested parties. The bibliography focuses on parenting, education, medical and mental health issues related to ADHD.
This online course is designed to provide the reader with a brief, current overview of the field of ADHD. It is not meant as a stand alone text on ADHD. The author of this online course, Sam Goldstein, Ph.D. has completed such a text and recent chapter updates. The reader is encouraged to seek this text for in-depth review of scientific issues and questions (Goldstein and Goldstein, 1998; Goldstein, 1999; Goldstein, 2002).
Upon completion of this course participants will be able to:
- Identify the core characteristics of ADHD.
- List appropriate assessment procedures for ADHD.
- Name co-morbid conditions commonly found in individuals with ADHD.
- Identify appropriate, effective treatments for ADHD.
- List at least three treatments for ADHD that are identified in the text as controversial.
What is ADHD?
Over the past fifty years the childhood cognitive and behavioral problems categorized as disorders of attention, impulsivity and hyperactivity have presented a clinical challenge for physicians, educators, and mental health professionals. This symptom constellation referred to as Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder or ADHD (APA, 2001) has become one of the most widely researched areas in childhood, adolescence and increasingly throughout the adult life span. For over thirty years problems arising from this constellation of symptoms have constituted the most chronic childhood behavior disorders and the largest single source of referrals to mental health centers. In clinic referred settings, males out number females six to one. In epidemiological or community based studies the ratio is three to one (Barkley, 1990a). The higher clinic ratio for males has been suggested as a function of the greater prevalence of other psychiatric disorders such as oppositional defiance and conduct disorder in males with ADHD (Breen and Barkley, 1988).
Symptoms of ADHD constitute one of the most complex disorders of childhood. Despite efforts to reach a consensus definition and agreement that inattention, hyperactivity and impulsivity are the hallmark for the diagnosis, debate continues concerning core deficits, associated problems and consequences. Increasingly it has been recognized that problems with faulty impulse control and self-regulation may lie at the core of problems for those with ADHD. Children with ADHD typically experience difficulty with home, school and community behavior involving family, peers, academics and emotional adjustment. The uneven, unpredictable behavior they demonstrate appears to be a function of knowing what to do but not always doing it. Their problems are one of inconsistency rather than inability. ADHD causes significant and pervasive impairment in day-to-day functioning.
Why is ADHD a Problem?
Success in childhood and throughout the adult years requires the capacity to plan, organize, sustain attention, control impulses, and complete often mundane tasks. It is now recognized that symptoms of ADHD have a significant impact on a child’s ability to meet these demands and on their emerging personality and cognitive skills as well. Although it was once suggested that the majority of children outgrow the core symptoms associated with ADHD, in the last twenty years it has become an accepted fact that symptoms of ADHD continue to exert a significant and pervasive impact on affected individuals throughout their childhood and into their adult years. A child experiencing years of negative feedback, negative reinforcement and an inability to meet the reasonable demands of family, friends and teachers will certainly be affected for life. The daily, small successes many children experience to build a bank account of positive self-esteem and success often runs in the red for children with ADHD. Such successes may be few and far between. Physicians today must not only be concerned with the core symptoms of ADHD and their impact on childhood, but with the significant, secondary impact these problems have on children’s current and future lives as well as upon their family members.
Through the mid-1980's, many children affected with ADHD went unreferred, undiagnosed and untreated. Their problems were suggested as reflecting poor motivation, ineffective parenting or simple disobedience. The rate of referral for ADHD has increased as reflected in the dramatic increase in the use of stimulant medications for the treatment of ADHD symptoms (Safer, Sito and Fine, 1996). Although critics have argued that too many children are being referred, accepting even a conservative research based, incidence rate of 3% to 7%, it still remains the case that more than half of all children with ADHD are still untreated. By the time most children are referred for ADHD, physicians are frequently presented with a complex set of problems that are often affected by a variety of social and non-social factors. Evaluation is then complicated by the fact that there continues to be no critical diagnostic test for ADHD. This is not the result of lack of effort by researchers but reflects the complex interaction of ADHD symptoms with environmental factors as a primary determinant of severity.
In many ways, ADHD reflects an exaggeration of what is normal behavior. Either too much (e.g., fidgeting) or not enough (e.g., lack of impulse control or attention) of what adults expect in certain settings results in complaints of problematic behavior. The fact that ADHD is not age limited necessitates the importance of early identification and treatment in an effort to alter negative adult outcome. The majority, if not all children, with ADHD continue to experience some degree of symptom related problems into adulthood with likely as many as one half meeting the diagnostic criteria for ADHD as well as experiencing a very high rate of comorbid psychiatric disorders (Biederman, Faraone, Spencer and Wilens, 1993; Biederman, Milberger, Faraone, Guite and Warbourton, 1994; for review see Goldstein, 2002). The prevalence of ADHD in the adult population is estimated at approximately 4% (Murphy and Barkley, 1996a).
ADHD is a disorder that confronts many practitioners in addition to physicians. Psychologists, educators, social workers, speech pathologists, physical therapists, occupational therapists, and an increasing number of attorneys find themselves dealing with ADHD problems. Often, physicians are placed in a position of having a limited amount of time to gather data and, in some cases, do the job of these other professionals, form diagnostic opinions and make treatment decisions. The physician’s best ally is the ability to network with other community professionals. He or she must recognize that the diagnosis and treatment of ADHD requires more than just a ten minute office visit and the signing of a prescription each month but an intimate knowledge of the field.
It is also important to recognize that the definition of ADHD and the field in general is not immune from controversy. Despite an enormous and increasing volume of research literature concerning ADHD (for review see Goldstein and Goldstein, 1998; Ellison, 2002) the precise definition of ADHD continues to be debated. In fact, many clinicians embrace the concept of ADHD as an impulse disorder and focus their evaluative search for symptoms primarily in this area. Differing views of the disorder, not surprisingly, causes inconsistent identification of ADHD in various research studies and in even in clinical settings. Despite these issues, ADHD is, and will continue to be a significant developmental problem. It is a disorder that when left untreated is likely to act catalytically to increase vulnerability for substance abuse and possibly criminal behavior (Goldstein, 1997a; Barkley and Gordon, 2002). The cost to society in terms of dollars in the vocational, legal and social service systems has yet to be estimated but is likely equivalent to the cost of other serious, lifetime psychiatric disorders such as depression.
How is the Problem of ADHD Best Solved?
Physicians must undertake and accept the responsibility for the task of doing a better job of translating what has been demonstrated scientifically into the clinical setting and beyond. They must begin to bring knowledge to the families, educators and professionals with whom they work. Because ADHD is a biopsychosoial disorder, physicians must possess a thorough knowledge of the developmental course, definition, evaluation and most importantly, proven treatments for the disorder. Although medications, specifically stimulant medications, statistically represent the treatment leading to the greatest symptom reduction, an effective treatment plan for ADHD requires the interface of medical, mental health and educational professions. Each specialty area must possess a working knowledge of all aspects of the diagnosis and treatment of ADHD. Although non-physician practitioners are often well aware of psychosocial treatment strategies for children and adults with ADHD, their knowledge of medication, the most effective treatment, as well as their ability to communicate efficiently with treating physicians, is often lacking. The corollary is true of physicians who may possess an excellent working knowledge of symptom targets for medication treatment but are often not in the position to gather the data necessary to demonstrate treatment effectiveness.
The topic of ADHD likely will continue to be the most widely researched and argued area in child development and psychopathology. New ground is broken daily. Research studies are more complex, better controlled and quicker to be replicated. Increasingly we are coming to recognize that “nature and nurture do not operate independently of each other and there needs to be an explicit focus on the interplay between them” (Rutter, 1997).
The five-year, multi-site, multi-modal treatment ADHD study done by the National Institute of Mental Health has provided well defined answers concerning comorbid conditions, gender issues, family history, home environment, and age variables as well as treatment effects (Richters, Arnold, Jensen, et al., 1995). This knowledge will impact diagnosis and treatment in the short and long term. At this time, the problem of ADHD is best solved through a combination of careful assessment and diagnosis, followed by the utilization of appropriate researched proven treatments, including medication, behavior management and educational interventions.
At four years of age, Tim has been a difficult and frustrating child for his parents. As an infant, Tim was often irritable, overactive and moody. He had trouble fitting routines and his irritable, high pitched crying resulted in his parents’ frequently curtailing family outings. At five years of age he continues to be overactive and temperamental. He rarely sits still and provides his parents with very little pleasure. He acts impulsively and appears to engage in a high degree of risk taking behavior. This has resulted in numerous bumps, bruises and a half dozen trips to the hospital emergency room. With his siblings and peers, Tim is extremely aggressive and his parents have been asked to remove him from two preschool settings. He continues to frustrate easily and tantrums on a daily basis. Tim’s parents are at their wits end. They are angry, frustrated and unhappy. They have also begun to anticipate that Tim may experience significant problems with learning and behavior as he enters kindergarten. Despite all of his difficulties, Tim too is well aware of his parents’ unhappiness. Tim demonstrates the fairly typical profile of a young child experiencing the early onset of the combined type of Attention Deficit Hyperactivity Disorder.
A seven year old first grader, George was referred by his physician due to a history of impulsive, hyperactive and oppositional behavior. George’s parents had separated two years prior. Although George had a good relationship with each parent, George was non-compliant and verbally abusive towards his stepfather. From an early age George was described as impulsive and hyperactive. His moods cycled frequently. He had chronic problems with sleep and appetite. His parents joked that he had never worked his way through the terrible two’s. Socially he was rejected due to his aggressive, disruptive behavior. He would tease, provoke, fight, interrupt or be argumentative with peers and adults. Although assessment suggested average intellectual skills, George’s reading, writing and spelling skills were markedly below his grade placement, necessitating special education services at school. During assessment George spoke about his anger and feelings of frustration. He revealed to the evaluator that he once thought about running into the middle of the street and being run over by a car because he felt nothing was going to help. His presentation reflected symptoms of the combined type of ADHD, oppositional defiance, learning disability and a significant risk for developing depression.
As a nine and a half year old fourth grader, Jeff was referred due to a history of impulsive and inattentive problems at school. The family history was positive for similar problems in his father. Two nephews on his mother’s side of the family had also received diagnoses of ADHD. Jeff’s early developmental milestones were reached normally. Although a bed wetter he did not experience any other developmental problems. His behavior as a young child was described as active but not seriously disruptive. At home, Jeff was described by his parents as inattentive and overactive. He enjoyed scouts but there was little else that he would stick with. His grades at school were adequate as he did not experience a specific learning disability. However, every year teachers commented about his problems completing work without significant prompts and supports. Interestingly, although his grades were about average, group achievement test data reflected that Jeff’s skills were in the top 10% for his age group. Clearly he was not performing at school at that level. Jeff demonstrates a fairly typical history for an elementary school child with ADHD, in the absence of other serious psychiatric or developmental problems.
As a fourteen year old, ninth grader, Susan was referred because teachers could not understand her reasons for poor school work. One of Susan’s siblings had been diagnosed with ADHD. Susan had never been a behavioral challenge for her parents nor teachers. She was very pleasant, related well to peers and did not appear to experience a specific learning disability. Yet as the demands of school increased, Susan struggled increasingly. She appeared disorganized and often misplaced items necessary for tasks or activities at school or home. During assessment, Susan’s responses did not suggest that she experienced depression or anxiety. She was well aware of her performance difficulties and had assumed that her problems were caused by laziness and lack of effort rather than a specific handicapping condition. During psychological testing she demonstrated above average intellectual skills and achievement. Yet on a number of tasks considered sensitive to measuring sustained attention and impulse control, Susan struggled. Susan demonstrates the fairly typical profile of females with a history of primarily the inattentive type of Attention Deficit Hyperactivity Disorder.
A forty-eight year old married male, Bob was referred at the insistence of his spouse. Bob reported a normal childhood. He recalled, however, disliking school yet he had managed to obtain a college degree. He remembered teachers telling his mother that he never worked up to his potential. He described himself as a daydreamer as a child, also noting that he had gotten into some trouble as a teenager for doing things without thinking. Bob denied a significant adult history of emotional, psychiatric or substance related problems. Nonetheless, Bob acknowledged that he drank multiple cups of coffee and smoked a pack of cigarettes each day. Bob was employed in sales full time. He had worked for the same company for nine years but expressed concern that he had missed promotions because he was disorganized and had difficulty at times getting along with supervisors. Bob and his first wife had been married for twenty years with four children. Two of their four children had been diagnosed with ADHD which prompted Bob to consider assessment for himself. Bob described chronically feeling tense, unable to relax, fatigued and having difficulty with concentration and memory. He noted that at times he felt stupid and that his moods would change frequently or unpredictably. He wondered if he had experienced depressive episodes in the past. Bob had also received numerous citations for speeding violations and had been involved in three automobile accidents. Bob demonstrates a typical profile of an adult with an undiagnosed history of ADHD in the absence of other serious psychiatric or life problems.
These five examples demonstrate typical cases of ADHD. Given the very recent interest in the adult population, it is likely that for a number of years to come adults with histories of undiagnosed ADHD will be identified and subsequently treated. It is likely, however, that many of the children of these individuals will be identified in childhood and thus, in the future a fewer number of adults with histories of ADHD will be first identified during their adult years.
The DSM-IV TR and ICD-10 Diagnoses of ADHD
It is important for physicians to possess a working understanding of the DSM-IV TR Diagnostic Criteria for ADHD as these are the primary criteria utilized in North America. The DSM-IV TR criteria are based upon a fairly extensive set of field studies. In the field studies, a number of interesting phenomena emerged. Of the 276 children diagnosed with ADHD, 55% had the combined type; 27% the inattentive type; and 18% the hyperactive-impulsive type. The hyperactive-impulsive group had fewer symptoms of inattention than children in the combined type. They also had fewer symptoms of hyperactive-impulsive problems, suggesting that this represents a less severe variant of the disorder. The hyperactive-impulsive group contained 20% females; the combined group 12%; and the inattentive group 27%. This over-representation of females in the inattentive group has yet to be explained by any theoretical model nor has it been understood why preliminary research suggests that females with ADHD may be less likely to demonstrate cognitive deficits in comparison to males with ADHD (Seidman, Biederman, Faraone, Weber, Mennin and Jones, 1997).
In the field studies, the hyperactive-impulsive population was younger. Seventy-six percent were between the ages of four and six years. In contrast the average age was eight and a half in the combined group and nearly ten years of age in the inattentive group. The late age diagnosis for the inattentive group is not surprising given the lack of disruptiveness of their symptoms. The DSM-IV TR criteria for Attention Deficit Hyperactivity Disorder follow (APA, 2001):
DSM-IV -Text Revision (TR)
A. Either (1) or (2):
1. Six or more of the following symptoms of inattention
have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
- often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
- often has difficulty sustaining attention in tasks or play activities
- often does not seem to listen when spoken to directly
- often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
- often has difficulties organizing tasks and activities
- often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as
- schoolwork or homework)
- often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)
- is often easily distracted by extraneous stimuli
- is often forgetful in daily activities
2. Six (or more) of the following symptoms of hyperactivity-impulsivity
have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
- often fidgets with hands or feet or squirms in seat
- often leaves seat in classroom or in other situations in which remaining seated is expected
- often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
- often has difficulty playing or engaging in leisure activities quietly
- is often "on the go" or often acts as if "driven by a motor"
- often talks excessively
- often blurts out answers before questions have been completed
- often has difficulty awaiting turn
- often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home)
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)
Attention-Deficit/Hyperactivity Disorder, Combined Types:
if both Criteria A1 and A2 are met for the past 6 months
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type:
if Criterion A1 is met but Criterion A2 is not met for the past 6 months
Attention Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type:
if Criterion A2 is met but Criterion A1 is not met for the past 6 months
For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.
Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified:
This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.
Although the majority of research with ADHD has utilized the DSM-IV TR diagnoses, the International Classification for Diseases has defined a disorder referred to as Hyperkinetic Disorder of Childhood used in many European studies. This diagnostic classification focuses heavily on hyperactive and impulsive symptoms. Nonetheless, the DSM-IV TR criteria appear to be making inroads as the diagnostic criteria of choice worldwide. Interested readers in the ICD diagnostic criteria and related research are referred to Taylor, Sandberg, Thorley and Giles (1991).
The proposed ICD-10 criteria for Hyperkinetic Disorder follows:
ICD-10 Diagnostic Criteria for Hyperkinetic Disorder
A. Demonstrable abnormality of attention and activity at HOME, for the age and developmental level of the child, as evidenced by at least three of the following attention problems:
(1)short duration of spontaneous activities;
(2)often leaving play activities unfinished;
(3)over-frequent changes between activities;
(4)undue lack of persistence at tasks set by adults;
(5)unduly high distractibility during study, e.g., homework or reading assignment;
(6)continuous motor restlessness (running, jumping, etc.);
(7)markedly excessive fidgeting and wriggling during spontaneous activities;
(8)markedly excessive activity in situations expecting relative stillness (e.g., mealtimes, travel, visiting, church);
(9)difficulty in remaining seated when required.
B. Demonstrable abnormality of attention and activity at SCHOOL or NURSERY (if applicable), for the age and developmental level of the child, as evidenced by at least two of the following attention problems:
(1)undue lack of persistence at tasks;
(2)unduly high distractibility, i.e., often orienting towards extrinsic stimuli;
(3)over-frequent changes between activities when choice is allowed;
(4)excessively short duration of play activities; and by at least two of the following activity problems:
(5)continuous and excessive motor restlessness (running, jumping, etc.) In school;
(6)markedly excessive fidgeting and wriggling in structured situations;
(7)excessive levels of off-task activity during tasks;
(8)unduly often out of seat when required to be sitting.
C. Directly observed abnormality of attention or activity. This must be excessive for the child’s age and developmental level. The evidence may be any of the following:
(1)direct observation of the criteria in A or B above, i.e., not solely the report of parent and/or teacher;
(2)observation of abnormal levels of motor activity, or off-task behaviour, or lack of persistence in activities, in a setting outside home or school (e.g., clinic or laboratory);
(3)significant impairment of performance on psychometric tests of attention.
D. Does not meet criteria for pervasive developmental disorder, mania, depressive or anxiety disorder.
E. Onset before the AGE OF SIX YEARS.
F. Duration of AT LEAST SIX MONTHS.
G. IQ above 50.
NOTE: The research diagnosis of Hyperkinetic Disorder requires the definite presence of abnormal levels of inattention and restlessness that are pervasive across situations and persistent over time, that can be demonstrated by direct observation, and that are not caused by other disorders such as autism or affective disorders.
Eventually, assessment instruments should develop to the point where it is possible to take a quantitative cut-off score on reliable, valid, and standardized measures of hyperkinetic behavior in the home and classroom, corresponding to the 95th percentile on both measures. Such criteria would then replace A and B above. (From the International Classification of Diseases (10th edition)
by the World Health Organization, 1990, Geneva: Author. Copyright 1990 by the World Health Association.)
The current DSM-IV TR distinction of the combined versus inattentive types of ADHD has significant meaning for the physician. The inattentive group appears to represent a very different population in terms of their presenting symptoms, comorbidities, developmental course and future life outcome. They appear to be significantly less negatively impacted than the combined group. Although these two groups may be distinguished by their performance on certain assessment measures, the true distinction lies in behavior observed in real-life settings.
At the present time this appears to best characterize differences between these two groups far beyond that obtained by comparison of laboratory measures or related risk factors. The hyperactive-impulsive group, based upon available data, present as very young children. Over time the majority of these children frequently progress to meet the criteria necessary for the combined ADHD diagnosis (Mitsis, McKay, Shulz, et al. 2000).
The validity of the current DSM-IV TR diagnostic conceptualization for ADHD has been closely examined. Such research has included batteries of neuropsychological tests, behavioral observation and neurological assessment. Among these well controlled, clinic and epidemiological studies, the current conceptualization of ADHD has been refined. Nonetheless, the DSM-IV TR criteria continue to focus excessively on inattention as the core problem, limiting the scope of the impact of impulsivity as the core deficit. Increasing, research suggests that of inattention, hyperactivity and impulsivity, impulsivity is the best predictor of life outcome. Change, however, takes time. Sandwiched between researchers and physicians, the authors of the diagnostic manual move slowly through a process involving much time and politics. Nonetheless, the continued focus on inattention perpetuates a number of major misconceptions, including that the inattentive type of ADHD represents a subtype of the combined type. Research increasingly suggests that it does not. More likely the inattentive type represents a distinct disorder primarily reflecting difficulty attending to repetitive, effortful tasks, distinct problems with organization and possibly problems with working memory. The problems that this group experiences may very well be the result of faulty skills as opposed to inconsistent or inadequate use of possessed skills. For the time being, however, the inattentive type is still considered part of a larger cluster of attention disorder diagnoses. This group responds to stimulants but not as robustly as the combined type. Ironically though these children are not disturbing or disruptive to the adults in their lives. Their disorder continues to be defined along the DSM-IV TR disruptive continuum.
As additional field studies are undertaken in the ongoing process of evolving diagnostic systems and in the preparation for DSM-V, it is likely that the diagnostic protocols will change slightly but the basic premise and diagnostic criteria are not likely to change much in the near future.
A Practical Definition of ADHD: Problems With Self-Regulation and Executive Skills
In 1990, a practical definition was proposed and revised in 1998, by Goldstein and Goldstein as a means of facilitating the ability to see the world through the eyes of children with ADHD. It was suggested that this definition would also facilitate physician’s ability to understand this group of children and assist parents, educators and other professionals in understanding the children they live, educate and work with. Understanding ADHD is the first and most crucial step in making change. This practical definition represents an effort to translate the volume of research findings and clinical symptoms of ADHD into a framework to understand the every day lives of these children. It offers a logical framework from which to evaluate and understand the seemingly illogical pattern of behavior this group of children exhibits. This practical definition was based in part on the hypotheses of Douglas and Peters (1979) and Douglas (1985). These authors suggested that children with ADHD experience a constitutional predisposition to experience problems with attention, effort, inhibitory control, poorly modulated arousal and have a need to seek stimulation. The five components of this practical definition will be briefly presented.
Children with ADHD have difficulty thinking before they act. They know what to do but don't do what they know. They have difficulty weighing the consequences of their actions before acting and do not reasonably consider the consequences of their past behavior. Their difficulty following rule governed behavior (Barkley, 1981a) appears to result directly from their inability to separate experience from response, thought from emotion, and action from reaction.
Although they may be well aware of a rule and able to explain it to you, in their environment they are unable to control their actions and to think before they act. This results in impetuous, non-thinking behavior and children who seemingly do not appear to learn from their experiences. In actuality, they have learned from their experiences but have difficulty acting efficiently upon that knowledge. Frequently they are repeat offenders. They appear to require more parental and teacher supervision than peers. They frustrate parents and teachers due to their seeming inability to benefit from experience. As one parent explained years ago, twenty-nine times he asked his child not to get into his tools. The child did so a thirtieth time. The child was able to explain what had been requested but the child's immediate need for gratification was overwhelmed by his limited capacity for self-control. Frequently, parent and teacher perspective of this problem is to label the behavior as purposeful, non-caring and oppositional, which in reality does not accurately describe what is taking place and often leads to punitive, ineffective interventions.
Children with ADHD have difficulty remaining on task and focusing attention in comparison to non-ADHD children of similar chronological age (APA, 1994). It has been suggested that as children mature they become more efficient in their ability to sustain attention with two year olds capable of sustaining attention on the average for barely a few minutes and five year olds able to sustain attention for much longer periods (Caul, 1985). From that point on, children's attention span increases quickly with age. By first grade we expect children to be able to sit and work for a half hour at a time. It is increasingly recognized, however, that the capacity to attend is intrinsically tied to multiple environmental factors. Thus, the measurement of attention as a unitary phenomenon has not provided very much benefit in the conceptualization and understanding of, as well as the assessment and intervention for ADHD. At one time it was also suspected that distractibility was the core problem (Strauss and Kephart, 1955). We are now aware that distractibility represents a minimal part of the child's problem. It is the inability to invest in the task rather than distractions that is primarily responsible for off task behavior. From an attention perspective, it has been increasingly recognized that repetitive, effortful, uninteresting and unchosen tasks are the most difficult ones for children with ADHD. Not surprisingly, these characteristics define the most difficult tasks for everyone to engage in. This reinforces an important point. ADHD represents an exaggeration, on a dimensional basis, of normal problems. Unfortunately, children with ADHD demonstrate too much or not enough of what adults have described, such as too much fidgeting around at the dinner table or an inadequate investment in tasks that must be completed. On a dimensional basis these children represent the extreme of what adults expect. Increasingly, it is recognized that this child's impulsiveness results in his or her inability to sustain attention under these circumstances.
Children with ADHD tend to be excessively restless, overactive and easily aroused emotionally. Their difficulty in controlling bodily movements is especially noted in situations in which they are required to sit still or stay put for long periods of time. They are quicker to become aroused. Whether happy or sad, the speed and intensity with which they move to the extreme of their emotions is much greater than that of their same age peers. This problem very clearly reflects their impulsive inability to separate thought from emotion. This pattern of behavior frequently frustrates parents because fifteen minutes after becoming extremely upset, the child has forgotten the upsetting event and moves on to something else. Parents, however, continue to be agitated by these events and cannot understand why the child no longer seems to be bothered. This child is then accused of lacking guilt. As one parent has aptly put it, children with ADHD wear their emotions on their coat sleeves.
(4) Difficulty with gratification.
As the result of impulsivity, children with ADHD require immediate, frequent, predictable and meaningful rewards. Once again they are at excess or exaggeration in comparison to normal children in regards to these variables. They experience greater difficulty working towards a long term goal for these reasons. They frequently require brief, repeated payoffs rather than a single long-term reward. They also do no appear to respond to rewards in a manner similar to other children (Haenlein and Caul, 1987). Rewards do not appear to be effective in changing their behavior on a long-term basis. Frequently once the reward and the accompanying structure of the behavior-change program is removed, the child with ADHD regresses and again exhibits behavior that was the target of change. Parents then perceive this child as manipulative, accusing him of blackmail or extortion. Increasingly it has been recognized that due to impulsiveness, children with ADHD appear to require more trials to consistently demonstrate mastery over behaviors which they possess. Thus, as noted, it is not that they don't learn what to do as quickly as others, it is that they do not exhibit those behaviors as effectively.
Problems result from missing the cue necessary to self-direct the behavior. Thus, they arrive at a street corner, forget to remember that the corner is a cue to look both ways and despite the fact that they understand traffic safety, blindly walk out in to the street. Because of their impulsiveness, their behavior remains consequentially bound. However, it also appears that given a sufficient number of trials and opportunity for generalization, their behavior, that is the capacity to do what one knows consistently, is shaped in a very similar way as unaffected children. For children with ADHD in regards to consequences and behavior development, the issue is not so much behavior modification but rather behavior management. The provision of a sufficient number of supervised, structured and reinforced trials for everything from simple tooth brushing behavior to social skills development is essential.
It also appears that this group of children receive significantly more negative reinforcement than others. That is, instead of learning to work to earn good consequences or having their mistakes shaped by punishment, the majority of their interactions with adults are shaped by the child's efforts to avoid aversive consequences. Because of their impulsivity and inconsistency, adults frequently place their hot breath on the child's neck. The child responds not to complete the task but to earn relief from the adult's aversive attention. Negative reinforcement appears to offer a plausible explanation for the diverse problems children with ADHD present, ranging from completing homework and not turning it in (e.g., homework is completed so mom will stop screaming not necessarily to earn a grade) to the lack of development of seemingly responsible behavior (e.g., if you are always acting to avoid an aversive consequence you learn to wait for the threat of an aversive consequence before doing what has to be done, whether it is chores, school work or appropriate behavior towards others). In many ways, children with ADHD are cursed with negative reinforcement. In our efforts to help them, we actually increase their helplessness. It is important to keep in mind that they like rewards and they do not like punishments. However, over time it is the avoidance of aversive consequences rather than the earning of positive consequences to which their behavior is shaped. They learn to respond to demands placed upon them by the environment, principally adults in the environment, when an aversive stimulus is removed contingent upon performance rather than for the promise of a future reward.
(5) Emotions and locus of control.
To the original four components of this definition, this fifth component has been added. Due to their impulsiveness and emotional overarousal, children with ADHD are often on a roller coaster ride of emotions. When they are happy, they are so happy, people tell them to calm down. When they are unhappy, they are so unhappy, people tell them to calm down. They frequently learn that emotions are not to be valued. Emotions, they come to learn, often lead to trouble. The combination of these qualities, feedback when received for emotionality, lack of ability to develop the skills necessary to control emotions and the disruption in relationships these qualities cause, exerts a significant impact on children's emerging sense of self, locus of control and likely subsequent personality. It has been argued children with ADHD appear prone to develop an external locus of control, projecting blame onto others and being unwilling to recognize and accept the role they play in their behavior. They appear vulnerable to developing certain personality problems, especially those related to anti-social difficulties likely in part because of these qualities combining with certain life experiences. They may also be prone to depression due to the lack of balance between successful and unsuccessful experiences on a day in and day out basis. It is important for physicians to recognize this emotional impact, not just because it holds importance for today but because it is increasingly recognized that the quality of children's emotional lives very powerfully shapes their adult outcome.
The concepts of impulsiveness, attention, motivation and consequences, emotional control and situational issues relative to aspects of ADHD have been critically and in some cases extensively examined. There has also been a trend to seek out and incorporate theories, concepts and research literature from diverse fields with the aim of better understanding and creating a working model of the daily behavior and cognitive processes underlying the behavior of children, adolescents and adults with ADHD. Interested readers are referred to an extensive discussion of these issues in Goldstein and Goldstein (1998). Among these issues it is critically important to recognize that a diverse literature lends strong support for impulsiveness as an important if not core deficit for individuals with ADHD.
Inefficient or ineffective impulse control appears to be at the root of poor self-regulation in regards to managing emotions, planning, organization, learning and meeting every day life demands. For practical purposes, impulsivity can be best understood as a set of problems that result from acting without control, inhibition, restraint or suppression; acting without thinking, reflection or consideration; acting without foresight, adequate planning or regard for consequences; or acting with a sense of immediacy and spontaneity.
Finally, it is important to recognize that problems with ADHD are increasingly conceptualized as representing functioning at the lower end of a normal curve for specific behaviors (e.g., the capacity to sustain effort, manage impulses, keep one’s body in place, control emotions, etc.). Thus, from a common sense perspective, as described, problems of ADHD are best understood as falling at the bottom of a bell curve. They are best understood on a dimensional basis. Thus, it matters little if you are in the bottom 1%, 2% or 5%. If 95% of children can sit, focus, complete tasks or control their emotions more effectively than a target child, that child will be quickly identified as deviant. The conceptualization of ADHD on a dimensional basis allows for a better understanding and estimation of severity. Dimensional placement is also better at predicting future life outcome than the black or white categorical definition in which you either receive a diagnosis or do not. It is not that the categorical diagnosis is unimportant, rather even children who may be subthreshold for a sufficient number of symptoms to meet the full diagnostic category can be considered impaired and diagnosed with ADHD NOS if their symptoms cause impairment. The issue that must be focused upon is that of impairment in every day life.
Disruptive vs. Non-disruptive Childhood Disorders.
Children’s emotional, behavioral and developmental disorders are defined not by cause or etiology but by the impact they have principally upon the adults in their lives. Thus, children can exhibit problems that may annoy or disrupt adults. These are referred to as externalizing. They may also exhibit a second set of problems that cause adults to worry about them but are non-disruptive. These are referred to as internalizing. ADHD represents a mild externalizing disorder. Within a larger framework it is considered mild because problems related to purposeful oppositional defiance leading to a diagnosis of Oppositional Defiant Disorder or more severe externalizing problems related to Conduct Disorder are clearly of greater disruption. These disorders will be discussed in greater depth in Section IX. In a nutshell, however, oppositional defiance leaves no doubt in the adult’s mind that the behavior is purposeful. In fact it is the apparent purposefulness of ADHD symptoms that likely misleads many adults to accuse children with ADHD of behaving in non-compliant ways. This accusation and the subsequent punishing response on the part of adults may actually precipitate the onset of resistance and oppositional defiance. In contrast, non-disruptive problems are those related to symptoms of emotional distress characteristic of depression and anxiety, as well as problems related to development such as those of language, motor skills and learning. Thus a depressed child with a reading delay would not annoy nearby adults on a bus but the child’s conditions would worry parents. In contrast, a restless, oppositional or outright delinquent child would be disruptive to any nearby adult.
Categorical vs. Dimensional Models.
The diagnostic systems of DSM-IV TR and ICD-10 are categorical models. As noted, they represent an all or nothing phenomenon. They are polythetic, such that to receive a diagnosis a child must manifest a minimum threshold of presenting symptoms. One symptom short and the diagnosis is not provided. However, on a dimensional basis, it is assumed that everyone exhibits these symptoms from a minimal to a maximal degree. On a dimensional basis, having all but one symptom necessary to receive a categorical diagnosis makes one quite different from others. A dimensional model predicts a complete and unbroken gradient for a particular skill or symptom such as impulsivity, ranging from those individuals only minimally impulsive to those mildly, moderately and eventually more significantly impulsive. Differences between individuals on a continuum are a function of severity rather than specific difference. Although categorical models may be excellent for research purposes and insurance reimbursement, they do not predict outcome nor lend themselves as easily to treatment management due to the fact that categorical symptoms tend to be qualitative while dimensional descriptions tend to be quantitative. The primary assessment methods utilized for ADHD eventually leading to the categorical diagnosis are dimensional. These are principally standardized questionnaires and laboratory tests. These will be discussed in Sections VII and VIII.
Immediate Symptoms vs. Long-term Outcome.
Parents bringing their children for assessment often have a list of immediate symptoms or problems in need of relief. This list is usually prioritized for children with ADHD based upon those behaviors that are most annoying to others. Unfortunately, a list of immediately bothersome symptoms may not be synonymous with a list of long-term symptoms that may be most predictive of future life problems. At times the behaviors and related problems of children that most annoy adults may have limited predictive validity. For example, adults often focus an inordinate amount of attention on the quality of a young child’s handwriting, yet in future life handwriting appears to predict very little. In regards to treatment with stimulant medication for ADHD, there appears to be minimal data to suggest that taking stimulants alone alters future life outcome. As a symptom reliever, however, stimulants have been strongly found to dramatically reduce the aversive symptoms of ADHD and lead to more efficient daily functioning. Given the current state of affairs, it is immediate symptoms and immediate functioning that should be the target and focus as well as rationale for the utilization of stimulant medication and the treatment of ADHD. Thus, the current conceptualization of ADHD treatment represents a two-pronged approach. Those interventions that are directly focused at reducing symptom severity for ADHD (e.g., medication and behavior management) combined with developing life factors that predict good outcome for all children (e.g., strong family, good education, supportive community, etc.).
In the past twenty years, the assessment process for ADHD has focused heavily on the concept of differential diagnosis. That is, attempting to determine if a specific set of symptoms better fits with one diagnosis or another. However, it has been increasingly demonstrated that the majority of children receiving a diagnosis of ADHD also demonstrate symptoms consistent with at least one if not a number of developmental and psychiatric diagnoses. Thus, the diagnostic process while still attempting to locate best fit for symptoms has for ADHD, has come to an equal focus on the careful evaluation for comorbid problems in addition to the diagnosis of ADHD. Research has consistently demonstrated that it is those children with ADHD and multiple comorbid diagnoses appear to fare the worst in childhood and have the greatest vulnerability for later life problems (for review see Goldstein and Goldstein, 1998 or Goldstein and Teeter, 2002).
Behavioral vs. Biological Differences.
Data are emerging suggesting that the severity of symptom complaints and for that matter symptom presentation can vary significantly within the same child suffering from ADHD based on the setting and the adults the child interacts with. The definitional process, if not the diagnostic process, must take into account this larger context. Arguing that ADHD is a biological disorder and that symptoms are consistent, unremitting and unwavering in severity across situations ignores the obvious. Insisting that these are biologically based problems, though likely accurate, has in fact created more conflict than consensus in the field of ADHD. As a biopsychosocial problem, symptoms of ADHD appear to be very powerfully contributed to by genetics and biological function. However, day in and day out behavior represents an interaction of biology and environment. The consequences or life outcome for any child are strongly mediated by life experience.
The sustained attention of children with ADHD has been suggested as highly interactive rather than unidirectionally influenced by environmental factors (Zentall, 1984). The primary issue facing most physicians are reported differences between home and school. Some researchers have argued that ADHD symptoms must manifest themselves in a scholastic setting for the diagnosis to be made. Others recognize the difference between settings, including differences within teacher and parent populations. Thus, differences in adults and settings may account for minimal or maximal differences in a number of symptom complaints and severity of complaints between settings. Research has consistently demonstrated that although parents and teachers often generally agree concerning ADHD, the rate of agreement drops dramatically when specific symptoms and severity of symptoms are discussed.
Executive vs. Secretarial Skills
Efficient functioning in the environment requires a set of processing or secretarial skills (e.g., memory, motor, attention). These skills require efficiency rather than thinking per se. Some researchers have considered ADHD a disorder of rote skill problems: inefficient attention or impulse control leading to faulty behavior. There has also been a fairly strong movement arguing that ADHD represents a problem of executive, conceptual or higher order thinking ability (e.g., comprehension, reasoning, judgment). The literature, however, has not consistently supported executive deficits as causative problems in and of themselves but rather as likely problems that occur from secretarial skill deficits, including poor impulse control (Barkley and Grodzinsky, 1994).
Sensitivity vs. Specificity
. There is a popular saying suggesting that if one’s only tool is a hammer, every problem in the world appears to be a nail. For a behaviorally defined disorder such as ADHD so easily influenced by myriad factors well beyond those few reviewed here, it is not surprising that questions arise concerning the issue of sensitivity (making the diagnosis so general that it includes 50% of the population; everyone with ADHD is identified but so too are an excess number of false positives), in contrast to specificity (identifying a very small group of children all of whom clearly have the disorder but also identifying too many false negatives). For the time being, the system of diagnosis for ADHD is based upon behavior. Too liberal an interpretation results in seemingly every child having the disorder. Too conservative fails to identify children in need. A poor understanding of children’s behavior at different developmental stages may result in over diagnosis of young children and under diagnosis of teens and adults. Therefore, the integration of diagnostic information must provide a balance between too liberal and too conservative symptom thresholds. Fortunately, the standardized questionnaires most physicians use have considered this issue. Most offer suggested cutoff points, such that a group of clearly impaired children will be diagnosed with ADHD.
A Brief Historical Overview: Early Citations
St. John the Baptist provides what may be the earliest report of any symptom traditionally related to ADHD. Luke 1:41 cites John describing fetal hyperactivity as “the babe lept in her womb.” There are allusions in many of the great early civilizations to these childhood problems as well. In 1845, Hans Hoffman wrote a poem about “The Story of Fidgety Phillip.” In this poem the hyperactive-impulsive symptoms that today are recognized as the most debilitating of ADHD are very accurately described along with their aversive consequences. This poem set the tone for these problems a stemming from naughtiness as well. Thus, it is not surprising that in 1902 George F. Still, an Englishman, described Still’s disease, a problem he characterized resulting from a defect in moral control. Picking up upon the prevailing thought developed in the 1890's that inattentive, restless and over aroused behavior was exhibited by brain injured individuals, Still suggested that children with this problem had experienced some type of brain damage. Through the 1930's the hypothesis that excessive motor activity was related to brain damage or dysfunction was very popular.
Charles Bradley, a physician in Rhode Island, initiated the first of a series of studies that eventually spanned forty years and greatly influenced the field of ADHD. Bradley and his colleagues utilized dextroamphetamine to treat children with syndromes of cerebral dysfunction or organic brain syndrome (Bradley, 1937). Bradley documented improvements in a variety of tasks in 60% to 75% of these children. In 1937 Bradley attributed improvement in the changed emotional attitude of these children towards their academic tasks to the drug treatment. Subsequent investigators were able to replicate Bradley’s work.
Working at the same facility as Bradley, Laufer and Denhoff (1957), a psychiatrist and a pediatrician, are credited with the first behavioral description of the hyperactivity syndrome. The 1950's saw a growing use of psychotropic medications. Laufer and Denhoff’s tripartite set of hyperactive, inattentive and impulsive symptoms were an early target of stimulant medication trials.
ADHD as a Cultural Phenomenon
The opinion that ADHD represents a specific cultural phenomenon (e.g., a North American disease) has been clearly disputed by well constructed research literature. ADHD has been accepted as a cross cultural disorder (Swanson, 1997). However, culture is but one ingredient that may predict how well or poorly symptoms of ADHD are accepted by a given community. It is a disorder in which the severity of the child’s problems results from the interaction of temperamental traits and the demands placed upon the child by the environment. In a non-technical culture, these symptoms may not be as disruptive as in a well developed cultural in which five year olds are expected to sit for long periods of time, completing often boring, repetitive school work. Researchers have documented a fairly consistent pattern of ADHD symptoms across multiple cultures, including those as diverse as China, Great Britain and India. Very clearly, qualities of ADHD are universal to the human species.
Controversy and Misdiagnosis
Not surprisingly, in our market economy as a particular problem becomes popular, controversy and opinion concerning that problem as well as diversity of solutions surfaces. As eminent child psychiatrist Dr. John Werry has noted, wrong information is frequently worse than no information. Although there is a clinical consensus concerning the definition and comorbid problems ADHD children experience, the lay literature abounds with inaccurate and inconsistent information. Unfortunately, some of this information is often incorporated into clinical practice. This phenomenon is very clearly reflected in a recent ambulatory care quality improvement program survey completed by the American Academy of Pediatrics with their pediatricians (1998). Although the pediatricians utilized a fairly standard means of assessing and diagnosing ADHD, nearly 76% reported recommending elimination of food additives and more than 67% had recommended elimination of food preservatives. Forty-five percent recommended vitamin therapy, 42% visual training, nearly 21% plant extracts and 16% antioxidants. Surprisingly, only 6% recommended elimination of sugar. None of these treatments in well-controlled, double blind research been found to be beneficial for ADHD. Yet, it appears that even educated physicians find themselves relying on anecdotal or marketing information in patient care. Readers interested in a more extensive overview of controversial treatments are referred to Ingersoll and Goldstein (1993) and Goldstein and Goldstein (1998).
The controversy, diversity and at times confusion concerning various aspects of ADHD in part may be the result of a tradition to view this disorder as a unitary phenomenon with a single cause. Voeller (1991) suggests it may be better to conceptualize ADHD as a “cluster of different behavioral deficits, each with a specific neuro-substraight of varying severity occurring in variable constellations and sharing a common response to psychostimulants” (pg.54). It has been well demonstrated that from an etiological perspective, a myriad of conditions beyond just genetics may lead to ADHD symptoms. These can be as diverse as Fragile X, Turner’s Syndrome, Noonan’s and William’s Syndrome. All are chromosomal or genetic abnormalities in which attentional problems have been reported (Hagerman, 1991). Toxins resulting in disorders such as fetal alcohol syndrome, cocaine exposure in utero, lead and vapor abuse and even radiation therapy secondary to leukemia have all been reported as responsible for creating inattentive and impulsive problems.
The second greatest controversy currently associated with ADHD likely lies in the area of intervention. Psychosocial treatments such as cognitive training (e.g., teaching children to stop, look and listen or pay attention) once considered promising in directly reducing ADHD symptoms now are recognized as at best offering only adjunctive help. The greatest volume of literature on ADHD is likely in the investigation of the benefits of psychostimulants and related medications directly upon symptoms of ADHD. A very large, diverse and scientifically rigorous literature has consistently demonstrated the benefits of psychostimulants for ADHD symptoms (for review see Greenhill and Osman, 2000).
Nonetheless, although it is presently recognized that stimulants offer excellent short term symptomatic relief for ADHD symptoms, they have not been demonstrated in the long run to significantly alter the life course for those with ADHD. Although common sense would dictate that if each day of one’s life was better the sum total of one’s life would be better, this finding has not been reported on a long term basis for the population with ADHD. The life outcome for children with ADHD taking medication versus those who do not take medication does not appear to be markedly different (for review see S. Goldstein, 1997b). However, saying the data has not been generated is not the same as concluding that the hypothesis is flawed. On the other hand, the biopsychosocial nature of ADHD makes it reasonable to conclude that it is the environment more than the direct treatments for ADHD that predict life outcome and course for affected individual. As discussed above, it is important for physicians to possess accurate information concerning the diagnosis, comorbidity, symptom course, life outcome and most importantly, interventions for ADHD. It would appear that many pediatricians in a well meant effort to assist their patients, may be leading them down a primrose path. This then only fuels further controversy and misinformation.
ADHD as a Biopsychosocial Disorder
It is important to recognize that ADHD is a biopsychosocial disorder affecting individuals differently but remaining throughout their life span. This shifts physicians’ focus from attempting to search for a cure to developing a balance between management and reduction of immediate symptom problems and the building in of resilience factors which are hypothesized to increase the likelihood of positive, long-term adult outcome. As Bob Brooks (1994) has noted, the best chances of success for children with ADHD lies in the appropriate treatment of their ADHD along with the “building of islands of competence” to ensure opportunities for success academically, socially and in community activities. The core symptoms of ADHD affect a significant minority of the population but for affected individuals, they represent a poor fit between society’s expectation and those individuals’ abilities to meet those expectations. The phenomenon is distinct from other disorders of childhood and adulthood and can be reliably evaluated and effectively treated.
ADHD as a Disorder of Inattention
By the 1970's research strongly began suggesting that the core problem in ADHD was not excessive activity but inattention. This lead to a major shift in the focus of research, diagnosis and treatment. Through the 1980's although the symptoms of impulsiveness and hyperactivity were studied but primarily inattention was considered the core deficit of the disorder. Research in the field of ADHD in the 1980's increased at nearly an exponential rate. Critics blamed parents, schools and the society at large for the increase in ADHD symptoms. The rate of the diagnosis of the disorder was equally accelerated yet a thoughtful analysis of the current diagnostic and treatment data suggests that it is likely that less than half of children with ADHD are currently identified and treated. Through the 1980's and into the 1990's the concept of ADHD as a life time disorder potentially affecting all areas of an individual’s functioning and possibly resulting in significant adult disability has become increasingly accepted.
ADHD as a Disorder of Impulsivity and Poor Self-Regulation
The change in focus to impulsivity as the core problem and significant cause of serious consequences for the majority of ADHD children has not come easily. The public has finally accepted the concept of attention deficit. In fact, inattentive problems as a cause of life’s difficulties have become well accepted by our community. The preponderance of the research literature in the past ten years, however, suggests that in laboratory settings the problem is not that these children cannot pay attention but that they do not pay attention as effectively as others. Their inconsistent attention occurs in repetitive, effortful situations and appears to primarily be a function of poor impulse control or faulty self-regulation. Converging lines of evidence, including laboratory tests, measures of physiological functioning and neuroimaging studies increasingly support disinhibition or poor self-regulation as a core deficit in ADHD (Barkley, 1997c; Quay, 1997).
Developmental Course: Symptoms of ADHD Through the Life Span
As researchers have become more sophisticated, a wider range of precise questions, evaluating consistency in ADHD problems among various settings and consensus by a number of raters concerning the severity of problems, have been found to increase the accuracy of diagnosis. Not surprisingly, when DSM symptoms are used epidemiologically, they may identify children with ADHD but also those with comorbid and other problems, finding in some studies an incidence rate of ADHD of nearly 15% to 18%. However, when a more careful analysis is conducted, including assessment of impairment, the rate of ADHD over the past twenty years consistently drops to a more reasonable, 2% to 7%. It is important for the reader to recognize that to some of extent, as discussed, the issue of prevalence is artificially determined. ADHD is defined by observable behavior not blood or brain tests. Thus the issue is not black or white nor specifically categorical but as previously discussed, dimensional. The prevalence or incidence of ADHD varies depending upon the stringency of the diagnostic process and criteria. What is important to keep in mind is that there is a significant minority of children who due to their impulsive qualities are compromised in their ability to meet environmental expectations and therefore meet the diagnostic criteria for ADHD. There is also no doubt that prevalence has increased as diagnostic criteria has changed. The consensus among some recent epidemiologic research studies finds an incidence of between 8% and 10% with less than 1% meeting the hyperactive-impulsive criteria and the remainder being divided evenly between the combined and inattentive types.
A recent National Institute of Mental Health Conference on sexual differences in ADHD noted the need for increased research in this area (Arnold, 1996). A number of studies in the past ten years have addressed this issue. Females with ADHD have been found to be more frequently retained in school and evidence greater impairment on certain cognitive tasks across developmental levels. Males with ADHD have been demonstrated to present relatively more aggression towards peers than females. Females with ADHD, however, appear to demonstrate a greater degree of internalizing problems (e.g., anxiety and depression) than males. Interested readers are referred to Gaub and Carlson (1997).
Infants, Toddlers and Preschoolers
ADHD is not a diagnosis of infancy. It has been demonstrated, however, that approximately 10% of infants appear difficult in their early temperamental presentation. It has been suggested that this group may be at greater risk to subsequently receive a diagnosis of ADHD. However, low socio-economic status has also been highly correlated with increased risk for a diagnosis of ADHD. Parents’ perception of children’s temperament relative to their actual temperament as observed by trained raters has also been cited. In retrospect, the most common problems parents of children complain about during their infancy years include delay in developing speech, toileting and chronic mild illness.
The overactive, temperamental infant is at risk to become the hyperactive, non-compliant preschooler. The identification of ADHD in preschool continues to be complex. Although the DSM-IV TR guidelines provide a ceiling by age seven when the symptoms must have been observed, they do not provide a lower limit or cutoff under which the diagnosis should be made with caution. As noted in the previous discussion of sensitivity and specificity, there is a tendency to over diagnosis younger children with the disorder. Physicians must be careful to draw the line between a three year old presenting with age appropriate behavior that may be typically vigorous and unrestrained and a child presenting a pattern of hyperactivity and impulsivity that is clinically significant. The erratic nature of symptoms and their variability as a function of situation makes the physician’s job that much more difficult as the physician must often rely almost completely on parent report concerning young children’s behavior. Further, a higher percentage of preschoolers with ADHD present with speech and language problems than in the normal population (Baker and Cantwell, 1987). It has been repeatedly demonstrated that young children with language impairments often, out of frustration, develop a pattern of hyperactive, impulsive and related disruptive behavior.
It may be best for the reader to keep in mind that research has demonstrated that when three year olds with early signs of hyperactivity and disruptive behavior are followed, nearly one half by school age are reported as experiencing behavioral problems with nearly one third receiving diagnoses of Attention Deficit Hyperactivity Disorder (Campbell, Ewing, Breaux and Szumowski, 1986). In summary, it appears that there is a group of infants whose behavior reflects a lack of fit in regards to qualities of temperament that may make them much more difficult to parent. The cause and relationship of children’s temperament impacting parents or environmental factors contributing to problem severity is still not well understood. Physicians should be reminded that a significant percentage of children receiving a diagnosis of ADHD are described by their parents, even through the infancy years, as being more difficult than siblings.
Behavior once dismissed as immature is no longer tolerated or accepted as children enter school. Given the strong biological underpinning of ADHD, this continuity of problems is not surprising. Within the home setting the child with the combined type of ADHD is a negative force. The inconsistency in the child’s behavior escalates family stress, even for the children whose primary problems reflect inattention rather than hyperactivity. Children with ADHD are described as beginning but never completing tasks at home or at school. They often receive a large amount of negative attention from their parents for what they are not doing. They experience an instability in sleep patterns as well. (Gruber, Sadeh and Raviv, 2000)
It has been suggested that during the middle childhood years children with ADHD appear to be at much greater risk to fall behind academically, even in the absence of having a specific learning disability. Academic tasks such as spelling, math facts and writing requiring practice for proficiency, often pose a challenge. This group of children also falls behind in their ability to socialize effectively and when accomplished in a particular extra-curricular activity often struggle due to their poor self-regulation. Children with ADHD during the middle school years are more likely to find themselves in special education, repeat grades and receive academic tutoring. Their performance is found to be weaker than siblings on measures of intelligence (Faraone, Biederman, Lehman and Spencer, 1993). However, a discussion of co-occurring problems in Section IX will reveal that these comorbid problems are more likely culprits for this excessive pattern of school problems. It is important for the reader to recognize that children with ADHD possess a normal range of intellectual ability but may not perform consistently up to their ability because of self-regulation problems. Sociometric studies point to children with ADHD as rarely being chosen by peers as best friends, partners in activities or seatmates. They often receive the poorest teacher ratings for academic competence and their overall rate of negative interactions with their teachers is much greater than other students.
The middle childhood years are when most children with ADHD are referred, subsequently diagnosed and treatments attempted. Current review of the literature suggests that physicians need to be cognizant of the myriad impact symptoms of ADHD have on children’s functioning and mastery at this age, as well as the additional co-occurring problems that may also impact and lead to similar negative outcomes at home, school and in the community. The diagnostic process must be sensitive to these data. In light of these data, lack of treatment success for ADHD following diagnosis during these years may be due as much to lack of attention to comorbid problems as to lack of effectiveness for specific ADHD treatments.
Recent research has supported a diagnostic continuity in the features, families and patterns of comorbidity in children and adolescents receiving diagnoses of ADHD (Biederman, Faraone, Taylor, Sienna, Williamson and Fine,1997). Longitudinal studies following groups of children with ADHD into their teen years consistently finds high rates of comorbid disruptive and non-disruptive problems including various types of depression, anxiety, oppositional defiance, conduct disorder and school failure.
occurs in those teens with ADHD also developing conduct disorder. Academically, adolescents with ADHD fail to finish work, are disorganized and described by high school teachers as having trouble following directions. In class and at home they may over-react to the teasing of peers. They may be less physically hyperactive but continue to possess a low frustration threshold. Although those youth with the inattentive type of ADHD may not demonstrate disruptive problems, nonetheless they still struggle to perform up to their capabilities in school settings. It is important for the reader to recognize that the discussion of children with the inattentive type of ADHD is often brief as the short history of this diagnostic entity results in limited availability of peer reviewed published research.
Differences from normal controls are most likely apparent when teens with ADHD are administered tests long enough to endure potential for boredom and when adult supervision is not immediately present. Fischer, Barkley, Fletcher and Smallish (1993), based upon their longitudinal studies, concluded that teens with ADHD demonstrated a developmental or maturational lag and do not appear to catch up. They continue to have more conduct and learning problems, exhibit more hyperactive, inattentive and impulsive behavior than controls. They are rated by their parents as having more numerous and intense family conflicts. However, it should also be noted that additional family factors play a significant role in the adolescent and subsequent adult outcome of those with ADHD (for review see S. Goldstein, 1997b). Correlates of delinquency have included childhood anti-social behavior problems, low verbal intelligence, reading difficulty and family adversity. When these factors are taken into account, ADHD is not particularly predictive of delinquent problems. In contrast, the pure attention deficit group more often demonstrates normal family functioning, intelligence and reading scores. They demonstrate only mild antisocial behavior in middle childhood. In fact, Moffitt (1990) reported that in a significant group of children with ADHD in the absence of comorbid conduct problems, home and family conditions were actually slightly more favorable than those in the normal group.
Adolescents with ADHD present a significant challenge for the physician. As the number of environmental and psychosocial stressors increases (e.g., low socio-economic status, family psychiatric history, etc.) and number of comorbid diagnoses increases (conduct disorder, depression, learning disability, etc.) the physician is faced with a tidal wave of problems that may overwhelm not only the adolescent with ADHD but his or her family and the best efforts of care providers. Adolescents newly diagnosed with ADHD and comorbid problems are at even greater risk as their patterns of interactions with the environment are frequently well entrenched and reinforced. These teens are often unwilling to accept responsibility for their problems and resistant to treatment. Increasingly work with teens experiencing ADHD has focused on helping the adolescent accept his or her problems and become an active rather than passive participant in the treatment process. It continues to be the case that the initial treatment hurdle with adolescents experiencing histories of ADHD is to convince them to be active, responsible partners in the assessment and treatment process.
Although some researchers have suggested that the persistence of ADHD into adulthood might reflect learned behavior, the concept of a fundamental disturbance in the central nervous system of adults with ADHD has been well documented. The picture of ADHD into adulthood can be extremely varied. Adults with histories of ADHD appear to fall into three categories: (1) those who experience childhood ADHD but seem to function fairly normally as adults; (2) those who continue to have significant problems with ADHD as well as life difficulty involving work, interpersonal relations, self-esteem, anxiety and emotional lability; and (3) those who develop serious and significant psychiatric and anti-social problems and are markedly dysfunctional. Soon to be published longitudinal studies from three sites in the United States are finding a very high rate of comorbid psychiatric problems, particularly depression in both males and females with histories of ADHD (Barkley, personal communication; Biederman, personal communication; Robin, personal communication).
At least half of adults with histories of ADHD appear to develop markedly dysfunctional personality disorders, including high rates of borderline, antisocial and passive aggressive personality disorders. At least half of adults with histories of ADHD develop a rather pessimistic, helpless, disorganized pattern of interacting with their environment. Contrary to the popular belief that adults with ADHD are bright, creative and outgoing, nearly 50% demonstrate this dysfunctional cluster, in comparison to only 4% of a normal population. At least 70% in one longitudinal study were described as abusing or being dependent on alcohol or related substances.
Most commonly endorsed ADHD symptoms by adults include difficulty following directions, poor sustained attention, a tendency to shift activities, to be easily distracted and lose things. Further, this group experiences lower educational achievement, poorer self-esteem and more marital problems than normal controls. As Biederman, Faraone, et al. (1993) concluded, referred and non-referred adults with histories of ADHD appear to have patterns of demographic, psychosocial, psychiatric and cognitive features that mirror the well documented findings among children with ADHD. Clearly, much more research is needed to better understand multiple outcomes, particularly those individuals with ADHD who manage to find success. Research must also focus heavily on treatment as at this time of the thousands of peer reviewed, published studies concerning ADHD, fewer than 100 have dealt directly with adults.
The Causes of ADHD
Causes for Which There is Minimal Support
Commonly suspected causes of ADHD have included toxins, developmental impairments, diet, injury, ineffective parenting and heredity. It has been suggested that these potential causes affect brain functioning and thus ADHD can also be considered a disorder of brain function.
At one time ADHD was referred to as a minimal brain dysfunction. This description was dropped by the 1950's due to an inability to identify specific physical or biochemical differences in the brains of individuals with ADHD. Given newer radiologic and related technology, such differences have been demonstrated. Nonetheless, the term minimal brain damage or minimal brain dysfunction has not come back in vogue. Although some children may demonstrate symptoms of ADHD as part of a more pervasive organic brain syndrome secondary to a direct trauma, the majority of children with ADHD do not have a demonstrated history of brain injury.
There is strong evidence that dietary sugar does not cause ADHD symptoms to worsen in groups of children. Although it is impossible to prove that sugar never worsens behavior in any child, carefully controlled studies failed to demonstrate that sugar ingestion by children is a significant contributor to the problem of attention deficit. In relation to ADHD, however, other foods or food additives have received possibly even wider interest that sugar. Feingold (1974) hypothesized from anecdotal observations that ingestion of certain commonly occurring foods and additives had a toxic effect and contributed to behavioral deterioration. He was concerned about artificial colors and a group of food constituents referred to as natural salicylates. These are compounds chemically related to salicylic acid found in many fruits and other common foods. Feingold postulated that elimination of these from the diet would produce substantial improvement in behavior. In 1986 when Esther Wender wrote a review of food additives, the conclusions were clear. Only one study suggested a significant effect of food additives. Subsequently, however, a number of additional studies have re-examined the question. The new approaches examine the combination of many substances and evaluates children on diets so restricted that all their food must be supplied by the examiners. Although there have been some reports these restricted diets can lead to improvement for some children, the available research does not support dietary intervention as an effective treatment for ADHD. Only further research will determine if this approach has any relevance at all to the daily lives of most children with ADHD.
Fetal Exposure to Drugs and Alcohol.
Alcohol and other substances consumed by mothers during pregnancy are transferred through the placenta to the fetus. It has been suspected and reported that in mothers abusing substances during pregnancy, there is a higher incidence of medical problems ranging from ADHD and learning disabilities to more severe impact such as Fetal Alcohol Effect. The available research inspires substantial concern that drug and alcohol exposure represents a risk factor for the development of ADHD during pregnancy. However, it is difficult to separate how much of the risk is due to the inheritance transferred from parents who suffer from both ADHD and possibly even a genetic based risk to abuse substances, how much is due to the chaotic environment in which these children are often born, and how much is due directly to the toxic effect of the drug or alcohol exposure.
. Some children with thyroid disorders show hyperactive behavior. Hauser and colleagues (1993) studied families afflicted with generalized resistance to thyroid hormone (GRTH). They found a close association between the inherited GRTH and ADHD symptoms and concluded that the study identified a linkage between ADHD and this genetic abnormality. The linkage could be due to a lack of thyroid hormone effect causing ADHD or the close proximity of the resistance of the GRTH gene to a gene that causes ADHD. Although these findings are interesting, they are not relevant to the majority of children with ADHD. Based upon the evidence, thyroid disorders are not a significant cause of ADHD.
Other Endocrine Disorders and Toxins
. There have been single case reports of low cholesterol, cortisol levels, amino acid abnormalities, candida yeast, serum carnosinase and cadmium toxicity as possibly being isolated causes of ADHD. Interested readers are referred to Goldstein and Goldstein (1998) for further review. Of interest is a study by Kiessling, Marcotte and Culpepper (1993) in which some children following strep infections have been found to produce anti-neural antibodies raising questions about a link between the production of these antibodies and symptoms of ADHD.
Lead is a trace element that has no known use in the human body. Ingested flakes of lead paint can poison the energy production within brain cells. As brain cells become more and more swollen, general brain function decreases and thinking becomes confused. Convulsions can occur and swelling can progress to brain injury and ultimate death. Most research with lead ingestion in children has focused on the relationship between lead level and a decrease in intelligence. Children living in high lead environments have been found to have higher lead blood levels. This has further been associated with lower non-verbal I.Q. However, studies of children with ADHD have rarely found elevated blood lead levels. These findings suggest that there may be a group of children with ADHD or developmental symptoms that, at least in part, are the result of lead exposure. However, this represents a very small minority. How much of the behavior and learning problem is caused by other differences (e.g., genetics, parenting, etc.) or by sample bias (e.g., higher percentage of males than females in the high lead group) is yet to be determined. Although there is a disturbing suggestion of a relationship between lead ingestion, learning and attention problems, this is not believed to be a primary cause of ADHD.
Allergy causes a wide range of symptoms, including stomach pain, diarrhea, runny nose, wheezing and sleeplessness to mention but a few. ADHD has been found to be more common in children treated for atopic problems (e.g., eczema, hayfever and asthma). It has been suggested that a small group of children with ADHD may be provoked by allergies (Marshall, 1989). However, in a large study of over 1,000 children in the development of allergic symptoms was not associated with increased incidence of ADHD (McGee, Stanton and Sears, 1993). Further, there is no research to suggest that treatment for atopic problems such as asthma leads to an increase in reports of ADHD symptoms. Although parents have reported that treatment with theophylline causes a worsening in some children’s behavior, this finding has not been consistently observed in well structured studies (Bender and Milgrom, 1992).
Otitis Media. Over ten years ago an association between otitis media (ear infection) and hyperactivity was reported by Hagerman and Falkenstein (1987). Initial reports of increased incidence of ear infections in children with ADHD raised concern that ADHD might be an additional sequelae of otitis. Prospective studies, however, have suggested that otitis media does not predispose one to ADHD. It is possible that although a screaming child is not more likely to develop otitis he or she may be more likely to have it diagnosed.
Heredity: The Genetics of ADHD
The majority of children with ADHD are found to have none of the specific etiologies mentioned above. A positive family history of ADHD symptoms, however, is a common finding. In many children, a close family member has had symptoms of ADHD in childhood. Symptoms of ADHD present in parents of children with ADHD four times more often than those of controls (Biederman, et al., 1986).
The genetic contribution to ADHD has been postulated by a number of researchers. The underlying mechanism genetically has recently been suggested to be associated with a single dopamine transporter gene as well as with variations in the D4 or dopamine receptor gene (Cook, Stein and Krasowski, 1995; LaHoste, Swanson and Wigal, 1996). It has also been suggested that the trait locus for reading disability on chromosome 6 may also be associated with ADHD (Warren, et al., 1995). Among the most recent findings of importance, however, has been the discovery in a number of studies of the relationship between ADHD and the DRD4 gene. The seven repeat form of this gene has been over-represented among children with ADHD (LaHoste, Swanson and Wigal, 1996). The finding of an association between this gene and ADHD is interesting as this gene has previously been associated with personality traits related to high novelty seeking behavior. However, it is important to keep in mind that only approximately 30% of individuals with ADHD appear to have this seven repeat gene. Although this rate is nearly twice that found in the normal population, this is obviously not the major gene for ADHD since most people with ADHD do not have this form of the gene.
Twin studies often help differentiate genetic and environmental factors. Monozygotic or identical twins have identical genetics as they originate from the same fertilized egg. Dizygotic or non-identical twins differ from each other genetically as they arise from separate eggs fertilized by different sperm. Monozygotic twins raised in different environments (adopted by different sets of parents) will develop similar genetically determined characteristics. The concordance of ADHD symptoms in identical twins over a series of studies has been found to range between at least 70% to 90% (Levy, Hay, McStephen, Wood and Waldman, 1997). The overlap is nearly 40% in non-identical twins. Thus, it is fair to conclude that heredity appears to represent the most common identifiable cause of ADHD. However, the disorder represents a complex interaction of genetics and experience (for review see Rutter, 1997). From an experiential perspective, the non-shared environment likely plays a more significant role than the shared environment in the presentation of behavioral disorders such as ADHD. Thus, ADHD can be best conceptualized as a disorder in which symptoms are strongly influenced by genetics but outcome may be equally influenced by a combination of genetics and environment.
Understanding Brain Functioning
Chemicals such as dopamine flow from the brain to the cerebral spinal fluid surrounding the brain. Changes in dopamine metabolism as measured in spinal fluid have been found in children with ADHD. Often there is a higher concentration in the spinal fluid of children with ADHD than normals supporting the view of an alteration in the central dopamine - mediated synaptic function as being the critical link in ADHD symptoms. However, other studies have suggested the importance of the noradrenaline system and the interaction of noradrenaline and dopamine systems in ADHD. Finally, other researchers have found that particularly aggressive males with ADHD demonstrate lower prolactin response leading to a conclusion that there may be a relationship between lower serotonergic function in this population. Attempts to demonstrate that ADHD is the result of a change in dopamine, noradrenaline or serotonin may suffer from oversimplification. The interconnection of dopamine, noradrenaline and serotonin systems raises the possibility that change in the function of the dopamine system may be reflected as decreased or increased performance of a different chemical system such as the noradrenaline or serotonin systems.
To understand this, consider the hypothetical change in dopamine in children with ADHD. This finding at first might seem to imply that dopamine is responsible for ADHD, however, a possible alternative explanation is that dopamine changes were a reaction to the ADHD. In other words, another system such as the noradrenaline system might be responsible for ADHD and in response to the noradrenaline change dopamine metabolism changes. These are complex systems. Nevertheless, the finding that metabolism of these chemicals is attended in children with ADHD and that these chemical systems are changed by the medications that are used to treat ADHD lead to the important conclusion that the chemical systems that have their nerve cell bodies in the brain, particularly brain stem, are important factors in ADHD.
There is also a significant research literature suggesting that differences in certain brain locations, particularly asymmetry or lack of symmetry or smaller size are also associated with ADHD. These findings were initially hypotheized based upon performance studies. For example, children with ADHD have been found to experience more difficulty with right hemisphere functioning, motor impersistance, sustained movement, tongue protrusion, lateral gaze and central fixation. However, there has also been evidence that not all attentional processes reside in the right hemisphere.
Network theories of ADHD suggest frontal striatal or posterior parietal differences as impacting symptoms of ADHD. The selective attention network deals with engagement and disengagement as well as orientation of attention. It is connected among the parietal lobes, thalamus and mid brain. Executive attention is postulated to be a function of the anterior cingulate and basal ganglia which detects and brings information into awareness. A vigilance network has been postulated for the front frontal lobes for the purpose of maintaining attention. Injury or abnormality in these networks will produce myriad findings, including symptoms of ADHD. However, even in uninjured individuals differences in these systems have been reported.
For example, the development of the right anterior cingulate region is proportional to development of ADHD. Several MRI studies of children with ADHD demonstrate that in comparison to normals, there is an increased risk for asymmetry and unusual findings. Reversal of the normal left to right asymmetry in the caudate, asymmetric caudate volume with the right larger than the left, and differences in right hemisphere basal ganglia and frontal lobe size have all been reported (Semrud-Clikeman, Steingard, Filipek, et al., 2000).
Further, total cerebral volume has been found to be smaller for boys with ADHD. This study by Castellanos and colleagues (1996) also found a loss of normal right/left asymmetry in the caudate and a smaller right globus pallidus right anterior frontal and cerebellar regions were seen. In addition, there was a reversal of the normal lateral geniculate asymmetry. The authors concluded that the cause of ADHD as a dysfunction of the right side pre-frontal striatal system was supported by these measures. Morphological studies of the corpus callosum, the main pathway for connections between the hemispheres, has also resulted in atypical findings in ADHD. It is important for the reader to keep in mind, however, that these are studies with few subjects and difficult to replicate. Findings have not always been consistent but there is a sufficient volume of studies most likely indicating structural differences.
Taken as a whole, it is reasonable to conclude that a dysfunction of the frontal striatal system is likely playing a role in the development of ADHD. It should not be surprising that the search for structural abnormalities underlying ADHD has been as elusive as finding consistent structural abnormalities underlying mental retardation, learning disabilities and other mental illnesses.
Efforts to directly study brain chemistry by evaluating the brain’s ability to metabolize glucose or oxygen through the utilization of PET or SPECT scans has also demonstrated differences in ADHD. A low brain metabolism in pre-frontal and cingulate regions as well as the right thalamus, caudate and hippocampus has been reported for adults with ADHD.
Regional abnormalities of glucose metabolism demonstrated by PET studies have been widely publicized and have appeared to show a fundamental, biologic difference between ADHD and normal subjects. However, difficulties in reproducing these studies have left some doubts as to the significance of these findings.
It is reasonable to conclude that the clinical disorder of ADHD can be seen as a dysfunction of an attention or self-regulation system. This system involves connections between the brain stem, frontal, parietal and limbic systems and right hemisphere neurons. Chemical systems, particularly noradrenaline and dopamine as well as other anatomic locations such as the frontal lobes or right hemisphere are involved as well, suggesting an attentional or self-regulatory system in the brain. Understanding the brain in this way can be used to understand various kinds of data concerning ADHD. Treatments that improve the functioning of the nerve cell bodies, axons, nerve endings, neurotransmitters or receptors, would result in improvement of the system. Injury to dopamine nerve endings would decrease efficient functioning. Low blood flow to the basal ganglia or low glucose utilization of the frontal lobes, even right hemisphere damage, can be seen as impacting this system, resulting in decreased activity in the frontal lobes. Stimulants and other chemical agents that improve ADHD symptoms could act to improve the functioning of nerve cell bodies in the brain stem or the release of neurotransmitter in the nerve endings to improve sensitivity of the post synaptic receptors. Thus, multiple defined locations create a network. The efficient functioning of this network is essential for effective self-regulation. When this network does not function effectively, self-regulation is poor. The phenotype is then reflected in symptoms of ADHD. However, the exact method by which a gene or certain genes code for certain proteins which then affect brain size, structure and chemistry has yet to be well understood.
Medical Evaluation of ADHD
The Physician’s Dilemma
Physicians often find the understanding and treating of children with ADHD more difficult than expected. The complexity of information required to make the diagnosis and develop medication and non-medication treatment options is greater for ADHD than for most medical illnesses. In a brief period of time most physicians are able to take an appropriate history, perform needed diagnostic studies and prescribe simple and effective treatments. For most common childhood illnesses this process may not take more than a short period. The patient, family and physician all may feel comfortable that a proper evaluation and treatment of the problem has been accomplished. Yet ADHD does not fit into this mode of medical evaluation and treatment. Information required to make the diagnosis cannot be obtained simply as the result of a brief conversation between physician and parent or brief examination. Important information is often obtained from parents, teachers, even siblings. Diagnostic tests are often not simple to order, perform or interpret. A history, which is the most ecologically valid means of diagnosis ADHD secondary to long term direct observation, can take between an hour and two hours to obtain.
In response to this dilemma, some physicians refuse to diagnose and treat ADHD while others obtain very brief histories and prescribe medications as a test of the diagnosis. Either of these approaches is unfortunately not of great benefit to the patient. Physicians with appropriate training and expertise may choose to expand their role beyond a simple medical evaluation. A physician may choose to undertake every aspect of the diagnosis and treatment of ADHD or a physician may choose to work with one or more non-medical practitioners such as a psychologist or educational specialist to accomplish the other aspects of the evaluation. The physician along with the patient, parents and others, including teachers, psychologists or educational specialists must work together in a loosely connected, interdisciplinary team.
The Role of the Physician in the Diagnostic Evaluation
The role of physician in the diagnostic evaluation of children suspected of having ADHD can be described through answers to four questions:
1. Does the child’s history or examination suggest the etiology of an underlying, medically remedial problem contributing to ADHD symptoms?
Although by far the majority of children presenting with ADHD symptoms likely do not have an underlying, medically remediable cause for their problems, it is prudent for physicians to consider the possibility that presenting problems could be the result of a specific medical illness. It is important for physicians routinely review systems in such an evaluation involving the organs, including the central nervous, gastrointestinal, genitourinary, cardiovascular, hematopoietic system and skin systems. The ease of this evaluation for the medical practitioner and the likelihood of its being negative do not diminish its importance.
2. Are any medical diagnostic tests needed to determine the presence or absence of remediable medical problems contributing to ADHD symptoms?
In some cases, clinical evaluation alone may not be sufficient to exclude medical illness as the underlying cause for ADHD. This is particularly true when problems such as petit mal epilepsy are suspected and an electroencephalogram is warranted. However, medical diagnostic tests should be reserved for specific indications (Rapin, 1995). Blood tests and other common medical tests such as CT, MRI and EEG are sometimes needed for children suspected of having ADHD. However, it is often additional symptom presentation above and beyond those of ADHD that warrants such assessments. Usually history and examination are sufficient to exclude such illnesses and these additional diagnostic tests are rarely needed. It is important for the reader to understand the difference between research findings and clinical practice. Although research studies have found differences in EEG patterns, brain structure and even evoked potentials in children with ADHD, the accuracy of these instruments for a single child in the diagnostic process is not good. Although some children with ADHD may demonstrate these abnormalities, others do not. Findings on group data are of interest but may not translate well as diagnostic tools for single children in clinical settings. Although continued research in this area may ultimately yield a useful clinical tool, for the time being such tools are not necessary in the assessment of ADHD. Further the American Academy of Neurology (Nuwer, 1997) has found that evidence is lacking for the usefulness of EEG and evoked potentials in the medical evaluation and diagnosis of ADHD.
3. What are the findings on a physical and neurological examination?
Although over twenty years ago it was suggested that the diagnosis of ADHD could be made based upon physical examination, neither a soft signs examination nor the assessment of minor physical anomalies can be used to either establish or rule out the diagnosis of ADHD, nor can this assessment be used to determine the effectiveness of treatment. Research studies using examination for physical anomalies and soft signs have provided valuable information suggesting there is a physiological basis to the cluster of clinical symptoms constituting ADHD. However, these findings as with medical diagnostic testing, are less helpful than other tests for the diagnosis or exclusion of ADHD. These findings are often present in normal children and often absent in children with ADHD. Soft signs such as clumsiness, motor overflow or speed of movement are considered soft because they are not clearly associated with dysfunction in a specific area of the brain. These are sometimes also referred to as non-localizing neurological abnormalities. Minor physical anomalies include measurements of the head, eyes, ears, mouth, hands and feet.
4. Are any medical problems apparent from the history or examination that would indicate an increased risk from medication intervention for ADHD?
Establishing baselines to determine any contraindication to medication intervention for ADHD is essential to serve as a comparison at subsequent re-evaluation. Although the decision to use medication in the treatment of ADHD is part of medication treatment rather than the diagnostic evaluation, gathering information concerning the risks of possible medication intervention is part of the physician’s initial diagnostic evaluation. A family medical and social history may contain clues to schizophrenia or Tourette’s Syndrome. Other family members may have had positive or negative response to medications used to treat ADHD. Some families may have a good or poor history of following through with treatment programs. The child’s medical history may demonstrate symptoms such as previous reactions to medications, psychosis, growth problems, or cardiovascular problems suggesting increased risk to treatment with stimulants. During physical examination, clues to increased medication risk may be found, including the child’s age, abnormalities of height, weight or blood pressure, signs of tics, depression or abnormality suggesting disorders of other organ systems.
Although the diagnostic process for adults suspected of having ADHD is in its infancy, physicians should be advised to take a similar approach when evaluating an adult suspected of ADHD. A thorough physical examination is essential. Thus, if the evaluating physician is a psychiatrist choosing to not complete such an assessment, it is critical that another physician evaluate the patient whether they are a child or adult.
Insuring that the patient, family, educators and mental health professionals understand what medical evaluation can and cannot accomplish will lead to more effective utilization of medical services. The physician must also understand what the medication evaluation can accomplish. Medical evaluation is only one part of a multi-disciplinary assessment for ADHD. Additional qualitative or quantitative information by direct observation as well as reports from other observers such as parents, teachers and even employers is needed to establish the diagnosis of ADHD. This additional information can be obtained by the physician if he or she has the appropriate training and expertise and are willing to take the time necessary to complete a thorough assessment.
Evaluation in the School and Home
It is rare that assessment in the home and school setting for ADHD involves direct observation of the patient. In some settings, a brief classroom assessment might be obtained. In some situations physicians may actually observe parents and their children interacting for a brief period of time. However, the key feature of ADHD is its chronic, consistent presentation across settings, over long periods of time. Obtaining a careful history is the first and most critical step in the assessment for ADHD. In most situations, prior to the history taking session parents complete a history form which is then used as the basis for conducting the interview. Parents and teachers are also encouraged to complete standardized behavioral questionnaires. The most common of these include: Conners Child Behavior Checklist, Behavioral Assessment System, Comprehensive Parents and Teachers Rating Scales, ADHD Symptom Checklist, Attention Deficit Disorders Evaluation Scale, ADHD Rating Scale, Home and School Situations Questionnaires. As the diagnosis of ADHD is focused increasingly on developing a symptom list and empirically determining symptom severity to increase reliability of diagnosis, these questionnaires have become increasingly sophisticated. Although many of these questionnaires directly utilize symptom descriptions from the DSM-IV TR, others contain a wide range of ADHD descriptors. Some questionnaires poll specifically for ADHD symptoms, while others offer a broad assessment for multiple childhood disorders, including ADHD. It is strongly recommended that the diagnosis of ADHD not be made in the absence of the completion of at least one of these questionnaires by parents and teachers. Physicians should be directed during the initial assessment process to ask five basic questions.
These have been described by DuPaul (1992) and are discussed at length in Goldstein and Goldstein (1998).
- Does the child exhibit a significant number of ADHD symptoms?
- Are the symptoms exhibited at a frequency that is greater than presented by other children?
- At what age do the symptoms begin and do they occur across situations?
- Is functioning at home, school or with peers significantly impaired?
- Are there other factors such as learning disability or emotional problems that could account for occurrence or severity of ADHD symptoms? If so, is the issue differential diagnosis or comorbidity?
The majority of parents save their children’s report cards. Report cards often provide a chronological history. They also provide the physician with an invaluable time line of the child’s functioning as he or she has progressed through school. Additionally, all children complete a battery of achievement tests, usually on an annual or alternate year basis. Because of their length, they are often as much a measure of the child’s lack of task persistence as a measure of achievement. Further, many children with ADHD have been referred and evaluated by the special education system and thus additional educational, intellectual and often behavioral data may be available for the physician to review.
It is important for the physician to keep in mind that observation and test behavior often correlate and are in agreement for most children receiving diagnoses of ADHD. When they are not, however, it does not necessarily mean that ADHD is not present. In making the diagnosis of ADHD, it is recommended that a child fall at either tail of a bell curve at approximately one and a half standard deviations different from the mean (either 5th or 95th percentile depending upon the direction of the questionnaire). It is additionally suggested that these problems cause the child difficulty in at least 50% of home and school situations. The collection of additional social, cognitive, academic and situational data assist the physician in making differential diagnoses and addressing comorbid problems. Once it is established that a child shares sufficient characteristics with children receiving a diagnosis of ADHD, the physician is also urged to consider qualities that the child shares with all others, as well as those qualities that are unique to a particular child. Physicians, however, are urged to trust parents and teachers as a large volume of data suggests that when provided with sufficient structure (e.g., interview, questionnaires, etc.) educators and caretakers are usually quite accurate in describing symptoms of ADHD.
Psychological Tests for ADHD
Researchers and clinicians have questioned the ecological validity of psychological tests to identify, define and determine the severity of symptoms of ADHD. As ADHD is a disorder defined by behavior in the real world it is not surprising that psychological measures (e.g., computer, paper and pencil or performance tests) frequently fall short in defining and identifying symptoms of the disorder in comparison to naturalistic observation, history and organized report in the form of questionnaires. Nonetheless, most physicians take comfort in supplementing clinical impressions with laboratory tests that generate objective scores. It is increasingly accepted, however, that these scores do not make the diagnosis of ADHD but may be helpful in the process of differential diagnosis (e.g., when is impulsivity a function of ADHD versus other disorders?) as well as the process of differentiating severity or related prognosis in a group of individuals with ADHD. However, based upon a careful review of the evidence of the relationship between psychological methods of assessing ADHD and measures of the same constructs in a natural setting, ecological validity of most methods is low to moderate with some proving unsatisfactory. Only a few tasks demonstrate acceptable degrees of ecological validity and these are still lacking. Thus, it is urged by most trainers in the field that physicians rely to a greater degree on the assessment of target behaviors in a natural setting.
The development of a norm referenced psychometric assessment battery specifically designed for ADHD has been an elusive goal for researchers and practitioners. Although individuals of all ages with ADHD have been found to perform poorly on a select battery of psychological tests, research is still needed to test the hypotheses that these dysfunctions hold diagnostic and prognostic significance.
It is important to note, however, that structured psychometric testing affords the physician the opportunity to obtain data from an interaction with the child in a well defined situation. It is rare that the physician will conduct such assessment as this is usually within the bailiwick of psychologists. Psychologists’ opinion during the assessment, however, adds additional qualitative data concerning the nature of the child’s behavior.
More often than not, the administration of assessment measures specifically directed at ADHD are offered within the framework of a thorough psychological evaluation. Given the significant comorbidity of ADHD with other childhood and adult disorders (see Section IX), it is recommended that regardless of age, a thorough psychological evaluation be completed for all individuals referred with suspected ADHD. A complete battery would include the administration of a standardized intelligence test, measures of motor, perceptual and academic skills, as well as an assessment of emotional status and personality. These data would then augment the history, questionnaires and observations obtained. Although clinical batteries for ADHD have been proposed, discussed and in some cases evaluated, at this time there is no precise battery or specific test that has been found to be more valid, accurate or reliable than obtaining a careful history supplemented by observation and questionnaires. However, as these tests are frequently cited in the diagnostic process, the following section will acquaint readers to the most commonly used instruments.
A Brief Overview of Psychological Assessment Research in ADHD
Over the past ten years, much research has been completed on individual or groups of assessment measures that may be sensitive to differentiating children with ADHD from children with other disorders and that may be clinically useful and manageable. Because children with ADHD usually perform similarly to their peers on traditionally administered laboratory measures, reports of daily classroom and home behavior and a review of history, as noted, are a more effective means of identifying and distinguishing this population. Over the past forty years, however, researchers have diligently attempted to develop psychological tasks that measure specific components of attention or inhibition. However, it is important for the reader to recognize that attention, as described by a laboratory test, may be very different from attention as a process necessary to perform effectively at school or work. On a group basis, children with ADHD have been found to perform poorly on tasks requiring monitoring, logical or perceptual search, memory and motor control. Although some of these instruments may discriminate children with ADHD from normals on a group basis, utility of these measures on an individual, clinical basis has yet to be clearly documented. In research studies, these instruments are evaluated comparing groups of previously identified normals and children with ADHD. In clinical settings, however, children do not arrive with diagnoses but rather symptoms. When put to the test, the predictive power of these instruments to determine whether a symptom may be related to one or another disorder has been poor.
The most popular tests used to assess ADHD are referred to as continuous performance tests (CPT). These are computer based instruments in which children are required to stick to a repetitive, effortful, uninteresting task requiring either responding or not responding when a target appears on the screen. The most commonly used of these instruments include the Conners CPT, the Tests of Variables of Attention, the Intermediate Test of Auditory and Visual Attention and the Gordon Diagnostic System. The last is by far the most researched and widely utilized. Numerous studies have suggested that scores on the Gordon Diagnostic System on a group basis may correlate with a variety of behavioral, academic and cognitive measures. These instruments have also been reported as sensitive to improvements observed with stimulant treatment. As a brief overview, the remainder of this section contains a discussion of the ecological validity of a number of the more popular laboratory or clinical measures that have been utilized over the last twenty years in the diagnostic process of ADHD.
CPT scores for omission and commission have been found to correlate statistically with a number of errors on some paper and pencil tasks. Modest correlations have been found between CPT scores and direct observation of ADHD behavior in the classroom. Omission scores appear to correlate modestly with behavioral categories on the Gordon Diagnostic System. CPT performance, however, has been found to be sensitive to stimulant medication but not always reliably so (Barkley, 1978a; Swanson and Kinsbourne, 1979; Barkley, DuPaul and McMurray, 1991; Barkley, Fischer, Newby and Breen, 1988). CPT scores, particularly commission scores may have moderate ecological validity as assessed by parent and teacher ratings of inattention and over activity. The physician must then question whether the CPT is necessary in the primary diagnosis of ADHD if similar information can be gleaned by obtaining history and parent-teacher ratings.
Performance on cancellation tasks, such as the Children’s Checking Task (Margolis, 1972) suggests that children with ADHD differ from normals on omission and commission errors (Brown, 1982; Aman and Turbott, 1986). They may not differ, however, from other clinical groups (Keogh and Margolis, 1976). This type of measure may also be sensitive to the benefits of stimulant medication (Charles, Schain, Zelniker and Guthrie, 1979).
Correlations of the Matching Familiar Figures Test with parent and teacher ratings of ADHD have been low to moderate but become non-significant when age and intelligence are partialed out (Brown and Wynne, 1982a; Fuhrman and Kendall, 1986; Milich and Kramer, 1984). Milich and Kramer suggest that the ecological validity of the Matching Familiar Figures Test as a measure of impulsivity in ADHD children appears weak.
The Draw-a-Line Slowly Test has been used to measure impulsivity but has not been found to discriminate children with ADHD from normals or other clinical groups once age and I.Q. are controlled for (Werry, Elkind and Reeves, 1987; deHaas and Young, 1984).
The Cookie Delay Test developed by Campbell, Szumowski, Ewing, Gluck and Breaux (1982) based on a model developed by Golden, Mantare and Bridger (1977) has found young children with ADHD to be significantly more impulsive than others. Rapport, Tucker, DuPaul, Merlo and Stoner (1986) provided a similar delay of gratification procedure that involved much longer time delays. 94% of the ADHD subjects, as compared to 31% of the controls chose the immediate over the delayed option. This issue holds significance for the physician as consequences are designed for a behavior change program. This will be discussed indepth in the intervention sections.
The ecological validity of movement or activity level devices such as an actometer or stabilimetric cushion or activity chair are similarly poor (Schulman and Reisman, 1959; Tryon, 1984). The actometer can discriminate ADHD from normal children (Luk, 1985; Tryon, 1984) but not in all cases (Barkley, DuPaul and McMurray, 1990; Koriath, Gualtieri, Van Bourgondien, Quade and Werry, 1985). Unfortunately these measurements have not correlated well with parent ratings of hyperactivity (Barkley and Ullman, 1975; Ullman, Barkley and Brown, 1978). There may be an exception when actometer measures are taken over longer periods of time but they may then correlate better with parent and teacher behavioral reports (Stevens, Kupst, Suran and Schulman, 1978).
Analog observations of ADHD appear to yield encouraging associations between observations in the laboratory analogue settings and naturalistic report. Beginning with the work of Hutt, Hutt and Ounsted (1963) in which the floor of a clinical playroom is divided into grids using tape on the floor, a number of studies with similar methodology have demonstrated that children with ADHD display more grid crossings, more toy changes and shorter durations of play with toys during free play than do normal children (Campbell, et al., 1982; Pope, 1970; Routh and Schroeder, 1976; Touwen and Kalverboer, 1973). Yet again some studies have not found differences between the ADHD groups and others (Barkley and Ullman, 1975; Koriath, et al., 1985). Barkley (1977b) found similar effects in reducing the number of grid changes and toy changes but not for mean duration of toy play. A few studies that have attempted to correlate free play with parent ratings of hyperactivity have yielded non-significant results (Barkley and Ullman, 1975; Ullman, et al., 1978). It is when children with ADHD in analogue settings are asked to complete directed tasks with parents that they appear to have the most problem, not in free play situations with parents.
Analog measures that evaluate out of seat, off task, vocalization and attention shifts during free play in restricted play settings have yielded more promising findings (Milich, 1984; Milich, Loney and Roberts, 1986). These findings have correlated significantly with parent and teacher ratings of hyperactivity. Studies comparing ADHD, normal and clinic control groups have found significant differences between the ADHD group, the ADHD group with aggression and the purely aggressive children, as well as normals (Roberts, 1990; Milich, Loney and Landau, 1982). Barkley, McMurray, Edelbrock and Robbins (1989) placed children in a playroom setting with a shelf full of toys and asked them to sit at a small table and complete a written math task at or below their grade level for fifteen minutes. They were told to not leave their seat or touch the toys. They were then observed. This procedure was found to discriminate the ADHD from normal children but was inconsistent in discriminating ADHD from other clinical groups when behavior such as off task, out of seat, vocalization, fidgeting and playing with objects was evaluated (Barkley, et al., 1990; Breen, 1989). Barkley (1991) provides a summary of these and other measures.
Brain Wave Analysis
The theory underlying abnormal EEG’s as discriminative of ADHD versus other childhood problems is consistent with what is known about low levels of arousal in frontal brain areas in individuals with ADHD. It has also been suggested that some children with ADHD produce more theta and fewer beta waves, particularly in frontal regions. However, not all studies have found EEG abnormalities in children with ADHD to have diagnostic utility.
The use of EEG measures as diagnostic tools for ADHD have been touted based upon limited research yet continues to become increasingly popular through a series of popular press articles and talk show appearances by proponents of this method of assessment and treatment for ADHD (see Section XV - EEG Biofeedback). However, there is even less well controlled research than for many of the other instruments reviewed in this section to suggest that the EEG assessment and other neurometric techniques should be considered by physicians as part of the ADHD assessment protocol. Based upon extensive reviews of the literature, Levy (1994) and Cantor (1990) concluded that these techniques have not been able to distinguish between children with ADHD and those with other psychiatric disorders. In general, the limited literature available concerning this assessment process frequently suffers from methodological flaws. It is an area in which clinical practice appears to have out paced scientific evidence.
Understanding Comorbid Psychiatric Problems:
Statistics and Incidence of Co-Occurring Problems in ADHD
The following discussion focuses primarily on the child and adolescent population as this represents the bulk of the research literature generated over the past twenty-five years. As reported earlier, there is an increasing volume of literature suggesting that adults with ADHD generally mirror the psychiatric problems of children with ADHD for occurrence but may in fact demonstrate greater prevalence of comorbid problems, particularly depression. Thus, assessment for ADHD in adults must very carefully focus upon and attend to the possible comorbid presentation or differential diagnosis of depression.
Oppositional Defiant and Conduct Disorders
It is not surprising that a large percentage of children with ADHD develop a pattern of oppositional behavior. Their behavior frequently does not meet the expectations of the adults in their lives, thus they are prone to receive a great deal of negative feedback concerning the inadequacy or inappropriateness of their behavior. This feedback is often in the form of punishment or negative reinforcement, neither leading to improvement. Eventually this pattern of feedback leads to frustration and an attitude on the part of the child to oppose or push back. Often parents initially perceive much of their child’s behavior as stemming from purposeful opposition. Closer scrutiny frequently reveals that for most children with ADHD this behavior results from an inability to perform rather than planned opposition. It would be rare that a child placed in such a position would not develop some pattern of oppositional attitude or behavior. It is not to deny that oppositionality in children is contributed to by temperament, rather to emphasize that parenting style and consistency of approach are also powerful contributors. Over time, a poor fit between the child’s competencies and parental style, expectation and consistency, not to mention parents’ temperament, leads to further, inappropriate parental demands and escalating punishment. The result may be an angry, frustrated child who may become negative, provocative and oppositional with parents and other authority figures. In clinic referred settings, the rate of oppositional defiance in children diagnosed with ADHD has been found to be as high as 50% to 70%. In epidemiologic studies this number is closer to 20% to 30%. Thus, physicians should be advised that it is likely that a significant group of children they evaluate for ADHD may also present with oppositional defiance as well. Careful analysis for many of these children will likely reveal that symptoms of ADHD preceded the onset of significant oppositional problems. It is also important to recognize that it is rare for a child with oppositional defiance only to present sufficient behavioral, situational and objective data to meet the criteria for ADHD.
It is also not surprising that there is a significant overlap in the presentation of ADHD and conduct disorder. Statistically, in clinic based studies the incidence is lower than oppositional defiance with perhaps 30% to 40% of teens diagnosed with ADHD meeting symptom criteria for conduct disorder. It is important for the reader to understand that conduct disorder is not analogous with delinquency. Conduct disorder is defined in the DSM-IV TR as the exhibition of at least three out of a list of problems over a one year period. This list primarily reflects difficulties that violate the rights of others (e.g., theft, fire setting, etc.) as well as juvenile status offenses (e.g., staying out over night, etc.).
As with oppositional defiance some of the milder conduct disordered symptoms are frequently seen in children with ADHD. Their impulsivity may lead them to steal, lie or engage in other non-thinking behaviors such as initiating physical fights when frustrated. Although the diagnostic system of the DSM is polythetic, it is important to recognize that meeting three of the milder symptoms for conduct disorder is very different from meeting three of the more significant symptoms. Again, because the non-thinking, impulsive, non-purposeful behavior of many children with ADHD is often perceived by adults as planned, it would be easy for their behavior to be misinterpreted. The seriously conduct disordered child or adolescent is destructive and aggressive. This youth often heralds malicious forethought consistently when he or she engages in activities designed to hurt others for their own gain. In epidemiologic or non-clinic settings the co-occurrence of ADHD with conduct disorder has been found to be between 10% and 20%.
In light of this large volume of data, it is reasonable for the physician to conclude that oppositional defiant and conduct disorder may occur at beyond chance levels with ADHD but that these reflect different disorders with different courses, impact symptoms and comorbid issues. It is likely that these two disorders are the most commonly co-occurring with ADHD. Physicians are advised that the assessment of disruptive problems should be targeted at also understanding motivational determinants. That is, the reasons children behave the way they do. These are clearly different for children with conduct disorder in which their behaviors are intentional versus those with ADHD in which their behaviors result not from wrong thinking but non-thinking.
The beyond chance relationship between ADHD and the emotionally distressing disorders of depression and anxiety makes these disorders of more than just passing interest to physicians assessing ADHD. In children, however, it is difficult at times to separate symptoms of depression and anxiety in that they appear to present a common underlying thread of emotional distress.
Epidemiologically the overlap between ADHD and depression occurs at a beyond chance level with some studies suggesting nearly 30% and a trend for this to continue if not increase in adulthood. Multiple measures suggest that children with the combined type of ADHD demonstrate significantly more symptoms of depression in general when compared to the inattentive type or normal controls. It is also important to note that symptoms of ADHD have been reported in as many as 60% of depressed children. This is not surprising as one of the nine hallmark symptoms of major depression is problems with concentration. Another reflects irritability and low emotional threshold.
Physicians and other evaluators should be cautioned to carefully apply the diagnostic criteria for depression and not move too quickly to assume depressive problems on the face of a single incident or symptom reports. Diagnosis of DSM-IV TR major depression must include five of nine symptoms present during a two week period, representing a change in previous functioning. This latter point is an important differentiating criteria for physicians to consider. ADHD by its very nature is chronic and persistent. Depression on the other hand again tends to represent a dramatic change for the worse in functioning. Dysthymia is considered to be a mild, more chronic form of depression. Symptoms of low self-esteem, lack of confidence, feelings of inadequacy, pessimism and hopelessness are all symptomatic descriptions of Dysthymia.
Because an individual only has to only meet three symptoms to fulfill a DSM IV TR dysthymic diagnosis, it would not be surprising for physicians to determine that a significant minority of children and for that matter teens and adults with ADHD also experience Dysthymia. Symptoms must be present for at least one year in children and teens and reflect depressed mood or irritability for most of the day, occurring more days than not. Dysthymia, however, is often observed to begin with a clear onset and chronic course.
Bipolar or manic depressive disorder may occur in children at a much higher rate than previously thought. It has been suggested that there is a subgroup of children with ADHD who have prodromal, bipolar disorder. Adult bipolar patients as a group report a higher than expected rate of ADHD symptoms in childhood. Parents in which bipolarity exists also appear to have a higher rate of children with ADHD symptoms. In one study, 21% of a sample of children with bipolarity demonstrated ADD with hyperactivity (Grigoroiu-Serbanescu, et al., 1989). It has been suggested that the picture of ADHD in children with bipolar disorder is much more severe with more severe symptoms and aggressivity (Wozniak, Biederman, Kiely, et al., 1995).
However, as has been clearly demonstrated, although there may be overlapping symptoms between ADHD and bipolar disorder, particularly irritability and impulsiveness, significant comorbidity between ADHD and mania, even after adjusting for the fact that some symptoms are shared, points to the need to consider making the two diagnoses when symptoms of each are present. One can retain the diagnostic status for both after removing overlapping symptoms. It is likely that some children with early onset mania have ADHD and children with ADHD have a higher risk to develop mania and subsequently manic depressive illness than others.
ADHD and anxiety has been reported to run in families but suggested as independently transmitted disorders (Perrin and Last, 1996). Anxiety is much more commonly associated with depression than ADHD or other disruptive behavior disorders. Roughly one third of referred and non-referred youth with ADHD have been found to have a life time history of some type of anxiety disorder. Interestingly it has also been reported that individuals with ADHD and anxiety tend to be less impulsive, less responsive to methylphenidate and experience fewer disturbances of conduct than those with ADHD alone.
Worrisome thoughts and fears generally referred to as anxiety appear to be common in childhood. These thoughts and fears change and diminish in severity and occurrence as children grow older. Thus, the assessment of anxiety as with ADHD must be from a developmental perspective. Childhood diagnoses of anxiety include separation anxiety, avoidant disorder, obsessive/compulsive disorder, panic disorder, simple phobias and post traumatic stress disorder. Recently Jensen, Martin and Cantwell (1997) suggested that the comorbidity of ADHD and anxiety might well represent a significant subtype of ADHD and is worthy of future study.
ADHD can and does occur in children independent of race, socio-economic level or intellectual ability. Thus, even developmentally delayed children in comparison to others functioning at their level can display excessive symptoms and warrant a diagnosis of ADHD. In school settings the most common underlying explanation for delayed achievement reflects speech and language based deficits. A significant percentage as high as one third of children with histories of such language and learning deficits appear at risk to develop patterns of inattention and hyperactivity. Many of these children develop this pattern of behavior in response to stress and frustration arising as the result of their difficulty communicating. Careful history often reveals that these children appeared asymptomatic for ADHD symptoms prior to or upon entering school with a gradual escalation in problems as the demands of school increased. Differential diagnosis for young and older language impaired children is difficult. Often a speech/language pathologist working with a psychologist can provide important data in assisting the diagnostic process. Young children with language disorders demonstrate a very high rate of disruptive behavior and are often easy to identify. School age children experiencing language and related processing impairments are significantly harder to find as these deficits may be more subtle and not easily observed. The frustrated, language impaired child struggling in school often presents symptoms of attention deficit but may not be significantly hyperactive nor impulsive. As children mature, those children with pragmatic (social) language problems may appear increasingly more inattentive.
Learning disabilities have been reported in children with ADHD at a rate of approximately 30%. However, by high school age many youth with ADHD fall behind as noted in subjects requiring practice for proficiency such as writing and spelling. It has been suggested that weaknesses in working memory may play an equal role in causing achievement problems at school for those with ADHD and learning disability. In the former group, working memory is applied inconsistently during learning situations. In the latter group, working memory is simply inefficient.
Related Low Incidence Disorders
ADHD has been reported to be present in approximately half of all Tourette’s cases. The relatives of children with Tourette’s present with a high rate of comorbid Tourette’s in ADHD as well.
Although autistic children are described as inattentive, theirs is a problem of lack of interest rather than poor self-regulation. Assessment of children with high functioning autism often yields complaints of inattentive symptoms. However, there is no reason to assume that autism and ADHD are in any way similar.
ADHD is reported quite frequently in children with Type 1 Neurofibromatosis. Neurofibromatosis 1 (NF1), occurs in 1:3,000 births, web characterized by multiple cafe-au-lait spots and neurofibromas on or under the skin. Enlargement and deformation of bones and curvature of the spine (scoliosis) may also occur. Occasionally, tumors may develop in the brain, on cranial nerves, or on the spinal cord. About 50% of people with NF also have learning disabilities.
Encopresis and Enuresis.
The prevalence of encopresis is estimated to be 1% to 3% in school age children with enuresis reducing to under 5% by five years of age. Some studies have reported a higher rate of enuresis though not encopresis in children with ADHD. The etiological connection between the two disorders is not well understood. It may be that there is a subset of children whose poor task persistence, poor prioritization, poor reinforcability and inefficient self-regulation propose them to poor toileting.
Central Auditory Processing Disorders.
Central auditory processing deficits are deficits in the processing of audible signals that cannot be attributed to impaired peripheral hearing sensitivity or to intellectual impairments but to limitations in the ongoing transmission, analysis, organization, transformation, elaboration, storage and retrieval of information contained in audible signals. The classical description of the inattentive child with auditory processing problems appears very similar to the current description of the inattentive type of ADHD. In fact, some have questioned whether central auditory processing and ADHD are in fact separate disorders.
Fragile X Syndrome
. Fragile X Syndrome has been associated with attentional problems, hyperactivity and general behavior problems at a fairly high rate. However, in addition to short attention span and hyperactivity, children with Fragile X Syndrome often appear tactiley defensive, demonstrate self-stimulatory behaviors such as hand flapping, exhibit poor eye contact, perseverative speech and exhibit large or prominent ears.
Sleep Problems. Although sleep disturbance has not been listed as a symptom of ADHD since the DSM III-R in 1987, it has been suggested that children with ADHD are less willing to go to bed, more often afraid of the dark, up more often during the night, have fewer hours of total sleep and are more difficult to wake in the morning. Laboratory polysonograms, however, have found few or no differences in the sleep architecture of children with ADHD in comparison to normals.
There are no reported studies specifically relating eating disorders and ADHD. Children who are choosy eaters with a history of refusal to eat in infancy or preschool age have been reported to have more pronounced general behavioral problems than others.
The most significant risk factors associated with suicide are major depression, bipolar disorder, substance abuse and conduct disorder. ADHD has not been found to be a specific risk factor for suicide completers.
Risk factors specific to substance abuse are tobacco use, academic difficulty and past episode of substance abuse. A number of longitudinal studies have suggested that although delinquency and conduct problems during middle childhood are significantly associated with later substance abuse, there is little association between early ADHD and substance abuse when the association between conduct problems and ADHD is taken into account. Recent studies have found that adults with histories of ADHD, however, appear at risk particularly to abuse alcohol and tobacco independent of the development of conduct disorder during their adolescent years. It has been suggested that perhaps nicotine, a stimulant, may be used to self-medicate. The same, however, cannot be said for alcohol. Adults with histories of ADHD also report consuming a high rate of caffeinated drinks, once again raising the question of efforts at self-medication.
Making the Diagnosis of ADHD
Once multiple sources of data are collected and reviewed, physicians should consider a step-by-step diagnostic tree for ADHD. This should include:
1. Does the child meet the DSM-IV TR diagnostic criteria for some type of ADHD?
2. Does the child demonstrate elevated abnormal scores on rating scales sensitive to ADHD in the home and school setting?
3. Has objective data attempting to measure inhibition, self-regulation and attention been collected? If not, is it necessary? If yes, Is it significant?
4. Are symptoms related to ADHD causing problems across at least two settings, including home, school, with peers and in the community?
5. Have differential and comorbid diagnoses been considered, including disruptive problems with oppositional defiance and conduct disorder, non-disruptive problems of depression, dysthymia, manic depression and anxiety disorders, low incidence problems such as Tourette’s and autism, life adjustment problems related to short term immediate stressors or crises and learning and related developmental weaknesses?
The risk of false diagnosis is minimized when a systematic approach is utilized. The two biggest problems facing the physician in making the diagnosis of ADHD occur when it is difficult to clearly rule out alternative etiologies and when the data do not consistently suggest ADHD. Because ADHD is a common disorder of childhood it is more likely than not that the majority of children experiencing emotional, learning or cognitive problems with concomitant symptoms of ADHD presented with foundational attention and impulse problems prior to or in conjunction with these other difficulties. As discussed, it is not uncommon for children with ADHD over time to be at greater risk to develop other disruptive disorders in the face of frustration and certain environmental variables. Further, children with ADHD have a higher life time risk for depression and anxiety and a higher occurrence of learning disability than unaffected children.
Information from checklists and behavioral observations offer valuable data. This can also be said of clinical and laboratory measures. In the end, it is up to the physician as a diagnostician to determine which data are relevant, weight them accordingly and make a final judgment.
Making the diagnosis is a critical part of the evaluation. However, helping parents understand the specific problems their child is experiencing and the implications of the diagnosis is even more important. This provides the critical link between diagnosis and intervention.
It is well recognized in medicine that compliance with recommended treatments is often quite poor. This phenomenon too has been demonstrated in regards to children’s behavioral, developmental and emotional problems. However, helping parents see the world through the eyes of their child and understand the reasons for and causes of the child’s difficulties facilitates the process of beginning treatment. It allows parents to play an active role and helps them make appropriate treatment decisions for their child.
Physicians must also recognize that the best predictors of outcome for a child with ADHD lie not in the treatments for ADHD but in the child’s social frame of reference. Parents must be helped to recognize that the most powerful predictors of positive adult outcome for children with ADHD include parents who are competent, develop a warm relationship with their child, are available, take an interest in the child’s education, bolster the child’s self-worth and meet the child’s physical needs. Parents should not be provided with guilt as a motivator but rather with an understanding that as long as the balance between stressful life events and surrounding protective factors is favorable, children with ADHD stand a significantly better chance of entering adulthood successfully. Section XVI contains a bibliography of resources concerning ADHD and parenting. Finally, in many cases it may appear to parents that ADHD is a diagnosis of exclusion. That is, if it isn’t anything else it must be ADHD. Therefore, physicians must take the time to help parents understand the diagnosis and its ramifications.
There has been an alarming and increasing trend in the general community to view ADHD as one of Rudyard Kiplings “Just So Stories” suggesting that at one time in man’s history behaviors related to ADHD were adaptive and beneficial. In fact, this could not be farther from the truth. Based upon a careful review of cultural anthropology and evolutionary psychology, the more likely explanation is that symptoms of ADHD represent falling at the lower end of the normal curve for self-regulatory abilities. Parents should be urged to not create myths to make themselves feel better or construct illusions to deny the truth. This is neither to pathologize, patronize nor demonize those with ADHD. It is to say that having ADHD holds no advantage. The disorder demands greater effort by both affected individuals and those who live with and love them to accommodate to their disabilities. Fortunately ADHD can be treated and managed effectively leading to more successful and happier lives for those who may struggle against its diminished capacities for executive functioning and self-regulation.
Finally, physicians may find it helpful to explain the diagnosis to parents by placing the child in specific situations and explaining how the child’s weaknesses compromise his or her ability to function and meet the demands of that setting. A day in the life of your child (Goldstein and Goldstein, 1998) is often a helpful way of explaining this to parents.
Multi-Disciplinary, Multi-Treatment Models for ADHD
The syndrome of ADHD symptoms, the myriad settings in which symptoms present, the extensive demands placed upon youth behaviorally and educationally as well as a high incidence of comorbid problems in the ADHD population have all served as barriers in the development of a literature clearly attesting to the benefits of single or combined treatments for ADHD in all but one case - the use of medications. However, even pharmacological treatments for ADHD may not always lead to effective change. ADHD is a disorder that is managed not cured. Thus, each of the child’s specific problems, whether behavioral, cognitive or psychological, must be identified and treated. At this time the primary symptoms of ADHD are most effectively treated with medication. Single treatments have included medication, behavioral techniques, parent training, educational interventions and social skills building. Many can be treated with a combination of medication, behavior management and skill building. The secondary byproducts of living with ADHD (e.g., low self-esteem issues) can be addressed through psychotherapy.
Parents and professionals must understand that with ADHD it is rare for an effective management or treatment plan to consist of only one intervention. It is essential that all involved develop sensitivity to the complex and pervasive impact ADHD has upon daily functioning and how the disorder can compromise a child’s or adult’s ability to meet the expectations of his or her world. Treatment for ADHD must consist of a partnership among the child, family, school personnel and physician.
At this time the most accepted combination of multi-treatment approaches for ADHD includes medication, parent training and educational management. Increasingly, a component focusing on helping build what is right about children (e.g., building their strengths and skills in areas of interest or competence) has also been a focus of interest. By far the greatest interest has been in the evaluation of the additive effects of medication and behavior management. A multi-site, multi-modal treatment program was initiated by the National Institute of Mental Health to address questions concerning the following: which child characteristics (comorbid conditions, gender, family history, home environment, age, nutrition, metabolic status, etc.) do which treatments or combinations of treatments (stimulants, behavior therapy, parent training, school based intervention) have which impacts (improvement, no change, deterioration) on which domains in child functioning (cognitive, academic, behavioral, neuropsychological, neurophysiological, peer relations, family relations) for how long (short versus long term) to what extent (affect size, normal versus pathological range) and why (processes, underlying change). The overall findings confirm the importance of multi-modal treatment for children with ADHD.
Although the best combination in methods of treatments for specific groups of children with ADHD have yet to be completely delineated, the philosophy of multi-modal treatment for ADHD has been well accepted. The available literature clearly reflects that the introduction of stimulant medication leads to the greatest percentage in improvement. It does not suggest that alternative or combined treatments are ineffective or should be discontinued. The mean effect size of medication has been suggested as twice as great as that of behavior modification, but behavioral interventions have demonstrated improvements in specific symptoms for children with ADHD.
In summary, the available data demonstrate that stimulant treatment accounts by far for the greatest percentage of behavioral improvement in children with ADHD. Non-medication treatments, educational modification and behavior management for parents and teachers have been demonstrated as beneficial for most children with ADHD, adding half or fewer to the improved observations reported. Finally, issues related to child, parent and teacher self-perceptions, knowledge of the disorder and sense of efficacy in perceiving symptoms as capable of being changed, may act catalytically to improve compliance with all interventions, including medication. For the time being, based upon the available research data, medication should be considered as a first line treatment for all children, adolescents and adults with an ADHD diagnosis. Education about the disorder and modification of tasks to make them more interesting and payoffs to make them more valuable to the child with ADHD should be considered as integral parts of a multi-treatment, multi-modal program. It is clear, however, that the combination does not provide a cure. However, in the short term the combination of interventions offers significant symptom relief and the promise of greater therapeutic progress than the use of any one treatment alone. Physicians must assist parents and affected individuals to understand the need for multiple treatment modalities to deal with multi-faceted problems.
Medications for ADHD
In the late 1980's, 700,000 children were treated with medication for ADHD. By 1995, the number had increased 2.5 fold to 1.6 million (Safer, 1995). It has been reported that the incidence of stimulant use continued to increase through the close of the 1990's. Yet only about half of the at least 7% of children believed to have ADHD were being treated. Prevalence of treatment varies by insurance company and geographic area (Goldstein and Turner, 2000; LeFever, Dawson and Morrow, 1999). It has been reported that males are four times more likely to be treated than females in primary grades and five times more likely than females in middle school. Medication is prescribed for a smaller percentage of African Americans than Caucasians.
Another trend in medication treatment for ADHD is the increasing number of adolescents continuing to take medication. Although the proportion of high school students to all students receiving medication was only 11% in 1975, it had risen to 30% in the 1990's (Safer and Krager, 1994). Based on global measures, 75% of children respond positively to stimulants. Stimulants improve attention and social interaction, increase academic productivity but not necessarily achievement and reduce disruptive and impulsive behavior in children with ADHD. The continued and wide spread use of stimulants in the treatment of ADHD is a result of both cost efficiency and the large volume of research demonstrating significant short term positive effects (for review see Greenhill and Osman, 2000; Barkley, 1998; Goldstein and Goldstein, 1998). However, despite their effectiveness, medications too have had their disadvantages. These include reports of a lack of effectiveness in a small but significant percentage of children, unwanted side effects, including problems with tics, anorexia, insomnia and irritability. A lack of consistent positive impact in improving long term outcome has also been reported. Additionally, ethical and legal questions relating to stimulant use have been raised, including the right of school systems to require children to take medication, alleged harm as the result of side effects, negligence in diagnosis leading to wrongful medication treatment and constitutional questions concerning limitations on parents’ right to decline medical care for their children balanced against the state’s interest in safeguarding children’s health and welfare.
Medications alone in the treatment of ADHD have not been found to contribute significantly to a positive outcome as children with ADHD grow into adulthood. It has been increasingly recognized that relieving symptoms of ADHD may not significantly equate with altering the future life problems of this population.
Methylphenidate has been by far the most common substance used for treatment of ADHD. Ritalin® is the brand name of methylphenidate. Stimulant treatment has been found to improve on task behavior while decreasing negative off task behaviors. In classroom settings, successfully treated children are less disruptive, follow class rules more effectively and complete more work with greater accuracy. Medication has been found to exert an improvement in peer relations and reduce family conflict. In children with combined learning disability and ADHD effective stimulant medication has been reported to lead to improvements in rate of academic achievement.
The earlier studies of medication treatment for ADHD symptoms were completed by Bradley in 1937 using amphetamine. Dextroamphetamine was first researched in an early study by Brown, Hunt, Ebert, Bunney and Kopin (1979). Dextroamphetamine was found to improve behavior dramatically between two to five hours post ingestion. Dextroamphetamine today is the only stimulant approved for children between the ages of three and six. The PDR (1997) describes Dexedrine - brand of dextroamphetamine - as “not recommended for children under three years of age.” The warning issued for methylphenidate, pemoline and other stimulants suggest these medications should not be used for children younger than six years of age. The optimal dosage of dextroamphetamine is often 5 mg to 10 mg per dose, almost half that of methylphenidate. In an extensive review by Barkley (1977a) studies of dextroamphetamine, methylphenidate and pemoline were presented. No significant differences between percentage of responders or percentage of non-responders was shown. No significant differences in the types, severity or frequency of the side effects was noted. Safer, et al. (1972) suggested that growth suppression was more pronounced with dextroamphetamine than with methylphenidate. Conners, et al. (1972) suggested that dextroamphetamine produced more sadness than pemoline. The growth suppressant effect of dextroamphetamine, however, has been subsequently shown to remit spontaneously with time and the depressant effects of dextroamphetamine were not considered severe nor do they require discontinuation of medication.
There have been more comparison studies of methylphenidate and dextroamphetamine for the treatment of ADHD symptoms than for any other two medications. In a review of five comparative studies in a 137 subjects, Elia, et al. (1991) found dextroamphetamine and methylphenidate to be equally useful with similar side effects. Some reports suggested more side effects for dextroamphetamine but the side effects were similar and not substantially different for the two medications despite anecdotal reports. As some children who do not respond to methylphenidate will respond to dextroamphetamine, and others who would be considered responders to one medication may do better on another, Elia and Rapaport (1991) strongly urged consideration of a trial of both stimulant medications for children with ADHD.
In general, medications that appear to exert a significant positive impact on neurotransmitter systems, particularly dopamine and norepinephrine, have been found to improve symptoms of ADHD. They appear to increase efficient distribution of neurotransmitters throughout the brain and increase the availability of these neurotransmitters at synaptic sites. It is believed they primarily act by blocking re-uptake of these neurotransmitters.
Although there have only been a few research studies with Adderall® as a treatment for ADHD, a number of others are being completed or prepared for publication. Given that Adderall® represents a combination of dextro and levo amphetamine it is reasonable to conclude that research studies demonstrating the benefits of other stimulants, such as methylphenidate and particularly dextroamphetamine, can be generalized to include Adderall®. It would would be expected that Adderall® would lead to a similar level of reduction of ADHD symptoms and improved related consequential problems. These initial studies, however, are suggesting that Adderall® may lead to greater symptom reduction at similar doses as methylphenidate with fewer side effects and a longer duration of action (Pelham, Gnagy, Chronis, et al., 1999). Advantages of Adderall® may include that fact that as a mixed salt of a single entity amphetamine product, dosing can be reduced to once or twice per day. This combination of amphetamine may have a longer onset, equating it to the methylphenidate sustained release preparation or dexedrine spansule and a gentler drop off reducing negative effects of withdrawal such as frequently reported rebound irritability. Adderall® is also available in a wider number of sizes, including a 30 mg double scored tablet.
Adderall XR® is a newer and longer-lasting medication which helps reduce hyperactivity and impulsivity in children with ADHD. Studies show the effects of Adderall XR® last throughout the school day. Long-acting methylphenidate products have also become available in the past two years. Concerta® and Metadate CD® have also been shown to improve core symptoms of ADHD through the afternoon with a once-daily morning does. Concerta® uses the Oros® technology to regulate the release of methylphenidate into the bloodstream at a consistent rate over approximately ten hours. MetadateCD® uses a bead technology (beads containing active medication dissolve at different rates) to control the delivery of the medicine and it has a duration of action of about eight hours. The obvious benefit to long-acting medications such as Adderall XR®, Concerta®, and Metadate CD® is they reduce the burden on school personnel to tend to the medical needs of ADHD students. Additionally, these agents may reduce the need for children to bring their medication to school which can reduce social stigma and decrease risks of diversion.
Tricyclic antidepressants (TCAs) are the next major class of medications, after stimulants, for the treatment of ADHD. Although less well studied than the stimulants, TCAs have been used for several years to treat children with ADHD. They are regarded as second-line medications for children who have not succeeded with stimulants, for whom stimulants produced unacceptable side effects, or who suffer from other conditions (such as depression, anxiety, Tourette’s syndrome, tics), or aggressive behavior and irritability along with ADHD. Imipramine (Tofranil), desipramine (Norpramin), amytriptyline (Elavil), and nortriptyline (Pamelor or Vivactyl) are the best studied TCAs to treat ADHD. TCAs have the advantage of longer duration of action (all day) as opposed to four to eight hours common to stimulants. This avoids the troublesome and even embarrassing midday stimulant dose taken at school. Unfortunately, TCAs may not be as effective as the stimulants in improving attention and concentration or reducing hyperactive-impulsive symptoms of ADHD. TCAs also can produce adverse side effects, the most common of which are drowsiness, dry mouth, constipation, and abdominal discomfort. More concern, however, has been expressed at possible adverse cardiac side effects, accidental overdose, and reduced effectiveness over time.
Noradrenergic agonists such as clonidine (Catapres) and guanfacine (Tenex) have been found to be useful in the treatment of ADHD children, especially those who are extremely hyperactive, excitable, impulsive, and defiant. They have less effectiveness in improving attention. They are often the drug of choice in treating children with tics or children who did not respond to stimulants. Clonidine is also prescribed to help children who have difficulty falling asleep. It can be a great benefit to children with sleep onset difficulties whether the cause is ADHD overarousal, stimulant medication rebound, or unwillingness to fall asleep.
Bupropion (Wellbutrin®) is an antidepressant drug that has been briefly studied. Clinicians using this medication find it has a place in treating ADHD, especially in children who do not tolerate stimulants or who may have co-existing problems with mood. Bupropion may worsen tics and should not be used when a seizure disorder is suspected. Selective serotonin reuptake inhibitors (SSRIs) have not been well studied in the treatment of ADHD. In this class are commonly prescribed medicines such as Prozac®, Paxil®, Celexa®, Luvox,® and Zoloft®. The anecdotal reports from clinicians do not support the use of SSRIs for treatment of ADHD. SSRIs have, however, gained considerable recognition for treatment of depression, anxiety, and obsessive-compulsive disorders. Buspirone, an anxiolitic medication, has been used in children and adolescents with anxiety disorders, and researchers have reported significant improvement with it. It has not been well studied in the treatment of ADHD in children. Fenfluramine, benzodiazepines, or lithium are of benefit in other psychiatric disorders but there is no support to their use in the treatment of ADHD. Atomoxetine, a noradrenergic antidepressant, is being studied for the treatment of ADHD in children and adults. Studies of the drug were compared with a placebo and atomoxetine was shown to be more effective than the placebo in reducing some of the core symptoms of ADHD.
New products for treating ADHD regularly come into the marketplace. These include a more effective long acting stimulant as well as at least one non-stimulant, atomoxetine (Strattera®). Strattera is a selective noradrenergic reuptake inhibitor (SNRI) that has been shown to be efficacious in the treatment of ADHD in children, adolescents, and adults. It can take up to several weeks to build up in the body to have optimal effect on ADHD symptoms, but some of the side-effects of stimulants can be avoided by those taking Strattera. Long acting stimulants include Concerta®, Metadate®, Focalin LA®, Methylin ER®, Daytrana®, and Vyvanse®. These have the advantage of once a day dosing and their effect can last from eight to twelve hours. Daytrana® was approved in 2006 and is unique in that it is a methylpenidate patch that is applied to the hip area each morning. When worn as directed, the patch provides medicine continuously throughout the waking day as long as the patch is on. It is recommended that the patch be worn for 9 hours. Its effects continue for 3 hours after it is removed. Vyvanse® is the newest medication approved by the FDA for treatment of ADHD. It was approved in 2007. It is a capsule for once-a-day oral dosing. The main ingredient in Vyvanse® is dexamfetamine dimesylate. Vyvanse® is a prodrug or 'conditionally bioreversible derivative' of amphetamine, the main ingredient in Adderall® and Adderall XR®. Not very much is yet known about Vyvanse®, but it is thought that because it is conjugated to an amino acid, then unlike Adderall®, it will have to go through the stomach and be digested before it can become active. That means it will be much less likely that Vyvanse® will be abused, since it can't be snorted, etc., like other ADHD medicines.
Teaching Parents to Cope and Manage ADHD at Home
In general, our society believes that good parenting leads to positive parent-child interactions and ultimately optimal child life outcome. The definition of good parenting, however, varies by culture and observer. Children with ADHD may be difficult to parent well which sets the stage for problems with trust and forming healthy relationships. Maternal knowledge and belief in fact provides a mechanism for facilitating long lasting change in child outcome. A diagnosis of ADHD in their children has been found to facilitate parents’ ability to feel better about themselves, understand their children and feel more competent in their ability to help (Siegal, 1992). Although it is clear that parent training for ADHD does not contribute as much to symptom relief as medication, it is important for physicians to recognize that family characteristics, including parenting style, contribute much to the life outcome for children.
Family characteristics and secondary symptoms associated with family functioning, such as aggression, have been demonstrated to be among the strongest predictors of long-term outcome for children with ADHD (Weiss and Hechtman, 1986). It is thus fair to conclude that so goes the family - so goes the child with ADHD. Positive future outcome for all children has been associated with stable family environments, consistent discipline, positive parental expectations for their future, positive parent child relationships, perceptions of competence perceived by parents, and low rates of parental criticism.
Parent training programs for parents of children with ADHD often begin by providing extensive information. There is a large trade library of books, videos and cassette tapes available for parents, providing accurate information concerning ADHD and research proven effective parenting strategies (See Section XVI). The following represents a brief review of a nine point set of strategies offered as beneficial to parents of children with ADHD (Goldstein and Goldstein, 1998).
Parents must be counseled to understand that managing their child’s behavior at home requires accurate knowledge of ADHD and its complications. Parents must be consistent, predictable and supportive of their child in their daily interactions. Parents must be helped to accept the primary cause of ADHD and understand the disorder thoroughly. This is not a problem, as noted, that can be cured. It will affect children throughout their life span. Parents will be repeatedly placed in an advocacy position with schools and community resources. It is also suggested that parents of children with ADHD consider joining a parent support organization directed at ADHD. Organizations such as CH.A.D.D. (see additional resources) offer parents a ready resource of information, monthly magazines, newsletters and presentations.
2. Understanding incompetence vs. non-compliance.
Parents must be helped to develop the capacity to distinguish between problems that result from incompetence and those that result from non-compliance. The former must be dealt with through education and skill building. The latter is usually quite effectively dealt with through manipulation of consequences. Parents must be helped to understand that punishing a child for symptoms of ADHD may lead to remorse and a promise of better behavior but stands little chance of changing behavior in the future. Parents must be helped to develop a set strategies to deal with ADHD symptoms by making tasks interesting, payoffs more valuable and increasing consistency and follow through at home while also providing a consistent set of punishments for purposeful non-compliant behavior. The best way of dealing with non-compliance is to make certain that parents have control over consequences, issue appropriate commands, manage rewards, and use of response cost.
3. Give positive directions.
Once parents understand the distinction between non-compliance and incompetence, they can begin to differentiate their child’s behavior. The next key step is to make certain that positive rather than negative directions are given. A positive direction tells the child what to begin doing rather than focusing on what to stop doing. Such directions are clear “please begin your math homework” rather than vague “pay attention.” However, the need for repeated trials to success for ADHD cannot be overemphasized. Parents of children with ADHD must be instructed that they serve as a control system for the child. Their child is going to require more management and supervision in an appropriate, consistent, affirmative way than other children.
4. Provide ample rewards.
Children with ADHD require more immediate, frequent, predictable and consistently applied consequences as well as more trials to mastery. Social and tangible rewards must be provided more frequently when a child with ADHD has completed or succeeds. The acquisition of behavior is not the issue here but rather the child’s ability to learn to consistently act when expected behaviors are required. ADHD leads to problems due to faulty executive management. That is, most children with ADHD know how to do what is requested but have difficulty doing so when they are supposed to. Children with ADHD have also been found to receive less positive reinforcement than their siblings. Parents must work to keep a balance as well as to avoid negative reinforcement which only results in the removal of aversive consequences when the child complies. This often leads to immediate compliance but in the long run reinforces rather than discourages inappropriate behavior.
Token economies have been found to be particularly effective for children and early teens with ADHD. Token systems fail at home, not because they are inherently ineffective for children with ADHD but because at times they can be cumbersome and then poorly managed. Token systems should be applied enthusiastically. Required activities should be kept to a reasonable length and an extensive list of reinforcers should be available with at least one third available each day. Tokens should be used with four to seven year olds and points with those eight years and older. Children should be able to spend approximately two thirds of points or tokens earned each day. Bonuses should be paid for a good attitude. Finally, parents should always allow their children to earn their way off a system through compliant behavior but a minimum of six to eight weeks on a token system once it is initiated should be required.
5. Choose your battles.
Parents should choose their battles, reinforcing the positive, applying immediate consequences for behaviors that cannot be ignored and using tokens or points with ADHD children. It is essential for parents to stay one step ahead. They should also walk awhile in the child’s shoes, recognizing and accepting the difficulties their child experiences due to ADHD. Consequences, both rewards and punishments, should be provided quickly and consistently.
6. Response cost.
Most parents understand the use of positive reinforcement as a means of motivating children. Few, however, understand the use of response cost. Response cost is a punishing technique in which you might lose what you have earned. Parents should be helped to understand that children with ADHD work harder to keep their plates full rather than to fill an empty plate. If a give and take response cost system is utilized, parents must make certain the child does not go bankrupt. It may be equally effective, especially with older children and teens, to start with the entire payoff and then have the individual work to keep it. For example, instead of providing the child with a $5.00 allowance at the end of the week when she behaves appropriately, parents may place $5.00 in nickels in a jar on the shelf that is visible to the child. So long as she behaves appropriately, the $5.00 belongs to her. For every infraction that has been clearly defined and agreed upon between parents and child, a nickel is removed from the jar. At the end of the week, whatever remains is given to the child.
Parents must be helped to understand the forces that affect their children. They must not personalize their child’s problems. When children act the way parents hope they will, it is natural for them to feel they are being good parents. When children do not meet expectations, parents tend to judge themselves harshly. Parents must learn to respond to their children’s limits in a pro-active way. Accepting the diagnosis of ADHD means accepting the need to make changes in the child’s environment. Routines should be consistent and rarely vary. Rules should be stated clearly and concisely. Activities or situations in which the child has a history of risk for problems should either be avoided or carefully planned.
Punishment is an effective way of helping children receive feedback for behavior that is to be stopped. However, it is essential that parents of children with ADHD understand that punishment alone likely will not reduce symptoms of ADHD. Punishment does, however, play a role with behaviors deemed to be directly non-compliant. Punishment is also partially appropriate if the rule is violated, even as the result of ADHD. However, in this circumstance, punishment must not be provided alone as it will not change the child’s long-term behavior. Parents must be helped to understand that for a child with ADHD unless a managing strategy is provided along with punishment, it is not likely that the punishment will precipitate change.
9. Building islands of competence.
In the end it is what is right about children rather than what is wrong about them, that best predicts their life outcome. Increasingly the mental health field is focusing on building upon strengths rather than attempting to hammer away at weaknesses. One of the best predictors of building upon strengths is a parent’s relationship with their child. Due to their greater stress, families with a child suffering from ADHD are more likely to experience even minor problems as more disruptive. Parents must recognize that due to their child’s ADHD there is a greater likelihood that the relationship they develop with this child will be more strained. Parents of children with ADHD must recognize that if they approach each day with a sense of hope, encouragement, acceptance and honesty they will empower themselves and their children. If they approach each day with a sense of despair, discouragement, anger and blame, they will not only jeopardize their child’s future but further feed their own sense of powerlessness and hopelessness.
Interventions with Young Children
With difficult infants and toddlers appearing at risk to receive a diagnosis of ADHD, it is essential to increase parental competence by providing education concerning the nature and pattern of children’s temperament, helping parents understand the role they may play in reinforcing certain behaviors and teaching behavior management skills. Effective daily management of the difficult infant and toddler is a crucial determinant of long term outcome.
Parents approaching a difficult off-spring with skill, patience and tolerance will diffuse power struggles and prevent the development of further problems. Parents approaching a similar child with anger, irritation, anxiety and ultimately emotional withdrawal, will certainly enhance the development of secondary emotional problems. Sleep difficulty, hyperactivity and outright non-compliance, particularly in public situations, are the most common complaints of parents of young children at risk for having received diagnoses of ADHD. The bibliography, Section XVI, contains a number of excellent resources for parents of young children.
Interventions for Adolescents
By twelve years of age, interventions effective with younger children very quickly lose their potency. The adolescent with ADHD often reacts to time out and over-correction with resistance. With adolescents, it is often helpful to bring the family together to learn negotiation and contracting skills. Problem behaviors in ADHD teens also differ, in part due to their forgetfulness and impulsivity. Much of the teen-parent conflict centers around school work and chores. Particular attention must be paid to help parents accept and understand the impact ADHD symptoms have upon teenagers. Adolescents who refuse to participate in parental interventions or who are passively resisting participants cannot be forced. It is therefore important for adolescents to feel that their opinion is important and their input will be considered in the rule and decision making process. Adolescents with ADHD often possess a well developed, at times dysfunctional pattern of behavior. This is habitual and often resistant to intervention. Helping the adolescent feel comfortable, accepted and in partial control of the treatment process will facilitate change.
It is recommended that at least a brief period of psychotherapy be considered for all adolescents with ADHD to help them understand their history and current problems as well as assisting them in beginning to think about their adult lives. They must be encouraged to be active participants in the treatment process. It is also recommended that medications not be used as punishment. For passive and marginally involved adolescents, medication will simply provide another conflict issue and opportunity to rebel. As Robin (1990) suggests, parents of adolescents with ADHD must:
- Take the time to understand normal adolescent development and how it impacts individuals with ADHD.
- Allow the adolescent with ADHD the opportunity to provide input and participate in the decision making process when possible.
- Straighten priorities so that parents can decide which are important versus unimportant issues.
- Develop an effective problem solving system with all family members.
- Stay involved, setting conditions and consequences.
- Learn effective communication skills.
- Encourage the continued use of medication.
Educating Children with ADHD
The presence of knowledgeable, understanding teachers, the availability of appropriate support systems and the opportunities for every student to engage successfully in a variety of activities are important components of good educational experiences. These build self-esteem, resilience and most likely contribute positively to the future lives of children with ADHD. Yet as straightforward an issue as good education would appear to be for children with ADHD, a controversy abounds. This should not be surprising given that controversy follows ADHD regardless of the setting or situation in which it presents. Issues concerning ADHD have fallen in two broad areas. The first reflects funding and legal issues concerning eligibility for assistance. The second has dealt with strategies and interventions that are effective and improve the educational climate and experience for children with ADHD.
The majority of children with ADHD alone will not qualify for special education services under the Individuals with Disabilities Education Act (IDEA). Some students with additional behavioral learning or physical problems may qualify under different classifications and then as part of their special education services receive behavior management or other interventions specifically directed at ADHD symptoms. The exact set and severity of symptoms necessary to receive special education services as a student with ADHD has not been well delineated. However, the most heated debate is not in the area of who may or may not qualify but rather whose responsibility is it to provide services and what services should be provided once students qualify.
Students with ADHD who do not experience a specific learning disability may be eligible for services in school under IDEA as Other Health Impaired if their ADHD is sufficient and severe enough to cause a significant disruption in school functioning. Although definitive guidelines have not been provided for school districts to make a determination as to when a child with ADHD requires such a placement, failing grades and disruptive behavior are often sufficient to justify a request for such a classification.
When students do not qualify under IDEA guidelines they may be eligible for services under Section 504 of the Americans for Disabilities Act, which protects all students with any disability recognized by the community, even if not acknowledged under IDEA. Such disabilities are defined as those related to physical and mental impairments that substantially limits one or more major life activities. Once again, definitive guidelines have not been described. Section 504 prohibits discrimination against persons with disabilities, including students. Thus, to fulfill its obligation under Section 504, the school district has a responsibility to avoid discrimination in policies and practices regarding its students. These 504 plans can be individually designed to include accommodations within the regular classroom. Examples of such plans include modifying assignments, assistance with note-taking, test taking, behavior management and the use of a daily school-home note. Students with ADHD also at this time do not qualify for Social Security benefits unless extenuating circumstances are present.
Goldstein and Goldstein (1990) first offered a model for classroom interventions suggesting the categorization of strategies into two sets. The first set designed to change thoughts and feelings with the goal of increasing self-management in children with ADHD. The second set designed to provide managed consequences as well as manipulate environmental factors to increase the likelihood of a child’s classroom success. Zentall (1995) subsequently suggested a model emphasizing the need for children with ADHD to move, talk/question and learn. Zentall emphasizes that a focus on antecedents directly affects learning and behavior falls within the realm of what teachers are trained to do. This model suggests that when students are allowed to move, channel activities appropriately, talk and question actively and are provided with novel, interesting instruction they function better in classroom settings.
Based in part on Zentall’s suggestions, Goldstein (1994) defined three key goals for children with ADHD trying to fit into the existing educational system: To start, stop and to think in a manner consistent with others. As a framework for educators, these goals focus intervention on increasing the child’s ability to start when everyone else begins for academic and non-academic tasks; to stop when everyone else stops, including completing the product required; and to think about what the teacher is directing students to focus upon. Everyone learns best when a conceptual framework is provided and understood this facilitates educators’ ability to develop an initial framework and encourages the reception of and ultimately the ability to successfully implement strategies offered. Additionally, for children with ADHD in classroom settings, making tasks interesting and payoffs valuable while allowing opportunities for repeated trials to reach mastery are key ingredients of effective educational interventions.
Three additional concepts are critical in working with children with ADHD (Jones, 1989):
Children with ADHD begin most tasks with less effort than is necessary. Although they may not decline in sustained attention more quickly than other children, the fact that they begin with less attention results in their more quickly falling below a threshold necessary to remain on task. Thus, the axiom that attention in classroom settings is greatest in short activities is valid for children with ADHD. Frequent brief drills or lessons covering small chunks of information result in better classroom performance.
Children with ADHD experience flagging attention. As tasks are presented repeatedly, they perform with decreasing effort and motivation. Thus, in a common sense way children with ADHD may be quicker to perceive tasks as repetitive or uninteresting. If they require the need for repeated trials to develop the same level of competence in some academic areas as their peers, the challenge for the classroom educator is to present the same material in slightly different ways or different applications to maximize the child’s interest in the task. Further, the availability of choice among what is to be learned is also an important variable. Choice likely increases task interest and thus subsequent effort and motivation.
A consistent routine enhanced by a highly organized format of activities is recommended to provide a focused environment for children experiencing difficulty investing in classroom tasks. Specific daily schedules, including well-planned experiences with managed and brief transitions are optimal for children with ADHD. Rules, expectations and consequences should be clearly stated and specific. With this in mind, it is obvious that as the number of transitions within an educational day increases the likelihood that children or teens with ADHD will struggle also increases. ADHD teens are particularly unsuited to meet the multiple demands required during the course of their school day.
Physicians consulting with teachers must help them understand that children with ADHD function better when a variety of materials to enhance visual, verbal and tactile interactions are offered. The manipulation of materials makes the task more interesting and increases motivation. Second, activities in which students work together during the learning process allowing the opportunity to model new behaviors and reinforce existing skills is effective for students with ADHD. Finally, the concepts of brevity, variety and routine along with the basic philosophy of making tasks interesting and payoffs valuable can be very effective for students with ADHD. This is true even for those receiving stimulant medication. Keep in mind research studies reflect a normalization in the behavior of students with ADHD while taking medication yet at least one third continue to demonstrate teacher identified problems.
It is also important for the physician to help teachers understand that the use of psychoactive medications with children is scientifically sound and that treatment decisions are based on changes observed in the child’s behavior in an ongoing rather than a one time evaluative process. As with the rest of the population, teachers can form distorted opinions about medications ranging from the idea that they cause additional problems to viewing medications as miracle cures. The physician must provide classroom teachers with a realistic overview of medications and the areas of problems that can be addressed through medication intervention.
Treatment of ADHD in Adults
Children with ADHD very clearly grow up to become adults with ADHD. Although symptom presentation may vary, it is reasonable to conclude that adults with ADHD are for the most part significantly impacted in their daily lives as the result of ADHD and more often than not experience secondary comorbid problems. Yet in contrast to the thousands of childhood treatment studies at this time there are likely fewer than 100 articles and treatment studies focusing on adults with ADHD. The bulk of these studies have, for the most part, focused upon the use of various medications. Although multiple types of medications have been suggested, based upon limited research as beneficial for adult ADHD, the consensus is that the stimulant medications are by far the most effective of the psychotropic treatments. However, unlike childhood ADHD in which behavior management strategies can be implemented by adults in the child’s environment, such opportunities are rarely possible for adults with ADHD. Spouses, although the best possible sources of such supervision, rarely wish to take on this role. In contrast, the teaching of self-management and counseling, which has not been found to be beneficial for children and teens with ADHD, may in fact be beneficial for adults with ADHD. Research in process and soon to be published suggests that a cognitive based psychotherapy (e.g., changing insight, ideas, and thoughts as a means of changing behavior) leads to self-reported improvements in ADHD symptoms.
In the absence of having yet developed an accepted, effective treatment protocol with positive outcome, supported by research with adults with ADHD, counselors must be willing to join the adult’s journey. Counseling to discuss life issues, experiences and feelings may be very beneficial as a means of increasing insight and building motivation. Counseling may also be helpful for those individuals with ADHD also experiencing depression, dysthymia or personality disorders. Given the increasing body of research suggesting the high rate of comorbidity among adults with ADHD, at least a brief period of counseling is recommended in conjunction with the initiation of stimulant treatment.
Nadeau (1998) based upon her ten years of clinical practice with adults with ADHD, suggests that counselors must be willing to work not only on self-esteem issues but problems with daily life management, social skills, relationships, patterns of underachievement educationally and vocationally. As Nadeau notes, counselors for adults with ADHD must have an intimate knowledge of typical work place dilemmas and relationship issues.
As with any issue facing the general public, from gasoline additives to treatments for children’s learning or behavior problems, the more attention drawn to a particular issue, the more likely it is that scientists, entrepreneurs and others will come forward for a variety of reasons proposing methods to benefit the problem. Regarding ADHD, these unproven treatments move into the realm of controversy when they are unfairly, inappropriately and at times ruthlessly marketed as proven effective. As reported earlier, some of these treatments have managed to place themselves so firmly in the mainstream as to be recommended by physicians. It is important, however, for physicians to possess a working knowledge of these controversial treatments. Make no mistake, most of these are not alternative treatments. These are not treatments that for the most part hold any research basis as benefitting ADHD nor when offered by their proponents are they suggested as might or could be of benefit but rather are presented with promises of great outcome.
Evaluating New Treatments
The scientific process by which a particular treatment is shown to be effective can be long and arduous. Each step takes time and careful planning. The process usually begins with a formulation of a hypothesis usually based on an existing body of knowledge. The second step requires the development of a protocol to evaluate the effectiveness of the proposed treatment. The treatment itself and the way in which it will be implemented is carefully defined. Researchers also specify the means by which effectiveness of treatment will be evaluated. The process can take years but it is the only way the scientific community can make sound decisions about new treatments. In regards to ADHD, effective treatments must impact the child at the point of performance. These treatments must fit with what is already known about ADHD and have consistently and repeatedly demonstrated effectiveness across a variety of situations and settings.
There is a second path that some scientist-practitioners follow sometimes to avoid the longer, more accepted, certainly arduous process. This path is fraught with danger. On this path proposed treatments often stem from concepts outside the mainstream of existing knowledge. These treatments are often instituted long before there is any research supporting their effectiveness. Often only brief, poorly designed trials involving a small number of subjects are offered as proof of the effectiveness of these treatments. Single case studies are often the major proof offered. Measurement techniques and statistical means of evaluation are usually limited. Often this path represents pseudo-science. Such science consists of anachronistic thinking, a casual approach to evidence, use of spurious similarities, research by literary interpretation, refusal to revise and most controversial, the belief that something is true until proven false.
The controversial treatments presented commonly claim effectiveness for a broad range of problems including ADHD. When pressed for proof, proponents of these treatments are often able to produce large volumes of information. However, closer analysis reveals that documentation does not scientifically support the treatment claims. Proponents of controversial treatments often claim to have access to knowledge and information not shared by the medical, mental health, or educational community at large. When their treatments are criticized they explain that this criticism reflects a conspiracy against them in the scientific community. Each of these controversial treatments will be discussed only briefly. Interested readers are referred to an indepth discussion of these treatments in Ingersoll and Goldstein (1993); Goldstein and Goldstein (1998).
ADHD may be influenced but is clearly not caused by dietary issues. After analyzing the existing evidence, multiple reviewers have consistently concluded that the evidence failed to support a link between modifying diet and improving ADHD symptoms. It is fair to conclude that children with ADHD require a healthy, well-balanced diet as do all children. There is also reason to believe that a good breakfast is particularly important and that to be most helpful, breakfast should offer a balance of protein and carbohydrate. Finally, although many children with ADHD are picky eaters or crave certain foods, there is no research to suggest that their dietary habits or cravings are related to their behavior.
Megavitamins and Mineral Supplements.
The use of very high doses or mega-doses of vitamins and minerals to treat ADHD has its roots in the model of orthomolecular psychiatry. It is suggested that some people possess a genetic abnormality that results in increased requirements for certain vitamins and minerals. When these higher than normal requirements are not met, various forms of illness, including ADHD can occur. In 1973, a task force appointed by the American Psychiatric Association concluded that the use of megavitamins and mineral supplements to treat behavioral and learning problems was not justified based on the available research literature. Thirteen years later the American Academy of Pediatrics issued a similar paper. In the past twenty years despite claims made by proponents of these types of treatments, there has not been any well constructed, scientific research to justify altering these conclusions.
The Vestibular System.
Two different schools of thought have proposed that an underlying dysfunction in the vestibular system is responsible for ADHD as well as other learning and behavior problems. Ayres (1965) views the vestibular system as the unifying system of the brain and suggests that when it does not function properly problems ensue. Levinson (1990) reports that a dysfunction in the cerebellar vestibular system causes a wide range of problems. He hypothesizes that there is a relationship between ADHD and problems with coordination and balance.
The solutions of these two individuals, however, are different. Ayres developed and implemented a treatment known as sensory integrative therapy. This treatment continues to be very popular with some occupational therapists. The popularity of this approach can be explained in part by the fact that exercise, like vitamins, appears to be a natural way to treat ADHD symptoms. Ayres’ theories, however, do not appear to be consistent with what is currently known about the cause nor treatment of ADHD. There is insufficient data to suggest that the vestibular system is primarily involved in regulating attention, activity level nor impulse control.
Levinson, in contrast, proposes a mixed array of medications including three anti-motion sickness antihistamines (meclizine, cyclizine and dimethylhydrinate) and three stimulants (pemoline, methylphenidate and dextroamphetamine). Using a variety of combinations of these medicines at various doses, Levinson claims a success rate in excess of 90%. Unfortunately his proof consists of single case studies. Levinson’s theory and approach is not consistent with what is currently known about ADHD. In response, Levinson reports that the combination of medications necessary to help most children makes it difficult if not impossible to provide proof that this is an effective treatment through well-controlled, double blind studies. At best, this response to a lack of scientific analysis is a convenient means of avoiding putting his theory to the test. Physicians need to be cautioned about the potential side effects when combinations of stimulants are prescribed in excessive doses.
Candida albicans is a type of yeast living in the human body. Crook (1991) has proposed that yeast infections cause ADHD. According to this theory, toxins produced by the overgrowth of yeast circulate through the body, weaken the immune system and make the individual susceptible to a frightening array of infections, illnesses and psychiatric disorders, including ADHD. Treatment includes a prescription of an antifungal medicine such as nystatin and a low sugar diet. Other aspects of this treatment program include an elimination diet to avoid food allergies and the use of vitamin and mineral supplements. This theory is not consistent with current knowledge concerning ADHD. There is no evidence from controlled studies supporting this method of treatment with only anecdotal evidence and testimonials provided.
The EEG biofeedback approach to treating ADHD has become popular and is receiving an increasingly larger share of media attention, particularly in the past year. Proponents of EEG biofeedback suggest that ADHD can be trained way by increasing the type of brain waves associated with sustained attention and decreasing the type of activity associated with daydreaming and distraction. Although proponents of this approach are not claiming that EEG abnormalities are the cause of ADHD, they suggest that by altering EEG patterns, the manner in which the brain operates can be modified and that this modification leads to improvement in ADHD symptoms. Limited research is available suggesting the benefits of this approach nor for that matter the use of any type of biofeedback as dramatically improving symptoms of ADHD. Biofeedback is truly a twentieth century treatment. Children are attached by wires to machines which measure various involuntary body functions and provide information to the individual who then uses this feedback to gain voluntary control over these body functions. EEG biofeedback specifically measures levels of electrical activity in various regions of the brain. This information is fed into a computer which transforms it into a signal such as a light, tone or in the case of children, movement in a video game. Proponents of this treatment suggest that training involved between forty and eighty sessions, each lasting forty minutes or more. Sessions are held as often as two to three times per week. The procedures are usually augmented by proven treatments, including behavior management, educational intervention, academic tutorial and even medication if necessary. Although the theory underlying EEG biofeedback as a treatment for ADHD is consistent with what is known about low levels of arousal in frontal brain areas in individuals with ADHD, the available research has been inconsistent and often unreplicable in demonstrating that abnormal EEG patterns are a consistent finding for most children with ADHD. Although some studies have suggested dramatic results for EEG biofeedback, in general most have been poorly controlled. It would appear when the trappings of technology are removed, EEG biofeedback simply reinforces a child for paying attention. If in fact brain wave activities are altered when children pay attention it would be expected that any activity children with ADHD engage in that requires them to pay attention and reinforces them for increasing consistent attention would yield the same type of benefits. The application of EEG biofeedback technology in the treatment of ADHD at this time must be considered unproven and controversial. It is an area worthy of continued research. Until that time, however, it is an expensive approach whose effectiveness for ADHD remains scientifically undemonstrated but one that is being increasingly and aggressively marketed.
Auditory training was developed by French neurologist Guy Berard. It was originally proposed to treat autism. The treatment is based on de-sensitizing children to certain auditory signals. It has been suggested in the lay press that this treatment may be also beneficial for ADHD. However, no controlled studies have been completed.
Recent studies and reviews of the literature have consistently demonstrated that cognitive interventions (e.g., teaching children with ADHD to stop, look, listen, plan or pay attention) have failed to provide more than limited positive effects for ADHD (for review see Abikoff, 1991). These studies have suggested that cognitive techniques are more beneficial for normal children or children with other developmental or behavioral problems than for children with ADHD. For children with ADHD, benefits even when statistically significant are usually small in comparison to other less difficult treatments such as behavior management or medication. For cognitive behavioral interventions to succeed with children with ADHD the interventions must be taught to primary care givers, used on a daily basis and implemented in a variety of settings over the long term. Thus, it is not recommended that children with ADHD be placed in problem solving, skill building programs. However, cognitive interventions in the form of changing children’s views of themselves or teachers’ and parents’ perceptions of their children, helping them explore and understand the thoughts, feelings and ideas they have formed about themselves and the children they live and work with can be an effective, adjunctive strategy in the overall treatment plan for children with ADHD.
Helping Parents Become Wise Consumers
The treatments reviewed in this section vary in their theoretical underpinnings, extensive research and claims for effectiveness. Some merit continued research. Some have demonstrated ancillary though proven benefits for ADHD and others actually could do harm. Physicians must be aware that when these treatments are offered in the market place they cross the line from unproven to controversial. Proponents of these treatments can be very convincing that their approach is proven and acceptable despite the fact that little if any data exists to support their claims. Physicians should caution parents considering these treatments that time and money, which are often limited resources, might be better spent on treatments with proven track records. As has been summarized among the most effective methods for treating children with ADHD are the judicious use of medication and behavior management. Finally, as we have emphasized, parent education is an essential component of any effective childhood treatment program.
The physician’s obligation is to assist parents in obtaining the most appropriate and best treatments for their children. Desperate parents faced with their children’s failure on the playground, at school and at home, are often at the mercy of the marketing techniques utilized by these controversial treatments. When faced with the question of how can it hurt to try?, physicians have the ethical responsibility to accurately and thoroughly inform parents, educators and other professionals concerning the current status of these various treatments.
Ingersoll and Goldstein (1993) suggest that parents considering these treatments or any others be advised of the following warning signs:
- Overstatement and exaggerated claims for certain treatments are "red flags." Parents should be suspicious of any product or treatment that is described as "astonishing", "miraculous", or "an amazing breakthrough." Legitimate medical and mental health professionals do not use words like these nor do they boast of their success in treating huge numbers of patients.
- Parents should be advised to be suspicious, too, of any therapy that claims to treat a wide variety of ailments. Common sense tells us that the more grandiose the claim, the less likely it is there is any real merit behind it.
- Parents should not rely on testimonials from people who say they have been helped by the product or the treatment. First, legitimate medical and mental health professionals do not solicit testimonials from their patients. Second, testimonials are not substitutes for evidence. Third, patient enthusiasm is also not a substitute for scientific evidence. Testimonials in no way prove effectiveness. Choosing treatments for children's attention and impulse problems is not like choosing a mechanic for your car.
- Parents should request printed information about a particular treatment they are considering. They should be wary if the bulk of this information is published by that particular practitioner or by a group whose sole purpose is to promote that treatment.
- Parents must be skeptical about claims that a treatment is being suppressed or unfairly attacked by the medical or mental health establishment. Legitimate medical and mental health professionals eagerly welcome new knowledge and better methods vof treatment. They have no reason to suppress or oppose promising new approaches derived from scientifically valid research.
Physicians are urged to ask themselves how do I know a particular treatment will really work? Asking this question and having a consistent set of guidelines to evaluate the answers provided for a proposed treatment will prevent over trust in costly quick fix cures. More important, it will ensure that consumers are informed of the benefits and risks associated with any treatment that is offered. Physicians must be knowledgeable about all of these treatments and willing to ethically accept their responsibility to communicate such knowledge to their patients and families.
Resources for Physicians
Resources for Parents and Teachers
- Barkley, R. (1998). Attention Deficit Hyperactivity Disorder (3rd Edition). New York, New York: Guilford Press.
- Goldstein, S. (1997). Managing Attention and Learning Disorders in Late Adolescence and Adulthood. New York, New York: John Wiley & Sons, Inc.
- Goldstein, S. & Ellison A.T. (Eds.) (2002). Clinical Interventions for Adult ADHD: A Comprehensive Approach. New York, NY: Academic Press.
- Goldstein, S. & Goldstein, M. (1998). Managing Attention Deficit Hyperactivity Disorder in Children: A Guide for Practitioners (2nd Edition). New York, New York: John Wiley & Sons, Inc.
- Goldstein, S. & Reynolds, C. (Eds.) (1999). Handbook of Neurodevelopmental Disorders. New York, NY: Guilford Press.
- Nadeau, K.G. (Ed.) (1995). A Comprehensive Guide to Attention Deficit Disorder in Adults. New York, New York: Brunner Mazel.
- Teeter, A. (1998). Interventions for Children and Adolescents with ADHD: A Developmental Perspective. New York, NY: Guilford Press.
- Goldstein, S. & Goldstein, M. (1997). A Parent's Guide: Attention Deficit Hyperactivity Disorders in Children, 4th Edition. Salt Lake City, Utah: Neurology, Learning and Behavior Center.
- Goldstein, S. & Goldstein, M. (1995). A Teacher's Guide: Attention Deficit Hyperactivity Disorders in Children, 3rd Edition. Salt Lake City, Utah: Neurology, Learn and Behavior Center.
- Goldstein, S. & Hinerman, P. (1988). A Parent's Guide: Language and Behavior Problems in Children. Salt Lake City, Utah: Neurology, Learning and Behavior Center.
- Goldstein, S. & Goldstein, M. (1992). Hyperactivity: Why Won't My Child Pay Attention? New York, NY: John Wiley & Sons, Inc.
- Ingersoll, B. & Goldstein, S. (1993). Attention Deficit Disorder and Learning Disabilities: Myths, Realities and Controversial Treatments. New York, NY: Doubleday.
- Ingersoll, B. & Goldstein, S. (1995). Lonely, Sad and Angry: A Parent's Guide to Depression in Children and Adolescents. New York, NY: Doubleday.
- Alexander-Roberts, C. (1995). A Parent's Guide to Making it Through the Tough Years, ADHD and Teens. Dallas, TX: Taylor Publishing Co.
- Barkley, R.A. (2000). Taking Charge of ADHD: The Complete Authoritative Guide for Parents- 2nd Edition. New York, NY: Guilford Press.
- Bloomquist, M. (1996). Skills Training for Children. New York, NY: Guilford.
- Bain, L.J. (1991). A Parent's Guide to Attention Deficit Disorders. New York, NY: Bantam Doubleday Dell Publishing Group.
Children and Adults with Attention Deficit Disorder (CH.A.D.D.) (1996). ADD in Adolescence: Strategies for Success from CH.A.D.D. Plantation, FL: Author.
- Clark, L. (1986). SOS: Help for Parents. Bolling Green, KY: Parent's Press.
- Conners, C.K. (1990). Feeding the Brain. New York, NY: Plenum Publishers.
- Dendy, C.A.Z. (1995). Teenagers with ADHD: A Parent's Guide. Bethesda, MD: Woodbine House.
- Crutsinger, C. & Moore, D. (1997). ADD Quick Tips: Practical Ways to Manage Attention Deficit Disorder Successfully. Carrollton, TX: Brainworks, Inc.
- Fowler, M. (1990). Maybe You Know My Kid: A Parent's Guide to Identifying, Understanding and Helping Your Child with Attention Deficit Hyperactivity Disorder. New York, NY: Birchline Press.
- Garber, S.W., Garber, M.D. & Spizman, R.S. (1990). If Your Child is Hyperactive, Inattentive, Impulsive and Distractible. New York, NY: Villard Books.
- Gordon, M. (1990). ADHD/Hyperactivity Consumer's Guide for Parents and Teachers.
- DeWitt, NY: GSI Publications.
- Greenburg, G.S. & Horne, W.F. (1991). Attention Deficit Hyperactivity Disorder: Questions and Answers for Parents. Champaign, IL: Research Press.
- Ingersoll, B. (1997). Dare Devils and Daydreamers: New Perspectives on Attention Deficit Hyperactivity Disorder. New York, NY: Doubleday.
- Jones, C.B. (1994). Attention Deficit Disorder: Strategies for School Aged Children. Tucson, AZ: Communication Skill Builders.
- Jones, C.B. (1991). Sourcebook for Children with Attention Deficit Disorder: A Guide for Early Childhood Professionals. Tucson, AZ: Communication Skill Builders.
- Katz, M. (1997). On Playing a Poor Hand Well: Insights from the lives of those who have overcome childhood risks and adversities. New York, NY: W.W. Norton & Co.
- McCarney, S.B. & Johnson, N.W. (1995). A Parent's Guide to Early Childhood Attention Deficit Disorders. Columbia, MO: Hawthorne Press.
- Parker, H.C. (1988). The ADD Hyperactivity Workbook for Parents, Teachers and Kids. Plantation, FL: Specialty Press. (Also available in Spanish).
- Patterson, G.R. & Forgatch, M. (1988). Parents and Adolescents Living Together: Part I. The Basics; Part II. Family Problem Solving. Eugene, OR: Castalia Press.
- Phelan, T. (1984). 1-2-3 Magic. Glen Ellyn, IL: Child Management Press.
- Phelan, T.W. (1993). All About Attention Deficit Disorder: A Comprehensive Guide.
- Glen Ellyn, IL: child Management, Inc.
- Shure, M.B. (1994). Raising a Thinking Child: Helping Your Young Child to Resolve Everyday Conflicts and Get Along with Others. New York, NY: Henry Holt & Co.
- Silver, L.B. (1993). Dr. Larry Silver's Advice to Parents on Attention Deficit Hyperactivity Disorder. Washington, DC: American Psychiatric Press, Inc.
- Taylor, J.F. (1990). Helping Your Hyperactive Child. Rocklin, CA: Prima Publishing.
- Turecki, S. & Tonner, L. (1985). The Difficult Child. New York, NY: Bantam Books.
- Zengall, S. & Goldstein, S. (1999). Seven Steps to Homework Success: A Family Guide for Solving Common Homework Problems. Plantation, Florida: Speciality Press.
- Goldstein, S. (1989). Why Won't My Child Pay Attention? Salt Lake City, Utah: Neurology, Learning and Behavior Center. (Also available in European PAL format)
- Goldstein, S. (1994). < b> Why Isn't My Child Happy? Salt Lake City, Utah: Neurology, Learning and Behavior Center. (Also available in European PAL format)
- Goldstein, S. & Goldstein, M. (1990). Educating Inattentive Children. Salt Lake City, Utah: Neurology, Learning and Behavior Center. (Also available in European PAL format)
- Goldstein, S. & Goldstein, M. (1991). It's Just Attention Disorder: A Video Guide for Kids. Salt Lake City, Utah: Neurology, Learning and Behavior Center. (Also available in European PAL format)
- Goldstein, S. & Goldstein, M. (1991). It's Just Attention Disorder: User's Manual. Salt Lake City, Utah: Neurology, Learning and Behavior Center.
- Barkley, R.A. (1995). ADHD: What Do We Know? New York, NY: Guilford Press.
- Barkley, R.A. (1995). ADHD: What Can We Do? New York, NY: Guilford Press.
- Barkley, R.A. (1995). ADHD in the Classroom: Strategies for Teachers. New York, NY: Guilford Press.
Materials, Information & Additional Resources
CH.A.D.D. < /b> www.chadd.org
8181 Professional Plaza, Suite 201 / Landover, MD. 20785
(301) 306-7070 / (301) 306-7090 (FAX) / 1-800-233-4050
National Attention Deficit Disorders Association (ADDA)
9930 Johnnycake Ridge, Suite 3E / Mentor, Ohio 44060
ADD Warehouse www.addwarehouse.com
300 N.W. 70th Avenue, Suite 102 / Plantation, Florida 33317
Learning Disabilities Association of America (LDA) www.ldanatl.org / firstname.lastname@example.org
4156 Library Road / Pittsburgh, Pennsylvania 15234
800 Gray Oak Drive / Columbia, Missouri 65201
American Psychiatric Association
1400 "K" Street, NW / Washington, DC 20005
American Psychological Association (APA)
750 First Street, NE / Washington, DC 20002-4242
Autism: A condition hypothesized as genetic but of uncertain etiology and course characterized by significant deficits in interpersonal relations language, general development and behavior.
Biopsychosocial: A description of the biological, psychological, and social or environmental contributions to a specific condition.
Categorical problems: a problem defined by meeting a specific set of criteria, crossing a threshold to enter the category. Categorical problems represent all or nothing conditions.
Comorbid: The co-occurrence of two problems either by chance or cause-and-effect.
Consequences: Any response made to behavior either reinforcing (e.g., rewards) or punishing (e.g., response cost).
Dimensional problems: Those problems that fall unevenly along a normal curve. In this case problems with ADHD fall along a normal curve with some individuals being very minimally affected and others much more significantly affected.
Disruptive childhood disorders: These are childhood conditions according to the DSM-IV TR that disturb or disrupt adults including ADHD, Oppositional Defiant Disorder and Conduct Disorder.
EEG - electroencephalograph: A tool for the measurement of electrical activity in the brain.
Encopresis: Fecal soiling.
Enuresis: Urinary incontinence.
Epidemiological: Screening large populations of individuals that have not been referred for specific problems. An entire population is screened without exception.
Executive skills: Those intellectual skills that require thinking, reasoning, judgment, planning, and organization.
Handicapping condition: A condition under the Individuals for Disabilities Education Act considered to cross the threshold so as to impair a child’s ability to benefit from their education, thereby necessitating special services.
Impulsivity: A lack of inhibition. The tendency to act without forethought, planning, or thinking.
Individuals with Disabilities Education Act: This Act recently re-enacted guarantees that all children will receive an appropriate education to meet their needs. It is an equal success law.
Locus of control: The place at which one views the control of behavior. An internal locus equates with individuals who recognize that they control their destiny. An external locus is characteristic of individuals who believe that they are controlled by the behavior and actions of others.
Longitudinal studies: Studies that follow a population of individuals over a long period of time, drawing conclusions about the relationship between their earlier functioning and functioning at a later date.
Monoamine neurotransmitters: Among the most common are dopamine, serotonin and noradrenalin. These have been implicated in playing a role in causing the symptoms of ADHD. These are brain-based chemicals, however, they are also found in other parts of the body.
Negative reinforcement: Reinforcement in which the individual works to avoid or earn relief from an aversive consequence.
Neuropsychological tests: Laboratory based tests that attempt to measure and assess the relationship between brain function and behavior.
Non-disruptive childhood disorders: According to the DSM-IV TR these are disorders that do not disrupt, but rather cause concern among adults. Included are depression, anxiety, and developmental problems.
PET scan - positron emission tomography: A form of brain scanning in which irradiated glucose or oxygen is sent to the brain during the completion of a specific cognitive task. Scanners then measure the location of the radiation to identify and correlate specific areas of the brain with specific types of functions.
Psychosocial treatments: Any treatment that is not medical or educational. This includes but is not limited to parent training, behavior management and counseling.
Section 504 of the American’s for Disabilities Act: The American’s for Disabilities Act is an equal access law. It guarantees that everyone in the community has access. In this case, Section 504 dealing with education has allowed students with ADHD to receive special services at school even if they do not qualify under IDEA.
Secretarial skills: Skills related to simple memory, motor, and attention. These skills primarily require efficiency rather than thinking.
Self-regulation: The capacity to efficiently govern oneself. In the case of ADHD, the self-regulation of behavior and action.
Sensitivity: The ability of an instrument to identify all true cases of a condition, avoiding false positives.
SPECT scan - single photon emission computed tomography: Similar to PET scan but using irradiated markers with longer half-life allowing this particular tool to be used in any hospital.
Special education: The branch of education providing services to children with handicapping conditions.
Specific learning disability: A delay or discrepancy between grade placement, age, intellect, and achievement in the areas of reading, writing, spelling and mathematics.
Specificity: The ability of an instrument to rule out a particular condition avoiding false negatives.
Tics: A repetitive movement that at one time had a purpose, but is done repeatedly without purpose (e.g., flicking hair from your eyes, clearing throat).
Token economy: The use of tokens or points as part of a behavior management or reinforcement system.
Tourette’s Syndrome: A movement disorder characterized by one vocal and two motor tics, occurring over a one year period.
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