Attention-deficit hyperactivity disorder (ADHD)

Overview
Attention-deficit hyperactivity disorder (ADHD) is defined as inconsistent levels of attention or the inability to consistently focus and sustain attention along with hyperactivity. The hyperactive-impulsive behaviors are considered to be excessive or inappropriate for the person's age and developmental level.
Symptoms must be present in two or more settings (such as school, work or home), but they may not be equally problematic in each setting. Without hyperactivity, the condition is called attention-deficit disorder (ADD).

Children who have ADHD may have an intense focus on whatever occupies their attention at the time. Or, they may have no apparent difficulty sustaining attention during interesting, pleasurable activities or one-on-one situations. The difficulties may appear when the child is asked to switch to a new activity. In households with more than one person who has ADHD, a child's behavior may not appear markedly different from that of other family members.

ADHD affects about 3 percent to 10 percent of American children. Based on limited data, an estimated 2 to 4 percent of American adults have ADHD. ADHD typically appears between ages 4 and 7. An estimated 67 percent of children diagnosed with ADHD will continue to have clinically significant symptoms of ADHD into adulthood. The condition appears to affect two to three times more males than females. Researchers have hypothesized that girls may not be diagnosed with ADHD as often as boys due to cultural differences regarding behavioral expectations for boys and girls.


Types of ADHD
Depending on the person's specific combination of symptoms, ADHD has three recognized subtypes:
The predominantly inattentive type is characterized by symptoms such as a lack of attention to details, distractibility, forgetfulness, a dislike or reluctance to work on tasks that require sustained mental effort, losing objects necessary to complete tasks, and difficulty following directions and completing tasks.

The predominantly hyperactive-impulsive type is characterized by symptoms such as getting up in situations where remaining seated is expected, blurting out answers before questions have been completed, fidgeting, inappropriately running or climbing, talking excessively, difficulty taking turns, interrupting, and behaving intrusively.

The combined type is characterized by symptoms of inattention, hyperactivity and impulsiveness.

Causes/associated factors
There is no single identifiable cause for ADHD. According to some theories, genetic factors, biochemical abnormalities, or injuries or diseases that occurred before or after birth may be to blame. Other theories currently being researched include premature birth, genetics, fetal distress and fetal exposure to alcohol, nicotine, other drugs or toxins such as lead. People do not generally "outgrow" ADHD at puberty, as once thought. In many cases, the condition can continue into adolescence and adulthood. However, people who have ADHD can learn to control their inattention and minimize their disruptive behaviors. Some need medication indefinitely, others do not.
People who have ADHD may have other conditions as well. The most common coexisting conditions are bipolar disorder and substance use disorders. People who have ADHD have a higher rate of smoking than the general population and tend to begin smoking earlier. Learning disabilities, oppositional defiant disorder, conduct disorder, depression, anxiety and tic disorders are also common coexisting conditions, especially for children.


Characteristics
Physically, a child or adult who has ADHD may fidget, pace and be unable to sit still. The person may have sleep problems. He or she may have more accidents and physical injuries than others, as well as be easily distracted or uncomfortable with touch or close physical proximity.
Psychologically, the child or adult may have trouble concentrating, low self-esteem and a low frustration threshold. He or she may have difficulty maintaining motivation and regulating emotions. Impulsivity (acting before considering consequences), disorganization and a poor memory are also common. A child may experience developmental delays. For an adult, distractibility may be interpreted as disinterest or rudeness. The person may also be irritable and sensitive to stimulation.

Socially, a child may challenge rules and authority figures, including teachers and parents. He or she may have trouble making and keeping friends. A person who has ADHD may talk and interrupt excessively, have difficulty waiting and taking turns, have trouble respecting boundaries, and be easily overstimulated. The person may seem intrusive and may easily abandon tasks and/or responsibilities, or might study or complete work better when under pressure. Both children and adults who have ADHD may have academic or occupational performance that is inconsistent with their abilities and achievement.

An adult who has ADHD may experience academic or occupational difficulty due to an aversion to details, chronic lateness, poor time perception, and difficulty with multitasking. He or she may also have trouble with time management, completing projects, and meeting deadlines. The person may engage in high-risk behaviors, have poor self-control, and turn to substance abuse.

Symptoms that require further evaluation
Sometimes ADHD can be more than a child or adult is able to handle at the time. Symptoms such as sleep disturbances, decreased energy, changes in appetite, anxiety, depression, inability to concentrate and hopelessness may warrant further evaluation by a health care professional.

As with all physical symptoms, consult a medical health care provider to rule out a medical condition. If these or any other symptoms cause distress that doesn't seem to improve, seek additional help and support from a mental health care professional.


Diagnosis
ADHD is difficult to diagnose before age 4 or 5 due to the variability of a young child's behavior. To complicate matters, there is no single test available to diagnose or confirm ADHD -- medical, psychological or otherwise. Instead, a battery of tests and questionnaires are typically done. Early detection and treatment positively impacts the prognosis. Evaluation typically includes:
observation of behavior by parents, teachers, spouse and other adults who have close contact with the child or adult, often based on standard questionnaires or checklists provided by a health care professional
a review of the person's family and developmental history, which may include teacher comments on report cards, parent-teacher conference summaries and other school records
a physical exam to rule out problems with vision, hearing, allergies, thyroid function, diabetes or other medical conditions
a psychological assessment to rule out or determine the coexistence of anxiety, depression or other emotional disorders
an assessment of intelligence, learning disabilities, perception problems and academic achievement
a computerized test (commonly called TOVA) that measures attentiveness
an electroencephalogram (EEG, a recording of the brain's electrical activity)
if appropriate, specific strategies to address the person's strengths and weaknesses
Symptoms must be present in at least two separate settings, such as home and school or work. Although psychologists most commonly diagnose ADHD, other health care professionals involved in the assessment may include a medical doctor, psychiatrist, neurologist, neuropsychologist, speech pathologist and occupational therapist. In the case of a child, a school psychologist or psychological/educational assessment team may be involved, as well as a family counselor and/or school nurse. It's important to keep in mind that cultural norms greatly affect the diagnosis of ADHD -- whether activity level is age-appropriate or excessive, for example. Some of the symptoms indicating ADHD may be seen as appropriate in some cultures. ADHD is diagnosed more often in the United States than in Europe. Since testing procedures do not always take cultural variables into account, ask the clinician about the particular instruments used in making the diagnosis.

Remember, ADHD must be professionally diagnosed. You cannot make an accurate diagnosis from a checklist in a popular magazine, Web site or other consumer source. Diagnosis typically takes a few hours and cannot be based on a single instrument or questionnaire. Previous testing, school records and related material provide important information regarding the assessment for ADHD.


Treatment
The successful treatment of ADHD generally requires a multifaceted approach. The goal of treatment is to help reduce symptoms, maximize learning, improve attention skills, increase self-esteem, and achieve success at home and other settings, such as school or work.
Current research supports behavioral and cognitive therapies, medication or a combination of both as treatments for ADHD.

Education about ADHD for parents, children and other significant adults is another key element of treatment. Parental training in behavioral management, such as setting clear, firm limits on behavior, may also be useful. Another important element is a structured daily routine at home and school. Support groups for parents and children and school consultations may also be helpful.

For children, school interventions can help ensure appropriate class placement and availability of needed resources, such as tutoring. These interventions must be tailored for the child and continually monitored. Work with the school personnel as early as possible to develop a mutually agreed-upon plan for managing your child's behavior. It's also important to maintain regular, consistent communication with the school personnel about your child's performance and progress.

The medication decision
Many doctors believe a combination of counseling and medication brings the most significant, long-lasting improvement in ADHD symptoms. A reported nine out of 10 children who have ADHD improve with appropriate drug therapy. Stimulants (drugs that stimulate activity in the brain) are the most commonly prescribed drugs for ADHD, including methylphenidate (brand name Ritalin), dextroamphetamine (Dexedrine) and pemoline (Cylert). For people who have ADHD, stimulants can create a calming effect and increase concentration. There is also an FDA-approved nonstimulant medication, atomoxetine HCl (brand name Strattera) for the treatment of ADHD.

If medication is prescribed, it's important to maintain the medication regimen. Keep in mind that effective drug therapy is often a matter of trial and error and can require frequent follow-up exams. (Depending on the particular medication and state laws, a follow-up visit may be needed every 30 days. In fact, many states require a new, written prescription every 30 days.) Several medications, as well as dosages and timing, may be tried until one proves successful. Ask the doctor or psychiatrist how long it will take to determine if the medication is going to be effective.

As a parent, address any concerns about these medications or the possible development of substance abuse with your child's doctor. And don't feel pressured by school officials to medicate your child. The decision requires careful professional evaluation. It is likely that more children are treated with stimulant drugs than actually meet the medical criteria for them -- Ritalin is used five times more often in the United States than in the rest of the world. If you opt for medication for your child, emphasis should be placed on a "trial period" approach. As a parent, you should have a strong role in judging the benefit (or lack of benefit) from any given drug. Remember, parents and teachers must not depend on medications alone as intervention, and you have the right to stop the drugs if you feel it's best for your child.


Summary
Without proper treatment, ADHD can result in school failure, social isolation or low self-esteem. However, people who have ADHD can look forward to full, productive lives, especially when they have the support and encouragement of loved ones.