Attention Deficit / Hyperactivity Disorder
What is Attention Deficit/Hyperactivity Disorder (ADHD)?
Attention-deficit Hyperactivity Disorder is characterized by excessive hyperactivity, impulsivity and inattention during a given developmental age. While all children have problems with their behavior from time to time, kids with ADHD have behavior problems that interfere with their regular life on a continual basis. A key feature of ADHD is its clinical heterogeneity. ADHD tends to coexist (is comorbid) with other neurodevelopmental disorders to include Oppositional Defiant Disorder, Learning disabilities, Tourette’s Disorder, Obsessive Compulsive Disorder and Anxiety disorder. ADHD used to be called Attention-Deficit Disorder or ADD. It is estimated that approximately 50% of children with ADD/HD may continue to experience problems as an adult. Children with Attention-Deficit Hyperactivity Disorder (ADHD or AD/HD) can have a variety of different kinds of symptoms: Inattention: These kids have trouble paying attention, are disorganized or daydream too much; Hyperactivity: These kids are always moving, can't sit down or talk too much; Impulsivity: These kids act and talk without thinking, interrupt a lot or show poor judgment. Finally, the above symptoms of inattention and hyperactivity can occur together.
How common is ADHD?
Attention-Deficit Hyperactivity Disorder is the most common behavior disorder in school-aged kids. It has a prevalence of approximately 5-7.5% (Barbaresi et al., 2004).
Is ADHD a learning disability?
ADHD and learning disabilities are two very different kinds of disorders. But they do often come together. Up to 30% of children with ADHD may have learning related challenges.
What causes it?
ADHD is arguably the most studied neurobehavioral disorder in children. However, to date the exact causes of ADHD are not yet known. Converging lines of evidence from multiple scientific studies point to dysfunction of both cortical and subcortical neural circuits as playing a major pathophysiological role in ADHD. Recent brain imaging studies of children with ADHD have found structural deficits in the form of decreased volumes in the cerebellum, basal ganglia, corpus callosum and frontal lobes (Durston, 2003). Additional series of functional neuroimaging research has pointed to decreased functioning in prefrontal regions of the brain associated with inhibitory deficits (Rubia et al., 1999, 2000b). These and other studies have supported the conclusion that a developmental lag in related frontal-striatal circuits underlies ADHD.
Is ADHD Inherited?
ADHD seems to run in families, so it may be inherited. Genetic research points to linkage in specific genes related to dopamine.
How is ADHD diagnosed?
ADHD is usually only diagnosed in school-aged kids (ages 6-12), because it is hard to diagnose in younger children. Part of the diagnostic challenge is that ADHD is highly heterogeneous and is found to coexist with other childhood disorders to include Tourette’s disorder (TD), Obsessive Compulsive Disorder (OCD) and mood related disorders such as anxiety or depression. The diagnostic process has many steps, and a team approach involving parents, teachers, psychologists and physicians may be necessary in order to make the diagnosis. To find out about diagnosis, read the American Academy of Pediatrics clinical practice guideline (see: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactiviy Disorder).
How is ADHD treated?
The best treatment for ADHD is usually medication, combined with behavior therapy (including training parents in behavior therapy such as Parent Child Interaction Therapy or PCIT) and helping your child get organized at home and at school to make it easier to pay attention. Because ADHD is a chronic condition, treatment must also be on going. Usually you will have a long-term plan that includes goals for your child. When all the parts of the treatment plan are in place, and everyone (child, parents, teachers, doctors, caregivers, etc.) works together, treatment will be most effective. (For further information see: www.aap.org/policy Treatment of the School-Aged Child with Attention-Deficit/Hyperactivity Disorder).
What about medication?
There is lots of news lately about medications and children. Some people think medication is prescribed too much. Stimulant medicines like Ritalin, Dexedrine and Adderall have been used for about 60 years and have demonstrated effectiveness in treating the symptoms of ADHD. A newer medication that is not a stimulant, called Strattera, may show promise for those who haven't done well on the stimulants. The National Institute of Mental Health and Columbia University conducted a study in 1999 of ADHD treatments. The findings of this study of multi-modal treatments (a combination of medication and behavioral treatments) indicate that (4):
1. Medication alone is as effective for ADHD symptoms as multi-modal therapy
2. Medication is more effective than behavioral alone
3. Multi-modal treatment is better for ADHD associated with coexisting conditions. These include anxiety, oppositional-defiant disorder (ODD), conduct disorders, etc.
There are also other kinds of medicine that your child's doctor may try if the stimulants don't work. Sometimes, your child's doctor may need to try a few different medicines at a few different doses to find the one that works best for your child. You could think of the brain as a black box that we can't see inside. The doctor doesn't know how a medicine will affect the brain until he or she tries it. Nine out of ten kids improve on stimulant medication.
If your child's doctor prescribes a medication for your child, make sure you ask about the benefits and risks of taking the drug. If your child is just starting medication, he or she should have their symptoms monitored to keep track of how they're doing so as to share this information with your child's doctor at your next office visit.
What if I think my child might have ADHD?
If you think your child may have ADHD, you should have them checked by their primary care provider or a child neurologist or child psychiatrist. Sometimes other problems can mimic ADHD to include: family stress, a learning disability (nonverbal learning disability) or communication disorder (central auditory processing problem). You should also get help from your school system and ask for an evaluation by a Child Study Team.
What can the school system do for my child?
If your child is struggling in school, ask your school system in writing for an evaluation of your child. They are required to provide it, at no cost to you. The purpose of an evaluation is to find out why your child is not doing well in school. A team of professionals will work with you to evaluate your child. If they do not find a problem, you can ask the school system to pay for an Independent Educational Evaluation (IEE). There are strict rules about this, so you may not get it. You can also have your child tested again privately, and pay for it yourself. But check with your school district first to make sure they will accept the private test results. By law, the school system must consider the results of the second evaluation when deciding if your child can get special services. Should testing show your child has ADHD, the school system may start your child in a special education program.
What is special education?
Special education means “educational programming designed specifically for the individual.” It can really help your child do better in school. If your school-aged child qualifies for special education, they will have an individualized educational plan (IEP) designed just for them. (For further information see: http://kidshealth.org/parent/growth/learning/iep_prt.htm).
What about alternative treatments?
A working definition of an alternative therapy is a “…treatment or intervention that do(es) not conform to standards of the medical community.” (Eisenberg, 1993). The role of complementary or unconventional medical treatments is on the rise with as many as 1 in 3 adults and approximately 50% of children receiving alternative medical care (Eisenberg, 1998). You may hear about new or alternative treatments that people are talking about. Before starting your child on one of these, talk about it with your child's doctor. You may feel desperate for a "silver bullet" that will cure your child's problem. Some of the alternative treatments may sound reasonable, and may even be developed by doctors or specialists. But if they are not scientifically proven, you risk spending time, money and hope on false promises. On the other hand, you and your child's doctor might decide it's worth it to try a low-risk alternative treatment. Not all approaches are created equally and consultation with a physician may help guide you according to the best available evidence based medicine. It must be stated many alternative treatments have not been proven to work. Such interventions like allergy treatments, vitamin supplements and eye-movement desensitization. Other interventions, although not clinically proven have demonstrated some results that are positive. For example, recent studies suggest that biofeedback could be a useful treatment for ADHD (Fuchs et al., 2004; Heinrich et al., 2004). (For more information please see www.aboutourkids.org/aboutourkids/articles/adhd_biofeedback.html, EEG biofeedback for children with ADHD).
What about girls with ADHD?
ADHD seems to be more easily recognized in boys than in girls. Girls with ADHD tend to draw less attention than boys do. Some experts believe that girls with ADHD may act very differently from the typical picture we have of the kid with ADHD. They may be active, messy and disorganized. Girls who have trouble paying attention may act more like daydreamers, and may go unnoticed at school because they are so quiet. Finally, girls with a combination of the two may be hyper-talkative, rather than hyperactive, and also be silly and excitable. When girls with ADHD fall through the cracks and go undiagnosed, they pay a high price. They may not do well in school and their self-esteem may suffer. They may come to think of themselves as not very bright, quitters or low achievers. Girls with ADHD can be overlooked and under-diagnosed. .
What can Parents Do about ADHD?
Parents can implement the following ADHD Management Strategies
1. Try to focus on your child's good qualities. "Catch" your child behaving well at least three times a day and tell them you noticed. Work up to more than three times a day.
2. When you praise your child, simply describe to them the behavior you saw that you'd like to see more of. For example, “You really stayed with me at the mall today.”
3. If anxiety contributes to the ADHD, then the development of simple relaxation techniques, such as breathing exercises can be helpful.
4. Kids with ADHD often have trouble sleeping. Excessive movements and sleep disordered breathing can contribute to ADHD symptoms.
Books:
1. Driven to Distraction by Edward Hallowell, M.D. & John Ratey, M.D.
2. Parenting the Strong-Willed Child by Rex Forehand and Nicholas Long (A Self-guided five-week program for dealing with behavior problems associated with being strong-willed. Also ways to develop a more positive atmosphere in the family and home.)
3. On Parenting by James Dobson (A Christian approach to parenting the strong-willed child).
Websites and Organizations:
1. The Attention Deficit Hyperactivity Disorder (ADHD) homepage from the National Institutes of Mental Health (NIMH) will lead you to in-depth information on many aspects of the disorder.
2. Learning Disabilities Association of America publishes news briefs and a professional journal and provides information and referral to state chapters, parent resources and local support groups. Call 1-412-341-8077
3. CHADD (Children and Adults with ADD) is an advocate and information source that sponsors support groups with local chapters. There are over 20 chapters in Michigan. Call or email for one near you. Call 1-800-233-4050.
4. ADD Warehouse is a catalog of books, videos, and other products to help parents, educators and health professionals understand and treat all developmental disorders, including ADHD and related problems. Call 1-800-233-9273 (1-800-ADD-WARE).
5. National Attention- Deficit Disorder Association supports education, research and public advocacy for adults with ADHD.
Literature Cited:
(1) A American Academy of Pediatrics. AAP parent pages: ADHD and your school-aged child. October 2001.
(2) B O'Brien JM, Felt BT, Van Harrison R, Kochhar PK, Riolo SA, Shehab N. Attention-deficit hyperactivity disorder guidelines for clinical care [draft 4/26/2005 ]. University of Michigan Health System.
(3) American Academy of Pediatrics. Clinical Practice Guideline: Treatment of the School-Aged Child With Attention- Deficit/Hyperactivity Disorder. Pediatrics 2001;108:1033-1044.
(4) A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Arch Gen Psychiatry. 1999;56:1073-86.
(5) Fuchs T, Birbaumer N, Lutzenberger W, Gruzelier JH, Kaiser J. Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: a comparison with methylphenidate. Appl Psychophysiol Biofeedback. 2003 Mar;28(1):1-12.
(6) Monastra VJ, Monastra DM, George S. The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Appl Psychophysiol Biofeedback. 2002 Dec;27(4):231-49.
(7) Thompson L, Thompson M. Neurofeedback combined with training in metacognitive strategies: effectiveness in students with ADD. Appl Psychophysiol Biofeedback. 1998 Dec;23(4):243-63.
(8) Linden M, Habib T, Radojevic V. A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback Self Regul. 1996 Mar;21(1):35-49.
(9) Lubar JF, Swartwood MO, Swartwood JN, O'Donnell PH. Evaluation of the effectiveness of EEG neurofeedback training for ADHD in a clinical setting as measured by changes in T.O.V.A. scores, behavioral ratings, and WISC-R performance. Biofeedback Self Regul. 1995 Mar;20(1):83-99.
(10) Heinrich H, Gevensleben H, Freisleder FJ, Moll GH, Rothenberger A. Training of slow cortical potentials in attention-deficit/hyperactivity disorder: evidence for positive behavioral and neurophysiological effects. Biol Psychiatry. 2004 Apr 1;55(7):772-5.
(11) Rossiter T. The effectiveness of neurofeedback and stimulant drugs in treating AD/HD: part II. Replication. Appl Psychophysiol Biofeedback. 2004 Dec;29(4):233-43.