ADHD, Attention deficit hyperactivity disorder is defined as a decrease in attention and concentration with increases in distractibility and impulsiveness. There are three categories of ADHD:

  • Hyperactive-impulsive type
  • Inattentive type
  • Combined type

adhd, attention deficit hyperactivity disorder

ADHD SYMPTOMS:

For the ADHD-combined type, a child will exhibit:

  • Decreased attention and concentration
  • Overactivity
  • Impulsiveness
  • Distractibility

For ADHD-inattentive type, a child will show:

  • Decreased attention and concentration

For ADHD-hyperactive/impulsive type, a child will show:

  • Overactivity
  • Impulsiveness
  • Distractibility

All of these symptoms will manifest themselves at home, school, and with peer relationships.

INCIDENCE:

The symptoms of ADHD are present in 5% of females and 10% of males at the elementary school age.

ADHD CAUSES:

Although there are many debated theories as to the underlying cause of ADHD, no specific cause has been proven. The theory that there is a disorder of central behavioral distribution seems to be the most favored theory. This theory states that the frontal lobe and basal ganglion of the brain respond inappropriately to stimulation due to a decreased release or an abnormal reuptake of dopamine or norepinephrine. Think of the brain as a series of nerves with spaces between them called synapses. In order for impulses to be transmitted from one neuron to the next, some enzyme or chemical bridge needs to be present. In the case of the frontal lobe of the brain where focus is located, this is dopamine or norepinephrine. If a person is not releasing the dopamine or norepinephrine or they reuptake it back into the neuron too quickly, the impulse may be slow in transmission. This under stimulation can cause lack of focus or inability to sit still. ADHD does tend to run in families and babies with true colic tend to exhibit ADHD as young children.

One theory that has been thoroughly disproved is that ADHD is caused or affected by certain foods, such as sugar or food colorings. 

ADHD DIAGNOSIS:

Unlike looking into an ear and seeing an ear infection, the diagnosis of a psychological disorder can be very complex. In order to diagnose ADHD, the symptoms and behavior of the child must be observed and those findings must fulfill certain criteria. These criteria are established by the American Psychiatric Association and are published in their Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (DSM-IV).

First, all of the following criteria must be fulfilled:

1) Either six or more symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the child’s developmental level; or six or more symptoms of hyperactivity/impulsivity have persisted for at least 6 months to a degree that it is maladaptive and inconsistent with the child’s developmental level.

2) Some of the hyperactive/impulsive or inattentive symptoms that caused impairment were present before the age of 7 years.

3) Some impairment from the symptoms is present in two or more settings (e.g., school [or work] and at home).

4) There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

5) 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.

AN INATTENTIVE INDIVIDUAL:

1) Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2) Has difficulty sustaining attention in tasks or play activities.

3) Does not seem to listen when spoken to directly.

4) 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).

5) Has difficulty organizing tasks and activities.

6) Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).

7) Loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

8) Is easily distracted by extraneous stimuli

9) Is forgetful in daily activities.

A HYPERACTIVE/IMPULSIVE INDIVIDUAL:

1) Fidgets with hands or feet or squirms in seat.

2) Leaves seat in classroom or in other situations in which remaining seated is expected.

3) Runs around or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).

4) Has difficulty playing or engaging in leisure activities quietly.

5) Is “on the go” or acts as if “driven by a motor”.

6) Talks excessively.

7) Blurts out answers before questions have been completed.

8) Has difficulty waiting for his or her turn.

9) Interrupts or intrudes on others (e.g., butts into conversations or games).

Questionnaires and behavior rating scales can also be helpful to aide in diagnosis and to show response to treatment. These scales consist of questions for parents and teachers that can help lead to a proper diagnosis. Examples are the Conner’s Parent Rating Scale, Conner’s Teacher Rating Scale, ACTers Teacher Rating Scale, Child Behavior Checklist, ADD-H Comprehensive Teacher Rating Scale, Barkley Home Situations Questionnaire, Barkley School Situations Questionnaire, and the Child Attention Problems Profile.

ADHD TREATMENT/DISCUSSION:

The goals of treatment are to:

  • Allow the child to perform well in school
  • Establish better peer relationships
  • Establish good behavior at home

Treatment should start with education. Parents, teachers, and the child (if old enough to comprehend) should understand what ADHD is and how it affects him or her as well as the family. There are many books, tapes, and internet resources available for this.

It should be understood that ADHD is at times uncontrollable and should not be placed in the same category as a purposeful misbehavior. If a child with ADHD is frequently punished for their behavior instead of being given positive reinforcement for the good things that they do, depression and decreased self-esteem will develop.

A team approach is most helpful.  The child, family, teachers, and physician should all be working together to form the best treatment plan for each individual. This plan should take into consideration the particular behavioral, emotional, academic, and medical issues of the child. When a treatment plan is set, everyone involved should evaluate its efficacy so that appropriate adjustments can be made. The child should also take an active role in management in order to instill a sense of control, responsibility, and competence.

Management includes behavioral, emotional, and academic changes as well as medications.

Behavioral modifications include:

  • Providing increased structure
  • Giving clear directions
  • Giving immediate feedback for both positive and negative behaviors

Emotional intervention includes:

  • Individual or family counseling to help deal with the emotional, psychological, social, and family issues associated with ADHD

Academic intervention includes:

  • Providing a structured learning environment
  • Repeating and simplifying instructions about in class and homework assignments
  • Supplementing verbal instructions with visual instructions
  • Using behavior management techniques (e.g., daily report cards)
  • Adjusting class schedules
  • Modifying test delivery (extended time, less distracting setting)
  • Using tape recorders, computer aided instruction, and other audiovisual equipment
  • Selecting modified textbooks or workbooks
  • Tailoring homework assignments
  • Consulting special resources
  • Using one on one tutorials
  • Providing classroom aides and note takers
  • Involving a service coordinator to oversee implementation
  • Modifying nonacademic times such as lunchroom, recess, and physical education

ADHD MEDICATION:

Medications may be indicated when academic, social, and behavioral functioning are not improving with other methods and a child is still showing difficulties. The most common medications for ADHD are called stimulants.

These include methylphenidate (Ritalin, Concerta, Ritalin LA, Metadate, Focalin, Methylin), dextroamphetamine (Dexedrine, Dextrostat), and mixed amphetamine salts (Adderall/Adderall XR).

This class of medications has been available since the 1930’s. They work by stimulating the release of dopamine or norepinephrine in the brain and by inhibiting their reuptake, which increases concentration and decreases impulsivity. These medications have shown benefit in 70%-90% of children using them.

The benefits include:

  • Increased attention to assigned tasks
  • Decreased response to irrelevant stimuli
  • Improved speed and accuracy of performance
  • Improved short term memory
  • Improved short term academic performance
  • Reduced activity level perhaps to normal
  • Decreased unwanted motor behavior
  • Decreased excessive talking or noise
  • Increased independent play or work
  • Improved fine motor control/handwriting
  • Decreased anger and aggression
  • Decreased emotional and behavioral intensity
  • Increased sensitivity to reinforcement
  • Increased compliance with adult requests
  • Decreased negative interactions with peers
  • Improved parent-child and family interaction
  • Improved teacher-student relations

Common Side Effects:

  • Appetite suppression
  • Weight loss
  • Delay in sleep onset
  • Abdominal discomfort
  • Headache
  • Dizziness
  • Minor increases in pulse and blood pressure
  • Behavioral rebound when the medication wears off

Infrequent Side Effects:

  • Wthdrawal hyperactivity (rebound)
  • Agitation/jitteriness
  • Moodiness/sadness
  • Tics/dyskinesias (abnormal body movements)
  • Reduced growth velocity

Overmedication/Toxic Effects:

  • Irritability/weepiness
  • Over-focusing
  • Dazed appearance
  • Fatigue
  • Psychosis

Once a medication is started, it can be adjusted until beneficial effects are seen. If side effects occur, the medication may need to be changed. Unlike most medications, the dosage is not dependent on weight or severity of symptoms. A small dose may be needed to help a large child with severe symptoms and a large dose may be needed for a small child with less severe symptoms. Dosages can range from 2.5 mg/day to 60 mg/day given 1-3 time a day. There are short acting brands such as Ritalin, Focalin, and Adderall that will last 3-4 hours and there are long acting versions including Adderall XR, Concerta, Ritalin LA, and Metadate that can last up to 12 hours. The stimulants can be used on days when they are needed and do not have to be used every day. They can be withheld on weekends, holidays, or the summer depending on your own opinion of whether the child needs them then or not. These medicines are considered controlled substances that require a special prescription.

They are monitored very closely. If stimulant medications are not helping, non-stimulant medication can be used in addition to or instead of stimulant medications. Strattera is a non-stimulant norepinephrine reuptake inhibitor. It will not stimulate the release of dopamine or norepinephrine but it will inhibit the reuptake of norepinephrine. It must be taken every day and takes about 2 weeks to start working. This medicine is supposed to last for 24 hours so it can be taken at night. It can be especially good as it sometimes causes sleepiness. It is not a stimulant and is therefore not a controlled substance. Other medications include tricyclic antidepressants such as imipramine (Tofranil), desipramine (Norpramin), or nortriptyline (Pamelor), heterocyclic antidepressants such as bupropion (Wellbutrin), and antihypertensives such as clonidine (Catapres) or guanfacine (Tenex). The tricyclic antidepressants are helpful if there is associated depression, moodiness, or tics. Heterocyclic antidepressants are useful if you are treating  depression and aggressive behavior. The antihypertensives are useful if there is associated aggressiveness or tics.

Therapy that has shown no benefit in any well-controlled study includes dietary changes, herbal remedies, vitamin therapy, anti-yeast treatment, anti-motion sickness treatment, sensory integration training, and chiropractic manipulation.

Treatment can be continued until it is agreed that it is not necessary anymore. Children can be taken off medication over weekends and vacations if this is not too disruptive. A trial off of medication can be done anytime to see the response although it is best not to try this at the beginning of a school year or during any significant changes in the child’s life.

OUTCOME:

30% – 70% of children with ADHD will continue to exhibit some symptoms throughout adulthood.

ONE DOCTOR’S OPINION:

ADHD is a disorder that today’s parents’ parents did not know about. Many years ago children were simply dismissed as difficult. Now, with better understanding, diagnostic capabilities and treatment, many children with ADD do not have to suffer the decreased self-esteem and alienation that was previously experienced.

Although ADHD can be over diagnosed and many children can be placed on medications unnecessarily, this is a real illness and medication has been very helpful and necessary for many children.

Many parents come to me with preconceived decisions not to use medication.  This can be detrimental to the child who really needs the medicines that are available today. I agree that many children are overmedicated and many children never needed medication in the first place, but with proper diagnosis, treatment, and follow-up, some children can benefit greatly.

I like to diagnose ADHD and determine if medication will work by doing a double-blinded placebo controlled study. The double-blinded study is the best way to perform most scientific studies. Double blinded means that neither the person giving the medication nor the person taking it knows whether medication or a placebo (fake medicine like a sugar pill) is being given. This method will remove most of the subjective data associated with a study.

For example, if a person takes a medicine and feels better, the question becomes whether or not the improvement is  due to the medicine or due to the natural course of the illness? This may sound odd, but hundreds of years ago physicians used leeches to suck out infection. The people got better but it obviously  had nothing to do with the leech. It was just the natural course of the illness. Today people take antibiotics for viruses even though they don’t cure viruses because some people think that antibiotics will cure anything. When you get better it’s not due to the antibiotic, but to the natural course of the illness. Today we laugh about the leeches, however hundreds of years from now we’ll be laughed at for the antibiotic overuse. My point is that when a person takes a medicine, their bias and opinion about the medication will determine how they feel more than the actual medicine in many cases. If a person who has an ADDHD child who is on medicine and doing well comes  in with another child wanting medicine and receives it, chances are they will grade him well because he is on the medicine they wanted. On the other hand, if the parents are against medicine and I convince them to try it and grade their child, chances are he will be graded poorly because the parents are against the medicine. I like to remove that bias.

I set up the double-blinded study as follows: I have a local pharmacist prepare four bottles of medication. The bottles contain Adderrall XR 20 mg, Ritalin LA 20 mg, Concerta 36 mg, and a placebo. The pharmacist will randomly label the bottles ‘A’, ‘B’, C”, and ‘D’. Neither the patient nor I know which medicine is in which bottle during the study. I have the patient start on a Sunday and use bottle A for the first week, B for the second, C for the third, and D for the fourth. At the end of each week I have the parents and teachers fill out evaluation forms using both the Conner’s and ACTers forms. At the end of the study I gather all of the forms and go through an interpretation using the forms as well as the comments from the parents and teachers. I then meet with the parents to review the findings and to make a decision about which week was best, if any.  At that point I open the envelope from the pharmacist that tells us what was in each bottle.

If a child did wonderfully on bottle A, mediocre on bottle B and C, and terrible on bottle D and bottle A was Adderrall, B was Concerta, C was Ritalin, and D was placebo, then I can safely say that the medication worked. If the evaluations were a big jumble with the parents and teachers all having different opinions as to which week was best or if there was no change from week to week, then I can safely say that the medication didn’t work and I investigate other options.

The important thing is to avoid assuming ADHD and starting a medication without a proper trial.  There are times when a child may seem better on medication, however it may have nothing to do with the medicine. It may be that the child is just trying to act better because they are on a medicine.  These children slowly slip back to the way they were prior to treatment. If proper diagnosis and treatment are used, there won’t be as many objections to this medication that can at times be so helpful.

Written by Dr. Michael Bornstein, who has over 28 years of experience as a pediatrician. 

Disclaimer: The contents of this article, including text and images, are for informational purposes only and do not constitute a medical service. Always seek the advice of a physician or other qualified health professional for medical advice, diagnosis, and treatment.