Attention-Deficit Hyperactivity Disorder (ADHD)

Attention-Deficit Hyperactivity Disorder (ADHD)

ADHD has been known by a variety of different names in the past, namely: Attention Deficit Disorder (ADD), Hyperactive Child Syndrome and Minimal Brain Dysfunction.

The most significant feature of ADHD is inattention, (which involves failure to finish things that the child starts), not seeming to listen to directions, and easy distractibility.  

The second major characteristic is impulsivity.  Children act before thinking, have difficulty organizing their work, shift excessively from one activity to another, disruptive behaviors in the classroom, difficulty waiting for their turn and require more supervision than other children.

The third major characteristic is hyperactivity, although seen in most, not all children exhibit this symptom.  Symptoms of hyperactivity include excessive running and climbing, difficulty sitting still, moving about excessively during sleep and always moving around.  

Children with ADHD often throw temper tantrums and generally have a low tolerance for frustration.  They are often socially immature although sociable.  They lose friends they make as they have the tendency to dominate play situations.  Relationships with adults also tend to be fraught with difficulties.  Academic difficulties are often reported.

Symptoms of Inattention:

• 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 difficulty 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

Symptoms of Hyperactivity:

• 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

Symptoms of Impulsivity:

• 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)

Medications

One reason for regarding ADD as a distinct disorder with a biological origin is the immediate and striking relief from some of its symptoms provided by the stimulant drugs methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and magnesium pemoline (Cylert). These drugs are helpful for about 75% of children and adults with ADD. They become less irritable and restless, and their attention and motor coordination improve; others begin to like them better, and they begin to think better of themselves. The drugs have no direct effect on learning disabilities, but may make special education and tutoring easier.

Several other kinds of drugs are also used in treating ADD, especially when the patient does not improve on stimulants or cannot tolerate their side effects. Beta-blockers such as propranolol (Inderal) or nadolol (Corgard) can be prescribed along with (or occasionally instead of) stimulants to reduce jitteriness. Tricyclic antidepressants, especially desipramine (Norpramin), are sometimes effective at doses lower than those used for depression; their most serious potential side effect is disturbance of heart rhythms. Another drug occasionally prescribed for ADD is Clonidine, which is ordinarily used to lower blood pressure and suppress tics. Its most common troublesome side effect is drowsiness.

Psychotherapy

Psychotherapy may help patients to identify and deflect the feelings that cause impulsive and aggressive reactions. (It is often best to ask children to talk not about themselves but about their reactions to other people's complaints.)  Since children with ADD often have difficulty following social rules and understanding social situations, therapy must be didactic; for example, they may have to learn how to look at others who talk to them, listen to what they say, and wait their turn before answering.  Some therapies work on the assumption that ADD patients have an inadequate sense of the past and future and must learn how to anticipate the consequences of their actions. Group therapy is often helpful, not only for mutual support and exchanges of advice, but because group meetings are a laboratory in which the situations most troublesome for these children can be recreated and they can see in others what they have not been able to see in themselves.

Children with ADD need structure and routine. They should be helped to make schedules and break assignments down into small tasks to be performed one at a time. It may be necessary to ask them repeatedly what they have just done, how they might have acted differently, and why others react as they do.  Especially when young, these children often respond well to strict application of clear and consistent rules. In school, they may be helped by close monitoring, quiet study areas, short study periods broken by activity (including permission to leave the classroom occasionally), and brief directions often repeated. They can be taught how to use flashcards, outlines, and underlining. Timed tests should be avoided as much as possible. Other children in the classroom may show more tolerance if the problem is explained to them in terms they can understand.

Establishing structure and routine is a form of behavior therapy - consistent schedules with rewards for acceptable behavior. Behavior therapy in a more formal sense may be useful to prevent a particular kind of aggressive or disruptive behavior that occurs in a few specific circumstances, but applying it to all the situations in which symptoms of ADD appear would be impractical - too time-consuming and demanding for anyone's patience and skill. Some behavior therapists have added cognitive techniques designed to change self-defeating thoughts, with inconclusive results.

Family conflict is one of the most troublesome consequences of ADD. Especially when the symptoms have not yet been recognized and the diagnosis made, parents blame themselves, one another, and the child. As they become angrier and impose more punishment, the child becomes more defiant and alienated, and the parents still less willing to accept his excuses or believe in his promises. A father or mother with adult ADD sometimes compounds the problem. Constantly compared unfavorably with his brothers and sisters, the child with ADD may become the family scapegoat, blamed for everything that goes wrong. When ADD is diagnosed, parents may feel guilty about not understanding the situation sooner, while other children in the family may reject the diagnosis as an excuse for attention-getting misbehavior.

To avoid constant family warfare, parents must learn to distinguish behavior with a biological origin from reactions to the primary symptoms or responses to the reactions of others. They should become familiar with signs indicating imminent loss of self-control by a child with ADD. A routine with consistent rules must be established; these rules can be imposed on young children but must be negotiated with older ones and with adolescents. The family should have a clear division of responsibility, and the parents should present a united front. It often helps to write out complaints and to praise good behavior immediately. Role-playing may help a child with ADD to see how others see him. Family therapy or counseling, parent groups, and child management training are sometimes useful.

Adults with Attention Deficit Hyperactivity Disorder

ADHD - Inattentive type - an individual must experience at least 6 of the following characteristics:

• Fails to give close attention to details or makes careless mistakes.
• Difficulty sustaining attention
• Does not appear to listen
• Struggles to follow through on instructions
• Difficulty with organization
• Avoids or dislikes requiring sustained mental effort
• Often loses things necessary for tasks
• Easily distracted
• Forgetful in daily activities

ADHD - Hyperactive/Impulsive type - an individual must experience at least 6 of the following characteristics:

• Fidgets with hands/feet
• Difficulty remaining seated
• Feelings of restlessness
• Difficulty engaging in activities quietly
• Talks excessively
• Blurts out answers before questions are completed
• Difficulty waiting in turn taking situations
• Interrupts or intrudes upon others

ADHD - not otherwise specified is defined by an individual who demonstrates some characteristics but an insufficient number of symptoms to reach a full diagnosis. These symptoms disrupt everyday life.

References and Links

American Psychological Association    Let's Talk Fact Series
        http://www.psych.org/main.html
Diagnostic and Statistical Manual of Mental Disorders.  Vol. IV  American 
        Psychiatric Association.  1994
Harvard Mental Health Letter, Copyright 1995
National Institute of Mental Health   
        http://www.nimh.nih.gov/about/index.cfm
National Mental Health Association    
        http://www.nmha.org/