A Closer Look at ADD/ADHD.
Shawn, a 6-year-old African-American child, arrives at the behavioral pediatrics clinic of a city hospital with his 55-year-old foster mother, who is a visibly harried African-American woman. The nurse cheerfully greets Shawn, but, unmindful of her greeting, he walks over to the computer at the nursing station, frantically taps its keys, and returns to pull at the stethoscope hanging around her neck. Not five seconds in the pediatrician's office, he touches the garbage can, the container for discarding used needles, and the blood pressure instrument. He then crawls under the pediatrician's chair to look into the filing cabinet. He continues in this vein despite continued requests to sit down and play with the dollhouse or to draw something. Smiling impishly--completely unaware of the havoc he is wreaking--his large eyes and cute demeanor disguise his turbulent mind.
"He cannot stay still," his foster mother--who is actually his grandmother--says. "He is always on the go, running all over the house, turning on and off the television, opening and closing the refrigerator. He stays up 'til 11 PM and then doesn't fall asleep until midnight. And he even tosses and turns in his sleep. Just look at these notes from school." She pulls a wad of crumpled papers from her pocketbook. His teacher repeatedly reports that Shawn does not sit quietly in the classroom, forgets instructions, disturbs other children, and constantly interrupts her. The principal wants a doctor's note that Shawn is on a medication to calm him before he is allowed back in the classroom.
"Don't touch anything!" his foster mother constantly admonishes the boy, who continues doing exactly what he was doing.
Melissa, a 10-year-old Caucasian girl, is brought by her mother to the clinic because she is failing in school.
"Melissa is hyper; she acts silly to get attention, at times even by deliberately offending people. If nothing else works, she touches and pulls at them," her mother says. "She talks constantly, interrupting others, and can't wait her turn."
In school, her mother continues, although Melissa is quick to respond, her answers are often thoughtless and wrong. "She forgets to bring homework home, and, if she does bring it, she either takes three or four hours to complete it or doesn't finish it at all. Her room is always a pigpen. I have to ask her at least ten times before she does anything," her mother continues. "No one likes her. She tries to boss other children around. When they exclude her, she throws a tantrum."
As she enters the room, Melissa rushes to give the doctor, whom she has never seen before, a warm hug. He gently disentangles himself and asks her to draw a picture of her house and the people in it, while he talks with her mother. Melissa turns immediately to the nurse, asks her name, why she is not wearing a white nurse's uniform, and "What's that thing hanging on the wall?" The nurse reminds her of the doctor's request for a picture. Melissa innocently rests her head on her closed fist and says, "I forgot." Before the nurse can reply, Melissa interrupts the doctor, "What did you ask me to draw?" Without waiting for a reply or looking at the drawing table, she asks the nurse, "Where are the crayons?" They are on the table. While drawing, she constantly interrupts the doctor with questions, saying "excuse me" each time: "Can I also draw my dog? Can I draw the sun? Is it alright to draw a bird?" She leaves the drawing twice, once to check the door when someone knocks, and once to pick up a ringing phone. She crumples three drawings before she finishes. Her final picture is chaotic, with too many people, fixings, and animals, each hurriedly drawn and with unnecessary shading. She asks the doctor, "Did I do good?" "Look mommy," she exclaims, "I also drew my cat. Can we go now?"
"Will you shut up!" her exasperated mother shouts.
"How was she as a baby?" the doctor asks.
"A real handful. She was a colicky baby; kept me awake at nights. And a terrible toddler, always running around, always saying `no!'"
Jason, a 12-year-old Hispanic child, is brought to the clinic because he is doing so poorly in school that he might be held back. The school wants to evaluate him for special education. His mother says that he is intelligent, but just does not put his mind to his work. "He's a nice kid," she says. "The teacher's too old, she doesn't know how to handle children. She wants to put everyone in special education. He's not hyper, doesn't bother anybody. He's just lazy."
His teacher, on the other hand, reports that Jason is inattentive and daydreams in class. He often looks out the window instead of at the blackboard, and has to be repeatedly reminded to pay attention. He forgets to take notes and does not follow instructions. He fidgets and squirms in his seat, his desk is messy, and his pens and pencils keep falling off. No one wants to sit next to him.
In the doctor's office, Jason sits like an angel, trying to draw a picture of a house, tree, and people in the house. It takes forever. Sometimes he looks out the window, sometimes he twiddles the crayons in his hands, and sometimes he squirms in his chair. When the doctor asks to see what he has drawn, Jason is startled, as if suddenly awakened. His drawing is incomplete.
Are Shawn, Melissa, and Jason normal or abnormal? Healthy or sick?
Making an ADD/ADHD diagnosis
It is difficult to draw a clear-cut line between normal and abnormal child behavior. All children are different and behave along a spectrum that ranges from normal to abnormal. Some children are noisy, some calm; some brash and others polite; some are dynamic, while some are passive; still others are gregarious, some shy. Shawn could be a smart, curious child who wants to touch and feel everything around him. Melissa could be a socially immature girl who will mature with time. Jason's classroom inattention may result from his all absorbing concern about his parents' impending divorce.
But the behaviors of all three children are excessive, pervasive, and persistent. Each one displays these behaviors everywhere: at home, in school, in restaurants, in the grocery store, at relatives' homes. They are failing in school and having problems with their teachers and peers. Their symptoms are not in response to a temporary stressor; they have always been like that. Their parents are exhausted and asking for help. These children have crossed the threshold of normalcy.
Could Shawn, Melissa, and Jason just be acting willfully? Children are programmed to please others. They do not act badly intentionally unless they are "driven" to do so by an underlying disease or condition. Children, innately, want to please others; they yearn for approval and accolades. Shawn, Melissa, and Jason are not acting willfully. They behave abnormally because they have an underlying behavioral disorder.
Diagnosis of behavioral disorders does not depend upon telltale signs that can be seen, touched, or heard with the stethoscope. It is inferential--an educated guess at best--based upon a constellation of observed behaviors. Isolated behaviors are not diagnostic; but when a set of behaviors occurs together at a degree and frequency such that the child cannot do what is expected of him (e.g., learn in school) or is not able to relate properly to people around him (parents, teachers, or peers), a behavior disorder is diagnosed.
The children described above are not able to focus and maintain attention, and are easily distracted. All three are impulsive and two are hyperactive. While individually their symptoms are not diagnostic of any disease, together they Constitute a disorder called attention deficit disorder (ADD) (also called attention deficit-hyperactive disorder or ADHD). Major symptoms are:
Attention deficit: Attention deficit, or failure' to attend to the task at hand, is the cardinal feature of ADD/ADHD. The process of paying attention to a task involves getting tuned into a task and remaining focused on it until the goal is achieved. It is like driving a car: you turn on the ignition (get focused), put the car (body and mind) in proper gear (necessary level of arousal for the task), hold the steering wheel in constant check (stay focused), look at the road ahead (stay vigilant), drive at the right speed (tempo), and reach the destination (complete the task) without getting lost due to distractions (off-task activities).
How much attention a child pays to a task depends upon the nature of the task. If it is pleasing, she will pay attention to it effortlessly. Most children are able to focus on a video game or a television show because they get instant pleasure from them, inviting more viewing (a process called reinforcement). Moreover, these programs flood their senses with so much input--flooding the gates, as it were--that other distractions cannot enter their brains. The litmus test of ADD/ADHD is the inability to focus on homework or on a task that does not reward the children immediately.
I have seen two types of inattentive children: those who cannot get focused on any task, the "failure-of-ignition" type, and those who cannot stay focused, the "failure-to-drive" type. "Failure-of-ignition" type children either wander aimlessly doing nothing meaningful or sit passively, looking out the window or twiddling their thumbs. They require constant reminders to begin a task, but may finish what they start. Failure-to-drive type children leap like frogs from task to task, failing to finish anything they start. Despite constant reminders, nothing is accomplished. Children who fail to sustain attention are easily bored and need a constant pep talk to keep up their rapidly fading interest. They bum out quickly. The speed and quality of their performance are very inconsistent: sometimes fast, sometimes slow; sometimes good, sometimes poor. They lack the motivation to accomplish something in the distant future.
Attention in a child matures from the exploratory, rapid, impulsive, and reinforcement-based manner of a 2-year-old (requiring constant approval from the parents) to the slow, deliberate, goal-directed, logical, and productive style of a 12-year-old. The attention skills of children with ADD/ADHD do not mature according to this schedule. Their attention remains divergent and, instead of being driven internally by a goal, is driven by constant reinforcement from the environment (context- and contingency-based).
Distractibility. Children with ADD/ADHD have a tendency to get easily distracted by every little noise or movement in their surroundings. To sustain attention to a task, one has to literally shut the gates of the brain so that irrelevant stimuli do not gate crash into conscious awareness. Children with ADD/ADHD are distracted by every sensation that reaches their five senses. Their situation is similar to a radio that has "constant static" even when it is tuned to a particular station. A truck drives by on the road, and children with ADD/ADHD run to the window, leaving their homework. Someone knocks at the door, and they are the first to ask, "Who's there?" When there are no external distractions, they can have a state of internal distractibility, daydreaming and wandering all over the globe.
The underlying neurological basis of distractibility in children with ADD/ADHD seems to be a lack of sensory filtration at the level of the caudate nucleus, a group of nerve cells in the brain that acts as a relay station for all sensory input before it reaches conscious awareness. Normally, the caudate nucleus serves as a gatekeeper, allowing only relevant stimuli to reach conscious awareness. In children with ADD/ADHD, the head of the right caudate nucleus is small compared with that in normal children and fails to inhibit the onslaught of input from various sense organs on the brain. Every stimulus makes it to conscious awareness.
Impulsivity: Children with ADD/ADHD have a short circuit in their nerve-cell wiring, causing them to act impulsively. They literally respond from the gut, not the mind, and frequently incorrectly. A child with ADD/ADHD is often the first to raise his hand to give an answer to a question, even if he does not know the correct one. He may actually blurt out the answer without even raising his hand. An adolescent with ADD/ADHD may destroy an appliance because she turns it on without reading the instructions. Adults with ADD/ADHD may impulsively buy stock without knowing the fundamentals of the company, simply because they heard someone in the elevator say it is a good buy. Individuals with ADD/ADHD often get into trouble with the law because they act without thinking about the consequences of their actions.
This tendency to act impulsively rather than reflectively is due to poor working memory, resulting in poor processing of incoming information. The working memory cannot simultaneously hold information about prior experience with an action and its likely consequence. In other words, they have no forethought or afterthought.
A related deficit that results in impulsivity is the inability of children with ADD/ADHD to delay gratification and wait their turn. A child with ADD/ADHD who goes to a restaurant with his parents cannot wait patiently to be served. He calls to the waitress many times despite his parents' admonition, twiddles with the silverware until it falls to the floor, and, finally, gets up and pulls at the waitress's dress and demands his food. This is not a "bad" child. Researchers have shown that impulsivity is not a flaw of character, but a defect of biology.
Hyperactivity: Although generally considered to be the most salient feature of this disorder because of its obtrusiveness, this symptom is not present in all ADD/ADHD cases. Hyperactivity can be present in various ways: a macro form, in which children are agitated, restless, and move constantly from place to place, touching people and things; a micro form, in which children squirm and fidget in their seats; and a hyperactive tongue (or hyper-tongue) type, in which children are garrulous, talking excessively, often out of context and interrupting others.
Deficits in the brain's executive functions: Executive functions of the brain involve organization, serf-monitoring, serf-regulation, and continuous quality-improvement functions similar to those that a manager performs in an office. As children grow and develop, they learn to perform these functions. Children with ADD/ADHD do not.
Because of such deficits, children with ADD/ADHD are not able to organize their space and time well. Their desks and rooms are disorganized. They also cannot self-monitor and self-regulate their actions, whether physical or verbal. They thunder around with no concept of the energy spent or the resulting din, even when admonished that they are making the house shake. In a similar way, their volume control can be on permanent "high."
Another result of such executive function deficits is that children with ADD/ADHD are unable to learn from experience. Not only are they unable to monitor themselves, they do not respond to admonitions and advice from those in charge. It is difficult for them to follow rules. This makes them hard to discipline and results in conflicts with those in authority. Parents often complain that their child does not listen, is disobedient, and deliberately tries to hurt their feelings. Sadly, once children organize their self-image around these negative behaviors, they deteriorate into opposition, non-compliance, and defiance.
Children with poor executive functions are also clumsy and accident-prone. They neither plan theft movements properly nor execute them smoothly. Unable to track theft movements within the environment in which they move, they trip over bumps and fall into holes.
Finally, children with deficits in the brain's executive function process incoming information very superficially. It is with great difficulty that things "sink" into theft heads. They often misinterpret what others say, which results in conflicts. They are also unable to process the visual information that they get from others' body language--whether others are welcoming theft interruption or are getting annoyed. Not only do they not process external information well, they are also unable to interpret the feedback theft brains receive from theft own ears, eyes, and body. A child who is shouting at the top of her voice, for example, may not be able to appreciate her mom's reprimand that she was screaming.
Deficits of social behavior: Most children with ADD/ADHD have problems understanding social context and mood (poor social cognition) and are unable to match theft behavior to them (poor social adaptability). In other words, they are socially inept: they do not understand whether the social mood is grim or jovial, they speak and act without understanding the social situation, they lack social grace, they are awkward and tactless, and they are intrusive and inopportune. These behaviors cause conflicts with theft siblings and peers, make them unpopular, and lead to social rejection.
Deficits in this category go beyond mastering social graces, however. Children with ADD/ADHD also have difficulty following instructions. Rules are a mystery to them because:
* they are so inattentive that they do not receive information properly;
* they have difficulty processing the information they receive as instruction; or
* theft impulses make it difficult for them to follow the instructions.
Rules are a set of instructions that a child is supposed to follow at home and in school. A particular house may have a rule that toys must be put away in the toy chest before bedtime. Ordinarily, after a few repetitions, this instruction would become part of a child's behavioral dictionary. Children with ADD/ADHD, however, will not be able to internalize it. They may have to be told what is expected of them again and again. This may be a nuisance and an aggravation for parents, who often perceive it as opposition and defiance.
Another deficit in social behavior for children with ADD/ADHD is the lack of both hindsight and foresight: With smaller working memories, they can neither retrieve past experience nor think about future consequences. This accounts for their failure to learn from past mistakes or to plan for the future. They live in the immediate present--moment to moment--driven by their impulses and immediate responses to external stimuli.
Aggression is yet another consequence. Children with ADD/ADHD can indulge in random acts of aggression because of impulsivity and the inability to think of the consequences of their actions. Children who indulge in aggressive acts in a deliberate and premeditated manner are likely to have conduct disorder and should be seen by a psychiatrist.
Deficits in social behavior often also cause children with ADD/ADHD to act out in order to be the center of attention. For example, Johnny is the class clown. He laughs, makes faces, grunts, and makes silly comments to get attention. If no one pays attention, he becomes louder and more obtrusive. When he is ignored, he becomes increasingly disruptive, blows on other's faces, touches them, and so on, until they pay attention.
These children also blame others for their own mistakes, are sensitive to criticism, do not accept responsibility for theft actions, pout and sulk, and seek attention maladaptively, as a toddler would. For example, a child with ADD/ADHD would blame his peers for his aggressive acts: "I hit him because he was bothering me;" "I yelled at the teacher because he was mean to me." Not only are theft actions driven by external contexts and contingencies--phenomena called external locus of control--theft sense of responsibility is projected to others as well. They rarely accept moral responsibility for their actions.
What happens in the ADD/ADHD brain?
The neurological basis of ADD/ADHD is still not fully known. Much of the available evidence points to a deficiency or imbalance of one or more of the neurotransmitters in the brain. Neurotransmitters are chemicals that carry the message of one brain cell (neuron) to another across the tiny space between them called the synaptic cleft (see Figure 1).
[Figure 1 ILLUSTRATION OMITTED]
Brain cells store these neurotransmitters in tiny vesicles, ready to be discharged upon command. Once discharged, they attach themselves to specific areas, called receptors, on the surface of the brain cell across the cleft. The union of a neurotransmitter with its specific receptor triggers some changes in the receiving brain cell, either stimulating it or inhibiting it. Thus, the neurotransmitters serve as the carriers of thoughts and emotions in the human brain. Once their job is done, neurotransmitters are transported back into the sending neuron, where they are repackaged as vesicles. This is a process called "reuptake."
The most popular, and perhaps the most plausible, theory of ADD/ADHD is that it occurs due to a deficiency or dysfunction of the neurotransmitter dopamine in those areas of the brain that regulate attention and activity. The exact nature of the defect is unknown. The proposed theories include defects in the synthesis, storage, release, and reuptake of dopamine, and changes in the sensitivity of dopamine receptors. Researchers have found abnormalities in the concentration of metabolites (waste products) of dopamine in the blood and spinal fluid of a few children with ADD/ADHD.
Regions of the brain that are involved in regulating attention are the prefrontal cortex, the caudate nucleus, the thalamus, and the nucleus accumbens. The caudate nucleus is a collection of nerve cells that lies between the cortex and the thalamus (see Figure 2) and serves as a relay station for nerve impulses. The nucleus accumbens, another collection of nerve cells, lies deeper than the caudate nucleus and is particularly rich in nerve cells that produce dopamine, the neurotransmitter whose function is implicated in ADD. There is some evidence from studies in animals that dopaminergic activity in the prefrontal cortex enhances attention and decreases motor activity. Whereas attention improves directly as a result of dopaminergic activity in the prefrontal cortex, motor activity is decreased through an inhibiting influence on the release of dopamine in the nucleus accumbens. It is thought that children with ADD/ADHD have decreased dopamine activity in the prefrontal cortex, resulting in inattention and hyperactivity. Lending support to this theory, brain-imaging techniques have shown that, in some individuals with ADD/ADHD, the right prefrontal cortex and the caudate nucleus are smaller and that there is decreased chemical activity during tasks requiring attention in the prefrontal cortex.
[Figure 2 ILLUSTRATION OMITTED]
The prefrontal cortex is also connected to the thalamus, which serves as the relay station for all the sensory stimuli that arrive in the brain. The thalamus serves to filter the relevant or salient stimuli from noise or irrelevant stimuli and allows only the relevant stimuli to reach conscious awareness. The prefrontal cortex enhances this activity by releasing dopamine through neural pathways. In children with ADD/ADHD, this gatekeeper role of the thalamus is impaired so that every stimulus--relevant or irrelevant--reaches conscious awareness, distracting them from the work at hand.
Some researchers believe that two other neurotransmitters, noradrenaline and serotonin, are also involved in children with ADD/ADHD. The levels of methoxy-hydroxyphenylglycol, a metabolite of noradrenaline, have been reported to be low in some children with ADD/ADHD. According to some scientists, the symptoms of ADD/ADHD vary depending on which neurotransmitter system is involved predominantly: deficits in dopamine, noradrenaline, and serotonin cause the inattentive, hyperactive, and impulsive types of ADD/ADHD, respectively.
According to another group of researchers, ADD/ADHD is due to an imbalance of chemicals in the two hemisphers, (or halves) of the brain, characterized by reduced dopamine in the left half of the brain and increased noradrenaline in the right hemisphere of the brain. Because the left hemisphere is concerned with focusing attention on specific tasks, decreased function therein results in the inattentive type of ADD/ADHD. The right hemisphere is concerned with attending to a wider space, so increased noradrenaline in the right brain boosts general wakefulness and attention to unimportant stimuli in the environment, resulting in distractibility and hyperactivity. Hyperactivity occurs because the prefrontal cortex--sometimes called the managerial module of the brain--is lazy in inhibiting a hyperactive child's urge to move. Additionally, excessive noradrenergic activity puts the right brain on hyperalert, increasing distractibility.
What causes ADD/ADHD?
A diagnosis of ADD/ADHD can lead to more confusion than clarity. Parents ask, "Why us? What did we do wrong?" Conditioned to finding answers for every question, they embark on a hunt to find a cause. They blame each other; friends and family members point accusing fingers at either or both parents, the environment, the medical profession, nutritional additives or deficits, stress, popular culture, and even evil spirits that insinuate themselves into the soul. Yet, the exact cause of ADD/ADHD is still unknown.
In the 1960s, a few neurologists theorized that ADD/ADHD, like other disabling conditions such as cerebral palsy and mental retardation, was caused by minimal brain damage--not identifiable by CAT scan or MRI--sustained during the birth process. This supposition was later dismissed, since most children with ADD/ADHD have normal birth histories and most children with abnormal birth histories do not have ADD/ADHD. Major brain damage caused by such conditions as birth trauma, birth asphyxia, and traumatic head injury can be associated with ADD/ADHD. Damage to the brain is visible on the CAT scan or MRI of the brain in such cases.
Heredity: Heredity is the process by which characteristics of the parents are passed to their children--resides in genes, located in the thread-like structures called chromosomes residing in each of our cells. A number of observations suggest that heredity causes ADD/ADHD. It is five times more common for a child with ADD/ADHD to have a parent, sibling, or other first-degree relative with ADD/ADHD than it is for ADD/ADHD to occur in the general population. However, it is difficult to separate the influence of environment (nurture) from that of heredity (nature). While those with abnormal behavior share certain abnormal genes, dysfunctional relatives in the family may also set bad examples for a child to emulate.
Studies on adoption suggest that ADD/ADHD is more common in blood relatives than in adoptive relatives. This supports the case that biology is more important than environment in causing ADD/ADHD. Similarly, studies of twins report higher rates of ADD/ADHD in both identical twins (one-egg twins) than in both fraternal twins (two-egg twins), again supporting the idea of a genetically-based disease. If the cause were environmental factors, the rates of ADD/ADHD would be similar in all twins, identical or fraternal, because they share the same environment.
Despite evidence of hereditary factors in causing ADD/ADHD, an "ADD/ADHD gene" has not been discovered. Until a definite gene can be identified, only children with facial or other abnormalities suggestive of genetic conditions (such as fragile X or Williams syndrome, which often include ADD/ADHD within their own family of symptoms) should be seen by genetic disease specialists.
Environment: There is a higher prevalence of ADD/ADHD among children from low socio-economic conditions, which is perhaps due to the phenomenon of social drifting. Individuals with ADD/ADHD tend to have lower income and, therefore, move lower on the social ladder. Because of the heredity factor, they tend to bear children with ADD/ADHD. An overcrowded and disorganized environment, in mm, causes further deterioration of their condition, creating a vicious cycle. Children from homes that are poor, overcrowded, and disorganized learn to be disorganized, noisy, and loud. Distractibility and impulsivity--also hallmarks of ADD/ADHD--give them a defensive edge in a predatory environment. However, not all children who grow up in poverty turn out hyperactive and disorganized.
Stress is another possible causative factor for ADD/ADHD including stress during pregnancy--directly, by causing pre-term birth; indirectly; or by creating a dysfunctional family environment that continues past the birth of the child. Very high levels of lead in the blood are also sometimes associated with symptoms of ADD/ADHD. A few nutritionists have found lower levels of essential fatty acids in some children with ADD/ADHD, but it is not clear if the deficiency causes the symptoms or is merely associated with ADD/ADHD by chance.
How is ADD/ADHD diagnosed?
Since there is no one fixed cause of ADD/ADHD, there are no set factors that can be identified by diagnostic tests. Diagnosis of ADD/ADHD is made clinically through parents' and teachers' reports of the child's behavior. The Diagnostic and Statistical Manual of Mental Disorders (the DSM) lists the signs and symptoms of ADD/ADHD as agreed on by a panel of psychiatrists belonging to the American Psychiatric Association.
The symptoms of ADD/ADHD fall into two categories, each with nine symptoms. The first category focuses on inattention and distractibility:
* failure to give close attention to details or making careless mistakes in schoolwork or other activities;
* difficulty in sustaining attention in tasks or play activities;
* failure to listen when spoken to directly;
* difficulty in following through on instructions from others;
* difficulty in organizing tasks and activities;
* avoiding tasks that require sustained mental effort (such as, schoolwork or homework);
* losing things necessary for tasks or activities;
* forgetfulness and easy distractibility.
The second category contains six symptoms of hyperactivity and three symptoms of impulsivity:
* fidgeting with hands or squirming when seated;
* subjective feelings of restlessness;
* difficulty in waiting turns in games and other group activities;
* shifting from one uncompleted activity to another;
* difficulty in playing quietly;
* engaging in physically dangerous activities without considering possible consequences;
* blurting out answers to questions before they have been completed;
* interrupting others;
* and excessive talking.
If a child has six or more symptoms in either or both of these categories, and they are considerably more frequent than in most children of the same age and intelligence, result in dysfunction at home and school, and have lasted more than six months, he or she is diagnosed with ADD/ADHD of one of three types:
* predominantly inattentive type;
* predominantly hyperactive-impulsive type; or
* combined type of ADD/ADHD.
Usually diagnosis is not attempted until after the age of 2, because 2-year-olds are generally inattentive and hyperactive. However, symptoms of ADD/ADHD generally can be observed before the age of 7.
ADD/ADHD symptoms should be observed in at least two settings, for example, school and home, for a diagnosis to be made. If the symptoms of ADD/ADHD occur only in one setting, the possibility of a situational stressor--a seriously ill parent or sibling or an impending divorce--should be considered. Similarly, if the symptoms occur with only one person, the child's relationship with that person should be considered. If a parent is experiencing depression, for example, that may influence the child's behavior.
Diagnosis of ADD/ADHD should not be made solely on the basis of the physician's observations of the child on an office visit. A medical facility is not a natural setting for a child, who may not reveal her normal behavior patterns. Parent and teacher reports and questionnaires are valuable tools for understanding a child's activities and demeanor in her regular environment. Structured questionnaires, such as the "Conners Parent and Teacher Questionnaires;" "Yale Children's Inventory;" and the "ADD/ADHD-H Comprehensive Teacher Rating Scale" (ACTeRS) provide more reliable information than the traditional medical interview, because they strip out the effects of emotion and one particular day's grueling events. These questionnaires are filled out by parents and teachers, when they are not angry or frustrated, and summarize their observations of the child over an extended period of time.
Consult a professional if you or your child's teacher suspects that your child has ADD/ADHD. Many schoolteachers are familiar with ADD/ADHD questionnaires and often use these to support their suspicion. However, the questionnaire should not be used to make a definitive diagnosis. It should serve as a signal to seek professional help. A professional familiar with the questionnaires by virtue of training in ADD/ADHD should review and score them and then make the diagnosis of ADD/ADHD after carefully excluding other possibilities. A detailed medical, developmental, behavioral, and psychosocial history should be obtained, along with a good physical and neurological examination, to rule out any treatable medical condition, to identify stressors and other diseases that may masquerade as ADD/ADHD, and to determine secondary complications and coexisting conditions. (Secondary complications of ADD/ADHD are shown in Figure 3, below). The child's, as well as the parent's, abilities and strengths should also be identified. It is important that parenting style also be assessed in order to help the parent adapt to deal with the needs of the child.
[Figure 3 ILLUSTRATION OMITTED]
Who gets ADD/ADHD?
ADD/ADHD is an equal-opportunity disorder. It is found in all social and economic classes, from the inner city to the suburbs to the rural countryside. It is equally unconcerned with race or ethnic origin. Nor is ADD/ADHD limited to the United States--it has also been reported in the United Kingdom, Canada, Australia, Spain, and Germany. While reported less often in Europe and Australia than in the US, this may be due to physicians adhering to a more conservative approach to diagnosis and treatment of ADD/ADHD in those countries, as researchers working in the United Kingdom, New Zealand, Australia, and Germany, as well as in the US, have concluded. Because physicians in the US know when and how to look for it, they find it more often than their colleagues in other countries. A closer scrutiny of children's behavior in urban centers of developing countries such as China, Hong Kong, India, and Brazil, for example, has meant a steep rise in the number of children identified with ADD/ADHD.
ADD/ADHD was also once thought to favor one gender over the other. Although ADD/ADHD occurs more frequently in boys than girls (in a ratio between 4:1 and 9:1), girls are by no means immune to it. The National Ambulatory Medical Survey indicated that the diagnosis for girls increased 3.9-fold from 1990 to 1995. As girls grow older, the prevalence of ADD/ADHD increases. Diagnosis for boys starts at younger ages, but, by adolescence, it is as common in girls. Although ADD/ADHD without the hyperactivity (inattentive type) is more common in girls than in boys, the disorder is essentially similar in both genders. Girls, however, report more social difficulties than boys, perhaps because a girl's social fabric becomes more complex earlier than that of a boy.
What brings about this new surge in diagnosis in girls? Society's perspective on girls, for one, has changed. In the past, they were expected to subdue the expression of their innate nature. Traditionally, girls were taught to walk and talk softly, while their brothers were allowed to scream and stomp. They were expected to participate in more passive behaviors, such as helping mom in the kitchen or playing with dolls, while their male peers played ball in the street. Today, girls participate in all the activities the boys do, including sports and roughhouse--without parental admonishment. ADD/ADHD expresses itself earlier and more freely under such conditions. In addition, parents are now just as concerned when their daughter does poorly at school as they are when their son does not perform well. A search for the causes of academic failure can mean ADD/ADHD being diagnosed early and more often.
What can be done about ADD/ADHD?
ADD/ADHD is not a death knell for a child's academic, social, or employment future. It is, however, a wake-up call. Once ADD/ADHD has been diagnosed, the strengths and weaknesses of the child should be identified for the purpose of treatment. The ADD/ADHD label should have the sole purpose of helping the child, not to disparage him or her. Labeling should not be stigmatizing; and, last but not least, certainly should not decrease either parents' or teachers' expectations--only make them realistic.
The mind is rooted in biology. Every thought, every feeling, and every behavior has a chemical change or an electrical reaction in the brain as its base. And if the problem is chemical, it is likely its solution will be as well. Next month's segment in this special series will cover treatments to consider for children diagnosed with ADHD.
Attention deficit disorder (ADD) and attention deficit-hyperactivity disorder (ADHD) may affect between four and twelve percent of school-age children in America. I use the word "may" because, over the past decade, physicians, other healthcare practitioners, psychologists and other behavioral therapists, educators, parents, and a broad range of other commentators have argued about the extent of ADD/ADHD in the US population, as well as its causes, symptoms, diagnosis, and treatments. Meanwhile, children and adults with ADD/ADHD continue to try to cope with a disability that interferes with fundamental skills such as the ability to focus and regulate impulsivity which ultimately can encumber academic achievement, hamper friendships and family harmony, impede job advancement, and frustrate social and economic life.
Following is an overview of the disorder--who gets it and why, as well as the signs and symptoms for diagnosis--developed by Vidya Bhushan Gupta, MD, MPH, from his forthcoming book, No Apologies for Ritalin (to be published in September 2000). As Director of Developmental-Behavioral Pediatrics at Metropolitan Hospital Center, New York City, Dr. Gupta has extensive experience working with children with ADD/ADHD, their parents, and their families. His book includes a thorough discussion of possible causes and techniques for diagnosis of ADD/ADHD. He attempts to educate parents of children with ADD about various treatments available to treat ADD/ADHD, so that they can make informed choices. It features a lengthy identification and examination of ADD/ADHD treatments--both medications and behavioral therapies--as well as helpful guidelines for parenting a child with ADD/ADHD.
--Maxwell J. Schleifer, PhD
AD-IN: Attention Deficit Information Network 475 Hillside Ave. Needham, MA 02494 Telephone: (781) 455-9895 E-mail: email@example.com Web site: http://www. addinfonetwork.com AD-IN offers support and information to families of children with ADD, adults with ADD, and professionals through a network of AD-IN chapters. Children and Adults with Attention Deficit Disorder (CHADD) 8181 Professional Plaza Ste. 201 Landover, MD 20785 Telephone: (800) 233-4050 E-mail: national@Chadd.org Web site: http://www.Chadd.org CHADD works to improve the lives of people with attention-deficit/hyperactivity disorder through education, advocacy, and support. CHADD-Canada, Inc. 1376 Bank St., Ste. 214 Ottawa, ON, Canada K1H 1B3 Telephone: (301) 306-7070 E-mail: firstname.lastname@example.org Web site: http://www.members. tripod.com/~chadd-canada/index, html Chadd Canada is a non profit parent run organization that aims to help support, educate, and ultimatly better the lives of individuals with ADD and of those who care for them. Learning Disabilities Association of America (LDA) 4156 Library Rd. Pittsburgh, PA 15234 Telephone: (412) 341-1575 The purpose of the Learning Disabilities Association of America is to advance the education and general welfare of children and adults of normal or potentially normal intelligence who manifest disabilities of a perceptual, conceptual, or coordinative nature. National Attention Deficit Disorder Association (NADDA) 1788 Second St., Ste. 200 Highland Park, IL 60035 Telephone: (847) 432-ADDA (2332) E-mail: email@example.com Web site: http://www.ADD.org NADDA's mission is to help people with ADD lead happier, more successful lives through education, research, and public advocacy.
Dr. Gupta is an Assistant Professor of Pediatrics at the New York Medical College and a visiting associate research scientist at the Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University. Certified by the American Board of Pediatrics in 1987, Dr. Gupta is a fellow of the American Academy of Pediatrics. He serves on the organization's Project Advisory Committee of Medical Home Initiatives for Children with Special Health Care Needs. He is known in print through his book, Manual of Developmental-Behavioral Problems on Children, and scholarly articles in publications such as Pediatrics, the American Journal of Clinical Epidemiology, Indian Pediatrics, The Record, and Weber Studies.
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|Title Annotation:||attention deficit disorder, also called attention deficit-hyperactivity disorder|
|Author:||Gupta, Vidya Bhushan|
|Publication:||The Exceptional Parent|
|Date:||Aug 1, 2000|
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