Attention-Deficit Hyperactivity Disorder

Attention-Deficit Hyperactivity Disorder (ADHD) is one of the most commonly diagnosed mental disorders among children. According to sources such as the CDC, the causes are currently unknown. There is no single medical test that can accurately diagnose ADHD, though there are assessment tools.

The authoritative definition of ADHD is to be found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-IV (Text Revision) (DSM-IV-TR), which also defines three subtypes of ADHD:

  • Predominantly Inattentive
  • Predominantly Hyperactive-Impulsive
  • Combined Type

Further details about diagnosis are given below in the section on Symptoms.

According to some recent studies, ADHD is an inheritable dysfunction of dopamine metabolism mainly in the frontostriatal region of the human brain. New studies consider the possibility that norepinephrine metabolism also affects this disorder (see Krause, Dresel, Krause in Psycho 26/2000 p.199ff). One should note that almost all of the latest studies have been sponsored by drug companies.

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Table of contents
1 Terminology
2 Symptoms
3 Incidence
4 Evidence for ADHD as an organic phenomenon
5 Is ADHD inherited?
6 Treatment
7 Positive aspects
8 Skepticism towards ADHD as a diagnosis
9 Psychological Testing for ADHD
10 External links

Terminology

The name Attention Deficit Disorder (ADD) was first introduced in DSM-III, the 1980 edition. In DSM-III-R, published in 1987, the name was in effect changed to ADHD.

Older names that have been used for ADHD or ADD include hyperkinetic syndrome (HKS) and minimal cerebral dysfunction (MCD). ADHD is sometimes called attention-deficit syndrome (ADS) to avoid the connotations of "disorder".

Symptoms

A diagnosis of ADHD is made based on a checklist of symptoms that can be found in DSM-IV-TR. A hyperlink to the Centers for Disease Control and Prevention (CDC) web page summarizing these criteria is given in the External Links section below. The CDC emphasizes that a diagnosis of ADHD should only be made by trained health care providers. This is important as many of the criteria can be readily misinterpreted.

Incidence

According to the 2000 edition of DSM-IV-TR, ADHD affects three to seven percent of all children in the U.S. However, rates of diagnosis vary widely even within the U.S. In some school districts as many as 60% of all children have been diagnosed with ADHD.

Two to three or four times more boys than girls are diagnosed with ADHD, but the causes of this gender disparity are also unknown.

Today ADHD is considered to be a problem all over the industrialized world, although in no other country are children diagnosed with this "disorder" nearly as often as in the United States.

The variation in the rates of diagnosis and in estimates of the rate of prevalence raises numerous issues. In fact, almost everything about ADHD has been the subject of intense debate, as discussed later in this article. This debate led the NIH to develop a Consensus Statement in 1998, a link to which is provided in the External Links section below.

ADHD often continues into adolescence and adulthood, and can cause a lifetime of frustrated dreams and emotional pain. However, children diagnosed with ADHD often go on to live normal lives, and wonder why their parents and schools felt the need to medicate them.

Evidence for ADHD as an organic phenomenon

Brain imaging research using a technique called magnetic resonance imaging (MRI) has shown that differences exist between the brains of children with and without ADHD. Many scientists consider these results to be significant in themselves, but in addition PET studies have shown that there might be a link between a person's ability to pay continued attention and the use of glucose - the body's major fuel - in the brain. In adults with ADHD, the brain areas that control attention use less glucose and appear to be less active, suggesting that a lower level of activity in some parts of the brain may cause inattention (Zametkin et al.). However, there is no evidence that this low level of glucose in fact causes the low level of attention; it could in fact be no more than an indicator for low attention. Maybe even more interesting are the results of some studies using SPECT (Single Photon Emission Computed Tomography). One study (Lou et al. in Arch. Neurol. 46(1989) 48-52) found that people with ADHD have a reduced blood circulation in the striatum. But even more important might be the discovery that people with ADHD seem to have a significantly higher concentration of dopamine transporters in the striatum (Dougherty et al. in Lancet 354 (1999) 2132-2133; Dresel et al. in Eur.J.Nucl.Med. 25 (1998) 31-39).

Is ADHD inherited?

According to the NIMH Q&A cited below:

Research shows that ADHD tends to run in families, so there are likely to be genetic influences. Children who have ADHD usually have at least one close relative who also has ADHD. And at least one-third of all fathers who had ADHD in their youth have children with ADHD. Even more convincing of a possible genetic link is that when one twin of an identical twin pair has the disorder, the other is likely to have it too.

Treatment

There are many options available to treat people diagnosed with ADHD. These options include a variety of medications such as Ritalin, behavior-changing therapies, and educational interventions.

Data from 1995 show that physicians treating children and adolescents wrote six million prescriptions for stimulants. Of all the drugs used to treat psychiatric disorders in children, stimulant medications are the most well-studied. However, to date there are no good long-term studies dealing with stimulants in children. A 1998 Consensus Development Conference on ADHD sponsored by the National Institutes of Health and a recent, comprehensive, scientific report confirmed many earlier studies showing that short-term use of stimulants is safe and effective for children with ADHD. This says nothing for the growing number of children who are on stimulants for years at a time.

In December 1999, NIMH released the results of a study of nearly 600 elementary school children, ages seven-to-nine, which evaluated the safety and relative effectiveness of the leading treatments for ADHD for a period up to fourteen months. The results indicate that the use of stimulants alone is more effective than behavioral therapies in controlling the core symptoms of ADHD - inattention, hyperactivity/impulsiveness, and aggression. In other areas of functioning, such as anxiety symptoms, academic performance, and social skills, the combination of stimulant use with intensive behavioral therapies was consistently more effective. (Of note, families and teachers reported somewhat higher levels of satisfaction for those treatments that included the behavioral therapy components.) NIMH researchers will continue to track these children into adolescence to evaluate the long-term outcomes of these treatments, and ongoing reports will be published. This study has been severely criticized, as it was not double-blind and the sponsors failed to provide a control group.

There has been a lot of interesting work done with biofeedback and ADHD. Children are taught, using video game-like technology, how to control their brain waves. This has a very high success rate, but is not widely used, or covered by insurance. It does not meet the standards for a quick-fix, which is what most people involved with ADHD children are looking for. Dietary and television restrictions are also sometimes useful environmental solutions. Sugar, wheat, and other foodstuffs have been shown to cause adverse behavioral reactions. And TV can be seen as encouraging ADHD attention spans with their fast paced layout.

Positive aspects

Though ADHD is classified as a serious disorder, many people have a different perspective. Some see it as a gift. In his book ADD - Attention Deficit Disorder (1997), Thom Hartmann developed the idea that people having ADHD symptoms may have simply inherited a collection of genes that were selected for when hunting was particularly important. This idea is the basis of another of his works, The Edison Gene: ADHD and the Gift of the Hunter Child (2003).

People who believe that ADHD is a gift find hints of ADHD in the lives of many famous people in history. Though such post mortem diagnosis is questionable, it is intriguing to ponder the evidence that people such as Thomas Edison might have been diagnosed as having ADHD if the current DSM criteria had been developed sufficiently long ago. Other historical figures who have been proposed as ADHD candidates include: Hans Christian Andersen, Ludwig van Beethoven, Winston Spencer Churchill, Walt Disney, Benjamin Franklin, Robert and John F. Kennedy, Adolf Hitler,Theodore Roosevelt, Jules Verne and the Wright brothers.

Some contemporary ADHD candidates have also been proposed, including George W. Bush, William J. Clinton, Whoopi Goldberg and Dustin Hoffman.

To see ADHD as a gift may seem somewhat problematic to anxious parents but it is at least a perspective that should be kept in mind.

Skepticism towards ADHD as a diagnosis

Critics have complained that the ADHD diagnostic criteria are sufficiently general or vague to allow most children with persistent unwanted behaviors to be classified as having ADHD of one type or another. Many people have wondered why the number of children diagnosed with ADHD in the U.S. has grown so dramatically over a short period of time. It has often been suggested that the causes of the ADHD epidemic lie in cultural patterns that variously encourage or sanction the use of drugs. Some people have asked whether many of the kids who are put on drugs wouldn't be better off with a little more love and attention.

Some critics have suggested that the ADHD label should be abolished. No doubt, as causes and cures are better understood, better labels will in time be found.

Psychological Testing for ADHD

Psychological testing generally consists of obtaining multiple types of assessments for the syndrome. This usually includes a clinical interview reviewing the DSM-IV criteria for ADHD. The interview also needs to rule out as much as possible other types of syndromes which can cause attention problems, such as depression, anxiety, and psychosis. Rating scales can be administered which provide measurement of the person's own view of their symptoms, as well as the views of parents, teachers, and significant others. Finally, computerized tests of attention can be helpful in providing a further independent assessment of attention. These different assessments may not be in total agreement but provide a well rounded view of the person's difficulties. A physician need not order psychological testing in order to make the diagnosis of ADHD, but many doctors use this kind of assessment to prevent over diagnosis and treatment.

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