adhd

Attention Deficit Hyperactivity Disorder (ADHD) has undoubtedly become the most common and controversial mental health diagnosis for children with behavior problems in our country. Because this disorder may affect as many as 7 to 9% of all children in the US, this topic comes up regularly in our practice. Statistically speaking, there is usually at least one child in each school classroom with ADHD. The presence of ADHD in a child can have a negative impact on academic development, well-being and social interactions.

Description and Cause of ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by persistent patterns of problematic behavior, such as inattention and/or hyperactivity and impulsivity, which can significantly impact daily functioning and developmental progress. It typically begins in childhood and often continues into adulthood. Symptoms may include difficulty maintaining focus, distractibility, forgetfulness, excessive fidgeting and movement, impulsiveness, and trouble organizing tasks. While the exact cause of ADHD is not fully understood in all cases, it is believed to involve genetic and environmental factors. In addition, some children with ADHD may have minor differences in brain structure.

Some specific gene variants are strongly linked to the disorder. Two genes related to dopamine function, DRD4 and DAT1 have been implicated. Dopamine is an important neurotransmitter whose function is thought to be diminished in people with ADHD. These gene variants are more common in people who have been diagnosed with ADHD compared to the general population.

Thus, ADHD is not a single genetically uniform condition; rather, multiple genetic variations may contribute to its symptoms. This genetic diversity helps explain why individuals with ADHD may respond differently to various treatments.

Because of its genetic basis, ADHD often runs in families. It is common for parents or siblings of children being evaluated for ADHD to realize they also have the condition and seek treatment themselves.

The Frontal Lobe

In individuals with ADHD, the prefrontal cortex of the frontal lobe does not function as effectively as it should. This area is essential for directing attention, maintaining focus, being self-aware, and managing executive functions like planning and decision-making. The frontal lobe also regulates emotions and controls voluntary movements. This area of the brain helps a person maintain cognitive control over their thoughts, actions, and interactions with others.

ADHD is believed to result from dopamine dysfunction in the frontal lobe of the brain, which is vital for attention, decision-making, organizational skills and impulse control. The dopamine dysfunction causes reduced neuronal activity in the prefrontal cortex of the frontal lobe. Stimulant medications enhance dopamine function, helping to normalize neuronal activity and alleviate ADHD symptoms.

Overview of the Management of ADHD

Effective ADHD management usually combines behavioral therapies, educational interventions, lifestyle changes, and medication to help manage symptoms and improve daily functioning.

The landmark Multimodal Treatment Study (MTA) of ADHD, published in 1999, examined four ADHD treatment strategies: medication alone, behavioral therapy alone, a combination of both, and standard community care. The study found that medication, especially stimulants like methylphenidate, was the most effective at managing core ADHD symptoms like inattention, hyperactivity, and impulsivity. Behavioral therapy offered some additional benefits, such as improvements in social skills and academic performance, but medication remained the key component of effective treatment.

ADHD medications provide significant symptom relief while active, but symptoms return once they wear off. Currently, there is no permanent cure for ADHD; the disorder is managed with daily medication that alleviates symptoms for several hours until it fades.

History of the Diagnosis of ADHD:

Despite common misconceptions, ADHD is one of the most extensively studied conditions in medical history. Thousands of studies, comprising millions of patient-years, have been conducted on children with ADHD. Effective treatments for ADHD have been known for well over 80 years. ADHD was first described over 120 years ago. It is a real medical condition with a vast history of research and effective treatment.

The Goulstonian lectures, given by Dr. George Frederic Still in London, took place in March 1902. In these lectures, Dr. Still described what is now recognized as ADHD, laying the groundwork for the modern understanding of the condition.

Presentation of ADHD:

ADHD is a psychiatric condition that may cause some or even all of the following behavioral and learning problems. Children with ADHD may:

• have problems with a deficit of sustained attention, which can result in learning and school problems. A child with ADHD cannot pay attention to what needs to be done. They tend to be easily distracted by other stimuli around them which unaffected children can ignore.
• show little inhibitory volitional control and have problems with self-regulation. Said another way, kids with ADHD cannot control themselves well. This can result in hyperactivity, impulsivity and a lack of control in many situations.
• be aggressive, defiant and resistant to discipline.
• be excessively emotional or excessively passionate.
• not learn from the consequences of their actions although their intellect is normal. They tend to not learn from their mistakes.
• forget what they have just learned. This is a defect in what is called working memory.

ADHD can present differently in different children. ADHD symptoms are categorized into three areas: inattention, hyperactivity, and impulsivity.

Children with inattention may have trouble focusing, organizing tasks, and following instructions. They often make careless mistakes, lose items, and appear not to listen when spoken to. Distractability by external stimuli or unrelated thoughts is common, as is avoidance of tasks requiring sustained mental effort. This can affect academic performance and daily activities unless managed with specific strategies.

Hyperactivity is characterized by an incessant need to move, leading to fidgeting, tapping, or inability to remain seated. Children may exhibit excessive energy, such as constant running and jumping, even when it’s inappropriate, like in classrooms or in medical settings. Excessive talking and difficulty participating in quiet activities are also common.

Impulsivity involves acting without thinking, often interrupting conversations, blurting out answers, and trouble waiting their turn. This can lead to hasty decision-making and taking unnecessary risks. Both hyperactivity and impulsivity can pose challenges in academic, social, and workplace environments.

There are three main types of ADHD:

ADHD predominantly inattentive type

These patients meet the criteria for inattention. They are not hyperactive or impulsive but struggle with focusing and keeping up with schoolwork. Paying attention in class and completing assignments, especially those requiring sustained focus, can be particularly challenging. Starting schoolwork is stressful, and doing homework often leads to frustration and tears.

This is the most common type of ADHD in girls, although boys can have it as well. It leads to easy distractability and frequent daydreaming. Homework can take a long time due to distractability, with forgetfulness and inattention being predominant issues. Thankfully, this type of ADHD is rarely linked to the behavioral problem of hyperactivity and impulsivity.

ADHD predominantly hyperactive type

These patients fulfill the criteria listed below for hyperactivity and impulsivity without attentional problems. This type of ADHD is rare.

ADHD combined type

Children with this form of ADHD exhibit symptoms of inattention, hyperactivity, and impulsivity, known as the combined type of ADHD. This type of ADHD is most common in boys, but can also be present in girls. It often leads to behavioral issues that become evident in the early school years or even preschool years. We can generally immediately recognize a child with the combined type of ADHD in our office, because they are the only patients who will inappropriately open every drawer, turn every knob, push every button, examine the contents of our pockets and run and jump in the exam room when staying seated is expected.

Children with combined ADHD struggle to sit still, concentrate, and complete schoolwork, leading to learning difficulties and falling behind in school. Parents often describe them as “bouncing off the walls,” with hyperactivity often inappropriate to the context. These children may disrupt conversations, look into things without permission, and invade others’ personal spaces by pushing or hitting.

Impulse control is a significant challenge. Children often act without thinking about consequences, such as blurting out answers or interrupting others. They may also engage in risky behavior, like blowing spitballs without regard for where they might land.

Emotional regulation can be problematic, leading to emotional outbursts in stressful situations. Their actions are often driven by immediate personal gratification rather than consideration for others, displaying insensitivity to peers’ feelings and disrupting social harmony.

It’s important to note that these behaviors do not indicate that a child with ADHD is inherently bad. Instead, the inattention, hyperactivity, and impulsivity arise from under-activity in the frontal lobe, meaning they lack the necessary filters for acceptable social interaction. These challenges are not due to a lack of effort or willpower, and typical disciplinary approaches from parents are almost always ineffective.

Children with ADHD often lack motivation for necessary tasks they dislike, such as doing their schoolwork and cleaning their room. However, they can maintain intense focus on activities that they enjoy, like playing video games, displaying high attention and motivation during the games. There is a clear distinction between tasks and activities that they want to do versus tasks that they ought do, but do not want to do. The brain processes “want to” and “ought to” motivations in different areas. The frontal lobe is affected by ADHD which controls activities that people ought to do, but may not want to do. This difference in brain processing can help explain the challenges faced by individuals with ADHD in completing necessary but unappealing tasks. This lack of motivation toward necessary, but unpleasant tasks creates major problems with kids with ADHD.

Executive Functions

The functions necessary for scholastic and vocational success, often embodied by successful business executives, are carried out in the brain’s frontal lobe and are known as executive functions. Just as a business executive coordinates various departments to work towards a common objective, executive functions help integrate and manage various cognitive resources to enable purposeful and goal-directed behavior. These are essential for the cognitive control of behavior and are crucial for good school performance, law-abiding citizenship, and healthy interpersonal relationships. Executive functions include attentional control, inhibitory control, working memory, cognitive flexibility, reasoning, problem-solving, and planning. In children with ADHD, these functions are unfortunately diminished.

The lack of executive function in children with ADHD often results in inattention, hyperactivity, impulsivity, emotional outbursts, impaired judgment, conduct issues, or any combination of these. These behaviors typically lead to negative social repercussions. Others may misinterpret the actions as intentional, not understanding that the child struggles with self-control, leading to interpersonal conflicts.

Parenting a Child with the Combined form of ADHD

Parents and caregivers of children with the combined form of ADHD often experience exasperation and frustration due to ongoing behavioral challenges and the child's inability to respond to correction. This may lead to negative parenting approaches which are not helpful to the child.

Children with this form of ADHD are more likely to engage in risk-taking behaviors, which increases their chances of injury or death compared to their peers without ADHD. Teenagers with ADHD combined type face higher risks of pregnancy and sexually transmitted infections (STIs). These tendencies stem from impaired frontal lobe function, which is crucial for risk assessment and avoidance.

Teenagers with ADHD are particularly at risk while driving, as they tend to have more accidents, DUIs, speeding tickets, and license suspensions due to inattentiveness and impulsivity. However, effective treatment for ADHD can significantly reduce all these risks, bringing them close to normal levels.

Co-Morbid Conditions

If all the symptoms of ADHD weren’t enough, many kids with ADHD may also have other disorders that complicate their condition further. Oppositional defiant disorder (ODD) is the most common co-morbid condition in children with ADHD. Children with ODD often argue with adults, lose their temper, defy authority, deliberately annoy others, blame others for mistakes, and may exhibit aggressive behaviors like bullying and fighting.

ODD can be likened to a “sourness of soul” that develops from the negative interactions with others that children with ADHD frequently encounter. Constant correction, discipline, and demands exceeding their capabilities often lead to feelings of injustice, frustration and exasperation. Fortunately, treating ADHD medically can alleviate ODD symptoms over time as the negative interactions with others diminish.

Other co-morbid conditions that may need treatment with ADHD include anxiety disorders, language disorders, dyslexia, learning disabilities such as in reading, mood disorders, insomnia, substance abuse and conduct disorder.

Practice experience and research indicates that children with ADHD are at a higher risk of abusing substances in their lifetime compared to those without ADHD. However, ADHD treatment reduces this risk to the level of the general population and does not increase it. Medicines used to treat ADHD are non-addictive.

Children with ADHD often perform below their potential on timed tests like the American College Testing (ACT) due to difficulties focusing attention and distractibility. Treating ADHD can enhance their test performance significantly. Ultimately, effective medical treatment for ADHD can significantly improve both behavior and outcomes, offering hope for children and their families.

Myths About ADHD

There are many myths about the causes of ADHD. Factors not generally accepted as causes include: excessive or insufficient sugar, aspartame, food sensitivities, additives or coloring, vitamin deficiencies, television (except possibly for very young children exposed to screens), fluorescent lighting, and allergies. While some of these factors, such as allergies, may influence a child’s behavior, they do not cause ADHD.

Diagnosis of ADHD

To determine if your child has ADHD, we use criteria from the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association). A diagnosis requires a persistent pattern of inattention and/or hyperactivity and impulsivity that affects functioning or development. For children, at least six symptoms of inattention and/or six symptoms of hyperactivity and impulsivity must be present.

These symptoms should occur in more than one setting, such as both school and home, to rule out situational behaviors. Additionally, several symptoms must have been present before age 12 and cannot be explained by another mental disorder.

The ADHD evaluation is comprehensive and often involves feedback from parents, teachers, and caregivers to accurately assess the child’s behavior across different environments. If six or more symptoms of inattention or six or more symptoms of hyperactivity-impulsivity persist for at least six months, you should consider having your child evaluated for ADHD.

Inattention:

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has difficulty sustaining attention in tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow through on instruction and fails to finish schoolwork, chores, or duties (not due to oppositional behavior or failure to understand instructions).
5. Often has difficulty organizing tasks and activities.
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as school work or homework).
7. Often loses things necessary for tasks or activities, such as toys, assignments, books, or tools.
8. Is often easily distracted by extraneous stimuli.
9. Is often forgetful in daily activities.

Total number of inattention items selected:           (Significant if 6 or greater)

Hyperactivity:

1. Often fidgets with hands or feet or squirms in seat.
2. Often leaves seat in classroom or in other situations in which remaining seated is expected.
3. Often runs about or climbs excessively in situations in which it is inappropriate (adolescents or adults may have feelings of restlessness).
4. Often has difficulty playing or engaging in leisure activities quietly.
5. Is often “on the go” or often acts as if “driven by a motor”.
6. Often talks excessively.
   

Impulsivity:

1. Often blurts out answers before questions are completed.
2. Often has difficulty awaiting their turn.
3. Often interrupts or intrudes on others, such as butting into conversations or games.

Total number of hyperactivity and impulsivity items selected: Significant if 6 or greater.

Vanderbilt forms used to diagnose ADHD can be downloaded by clicking here.