Attention Deficit Hyperactivity Disorder (ADHD) has undoubtedly become the most common and controversial diagnosis for children with behavior problems in our country. Because this disorder may affect as many as 5 to 7% 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. Although all the causes of ADHD are not known for sure, evidence suggests that these disorders are genetic, inherited problems in which the chemistry of the frontal lobe of the brain is disordered.
Although most people don’t realize this, ADHD is one of the most studied conditions in the history of medicine. Thousands of studies with millions of patient years have been done on children with ADHD. The treatments for ADHD have been in use for 80 years. It is instructive to look at two of these studies to get a grasp of what ADHD is and how it is treated.
Sir George F. Still, Great Britain’s first professor of pediatrics, was the first physician to describe ADHD in a formal medical setting and in the medical literature. He presented three lectures in March, 1902 to the Royal College of Physicians in London, under the title Goulstonian lectures on “some abnormal psychical conditions in children”. He later published papers on the subject that same year in the Lancet, a prominent English medical journal. Dr. Still described 43 children he had treated who had problems with sustained attention and self-regulation, who were often aggressive, defiant, resistant to discipline, excessively emotional (passionate), who showed little inhibitory volition, had serious problems with sustained attention and could not learn from the consequences of their actions, although their intellect was normal. He wrote “I would point out that a notable feature in many of these cases of moral defect without general impairment of intellect is a quite abnormal incapacity for sustained attention.” He concluded: “there is a defect of moral consciousness which cannot be accounted for by any fault of environment.” Dr. Still’s observations are instructive for us even today.
In 1937 a surprising treatment for ADHD was discovered by psychiatrist Charles Bradley. Dr. Bradley administered Benzedrine sulfate, an amphetamine, to “problem” children at the Emma Pendleton Bradley Home in Providence, Rhode Island, attempting to treat headaches. Dr. Bradley noticed an unexpected beneficial effect on the behavior of a subset of children who were given Benzedrine. The amphetamine improved school performance, social interactions, and emotional responses in the children with inattentive and hyperactive behavioral problems. After only a week of amphetamine treatment, Bradley observed: “The most striking change in behavior occurred in the school activities of many of these patients. There appeared a definite ‘drive’ to accomplish as much as possible. Fifteen of the 30 children responded to Benzedrine by becoming distinctly subdued in their emotional responses. Clinically in all cases, this was an improvement from the social viewpoint.”
Thus, Dr. Still gave us an initial description of ADHD and Dr. Bradley discovered the needed treatment. Although Dr. Bradley’s work was largely ignored for 25 years, it did pave the way for studies of amphetamines like methylphenidate (Ritalin) and their use in attention deficit hyperactivity disorder (ADHD). Since Dr. Bradley’s 1937 study, thousands of additional studies with millions of patient years of use have consistently shown that ADHD is best treated with amphetamine (stimulant) medications. This continues to be the mainstay of ADHD treatment even today. The American Academy of Pediatrics recommends stimulant treatment for ADHD. We at All For Kids treat ADHD in this way as well. Amphetamine type medications are known to increase the activity of a neuro-transmitter called dopamine in the pre-frontal cortex of the brain, making that part of the brain more effective. Treating children with an amphetamine type medication for ADHD shocks many parents. Please remember that the amphetamine type medications used for ADHD are not the street drug methamphetamine. These are different compounds.
What causes ADHD? ADHD is an inherited psychiatric disorder that results in certain behavioral problems. Studies show that ADHD tends to run in families. We know that at least 30 to 40% of children with the disorder have a relative with it also. Said another way, a child with ADHD is four times as likely to have a relative who is also diagnosed with the disorder. Further evidence for a genetic link is that if one twin has ADHD, the other twin has an 80% of having the disorder also. Thus, there is strong evidence for a genetic cause of ADHD. That is, most kids have ADHD because their parents passed it down to them. A very common scenario in our office is that during a work up for ADHD in their child, one of the parents or even siblings of that child may realize that they too have the disorder and seek treatment. Not all kids with ADHD have a parent with the condition and thus have no obvious genetic causation.
What is ADHD? Frankly, it’s hard to improve on Dr. Still’s initial description. Children with ADHD have a psychiatric condition that may cause some or all of the following behavioral problems:
- have serious problems with sustained attention, which can result in learning and school problems. They can’t pay attention.
- show little inhibitory volitional control and have problems with self-regulation. Said another way, kids with ADHD cannot control themselves. This can result in hyperactivity, impulsivity and a lack of control in many situations.
- aggressiveness, defiance and resistance to discipline.
- excessively emotional, excessively passionate.
- can not learn from the consequences of their actions although their intellect is normal.
We now group Dr. Still’s descriptions into three areas of behavioral impairment: inattention, hyperactivity and impulsivity. Kids with the more severe, combined form of ADHD have all three impairments. Some kids with ADHD have the predominantly inattentive type with just problems of inattention and not the behavior problems of hyperactivity and impulsivity.
Let us describe the more severe form: ADHD combined type. Kids with ADHD combined type may find it difficult to sit still, concentrate on their school work, focus their attention for long periods of time and finish their school work. Because of this, learning can be slowed and the child can become behind in their school attainments. They tend to be hyperactive, “bouncing off the walls” as some parents describe this. This hyperactivity is often inappropriate to the social context in which a child may be in. For example, a child with ADHD may inappropriately open every drawer in a room that they have not been invited to open, look in pockets that are not theirs, push buttons which they are not authorized to push, inappropriately intrude on conversations, walk, run or jump when staying seated is expected and even become intrusive and aggressive towards others. There may be a tendency to not be able to control emotional outbursts and responses in certain stressful circumstances. A lack of control in many areas of a child’s life is a prominent feature of this disorder.
In addition to inattention and hyperactivity, kids with the combined form of ADHD have problems controlling their impulses, a condition called impulsivity. This refers to people who act without thinking about the moral consequences and interpersonal consequences of their actions. Kids with impulsivity often blurt out answers before it is appropriate to answer the question. They have difficulty in awaiting their turns to do different things. They inappropriately interrupt or intrude on others such as in games and conversations. In their dealing with other people, most children with the combined form of ADHD tend not to be sensitive to the feelings, desires and reactions of others. Their personal gratification is their only consideration. They may not want to take turns with others, not listen, and not share. If they don’t get what they want they may resort to pushing others, hitting others, shoving, saying hurtful things, and even starting physical fights. They tend to have no remorse if they have hurt someone.
In later life, ADHD impulsivity can result in buying things one can’t afford, entering early sexual relationships, trying illegal drugs, breaking laws (such as speeding tickets), and other inappropriate or even immoral actions. Most parents feel that “their child just doesn’t get it” when it comes to controlling themselves according to societal norms. It is important to know that these negative ADHD behaviors are not due to the child being a bad or evil person. The hyperactivity, inattention and impulsivity of ADHD is due to the frontal lobe of the brain not functioning properly as the result of a genetic defect. It is thought that this genetic defect involves dopamine, a neuro-transmitter mentioned earlier. The frontal lobe of children with ADHD is relatively silent, not working. Thus, in ADHD, what the frontal lobe is supposed to be doing is not getting done. Either the release or the reception of dopamine is disordered and the pre-frontal cortex is relatively silent. Simply, that part of the brain is not working properly. In other words, the child just can’t help it. They cannot control themselves. Treatment is needed and thankfully, it is quite effective.
The three main types of ADHD are:
ADHD predominately inattentive type
These patients fulfill the criteria listed below for inattention. They are not hyperactive or impulsive, but instead are inattentive and have problems keeping up with school work. They tend to have difficulty paying attention in class and finishing their school work. School assignments that require sustained attention is particularly difficult for them. Homework often causes tears. Just getting started on school work is stressful to them. This is the most common type of ADHD found in girls, although boys have it as well. This type of ADHD causes the child to be easily distractable. Daydreaming is a big problem. Home work can take a very long time to complete because of the distractability. Thankfully, this type of ADHD is rarely associated with behavioral problems. Forgetfulness and inattention predominate.
ADHD predominately hyperactive type
These patients fulfill the criteria listed below for hyperactivity without attentional problems. They tend to have normal attention, but are unable to sit still for long periods of time to do their school work. This type of ADHD is rare.
ADHD combined type
Children with this form of ADHD have all the symptoms of ADHD: hyperactivity, inattention and impulsivity. This form of ADHD is most common in boys. Because of the problems that ADHD cause: hyperactivity, inattention and impulsivity, children with this disorder generally begin to have problems in early school years. We can generally recognize a child with this form of ADHD in our office because they are the ones who will inappropriately open every drawer, turn every knob, push every button and examine the contents of our pockets.
In all forms of ADHD, there seems to be precious little motivation to do things that need to be done but that the child does not want to do, such as school work and cleaning and organizing their bedroom. Paradoxically, children with ADHD can play video games and other games that they enjoy for hours with complete attention to each detail and excellence in the execution of those associated tasks. It seems that things they want to do can be easily accomplished with high levels attention and motivation, but the things that they ought to do, but do not want to do can be a tremendous struggle to accomplish. These “want to” and “ought to, but don’t want to” motivations actually come from different parts of the brain. The “want to” motivated actions are not affected by ADHD. The “ought to, but don’t want to” actions are involved in what we call executive functions. These are functions that are carried out in the frontal lobe of the brain and are what make business executives successful. These actions include attentional control, inhibitory control, working memory, cognitive flexibility, reasoning, problem solving, and planning. These executive functions are necessary for the cognitive control of behavior and are crucial to good school performance, being a good citizen (following laws) and healthy relationships with others. These functions are missing in the combined form of ADHD.
Because of their lack of executive function, associated with the presence of hyperactivity, inattention, impulsivity, emotional outbursts, impaired judgment, conduct problems and an inability to learn from the consequences of their actions, (whew!) unfortunately, negative social consequences with other people begin to pile up. Others instinctively react negatively to ADHD behaviors, not realizing that the child with ADHD just can’t help it. This can create interpersonal conflicts. Most parents of children with the combined form of ADHD eventually become exasperated with their child’s behavior. Parental tears are common when discussing these things at the time of an office visit. As time goes on with more and more negative interactions, the child may become socially isolated. Some children with ADHD may over time be excluded from social activities with their peers such as birthday parties and other activities. They may also have difficulty keeping friends. The child may choose friends who are “from a rough crowd” with the social problems that come from those choices. Because of their behavior and the interactions of those around the child, deep emotional, social and family problems can occur. If left untreated, the disorder can have major complications of school failure with its attendant employment challenges, a sense of worthlessness and failure which can lead to depression, an increased risk of substance abuse, legal problems because of conduct and interpersonal conflicts.
Children with ADHD tend to take more chances with their bodies in their daily living and are more likely to be injured or even killed than children who do not have the disorder. Likewise, teenagers with ADHD tend to be much worse at driving an automobile with more accidents, more DUI’s, more speeding tickets and more license suspensions than their unaffected peers. Inattentive driving is frequently listed on the officer’s ticket.
American College Testing (ACT) results are frequently much lower than the knowledge and ability the child with ADHD actually possesses. Children with ADHD must constantly refocus their attention, thus lowering their scores on timed testing. All that negative behavior sounds disastrous, and frankly, it can be if not treated. Thankfully there is wonderful treatment for ADHD which can normalize that negative behavior. More on this later.
If all the symptoms of ADHD weren’t enough, many kids with ADHD may also have other disorders that complicate their condition further. These are called co-morbid conditions. Oppositional defiant disorder (ODD) is the most common co-morbid condition. Children with ODD tend to argue with adults, lose their temper, actively defy authority, deliberately annoy others, blame others for their mistakes, become angry easily, bully, threaten others, and start fights. This condition can be likened to a “sourness of soul” that happens because of all of the negative interactions that kids with ADHD have with others. A child with ADHD gets tired of being constantly corrected, threatened, disciplined, confronted and made to do things that they do not have the capacity to do. They feel injustice and it comes out with this “sourness of soul”. Thankfully, ODD tends to lessen with the medical treatment of ADHD. As ADHD is treated, the negative behaviors become less. As the negative ADHD behaviors become less, the “sourness of soul” diminishes.
In addition, language disorders, anxiety disorder, learning disabilities, mood disorders, substance abuse and conduct disorder are other co-morbid conditions that may need treatment. Children with ADHD have a 55% chance of abusing substances in their lifetime compared with an 18% chance with an unaffected child. Treatment of ADHD reduces the substance abuse risk to that of the general population: 18%. Therefore, stimulant medication reduces the chance of substance abuse in ADHD. It does not increase it.
Part of our job as a pediatrician in the treatment of children with ADHD is to help you unravel the causes of the behavior problems that may be affecting your child and develop treatment strategies for those conditions. It is complicated.
There are many myths about the causes of ADHD. Some factors that are not generally accepted as a cause of ADHD include: too much sugar, too little sugar, aspartame, food sensitivity, food additives or coloring, lack of vitamins, television (although this may not be case for very young children exposed to screens), fluorescent lighting, video games, and allergies. For a given child some of the above factors may influence behavior (such as an allergic child), but it is not the cause of ADHD.
How do you know if your child has ADHD? We follow the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) from the American Psychiatric Association to make this diagnosis. This is the standard that is followed by the American Academy of Pediatrics. The following checklist contains the criteria for making this diagnosis. It is quite helpful in determining if your child has ADHD. If 6 or more symptoms of inattention or 6 or more symptoms of hyperactivity-impulsivity have persisted for at least 6 months then you should bring your child in for an evaluation. ADHD is possible.
- Often does not 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 instruction and fails to finish schoolwork, chores, or duties (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 school work or homework).
- Often loses things necessary for tasks or activities, such as toys, assignments, books, or tools.
- Is often easily distracted by extraneous stimuli.
- Is often forgetful in daily activities.
-Total number of inattention items selected: Significant if 6 or greater.
Hyperactivity – Impulsivity:
- 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 (adolescents or adults may have 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.
- Often blurts out answers before questions are completed.
- Often has difficulty awaiting their turn.
- Often interrupts or intrudes on others, such as butting into conversations or games.
-Total number of hyperactivity plus impulsivity items selected: Significant if 6 or greater.
ADHD is a diagnosis that we make by taking a history of the problems a child is having and by determining if the child meets the criteria set forth for the diagnosis of ADHD in the DSM5 explained above. We generally need history about your child’s behavior from at least two different sources, usually a teacher and a parent. We then arrive at a conclusion. Because behavior problems in children can have many causes and because the treatment of those causes is so different and at times associated with side effects, it is important that the correct diagnosis of your child’s behavior problem be obtained.
Parenthetically, parents should be aware that stress in a child’s life from events in the family structure such as divorce, can create behaviors in children that mimic ADHD. Child abuse such as physical and sexual abuse can also cause severe stress in children, causing behavior problems. Learning disabilities (such as reading) can also mimic ADHD. Bipolar disease can mimic ADHD. If there is a family history of bipolar disease in your family, make sure that we have this information during an ADHD workup. Bipolar disease in children is regularly misdiagnosed as ADHD.
Children whose parents are either unable or too busy to give them all the love, attention and affection that they need can also have behavior problems. Of course, a child’s emotional needs must be met. As you can see, because this condition is so complex, extended office visits to discuss the problem are necessary. In addition to our services as pediatricians, often times psychology services and even psychiatric services are necessary for children with behavior problems. We will help you with these services should they become necessary. When making an appointment for behavior problems, be sure to tell the receptionist why you are coming in for the visit so that she can schedule adequate time and so that you can obtain the necessary paperwork for your visit to our office. ADHD appointments are usually scheduled well in advance. It is helpful to fill out Vanderbilt forms prior to an office visit for ADHD. These are available below. Vanderbilt forms have DSM5 criteria built into them for accurate diagnosis.
To get started with and ADHD workup click here to download forms to fill out.
In addition to our services as pediatricians, often times psychology services and even psychiatric services are necessary for children with ADHD. We will help you with these services should they become necessary.
Click on the link that follows for the American Academy of pediatrics information sheet regarding ADHD. aap_adhd.pdf