112 Attention-Deficit/Hyperactivity Disorder

There are two types of ADHD: 1) Inattentive Type, and 2) Hyperactive-Impulsive Type.

DSM-IV-TR criteria

Inattentive Type

• Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
  • 1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
  • 2) Often has trouble keeping attention on tasks or play activities.
  • 3) Often does not seem to listen when spoken to directly.
  • 4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
  • 5) Often has trouble organizing activities.
  • 6) Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
  • 7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
  • 8) Is often easily distracted.
  • 9) Often forgetful in daily activities.
• Attention can mean a number of different things.
• In ADHD, the main problem is the inability to have sustained attention or persistence on tasks, remember and follow rules and resist distractions.
  • May be more related to working memory than true “attention” problems.
• People with ADHD exhibit more “off-task” time and less productivity.
• Even occurs during things like television.

Hyperactive-Impulsive Type

• Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
  • Hyperactivity:
    • 1) Often fidgets with hands or feet or squirms in seat.
    • 2) Often gets up from seat when remaining in seat is expected.
    • 3) Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
    • 4) Often has trouble playing or enjoying leisure activities quietly. Is often “on the go” or often acts as if “driven by a motor”.
    • 5) Often talks excessively.
  • Impulsiveness:
    • 6) Often blurts out answers before questions have been finished.
    • 7) Often has trouble waiting one’s turn.
    • 8) Often interrupts or intrudes on others (e.g., butts into conversations or games).

• Some symptoms that cause impairment were present before age 7 years. There has to be an onset of symptoms prior to 7 years old, but a diagnosis can occur much later.
• Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
• There must be clear evidence of significant impairment in social, school, or work functioning.
• The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Don’t forget: Children who meet the criteria for both inattentive type and hyperactive-impulsive type meet the criteria for ADHD Combined Type.

ADHD Subtypes

• ADHD, Combined Type:
  • If both criteria for inattentive and hyper-impulsive symptoms are met for the past 6 months.
• ADHD, Predominantly Inattentive Type:
  • If criterion for inattentive is met but criterion for hyper-impulsive is not met for the past 6 months.
• ADHD, Predominantly Hyperactive-Impulsive Type:
  • If criterion for hyper-impulsive is met but criterion for inattentive is not met for the past 6 months.
• Evidence mountng that predominately inattentive type is a separate disorder:
  • Sluggish cognitive style, selective attention deficits.
  • Lower rates of co-morbidity with ODD and CD.
  • Memory retrieval problems.
  • Different development course.

Peers

One effect Attention-Deficit/Hyperactivity Disorder (ADHD) can have on a child’s life is to make childhood friendships, or peer relationships, very difficult. These relationships contribute to children’s immediate happiness and may be very important to their long-term development.

Research suggests that children with difficulty in their peer relationships, like being rejected by peers or not having a close friend, may in some cases have higher risk for anxiety, behavioral and mood disorders, substance abuse and delinquency as teenagers.

Parents of children with ADHD may be much less likely to report that their child plays with groups of friends or is involved in after-school activities, and half as likely to report that their child has many good friends. Parents of children with ADHD may be more than twice as likely than other parents to report that their child is picked on at school or has trouble getting along with other children.

Associated features

There are three core features of ADHD. They are inattention, hyperactivity and impulsivity. Attention Deficit/Hyperactivity Disorder (ADHD) can be seen in both children and adults even though it is more prevalent in children. The onset of ADHD is usually before the age of seven. People with ADHD have to demonstrate at least one of three core features of the disorder: inattention, hyperactivity, and impulsive. Given these features, there are three subtypes of ADHD: Primarily Inattentive Type, Primarily Hyperactive-Impulsive Type, and Combined Type. Due to random cases and unique patients, the DSM-IV-TR includes an additional category, ADHD NOS (Not Otherwise Specified). This category is most often used in cases where the onset of ADHD occurs after seven years of age or when hypo-active behaviors accompany inattentive symptoms. The Inattentive Type of ADHD is characterized by poor organizational skills, poor ability to maintain mental focus, poor attention to details, forgetfulness, etc. Also the Inattentive type is the criterion for predominately inn-attentive type is met but not the hyperactive impulsive type for the past six months. The Hyperactive-Impulsive Type of ADHD is characterized by fidgety behavior, non-stop motion, excessive talking, blurting out thoughts and answers, impatience, etc. This type is predominately met if criterion for hyper impulsive type is met but inattentive criterion is not met for the past six months. The DSM-IV-TR requires six of the nine listed symptoms for a diagnosis of Inattentive Type or Hyperactive-Impulsive Type. In addition, the DSM requires the child to meet four other conditions: symptoms must be present for at least six months, symptoms must cause problems with everyday life, symptoms must stay steady over different situations, and symptoms must occur before seven years of age. Children with this type of ADHD have difficulties with certain impulses, such as waiting their turn, which puts them at a greater risk socially with their peers. These children often have trouble maintaining friendships and tend to gravitate towards other children who exude disruptive behavior. Children who meet the qualifications and symptoms for the past six months for both Inattentive Type and Hyperactive-Impulsive Type ADHD are diagnosed with Combined Type ADHD.

The main problem is the inability to have sustained attention or persistence on tasks, remembering and following rules, and resisting distractions. This may be more related to working memory than true attention problems. These individuals display more off-task time and less productivity, even with television. In ADHD, thought to involve problems with voluntary inhibition of responses, not impulsively due to motivators. Some impairment from the symptoms is present in two or more settings, at school or work and home. There must be clear evidence of significant impairment in social, school, or work functioning.

Their are subtypes of ADHD that need to be recognized: Combined Type (if both criteria for inattentive and hyper-impulsive symptoms are met for past 6 months), Predominantly Inattentive Type (criteria for inattentive is met, but not hyper-impulsive criteria met for past 6 months), and lastly Predominantly Hyperactive-Impulsive Type (vice verse criteria as for Inattentive Type).

Child vs. adult presentation

ADHD is more prevalent in children, but it can also occur in adults. When present in adults, it is categorized as Adult Attention Deficit Disorder (AADD). The symptoms for AADD and ADHD are fairly similar. For example, AADD is characterized as having low self-motivation and low self-regulation due to procrastination, organization problems, problems being easily distracted, etc. Studies show that 70 percent of children diagnosed with ADHD will continue to have related symptoms into and possibly throughout adulthood. At some level, all of the core symptoms are present in all children. It is a very normal thing to be a kid and that involves a lot of random behaviors and spurts of likes and dislikes. The degree of the symptoms and the impairment they cause separates ADHD from ordinary exuberance. Symptom thresholds may not apply outside 4 to 16 year old range. The behavior of hyperactivity can be seen in 22% to 57% of children and only 4.2% to 6.3% meet criteria for the actual disorder. Parent reports are much lower than the reports by the teachers.

Gender and cultural differences in presentation

Regarding ratios of male to female, there have been assorted reports of ADHD ranging from 2:1 to 9:1. In other words, ADHD is seen two to four times more in boys than girls. Males are 2.6% to 5.6% time more likely to be diagnosed as females. Clinic referred samples have an even higher ratio due to co-morbid ODD/CD. Males and females tend to have the same functional deficits and impairments. Although recent studies have shown that children who express Inattentive Type ADHD symptoms are more likely to be female, experts are still debating whether prevalence rates indicate gender differences. ADHD is viewed differently across cultures. For example, some cultures view ADHD as it is described in the DSM-IV-TR. On the other hand, some cultures see it on a biological level and portray ADHD symptoms as character flaws. Studies show that Africa and the Middle East have lower prevalence rates of children diagnosed with ADHD than children diagnosed in North America.

Epidemiology

Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common childhood mental disorders. Prevalence rates of ADHD in school-aged children, according to the DSM-IV-TR, runs from three to seven percent of the total population. In other words, three to seven percent of school-aged children will be diagnosed with one of the three types of ADHD. The Hyperactive-Impulsive Type of ADHD consumes ninety percent of these children. This could be due to the fact that most children showing symptoms of the Inattentive Type of ADHD are undiagnosed because of their passive and subtle behavior. Children with ADHD usually experience academic problems as well. It is estimated that comorbid rates between ADHD and specific learning disabilities are anywhere from 16 to 21 percent. It is important to note that symptoms of childhood depression and Bipolar Disorder often overlap with symptoms of ADHD. For example, irritability is one of the most common symptoms of childhood depression. Irritability can cause problems concentrating, agitation, frequent squirming, etc. Studies show that 70 percent of depressed children and 90 percent of younger children and 30 percent of adolescent children with Bipolar Disorder have co-morbid ADHD. ADHD and externalizing disorders also have co-morbid rates. Studies show that co-morbid rates between children with ADHD and ODD (Oppositional Defiant Disorder) range from 35 to 60 percent. Also, almost half of the children diagnosed with ADHD will develop CD (Conduct Disorder) later in life. Studies show that hyperactive teens with ADHD are significantly more likely to use cigarettes and alcohol. Lastly, ADHD causes its inhabitants to develop problematic relationships with their peers. This can cause social anxiety along with many other problems. Anxiety symptoms resemble ADHD symptoms and most children with ADHD have sleeping problems.

ADHD fits the criterion such as engender substantial harm, and incur dysfunction of mechanisms that have been selected for survival value, and these back up ADHD’s realness or validity.

The earliest age at which a diagnosis of ADHD might be possible is about three years; symptoms of inattention are not likely to be noticed until much later. About two-thirds of of elementary school children diagnosed with ADHD have an additional diagnosable disorder. The course of this disorder is particularly prone to bad outcomes because of high rates of comorbidity with internalizing and externalizing disorders.

Etiology

The exact cause of ADHD is still debated among experts even though it is one of the most prevalent childhood disorders. The occurrence of ADHD is most likely due to a combination of environmental and biological factors. The biological factors pertain to abnormal brain activity and genetic factors. In children with ADHD, functional resonance imaging (FMRI) and single photon emission computed topography (SPECT) shows that the cingulate gyrus is more active. The cingulate gyrus is responsible for directing response selection and the ability to focus one’s attention. On the other hand, brain scans show that frontal brain activities are less frequent than normal. The frontal brain system is in charge of executive and motor functioning. Another area of abnormal brain activity for children with ADHD is neurotransmission. Studies show that these children have low levels of catecholamines (nor epinephrine, dopamine, and epinephrine). These neurotransmitters are responsible for motor activity and attention. In addition to abnormal brain activity, there are genetic factors in ADHD. Nearly 50 percent of parents who have ADHD have children with this disorder.

• There is much debate over the symptoms and name for what is now called or referred to as ADHD. Some other names and symptoms are explosive will, minimal brain dysfunction, volatile inhibition, and hyperactive child syndrome. In the DSM III, ADHD was called simply Attention Deficit Disorder.
• Evidence is mounting that the predominately inattentive type is a separate disorder such as a sluggish cognitive style, lower rates of co-morbidity with ODD and CD., memory retrieval problems, more passive social relationships and a different developmental course.
• As infants, children with difficult temperaments tend to be at greater risk for developing ADHD later in life.
• Other early risk factors include excessive activity, difficult sleeping (insomina), and irritability.

Empirically supported treatments

Treatments for ADHD can vary between patients according to their comorbid features. Recent studies show that stimulant medication is more effective in reducing the core symptoms of ADHD than behavior therapy. Given this, medication should still be a short-term fix. There are many forms of stimulant medication. For example, Ritalin (Methylphenidate) and Dexedrine are short-acting medications, Ritalin-SR is a slow release medication, and Ritalin-LA is a long-acting medication. Also, stimulant medications such as Ritalin, Cylert (Pemoline), and Dexedrine increase the number of neurotransmitters that ADHD inhibits.

Cylert (pemoline) is supplied as tablets containing 18.75 mg, 37.5 mg or 75 mg of pemoline for oral administration. Cylert is also available as chewable tablets containing 37.5 mg of pemoline. Cylert side effects cannot be anticipated. If any develop or change in intensity, inform your doctor as soon as possible. The most common Cylert side effect may include insomnia. Less common Cylert side effects may include depression, dizziness, drowsiness, hallucinations, headache, hepatitis and other liver problems, increased irritability, involuntary, fragmented movements of the face, eyes, lips, tongue, arms, and legs, loss of appetite, mild depression, nausea, seizures, skin rash, stomachache, suppressed growth, uncontrolled vocal outbursts, weight loss, and yellowing of skin or eyes. Rare Cylert side effects may include a rare form of anemia with symptoms such as bleeding gums, bruising, chest pain, fatigue, headache, nosebleeds, and abnormal paleness.

Methylphenidate or Ritalin is a central nervous system stimulant. It affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control. Methylphenidate is used to treat attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and narcolepsy. Methylphenidate may also be used for purposes not listed in this medication guide. If a child is taking Ritalin it should be taken 2 times a day; morning before breakfast and at night before dinner. Usually children start out at 6mg tablets and then can move up to at least 60mg a day. Ritalin should not be used in children under six years, since safety and efficacy in this age group have not been established. Sufficient data on safety and efficacy of long-term use of Ritalin in children are not yet available. Although a causal relationship has not been established, suppression of growth (ie, weight gain, and/or height) has been reported with the long-term use of stimulants in children. Therefore, patients requiring long-term therapy should be carefully monitored. Ritalin should be given cautiously to emotionally unstable patients, such as those with a history of drug dependence or alcoholism, because such patients may increase dosage on their own initiative. Chronically abusive use can lead to marked tolerance and psychic dependence with varying degrees of abnormal behavior. Frank psychotic episodes can occur, especially with parental abuse. Careful supervision is required during drug withdrawal, since severe depression as well as the effects of chronic over activity can be unmasked. Long-term follow-up may be required because of the patient’s basic personality disturbances.

The dose of **Dexedrine**® (**dextroamphetamine** sulfate) prescribed by your healthcare provider will vary depending on a number of factors, including: the condition being treated (**ADHD** or **narcolepsy**), your age, other medical conditions you may have, other medications you may be taking. As is always the case, do not adjust your dose unless your healthcare provider specifically instructs you to do so. Dexedrine Dosing for ADHD; refer to the following table for the Dexedrine dosing for children and teenagers with ADHD:

Generally, the lower dosage of Dexedrine should be tried first. The dosage should be increased slowly and only if necessary.

As with any medicine, there are possible side effects with **Dexedrine**® (**dextroamphetamine** sulfate). However, not everyone who takes this medicine will have problems. In fact, most people tolerate it well. When side effects do occur, in most cases they are minor, meaning they require no treatment or are easily treated by you or your healthcare provider. Most common side effects of Dexedrine include: overstimulation, restlessness, or **insomnia**, dizziness, **Headache**, dry mouth, unpleasant taste, **Diarrhea**, **Constipation**, loss of appetite and decreased eating, weight loss (see **Dexedrine and Weight Loss**), and **Erectile dysfunction** (**ED** or **impotence**) or changes in sex drive (see **Dexedrine Sexual Side Effects**). Dexedrine can also cause a temporary slowing of growth in children. This slowing of growth is usually small (less than an inch and less than two pounds), and children usually catch up to within normal limits in time.

There are behavioral benefits to stimulant medication too. Studies show that improvements in parent-child interactions and decreases in aggressive behaviors can result from stimulant medications. Studies also show that Parent Training Programs (PT) are effective in that they improve parenting skills while reducing parent stress. Behavior treatment is used and can show improvements in areas such as parent-child interactions, aggressive responses, and social skills. Given the above information, medication is still the most effective treatment for ADHD.

Critics

• Symptom thresholds may not apply outside 4-16 year old range.
• Research has found the following recommended levels for different age groups:
  • 4/9 and 5/9 for age 17-29.
  • 4/9 and 4/9 for age 30-49.
  • 3/9 and 3/9 for ages 50+.
  • No research on below age 4.
• Appropriateness of items sets for different ages and genders.
  • Inattention seem more geared for school-age or adolescents.
  • Hyper/Impulsive seem more applicable to younger children.
• Could influence rates of diagnosis across age groups, resulting in more false-negative as one gets older.
• Onset before age 7 not research supported.
  • No other mental disorder has a precise an age of onset.
• No lower-age or IQ boundary in DSM-IV-TR.
• No research support for symptom durationof 6 month; some support for a 12 month period.
• Requirement of impairment 2/3 environments.
  • Situational specificity
  • Lack of parent-teacher agreement
• Problems likely to be addressed in DSM-V, but can be used for more effective diagnosis now.
• Many critics of the realisy of ADHD, say that it is merely pathologizing normal behavior.
  • Includes Rush Limbaugh, Psylis Schafly, George Will, Ariana Huffington, Hillary Clinton, and even some actual scientists.
• If this is true, differences would not be found between ADHD and non-ADHD children.
  • Obviously not the case, 30 years of research on the differences.

The MTA study

The Multimodal Treatment Study of Children (MTS) with ADHD is the largest and most comprehensive study done on children with ADHD. A summary of the study is summarized by Dr. David Rabiner, Ph.D at the following link: MTA study.

Links

• Robert Jergen, author of Little Monster: Growing Up with ADHD and professor at the University of Wisconsin, tells about his life as an adult with ADHD:
  • “Dealing with ADHD as an Adult.” Talk of the Nation. National Public Radio. July 12, 2005.

Barkley’s model

• focuses on how behavioral disinhibition impacts four primary executive functions:
  • Poor working memory
  • Delayed interalization of speech
  • Immature regulation of affect/ motivation/ arousal
  • Impaired reconstitution

Barkley’s Assumptions

• Behavioral inhibition (BI) develops ahead of these four executive functions (EF).
• Each EF emerges at different times and has a different developmental trajectory.
• ADHD impairs the BI, which in turn impairs the EF.
• Deficit in BI due to biological factors.
• Deficits in self-regulation are caused by the primary BI, but in turn feed back to cause even poorer BI.
• Model does not apply to the inattentive type of ADHD.

• With approximately four million children in the United States it can be difficult to realize the individual nature of ADHD symptoms in children. Each child presents a unique case. See video http://www.youtube.com/watch?v=z2hLa5kDRCA.
• Journal article: Social cognition in ADHD.
• Journal article: Genetics of ADHD.
• A report done by CNN on the over diagnosis of ADHD: CNN report on ADHD.
• A satirical view of ADHD as shown on Comedy Centrals “The Daily Show”, with John Stewart but refer back to the previous information to see correct symptoms and diagnostic criteria for ADHD: Daily Show ADHD> .
• To learn more about the effects ADHD can have on children with peer interactions, click here.
• Below is a YouTUBE video of a young boy with ADHD. It shows how even though he has a mental illness he can still perform with music. ADHD does not affect this kid with his music ability.