David Rabiner, Ph.D. Research
Professor, Duke University
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David Rabiner, Ph.D.
(Note: If you are looking for information on Attention Deficit Disorder (ADD) please be aware that much of what is discussed below should also be relevant. Technically, the term ADD is no longer used. Instead, children who have the inattentive symptoms of ADHD but who do not show hyperactive/impulsive symptoms are now diagnosed with ADHD, Predominantly Inattentive Type rather than with ADD. These terms mean pretty much the same thing but the latter is no longer technically correct.)
What is ADHD: A General Overview
Attention Deficit Hyperactivity Disorder (ADHD) is a disorder characterized
by a persistent pattern of inattention and/or hyperactivity/impulsivity that
occurs in academic, occupational, or social settings. Problems with attention
include making careless mistakes, failing to complete tasks, problems staying
organized and keeping track of things, becoming easily distracted, etc. Problems
with hyperactivity can include excessive fidgetiness and squirminess, running
or climbing when it is not appropriate, excessive talking, and being constantly
on the go. Impulsivity can show up as impatience, difficulty awaiting one's
turn, blurting out answers, and frequent interrupting. Although many individuals
with ADHD display both inattentive and hyperactive/impulsive symptoms, some
individuals show symptoms from one group but not the other. For more detailed information on ADHD symptoms
and diagnostic criteria click here.
"But don't all children show these kinds of behaviors?"
"How come a child with ADHD can play Nintendo for hours but can't concentrate on homework for ten minutes?"
For children with ADHD, this variability in symptoms does not indicate
laziness or defiance (although these can be issues that must also be dealt
with). Instead, it demonstrates that ADHD symptoms are simply more likely
to be evident in some settings rather than others. Unfortunately, the classroom
is one setting where ADHD symptoms are very likely to be prominent, and sometimes
this explains the very different views that parents and teachers have of
the same child.
"Some days my child does real well at school, but other days are terrible. If he can do okay some times, why not all the time?"
An analogy may be useful here. Suppose you are a mediocre golfer and generally hack your way around the course in between 90 and 100 strokes. One day, however, for some inexplicable reason, you shoot a 78 and beat your best previous score by 10 strokes. For the rest of the summer, you're back in the 90's. Is this because you stopped concentrating or trying? Should your golf instructor get angry because you've shown that you are capable of much better play?
Although this analogy is far from perfect, it illustrates that our
performance fluctuates and that to expect peak performance all the time is
not realistic. Children with ADHD also show fluctuations in performance,
which are likely to be more dramatic and frequent. Their inability to perform
consistently at a level they demonstrate on occasion does not mean that they
must not be trying hard enough. In fact, Dr. Russell Barkley, one of the
world's leading authorities on ADHD, has argued that being unable to consistently
apply one's knowledge and ability to tasks (e.g. school work) over an extended
time period is an essential feature of ADHD. This does not mean that any child
who shows fluctuations in school performance has ADHD, as there can be a
variety of reasons for erratic performance. For children with ADHD, however,
this variability is common.
"It seems like any child with a behavior problems these days is called ADHD. Is ADHD really that common?"
"What about other problems that go along with ADHD?"
It is important to emphasize that these associated difficulties
are not symptoms of ADHD itself, that they can occur for a variety of reasons
besides ADHD, and that not all children with ADHD display them. It is incorrect,
as is sometimes done, to diagnose ADHD based on these associated problems
rather than on the primary symptoms of inattention and/or hyperactivity/impulsivity.
"What causes ADHD?"
Most experts in the field do not believe that dietary factors (e.g. artificial food colorings, sugar) cause ADHD, and in those well controlled studies in which such links have been examined, significant relationships have not been found. This does not mean, however, that the symptoms exhibited by some children may not be affected by dietary factors.
There is also little evidence to suggest that parenting practices
and family stress are important causal factors in the development of ADHD.
These factors may influence the severity of a child's symptoms, however.
This is important because it highlights the tremendously important role that
parents can play in helping to promote the successful development of their
child with ADHD.
"Do children outgrow ADHD? If a child has ADHD, what does that mean for their future?"
"What treatments have been demonstrated to be effective in treating ADHD?"
In regards to treating the core symptoms of inattention, hyperactivity, and impulsivity, it has been shown in numerous studies that stimulant medication provides significant benefit to approximately 80% of children with ADHD. The most commonly prescribed medication used to treat ADHD is Ritalin (the generic form is called methylphenidate), although a number of other stimulant medications are also used including Adderall, Dexedrine, and Cylert. Although the exact mechanism by which stimulant medication works is not known, available evidence suggests that it works by correcting a biochemical condition in the brain that interferes with attention and impulse control. For children who are not helped by stimulants, or who have symptoms of depression and/or anxiety in addition to ADHD, several types of anti-depressant medication have been demonstrated to be helpful.
The beneficial effects of stimulant medication treatment can be
dramatic, and for some children with ADHD it enables them to function at
a level that is no longer distinguishable from their classmates. The majority
of children who receive stimulant medication do not experience any adverse
side effects. Stimulant medication has been used to treat children with ADHD
for years, and is generally believed to be quite safe for long term use.
For additional information on the use
of medication in treating ADHD click here.
"What about treatments besides medication? Are you saying that all children with ADHD should be on medication?"
One very important treatment that has demonstrated efficacy when designed and implemented properly is behavioral therapy. Many excellent books have been written on this subject (I especially recommend Taking Charge of ADHD, by Dr. Russell Barkley) and these can help parents learn the specialized child management strategies that are often helpful and necessary in dealing with the challenges a child with ADHD can present.
Although the design of an individualized behavioral treatment plan is best done in cooperation with an experienced mental health professional, the basic principles are easy to understand. Behavioral treatment is based on the simple premise that specific behaviors will increase or decrease depending on the consequences they produce. Thus, a parent can increase their child's desirable behavior by providing positive consequences when such behavior occurs. Similarly, undesirable behavior can be reduced by making sure it results in a negative consequence (i.e. punishment). In theory, if these consequences are applied consistently, the child learns that good things result from good behavior, and bad things result from bad behavior. As a result, significant improvements in behavior should occur.
In practice, behavioral treatment is more difficult than this sounds. It is not easy for anyone to be entirely consistent, finding appropriate rewards and punishment is not always easy, and children sometimes do not seem to "obey" these simple laws of learning. In addition, children with ADHD often require frequent feedback and "consequences" for behavioral strategies to be successful. For example, a promised weekend reward for good behavior during the week may not work because it is too far in the future to be an effective motivator. Instead, rewards generally need to be delivered on a daily basis, or even more frequently, to motivate good behavior. For example, some behavioral programs that have been successful provide feedback and the opportunity to earn rewards every 15 minutes.
Because of the difficulties involved in using behavioral treatment effectively, it is recommended that parents to work with a skilled mental health professional to assist them in this important work. This is an essential aspect of treatment for many children with ADHD, and it can be extremely helpful in preventing the development of associated difficulties as the child grows older. To review more detailed information on behavioral treatment click here.
In addition to medical and behavioral treatments, additional interventions are often necessary. These will depend on the other difficulties a child is having. For example, if your child is struggling academically, specialized educational assistance may be required. Children who have difficulty making friends, as many children with ADHD unfortunately do, may require special assistance to learn how to develop better peer relationships. When emotional difficulties (e.g. depressed mood, poor self esteem) have developed in response to the struggles created by ADHD symptoms, individual counseling may be helpful and necessary.
The important principle is that the effective treatment and management of ADHD requires that all the problems a child is having get addressed. For some children, treating the primary symptoms via medication may also reduce any associated problems to the point where adjunctive interventions are not necessary. In many cases, however, problems will persist even when medication has been effective in reducing the primary ADHD symptoms. When this is the case, it is essential that these difficulties be targeted with additional treatments.
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