What is ADHD?: A General Overview

David Rabiner, Ph.D. Research Professor, Duke University

      
       



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David Rabiner, Ph.D.
Duke University

(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?"

Because most individuals - especially children - display these behaviors from time to time, it can be difficult to differentiate behaviors that reflect ADHD from those that are a normal part of growing up. The key distinction is that for individuals with ADHD, problems with attention and/or hyperactivity/impulsivity are substantially more persistent, severe, and intense. There is a difference between an energetic child and one whose activity level causes persistent problems; between a friendly, talkative child and a child whose excessive talking is an ongoing source of difficulty; and between a child who sometimes has difficulty completing homework or chores and a child who requires constant monitoring and supervision to get things done. The difference is that for a child with ADHD these behaviors cause significant impairment in daily functioning. When such impairment is not evident, and the behaviors occur only occasionally, they are more likely to reflect typical childhood behavior.
 

"How come a child with ADHD can play Nintendo for hours but can't concentrate on homework for ten minutes?"

One perplexing aspect of ADHD is that a child's symptoms can vary considerably at different times and in different settings. For example, it is common for parents to wonder how their child can have ADHD when that child focuses intently when watching TV or playing Nintendo. Similarly, when engaged in free play activities, children with ADHD are often indistinguishable from their peers. In other settings, however, particularly those where activity must be restricted and attention sustained to tasks that seem uninteresting, the symptoms are quite evident. 

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?"

ADHD symptoms vary not only across settings but can also fluctuate dramatically within the same setting. Erratic performance at school and/or at home is quite common. Unfortunately, this can be misinterpreted as laziness or lack of motivation. After all, if a child can have one good day, doesn't that mean everyday can be a good one?

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?"

ADHD has certainly received lots of publicity in recent years and the question as to whether it is over diagnosed is an important one. When appropriate diagnostic criteria and procedures are used, however, it is found to occur in between 3 and 5% of school age children. It occurs more frequently in boys than in girls, with male to female ratios ranging from approximately 4:1 to 9:1 depending on the setting. ADHD is known to occur in various cultures and in individuals from all socioeconomic levels.

"What about other problems that go along with ADHD?"

In addition to the primary symptoms of inattention and/or hyperactivity/impulsivity, children with ADHD often display a number of other difficulties. These associated features will vary according to the child's age and may include low frustration tolerance, temper outbursts, bossiness, problems in peer relationships, depressed mood, and poor self esteem. Academic underachievement is very common, and the vast majority of children with ADHD will have trouble with school performance. Family relationships are often strained, sometimes because the variability in a child's symptoms leads parents to believe that their child's problematic behavior must be deliberate and willful.

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?"

At this point, no truly definitive statements about the cause of ADHD are possible. Based on currently available evidence, it appears that a variety of biological factors may predispose some children to have significant problems with attention and/or higher levels of activity and impulsivity. Specifically, recent evidence suggests that for individuals who develop ADHD, hereditary factors may affect brain functioning in those areas that are responsible for inhibiting and modulating behavior.

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?"

Until relatively recently it was widely believed that children with ADHD would outgrow their symptoms and behavioral difficulties by adolescence or early adulthood. Unfortunately, as data on the long term outcomes for children with ADHD has accumulated, it has become increasingly clear that this is often not the case. It is now believed that between 70-80% of children with ADHD will continue to exhibit significant deficits in attention and impulsivity relative to their same age peers during adolescence. Thus, even though the frequency and intensity of their symptoms may decline in an absolute sense, relative to their same age peers they continue to exhibit deficits. In the few studies in which children with ADHD have been followed into early adulthood, approximately 50% continued to evidence symptoms of the disorder, even though they may not still qualify for the formal diagnosis. Clearly, ADHD can influence an individuals development over many years, and it can no longer be considered to be a disorder of childhood alone.
 

"What treatments have been demonstrated to be effective in treating ADHD?"

In deciding on the types of treatment required by a child with ADHD, it is important to distinguish between the primary symptoms of inattention, hyperactivity, and impulsivity, and the associated problems such as academic struggles, disruptive behavior, social difficulties, and emotional problems such as depressed mood and low self esteem.

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?"

Despite the benefits summarized above, stimulant medication is no panacea and most children with ADHD - some would say all - will generally require additional treatments.

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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