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Identifying and Treating Attention Deficit Hyperactivity Disorder

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By American Institutes for Research

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We have all had one of these experiences at one time or another. Perhaps it was at the grocery store, watching frustrated parents call their children's names repeatedly and implore them to 'put that down.' Maybe it was a situation at school with a child who could not seem to sit still and was always in motion. Maybe we noticed a child who appears always to be daydreaming in class—the student who will not focus on an activity long enough to finish it. Possibly the child is bored with a task, seemingly as soon as it has begun, and wants to move on to something else. We all puzzle over these challenging behaviors.

Attention Deficit Hyperactivity Disorder (ADHD) has many faces and remains one of the most talked-about and controversial subjects in education. Hanging in the balance of heated debates over medication, diagnostic methods, and treatment options are children, adolescents, and adults who must manage the condition and lead productive lives on a daily basis.

What is ADHD?

Attention Deficit Hyperactivity Disorder (ADHD) is a neurological condition that involves problems with inattention and hyperactivity-impulsivity that are developmentally inconsistent with the age of the child. We are now learning that ADHD is not a disorder of attention, as had long been assumed. Rather, it is a function of developmental failure in the brain circuitry that monitors inhibition and self-control. This loss of self-regulation impairs other important brain functions crucial for maintaining attention, including the ability to defer immediate rewards for later gain (Barkley, 1998a). Behavior of children with ADHD can also include excessive motor activity. The high energy level and subsequent behavior are often misperceived as purposeful noncompliance when, in fact, they may be a manifestation of the disorder and require specific interventions. Children with ADHD exhibit a range of symptoms and levels of severity. In addition, many children with ADHD often are of at least average intelligence and have a range of personality characteristics and individual strengths.

Children with ADHD typically exhibit behavior that is classified into two main categories: poor sustained attention and hyperactivity-impulsiveness. As a result, three subtypes of the disorder have been proposed by the American Psychiatric Association in the fourth edition of the Diagostic and Statistical Manual of Mental Disorders (DSM-IV): predominantly inattentive, predominantly hyperactive-impulsive, and combined types (Barkley, 1997). A child expressing hyperactivity commonly will appear fidgety, have difficulty staying seated or playing quietly, and act as if driven by a motor. Children displaying impulsivity often have difficulty participating in tasks that require taking turns. Other common behaviors may include blurting out answers to questions instead of waiting to be called and flitting from one task to another without finishing. The inattention component of ADHD affects the educational experience of these children because ADHD causes them to have difficulty in attending to detail in directions, sustaining attention for the duration of the task, and misplacing needed items. These children often fail to give close attention to details, make careless mistakes, and avoid or dislike tasks requiring sustained mental effort.

Although these behaviors are not in themselves a learning disability, almost one-third of all children with ADHD have learning disabilities (National Institute of Mental Health [NIMH], 1999). Children with ADHD may also experience difficulty in reading, math, and written communication (Anderson, Williams, McGee, & Silva, 1987; Cantwell & Baker, 1991; Dykman, Akerman, & Raney, 1994; Zentall, 1993). Furthermore, ADHD commonly occurs with other conditions. Current literature indicates that approximately 40-60 percent of children with ADHD have at least one coexisting disability (Barkley, 1990a; Jensen, Hinshaw, Kraemer, et al., 2001; Jensen, Martin, & Cantwell, 1997). Although any disability can coexist with ADHD, certain disabilities seem to be more common than others. These include disruptive behavior disorders, mood disorders, anxiety disorders, tics and Tourette’s Syndrome, and learning disabilities (Jensen, et al., 2001). In addition, ADHD affects children differently at different ages. In some cases, children initially identified as having hyperactive-impulsive subtype are subsequently identified as having the combined subtype as their attention problems surface.

These characteristics affect not only the academic lives of students with ADHD, they may affect their social lives as well. Children with ADHD of the predominantly hyperactive-impulsive type may show aggressive behaviors, while children of the predominantly inattentive type may be more withdrawn. Also, because they are less disruptive than children with ADHD who are hyperactive or impulsive, many children who have the inattentive type of ADHD go unrecognized and unassisted. Both types of children with ADHD may be less cooperative with others and less willing to wait their turn or play by the rules (NIMH, 1999; Swanson, 1992; Waslick & Greenhill, 1997). Their inability to control their own behavior may lead to social isolation. Consequently, the children’s self-esteem may suffer (Barkley, 1990a).

In the United States, an estimated 1.46 to 2.46 million children (3 percent to 5 percent of the student population) have ADHD (American Psychiatric Association, 1994; Anderson, et al., 1987; Bird, et al., 1988; Esser, Schmidt, & Woemer, 1990; Pastor & Reuben, 2002; Pelham, Gnagy, Greenslade, & Milich, 1992; Shaffer, et al., 1996; Wolraich, Hannah, Pinock, Baumgaertel, & Brown, 1996). Boys are four to nine times more likely to be diagnosed, and the disorder is found in all cultures, although prevalence figures differ (Ross & Ross, 1982).

What Causes ADHD?

ADHD has traditionally been viewed as a problem related to attention, stemming from an inability of the brain to filter competing sensory inputs such as sight and sound. Recent research, however, has shown that children with ADHD do not have difficulty in that area. Instead, researchers now believe that children with ADHD are unable to inhibit their impulsive motor responses to such input (Barkley, 1997; 1998a).

It is still unclear what the direct and immediate causes of ADHD are, although scientific and technological advances in the field of neurological imaging techniques and genetics promise to clarify this issue in the near future. Most researchers suspect that the cause of ADHD is genetic or biological, although they acknowledge that the child’s environment helps determine specific behaviors.

Imaging studies conducted during the past decade have indicated which brain regions may malfunction in patients with ADHD, and thus account for symptoms of the condition (Barkley, 1998a). A 1996 study conducted at the National Institutes for Mental Health (NIMH) found that the right prefrontal cortex (part of the cerebellum) and at least two of the clusters of nerve cells known collectively as the basal ganglia are significantly smaller in children with ADHD (as cited in Barkley, 1998a). It appears that these areas of the brain relate to the regulation of attention. Why these areas of the brain are smaller for some children is yet unknown, but researchers have suggested mutations in several genes that are active in the prefrontal cortex and basal ganglia may play a significant role (Barkley, 1998a). In addition, some nongenetic factors have been linked to ADHD including premature birth, maternal alcohol and tobacco use, high levels of exposure to lead, and prenatal neurological damage. Although some people claim that food additives, sugar, yeast, or poor child rearing methods lead to ADHD, there is no conclusive evidence to support these beliefs (Barkley, 1998a; Neuwirth, 1994; NIMH, 1999).

How Do We Identify ADHD?

Although toddlers and preschoolers, on occasion, may show characteristics of ADHD, some of these behaviors may be normal for their age or developmental stage. These behaviors must be exhibited to an abnormal degree to warrant identification as ADHD. Even with older children, other factors (including environmental influences) can produce behaviors resembling ADHD.

The criteria set forth by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are used as the standardized clinical definition to determine the presence of ADHD (see DSM-IV Criteria for ADHD). A person must exhibit several characteristics to be clinically diagnosed as having ADHD:
Severity. The behavior in question must occur more frequently in the child than in other children at the same developmental stage.
Early onset. At least some of the symptoms must have been present prior to age 7.
Duration. The symptoms must also have been present for at least 6 months prior to the evaluation.
Impact. The symptoms must have a negative impact on the child’s academic or social life.
Settings. The symptoms must be present in multiple settings.

The specific DSM-IV criteria are set forth in the following chart.

DSM-IV Criteria for Attention Deficit/Hyperactivity Disorder

  1. According to the DSM-IV, a person with Attention Deficit/Hyperactivity Disorder must have either (1) or (2):
    1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
      Inattention
      1. often fails to give close attention to details or makes careless mistakes in school work, 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 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 difficulty organizing tasks and activities
      6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
      7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
      8. is often easily distracted by extraneous stimuli
      9. is often forgetful in daily activities
    2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
      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 (in adolescents or adults, may be limited to subjective feelings or 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
      7. often blurts out answers before questions have been completed
      8. often has difficulty awaiting turn
      9. often interrupts or intrudes on others (e.g., butts into conversations or games)
  2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
  3. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
  4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
  5. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Disassociative Disorder, or a Personality Disorder).
    Attention Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months.

Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months.

Attention Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months.

Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Washington, DC, American Psychiatric Association, 1994.

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