ATTENTION DEFICIT HYPERACTIVITY DISORDER

C. Some impairment from the symptoms is present in more than two or more settings (e.g. at school or work or at home)

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

The symptoms of ADHD may vary considerably between home and school, in structured versus nonstructured settings, large versus small groups and situations having high versus low performance demands. For example, a child with ADHD has difficulty concentrating when faced with routine, monotonous activities but has no problem when engaged in certain activities of his/her choice like watching TV, or playing Nintendo. Most children with ADHD have difficulty concentrating on many activities that other children enjoy, e.g. colouring, pasting and puzzles. Children with ADHD may also exhibit any of the following: free flight of ideas, difficulty feeling satisfied, social immaturity, performance inconsistency, and mood swings.

There is now evidence that ADHD without hyperactivity, also known as Undifferentiated Attention Deficit Disorder (UADD) is a discrete entity. These children function with a slower cognitive speed and appear more confused, apathetic, and lethargic and more likely to be depressed than are children who have ADHD with hyperactivity (ADHD+H). They also are identified later when they begin to fall behind academically in later primary grades. Children with ADHD+H are described as being more noisy, disruptive, messy, irresponsible, and immature and have more problems with peer relationships.

Academic Problems and Learning Disabilities

25% to 30% of ADHD children have a learning disability. Despite normal or even superior intelligence, the ADHD child is often a chronic underachiever. By adolescence up to one-third of ADHD children have failed at least one grade in school.

Speech and Language Disorders

Many ADHD children have language disorders, most prominently found in expressive language. They may have limited vocabularies, word-finding difficulties and poor grammar. Some psychologists feel language development is also linked to the development of self-control, as children use inner language to help them monitor behaviour.

Psychiatric Disorders

As many as 50% to 65% of ADHD children have at least one additional psychiatric disorder. Additional diagnoses frequently include Oppositional Defiant Disorder and Conduct Disorder. The greatest risks for those who develop serious antisocial behaviour during adolescence are those who come from dysfunctional families involving alcoholism, drug abuse, and violence. Problems with poor self esteem are common and 25% to 33% of ADHD children experience at least one episode of major depression during their childhood years. Anxiety disorders resulting in fears and worries also occur in up to 25% of ADHD children.

The cause of ADHD is unknown. However, there is evidence that the frontal lobes of the brain may have a role in ADHD. The frontal lobes have long been known to play a critical role in regulating attention, activity, and emotional reactions. Studies have shown decreased blood flow in the frontal areas of children with ADHD. It has also been shown using a "PET scan," that adults with ADHD have reduced brain glucose metabolism in the frontal lobes of the brain, compared to non-ADHD individuals, when told to concentrate on a task. It is felt that this pattern of underactivity is due to abnormalities in the neurotransmitters (chemical messengers) in the frontal areas. Stimulant medication is postulated to compensate for the neurotransmitter abnormalities, since ADHD subjects show increased activity in these frontal areas when treated with stimulant medication.

Heredity plays a role in ADHD since ADHD children are 4 times as likely to have close family members with the same problem. Also identical twins are more likely to share ADHD than fraternal twins or other siblings.

Birth injuries associated with fetal distress and difficult labour play a negligible role in ADHD. However, damage prior to birth, may play a role. Mothers who abuse drugs or alcohol during pregnancy have children who suffer from ADHD and learning disabilities.

Environmental toxins, including lead, and artificial flavors, dyes, preservatives and other food additives have been claimed by some to be the primary cause of ADHD. Drs. Benjamin Feingold, Lendon Smith, and Doris Rapp have been advocates of sugar, food allergy and food additives causing ADHD. Anecdotal evidence and testimonials have been used by the above to back their claims, however double-blind controlled studies have shown these not to be important causes. Recent research has shown, however, that in a select group of children, food allergies and sensitivities to food dyes may contribute to behavioural problems and physical symptoms, although no differences were noticed in psychological test scores. Some of these studies involved preschool children with ADHD and known allergies or sensitivities to certain foods. Avoidance of these resulted in behavioural improvement as well as improvement in headaches, runny nose, and sleep problems. In neither study were these children representative of ADHD children in general.

There is no single diagnostic test that definitively makes the diagnosis of ADHD. Instead, the diagnosis involves the collection of information from a variety of sources.

A history of long-standing problems with attention, impulsivity and hyperactivity is the best source of information concerning ADHD. Because of the situation-specific nature of these symptoms, the physician should obtain separate accounts of behaviour from parents and teachers. Reports from teachers concerning the child’s ability to finish work, stay on task, and respect others are important. As well, because of the association of ADHD and learning difficulties, reports from teachers may help assess the level of academic achievement and general intelligence. In many cases, behavioural therapies and a trial of medication (discussed below) may result in significant improvement in the child’s behaviour and school performance. If this does not occur, then referral to other specialists may be necessary. A referral to an educational psychologist may be necessary to exclude learning disabilities. Speech and language assessment may be necessary if one suspects a communication problem. Examination of the child’s emotional status may be necessary to rule out depression and anxiety disorders and to distinguish ADHD from other disruptive behaviour disorders such as conduct disorder and oppositional defiant disorder. A medical examination is necessary to rule out visual and hearing problems because attention and memory may be impaired further by any sensory deficits.

Various rating scales have been used to assess behaviour at home and in school. The Conners Teacher Rating Scale rates children on several aspects of behaviour as does the ADDH Comprehensive Teacher Rating Scale (ACTeRS) which allows for separate evaluation of four areas of child behaviour. These scales are helpful in making an initial diagnosis and in monitoring response to treatment. There are also performance tests to assess a child’s ability to sustain and focus attention, as well as his/her ability to refrain from responding impulsively. These include the Matching Familiar Figures Test and the Continuous Performance Test. These tests provide useful information but the results are not infallible and therefore should be interpreted in the context of all available information.

The goals of therapy of ADHD are to improve the child’s functioning at home, in school and with peers through the modification of his/her inattention, impulsivity and hyperactivity. In addition one tries to maximize cognitive functioning, social and behaviour skills, and self esteem with minimal side effects.

The long-term outcome of ADHD has shown to be improved most when one uses a combination of education, medication, psychological treatments, and appropriate classroom intervention.

The first step in treatment is for the family and child to obtain comprehensive, accurate information from their doctor, about ADHD, associated problems and their treatments. Parental support groups such as CHADD (Children with Attention Deficit Disorders) and ADDA (Attention Deficit Disorders Association) provide important educational and support services to parents. They allow parents a forum in which to discuss problems, provide emotional support, and share effective ways to deal with schools, doctors and service institutions.

Medication

Stimulants such as Ritalin (the most commonly used stimulant), Dexedrine and Pemoline are the first choice of medications for children with ADHD. Numerous studies have shown they are effective in over 70% of ADHD children. If a child fails to respond to one of these drugs, 70% of these nonresponders will respond to a second stimulant. Stimulant medication do not sedate the ADHD child but it helps him/her focus his/her attention, control his/her impulsive behaviour and regulate his/her activity level. Stimulants are felt to act as a neurotransmitter in certain areas of the brain, correcting a biochemical condition which interferes with attention and impulse control. Often within the first hour after starting treatment, one can see a change in handwriting, talking, attention, improvement in inappropriate activity, non-compliance, and academic performance.

Stimulant medications have been shown in many studies to be quite safe and side effects are minimal and mild. Side effects most commonly seen are insomnia, loss of appetite, and weight loss. Other less common side effects include sadness, depression, fearfulness, social withdrawal, sleepiness, headaches, nail biting, and stomach aches. All side effects are short-term and the majority disappear with a lowering in drug dosage. Long term studies have found that children treated with stimulant medication do not become addicted, nor does it lead to illegal drug use in later years. Studies have also shown that stimulant may cause some suppression of growth during the first year or two of treatment, but this is a transient problem and any ultimate effects on adult height are minimal. Stimulant drugs are effective in adolescents and adults with ADHD, even though the dosage is the same as in older children.

Tricyclic antidepressants, such as Imipramine and Desipramine can produce improvement in over 70% of ADHD children. Improvements in behaviour are usually more prominent than improvements in attention. It is felt that tricyclics also act as neurotransmitters but work by improving mood, impulsivity, and frustration tolerance.
Common side effects include dry mouth, constipation and drowsiness. Rarely, heart arrhythmias have been reported in children taking tricyclics, so an electrocardiogram (EKG) should be monitored regularly by a physician. Generally, tricyclics are used as a second line of drug therapy for ADHD children who don’t benefit from Ritalin or develop side effects when on stimulant medication. It is the first drug of choice in those who have depression or anxiety associated with ADHD. It may also be used in children with ADHD who have tics or Tourette syndrome.

Clonidine is a blood pressure medication that has been found to decrease overactivity, aggression and impulsivity in about 50% of ADHD children. Clonidine does not improve distractibility but may be used in combination with Ritalin. Clonidine takes about two weeks for any improvement to be seen and its most common side effect is drowsiness, which is usually short-lived. As with tricyclics, clonidine should never be discontinued abruptly but should be carefully tapered.

A variety of psychological and behavioural therapies, alone and in combination, have been used in treating ADHD with varying degrees of success. The aim of these therapies is to modify the associated problems such as oppositional-defiant behaviour and conduct problems.

This training provides a variety of management strategies for the behavioural problems seen in ADHD children. Problems such as noncompliance, defiance and aggression are treated by methods outlined previously for the oppositional-defiant and aggressive child. This training can be offered for individuals or in groups and involves direct instruction, modelling, role playing and discussion. This training has been shown to be moderately effective in helping parents manage and change behaviour in ADHD children.

Family therapy deals with a variety of approaches to family skills training. This includes problem solving, open and effective communication skills, anger management or conflict resolution.

Many well-conducted studies have proved that behaviour modification in the classroom improves classroom behaviour and academic productivity.The procedures used in the classroom are similar to those strategies parents learn in parent training (e.g. praise and reinforcement, aggression management).The ideal classroom for the ADHD child is a highly structured and well organized class, with clear expectations and a predictable schedule. The child should be seated near the teacher and away from windows and other distractions. Because he/she works slowly, he/she should be allowed extra time to complete tests and assignments. Additionally, the amount of written work could be reduced until such time that the child is better able to cope. A daily homework planner will help develop organizational and time management skills. Communication with teachers is important in order to monitor academic progress.

The goal of this training is to help the ADHD child deal with impulsive behaviour. The child is taught to solve a problem by saying to himself, "Stop, decide possible plans of action, do the plan, evaluate the success of the plan." Both parents and teachers must help the child by modelling, promoting and encouraging the use of problem solving. Used alone, this type of training is not as effective as stimulant therapy or behaviour modification programs.

This training involves instruction about recognizing anger signals, and using techniques like relaxation methods and coping self-statements to cope with the anger.

This is helpful for children who have poor social skills and experience peer relation difficulties. The child is taught pragmatic skills such as maintaining eye contact, initiating and maintaining conversation, and cooperating.

Those children who have learning disabilities will require individual remedial education to optimize their learning. Decisions, by parents and educators, will have to be made about the optimal classroom placement for these children. This process generally occurs through an IPRC (Individual Placement and Review Committee) at the child’s school.

Many nonstandard therapies have been tried for ADHD and learning disorders. Although few of these treatments are harmful, most of these are unproved in having any benefit.

Long-term studies have shown that 40% to 60% of children who have ADHD still have symptoms into adulthood. Untreated adults have an increased incidence of aggressive behaviour, anti-social personality disorder, conduct disorder, depression, divorce, school drop-out and alcohol and drug abuse. Adult ADHD is now being recognized more frequently and treated with similar medications as children.

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