What is ADHD?
ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for a child’s age and development.(Source:http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/)
HistoryMain article: History of attention-deficit hyperactivity disorder Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes “mental restlessness” in his book An Inquiry Into the Nature and Origin of Mental Derangement written in 1798. The terminology used to describe the symptoms of ADHD has gone through many changes over history including: “minimal brain damage”, “minimal brain dysfunction” (or disorder), “learning/behavioral disabilities” and “hyperactivity”. In the DSM-II (1968) it was the “Hyperkinetic Reaction of Childhood”. In the DSM-III “ADD (Attention-Deficit Disorder) with or without hyperactivity” was introduced. In 1987 this was changed to ADHD in the DSM-III-R and subsequent editions. The use of stimulants to treat ADHD was first described in 1937. (Source: http://en.wikipedia.org/wiki/Attention_deficit_hyperactivity_disorder#Cause)
Symptoms of ADHD
1. Lack of attention (inattentiveness)
- Inability to pay attention to details or a tendency to make careless errors in schoolwork or other activities
- Difficulty with sustained attention in tasks or play activities
- Apparent listening problems
- Difficulty following instructions
- Problems with organization
- Avoidance or dislike of tasks that require mental effort
- Tendency to lose things like toys, notebooks, or homework
- Is easily distracted
- Is often forgetful in daily activities
- Forgetfulness in daily activities
2. Hyperactive-impulsive type
- Fidgeting or squirming
- Difficulty remaining seated
- Excessive running or climbing
- Difficulty playing quietly
- Always seeming to be “on the go”
- Excessive talking
- Dlurting out answers before hearing the full question
- Difficulty waiting for a turn or in line
- Problems with interrupting or intruding
3. Combined type
- Which involves a combination of the other two types and is the most common
Signs and tests
Too often, difficult children are incorrectly labeled with ADHD. On the other hand, many children who do have ADHD remain undiagnosed. In either case, related learning disabilities or mood problems are often missed. The American Academy of Pediatrics (AAP) has issued guidelines to bring more clarity to this issue.
The diagnosis is based on very specific symptoms, which must be present in more than one setting.
- Children should have at least 6 attention symptoms or 6 hyperactivity/impulsivity symptoms, with some symptoms present before age 7.
- The symptoms must be present for at least 6 months, seen in two or more settings, and not caused by another problem.
- The symptoms must be severe enough to cause significant difficulties in many settings, including home, school, and in relationships with peers.
In older children, ADHD is in partial remission when they still have symptoms but no longer meet the full definition of the disorder.
The child should have an evaluation by a doctor if ADHD is suspected. Evaluation may include:
- Parent and teacher questionnaires (for example, Connors, Burks)
- Psychological evaluation of the child AND family, including IQ testing and psychological testing
- Complete developmental, mental, nutritional, physical, and psychosocial examination
Causes of ADHD
Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75 percent of all cases. Hyperactivity also seems to be primarily a genetic condition; however, other causes have been identified.
Researchers believe that a large majority of ADHD cases arise from a combination of various genes, many of which affect dopamine transporters. Candidate genes include DAT1, DRD4, DRD5,5HTT, HTR1B, and SNAP25. There is also strong heterogeneity for the associations between ADHD and DAT1, DRD4, DRD5, dopamine beta hydroxylase, ADRA2A, 5HTT, TPH2, MAOA, andSNAP25. A common variant of a gene called LPHN3 is estimated to be responsible for about 9% of the incidence of ADHD, and ADHD cases where this gene is present are particularly responsive to stimulant medication.Evolution
As ADHD is more common than 1 percent of the population, researchers have proposed that due to the high prevalence of ADHD that natural selection has favoured ADHD possibly because the individual traits may be beneficial on their own, and only become dysfunctional when these traits combine to form ADHD. The high prevalence of ADHD may in part be because women in general are more attracted to males who are risk takers, thereby promoting ADHD in the gene pool.
Further evidence showing hyperactivity may be evolutionarily beneficial was put forth in 2006 in a study that found it may carry specific benefits for certain forms of society. In these societies, those with ADHD are hypothesized to have been more proficient in tasks involving risk, competition, and/or unpredictable behavior (i.e. exploring new areas, finding new food sources, etc.), where these societies may have benefited from confining impulsive or unpredictable behavior to a small subgroup. In these situations, ADHD would have been beneficial to society as a whole even while severely detrimental to the individual.More recent research suggests that because ADHD is more common in mothers who are anxious or stressed that ADHD is a mechanism of priming the child with the necessary traits for a stressful or dangerous environment, such as increased impulsivity and explorative behaviour etc. A genetic variant associated with ADHD (DRD4 48bp VNTR 7R allele) has been found to be at higher frequency in more nomadic populations and those with more of a history of migration. Consistent with this, another group of researchers observed that the health status of nomadic Ariaal men was higher if they had the ADHD associated genetic variant (7R alleles). However in recently sedentary (non-nomadic) Ariaal those with 7R alleles seemed to have slightly worse health.
ADHD is predominantly a genetic disorder with environmental factors contributing a small role to the etiology of ADHD. Twin studies have shown that ADHD is largely genetic with 76 percent of the phenotypic variance being explained by inherited genetic factors.Alcohol intake during pregnancy can cause the child to have a fetal alcohol spectrum disorder which can include symptoms similar to ADHD. Exposure to tobacco smoke during pregnancy impairs normal development of the feotus including the central nervous system and can increase the risk of the child being diagnosed with ADHD. Many children exposed to tobacco do not develop ADHD or else only have mild symptoms which do not reach the threshold of a diagnosis of ADHD. A combination of a genetic vulnerability to developing ADHD as well as the toxic developmental effects of tobacco on the foetus explain why some children exposed to tobacco smoke in uterodevelop ADHD and others don’t. Children exposed to lead, even relatively low levels of lead develop neurocognitive deficits which resemble ADHD and these children can fufil the diagnostic criteria for ADHD. There is also some evidence that exposure to polychlorinated biphenyls during childhood causes developmental damage and can cause ADHD type symptoms which are the diagnosed as ADHD. Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk of ADHD. However, the evidence is not definitive as 5 of 17 studies failed to find an association.
Very low birth weight, premature birth and exceptional early adversity increase the risk of the child having ADHD. At least 30 percent of children who experience a paediatric traumatic brain injury develop ADHD. Infections during pregnancy, at birth, and in early childhood are linked to an increased risk of developing ADHD. These include various viruses (measles, varicella, rubella, enterovirus 71) and streptococcal bacterial infection.
Concerns were first raised by Benjamin Feingold, a paediatric allergist that food colourings and additives may effect children’s behaviour in 1973. There has is evidence suggesting that some food colourings may make some children hyperactive. However, the evidence for a link between food colourings and hyperactive behaviour remains uncertain. The FDA interpreted the evidence as being inconclusive as to whether food colours caused hyperactivity or not. The FDA review of food colours has been criticised for only doing a very narrow investigation into food colourings and their possible association with causing hyperactivity instead of investigating their possible effect on neurobehaviour in general.The U.K, followed by the European Union took regulatory action on food colourings due to concerns about their possible adverse effects in children. It is possible that certain food colourings act as a trigger for ADHD symptoms in subgroup of children who have a genetic vulnerability. According to the Food Standards Agency, the food regulatory agency in the UK, food manufacturers were encouraged to voluntarily phase out the use of most artificial food colors by the end of 2009. Sunset yellow FCF (E110), quinoline yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124) are collectively called the “Southampton six”. Following the FSA’s actions, the European Commission ruled that any food products containing the contentious colourings must display warning labels on their packaging by 2010.
The World Health Organization states that the diagnosis of ADHD can represent family dysfunction or inadequacies in the educational system rather than individual psychopathology. Other researchers believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities. A study of foster children found that a high number of them had symptoms closely resembling ADHD. Researchers have found behavior typical of ADHD in children who have suffered violence and emotional abuse. Furthermore, Complex Post Traumatic Stress Disorder can result in attention problems that can look like ADHD. ADHD is also considered to be related to sensory integration dysfunction. A 2010 article by CNN suggests that there is an increased risk for internationally adopted children to develop mental health disorders, such as ADHD and ODD.
Treating ADHD is a partnership between the health care provider, parents or caregivers, and the child. For therapy to succeed, it is important to:
- Set specific, appropriate target goals to guide therapy.
- Start medication and behavior therapy.
- Follow-up regularly with the doctor to check on goals, results, and any side effects of medications. During these check-ups, information should be gathered from parents, teachers, and the child.
If treatment does not appear to work, the health care provider should:
- Make sure the child indeed has ADHD
- Check for other, possible medical conditions that can cause similar symptoms
- Make sure the treatment plan is being followed
A combination of medication and behavioral treatment works best. There are several different types of ADHD medications that may be used alone or in combination.
Psychostimulants (also known as stimulants) are the most commonly used ADHD drugs. Although these drugs are called stimulants, they actually have a calming effect on people with ADHD.
These drugs include:
- Amphetamine-dextroamphetamine (Adderall)
- Dexmethylphenidate (Focalin)
- Dextroamphetamine (Dexedrine, Dextrostat)
- Lisdexamfetamine (Vyvanse)
- Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)
A nonstimulant drug called atomoxetine (Strattera) may work as well as stimulants, and may be less likely to be misused.
Some ADHD medicines have been linked to rare sudden death in children with heart problems. Talk to your doctor about which drug is best for your child.
Research has shown that medications used to help curb impulsive behavior and attention difficulties are more effective when combined with behavioral therapy.
Behavioral therapy attempts to change behavior patterns by:
- reorganizing a child’s home and school environment
- giving clear directions and commands
- setting up a system of consistent rewards for appropriate behaviors and negative consequences for inappropriate ones
Here are examples of behavioral strategies that may help a child with ADHD:
- Create a routine. Try to follow the same schedule every day, from wake-up time to bedtime. Post the schedule in a prominent place, so your child can see what’s expected throughout the day and when it’s time for homework, play, and chores.
- Get organized. Put schoolbags, clothing, and toys in the same place every day so your child will be less likely to lose them.
- Avoid distractions. Turn off the TV, radio, and computer games, especially when your child is doing homework.
- Limit choices. Offer a choice between two things (this outfit, meal, toy, etc., or that one) so that your child isn’t overwhelmed and overstimulated.
- Change your interactions with your child. Instead of long-winded explanations and cajoling, use clear, brief directions to remind your child of responsibilities.
- Use goals and rewards. Use a chart to list goals and track positive behaviors, then reward your child’s efforts. Be sure the goals are realistic (think baby steps rather than overnight success).
- Discipline effectively. Instead of yelling or spanking, use timeouts or removal of privileges as consequences for inappropriate behavior. Younger kids may simply need to be distracted or ignored until they display better behavior.
- Help your child discover a talent. All kids need to experience success to feel good about themselves. Finding out what your child does well — whether it’s sports, art, or music — can boost social skills and self-esteem.
Currently, the only ADHD therapies that have been proven effective in scientific studies are medications and behavioral therapy. But your doctor may recommend additional treatments and interventions depending on your child’s symptoms and needs. Some kids with ADHD, for example, may also need special educational interventions such as tutoring, occupational therapy, etc. Every child’s needs are different.
A number of other alternative therapies are promoted and tried by parents including: megavitamins, body treatments, diet manipulation, allergy treatment, chiropractic treatment, attention training, visual training, and traditional one-on-one “talking” psychotherapy. However, scientific research has not found them to be effective, and most have not been studied carefully, if at all.
Parents should always be wary of any therapy that promises an ADHD “cure.” If you’re interested in trying something new, speak with your doctor first.Parent Training
Parenting a child with ADHD often brings special challenges. Kids with ADHD may not respond well to typical parenting practices. Also, because ADHD tends to run in families, parents may also have some problems with organization and consistency themselves and need active coaching to help learn these skills.
Experts recommend parent education and support groups to help family members accept the diagnosis and to teach them how to help kids organize their environment, develop problem-solving skills, and cope with frustrations. Training can also teach parents to respond appropriately to a child’s most trying behaviors with calm disciplining techniques. Individual or family counseling can also be helpful.
Video “ADHD and the Brain”
Video “What Is Attention Deficit Hyperactivity Disorder (ADHD)? “