Understanding AD/HD

Attention deficit hyperactivity disorder (AD/HD) is a commonly diagnosed behavioral disorder in childhood. Children with AD/HD may know what to do, but they are not always able to do it because of an inability to focus, impulsivity, or distractibility.

Estimated to affect about 5% of American children, AD/HD can create problems for children at home, in school, and in their peer relationships. The disorder may also have a long-term adverse impact on their later academic, behavior, social lives, and emotional well being.

What Are the Symptoms and Signs?

Symptoms of AD/HD include developmentally inappropriate levels of activity, distractibility, and impulsivity. Children with AD/HD often cannot sit still or pay attention in class. The behavior often leads to academic and social problems.

According to the National Institute of Mental Health, 2 to 3 times more boys than girls are affected by this disorder, although the reason for this difference is, as of yet, unclear.

The American Psychiatric Association's Diagnostic and Statistics Manual (DSM-IV) recently renamed the disorders formerly known as ADD and ADHD to be AD/HD. AD/HD includes three subtypes:

1.        A predominantly inattentive subtype (formerly attention deficit disorder, or ADD). Signs include becoming easily distracted by irrelevant sights and sounds; failing to pay attention to details and making careless mistakes; rarely following instructions carefully and completely; losing or forgetting things like toys, pencils, books, and tools needed for a task.

2.      A predominantly hyperactive-impulsive subtype (formerly attention deficit hyperactivity disorder, or ADHD). Signs include feeling restless, fidgeting and squirming; running, climbing, leaving a seat in situations where sitting or quiet behavior is expected; blurting out answers before hearing the entire question; and having difficulty waiting in line or for a turn.

3.      A combined subtype, which is the most common of the three. AD/HD refers to all types of attention deficit disorders, both with and without hyperactivity.

To be considered for a diagnosis of AD/HD, these behaviors must appear before age 7 and last for at least 6 months. The level of disturbance must occur more frequently and in a more severely pronounced manner than among other children in the same age group. And above all, these behaviors must create a real handicap in at least 2 areas of a child's life, such as school, home, or a social setting.

Any possible problems your child is having with his vision or hearing should be ruled out before diagnosing AD/HD.

Does It Coexist With Other Disorders?

An added difficulty in diagnosing AD/HD is that it often coexists with other problems.

Many children with AD/HD also have a specific learning disability, which means that they have trouble mastering language or certain skills, such as reading, math, or handwriting. Although AD/HD is not categorized as a learning disability, its interference with concentration and attention can make it even more difficult for a child to perform well in school.

More seriously, perhaps, is that nearly half of all children with AH/HD - mainly boys - also have oppositional defiant disorder. These children can be stubborn, have outbursts of temper, and act belligerently or defiantly. At times, these behaviors may progress into more serious conduct disorders. Children with this combination of problems may fall into trouble with school officials, take unsafe risks, or break laws by stealing, setting fires, destroying property, or driving recklessly.

What Causes AD/HD?

At present, there is no one single, clear cause identified for AD/HD. Experts are researching a number of genetic and environmental roots of AD/HD. Their work has shown that some children may inherit a biochemical condition that influences the expression of AD/HD symptoms. Other children may have experienced abnormal fetal development, which leads to subtle damaging effects on brain regions that control attention and movement in some cases.

Recently, scientists using imaging techniques to localize the brain areas involved in AD/HD have found that specific areas (in the frontal lobe and basal ganglia) are reduced by about 10% in both size and activity in children with AD/HD. It is not yet known whether this difference is a cause of AD/HD. Other research based on genetic mechanisms has focused on dopamine as the primary neurotransmitter (substance that sends nerve impulses in the brain) involved in AD/HD. Dopamine pathways in the brain, which link the basal ganglia and frontal cortex, appear to play a major role in AD/HD.

When Should I Seek Help?

Because many children exhibit occasional inappropriate or hyperactive behaviors, widespread confusion has arisen about the diagnosis and treatment of AD/HD. Due to these uncertainties, parents should not attempt to diagnose their children. Children who are responding to stressful family situations, are bored in the classroom, or are passing through during certain stages of development may, at times, appear inattentive, hyperactive, or impulsive -- yet they do not have AD/HD.

To determine whether your child needs to be examined by a physician, psychologist, or other medical specialist, you should consider several critical questions:

• Are your child's troublesome behaviors excessive, long-term, and pervasive? Do they occur more often than in his peers?
• Are his behaviors a continuous problem and not just a response to a temporary situation?
• Do his behaviors occur in several settings, or only in one specific place like the playground or school?

You should talk to your child's teacher to get a clearer reading on your child's daily behaviors. You should also seek a consultation with a health professional to rule out other possible psychological problems, such as depression or a learning disorder.

This can be a frustrating time for parents. You need to remember to be patient and understanding with your child. Talking to other parents or getting involved with a support group, such as Children and Adults With Attention Deficit Disorder, through your local hospital may be helpful.

Is AD/HD Overdiagnosed?

The appearance of symptoms of AD/HD, the degrees of impairment, and the course of the disorder form a coherent pattern so that well-trained clinicians can reliably diagnose AD/HD. However, diagnosing the disorder has remained controversial. The National Institutes of Health (NIH) notes, "Parents, health care providers, educators, and policy makers remain uncertain about the status of the disorder and its long-term consequences; whether it should be treated, and if so, how; which treatments yield the best outcomes; and what the personal family and societal costs and consequences of the disorder are, whether treated or not."

Further clouding the picture is that, at present, no single reliable medical or psychological test exists to determine whether a child has AD/HD. Because psychostimulant drugs are often used as part of the treatment for AD/HD, it is even more important to verify the diagnosis. Therefore, the NIH report also stresses an immediate need for researchers to develop further and more precise standardized diagnostic criteria for the disorder.

The question of whether AD/HD is overdiagnosed or underdiagnosed is a difficult and controversial one. How frequently the diagnosis is made and which treatments are selected are often related to the type of doctor making the diagnosis. Primary care and developmental pediatricians, family practitioners, child neurologists, psychologists, and psychiatrists assess, diagnose, and treat AD/HD.

What Is the Treatment?

Psychostimulants, such as Ritalin (methylphenidate) and Dexedrine (dextroamphetamine), and some antidepressants are the most well-known treatments of AD/HD. The exact mechanism of their action is unknown, but they probably work by modulating the neurotransmitters (substances that send nerve impulses) in the brain. Dopamine, noradrenaline, and serotonin levels in the central nervous system are affected by these medications. This has led to further investigation into the role of each of these neurotransmitters in AD/HD.

Taken in normal doses, stimulants can result in decreased appetite, stomachaches, agitation, irritability, and insomnia for some children. The long-term effects of taking these drugs are not yet known.

Medications can result in an improvement in core symptoms such as impulsive behavior and inattention as well as an improved school and social performances. For that reason, treatment for AD/HD is more effective when regular use of drugs is combined with behavior treatment. Reward systems for appropriate behavior or performance, teaching parents child-management skills, and therapy that instructs parents and teachers in improved contingency management skills can help most children.

Special parenting skills are often needed because children with AD/HD may not be as responsive to common parenting practices -- especially punishment as the lone practice. Cognitive behavioral skills may help your child monitor his behavior, introduce problem-solving strategies, and self-reinforce his positive behaviors.

Children who regularly take their medication and practice behavior techniques routinely do better than those who rely on stimulants alone. Psychological therapies without medications do not appear to be optimally effective on the most severe core behaviors of AD/HD.

In addition to drug and psychosocial therapies, there also exists a long history of other treatments, including herbs, vitamins, minerals, biofeedback, and dietary solutions. Many of these therapies, although appealing, have not been proven in therapeutic trials to be effective.

Can the Home and School Environments Be Improved?

AD/HD affects all aspects of home and school life. Specialized intervention is needed for children with AD/HD. Specialists on AD/HD advise parent education and support therapies to help family members accept the diagnosis and teach them how to help the child organize, cope with frustrations, and develop problem-solving skills.

Positive reinforcement from teachers and you is crucial to helping your child progress. Praise-and-reward systems that emphasize strengths over weaknesses can build his self-esteem.

As your child's most important advocate, you must deal with the medical and educational systems to ensure appropriate services by becoming familiar with his educational legal rights and actively participating in his education. Federal laws mandate educational interventions for many children with AD/HD. Modifications and special placements in public school settings can be part of AD/HD treatment. The coordination of school-based interventions with medical interventions has become possible due to these changes in educational law regulations.

One problem with current AD/HD treatment is that those who diagnose a child with AD/HD and those who implement and monitor treatment may not be the same people. There should be a team approach in diagnosing and treating children with AD/HD.

Adjustments -- both physical and in the teacher's curriculum -- may be necessary for the student with AD/HD in the classroom. Because not every child with AD/HD will require the same adjustment or all of the adjustments covered below, the purpose of any modification should be to teach the child with AD/HD the mechanisms for coping with this disorder.

Among the range of modifications for the child with AD/HD:

• Modify the environment: ask your child's teacher to place your child close to the front of the room; limit open spaces, which may encourage hyperactive behaviors; reduce distracting stimuli.
• Provide clear instructions: keep oral instructions brief and repeat them as necessary; provide written instructions (and review them orally) for multistep processes; break up tasks and homework into small steps.
• Focus on success: provide formal feedback (such as star charts) to reinforce specific positive behaviors; reward progress even if achievement does not meet standard requirements.
• Organize: establish daily checklists; help your child start a homework notebook, with homework assignments listed with due date and textbooks/supplies needed; remind him to consult his notebook at the end of the day to ensure he takes home the needed supplies.
• Improve handwriting: encourage computer usage by older children; de-emphasize untidiness/spelling errors and focus on content; offer help with handwriting skills.
• Help control impulse: urge your child to slow down when completing answers; direct him to check his work before turning it in.
• Maintain self-esteem: encourage performance in your child's areas of strength; provide feedback privately; do not ask him to perform a task publicly that is too difficult; focus on positive reinforcement.
• Design a specific behavior program: target a few unacceptable behaviors with clear consistent consequences explained privately to your child; consequences should not be publicly humiliating; hand signals may be used to privately warn your child of inappropriate behavior.
• Teach your child to be an active learner: encourage visual aids and hands-on experiences; teach active reading (underlining), active listening (note taking), reading for detail, and subvocalization (whispering) as a memory aid.

AD/HD is a disorder that affects the lives of many families, but proper treatment and environmental changes can positively impact the lives and futures of these children.