Attention
Deficit/Hyperactivity Disorder Introduction:
Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral
disorder in children, particularly in the elementary/high school age. If untreated,
it can cause a lot of social disturbance and can get the affected adolescents
into trouble with the law. The 4th edition of the American Psychiatric
Association's Diagnostic and Statistical Manual (DSM-IV) states that ADHD is characterized
by inattention, easy distractibility, difficulties sustaining attention and poor
impulse control. There is also a decrease in the capacity for self-inhibition.
Motor restlessness and motor overactivity are hallmark symptoms as well.
Symptoms of ADHD: As
many of the symptoms are rather vague, the DMS-IV defines ADHD in the following
way. Below are two lists of symptoms. The first list consists of inattention symptoms,
the list underneath that consists of hyperactivity/impulsivity symptoms. The diagnosis
is positive for ADHD, if the requirements outlined below are met. Of the
following list of 9 inattention symptoms 6 (or more)
have to be present for more than 6 months to make a diagnosis of ADHD.
- Failing to pay close attention to detail or making careless mistakes with
school work, work or other activities.
- Having difficulties with sustained
attention during tasks or play activities
- Not following through on instructions
or failing to finish school work, chores or work duties
- Does not seem
to listen when spoken to directly
- Having difficulties organizing tasks
or activities
- Disliking, avoiding and showing reluctance in doing mental
effort tasks (completing school work or chores at home)
- Often looses
things required to complete such tasks (pencils, books, toys, tools, school assignments
etc.)
- Easily distractible by extraneous stimuli (background noises,
passing cars etc.)
- Being forgetful in daily activities
Alternatively,
if 6 (or more) symptoms of the following hyperactivity/impulsivity
list of 9 symptoms are present, and these symptoms are present for 6 months or
more, this would also qualify for the diagnosis of ADHD. - Fidgeting
with hands or feet and/ or squirming in seat
- Often leaves the seat in
situations where the person is expected to be seated (classroom, church etc.)
- Running about or climbing excessively in situations where this is inappropriate
(adolescents may feel an internal restlessness)
- Having difficulties
playing or doing leisure activities quietly
- Often being “on the go”
or behaving as “driven by a motor”
- Talking excessively (this is
a measure for impulsivity)
- Having difficulties awaiting one’s turn
- Blurting out answers before questions have been completed
-
Interrupting or intruding on others (butting into conversations or games)
In
addition to the requirement regarding either one of these lists of symptoms, there
is a requirement that the condition would have to be evident before the age of
7 years. Also, some of the impairment from the symptoms must be present in 2 or
more settings (school, at home etc.). There must be evidence of impaired functioning
in the setting of school, socially or at work. Finally, there is a requirement
that the ADHD symptoms cannot just be present at the time of another psychiatric
disorder (schizophrenia, developmental disorder, mood disorder, personality disorder,
anxiety disorder or dissociative disorder). If this is the case, the other psychiatric
diagnosis would be the primary diagnosis.
Diagnosis of ADHD:
The
diagnosis is made by using the diagnostic criteria involving the symptoms outlined
above and is best done by a pediatrician or child psychiatrist with experience
in treating ADHD patients. The tools used in the process of making the diagnosis
are standardized behavior rating scales, clinical interviews, a neuropsychological
evaluation and a physical examination. It may be best done in a clinic that specializes
in ADHD diagnosis and treatment and where a team of experts in the field can evaluate
the patient. Caution is required in that the patient may appear more normal in
the unfamiliar surrounding of the doctor’s office or clinic setting and the
symptoms may not be that obvious as they would be when in the familiar school
setting or at home. Treatment
of ADHD: When other mental illnesses have been ruled out and the
diagnosis of ADHD has been confirmed, treatment can begin. It consists of a combination
of behavior management training, psychosocial intervention and medication. It
would be a mistake to rely on medication alone as this would fail or end up in
overdosing the patient in an attempt to maximize the effect. Much has been learnt
from studying ADHD in detail over the years. What has been learnt is that positive
reinforcements when desired behaviors are observed have a very beneficial effect.
This is combined with negative enforcements for times when a goal has not been
achieved. Courses for patients and care givers are usually given that would last
in the order of 8 to 12 weeks. There are non profit organizations that help with
information as well: - "Children
and Adults with Attention-Deficit/Hyperactivity Disorder" (CHADD)
is a non-profit organization with many local support groups.
- Attention
Deficit Disorder Association (ADDA) is also a non-profit organization
providing a lot of links.
Psychological therapeutic intervention
concentrates on improving learning, behavior, social skills, family functioning
as well as self esteem and peer interaction. Medications that have been found
to be beneficial over the past 60 years are the stimulants. Two main classes of
medication are Ritalin (and similar derivatives of methylphenidate such as Concerta,
Metadate CD, Methylin) and amphetamines and derivatives (Dexedrine, Adderall).
These medications are considered to be the first-line medications (true and tested
for a long time). Second-line medications are antidepressant medications such
as tricyclics (Imipramine, Desipramine) and bupropion (Wellbutrin).
Prognosis and comments regarding ADHD: There
is a popular misconception that the stimulants listed above would be addictive.
Long-term studies have shown that this is not so as there is no development of
tolerance (meaning that more and more drug would be required to achieve the same
effect). There is also no withdrawal or craving upon termination of the medication.
Studies also showed that patients who have been on stimulants do not get into
drug addiction behavior later in life. To the contrary, it was found that adolescents
who are treated a supervised stimulant treatment protocol in combination with
the other treatments described above will have much less incidences of illicit
drug use and alcohol abuse than patients who refuse treatment. Furthermore, patients
on stimulants do not engage in aggressive behaviors (assaults etc.) and do not
experience more seizures. All these are popular misconceptions and unfortunately
are used by certain interest groups that do not understand the seriousness on
this disorder and the seriousness of NOT treating it adequately. It needs to be
said that about 80% of ADHD children will continue to have the condition even
in adulthood. The earlier the above mentioned clinical and educational measures
are taken and the children are put on appropriate medication for ADHD, the faster
their lives will normalize. Studies have shown that it is the children/adolescents
that have slipped through screening programs and whose ADHD was missed that will
get into trouble with the law (more frequently involved in accidents, showing
risky sexual behaviors, engaging in criminal behaviors etc.). Many inmates in
prisons have undiagnosed and untreated ADHD. Society needs to rethink this scenario
based on the reality of the findings mentioned above and realize that it is much
better for everyone involved to diagnose ADHD early and to treat ADHD appropriately
and for long enough. |
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