Attention-deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and controversial mental disorders among children, and is increasingly recognized as afflicting adults as well. Its symptoms include inattention, hyperactivity, and impulsivity. According to sources such as the CDC, the causes are currently unknown, and it is thought that the term covers a variety of related disorders. There is no single medical test that can accurately diagnose ADHD, though there are assessment tools.
The authoritative definition of ADHD is to be found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-IV (Text Revision) (DSM-IV-TR), which also defines three subtypes of ADHD:
Older names that have been used for ADHD or ADD include hyperkinetic syndrome (HKS) and minimal cerebral dysfunction (MCD). ADHD is sometimes called attention-deficit syndrome (ADS) to avoid the connotations of "disorder".
In children the disorder is characterised by inattentiveness, impulsive behavior and restlessness. In adults the main problem is often their inability to structure their lives and plan simple daily tasks. Thus inattentiveness and restlessness often become secondary problems. The CDC emphasizes that a diagnosis of ADHD should only be made by trained health care providers. This is important as many of the criteria can be readily misinterpreted and the prescribed drugs can be very dangerous.
The 1918-1919 influenza pandemic left many survivors with encephalitis, affecting their neurological functions. Some of these exhibited immediate behavioral problems which correspond to ADD. This caused many to believe that the condition was the result of injury rather than genetics.
In 1937, a group of children in an institution with behavioural problems were treated with amphetamine drugs for the first time, resulting in behavioural improvements. However treatment with stimulants was not widely used until the late 1950s.
In 1957, the new stimulant Methylphenidate (Ritalin) became available.
By the 1950s and 1960s, researchers changed the terminology from Minimal Brain Damage to Minimal Brain Dysfunction. This followed observations that the condition existed without any known injury.
The "Hyperactive Child Syndrome" was first described in the 1960s, and was also regarded as not caused by injury. By the late 1960s and 1970s, hyperactivity had caught hold as a popular term, although MBD was also used professionally.
In the early 1970s an erroneous newspaper article, which is still often cited, inflated the prescribing rate of medication by a factor of 10, influencing some to avoid treatment with stimulants.
In 1973 Dr Ben F. Feingold, once a Professor of Allergy in San Fransisco, claimed that hyperactivity was increasing in proportion to the level of food additives, and proposed a specific diet believing that it would help 50% of hyperactive children. The popularity of the claims caused an American Congressional Commission to investigate additives and encourage research. Most carefully controlled studies showed that only 5% of ADD children were impacted by food (but this was obviously an important finding for that 5%), but some have shown a figure of 60%. One study tested the 50% who claimed to be helped by diet, finding that 10% showed behavioral changes from food triggers. The Feingold diet excluded cola drinks, chocolate, preservatives and flavour additives, as well as salicylates that occur naturally in fruit such as tomatoes, strawberries, pineapples and oranges. However pineapple juice was suggested as a "safe" drink. Professional dieticians exclude and re-introduce food groups on a more controlled basis to identify triggers.
The Canadian Virginia Douglas in the early 1970s made various publications to promote the idea that attention deficit was of more significance than hyperactivity, influencing the American Psychiatric Association. The name attention deficit disorder (ADD) was first introduced in DSM-III, the 1980 edition.
The early 1980s saw the vitamin B6 promoted as a helpful remedy for children with learning difficulties including inattentiveness. After that, zinc was promoted for ADD and autism. Multivitamins later became the claimed solution. No reputable research has appeared to support any of these claims, except in cases of malnutrition.
In the mid-1980s, Helen Irlen from California took out a patent on certain tints for lenses to help those with reading problems. Despite wide media coverage and a number of studies, it appears that only a small percentage of subjects saw improvement.
In the late 1980s, the Church of Scientology set up the Citizen's Commission on Human Rights (CCHR), which lobbied using the media against psychiatric medication in general, and Ritalin in particular. They were very effective at the time in scaring people away from treatment with stimulants, as well as increasing the social stigma.
In 1994, DSM-IV described three groupings within ADHD, which can be simplified as: mainly inattentive; mainly hyperactive-impulsive; and both in combination.
According to the 2000 edition of DSM-IV-TR, ADHD affects three to seven percent of all children in the U.S. According to 2002 data from the CDC's annual National Health Interview Survey, released in 2004, nearly 4 million children younger than 18 in the United States had been diagnosed with attention deficit hyperactivity disorder (ADHD). However, rates of diagnosis vary widely even within the U.S. In some school districts as many as 60% of all children have been diagnosed with ADHD.
The 2002 data indicated that twice as many boys were diagnosed with ADHD as girls (10% vs. 4%). The causes of this gender disparity are unknown. Some experts theorize that ADHD is underdiagnosed in girls, since their symptoms tend to be less dramatic than those in boys and thus draw less attention from parents and teachers.
Today ADHD is considered to be a problem all over the industrialized world, although in no other country are children diagnosed with this "disorder" as often as in the United States.
The variation in the rates of diagnosis and in estimates of the rate of prevalence raises numerous issues. In fact, almost everything about ADHD has been the subject of intense debate, as discussed later in this article. This debate led the NIH to develop a Consensus Statement in 1998, a link to which is provided in the External Links section below.
ADHD often continues into adolescence and adulthood, and can cause a lifetime of frustrated dreams and emotional pain. However, children diagnosed with ADHD often go on to live normal lives, and wonder why their parents and schools felt the need to medicate them. Many complain of having needlessly suffered from the psychological trauma of the diagnosis and adverse effects of the drugs. Others have written of how diagnosis and treatment improved their lives.
Evidence for ADHD as an organic phenomenon
Brain imaging research using magnetic resonance imaging (MRI) has shown that differences exist between the brains of children with and without ADHD. Many scientists consider these results to be significant in themselves, but in addition PET studies have shown that there might be a link between a person's ability to pay continued attention and the use of glucose - the body's major fuel - in the brain. In adults with ADHD, the brain areas that control attention use less glucose and appear to be less active, suggesting that a lower level of activity in some parts of the brain may cause inattention (Zametkin et al.). However, there is no evidence that this low level of glucose in fact causes the low level of attention; it could in fact be no more than an indicator for low attention. Maybe even more interesting are the results of some studies using SPECT (Single Photon Emission Computed Tomography). One study (Lou et al. in Arch. Neurol. 46(1989) 48-52) found that people with ADHD have a reduced blood circulation in the striatum. But even more important might be the discovery that people with ADHD seem to have a significantly higher concentration of dopamine transporters in the striatum (Dougherty et al. in Lancet 354 (1999) 2132-2133; Dresel et al. in Eur.J.Nucl.Med. 25 (1998) 31-39).
It has been known for some decades that head injuries can produce ADHD-type behavior.
Research shows that ADHD tends to run in families, so there are likely to be genetic influences. Children who have ADHD usually have at least one close relative who also has ADHD. And at least one-third of all fathers who had ADHD in their youth have children with ADHD. Even more convincing of a possible genetic link is that when one twin of an identical twin pair has the disorder, the other is likely to have it too.
Though ADHD is classified as a serious disorder, many people have a different perspective. Some see it as a gift. In his book ADD - Attention Deficit Disorder (1997), Thom Hartmann developed the idea that people having ADHD symptoms may have simply inherited a collection of genes that were selected for when hunting was particularly important. This idea is the basis of another of his works, The Edison Gene: ADHD and the Gift of the Hunter Child (2003).
People who believe that ADHD is a gift find hints of ADHD in the lives of many famous people in history. Though such post mortem diagnosis is questionable, it is intriguing to ponder the evidence that people such as Thomas Edison might have been diagnosed as having ADHD if the current DSM criteria had been developed sufficiently long ago. Other historical figures who have been proposed as ADHD candidates include: Hans Christian Andersen, Ludwig van Beethoven, Winston Spencer Churchill, Walt Disney, Benjamin Franklin, Robert and John F. Kennedy, Theodore Roosevelt, Jules Verne and the Wright brothers.
Some contemporary ADHD candidates have also been proposed, including George W. Bush, William J. Clinton, Whoopi Goldberg and Dustin Hoffman.
To see ADHD as a gift may seem somewhat problematic to anxious parents but it is at least a perspective that should be kept in mind.
Psychological testing for ADHD
Psychological testing for ADHD generally consists of obtaining multiple types of assessments. These usually include a clinical interview reviewing the DSM-IV criteria for ADHD. The interview also needs to rule out as much as possible other types of syndromes which can cause attention problems, such as depression, anxiety, and psychosis. Rating scales can be administered which provide measurement of the person's own view of their symptoms, as well as the views of parents, teachers, and significant others. Finally, computerized tests of attention can be helpful in providing a further independent assessment. These different assessments may not be in total agreement but provide a well-rounded view of the person's difficulties. A physician need not order psychological testing in order to make the diagnosis of ADHD, but many doctors use this kind of assessment to avoid over-diagnosis and treatment.
Neurometrics, PET scans, or SPECT scans have been used for a more objective diagnosis. These are not usually suitable for very young children.
Attention deficit disorder also exists in adults, and an assessment for this is also needed.
Skepticism towards ADHD as a diagnosis
Critics have complained that the ADHD diagnostic criteria are sufficiently general or vague to allow most children with persistent unwanted behaviors to be classified as having ADHD of one type or another. It should be noted that diagnostic questionnaires are often subject to copyright restrictions, preventing a wider awareness of their specificness.
Many people have wondered why the number of children diagnosed with ADHD in the U.S. has grown so dramatically over a short period of time. It has often been suggested that the causes of the ADHD epidemic lie in cultural patterns that variously encourage or sanction the use of drugs as a simple cure for complex problems. Some critics assert that many kids are diagnosed with ADHD and put on drugs as a substitute for parental attention, whereas many parents of ADHD children assert that the associated demand for attention goes beyond what can be humanly provided, causing massive disruption to other individuals and relationships, as well as to environments with structured relationships such as classrooms.
Some schools have required "problem" pupils to undergo ADHD diagnosis (and treatment if diagnosed), which has caused protests.
Some critics have suggested that the ADHD label should be abolished.
Douglass Rushkoff, among other critics of ADHD diagnosis, suggest that the disorder may be a result of cultural conditions to which children and adults alike are subjected. Primary among these is the omnipresence and exploitive qualities of advertising. In the time that ADHD has arisen as the epidemic it is often portrayed as, advertisement has become virtually unavoidable, and advertisements utilize much more sophisticated methods of deception. Some suggest that people (children, especially) are aware of this attempt at pervasive trickery, whether consciously or subconsciously, and react by avoiding extended attention in order to avoid being deceived. Naturally, this self-defense reaction, when carried over to school and home, presents obvious problems. From this point of view, prescribing drugs is effectively only to alleviate symptoms, but entirely avoids the cause.
The first-line medications used to treat ADHD are stimulants, including Ritalin (a trade name for methylphenidate, marketed by Novartis), Adderall/amphetamine (Adderall is a trade name for a mixture of dextroamphetamine and laevoamphetamine salts, marketed by Shire Pharmaceuticals), Desoxyn/methamphetamine (Desoxyn is a trade name for methamphetamine, marketed by Ovation Pharma), and others. Because nearly all the drugs used to treat ADHD are Schedule II under the U.S. DEA schedule system, and are considered powerful stimulants with a potential for diversion and abuse, there is controversy surrounding prescribing these drugs for children and adolescents.
However, research studying ADHD sufferers who either receive treatment with stimulants or go untreated has indicated that those treated with stimulants are in fact much less likely to abuse any substance than ADHD sufferers who are not treated with stimulants.
Second-line medications include less-powerful stimulants such as benzphetamine and Provigil/modafinil, although research as to the efficacy of these drugs is not complete.
Data from 1995 show that physicians treating children and adolescents wrote six million prescriptions for stimulants. Of all the drugs used to treat psychiatric disorders in children, stimulant medications are the most well-studied. However, to date there are no good long-term studies dealing with stimulants in children. A 1998 Consensus Development Conference on ADHD sponsored by the National Institutes of Health and a recent, comprehensive, scientific report confirmed many earlier studies showing that short-term use of stimulants is safe and effective for children with ADHD. This says nothing for the growing number of children who are on stimulants for years at a time. Some non-stimulant medications are now becoming available to treat ADHD such as Strattera (atomoxetine HCl), a selective norepinephrine reuptake inhibitor.
In December 1999, NIMH released the results of a study of nearly 600 elementary school children, ages seven-to-nine, which evaluated the safety and relative effectiveness of the leading treatments for ADHD for a period up to fourteen months. The results indicate that the use of stimulants alone is more effective than behavioral therapies in controlling the core symptoms of ADHD - inattention, hyperactivity/impulsiveness, and aggression. In other areas of functioning, such as anxiety symptoms, academic performance, and social skills, the combination of stimulant use with intensive behavioral therapies was consistently more effective. (Of note, families and teachers reported somewhat higher levels of satisfaction for those treatments that included the behavioral therapy components.) NIMH researchers will continue to track these children into adolescence to evaluate the long-term outcomes of these treatments, and ongoing reports will be published. This study has been severely criticized, as it was not double-blind and the sponsors failed to provide a control group.
There has been a lot of interesting work done with neurofeedback and ADHD. Children are taught, using video game-like technology, how to control their brain waves. This has a very high success rate, but is not widely used, or covered by insurance. Many professionals consider the treatment promising, but state that there is not yet sufficient evidence that it works after the immediate treatment is complete. Dietary and television restrictions are also sometimes useful environmental solutions. Sugar, wheat, and other foodstuffs have been shown to cause adverse behavioral reactions.
The Norwegian scientist Dr. Karl Ludwig Reichelt claims that peptides from casein (milk-protein) and gluten (grain-protein) worsen the symptoms in many ADHD-patients. Extensive testing of ADHD-patients is taking place in Norway, and diet has astonishing effects for many of them. Although good result are achieved in Norway, the peptide-theory is discarded by the scientific community.
Mark specializes in Individual, Couples, and Family Therapy. He also has expertise in dealing with a broad range of issues from Anxiety and Depression to Anger and Stress Management.
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