An Overview of Attention Deficit/Hyperactivity Disorder
Attention-deficit/hyperactivity disorder (ADHD), often referred to as hyperactivity, is characterized by difficulties that interfere with effective task-oriented behavior in children—particularly impulsivity, excessive or exaggerated motor activity such as aimless or haphazard running or fidgeting, and difficulties in sustaining attention (Nigg et al., 2005; see DSM-IV-TR Criteria for Attention-Deficit/Hyperactivity Disorder).
There are some proposed changes to the Attention Deficit/Hyperactivity Disorder criteria for DSM-5; however, many of the symptoms and behaviors shown in the criteria for DSM-IV-TR are maintained.
The proposed modifications in the forthcoming DSM-5 include some clarification of criteria for Attention Deficit/Hyperactivity Disorder.
Children with Attention Deficit/Hyperactivity Disorder
Children with Attention Deficit/Hyperactivity Disorder are highly distractible and often fail to follow instructions or respond to demands placed on them (Wender, 2000). Perhaps as a result of their behavioral problems, children with Attention Deficit/Hyperactivity Disorder are often lower in intelligence, usually about 7 to 15 IQ points below average (Barkley, 1997).
Children with Attention Deficit/Hyperactivity Disorder also tend to talk incessantly and to be socially intrusive and immature.
Recent research has shown that many children with Attention Deficit/Hyperactivity Disorder show deficits on neuropsychological testing that are related to poor academic functioning (Biederman et al., 2004).
Children with Attention Deficit/Hyperactivity Disorder generally have many social problems because of their impulsivity and overactivity.
Hyperactive children usually have great difficulty in getting along with their parents because they do not obey rules. Their behavior problems also result in their being viewed negatively by their peers (Hoza et al., 2005).
In general, however, hyperactive children are not anxious, even though their overactivity, restlessness, and distractibility are frequently interpreted as indications of anxiety. They usually do poorly in school and often show specific learning disabilities such as difficulties in reading or in learning other basic school subjects.
Hyperactive children also pose behavior problems in the elementary grades. The case study on page 527 reveals a typical clinical picture.
Symptoms of Attention Deficit/Hyperactivity Disorder.
The symptoms of Attention Deficit/Hyperactivity Disorder are relatively common among children seen at mental health facilities in the United States, with from 3 to 7 percent reported in DSM-IV-TR and 8 percent reported in a recent study in the United Kingdom (Alloway et al., 2010).
In fact, hyperactivity is the most frequently diagnosed mental health condition in children in the United States (Ryan-Krause et al., 2010). The disorder occurs most frequently among preadolescent boys—it is six to nine times more prevalent among boys than among girls.
Attention Deficit/Hyperactivity Disorder occurs with the greatest frequency before age 8 and tends to become less frequent and to involve briefer episodes thereafter.
Attention Deficit/Hyperactivity Disorder has also been found to be comorbid with other disorders such as oppositional defiant disorder (Staller, 2006), which we discuss later. Some residual effects, such as attention difficulties, may persist into adolescence or adulthood (Odell et al., 1997).
Attention Deficit/Hyperactivity Disorder (ADHD) is found in other cultures (Bauermeister et al., 2010)—for example, one study of 1,573 children from 10 European countries reported that Attention Deficit/Hyperactivity Disorder (ADHD) symptoms are similarly recognized across all countries studied and that the children are significantly impaired across a wide range of domains.
DSM-IV-TR
Criteria for Attention-Deficit/Hyperactivity Disorder A. Either (1) or (2): 1. six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
a. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b. often has difficulty sustaining attention in tasks or play activities
c. often does not seem to listen when spoken to directly d. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e. often has difficulty organizing tasks and activities
f. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
g. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
h. is often easily distracted by extraneous stimuli i. is often forgetful in daily activities.
Hyperactivity
a. often fidgets with hands or feet or squirms in seat b. often leaves seat in classroom or in other situations in which remaining seated is expected
c. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
d. often has difficulty playing or engaging in leisure activities quietly
e. is often “on the go” or often acts as if “driven by a motor”
f. often talks excessively
Impulsivity
g. often blurts out answers before questions have been completed
h. often has difficulty awaiting turn i. often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder,Dissociative Disorder, or a Personality Disorder.
Causal factors of Attention Deficit/Hyperactivity Disorder
The cause or causes of ADHD in children have been much debated. It still remains unclear to what extent the disorder results from environmental or biological factors (Carr et al., 2006; Hinshaw et al., 2007), and recent research points to both genetic (Sharp et al., 2009; Ilott et al., 2010) and social environmental precursors (Hechtman, 1996).
However many researchers believe that biological factors such as genetic inheritance will turn out to be important precursors to the development of ADHD (Durston, 2003). But firm conclusions about any biological basis for ADHD must await further research.
The search for psychological causes of Attention Deficit/Hyperactivity Disorder has yielded similarly inconclusive results, although temperament and learning appear likely to be factors.
One study suggested that family pathology, particularly parental personality, can be transmitted to children (Goos et al., 2007). Currently, ADHD is considered to have multiple causes and effects (Hinshaw et al., 1997).
Whatever cause or causes are ultimately determined to be influential in Attention Deficit/Hyperactivity Disorder , the mechanisms underlying the disorder need to be more clearly understood and explored.
There is general agreement that processes operating in the brain are disinhibiting the child’s behavior (Nigg, 2001), and some research has found different EEG patterns occurring in children with Attention Deficit/Hyperactivity Disorder than in children without ADHD (Barry et al., 2003).
At this time, however, theorists do not agree what those central nervous system processes are.
Treatment and Outcomes
Although the hyperactive syndrome was first described more than hundred years ago, disagreement over the most effective methods of treatment continues, especially regarding the use of drugs to calm a child with Attention Deficit/Hyperactivity Disorder.
Yet this approach to treating children with Attention Deficit/Hyperactivity Disorder has great appeal in the medical community; one survey (Runnheim et al., 1996) found that 40 percent of junior high school children and 15 percent of high school children with emotional and behavioral problems and Attention Deficit/Hyperactivity Disorder are prescribed medication, mostly Ritalin (methylphenidate), an amphetamine.
In fact, school nurses administer more daily medication for Attention Deficit/Hyperactivity Disorder than for any other chronic health problem.
Interestingly, research has shown that amphetamines have a quieting effect on children—just the opposite of what we would expect from their effects on adults. For children with ADHD, such stimulant medication decreases overactivity and distractibility and, at the same time, increases their alertness (Konrad et al., 2004).
As a result, they are often able to function much better at school (Hazell, 2007; Pelham et al., 2002). Jensen and colleagues (2007), in a NIMH study, conclude that medication treatment of ADHD can make a long-term difference for some children if it is appropriately continued and initiated early in the child’s clinical course.
Fava (1997) concludes that Ritalin can often lower the amount of aggressiveness in children with ADHD. In fact, many children whose behavior has not been acceptable in regular classes can function and progress in a relatively normal manner when they use such a drug. In a five-year follow-up study,
Charach and colleagues (2004) reported that children with ADHD on medication showed greater improvement in teacher reported symptoms than non treated children.
The possible side effects of Ritalin, however, are numerous: decreased blood flow to the brain, which can result in impaired thinking ability and memory loss; disruption of growth hormone, leading to suppression of growth in the body and brain of the child; insomnia; psychotic symptoms; and others.
Although amphetamines do not cure ADHD, they have reduced the behavioral symptoms in about one-half to two-thirds of the cases in which medication appears warranted.
Ritalin has been shown to be effective in the short-term treatment of ADHD (Goldstein, 2009; Spencer, 2004a). There are newer variants of the drug, referred to as extended-release methylphenidate (Concerta), that have similar benefits but with available doses that may better suit an adolescent’s lifestyle (Mott & Leach, 2004; Spencer, 2004b).
Three other medications for treating ADHD have received attention in recent years. Pemoline is chemically very different from Ritalin (Faigel & Heiligenstein, 1996); it exerts beneficial effects on classroom behavior by enhancing cognitive processing but has less adverse side effects (Bostic et al., 2000; Pelham et al., 2005). Strattera (atomoxetine), a non controlled treatment option that can be obtained readily, is an FDA-approved nonstimulant medication (FDA, 2002).
This medication reduces the symptoms of ADHD (Friemoth, 2005) but its mode of operation is not well understood. The side effects for the drug are decreased appetite, nausea, vomiting, and fatigue. The development of jaundice has been reported, and the FDA (2004) has warned of the possibility of liver damage from using Strattera.
Although Strattera has been shown to reduce some symptoms of ADHD, further research is needed to evaluate its effectiveness and potential side effects (Barton et al., 2005).
Another drug that reduces symptoms of impulsivity and hyperactivity in children with attention deficit/ hyperactivity disorder is Adderall. This medication is a combination of amphetamine and dextroamphetamine; however, research has suggested that Adderall has no advantage or improvement in results over Ritalin or Strattera (Miller-Horn et al., 2008).
Although the short-term pharmacological effect of stimulants on the symptoms of hyperactive children is well established, their long-term effects are not well known (Safer, 1997a). Carlson and Bunner (1993) reported that studies of achievement over long periods of time failed to show that the medication has beneficial effects.
The pharmacological similarity of Ritalin and cocaine, for example, has caused some investigators to be concerned about its use in the treatment of ADHD (Volkow et al., 1995).
There have also been some reported recreational uses of Ritalin, particularly among college students. Kapner (2003) described several surveys in which Ritalin was reportedly abused on college campuses.
In one survey, 16 percent of students at one university reported using Ritalin, and in another study 1.5 percent of the population surveyed reported using Ritalin for recreational purposes within the past 30 days. Some college students share the prescription medications of friends as a means of obtaining a “high” (Chutko et al., 2010).
Some authorities prefer using psychological interventions in conjunction with medications (Mariani & Levin, 2007). The behavioral intervention techniques that have been developed for ADHD include selective reinforcement in the classroom (DuPaul et al., 1998) and family therapy (Everett & Everett, 2001).
Another effective approach to treating children with ADHD involves the use of behavior therapy techniques featuring positive reinforcement and the structuring of learning materials and tasks in a way that minimizes error and maximizes immediate feedback and success (Frazier & Merrill, 1998).
An example is providing a boy with ADHD immediate praise for stopping to think through a task he has been assigned before he starts to do it. The use of behavioral treatment methods for ADHD has reportedly been quite successful, at least for short-term gains.
The use of psychosocial treatment of ADHD has also shown positive results (Pelham & Fabiano, 2008; Corcoran, 2011). Van Lier and colleagues (2004) conducted a school-based behavioral intervention program using positive reinforcement aimed at preventing disruptive behavior in elementary school children.
They found this program to be effective with children with ADHD with different levels of disorder but most effective with children at lower or intermediate levels.
It is important to recognize that gender differences, as noted above, are found in ADHD, with the disorder being more prominent among boys than girls and the symptoms appraised differently.
Recent concerns have been expressed over the possibility that treatment of females with symptoms of ADHD might not be provided because they are more often diagnosed as “predominantly inattentive” than boys.
Rucklidge (2010) points out that females are less likely to be referred to treatment than males with ADHD although treatments appear to be equally effective for both genders. She points out that future research should be attentive to gender differences in the disorder and further examine potential differences that might occur in treatment and outcomes.
Attention Deficit/Hyperactivity Disorder beyond adolescence
Some researchers have reported that many children with ADHD retain symptoms and behavior into early adulthood.
Kessler, Adler, and colleagues (2006) reported a prevalence rate of 4.4 percent in adult patients. Many children with ADHD go on to have other psychological problems such as overly aggressive behavior or substance abuse in their late teens and early adulthood (Barkley et al., 2004).
For example, Carroll and Rounsaville (1993) found that 34.6 percent of treatment-seeking cocaine abusers in their study had met the criteria for ADHD when they were children. In a 30-year follow-up study of hyperactive boys with conduct problems, Satterfield and colleagues (2007) reported that such boys are at substantial increased risk for adult criminality.
Biederman and colleagues (2010) conducted an 11-year follow-up study of girls with ADHD and found that girls with ADHD were at high risk for antisocial, addictive, mood, anxiety, and eating disorders.
In another recent study, college students with ADHD have been shown to exhibit more on-the-job difficulties than peers without ADHD (Shifrin et al., 2010).