Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder (ADHD), is a condition
that becomes apparent in some children in the preschool and
early school years. It is hard for these children to control
their behavior and/or pay attention.
It is estimated that between 3 and 5 percent of children have
ADHD, or approximately 2 million children in the United States.
This means that in a classroom of 25 to 30 children, it is
likely that at least one will have ADHD.
ADHD was first described by Dr. Heinrich Hoffman in 1845. A
physician who wrote books on medicine and psychiatry, Dr.
Hoffman was also a poet who became interested in writing for
children when he couldn't find suitable materials to read to his
3-year-old son.
The result was a book of poems, complete with illustrations,
about children and their characteristics. "The Story of Fidgety
Philip" was an accurate description of a little boy who had
attention deficit hyperactivity disorder.
Yet it was not until 1902 that Sir George F. Still published a
series of lectures to the Royal College of Physicians in England
in which he described a group of impulsive children with
significant behavioral problems, caused by a genetic dysfunction
and not by poor child rearing--children who today would be
easily recognized as having ADHD. Since then, several thousand
scientific papers on the disorder have been published, providing
information on its nature, course, causes, impairments, and
treatments.
A child with ADHD faces a difficult but not insurmountable task
ahead. In order to achieve his or her full potential, he or she
should receive help, guidance, and understanding from parents,
guidance counselors, and the public education system. This
document offers information on ADHD and its management,
including research on medications and behavioral interventions,
as well as helpful resources on educational options.
Because ADHD often continues into adulthood, this document
contains a section on the diagnosis and treatment of ADHD in
adults.
Symptoms
The principal characteristics of ADHD are inattention,
hyperactivity, and impulsivity. These symptoms appear early in a
child's life. Because many normal children may have these
symptoms, but at a low level, or the symptoms may be caused by
another disorder. It is important that the child receive a
thorough examination and appropriate diagnosis by a
well-qualified professional.
Symptoms of ADHD will appear over the course of many months,
often with the symptoms of impulsiveness and hyperactivity
preceding those of inattention. Which may not emerge for a year
or more. Different symptoms may appear in different settings,
depending on the demands the situation may pose for the child's
self-control. A child who "can't sit still" or is otherwise
disruptive will be noticeable in school, but the inattentive
daydreamer may be overlooked.
The impulsive child who acts before thinking may be considered
just a "discipline problem," while the child who is passive or
sluggish may be viewed as merely unmotivated. Yet both may have
different types of ADHD.
All children are sometimes restless, sometimes act without
thinking, sometimes daydream the time away. When the child's
hyperactivity, distractibility, poor concentration, or
impulsivity begin to affect performance in school, social
relationships with other children, or behavior at home, ADHD may
be suspected. But because the symptoms vary so much across
settings, ADHD is not easy to diagnose. This is especially true
when inattentiveness is the primary symptom.
According to the most recent version of the Diagnostic and
Statistical Manual of Mental Disorders2 (DSM-IV-TR), there are
three patterns of behavior that indicate ADHD. People with ADHD
may show several signs of being consistently inattentive. They
may have a pattern of being hyperactive and impulsive far more
than others of their age. Or they may show all three types of
behavior.
This means that there are three subtypes of ADHD recognized by
professionals. These are the predominantly hyperactive-impulsive
type (that does not show significant inattention); the
predominantly inattentive type (that does not show significant
hyperactive-impulsive behavior) sometimes called ADD--an
outdated term for this entire disorder; and the combined type
(that displays both inattentive and hyperactive-impulsive
symptoms).
Hyperactivity-Impulsivity
Hyperactive children always seem to be "on the go" or constantly
in motion. They dash around touching or playing with whatever is
in sight, or talk incessantly. Sitting still at dinner or during
a school lesson or story can be a difficult task. They squirm
and fidget in their seats or roam around the room. Or they may
wiggle their feet, touch everything, or noisily tap their
pencil. Hyperactive teenagers or adults may feel internally
restless. They often report needing to stay busy and may try to
do several things at once.
Impulsive children seem unable to curb their immediate reactions
or think before they act. They will often blurt out
inappropriate comments, display their emotions without
restraint, and act without regard for the later consequences of
their conduct.
Their impulsivity may make it hard for them to wait for things
they want or to take their turn in games. They may grab a toy
from another child or hit when they're upset. Even as teenagers
or adults, they may impulsively choose to do things that have an
immediate but small payoff rather than engage in activities that
may take more effort yet provide much greater but delayed
rewards.
Some signs of hyperactivity-impulsivity are:
Feeling restless, often fidgeting with hands or feet, or
squirming while seated Running, climbing, or leaving a seat in
situations where sitting or quiet behavior is expected Blurting
out answers before hearing the whole question Having difficulty
waiting in line or taking turns.
Inattention Children who are inattentive have a hard time
keeping their minds on any one thing and may get bored with a
task after only a few minutes. If they are doing something they
really enjoy, they have no trouble paying attention. But
focusing deliberate, conscious attention to organizing and
completing a task or learning something new is difficult.
Homework is particularly hard for these children. They will
forget to write down an assignment, or leave it at school. They
will forget to bring a book home, or bring the wrong one. The
homework, if finally finished, is full of errors and erasures.
Homework is often accompanied by frustration for both parent and
child.
The DSM-IV-TR gives these signs of inattention:
Often becoming easily distracted by irrelevant sights and sounds.
Often failing to pay attention to details and making careless
mistakes.
Rarely following instructions carefully and completely losing or
forgetting things like toys, or pencils, books, and tools needed
for a task.
Often skipping from one uncompleted activity to another.
Children diagnosed with the Predominantly Inattentive Type of
ADHD are seldom impulsive or hyperactive, yet they have
significant problems paying attention. They appear to be
daydreaming, "spacey," easily confused, slow moving, and
lethargic.
They may have difficulty processing information as quickly and
accurately as other children. When the teacher gives oral or
even written instructions, this child has a hard time
understanding what he or she is supposed to do and makes
frequent mistakes. Yet the child may sit quietly, unobtrusively,
and even appear to be working but not fully attending to or
understanding the task and the instructions.
These children don't show significant problems with impulsivity
and overactivity in the classroom, on the school ground, or at
home. They may get along better with other children than the
more impulsive and hyperactive types of ADHD. They may not have
the same sorts of social problems so common with the combined
type of ADHD. So often their problems with inattention are
overlooked. But they need help just as much as children with
other types of ADHD, who cause more obvious problems in the
classroom.
Is It Really ADHD?
Not everyone who is overly hyperactive, inattentive, or
impulsive has ADHD. Since most people sometimes blurt out things
they didn't mean to say, or jump from one task to another, or
become disorganized and forgetful, how can specialists tell if
the problem is ADHD?
Because everyone shows some of these behaviors at times, the
diagnosis requires that such behavior be demonstrated to a
degree that is inappropriate for the person's age. The
diagnostic guidelines also contain specific requirements for
determining when the symptoms indicate ADHD.
The behaviors must appear early in life, before age 7, and
continue for at least 6 months. Above all, the behaviors must
create a real handicap in at least two areas of a person's life
such as in the schoolroom, on the playground, at home, in the
community, or in social settings. So someone who shows some
symptoms but whose schoolwork or friendships are not impaired by
these behaviors would not be diagnosed with ADHD. Nor would a
child who seems overly active on the playground but functions
well elsewhere receive an ADHD diagnosis.
To assess whether a child has ADHD, specialists consider several
critical questions: Are these behaviors excessive, long-term,
and pervasive? That is, do they occur more often than in other
children the same age?
Are they a continuous problem, not just a response to a
temporary situation? Do the behaviors occur in several settings
or only in one specific place like the playground or in the
schoolroom? The person's pattern of behavior is compared against
a set of criteria and characteristics of the disorder as listed
in the DSM-IV-TR.
Diagnosis
Some parents see signs of inattention, hyperactivity, and
impulsivity in their toddler long before the child enters
school. The child may lose interest in playing a game or
watching a TV show, or may run around completely out of control.
But because children mature at different rates and are very
different in personality, temperament, and energy levels, it's
useful to get an expert's opinion of whether the behavior is
appropriate for the child's age. Parents can ask their child's
pediatrician, or a child psychologist or psychiatrist, to assess
whether their toddler has an attention deficit hyperactivity
disorder or is, more likely at this age, just immature or
unusually exuberant.
ADHD may be suspected by a parent or caretaker or may go
unnoticed until the child runs into problems at school. Given
that ADHD tends to affect functioning most strongly in school,
sometimes the teacher is the first to recognize that a child is
hyperactive or inattentive and may point it out to the parents
and/or consult with the school psychologist.
Because teachers work with many children, they come to know how
"average" children behave in learning situations that require
attention and self-control. However, teachers sometimes fail to
notice the needs of children who may be more inattentive and
passive yet who are quiet and cooperative, such as those with
the predominantly inattentive form of ADHD.