Attention deficit-hyperactivity disorder (ADHD), also called hyperkinetic disorder, is a neurobehavioral disorder or mental disorder that is typified either by significant inability to pay attention or control hyperactivity or impulsiveness, or a combination of those. Symptoms typically manifest before patients turn seven years old (Bray). There are three major types: ADHD-PI (predominantly inattentive), ADHD-HI (hyperactive-impulsive) or ADHD-C (a combination. Many people refer to ADHD-PI as ADD because hyperactivity is not typically a part of the diagnosis. ADHD significantly impacts children of school age and leads to impulsive behaviors, restlessness and a general lack of focus which keeps them from learning effectively.
ADHD is the most frequently diagnosed and studies psychiatric disorder among children. Worldwide, it affects between three and five percent of all children; in school-aged children, it is found in between two and 16 percent. Between a third and a half of people who receive an ADHD diagnosis during childhood continue to have those symptoms during adulthood. Adolescents and adults who have ADHD usually develop a series of coping mechanisms to compensate for the impairments that the condition causes (Gentile et al.). Between two and five percent of adults are estimated to be living with ADHD. It appears about three times as often in boys as it does in girls. However, the symptoms make it tricky to differentiate ADHD from some other disorders, which makes it likelier that ADHD diagnosis can be missed. Also, many clinicians have not taken formalized training in the best methods for assessing and treating ADHD, particularly in adult age patients.
Managing ADHD is different from patient to patient. However, a combination of counseling, lifestyle alterations, behavior therapy and medications is the general treatment pattern. Only those children who show severe symptoms of ADHD should start treatment with medications. Medical therapy should only be considered for moderate-symptom patients who do not agree to the psychotherapeutic treatment options or who fail to improve with that sort of treatment. Because it involves school aged children, ADHD and its management have been a source of controversy for four decades now. These controversies have drawn in teachers, clinicians, policy planners, parents and even the media. Topics under discussion include the causes and in particular the utilization of stimulant prescriptions to treat it (Cohen & Ciccheti). Today, the vast majority of health care providers view ADHD as an authentic disorder, meaning that the primary controversy has to do with diagnosis and treatment protocols.
The most common symptoms of ADHD are disruptive behavior, impulsivity, hyperactivity and inattention (Bray). Academic struggles also are common, but they are not a necessary element for diagnosis. Because it is difficult to establish where normal metrics of those four symptoms lie for each individual child, though, planning initial treatment plans can be difficult. In order for a person to receive a diagnosis of ADHD, the symptoms must manifest and be observed in two different settings for at least six months, with a degree that must be higher than what is considered acceptable for a child of that age.
For ADHD-PI, the symptoms include the following:
- Being easy to distract, omitting details, forgetting objects, switching quickly among activities
- Losing interest in a task after just a few minutes, unless involved in an enjoyable task
- Losing focus when working on just one task for a long period of time
- Seeming to ignore others who are speaking to you
- Daydreaming, becoming confused, and moving very slowly
- Struggling to precisely follow instructions
- Having difficulty with focus and organization (National Institute of Mental Health)
For ADHD-HI, the symptoms are somewhat different, because of the movement involved in the condition:
- Talking without stopping and fidgeting or squirming in seats
- Moving constantly, running around and playing with and touching all objects in sight
- Having trouble with sitting still during meals, classes and other environments
- Blurting out comments that are inappropriate and showing feelings without restraint
- Acting without any consideration of consequences
- Having a very hard time waiting for desired objects or for turns in game (National Institute of Mental Health)
It is worth noting, of course, that the vast majority of people demonstrate some, or even many, of these behaviors but do not suffer from ADHD. When those behaviors do not interfere with studies, relationships or work in a significant way, then a diagnosis of ADHD is inappropriate. However, for those who do have ADHD, there is an increased risk of difficulties with basic social skills, such as developing and maintaining friendships and interacting with others in social situations. About half of all children and teens who have ADHD find rejection from peers, as opposed to about an eighth of children and teens who do not have ADHD. One form of treatment for these patient can include training in behaviors and social skills, as well as medications. However, the key factor in eliminating the possibility of such psychopathological outcomes as criminal behavior, significant depression and substance abuse is the creation of friendships with others who do not get into delinquent activities (Mikami).
Another unpleasant fact about ADHD is that it generally exists in combination with other disorders or problems. The co-incidence of ADHD with those conditions can make both diagnosis and treatment a lot more complicated. There are significant conditions, though, that can manifest alongside ADHD and need their own courses of recommended treatment. Some of these associated conditions include:
- Oppositional Defiant Disorder (ODD), which manifests with ADHD at about a rate of 50 percent, is typified by such antisocial signs as aggression, stubbornness, temper tantrums, lying, stealing or deceitfulness. While this co-manifestation is so common, brain imaging technology has shown that these two have unique causes and are not related on a physiological level (Mikami)
- Bipolar Disorder, Major Depressive Disorder and other Mood Disorders; boys who have received a diagnosis of ADHD-C are more likely to have one of these related disorders.
- Anxiety Disorders, which are more common in the ADHD population
- Obsessive Compulsive Disorder (OCD), which actually shares a lot of the characteristics of ADHD; both can occur at the same time
- Substance Use Disorders, the risk of which goes up significantly for those with ADHD; substance disorders make evaluating and treating ADHD almost impossible. Because the reward pathways in the minds of ADHD individuals are different from other people’s, there may be a heightened risk of substance abuse in those individuals as well (Gentile et al.).
- Restless Leg Syndrome accompanies ADHD quite frequently; sometimes it is due to iron deficiency, but sometimes it is just one of the ADHD symptoms.
- Sleep disorders like obstructive sleep apnea can lead to symptoms in children that match the ADHD criteria. Sometimes the medicines used to treat ADHD can cause insomnia; for this reason, behavioral therapy is a preferred first line of treatment in both cases.
Other problems that commonly strike ADHD children include regular bed wetting and dyspraxia; about one of every two dyspraxic children also has ADHD (Bray). Depression becomes more and more common among ADHD patients as they age from childhood into adolescence (more frequently among girls than boys). When mood disorders accompany ADHD, it is recommended to treat the mood disorder first (Gentile et al.).
The causes of ADHD are not specifically known at this time (Bray). There are many factors that contribute to its incidence, such as genetics, nutrition and general environment. Genetics plays a factor in about three of four ADHD cases, and hyperactivity also is passed down genetically quite frequently (Bray). Many of the genes that affect transportation of dopamine are the likely causes for ADHD to occur; candidate genes do include DAT1, DRD4, DRD5, 5HTT, HTR1B and SNAP25 (Gizer, et al.). Just a variant of the LPHN3 gene causes almost a tenth of all cases of ADHD; cases in which that gene exists do respond well to stimulant medicines (Gentile et al.).
Another reason behind the growing incidence of ADHD is that natural selection may actually favor the condition. Some of the individual traits can be helpful by themselves, only to cause more dysfunction when they combine to form the disorder. The fact that women are often attracted to men who take risks means that men with ADHD are generally more attractive, placing more ADHD-likely genes into the pool (Bray). There was a 2006 study about the ways in which ADHD traits actually cause benefits (Williams & Taylor). Because people with ADHD tend to have some more success in tasks that involve competition, risk and behavior that is unpredictable, ADHD can be both beneficial for individuals and in social situations. Because ADHD is quite common in mothers who are stressed or anxious, ADHD prepares a child to face that stress with explorative behavior and heightened impulsivity (Williams & Taylor). In societies that are less regimented than ours, such as nomadic ones or migratory ones, these traits actually cause significant social benefits.
There are also some environmental factors that promote the development of ADHD. One is alcohol consumption during pregnancy; if the intake is high enough, it can give the child a place on the fetal alcohol spectrum disorder, which produces similar to those of ADHD. Those who are exposed to cigarette smoke during pregnancy can give their fetus impaired development, including elements of the central nervous system, which can also lead to symptoms that warrant an ADHD diagnosis. While not all children exposes to these substances in the womb develop ADHD, there is the possibility that a combination of environmental and genetic factors leads to a greater likelihood of developing the condition. Exposure to lead can also lead to similar neurocognitive deficits that look like ADHD, leading to positive diagnoses (Bray). Other environmental factors include premature birth, extremely low weight at birth and early adversity in infancy can lead to ADHD. About one in three children who have a traumatic brain injury as a child develop ADHD (Eme).
Diet is another factor that can lead to ADHD incidence. Benjamin Feingold, a pediatric allergist, was the first medical professional to suggest that additives and colorings in food could cause changes in juvenile behavior (Bray). The evidence between food coloring and hyperactivity is inconclusive, but for those children who already have a genetic predisposition toward ADHD, some food colorings could be a risk factor. Sunset yellow FCF, allura red, tartrazine, ponceau 4R, carmoisine and quinoline yellow have all been identified as the colorings with the most risk of causing ADHD in children (Chapman).
There is also the possibility that social variables can lead to instances of ADHD. Dysfunction or other shortcomings in the family structure can cause neurological issues, and there is research indicating that strong relationships with caregivers have positive relationships on self-regulatory and attentional abilities. One study indicated that foster children were much more likely to show symptoms of ADHD (Finkelstein, et al.) Homes with emotional abuse and violence also had children with signs of ADHD. Indeed, children and adolescents suffering from post-traumatic stress disorder (PRSD) show many symptoms that can be erroneously diagnoses as ADHD (Chapman).
Because the specific causes of ADHD are not proven beyond a doubt, though, eliminating the disorder is not currently an option open to scientists. Given the fact that there are several positive personality traits associated with the disorder, it might not be prudent to eliminate it anyway. Rather, the challenge is on instructional designers to find ways to channel the energies of ADHD children effectively, so that classroom instruction can take place, and children everywhere on the spectrum of ADHD can learn.
Works Cited
Bray, Melissa A., and Thomas Kehle, eds. The Oxford Handbook of School Psychology. New York: Oxford University Press, 2011.
Chapman, Sarah. “Guidelines on Approaches to the Replacement of Tartrazine, Allura Red, Ponceau 4R, Quinoline Yellow, Sunset Yellow, and Carmoisine in Food and Beverages.” http://www.food.gov.uk/multimedia/pdfs/publication/guidelinessotonsixcolours.pdf
Eme, R. “ADHD: An Integration with Pediatric Traumatic Brain Injury.” Expert Review of Neurotherapy 12(4): 475-483.
Gentile, Julie, Atiq, R., and Gillig, P.M. “Adult ADHD: Diagnosis, Differential Diagnosis and Medication Management.” Psychiatry 3(8): 24-30.
Gizer, I.R., Ficks, C. and Waldman, I.D. “Candidate Gene Studies of ADHD: A Meta-Analytic Review.” Human Genetics 126(1): 51-90.
Mikami, A.Y. “The Importance of Friendship for Youth with Attention-Deficit/Hyperactivity Disorder.” Clinical Child & Family Psychological Review 13(2): 181-198.
National Institute of Mental Health. “Attention Deficit Hyperactivity Disorder.” http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity- disorder/complete-index.shtml
