2008-07-19
ADHD
is characterized by difficulties with frequent distractibility, coupled
with an inability to sustain attention to tasks or persist toward goals
as well as others, particularly if the situation demands effort. Just
as problematic are difficulties with making impulsive decisions and
otherwise being less able to control behavioral impulses. This
often leads people with the disorder to talk excessively, frequently
interrupt others, make impulsive comments, be more impatient, and less
able to delay gratification or wait for things; they are more prone to
take risks without thinking. Many people, though by no means all, may also have problems with controlling their activity level. They
are typically fidgety, restless, hyperactive, and otherwise engage in
frequent task-irrelevant behavior, or activity that is frankly
inappropriate for the situation. Hyperactivity is more likely to be
present in childhood, and usually declines substantially by adolescence
and adulthood, often becoming more subjective and manifested as an inner
sense of restlessness and needing to be busy.
Over
the past century, ADHD was previously named defective moral control,
hyperkinetic reaction of childhood, hyperactivity or hyperactive child
syndrome, minimal brain damage or dysfunction, and Attention Deficit
Disorder (with or without Hyperactivity), among other terms. For a more thorough history of ADHD, see the professional textbook below by Barkley (2006), or visit the Web sites http://russellbarkley.org (under Research to Read, Chapter 1) or http://chadd.org/.
Normal individuals, particularly young children, may show some of the behavioral characteristics of ADHD in some contexts, such as occasional distractibility or poor concentration. What distinguishes the individual with ADHD from others is the considerably greater degree or frequency with which they display these characteristics. Their behavior rises to a level of being developmentally inappropriate (rare) for their age group. This can result in impairment in major life activities.
During
childhood, these impairments manifest in more stressful and
conflict-ridden family functioning, poor peer relationships, and few or
no close friendships, disruptive behavior in community settings (stores,
church, etc.), less regard for personal safety leading to increased
accidental injuries, slower development of self-care and personal
responsibility, and significantly lower school performance and eventual
educational attainment. In adolescence and adulthood, it can result in
poorer occupational functioning, frequent job changes, and risky sexual
activities leading to a marked increase in teen pregnancy and sexually
transmitted disease. It is also associated with unsafe
driving (speeding, frequent accidents), difficulties managing finances
(impulsive spending, excessive use of credit cards, poor debt repayment,
little or no savings, etc.), and greater problems in dating or marital
relationships (conflict-ridden interactions, high rates of expressed
emotion, risky sexual activity, infidelity, etc.). A
significant minority of teens and adults manifest a greater propensity
for antisocial activities, such as lying, stealing, and fighting, and
this is often associated with a greater risk for illegal drug use and
abuse. Adults with ADHD often lead a generally less
healthy lifestyle, exercising less and engaging in more solitary means
of self-entertainment, such as playing video games, watching television,
surfing the Internet, and pointless socializing on the phone. They
may be more prone to obesity, poorer nutrition, greater use of
nicotine, alcohol, and marijuana, and consequently an increasing risk
for coronary heart disease (see Barkley, Murphy, & Fischer, 2008).
- Poorly sustained attention or persistence of effort to tasks, particularly those that are relatively tedious, boring, and protracted. The individual becomes bored rapidly during repetitive tasks, shifts from one uncompleted activity to another, frequently loses concentration during lengthy tasks, and fails to complete routine assignments without supervision. Combined with these problems of persistence are striking difficulties with distractibility such that the person’s concentration is often easily interrupted by irrelevant thoughts or even minor external events.
- Impaired impulse control and delay of gratification. This is often noted in the individual's not being able to stop and think before acting; making impulsive decisions; being less able to tolerate waiting, such as taking turns while playing or talking with others; inability to work for larger, longer-term rewards rather than smaller, immediate ones (delaying gratification); excessive talking and tangential rambling across ideas, and not being able to inhibit behavior as a situation demands. As teens or adults, they are more prone to speeding with a motor vehicle, driving-related anger and hostility, and otherwise low frustration tolerance.
- Excessive task-irrelevant activity or poorly regulated activity to situational demands. Most, but by no means all individuals with ADHD, are excessively fidgety, restless, and "on the go" as children. They display movement that is not needed to complete a task, such as wriggling feet and legs, squirming in their seats when required to remain seated, tapping their hands or feet, touching things frequently, rocking, or often shifting their position while performing relatively boring tasks. Trouble sitting still or inhibiting their movement as a situation demands is most often seen in younger children with ADHD. This hyperactivity may decline with age more so than the inattentiveness and impulsiveness noted above and, by adulthood, is often reported to be a more internal or subjective feeling of the need to be busy or always doing things than the overt hyperactivity seen in childhood.
Individuals who exhibit chiefly the attention problems but do not display excessive activity levels or poor impulse control are presently considered to have the Predominantly Inattentive Type of ADHD. First recognized around 1980, they comprise 30% or more of clinically referred cases. Many of these cases are just milder forms of the Combined Type noted above. But 30-50% of cases of this type appear to have a qualitatively different form of attention problem from that seen in the Combined Type. Researchers now refer to this subset of cases as having a “sluggish cognitive tempo” (SCT) and view them as differing in many respects from the Combined Type of ADHD. These differences are becoming numerous enough that some researchers have argued that this may represent a separate disorder from ADHD. Other scientists do not go quite this far, yet realize this subgroup differs in some qualitative ways from the Combined Type. These differences include:
- Different symptoms of inattention and motor activity, including:
- Daydreaming, spacey appearance, frequent staring
- Hypoactivity, slow moving, lethargic, and sluggish
- Easily confused, mentally “foggy”
- Slow, error prone information processing
- Poor focused or selective attention (identifying what is important from what is not in the information one must process rapidly).
- Possibly more erratic retrieval of information from long-term memory
- Being socially reticent, shy, apprehensive, or withdrawn
- Not impulsive
- Having different co-existing disorders from that pattern seen in the Combined Type, such as:
- Rarely showing social aggression, known as oppositional defiant disorder, or conduct disorder (antisocial behavior such as frequent lying, stealing, fighting, etc.), both of which occur considerably more often in children with the Combined Type
- Greater risk of anxiety symptoms and possibly depression
- Equally impaired in educational performance but possibly due to making more errors in the accuracy of their work whereas Combined Type cases show relatively more problems with productivity or the amount of work completed
- Just as likely to have learning disabilities (20-50%) but to have a possibly greater frequency of math disorders
- Possibly less likely to have a clinically impressive response to stimulant medications
- Possibly a better response to social skills training and as food or better response to home and school behavior management methods than ADHD Combined Type cases are likely to show
Other Features of ADHD
Several other features characterize the disorder, particularly of the Combined Type of ADHD:An early onset of the symptoms. Many ADHD individuals begin to show symptoms in early childhood, often at 3 or 5 years of age, and half or more have had their difficulties since the age of 7. Nearly all cases have developed their symptoms by 14-16 years.
Deficits in executive functioning or self-regulation. ADHD is frequently associated with problems with working memory, which involves holding information in mind that is guiding one’s behavior toward tasks or goals. Another executive deficit seen in ADHD is exceptionally poorer self-motivation, or an inability to sustain one’s work or effort in the absence of immediate consequences. Additional executive deficits involve difficulties with planning ahead, problem-solving, or otherwise efficiently accomplishing goal-directed behavior. These cognitive abilities are part of a larger complex of mental faculties known as the executive functions because they contribute to self-control and future-directed actions. Like a chief executive officer of a company whose purpose is to guide, direct, and otherwise oversee the activities of a company to accomplish its overall missions, the executive system of the brain engages and orchestrates the other brain functions to enlist them in completing goals or in other ways directing behavior toward effectively anticipating and preparing for future events.
A highly variable or inconsistent pattern of work performance. ADHD individuals show wide swings in their performance of various tasks and in the amount of work they produce across time. To a lesser extent, there is also greater variability in the quality, correctness, and speed with which they perform assigned work. This may be seen in behavior as simple as greater variability in one’s reaction time to unexpected events, such as while driving, and as more variable productivity in complex tasks such as school or work performance. This variability and the other symptoms of ADHD are less apparent in situations involving one-to-one activities with others, highly rewarding or high-interest activities for that individual, and in novel situations. In children, the symptoms may be particularly less apparent if they are with their fathers or other authority figures, as compared with their mothers. They also do better at sustaining their attention when the activities are new, highly interesting, or involve an immediate consequence for completing them. Group situations or relatively repetitive, familiar, and uninteresting activities are likely to cause the most problems with concentration, distractibility, poor persistence, and generally disruptive behavior. Situations that involve waiting or being patient also pose difficulties for their self-restraint.
Trouble following directions, instructions, or rules. ADHD individuals often have difficulty following through on instructions or assignments, particularly without supervision. This is not due to poor language skills, defiance, or long-term memory impairment. It seems as if instructions do not guide behavior as well in ADHD individuals, perhaps in part due to not being able to hold the instruction in mind (working memory) and to a relatively weak influence of internal language (self-directed speech) over one’s behavior.
A relatively persistent course. Over 70% of children with ADHD continue to have sufficient symptoms to retain their diagnosis from childhood to adolescence. Although the major features improve with age, most ADHD individuals remain behind others in their ability to sustain attention, inhibit behavior and emotions, resist distractions, control their activity level, and self-organize their work. Recent studies suggest that as many as 65-86% continue to have significantly elevated symptoms that result in some impairment in adulthood.
Conditions Frequently Associated with ADHD
People with ADHD are more likely to have other psychiatric, learning, and health-related disorders, known as comorbidity. These include:Academic under-productivity, underachievement, and learning disabilities. The vast majority of individuals with ADHD produce far less work in school than do others of their age with the resultant adverse affects upon their grades, class ranking, and teacher relations. Probably because they are distractible, and “off-task” so often when work must be done, they often get less work done than others and may be less accurate in the work that they do. Studying or other academic work often requires a far greater expenditure of effort to complete successfully. They also often perform below their expected levels of academic achievement, such as in math, reading comprehension, history, etc. when tested relative to their intellectual abilities. As many as 30% of those with ADHD may have reading disorders, or dyslexia. Between 10-25% may have spelling disorders, 10-35% may have math disorders, and more than half have handwriting problems. Language problems may occur in 15-35% of cases while difficulties with using language during interactions with others, known as pragmatics, are far more common. Excessive and irrelevant speech, tangential rambling of ideas, and inability to quickly get to their point, limited reciprocity or turn-taking, and greater expressed emotion are often seen in their conversations with others, as is an inability to appropriately terminate or shift conversations as the situation demands.
Aggression or conduct problems. Studies suggest that 45-84% of individuals with ADHD have a co-existing condition known as Oppositional Defiant Disorder (ODD) or social aggression. This is characterized in childhood and adolescence as frequent arguing, defiance toward adults or other authorities, stubbornness, disobedience, or temper outbursts. Approximately 20-45% may show more serious forms of social aggression known as Conduct Disorder and exemplified by lying, stealing, destructiveness, verbal or physical aggression toward others, and otherwise violating rules and the law, as well as the rights of others.
Excessive emotional displays or immaturity. A pattern of exaggerated emotional expressions may be observed, particularly in children with ADHD, in which the individual tends to react to frustrating, provocative, or stressful situations impulsively and often with poorly moderated emotions that others would have dampened or quelled entirely, considering the consequences at stake for their social acceptance by others. Such excessive displays of emotional dyscontrol or relatively raw feelings can lead to significant social conflicts and eventual rejection by others, especially peers and employers. Individuals with ADHD may be described as being hot-headed, having a low frustration tolerance, being excessively impatient, and as being more moody or emotionally sensitive than others. In a sense, their emotional reactions to events are as impulsive as the rest of their behavior. A quickness to display anger, sadness, elation, or other normal emotions occurs frequently in people with ADHD. It is not that these reactions are abnormal or grossly inappropriate for the place or setting as might be seen in manic-depression, schizophrenia, or autism. Instead they are more easily expressed than is normal for their age and are often less moderated than what others would have shown in a like circumstance.
Problems in social relationships. At least 50% of individuals with ADHD have problems initiating or maintaining social relationships and frequently have trouble negotiating and resolving conflicts with others. They may be described as self-centered, demanding, intrusive, insensitive to the feelings or needs of others, and unappreciative of assistance from others. These problems are especially common in that subset of cases that also have oppositional defiant disorder or conduct disorder (anti-social and aggressive behavior).
The Prevalence of ADHD
ADHD occurs in approximately 3-8% of the childhood population and 4-5% of adults. It is three times more common in boys than girls in childhood but by adulthood it is approximately 2 males to every female with the disorder, or less. The disorder is found in all countries and ethnic groups studied to date. ADHD is somewhat more common in urban and population dense regions than in suburban or rural settings and is found across all social classes and in all ethnic groups. It is more commonly seen in individuals with a history of oppositional defiant disorder, conduct disorder (aggression, delinquency, truancy, etc.), learning disabilities (delays in reading, spelling, math, writing, etc.), childhood bipolar disorder, juvenile offenders, adult antisocial personality, cigarette smokers, alcoholics and those having other substance use or abuse disorders, people with tic disorders or the more severe Tourette's Syndrome (multiple motor and vocal tics), and those having autistic spectrum disorders.The Causes of ADHD
ADHD is clearly the result of multiple causes. Nearly all of those recognized as having a sound scientific basis fall in the realm of neurology and genetics. A purely social cause of ADHD has not been identified, which is to say that one cannot turn a normal child into one with ADHD merely by exposing them to some social circumstance. The evidence for the hereditary or genetic basis of ADHD is now overwhelming and irrefutable. It is now believed that genetics probably accounts for 65-75% of all clinical cases. Numerous studies of twins hae found that an average of 80% of the differences among people in a general population in their level of ADHD symptoms results from differences in their genes. The disorder is also found to occur far more often among biological family members of those diagnosed with the disorder. For instance, if a child is diagnosed with ADHD, 20-30% of their biological mothers, 25-35% of their biological fathers, 25-40% of their biological siblings, and 78-92% of their identical twins (if they are such a twin) will also have the disorder. This demonstrates that the closer is the genetic relationship between two people the greater is the likelihood that one will have the disorder should the other one already do so; clear evidence that heredity plays a substantial role in the disorder.Given this strong pattern of inheritance, it is not surprising that researchers are finding that ADHD is associated with variations in certain genes that regulate neurotransmitters in the brain, such as dopamine (e.g., genes labeled DRD4, DAT1, DRD2, DRD5, DBH, etc.), and likely norepinephrine as well. Other genes related to the development of the disorder are likely to be identified given that recent studies that scanned the entire human genome searching for ADHD risk genes have found at least 20 sites on chromosomes that are associated with ADHD. It is therefore likely that ADHD arises from a combination of multiple risk genes, with each contributing a small likelihood of risk for the disorder. The more risk genes one inherits, the greater the number and severity of ADHD symptoms and so the greater the probability one will be impaired by, and diagnosed with the disorder. In the future, genetic subtypes of the disorder are likely to be identified with each differing from the others in the types of symptoms that are most apparent and the nature and forms of impairments (consequences) they are likely to experience across the lifespan. Already, research shows that certain genes related to ADHD may also predict the person’s likelihood of responding to the various anti-ADHD medications currently available. There is hope that genetic testing may eventually facilitate more accurate diagnosis and subtyping.
In a smaller percentage of cases (25-35%), ADHD may arise from early brain injuries or other disruptions to normal brain development, such as being exposed to maternal alcohol consumption or smoking during pregnancy, greater pregnancy or birth complications, frequent maternal upper respiratory infections during pregnancy, early and serious lead poisoning of the child, atypical auto-immune reactions to bacterial infections, head trauma, brain tumors, stroke, etc. In summary, a substantial minority of cases of ADHD appear to be related to early brain injuries while a majority of cases are due to gene variations in the human population.
Studies employing various techniques for imaging the human brain have identified at least four brain regions linked to ADHD that appear to be somewhat smaller in brain volume and are less active than in control samples. These areas include the orbital prefrontal cortex, particularly in the right hemisphere, the basal ganglia and especially the striatum within this neural complex, and the cerebellum, particularly the central vermis region and likely more in the right hemisphere. More recent studies of brain function have also identified the anterior cingulate, located in the central midline region of the frontal lobes to be considerably less active in those with ADHD during tasks that demand inhibition, persistence, resistance to distraction, and evaluating short-term versus longer-term consequences for a particular behavior.
A more popular view is that ADHD is frequently due to the consumption of food additives, preservatives, or sugar. Available evidence suggests that sugar plays no role in the disorder and that fewer than 1 in 20 preschool children with ADHD may have their symptoms worsened by additives and preservatives. While various allergies, ear infections, and food intolerances can contribute to a worsening of ADHD in a few cases, these factors are not viewed as the cause of ADHD. Just as popular is the view that ADHD is the result of watching too much television or spending too much time playing video games as a child. No compelling evidence exists to support this idea other than that people growing up with ADHD may be more likely to watch television or play video games, but they are also more likely to talk on the phone, or go joy riding in cars while spending less time reading for pleasure or self-improvement, exercising, or continuing their education past high school. This difference in the pattern of how leisure time is spent appears to be the result of having the disorder instead of being the cause of it.
Individuals with seizures or epilepsy have a 2-3 times greater likelihood of having ADHD just as those with ADHD have the same risk of having seizure disorders. Those who must take sedatives or anticonvulsant drugs may develop ADHD as a side effect of their medication or may find their pre-existing ADHD features made worse by some of these older medications, such as Phenobarbital or Dilantin.
The Life Course Risks and Adult Outcomes of ADHD
It has been estimated that from 14-35% of children with ADHD ultimately outgrow the disorder, placing them within the upper normal range of adults in their symptoms and extent of associated impairment by their late 20s. But two-thirds or more of individuals diagnosed as children will continue to display significantly elevated levels of their symptoms into adulthood that will result in impairment in one or more major life activities. Up to 54% of cases diagnosed in childhood may retain the full disorder as adults by their late 20s.Children with ADHD who begin to exhibit serious aggressiveness, defiance, and lying or stealing during elementary school years are most likely to be at serious risk for later antisocial behavior problems and drug use and abuse. This leads them to be more likely to have been arrested and jailed by the time they are adults. Yet even those children with ADHD who did not have serious conduct problems may also be at risk for drug-related problems in adulthood. Teens and adults with ADHD are also more likely to smoke tobacco or use caffeine and to do so more frequently. They drink more alcoholic beverages per week and use more marijuana than do others. Those who developed conduct disorder by adolescence were the ones most likely to abuse prescription drugs or to use harder drugs such as crack, cocaine, heroin, or hallucinogens. In these cases, the increased use of drugs is likely to feed back and further worsen the risk for subsequent antisocial activities, suggesting a mutual spiraling effect between these two domains of behavior. The failure to complete high school can further worsen these risks for later crime and drug use/abuse. Abundant research exists to show that this increased propensity for drug use and abuse is not a consequence of having been treated with anti-ADHD drugs in childhood, such as the use of stimulants, but is a direct correlate or consequence of ADHD itself and especially of its association with conduct disorder by age 15 years.
The most common area of maladjustment is in educational performance and the extent of education one eventually attains. People with ADHD are more likely to be held back in a grade (25-50%), to be placed in special education (50-80%), to be suspended for inappropriate conduct (10-20%), to be expelled (10-15%), or to quit (30-40%) before completing high school. They are therefore less likely to attend college and, if they do attend, are less likely to complete that program (5-10% for those with ADHD vs. 35% of adults in the general population). ADHD individuals therefore often have less education than do others their age. Obviously, those with high levels of intelligence are better able to achieve more years of education and some may even complete advanced graduate degrees.
Besides showing a substantial adverse impact on educational success, ADHD also leads to significant impairment in operating motor vehicles. Substantial research shows that people with the disorder employ less safe driving practices and have more problems with attention, distractibility, and impulse control while driving. As a consequence, they may show 3-4 times the frequency of speeding and parking tickets, are 2-3 times more likely to have a crash with a vehicle and to have more such crashes, are more likely to be at fault in causing the crash, and have more severe accidents as reflected in dollar damage to property and risk of bodily injuries in the crash. It is not surprising that they therefore are 2-3 times more likely to have their license suspended or revoked over the first 10 years of driving.
A few studies have evaluated the sexual activities and lifestyles of teens and adults with ADHD. The results are consistent in showing a more risky pattern to these activities than is seen in the general population. For instance, teens with ADHD appear to have their first episode of sexual intercourse an average of a year earlier than other teens. They are also likely to spend less time in each of their close or intimate relationships and therefore to change partners more often than others. They may also engage in brief sexual relations with others besides those with whom they have a committed relationship (infidelity). They also tend to be less likely to employ contraception during sex. Consequently, they are nearly 10 times more likely to have a child before age 21 and are 4 times more likely to have contracted a sexually transmitted disease. This pattern of earlier parenthood was also typical of their own parents, probably due to the increased risk of ADHD in those parents as well. They and their partners also report a significantly lower level of marital or relationship satisfaction than is typical of the general population. And given the strong genetic contribution to the causes of ADHD, studies have found that adults with the disorder are 8 times more likely to have children with the disorder (40-54%) than is the case for adults without the disorder. As parents, they are also likely to report greater stress in their relationships with their children than do other parents, some of which is clearly due to their own children having the same disorder and/or more oppositional behavior generally.
As they enter the workforce, teens and adults with ADHD have more problems in their occupational functioning. They start working earlier than others due to the lower likelihood of attending college. Many change jobs more often out of boredom, are 2-3 times more likely to be dismissed from a job due to poor conduct, demonstrate more ADHD and oppositional behavior in their workplace, and may be more hostile to others. They are less punctual for work, appear to manage their time less efficiently, and require more supervision than do other workers, resulting in their receiving lower ratings of their work performance from supervisors than do others without ADHD. This can result in their having a greater likelihood of formal disciplinary actions taken against them by their employers than do others who are not ADHD. Adults with ADHD have recently been found to make more claims for workman’s compensation, take more unexcused absences from work, and use more of their sick leave relative to the general population of working adults.
Managing their finances can also be an additional area of risk for adults with ADHD. They report a higher incidence of problems with managing money, saving money, buying on impulse, nonpayment of utilities resulting in their termination, missing loan payments, exceeding credit card limits, having their cars repossessed, and having a poor credit rating. They are also less likely to be able to save money or invest for retirement than does the general population.
Research is beginning to show that ADHD that persists into adulthood may be associated with a less healthy lifestyle and a growing risk for coronary heart disease. Adults with ADHD report more sleep problems, trouble in social relationships and family interactions, and in use of tobacco and non-prescribed drugs. They also have poorer preventive medical/dental care, poorer motor vehicle safety, greater stress in their work and leisure lives, and more concerns about their emotional health than do adults without ADHD. One study recently found a growing risk for future heart disease in patients with ADHD as reflected in lower levels of good cholesterol (HDLs) and a higher HDL-to-LDL ratio, greater body mass index, greater frequency of smoking, and lower levels of routine physical exercise (see text by Barkley, Murphy, & Fischer, 2008).
Left untreated, ADHD therefore appears to convey a variety of risks for impairment in many major life activities across the lifespan.
The Treatments for ADHD
No treatments have been found to cure this disability, but many exist that have shown substantial effectiveness in reducing either the level of symptoms or the degree to which they impair adjustment. The best substantiated treatments for children with ADHD are medication management (stimulants, such as methylphenidate and amphetamines, and the non-stimulant, atomoxetine), behavioral parent training, behavioral interventions in educational settings, special educational placements, and information-based counseling of parents and family members. Social skills training has shown less promise and rather contradictory findings in the current literature.Stimulants have been used to treat ADHD children since 1937. They are the best-studied medications for the management of ADHD, showing efficacy in 75% or more of ADHD children, and possibly more if all stimulant classes are tested in sequence during the drug trial. Beneficial effects are substantial, with 50–60% of children with ADHD being normalized in their behavior during active medication therapy, and another 20% or more improved but not normalized. The response rate for children below 5 years of age may be less robust and side effects may be somewhat greater. The side effects of stimulants are fairly benign, short-lived, dose related, and often managed through dose or timing adjustments, or by switching to a different delivery system or stimulant. Initial concerns about growth were over-rated, with more recent studies suggesting a relatively limited impact on weight gain, averaging 1–4 pounds during the first year or two of treatment with little or no impact thereafter. Effects on delayed growth in height are arguable and may be in the range of 1–2 cm during the initial year of treatment, again with little evidence for any ongoing growth delay thereafter. However, the fact that a few children may have more significant growth problems on stimulants warrants periodic monitoring and plotting of growth parameters on published standardized growth charts.
The two most commonly used stimulant categories for management of ADHD are methylphenidate (trade names: Ritalin, Ritalin SR, Ritalin LA, Concerta, Metadate CD, Methylin, Daytrana, Focalin XR) and the amphetamines (trade names: Dexedrine, Adderall, Adderall XR, Vyvanse). They are well-studied medications and highly effective for the management of most cases of ADHD. Recent years have witnessed the development of once-daily delivery systems for methylphenidate and related medications (Concerta, Metadate CD, Ritalin LA, Daytrana, Focalin XR) and the amphetamines (Adderall XR, Vyvanse) such that children may not require any administration of medication while in school. These new delivery systems can provide 8–14 hours of therapeutic benefit.
The evidence on the safety and efficacy of the stimulants is substantial. When prescribed appropriately and monitored carefully, these medications are safe and effective with no evidence currently available suggesting any long-term consequences from years of medication use. The effects of the immediate release preparations of the stimulants are evident within 15–30 minutes of ingestion, seem to peak in 2–4 hours, and typically dissipate in 3–5 hours. The once-daily extended release preparations result in a considerable extension of this time course such that behavioral effects may last for 8–14 hours, depending on the delivery system and person’s individual rate of metabolizing the drug. The most common side effects for the stimulants are insomnia (trouble falling asleep), loss of appetite (particularly at lunch), headaches, and stomachaches. Less likely are irritability, increased tics or nervous mannerisms, a temporary delay in weight gain and growth in height, and rarer still, hallucinations (usually of skin sensations).
Atomoxetine (Strattera) is a non-stimulant FDA-approved drug for management of ADHD. It was approved in the United States in 2003. Atomoxetine is the first drug indicated for ADHD that is not a Schedule II controlled substance because it has a low potential for abuse, making it more convenient than the stimulants for sampling, prescribing, and titrating. Available evidence suggests a nearly equal percentage of responders to this medication compared with immediate release methylphenidate yet with fewer side effects (less insomnia, better morning behavior). However, the degree of symptom improvement produced by atomoxetine may be somewhat less than that achieved by the stimulants. Doses can be dispensed either once or twice daily. Over 75% of children show a positive response and this response has been maintained for up to 3 years in longitudinal research. Studies indicate that atomoxetine reduces symptoms of ADHD and of ODD or aggression, increases school productivity, improves social behavior and self-esteem, benefits parent–child relations, and may improve enuresis where present. Interestingly, “morning after dose” behavior is also improved, perhaps owing to greater sleep the previous evening since atomoxetine does not result in insomnia, as can stimulants. Side effects include: sedation (10–20+%), decreased appetite (14–22%); nausea (12%); dizziness (6%); increased blood pressure (2 mmHg diastolic, 3 mmHg systolic); increased heart rate of 8 bpm; temporary weight loss (0.5–2.3 kg), and a very rare occurrence of abnormal liver function tests (1 per every million cases treated). Atomoxetine takes longer to adjust the dose of medicine up to its therapeutic range, and so the full effects of atomoxetine can take up to 3 weeks or longer to become evident.
Other medications have been used to treat ADHD but have not been approved by the Food and Drug Administration (FDA) specifically for such use. These include bupropion (trade name: Wellbutrin), the tricyclic antidepressants (TCAs), anti-hypertensive drugs (clonidine and guanfacine), and the anti-narcoleptic drug modafinil (Provigil). The TCAs are declining in use due to the availability of the safer noradrenergic agents such as atomoxetine and bupropion. The TCAs require cardiac monitoring both before and during treatment, may be prone to habituation in some cases, and often manifest greater side effects than do atomoxetine or bupropion. Clonidine and guanfacine are drugs used to treat high blood pressure that have some effectiveness for the management of hyperactive-impulsive ADHD symptoms. They are also considered ‘off-label’ treatments as they have not been specifically approved by the FDA for treatment of ADHD. They work in part by decreasing arousal but also may indirectly boost norepinephrine levels, as do the stimulants and atomoxetine. Such medications should be considered second or third line because of greater concerns regarding their safety with children, their markedly longer phase for titration, their potential need for monitoring of cardiac functioning, as well as the frequent sedation that may occur during the titration and even maintenance stages of management relative to stimulants and atomoxetine. These antihypertensive agents may be useful where the child demonstrates a failed response to stimulants and atomoxetine, or has significant problems with serious aggressive or destructive/explosive behavior, severe hyperactivity, or tic disorders that have been shown to be exacerbated in a stimulant trial.
Behavioral parent training, or BPT, generally results in improvements in child oppositional behavior rather than in ADHD symptoms specifically, suggesting that the treatment is most useful where parent-child conflict exists. Studies of preschool children with ADHD, however, have found significant improvements in symptoms of ADHD specifically as a function of BPT. BPT techniques generally consist of training parents in general operant conditioning techniques such as contingent application of reinforcement or punishment following appropriate/inappropriate behaviors. Reinforcement procedures have typically relied on praise, privileges, or tokens while punishment methods have usually been loss of positive attention, privileges, or tokens or formal time out from reinforcement. For an example of such training, see the professional books Defiant Children: A Clinicians Manual for Parent Training, or Defiant Teens: A Clinicians Manual for Family Training. Or see the parent book equivalents, Your Defiant Child, or Your Defiant Teen all by Barkley (Guilford Publications, guilford.com). Other similar programs are The Noncompliant Child by Rex Forehand, Ph.D. (University of Georgia) and Robert McMahon, Ph.D. (University of Washington), Parent-Child Interaction Therapy by Sheila Eyberg, Ph.D. (University of Florida), Triple-P (positive parenting program) by Matthew Dadds, Ph.D. (Australia), and The Incredible Years by Carolyn Webster-Stratton, Ph.D. (University of Washington School of Nursing).
BPT programs often use weekly training sessions, either in groups of parents or with individuals, each focusing on a discrete behavior management technique. These methods can be grouped into three basic types of procedures: (1) those that manipulate the setting events that may precede or surround a child’s tasks or activities so as to increase positive or negative behavior (i.e., parental commands, task demands, teacher instructions, etc.); (2) those which may restructure the tasks to be done (reduce work quotas, insert more interesting task materials, etc.); (3) and those that manipulate the positive and negative consequences and their timing for child behavior in that setting (i.e., attention, praise, token reinforcement, punishment, etc.). Because ADHD is a highly genetic condition it is likely that one or both parents may have the same disorder. When present, parental ADHD may reduce the success of BPT. Parental depression, antisocial personality and drug use, limited intelligence or education, parenting stress, or marital distress could likewise limit the success of behavioral parent training.
The contingent use of rewards for good behavior in school, such as staying in seat, doing academic work, and interacting well with others, is a quite successful means of dealing with ADHD-related behavior problems and improving performance in the school setting. These programs generally incorporate token rewards besides praise, which may not be sufficient to increase or maintain normal levels of on‑task behavior in hyperactive children. Disciplinary programs for ADHD-related behavior problems often include taking away tokens or privileges for misbehavior, known as response cost, and time out periods (sitting in a chair in a corner). Also effective has been the use of daily school behavior report cards in which children are rated by their teachers for how well they adhere to specific rules of good conduct at school. These ratings are then converted to tokens or points at home by parents that can be used by the child to buy their favorite privileges, such as time on video games, watching TV, using computers and the Internet, etc. School interventions may also include alterations to the curriculum and work load to better suit the limited attention, persistence, and disorganization of the child with ADHD. Peer-tutoring or other innovative approaches (e.g., competition among small work group teams) to using peer influence to achieve classroom goals have also proven useful. More frequent communication with parents, such as with the daily behavior report card noted above, can also be helpful. In short, greater accountability of the child to teachers and others including more immediate, frequent, and salient feedback or consequences for performance and rule-following, and increased structuring of the classroom environment and teaching materials have all been shown to benefit the child with ADHD in school.
ADHD is included within the Individuals with Disabilities in Education Act (IDEA) that governs the provision of special educational services to children in public schools in the United States. ADHD is also included in Section 504 of the U.S. Rehabilitation Act of 1973 that also provides some accommodations in school for children with disabilities. Many children with ADHD are eligible for free educational evaluations through their school districts and in many cases access to a variety of special educational services and 504 accommodations. A child can be eligible for 504 accommodations (classroom and curriculum modifications and adaptations) if it can be demonstrated that a child’s ADHD adversely affects his or her learning. Under the IDEA, ADHD may be considered under the specific category of “Other Health Impaired” and special education and related services can be provided. Simply having an ADHD diagnosis does not qualify the child in either the Americans with Disabilities Act (ADA) or IDEA; the link between ADHD and adverse learning outcomes must be demonstrated for the child to qualify.
For adults with ADHD, educating them about their disorder and providing practical methods of coping with their disability are the first steps in counseling. Further advice on enlisting the assistance of others in helping to better organize and structure work-related activities may prove helpful. Training in cognitive-behavioral self-control and time-management skills has recently shown some success as a supplement to medication management. Unquestionably, the ADHD medications noted above are the most effective treatments found for ADHD in adults to date. Such medication management can also be supplemented with counseling, stress management, marital or relationship counseling, and assistance with credit and financial management as needed. Those adults with drug use problems will also require treatment from substance rehabilitation programs.
A positive response to medication and the implementation of behavioral and educational accommodations can bring about a dramatic change in a child’s ability to attend, inhibit, persist, be organized and timely, and produce more schoolwork as well as in his or her ability to interact more positively and reasonably with others. To date there is no evidence that treatment with medication, behavioral therapy, and/or special education that is limited to just a few years of childhood results in any sustained improvement in academic functioning or other major life activities after treatment is withdrawn. Hence, there is a need in many cases to extent treatment into adolescence or adulthood. Continuation of medication and behavioral treatments into adolescence will more likely result in improved outcomes, such as greater educational success and a reduced risk for substance use disorders and even antisocial behavior. Evidence from longer-term trials (1–3 years) of medication and behavioral-educational accommodations suggests them to be beneficial so long as treatment is sustained. Frequent or routine physical exercise may also be beneficial in helping patients to cope with their ADHD symptoms.
Numerous treatments for ADHD exist that have little or no evidence for their effectiveness, even though they are popular. These include dietary management (elimination of sugar or food additives), dietary supplements (vitamins, minerals, fish oils, or anti-oxidants), long-term psychotherapy, chiropractic skull manipulation, sensory integration training or other physical movement-based programs such as metronome therapy or DORE clinic exercises, visual perspective training, and cognitive therapy or self-instruction training. Biofeedback with EEG techniques (neurotherapy), cognitive training of working memory (CogMed), and training in meditation techniques remain experimental treatments at this time. This is due to their limited evidence of effectiveness and their need for more carefully and rigorously controlled research.
The treatment of ADHD requires a comprehensive behavioral, psychological, educational, and medical/psychiatric evaluation. This should be followed by the education of the individuals or their caregivers as to the nature of the disorder and the methods proven to assist with its management. Treatment is likely to be multi-disciplinary, requiring the assistance of the mental health, educational, and medical professions at various points in its course. Treatment must be provided periodically over long intervals to assist individuals with ADHD in coping with their behavioral disability so long as impairment from their symptoms is evident.
Additional Reading Adler, L. (2006). Scattered Minds: Hope and help for adults with attention deficit hyperactivity disorders. New York: G. Putnam & Sons.
Barkley, R. A. (2001). Taking Charge of ADHD: The Complete, Authoritative Guide for Parents (2nd ed.). New York: Guilford Publications.
Barkley, R. A. (2006). Attention Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment (3rd edition). New York: Guilford Publications.
Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford Publications.
Brown, T. (2000). Attention deficit disorders and comorbidities in children, adolescents, and adults. Washington, DC: American Psychiatric Press.
CHADD (2001). The CHADD Information and Resource Guide to AD/HD. Landover, MD: Children and Adults with ADD.
Dendy, Chris A. Z. (2007). Teenagers with ADD and ADHD: A Guide for Parents and Professionals. Bethesda, MD: Woodbine House.
DuPaul, G. J., & Stoner, G. (2003). ADHD in the schools. New York: Guilford Publications.
Fowler, M. (2007). 20 Questions to Ask if Your Child Has ADHD. Franklin Lakes, NJ: Career Books.
Goldstein, S. (1998). Managing attention and learning disorders in late adolescence and adulthood. New York: Wiley.
Goldstein, S., & Goldstein, M. (1998). Managing attention deficit hyperactivity disorder in children. New York: Wiley.
Goldstein, S. & Teeter Ellison, A. (2002). Clinician’s Guide to Adult ADHD. New York: Academic Press.
Hanna, M. (2006). Making the Connection: A Parent’s Guide to Medication in AD/HD. Washington, DC: Ladner-Drysdale.
Jensen, P. S., & Cooper, J. R. (2003). Attention deficit hyperactivity disorder: State of Science – Best Practices. Kingston, NJ: Civic Research Institute.
Mash, E. J., & Barkley, R. A. (2005). Treatment of childhood disorders (3rd edition). New York: Guilford Publications.
Nigg, J. T. (2006). What causes ADHD? New York: Guilford Publications.
Robin, A. R. (1998). ADHD in adolescents: Diagnosis and treatment. New York: Guilford Publications.
Rojas, N. L., & Chan, E. (2005). Old and new controversies in
alternative treatments for attention deficit hyperactivity disorder. Mental Retardation and Developmental Disabilities Research Reviews, 11, 116-130.
Weiss, M., Hechtman, L., & Weiss, G. (1999). ADHD in adulthood: A guide to current theory, diagnosis, and treatment. Baltimore, MD: Johns Hopkins Press.
Wilens, T. (1999). Straight talk about psychiatric medications for kids. New York: Guilford Publications.
Web sites with Information on ADHD
Children and Adults with ADD (CHADD) Organization: chadd.org
This is the largest of the national nonprofit organizations dedicated to children and adults with ADHD and their families. The
site contains a variety of types of information on ADHD as well as on
local chapters of CHADD throughout the U.S. and international groups
affiliated with the organization.
National Attention Deficit Disorders Association (ADDA) Organization: add.org
ADDA is a smaller nonprofit organization that appears to give greater emphasis to information on ADHD in adults. Visitors to the site will find information on a variety of topics and about local affiliates of the organization.
National Institute of Mental Health: help4adhd.org
This site was created jointly between experts at the National Institute of Mental Health and the CHADD organization. It provides free information on ADHD on a variety of topics.
Charles Schwab Foundation (for Learning Disorders): SchwabLearning.org
This
site is devoted principally to information about children with learning
disabilities, such as dyslexia, and to projects of interest to the
Schwab Foundation that they may be funding. It does contain some information on ADHD but not as much as the above sites.
Council for Exceptional Education (CEC): cec.sped.org
This site provides information on a variety of childhood developmental, learning, and psychiatric disorders. While some information on ADHD is present, more comprehensive information is to be found above at the help4adhd.org website.
American Academy of Child & Adolescent Psychiatry: aacap.org
This
is the official site of this professional society, but it does provide
some information about various child psychiatric disorders.
American Academy of Pediatrics: aap.org
This is the official website of the academy. It also provides information on various pediatric disorders including a small amount on ADHD.
Learning Disabilities Association of America (LDA): ldanatl.org
This site is principally devoted to information about the association and about various learning disabilities in children. Some information on ADHD is available as well.
National Information Center for Children and Youth with Disabilities: nichcy.org
This
site has information on a variety of disorders in children and
adolescents though its information on ADHD is less comprehensive than
that provided by the sites above that are exclusively devoted to ADHD.
Russell A. Barkley, Ph.D.: russellbarkley.org
This is the author’s official website. It also contains free information on the nature of ADHD, its history, and the International Consensus Statement of ADHD. It
also lists more than 2300 scientific references on ADHD up through 2005
and has connections to other sites on which lectures by Dr. Barkley are
available for viewing.