Attention deficit hyperactivity disorder (ADHD) is one of the most common, most talked about, and most vexing of the psychiatric disorders. Symptoms of restlessness, distractibility, and poor self-control have been recognized since the mid-1800s when Heinrich Hoffman, a German physician, wrote a poem about “Fidgety Phil.” Over time, the disorder has been seen as a manifestation of brain damage, “brattiness,” and poor parenting. Diagnostic manuals have focused on the high level of physical activity, later on the short attention span, and more recently on the inadequate self-control features of the disorder. Few disorders have been surrounded by the controversy about assessment, treatment, and even its very existence!
The primary features of ADHD are inattention, hyperactivity, and impulsivity. People with ADHD are described as often failing to attend to details, giving up on a task before completion, and having organizational difficulties. Restless, impatient, and intrusive are other common descriptors. However, individuals can show different levels of these features, and therefore, different subtypes of ADHD are currently recognized (e.g., predominately combined, hyperactive-impulsive, and inattentive types). Because these symptoms are part of the human condition, some question the legitimacy of the disorder. Therefore, for a diagnosis of ADHD, symptoms must be so severe that the person has significant difficulty functioning in a variety of settings. Further, the symptoms must be consistently present for at least 6 months, with an onset in childhood. People with ADHD also experience a number of other symptoms. For example, it is often very difficult for people with ADHD to keep information “in mind” while trying to solve problems or follow directions. They may have difficulty getting started and, once under way, are likely to lose interest or energy to finish the project. Emotional control is often lacking, and intense, but usually brief, emotional outbursts are common. Those with ADHD may have difficulty keeping things to themselves and are excessively talkative. The ability to think of alternative solutions to problems is diminished. Social problems, under achievement, and conflict with authority are common to ADHD.
Although there are many theories about the cause of ADHD, current thinking has suggested that ADHD is the result of multiple biological processes. First, ADHD has a very strong tendency to run in families, at about the same rate that height does. Second, the genetics seem to lead to differences in brain anatomy (e.g., a smaller frontal area of the brain), function (e.g., underactivity in certain brain areas), and chemistry (e.g., abnormalities in amounts of neurotransmitters). Third, prenatal complications, maternal substance use, brain damage, and lead consumption increase the risk for developing ADHD. Certain psychosocial factors, such as low socioeconomic status, a chaotic environment, and poor parenting, make it more likely that one will be diagnosed with ADHD.
ADHD is a common disorder and one of the most frequent reasons for bringing a child to a professional for assessment and treatment. Although the number of people diagnosed with ADHD varies according to the methods of the study that identified them, the accepted figures are 3% to 5% in the United States. Worldwide rates of ADHD range from 3% in the Netherlands to 20% in the Ukraine. Thus, the data are overwhelming that ADHD exists across cultures. More boys than girls are diagnosed with ADHD, with the ratios again varying according to method and ranging from 2:1 (in community-based investigations) to 6:1 (from clinic referrals). Although there has been recent debate about differences in the presentation of ADHD between genders, it appears that males and females with ADHD show about the same symptoms, with roughly the same onset, with similar co-occurrence of other disorders, and with the same potential for impairment.
The conventional wisdom about ADHD was that it was a disorder of childhood and would be grown out of. We now know that ADHD is a chronic disorder that persists across the life span. When research takes into account the decrease in hyperactivity and impulsivity symptoms that occur with age, 40% to 80% of ADHD children grow into adulthood with at least some impairment in functioning. The appearance of adult ADHD differs from childhood, and most adults who seek treatment for ADHD complain of inattention, forgetfulness, problems focusing, and organizational difficulties. ADHD places adults at risk for relationship problems, job dissatisfaction, traffic accidents, underachievement, and health problems.
The co-occurrence of other disorders is the rule with ADHD. The disorder has a strong association with other disruptive behaviors, and between 35% and 60% of referred children demonstrate defiance, conduct problems, and aggression. Fewer adults (12%–21%) persist in these antisocial behaviors. Anxiety disorders frequently occur along with ADHD and may be even more common with ADHD adults (25%–50%). Twenty to 30% of people with ADHD may also have a mood disorder. It is not surprising that children with ADHD have difficulties in the academic setting. Disorders of learning are commonly found in children with ADHD (10%–50%). Compared with others, children with ADHD, as a group, score slightly lower on intelligence tests and are more likely to repeat a grade, be suspended, and drop out of high school. There is some controversy about the risk that ADHD poses for future substance abuse. One in every two or three adults with ADHD has a problem with alcohol abuse. Although most studies have attributed the increased frequency of substance abuse to the other disorders (particularly conduct problems) co-occurring with ADHD, a recent study has suggested that ADHD carries its own risk, independent of other conditions.
The assessment of ADHD is a complex process. Given the controversy about ADHD, it is important that those assessing the disorder use professionally accepted, rigorously researched diagnostic criteria. Further, information should be gathered from a variety of sources, across numerous settings, using diverse methods. First, a medical examination should be conducted to ensure that the behavioral disturbances are not caused by any of a variety of medical conditions (e.g., thyroid disorder, medication, seizure disorder, sensory deficits, genetic syndromes). Next, interviews with the family and important others will cover family history, development, medical history, school performance, work history, current stressors, a detailed description of the symptoms, and the steps that have been taken to resolve them. Questionnaires, some with a narrow focus on ADHD symptoms and some with a broad view of other behaviors, are used to make normative comparisons and rule out alternative disorders. Formal testing can include computerized measures of attention and self-control and tests of memory, problem solving, decision making, and mental efficiency. At times, there may be questions that can be answered by tests of intelligence, academic achievement, or language proficiency. The clinician then assimilates all the information in order to answer the family’s questions, including making a diagnosis, if appropriate.
In addition to the more traditional treatment approaches, such as medication, behavior management, and classroom or workplace accommodation, there has been much recent interest in alternative treatments such as natural remedies, biofeedback, and dietary supplements. The most effective treatment for ADHD is also the most controversial. Psychostimulant medications, and newer nonstimulants, enhance the effectiveness of specific neurotransmitters and, theoretically, increase activity in the areas of the brain that regulate behavior and attention. The clinical effects of medication include improved concentration, reduced random activity, enhanced self-control, greater academic productivity, and less frequently, reduced oppositional and aggressive behavior. Medication is effective in about 70% to 80% of children and 60% to 80% of adults. The most common side effects of these medications are reduced appetite, headache, and sleep disturbance. Long-term studies have shown that concerns about growth retardation are exaggerated and that there is no increased risk for later substance abuse as a result of the use of medication.
Nonetheless, some parents are strongly opposed to using medication with their children.
The use of behavior management strategies is also very common. The approaches that are most effective are those that address the problems with behavioral regulation. A frequent approach is to provide extra reminders, guidelines, and feedback in order to have rules and expectations that have a greater impact on behavior. This might involve making a list of chores or assignments, posting it in prominent places, and providing frequent and meaningful consequences for efforts that are directed toward the completion of the assignment. Points or tokens are often used to provide immediate feedback and can later be redeemed for rewards. To retain their effectiveness, consequences may need to be more powerful and varied than those used with other children. Intervention should take place when and where the desired behavior is to occur, thus compensating for the individual’s difficulties in reflecting on past behavior and thinking ahead.
School environments are often difficult for children with ADHD because the academic demands emphasize their weaknesses. Teachers and parents will often make informal accommodations that support the child with ADHD. For example, these children may be granted alterations in their curricula, take tests in alternate sites that reduce distractions, use daily report cards, have more time to complete assignments, or use assistive technology, such as computers or recorders. At times, formal procedures will establish goals and teaching methods, with accommodations, by which they will be accomplished.
Alternative treatments have received much interest but little in the way of scientific support. Diets and dietary supplements have not been shown to be effective, and the side effects of many herbal remedies remain unknown. Biofeedback, the use of sensitive equipment to monitor subtle changes in the body’s activities, has been suggested as a method to alter brainwaves and reduce ADHD symptoms. The claims of biofeedback advocates have yet to meet scientific standards that would demonstrate its effectiveness, long-term effects, or competitive cost.
- Barkley, (1998). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). New York: Guilford.
- Barkley, R. (2000). Taking charge of ADHD (2nd ). New York: Guilford.
- Children and Adults with Attention Deficit Hyperactivity Disorder, http://www.chadd.org
- Nadeau, (1994). Survival guide for college students with ADD or LD. New York: Magination Press.
- Resnick, R. (2000). The hidden disorder. Washington, DC: American Psychological
- State University of New York, Buffalo, Center for Children and F (n.d.). What parents and teachers should know about ADHD. Retrieved from http://ctadd.net/ctadd/ PDFs_CTADD/What_Parents_Teachers.pdf
- Wodrich, D. (1999). ADHD: What every parent wants to know (2nd ). Baltimore: Brookes.
- Worley, , & Wolraich, M. (2003). Attention deficit hyperactivity disorder. In M. Wolraich (Ed.), Disorders of learning and development (3rd ed., pp. 311–327). Hamilton, Ontario: BC Decker.