Attention-deﬁcit/hyperactivity disorder (ADHD) is a childhood disorder, usually classiﬁed as a learning disability, in which the child has great difﬁculty concentrating on anything for more than a few moments at a time, and also has great difﬁculty sitting still or controlling physical activity levels. Their impulsiveness and lack of self-control, combined with inattentiveness, frustrate and annoy those around these children, and can lead to serious problems in school. In fact, the diagnosis of ADHD is usually made in response to school-related problems. Epidemiological studies suggest that approximately ﬁve percent of U.S. schoolchildren have the disorder, a majority of whom are boys.
According to the DSM-IV, there are three subtypes of ADHD: impulsive type, inattentive type, and combined type. For each of the impulsive and the inattentive types, the DSM-IV lists nine symptoms, at least six of which must be present for at least six months to a degree that is maladaptive and inconsistent with developmental level. For the combined subtype, criteria for both types must be met. The criteria for impulsive types is:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
- Often has difﬁculty sustaining attention in tasks or play activities c. Often does not seem to listen when spoken to directly
- 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). Often has difﬁculty organizing tasks and activities.
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as homework)
- Often loses things necessary for tasks or activities (toys, school assignments, pencils, books, or tools)
- Is often easily distracted by extraneous stimuli i. Is often forgetful in daily activities
The criteria for inattentive types is:
- Often ﬁdgets with hands or feet or squirms in seat
- Often leaves seat in classroom or in other situations in which remaining seated is expected
- 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)
- 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”
- Often talks excessively
- Often blurts out answers before questions have been completed h. Often has difﬁculty awaiting turn
- Often interrupts or intrudes on others (such as butting into conversations or games)
The diagnostic requirements are rather stringent because of the risk of misdiagnosis and overdiagnosis. The symptoms listed, such things as “does not seem to listen when spoken to directly,” “often has difﬁculty organizing tasks or activities,” and “often talks excessively,” are not particularly unusual in children, at least on occasion, and do not individually provide cause for alarm.
The underlying problem in ADHD appears to be neurological, as evidenced by the remarkable success of psychoactive medication in treating the symptoms of the disorder. For reasons which are still not fully understood, drugs which act as central nervous system stimulants seem to have the reverse effect on many children with ADHD. The most widely used of these drugs is methylphenidate, mostly sold under the trade name Ritalin, an amphetamine-like drug that can have remarkable effects, allowing children to sit still and concentrate on their work for the ﬁrst time. Its apparent effectiveness has led to very widespread use. In 1999, 9.9 million prescriptions for Ritalin were written in the United States alone, most of them for children.
It is important to note, however, that stimulants are not a cure for ADHD; they merely help to control the symptoms. A combination of drugs and psychotherapy, preferably involving applied behavior analysis, is necessary to produce real, lasting improvement. Furthermore, in the absence of proper diagnosis and follow-up care, the drugs can do more harm than good. Stimulants do not produce improvement in all cases, and overmedication may actually make the problem worse or produce lethargy and lack of interest in learning. Overmedication is a fairly common problem, since the effective dose of methylphenidate varies from individual to individual. Also, given the effectiveness of behaviorally based treatments in the absence of drugs, there are many who feel that prescribing amphetamines to children is inappropriate when alternative treatments exist without the side effects associated with amphetamine use. The drugs are used because they work, however, and such use is therefore appropriate as long as their primary purpose is controlling symptoms in order to make use of other techniques, such as behavior modiﬁcation and family therapy, more feasible.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994;
- Krusch, D. A., Klorman, R., Brumaghim, J. T., Fitzpatrick, P. A., Borgstedt, A. D., and Strauss, I. “Methylphenidate Slows Reactions of Children with Attention Deﬁcit Disorder during and after an Error.” Journal of Abnormal Child Psychology, 24 (1996): 633– 650;
- Rapport, M. D., Loo, S., Isaacs, P., Goya, S., Denney, C., and Scanlan, S. “Methylphenidate and Attentional Training: Comparative Effects on Behavior and Neurocognitive Performance in Twin Girls with Attention-Deﬁcit/ Hyperactivity Disorder.” Behavior Modiﬁcation, 20 (1996): 428–450.