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Attention Deficit Hyperactivity Disorder

What is ADHD?
Many people, children and adults, are referred by schools, employers, doctors, and family members, wondering if they have an attention deficit disorder. Now called Attention Deficit Hyperactivity Disorder (ADHD), this syndrome occurs in about 3-6% of U.S. school children. It has been called ADD in the past, and even 'minimal brain dysfunction', and it has been described in the medical literature for hundreds of years.

ADHD is primarily a disorder of self-control. It is a genetically linked, inhibitory disorder. The major signs of ADHD are impulsivity, hyperactivity and inattention. People with ADHD may have difficulty focusing on the present, anticipating the future, and remembering experiences of the past. They may have an extremely distorted sense of time, they may have difficulty delaying gratification, they may have difficulty holding events in mind, and they may have limited self-awareness. People with the inattentive part of ADHD are typically distractible and do not seem to listen when spoken to. They may have problems organizing and completing tasks, especially those requiring mental effort. The overactive/impulsive part is characterized by such things as fidgeting and talking out of turn. ADHD begins in childhood. About two thirds of children with ADHD carry it into adulthood, though as they get older many people are not so overactive but may feel restless inside. Often ADHD first becomes apparent when someone is required to concentrate more than before. This may arise as early as kindergarten, when children are first asked to conform to social rules, in early grades when they are asked to concentrate on desk work or homework, or perhaps later in life when demands of school or work lead to great frustration and sometimes poor advancement.

Many parents experience the frustration and emotional upheaval caused by living with a child with ADHD. In general, parenting children is a difficult task that can bring us from one end of the emotional spectrum to the other. Raising children brings out the extreme of emotions from lack of control, frustration, anger, sadness, or pain, to joy, happiness, warmth, pride, and love. Living with an ADHD child exaggerates those emotions many times over.

Parents of ADHD children will say things like, "but my child is so smart", or "my child knows better", when wondering why their child has or hasn't done something. It is important to understand that ADHD interferes with self-regulation and is a disorder of performance, not a lack of skill or intelligence. These children have problems with self-control. They have poor problem-solving behavior, limited emotional self-control, and poor social behavior.

Children with this disorder may also show signs of oppositional/defiant behavior, which may at some point, lead to conduct disorder. These children have difficulty following rules and taking responsibility for their behavior. They frequently blame others for their mistakes or misbehavior, they constantly test and push limits, and they are often angry and argumentative. These children often appear to invest more energy in the argument than in its outcome, and they are excellent at getting others, especially their parents, hooked into the process of arguing.

Approximately one third of people with ADHD also have learning disorders. Depression is also common in people with ADHD, perhaps in part related to the chronic frustration of trying to get along in a world that demands an ability to focus and concentrate. One recent study suggests that over 20% of people diagnosed with ADHD have bipolar (manic depressive) disorder. Drug problems and anxiety disorders can also complicate the diagnosis. Given these complexities, it is no surprise that ADHD is both over diagnosed and under diagnosed.

How do we diagnose and treat ADHD?

Diagnosis and treatment of ADHD is a comprehensive process involving cooperation of parents, teachers, and experienced health professionals. Medical and family history, information provided by parents and teachers through the use of certain questionnaires and personal interviews, will help provide the information necessary to make the diagnosis. Administration of a brief continuous performance test (CPT) is helpful to confirm or rule out the diagnosis and to determine other possible causes of reported symptoms.

Once an appropriate diagnosis has been made, the treatment of ADHD involves education, medication, and development of appropriate strategies to learn to function more effectively. These children are developmentally delayed in their communication skills, social functioning, and other areas of performance. Therefore, establishing a model in which they are seen as disabled and in need of special assistance is important. Making changes in the child's environment to assist him/her to best deal with his/her disability is essential. Parent training, teacher training and child training, are necessary to manage this disorder and to help these children feel better about themselves and feel more successful overall.

No treatment for ADHD is complete without an appropriate evaluation for medication. Stimulant medications such as Concerta, Ritalin, Adderall, and Vyvanse are the primary medicines prescribed. Stratera is a, non-stimulant medication that seems effective for some individuals. There are various preparations, with varying side effects, and while they are usually quite safe to use, their effectiveness depends on the individual, the situation where they are being used (school, work, etc.) and on the skill of the person prescribing the medicine. Other medications such as antidepressants and those used to treat hypertension are also prescribed at times. Many of these, including clonidine and imipramine, can have dangerous side effects and while they can be used safely in some persons they must be used with appropriate care, often including EKGs or measuring blood levels. Sometimes more modern antidepressants are given with or instead of stimulants. SSRI's (Prozac and cousins) can help mood but may also worsen concentration or over-activity. Welbutrin is sometimes used to help both mood and attention but may carry a risk of seizures. Other medicines are being tried all the time for ADHD. Most of these medicines are not FDA approved for marketing for children, although doctors are allowed to prescribe them. While this discussion sounds scary, medicines can make the difference between good and happier function and continuing frustration. The point is that you must work with an experienced professional when using medicines. The beneficial effects of medication for ADHD have been known for many years. They include but are not limited to increased attention span and concentration, decreased impulsivity, decreased motor activity, decreased aggressiveness, increased compliance, improved fine motor skills, improved peer relations and improved participation in sports. The prescribing physician should inform patients of possible side effects and should assist in providing education regarding myths and realities concerning these medicines.

Who can help?

Your doctor or your child's school may guide you to experienced health professionals dealing with the diagnosis and treatment of attention problems. There are some excellent books on ADHD available at libraries and bookstores. A favorite is Driven to Distraction, by Dr. Hallowell. There are also free community support groups for persons and families with ADHD. CHADD is one of these. There are chapters of this organization in most major cities and they have a website as well. It is often very helpful to meet other families facing the same kinds of challenges to get ideas as well as support.

Teachers and schools can also help. Federal law requires that public schools make appropriate accommodations for students with ADHD which may include giving untimed tests, keeping school work at school (not sending it home), and keeping an eye out for learning problems (dyslexia, math difficulties, etc). A colleague, Dr. David Weiss, has listed the following "Ten Commandments for Teachers of ADD Children", which applies to families and employers too:

1. Understand that ADD is a handicapping condition, and the nature of the ADD child's deficits.

2. Be tough as nails about rules, but always stay calm and positive.

3. Speak clearly, in brief understandable sentences.

4. Provide immediate and consistent feedback (consequences) regarding behavior, as well as academic success. Use as much positive reinforcement as possible.

5. Run a predictable and organized classroom.

6. Don't overwhelm the ADD child with a large volume of work. Go for quality, not quantity. Keep assignments to the minimum length sufficient to demonstrate mastery.

7. Look for the ADD child's strengths and build on them.

8. Help the ADD child organize his desk area and materials.

9. Closely monitor the child's behavior without being intrusive.

10. Maintain a good sense of humor!

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