Attention Deficit Hyperactivity Disorder

Experts suggest that attention deficit hyperactivity disorder (ADHD) affects an estimated 8 percent of school-aged children, and about two-thirds of children diagnosed with ADHD continue to show signs of the disorder into adulthood.

ADHD interferes with your ability to regulate motor activity (hyperactivity), control key behaviors (impulsivity) and focus on tasks (inattention). When the hyperactivity is not present, the condition is sometimes called attention deficit disorder (ADD), although the more accurate term is ADHD-inattentive type.

By current estimates, more than two times as many boys as girls are affected by ADHD, but the ratio appears to become more even by adulthood.

Overall, women and girls may exhibit fewer of the typical symptoms associated with ADHD in boys. For example, girls with ADHD are more likely to be reserved than hyperactive. They tend to be less defiant and more compliant than boys and men with the condition. Like boys and men with ADHD, however, women with the condition may have difficulty completing tasks and remaining organized. Instead of being tested for ADHD, they’re often dismissed as flighty or spacey.

Thus, because girls are less likely to disrupt class—the kind of behavior that often brings boys with the condition to medical professionals’ attention—girls are less likely to get diagnosed with ADHD. Consequently, many girls and women do not get the help they need. Often, girls’ self-esteem suffers as they encounter academic problems in school. They may have difficulty with interpersonal relationships as well as social challenges.

These secondary difficulties may result in depression, anxiety disorders, problems sleeping, self-harmful (cutting) behaviors and/or abuse of alcohol or other substances. Furthermore, girls with ADHD are at greater risk for early pregnancy, promiscuity and sexually transmitted diseases. A recent study following girls for 10 years showed significantly higher risk for suicide attempts and self-injury compared to a comparison group.

Once diagnosed, many women recall painful or difficult childhood experiences in school that were likely to have been linked to ADHD but attributed at the time to other causes, such as laziness or lack of ability. This misattribution can itself lead to significant damage to self-esteem and self-confidence, resulting in demoralization.

Causes of ADHD

Although no one knows for sure what causes ADHD, the condition does run in families, suggesting a strong genetic component. Children who have a parent with ADHD are at an increased risk for ADHD themselves. And twin and adoption studies confirm a high degree of genetic connection with this condition. For identical twins, there is a strong chance the other twin has it. Again, this “family resemblance” appears strongly related to genes rather than social factors. Many researchers around the world are now investigating various genes that may contribute to the development of ADHD in families. It is unlikely a single gene is responsible, but undoubtedly many genes, operating interactively with one another and with environmental risks.

A smaller percentage of cases of ADHD are due to environmental or nongenetic biological risk factors, including premature birth, low birth weight; prenatal use of alcohol, tobacco and/or cocaine; and exposure to lead, which can alter brain development in the fetus. Infections and complications during pregnancy can also increase the chances that a baby will eventually develop ADHD in childhood. Additionally, some postnatal problems, such as chronic low levels of lead, recurrent ear infections or severe head trauma, can result in ADHD.

For years, ADHD was thought to be a disruptive behavior disorder that most experts intuitively believed involved some brain abnormality. With the development of more sophisticated brain scanning techniques, it is now known that people with ADHD do have anatomical differences in their brains, as well as differences in the biochemical balance that controls everything from mood to impulses.

Brain imaging studies show differences in ADHD brains in several areas:

differences in dopamine receptors in specific areas of the brain
differences in total brain volume and brain volume of specific areas of the brain
differences in the brain networks that are used to solve specific tasks
differences in the rate of maturation of frontal/prefrontal areas of the brain
Children with ADHD show a pattern of delayed maturation of certain regions of the brain compared to their peers without the disorder. These regions of delayed development are involved with controlling motor behavior, impulse control and attention levels. The conclusion is that slower brain development is a characteristic of ADHD brains and may explain the delay in development of emotion/impulse control and organizational skills.

Another biological component of ADHD has to do with levels of certain neurotransmitters in the brain. Adults with ADHD who have never received any medication have lower amounts of receptors for the neurotransmitter dopamine in key subcortical regions linked to motivation and reward than do adults without the disorder. In fact, stimulant medications used in the treatment of ADHD help balance levels of dopamine, improving symptoms of inattention, hyperactivity and impulsivity.

ADHD is not caused by many environmental triggers commonly believed to be associated with the disorder, such as too much TV, food allergies, eating too much sugar, problematic home life, poor teaching or schools or permissive parenting. Still, it is essential to realize that the home environment and the school setting are extremely important in managing ADHD—and that ineffective parenting and educational settings can exacerbate the symptoms and lead to additional impairments.

Diagnosis

Attention deficit hyperactivity disorder (ADHD) is the most prevalent chronic neurobiological disorder in children. Once thought to affect only children, it is now recognized as a disorder that most often continues into adulthood and presents unique issues for girls and women.

Common symptoms of ADHD can include:

failing to give close attention to details or making careless mistakes
difficulty sustaining attention to tasks
appearing not to listen when spoken to directly
failing to follow instructions carefully and completely
losing or forgetting important things
feeling restless or fidgeting
talking excessively or blurting out answers before hearing the whole question
ADHD is a serious diagnosis that can have a tremendous negative impact on your life, work and family. It may require long-term treatment with counseling and medication, so it’s important that a health care professional carefully evaluate all symptoms to rule out other conditions that could cause similar symptoms or behaviors.

For instance, stress can cause symptoms similar to those seen in ADHD, such as forgetfulness or feeling overwhelmed and disorganized. However, reactions to stress are usually temporary, subside when the stressful events pass, and are not present in a chronic fashion since childhood. Symptoms caused by ADHD are persistent, chronic and unchanging since childhood or early adolescence.

The diagnosis itself, however, must be approached very carefully and shouldn’t be done during a time-limited office visit with a pediatrician or other medical doctor. Improper treatment from misdiagnosis or failure to obtain treatment because of a missed ADHD diagnosis can both have significant, long-term consequences.

To reach an ADHD diagnosis in children, health care professionals use diagnostic criteria published by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV-TR) and consider information from other sources. For example, interviews with the patient, the patient’s family and, in the case of children, information provided by caregivers and teachers who see the child regularly can provide a picture of the patient’s behavior and learning styles.

Diagnosing and treating adults is challenging. The diagnostic criteria, with their emphasis on school behavior and performance, are designed to make the diagnosis in children, not adults. Hyperactivity, for instance, tends to diminish by adulthood, although other symptoms, such as inattention, may appear worse because of mounting adult responsibilities.

The following informal checklist further describes behaviors in adults that may be the result of ADHD. An individual having chronic problems since childhood with many of these symptoms may require further evaluation:

I am constantly trying to get organized, but can never seem to get or stay there.
I often feel that I talk too much or impulsively blurt things out.
I often feel overwhelmed.
I make impulsive purchases and decisions.
I frequently misplace personal items.
I start one thing but never finish it because I am distracted by something else.
I am frequently late.
I am a procrastinator.
I often make careless errors and oversights during the day.
I often pay bills late and have difficulty managing my money.
There are three primary subtypes of ADHD: predominantly hyperactive-impulsive, predominantly inattentive and combined hyperactive-impulsive and inattentive. The DSM-IV lists these other signs of ADHD, many of which apply to children in the classroom:

Inattention

Those who are inattentive find it difficult to keep their minds on any one thing and may get bored with a task after only a few minutes. They may, however, give effortless, automatic attention to activities and things that are highly engaging, like video games. But they may have difficulty with deliberate focus, conscious attention on organizing and completing tasks, responses to repetitive materials or mastery of challenging information.

Hyperactivity-impulsivity

Hyperactivity: Those who are hyperactive always seem to be in motion and have trouble sitting still. They squirm in their seats or roam around the room. Or they might wiggle their feet, touch everything or noisily tap their pencils. They may be fidgety or try to do several things at once, bouncing around from one activity to the next. They report an internal sense of restlessness and the need to continually move around.
Impulsivity: Those who are overly impulsive seem unable to curb or weigh their immediate reactions, thoughts and behaviors before acting. As a result, they may blurt out inappropriate comments or physically attempt something without thinking it through. This could apply to taking tests in school as well as participating in potentially dangerous behaviors. Their impulsivity also makes it hard for them to wait for things they want. This leads to poor frustration tolerance and temper outbursts.
Not everyone who is overly hyperactive, inattentive or impulsive has an attention disorder. Nor does everyone with ADHD exhibit all behaviors associated with the disorder. It’s important to realize that during certain stages of development, it may be normal for children to be inattentive, hyperactive or impulsive, and that these behaviors at these stages don’t fit an ADHD profile.

For example, preschoolers typically have lots of energy and run everywhere they go, but that doesn’t mean they are hyperactive. And many teenagers go through a phase when they are messy, disorganized and reject authority. This phase doesn’t necessarily persist as a lifelong problem with attention, organization and/or impulse control.

Because everyone exhibits some of these behaviors at times, the DSM-IV contains very specific guidelines for determining when the behaviors indicate ADHD. Specific symptoms must appear early in life, before age seven, and continue for at least six months. In children, they must be much more frequent or severe than in others the same age. Above all, the behaviors must create a real handicap in at least two areas of a person’s life, such as school, home, work or social settings. However, it’s important to know that the inattentive type of ADHD may not be diagnosed until age nine or 10, the age when symptoms of inattention become noticeable and problematic because school demands have increased.

So if your behavior or your child’s doesn’t impair work, friendships or other relationships, you probably won’t be diagnosed with ADHD. Nor would a child who seems overly active at school but who functions well elsewhere.

Health care professionals also consider the following questions during an assessment for ADHD:

Are these behaviors excessive, long-term and pervasive? That is, do they occur more often in you or your child than in others the same age?
Are they a continuous problem rather than a response to a temporary situation?
Do the behaviors occur in several settings or only in one specific place?
The health care professional pieces together a profile of behaviors, based on all available information, and then considers:

Which ADHD-like behavior patterns listed in the DSM-IV are apparent?
How often and in what situations?
How long have they been going on?
How old was the child/adult when the problem(s) started?
Are the behaviors seriously interfering with school, friendships, activities or home life?
Are there any other related problems?
Is there a parent with ADHD symptoms?
The answers to these questions help identify whether the hyperactivity, impulsivity and inattention are significant and long-standing. If so, a diagnosis of ADHD may be made.

Other conditions may occur with ADHD, making it more difficult to arrive at a clear diagnosis. Women and girls with ADHD, for example, are more prone to depression than men and boys with ADHD. A serious but treatable mental disorder, depression can disrupt all areas of your life, including mood, sleep, appetite, relationships, and the ability to think clearly. If you think you’re suffering from depression, it’s critical that you get a diagnosis and proper treatment. Left untreated, depression can be life-threatening, given the risk of suicide that accompanies the disorder.

Anxiety is another common condition seen in those with ADHD. Some children with ADHD, for example, feel tremendous worry, tension or uneasiness, even when there’s nothing to fear. Because the feelings are scarier, stronger and more frequent than normal fears, they can affect the child’s thinking and behavior.

Children with ADHD are also more likely to have achievement problems than children without the disorder, even if they don’t have a full-blown learning disability. ADHD is not in itself a learning disability but learning disabilities commonly occur with ADHD. But because it can interfere with concentration and attention, it can make it doubly hard for a child to do well in school, creating lifelong frustrations.

A very small number of people with ADHD have a rare disorder called Tourette syndrome. People with Tourette syndrome have tics and other involuntary movements like eye blinks or facial twitches they can’t control. Some may grimace, shrug, sniff or bark out words. Fortunately, these behaviors can be controlled with medication.

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