| ADHD
Symptoms, Diagnosis and Management
-
-
- Can
other conditions cause these symptoms?
- Can
other disorders accompany ADHD?
- What
causes ADHD?
- Treatment
options
- Coping
with ADHD in the family
What
are the Symptoms of ADHD?
ADHD
is not like a broken arm, or strep throat. Unlike these
two disorders, ADHD does not have clear physical signs
that can be seen in an x-ray or a lab test. ADHD can
only be identified by looking for certain characteristic
behaviors, and these behaviors vary from person to person.
Scientists have not yet identified a single cause behind
all the different patterns of behavior--and they may
never find just one. Rather, someday scientists may
find that ADHD is actually an umbrella term for several
slightly different disorders.
At
present, ADHD is a diagnosis applied to children and
adults who consistently display certain characteristic
behaviors over a period of time. The most common behaviors
fall into three categories: inattention, hyperactivity,
and impulsivity.
Inattention.
People who are inattentive have a hard time keeping
their mind on any one thing and may get bored with a
task after only a few minutes. They may give effortless,
automatic attention to activities and things they enjoy.
But focusing deliberate, conscious attention to organizing
and completing a task or learning something new is difficult.
Hyperactivity.
People who are hyperactive always seem to be in
motion. They can't sit still. They may dash around or
talk incessantly. Sitting still through a lesson can
be an impossible task. Hyperactive children squirm in
their seat or roam around the room. Or they might wiggle
their feet, touch everything, or noisily tap their pencil.
Hyperactive teens and adults may feel intensely restless.
They may be fidgety or they may try to do several things
at once, bouncing around from one activity to the next.
Impulsivity.
People who are overly impulsive seem unable to curb
their immediate reactions or think before they act.
As a result, hey may blurt out inappropriate comments.
Or, they may run into the street without looking. Their
impulsivity may make it hard for them to wait for things
they want or to take their turn in games. They may grab
a toy from another child or hit when they're upset.
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Assessing
ADHD
Not
everyone who is overly hyperactive, inattentive, or
impulsive has an attention disorder. Since most people
sometimes blurt out things they didn't mean to say,
bounce from one task to another, or become disorganized
and forgetful, how can specialists tell if the problem
is ADHD?
To
assess whether a person has ADHD, specialists consider
several critical questions: Are these behaviors excessive,
long-term, and pervasive? That is, do they occur more
often than in other people the same age? Are they a
continuous problem, not just a response to a temporary
situation? Do the behaviors occur in several settings
or only in one specific place like the playground or
the office? The person's pattern of behavior is compared
against a set of criteria and characteristics of the
disorder. These criteria appear in a diagnostic reference
book called the DSM (short for the Diagnostic and
Statistical Manual of Mental Disorders).
According
to the diagnostic manual, there are three patterns of
behavior that indicate ADHD. People with ADHD may show
several signs of being consistently inattentive. They
may have a pattern of being hyperactive and impulsive.
Or they may show all three types of behavior.
According to the DSM, signs of inattention
include:
- becoming
easily distracted by irrelevant sights and sounds
-
failing to pay attention to details and making careless
mistakes
- rarely
following instructions carefully and completely
- losing
or forgetting things like toys, or pencils, books,
and tools needed for a task
Some
signs of hyperactivity and impulsivity
are:
-
feeling restless, often fidgeting with hands or feet,
or squirming
-
running, climbing, or leaving a seat, in situations
where sitting or quiet behavior is expected
- blurting
out answers before hearing the whole question
-
having difficulty waiting in line or for a turn
Because everyone shows some of these behaviors at times,
the DSM contains very specific guidelines for determining
when they indicate ADHD. The behaviors must appear early
in life, before age 7, and continue for at least 6 months.
In children, they must be 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.
So someone whose work or friendships are not impaired
by these behaviors would not be diagnosed with ADHD.
Nor would a child who seems overly active at school
but functions well elsewhere.
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Can
other conditions cause these symptoms?
The
fact is, many things can produce these behaviors. Anything
from chronic fear to mild seizures can make a child
seem overactive, quarrelsome, impulsive, or inattentive.
For example, a formerly cooperative child who becomes
overactive and easily distracted after a parent's death
is dealing with an emotional problem, not ADHD. A chronic
middle ear infection can also make a child seem distracted
and uncooperative. So can living with family members
who are physically abusive or addicted to drugs or alcohol.
Can you imagine a child trying to focus on a math lesson
when his or her safety and well-being are in danger
each day? Such children are showing the effects of other
problems, not ADHD.
In
other children, ADHD-like behaviors may be their response
to a defeating classroom situation. Perhaps the child
has a learning disability and is not developmentally
ready to learn to read and write at the time these are
taught. Or maybe the work is too hard or too easy, leaving
the child frustrated or bored.
Some
children's attention and class participation improve
when the class structure and lessons are adjusted a
bit to meet their emotional needs, instructional level,
or learning style. Although such children need a little
help to get on track at school, they probably don't
have ADHD.
It's
also important to realize that during certain stages
of development, the majority of children that age tend
to be inattentive, hyperactive, or impulsive--but do
not have ADHD. Preschoolers have lots of energy and
run everywhere they go, but this doesn't mean they are
hyperactive. And many teenagers go through a phase when
they are messy, disorganized, and reject authority.
It doesn't mean they will have a lifelong problem controlling
their impulses.
ADHD
is a serious diagnosis that may require long-term treatment
with counseling and medication. So it's important that
a person first be assessed for any other causes for
these behaviors.
What
Can Look Like ADHD?
- Underachievement
at school due to a learning disability
-
Attention lapses caused by petit mal seizures
- A
middle ear infection that causes an intermittent hearing
problem
-
Disruptive or unresponsive behavior due to anxiety
or depression
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Can
other disorders accompany ADHD?
One
of the difficulties in diagnosing ADHD is that it is
often accompanied by other problems. For example, many
children with ADHD also have a specific learning disability
(LD), which means they have trouble mastering language
or certain academic skills, typically reading and math.
ADHD is not in itself a specific learning disability.
But because it can interfere with concentration and
attention, ADHD can make it doubly hard for a child
with LD to do well in school.
A
very small proportion of people with ADHD have a rare
disorder called Tourette's syndrome. People with Tourette's
have tics and other movements like eye blinks or facial
twitches that they cannot control. Others may grimace,
shrug, sniff, or bark out words.
More
serious, nearly half of all children with ADHD--mostly
boys--tend to have another condition, called oppositional
defiant disorder. These children may overreact or lash
out when they feel bad about themselves. They may be
stubborn, have outbursts of temper, or act belligerent
or defiant. Sometimes this progresses to more serious
conduct disorders. Children with this combination of
problems are at risk of getting in trouble at school,
and even with the police. They may take unsafe risks
and break laws--they may steal, set fires, destroy property,
and drive recklessly. It's important that children with
these conditions receive help before the behaviors lead
to more serious problems.
At
some point, many children with ADHD--mostly younger
children and boys--experience other emotional disorders.
About one-fourth feel anxious. They 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. Others experience
depression. Depression goes beyond ordinary sadness--people
may feel so "down" that they feel hopeless
and unable to deal with everyday tasks. Depression can
disrupt sleep, appetite, and the ability to think.
Because
emotional disorders and attention disorders so often
go hand in hand, every child who has ADHD should be
checked for accompanying anxiety and depression. Anxiety
and depression can be treated, and helping children
handle such strong, painful feelings will help them
cope with and overcome the effects of ADHD.
Of
course, not all children with ADHD have an additional
disorder. Nor do all people with learning disabilities,
Tourette's syndrome, oppositional defiant disorder,
conduct disorder, anxiety, or depression have ADHD.
But when they do occur together, the combination of
problems can seriously complicate a person's life. For
this reason, it's important to watch for other disorders
in children who have ADHD.
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What
causes ADHD?
Understandably,
one of the first questions parents ask when they learn
their child has an attention disorder is "Why?
What went wrong?"
Health
professionals stress that since no one knows what causes
ADHD, it doesn't help parents to look backward to search
for possible reasons. There are too many possibilities
to pin down the cause with certainty. It is far more
important for the family to move forward in finding
ways to get the right help.
Scientists,
however, do need to study causes in an effort to identify
better ways to treat, and perhaps some day, prevent
ADHD. They are finding more and more evidence that ADHD
does not stem from home environment, but from biological
causes. When you think about it, there is no clear relationship
between home life and ADHD. Not all children from unstable
or dysfunctional homes have ADHD. And not all children
with ADHD come from dysfunctional families. Knowing
this can remove a huge burden of guilt from parents
who might blame themselves for their child's behavior.
Over
the last decades, scientists have come up with possible
theories about what causes ADHD. Some of these theories
have led to dead ends, some to exciting new avenues
of investigation.
One
disappointing theory was that all attention disorders
and learning disabilities were caused by minor head
injuries or undetectable damage to the brain, perhaps
from early infection or complications at birth. Based
on this theory, for many years both disorders were called
"minimal brain damage" or "minimal brain
dysfunction." Although certain types of head injury
can explain some cases of attention disorder, the theory
was rejected because it could explain only a very small
number of cases. Not everyone with ADHD or LD has a
history of head trauma or birth complications.
ADHD
Is Not Usually Caused by:
- too
much TV
-
food allergies
- excess
sugar
- poor
home life
- poor
schools
Research
shows that a mother's use of cigarettes, alcohol, or
other drugs during pregnancy may have damaging effects
on the unborn child. These substances may be dangerous
to the fetus's developing brain. It appears that alcohol
and the nicotine in cigarettes may distort developing
nerve cells. For example, heavy alcohol use during pregnancy
has been linked to fetal alcohol syndrome (FAS), a condition
that can lead to low birth weight, intellectual impairment,
and certain physical defects. Many children born with
FAS show much the same hyperactivity, inattention, and
impulsivity as children with ADHD.
Drugs
such as cocaine--including the smokable form known as
crack--seem to affect the normal development of brain
receptors. These brain cell parts help to transmit incoming
signals from our skin, eyes, and ears, and help control
our responses to the environment. Current research suggests
that drug abuse may harm these receptors. Some scientists
believe that such damage may lead to ADHD.
Toxins
in the environment may also disrupt brain development
or brain processes, which may lead to ADHD. Lead is
one such possible toxin. It is found in dust, soil,
and flaking paint in areas where leaded gasoline and
paint were once used. It is also present in some water
pipes. Some animal studies suggest that children exposed
to lead may develop symptoms associated with ADHD, but
only a few cases have actually been found.
Other
research shows that attention disorders tend to run
in families, so there are likely to be genetic influences.
Children who have ADHD usually have at least one close
relative who also has ADHD. And at least one-third of
all fathers who had ADHD in their youth bear children
who have ADHD. Even more convincing: the majority of
identical twins share the trait. At the National Institutes
of Health, researchers are also on the trail of a gene
that may be involved in transmitting ADHD in a small
number of families with a genetic thyroid disorder.
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Treatment
Options
For
decades, medications have been used to treat the symptoms
of ADHD. Three of these medications are methylphenidate
(Ritalin), dextroamphetamine (Dexedrine or Dextrostat),
and pemoline (Cylert). However, most prescription psychiatric
drugs also carry far-reaching negative side effects
and risks (see below).
Unfortunately,
people think medication is all that's needed. For lasting
improvement, numerous clinicians believe that the most
significant, long-lasting gains appear when medication
is combined with behavioral therapy, emotional counseling,
dietary control and practical support.
The
Medication Debate
Ritalin
and the other stimulants have sparked a great deal of
controversy. The potential side effects should be carefully
weighed against the benefits before prescribing the
drugs. While on these medications, some children may
lose weight, have less appetite, and temporarily grow
more slowly. Others may have problems falling asleep.
Some doctors believe that stimulants may also make the
symptoms of Tourette's syndrome worse. Some doctors
say if they carefully watch the child's height, weight,
and overall development, the benefits of medication
far outweigh the potential side effects. Side effects
that do occur can often be handled by reducing the dosage.
However, that is not necessarily true, and you should
educate yourself on all aspects of the debate before
making a decision.
A
far safer approach is often found with natural (herbal
or homeopathic) remedies, which should be considered
as a first step ahead of prescription psychiatric drugs.
When combined with strong dietray control, counseling
as necessary and a healthy lifestyle, natural remedies
have been show to be effective in helping to alleviate
the symptoms of ADHD.
Another
debate is whether Ritalin and other stimulant drugs
are prescribed unnecessarily for too many children.
Remember that many things, including anxiety, depression,
allergies, seizures, or problems with the home or school
environment can make children seem overactive, impulsive,
or inattentive. Critics argue that many children who
do not have a true attention disorder are medicated
as a way to control their disruptive behaviors.
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Treatments
To Help People With ADHD and Their Families Learn To
Cope
Life can be hard for children with ADHD. They're the
ones who are so often in trouble at school, can't finish
a game, and lose friends. They may spend agonizing hours
each night struggling to keep their mind on their homework,
then forget to bring it to school.
It's
not easy coping with these frustrations day after day.
Some children release their frustration by acting contrary,
starting fights, or destroying property. Some turn the
frustration into body ailments, like the child who gets
a stomachache each day before school. Others hold their
needs and fears inside, so that no one sees how badly
they feel.
It's
also difficult having a sister, brother, or classmate
who gets angry, grabs your toys, and loses your things.
Children who live with or share a classroom with a child
who has ADHD get frustrated, too. They may feel neglected
as their parents or teachers try to cope with the hyperactive
child. They may resent their brother or sister never
finishing chores, or being pushed around by a classmate.
They want to love their sibling and get along with their
classmate, but sometimes it's so hard!
It's
especially hard being the parent of a child who is full
of uncontrolled activity, leaves messes, throws tantrums,
and doesn't listen or follow instructions. Parents often
feel powerless and at a loss. The usual methods of discipline,
like reasoning and scolding, don't work with this child,
because the child doesn't really choose to act in these
ways. It's just that their self-control comes and goes.
Out of sheer frustration, parents sometimes find themselves
spanking, ridiculing, or screaming at the child, even
though they know it's not appropriate. Their response
leaves everyone more upset than before. Then they blame
themselves for not being better parents. Once children
are diagnosed and receiving treatment, some of the emotional
upset within the family may fade.
Medication
can help to control some of the behavior problems that
may have lead to family turmoil. But more often, there
are other aspects of the problem that medication can't
touch. Even though ADHD primarily affects a person's
behavior, having the disorder has broad emotional repercussions.
For some children, being scolded is the only attention
they ever get. They have few experiences that build
their sense of worth and competence. If they're hyperactive,
they're often told they're bad and punished for being
disruptive. If they are too disorganized and unfocused
to complete tasks, others may call them lazy. If they
impulsively grab toys, butt in, or shove classmates,
they may lose friends. And if they have a related conduct
disorder, they may get in trouble at school or with
the law. Facing the daily frustrations that can come
with having ADHD can make people fear that they are
strange, abnormal, or stupid.
Often,
the cycle of frustration, blame, and anger has gone
on so long that it will take some time to undo. Both
parents and their children may need special help to
develop techniques for managing the patterns of behavior.
In such cases, mental health professionals can counsel
the child and the family, helping them to develop new
skills, attitudes, and ways of relating to each other.
In individual counseling, the therapist helps children
or adults with ADHD learn to feel better about themselves.
They learn to recognize that having a disability does
not reflect who they are as a person. The therapist
can also help people with ADHD identify and build on
their strengths, cope with daily problems, and control
their attention and aggression. In group counseling,
people learn that they are not alone in their frustration
and that others want to help. Sometimes only the individual
with ADHD needs counseling support. But in many cases,
because the problem affects the family as well as the
person with ADHD, the entire family may need help. The
therapist assists the family in finding better ways
to handle the disruptive behaviors and promote change.
If the child is young, most of the therapist's work
is with the parents, teaching them techniques for coping
with and improving their child's behavior.
Several
intervention approaches are available and different
therapists tend to prefer one approach or another. Knowing
something about the various types of interventions makes
it easier for families to choose a therapist that is
right for their needs.
Psychotherapy
works to help people with ADHD to like and accept themselves
despite their disorder. In psychotherapy, patients talk
with the therapist about upsetting thoughts and feelings,
explore self-defeating patterns of behavior, and learn
alternative ways to handle their emotions. As they talk,
the therapist tries to help them understand how they
can change. However, people dealing with ADHD usually
want to gain control of their symptomatic behaviors
more directly. If so, more direct kinds of intervention
are needed.
Cognitive-behavioral
therapy helps people work on immediate issues.
Rather than helping people understand their feelings
and actions, it supports them directly in changing their
behavior. The support might be practical assistance,
like helping Henry learn to think through tasks and
organize his work. Or the support might be to encourage
new behaviors by giving praise or rewards each time
the person acts in the desired way. A cognitive-behavioral
therapist might use such techniques to help a belligerent
child learn to control his fighting, or an impulsive
teenager to think before she speaks.
Social
skills training can also help children learn new
behaviors. In social skills training, the therapist
discusses and models appropriate behaviors like waiting
for a turn, sharing toys, asking for help, or responding
to teasing, then gives children a chance to practice.
For example, a child might learn to "read"
other people's facial expression and tone of voice,
in order to respond more appropriately. Social skills
training helps ADHD children learn to join in group
activities, make appropriate comments, and ask for help.
A child might learn to see how his behavior affects
others and develop new ways to respond when angry or
pushed.
Support
groups connect people who have common concerns.
Many adults with ADHD and parents of children with ADHD
find it useful to join a local or national support group.
Many groups deal with issues of children's disorders,
and even ADHD specifically. The national associations
listed at the back of this booklet can explain how to
contact a local chapter. Members of support groups share
frustrations and successes, referrals to qualified specialists,
and information about what works, as well as their hopes
for themselves and their children. There is strength
in numbers--and sharing experiences with others who
have similar problems helps people know that they aren't
alone.
Parenting
skills training, offered by therapists or in special
classes, gives parents tools and techniques for managing
their child's behavior. One such technique is the use
of "time out" when the child becomes too unruly
or out of control. During time outs, the child is removed
from the agitating situation and sits alone quietly
for a short time to calm down. Parents may also be taught
to give the child "quality time" each day,
in which they share a pleasurable or relaxed activity.
During this time together, the parent looks for opportunities
to notice and point out what the child does well, and
praise his or her strengths and abilities.
An
effective way to modify a child's behavior is through
a system of rewards and penalties. The parents
(or teacher) identify a few desirable behaviors that
they want to encourage in the child--such as asking
for a toy instead of grabbing it, or completing a simple
task. The child is told exactly what is expected in
order to earn the reward. The child receives the reward
when he performs the desired behavior and a mild penalty
when he doesn't. A reward can be small, perhaps a token
that can be exchanged for special privileges, but it
should be something the child wants and is eager to
earn. The penalty might be removal of a token or a brief
"time out." The goal, over time, is to help
children learn to control their own behavior and to
choose the more desired behavior. The technique works
well with all children, although children with ADHD
may need more frequent rewards.
In
addition, parents may learn to structure situations
in ways that will allow their child to succeed. This
may include allowing only one or two playmates at a
time, so that their child doesn't get overstimulated.
Or if their child has trouble completing tasks, they
may learn to help the child divide a large task into
small steps, then praise the child as each step is completed.
Parents
may also learn to use stress management methods, such
as meditation, relaxation techniques, and exercise to
increase their own tolerance for frustration, so that
they can respond more calmly to their child's behavior.
Controversial
Treatments
Understandably, parents who are eager to help their
children want to explore every possible option. Many
newly touted treatments sound reasonable. Many even
come with glowing reports. A few are pure quackery.
Some are even developed by reputable doctors or specialists--but
when tested scientifically, cannot be proven to help.
Here
are a few types of treatment that have not been scientifically
shown to be effective in treating the majority of children
or adults with ADHD:
-
biofeedback
- allergy
treatments
- medicines
to correct problems in the inner ear
- megavitamins
- chiropractic
adjustment and bone re-alignment
- treatment
for yeast infection
- eye
training
- special
colored glasses
A
few success stories can't substitute for scientific
evidence. Until sound, scientific testing shows a treatment
to be effective, families risk spending time, money,
and hope on fads and false promises.
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