Attention-deficit hyperactivity disorder |
Attention-deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and controversial
mental disorders among children, and is increasingly recognized as
afflicting adults as well. Its symptoms include inattention, hyperactivity, and impulsivity. According to sources such as the
CDC, the causes
are currently unknown, and it is thought that the term covers a variety of related disorders. There is no single medical test
that can accurately diagnose ADHD, though there are assessment tools.
The authoritative definition of ADHD is to be found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-IV (Text
Revision) (DSM-IV-TR), which also defines three subtypes of ADHD:
- Predominantly Inattentive
- Predominantly Hyperactive-Impulsive
- Combined Type
According to some recent studies, ADHD is an inheritable dysfunction of dopamine
metabolism mainly in the frontostriatal region of the human brain. New studies consider the possibility that norepinephrine metabolism also affects this disorder (see Krause, Dresel, Krause in Psycho 26/2000
p.199ff). One should note that almost all of the latest studies have been sponsored by drug companies.
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- Please remember that Wikipedia is offered for informational use only. The information in most cases is not reviewed by
professionals. You are advised to contact your doctor for health-related decisions.
Terminology
The name attention deficit disorder (ADD) was first introduced in DSM-III, the 1980 edition. In DSM-III-R, published
in 1987, the name was in effect changed to ADHD.
Older names that have been used for ADHD or ADD include hyperkinetic syndrome (HKS) and minimal
cerebral dysfunction (MCD). ADHD is sometimes called attention-deficit syndrome (ADS) to avoid the
connotations of "disorder".
Symptoms
- In children the disorder is characterised by inattentiveness, impulsive behavior and restlessness.
- In adults the main problem is often their inability to structure their lives and plan simple daily tasks. Thus
inattentiveness and restlessness often become secondary problems.
A diagnosis of ADHD is made based on a checklist of symptoms that can be found in DSM-IV-TR. A hyperlink to the Centers for Disease Control
and Prevention (CDC) web page summarizing these criteria is given in the External
links section below. The CDC emphasizes that a diagnosis of ADHD should only be made by trained health care providers. This
is important as many of the criteria can be readily misinterpreted and the prescribed drugs can be very dangerous.
20th century history
In 1902, the English pediatrician
George Still described a
condition analogous to ADHD. He regarded it as innate and not caused by the environment.
The 1918–1919 influenza pandemic left many survivors with encephalitis, affecting their neurological functions. Some of these exhibited
immediate behavioural problems which correspond to ADD. This caused many to believe that the condition was the result of injury
rather than genetics.
In 1937, a group of children in an institution with behavioural problems were treated
with amphetamine drugs for the first time, resulting in behavioural
improvements. However treatment with stimulants was not widely used until the late 1950s.
In 1957, the new stimulant Methylphenidate (Ritalin) became available.
By the 1950s and 1960s, researchers changed the terminology from Minimal Brain Damage to Minimal Brain
Dysfunction. This followed observations that the condition existed without any known injury.
The "Hyperactive Child Syndrome" was first described in the 1960s, and was also regarded as not caused by injury. By the late
1960s and 1970s, hyperactivity had caught hold as a popular term, although MBD was also used
professionally.
In the early 1970s an erroneous newspaper article, which is still often cited, inflated the prescribing rate of medication by
a factor of 10, influencing some to avoid treatment with stimulants.
In 1973 Dr Ben F. Feingold, once a Professor of Allergy in San Fransisco, claimed that hyperactivity was increasing
in proportion to the level of food additives, and proposed a specific diet believing that it would help 50% of hyperactive
children. The popularity of the claims caused an American Congressional Commission to investigate additives and
encourage research. Most carefully controlled studies showed that only 5% of ADD children were impacted by food (but this was
obviously an important finding for that 5%), but some have shown a figure of 60%. One study tested the 50% who claimed to be
helped by diet, finding that 10% showed behavioural changes from food triggers. The Feingold diet excluded cola drinks, chocolate, preservatives and flavour additives, as well as salicylates that occur naturally in
fruit such as tomatoes, strawberries,
pineapples and oranges. However pineapple juice was suggested as a "safe" drink. Professional dieticians exclude and re-introduce food groups
on a more controlled basis to identify triggers.
The Canadian Virginia
Douglas in the early 1970s made various publications to promote the idea that attention deficit was of more significance that
the hyperactivity, influencing the American Psychiatric Association. The name attention deficit disorder (ADD) was first
introduced in DSM-III, the 1980 edition.
The early 1980s saw the vitamin B6 promoted as a helpful
remedy for children with learning difficulties including inattentiveness. After that, zinc
was promoted for ADD and autism. Multivitamins later became the claimed solution. No reputable research has appeared to support any of these
claims, except in cases of malnutrition.
In the mid-1980s, Helen Irlen
from California took out a patent on
certain tints for lenses to help those with reading problems. Despite wide media coverage and a number of studies, it appears
that only a small percentage of subjects saw improvement.
In the late 1980s, the Church of Scientology set up
the Citizen's Commission on Human Rights (CCHR), which lobbied using the media against
psychiatric medication in general, and Ritalin in particular. They were very effective at the time in scaring people away from
treatment with stimulants, as well as increasing the social stigma.
In 1994, DSM-IV described three groupings within ADHD, which can be simplified as: mainly inattentive; mainly
hyperactive-impulsive; and both in combination.
Incidence
According to the 2000 edition of DSM-IV-TR, ADHD affects three to seven percent of
all children in the U.S. According to 2002 data from the CDC's annual National Health Interview Survey, released in 2004, nearly 4 million children younger than
18 in the United States had been diagnosed with attention deficit hyperactivity disorder (ADHD). Twice as many boys were
diagnosed with ADHD as girls (10% vs. 4%). However, rates of diagnosis vary widely even within the U.S. In some school districts
as many as 60% of all children have been diagnosed with ADHD.
Two to three or four times more boys than girls are diagnosed with ADHD, but the causes of this gender disparity are unknown.
Some experts theorize that ADHD is underdiagnosed in girls, since their symptoms tend to be less dramatic than those in boys and
thus draw less attention from parents and teachers.
Today ADHD is considered to be a problem all over the industrialized world, although in no other country are children
diagnosed with this "disorder" as often as in the United States.
The variation in the rates of diagnosis and in estimates of the rate of prevalence raises numerous issues. In fact, almost
everything about ADHD has been the subject of intense debate, as discussed later in this article. This debate led the NIH to
develop a Consensus Statement in 1998, a link to which is provided in the External
Links section below.
ADHD often continues into adolescence and adulthood, and can cause a lifetime of frustrated dreams and emotional pain.
However, children diagnosed with ADHD often go on to live normal lives, and wonder why their parents and schools felt the need to
medicate them. Many complain of having needlessly suffered from the psychological trauma of the diagnosis and adverse effects of
the drugs. Others have written of how diagnosis and treatment improved their lives.
Evidence for ADHD as an organic phenomenon
Brain imaging research using a technique called magnetic resonance imaging (MRI) has shown that differences exist between the brains of children
with and without ADHD. Many scientists consider these results to be significant in themselves, but in addition PET studies have shown that there might be a link
between a person's ability to pay continued attention and the use of glucose - the
body's major fuel - in the brain. In adults with ADHD, the brain areas that control attention use less glucose and appear to be
less active, suggesting that a lower level of activity in some parts of the brain may cause inattention (Zametkin et
al.). However, there is no evidence that this low level of glucose in fact causes the low level of attention; it could in
fact be no more than an indicator for low attention. Maybe even more interesting are the results of some studies using SPECT (Single Photon Emission Computed Tomography). One study (Lou et al. in
Arch. Neurol. 46(1989) 48-52) found that people with ADHD have a reduced blood circulation in the striatum. But even more important might be the discovery that people with ADHD seem to have a significantly
higher concentration of dopamine transporters in the striatum (Dougherty et al. in Lancet 354 (1999) 2132-2133; Dresel et al. in Eur.J.Nucl.Med. 25 (1998)
31-39).
It has been known for some decades that head injuries can produce
ADHD-type behaviour.
Is ADHD inherited?
According to the NIMH Q&A cited below:
Research shows that ADHD tends 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
have children with ADHD. Even more convincing of a possible genetic link is that when one twin of an identical twin pair has the
disorder, the other is likely to have it too.
Positive aspects
Though ADHD is classified as a serious disorder, many people have a different perspective. Some see it as a gift. In his book
ADD - Attention Deficit Disorder (1997), Thom Hartmann developed the idea that people having ADHD symptoms may have
simply inherited a collection of genes that were selected for when hunting was particularly important. This idea is the basis of
another of his works, The Edison Gene: ADHD and the Gift of the Hunter Child (2003).
People who believe that ADHD is a gift find hints of ADHD in the lives of many famous people in history. Though such post
mortem diagnosis is questionable, it is intriguing to ponder the evidence that people such as Thomas Edison might have been diagnosed as having ADHD if the current DSM criteria had been developed
sufficiently long ago. Other historical figures who have been proposed as ADHD candidates include: Hans Christian Andersen, Ludwig van Beethoven, Winston
Spencer Churchill, Walt Disney, Benjamin Franklin, Robert and John F. Kennedy, Theodore Roosevelt, Jules Verne and the Wright brothers.
Some contemporary ADHD candidates have also been proposed, including George W. Bush, William J. Clinton, Whoopi Goldberg and Dustin Hoffman.
To see ADHD as a gift may seem somewhat problematic to anxious parents but it is at least a perspective that should be kept in
mind.
Psychological testing for ADHD
Psychological testing for ADHD generally consists of obtaining multiple types of assessments. These usually include a clinical
interview reviewing the DSM-IV criteria for ADHD. The interview also needs to rule out as much as possible other types of
syndromes which can cause attention problems, such as depression, anxiety, and psychosis. Rating scales can be administered which
provide measurement of the person's own view of their symptoms, as well as the views of parents, teachers, and significant
others. Finally, computerized tests of attention can be helpful in providing a further independent assessment. These different
assessments may not be in total agreement but provide a well-rounded view of the person's difficulties. A physician need not
order psychological testing in order to make the diagnosis of ADHD, but many doctors use this kind of assessment to avoid
over-diagnosis and treatment.
Neurometrics, PET scans, or SPECT
scans have been used for a more objective diagnosis. These are not usually suitable for very young children.
Attention deficit disorder also exists in adults, and an assessment for this is also needed.
Skepticism towards ADHD as a diagnosis
Critics have complained that the ADHD diagnostic criteria are sufficiently general or vague to allow most children with
persistent unwanted behaviors to be classified as having ADHD of one type or another. It should be noted that diagnostic
questionaires are often subject to copyright restrictions, preventing a wider
awareness of their specificness.
Many people have wondered why the number of children diagnosed with ADHD in the U.S. has grown so dramatically over a short
period of time. It has often been suggested that the causes of the ADHD epidemic lie in cultural patterns that variously
encourage or sanction the use of drugs as a simple cure for complex problems. Some critics assert that many kids are diagnosed
with ADHD and put on drugs as a substitute for parental attention, whereas many parents of ADHD children assert that the
associated demand for attention goes beyond what can be humanly provided, causing massive disruption to other individuals and
relationships, as well as to environments with structured relationships such as classrooms.
Some schools have required "problem" pupils to undergo ADHD diagnosis (and treatment if diagnosed), which has caused
protests.
Some critics have suggested that the ADHD label should be abolished.
Douglass Rushkoff, among other critics of ADHD diagnosis, suggest that the disorder may be a result of cultural conditions to
which children and adults alike are subjected. Primary among these is the omnipresence and exploitive qualities of advertising.
In the time that ADHD has arisen as the epidemic it is often portrayed as, advertisment has become virtually unavoidable, and
advertisements utilize much more sophisticated methods of deception. Some suggest that people (children, especially) are aware of
this attempt at pervasive trickery, whether consciously or subconsciously, and react by avoiding extended attention in order to
avoid being deceived. Naturally, this self-defense reaction, when carried over to school and home, presents obvious problems.
From this point of view, prescribing drugs is effectively only to alleviate symptoms, but entirely avoids the cause.
Treatment
There are many options available to treat people diagnosed with ADHD. These options include a variety of medications such as
Ritalin, behavior-changing therapies, and educational interventions.
Data from 1995 show that physicians treating children and adolescents wrote six million prescriptions for stimulants. Of all
the drugs used to treat psychiatric disorders in children, stimulant medications are the most well-studied. However, to date
there are no good long-term studies dealing with stimulants in children. A 1998 Consensus Development Conference on ADHD
sponsored by the National Institutes of
Health and a recent, comprehensive, scientific report confirmed many earlier studies showing that short-term use of
stimulants is safe and effective for children with ADHD. This says nothing for the growing number of children who are on
stimulants for years at a time. Some non-stimulant medications are now becoming available to treat ADHD such as Strattera (atomoxetine HCl), a selective norepinephrine reuptake inhibitor.
In December 1999, NIMH released the results of a study of nearly 600 elementary school children, ages seven-to-nine, which
evaluated the safety and relative effectiveness of the leading treatments for ADHD for a period up to fourteen months. The
results indicate that the use of stimulants alone is more effective than behavioral therapies in controlling the core symptoms of
ADHD - inattention, hyperactivity/impulsiveness, and aggression. In other areas of functioning, such as anxiety symptoms,
academic performance, and social skills, the combination of stimulant use with intensive behavioral therapies was consistently
more effective. (Of note, families and teachers reported somewhat higher levels of satisfaction for those treatments that
included the behavioral therapy components.) NIMH researchers will continue to track these children into adolescence to evaluate
the long-term outcomes of these treatments, and ongoing reports will be published. This study has been severely criticized, as it
was not double-blind and the sponsors failed to provide a control group.
There has been a lot of interesting work done with biofeedback and ADHD. Children are taught, using video game-like
technology, how to control their brain waves. This has a very high success rate, but is not widely used, or covered by insurance.
Many professionals consider the treatment promising, but state that there is not yet sufficient evidence that it works after the
immediate treatment is complete. Dietary and television restrictions are also sometimes useful environmental solutions. Sugar,
wheat, and other foodstuffs have been shown to cause adverse behavioral reactions.
Other ADHD-related controversies
There are other controversies intersecting with ADHD, to do with:
- prescribing psycho-active medication to children in general,
- prescribing medication for mental illness at all,
- psychiatry itself (see Anti-psychiatry), and
- the involvement of the Church of Scientology in
opposing specific treatments.
The controversies attract popular attention including the mass media. Media
critics in the scientific community say that, despite often employing science reporters, such reporters
have inherent inabilities to accurately report on scientific papers without sensationalising them, using exaggeration, undue
emphasis of aspects, taking aspects out of context, and publishing point-of-view features within news contexts. They also say the
mass media fails to identify procedural lapses in studies allowing dubious conclusions to be publicized. Such lapses include:
lack of peer review, small sample sizes, lack of published error
ranges, filtering of results, lack of control groups and lack of
use of double-blind techniques or placebos. Examples of cited of such media misrepresentation include the University of Washington study (see below), which was
widely reported as proving that television causes ADHD, despite disclaimers
within the published study apparently seeking to avoid this very headline.
References
- Understanding ADD by Dr Christopher Green & Dr Kit Chee, ISBN 0-86824-587-9, Doubleday 1994
- The ADHD-Autism Connection: A Step toward more accurate diagnosis and effective treatment, by Diane M. Kennedy, ISBN 1578564980 (The aim of this book is to
explore the similarities that attention deficit hyperactivity disorder (ADHD) shares with a spectrum of disorders currently known
as pervasive developmental disorders.)
External links
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