Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder, also known as ADHD, is a relatively common behavioral disorder affecting 3 to 7 percent of the school-age population. It is a persistent pattern of inattention and/or hyperactivity-impulsivity that is not typically observed in individuals of a comparable age. Behavioral characteristics of the disorder are observable from the preschool years onward. Assessment requires a careful, multisource approach as ADHD must be differentiated from a wide range of other psychiatric, developmental, and medical conditions. The effects of ADHD are life encompassing and, without treatment, may lead to a wide range of severe impairments including poor academic outcome, work difficulty, social rejection, driving accidents, increased risk of smoking, alcohol and drug abuse, and poor self-esteem.

[Page 183]Classification of what constitutes ADHD has changed over the past 20 years based upon revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the criteria used to define the disorder. Currently, DSM-IV notes specific criteria for diagnosing subtypes of ADHD. The main symptoms consist of inattention, hyperactivity, and impulsivity, and have been present before the age of 7. The symptoms are present in two or more settings, lead to significant impairment, and cannot be better accounted for by another psychiatric disorder. Those diagnosed with ADHD are also more likely to have other developmental, social, and health problems. ADHD is commonly associated with oppositional defiant disorder, conduct disorder, depression, and anxiety. A significant number of children and adolescents will continue to have some symptoms of the disorder into adulthood.

The actual cause of ADHD is not known but is believed to include multiple factors. Explanations can be simply divided into biological and environmental. Biological explanations include genetics and brain structure, while environmental includes parenting and diet. Studies have demonstrated that cases of ADHD tend to run in families and suggest that transmission may be partly mediated by genetics. Current studies are looking at specific dopamine genes as well as how brain structure relates to behavior. Evidence for environmental influences on ADHD have been noted in intervention studies demonstrating improvement in symptoms when parents have been taught alternative parenting skills (this does not imply that parents of children with ADHD are bad parents). Food additives, refined sugars, and fatty acid deficiencies have all been associated with ADHD symptoms; however, the clinical importance of dietary change as a means of treating ADHD symptoms remains uncertain.

Treatment of ADHD requires special consideration of the core symptoms and also family and social factors. The largest study of long-term treatment of ADHD to date is known as the Multimodal Treatment Study of Children with ADHD. This study found that stimulant medications used as the sole form of treatment led to significantly better results of core symptoms than behavioral therapy alone. On the other hand, a combination of medication and behavior therapy led to the best overall improvement in symptoms of ADHD. The American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry have published treatment guidelines for ADHD. Both support that treatment should be based on specific target symptoms and goals. Stimulant medications (methylphenidate and amphetamine products) are a first-line treatment recommendation for most children with ADHD, often in combination with behavioral therapy and other forms of treatment. In addition, special educational services are often required for the ADHD child. Two federal laws guarantee a child's right to receive such services and are noted under Section 504 of the 1973 Vocational Rehabilitation Act, and a 1991 addendum to the 1990 Individuals with Disabilities Education Act (IDEA).

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