ADHD: An Overview

ADHD is neither a “new” mental health problem nor is it a disorder created for the purpose of personal gain or financial profit by pharmaceutical companies, the mental health field, or by the media.  It is a very real behavioral and medical disorder that affects millions of people nationwide.  According to the National Institute of Mental Health (NIMH), ADHD is one of the most common mental disorders in children and adolescents.  According to research sponsored by NIMH, estimated the number of children with ADHD to be between 3% - 5% of the population.  NIMH also estimates that 4.1 percent of adults have ADHD.  

Although it has taken quite some time for our society to accept ADHD as a bonafide mental health and/or medical disorder, in actuality it is a problem that has been noted in modern literature for at least 200 years.  As early as 1798, ADHD was first described in the medical literature by Dr. Alexander Crichton, who referred to it as “Mental Restlessness.”  A fairy tale of an apparent ADHD youth, “The Story of Fidgety Philip," was written in 1845 by Dr. Heinrich Hoffman.  In 1922, ADHD was recognized as Post Encephalitic Behavior Disorder.  In 1937 it was discovered that stimulants helped control hyperactivity in children.  In 1957 methylphenidate (Ritalin), became commercially available to treat hyperactive children.

The formal and accepted mental health/behavioral diagnosis of ADHD is relatively recent.  In the early 1960s, ADHD was referred to as “Minimal Brain Dysfunction.”  In 1968, the disorder became known as “Hyperkinetic Reaction of Childhood.”  At this point, emphasis was placed more on the hyperactivity than inattention symptoms.  In 1980, the diagnosis was changed to “ADD--Attention Deficit Disorder, with or without Hyperactivity,” which placed equal emphasis on hyperactivity and inattention.  By 1987, the disorder was renamed Attention Deficit Hyperactivity Disorder (ADHD) and was subdivided into four categories (see below).  Since then, ADHD has been considered a medical disorder that results in behavioral problems.

Currently, ADHD is defined by the DSM IV-TR (the accepted diagnostic manual) as one disorder which is subdivided into four categories:

1.  Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type--previously known as ADD--is marked by impaired attention and concentration.

2.  Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive, Impulsive  
Type--formerly known as ADHD--is marked by hyperactivity without inattentiveness.

3.  Attention-Deficit/Hyperactivity Disorder, Combined Type--the most common type--
involves all the symptoms: inattention, hyperactivity, and impulsivity.

4.  Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified. This category
is for the ADHD disorders that include prominent symptoms of inattention or    
hyperactivity-impulsivity, but do not meet the DSM IV-TR criteria for a  
diagnosis.  

To further understand ADHD and its four subcategories, it may be helpful to illustrate hyperactivity, impulsivity, and/or inattention through examples.

Typical hyperactive symptoms in youth include:
• Often "on the go" or acting as if "driven by a motor"
• Feeling restless
• Moving hands and feet nervously or squirming
• Getting up frequently to walk or run around
• Running or climbing excessively when it's inappropriate
• Having difficulty playing quietly or engaging in quiet leisure activities
• Talking excessively or too fast
• Often leaving seat when staying seated is expected
• Often can't be involved in social activities quietly

Typical symptoms of impulsivity in youth include:
• Acting rashly or suddenly without thinking first
• Blurting out answers before questions are fully asked
• Having a difficult time awaiting a turn
• Often interrupting others' conversations or activities
• Poor judgment or decisions in social situations, which result in the child not being accepted by his/her own peer group.

Typical symptoms of inattention in youth include:
• Not paying attention to details or makes careless mistakes
• Having trouble staying focused and being easily distracted
• Appearing not to listen when spoken to
• Often forgetful in daily activities
• Having trouble staying organized, planning ahead, and finishing projects
• Losing or misplacing homework, books, toys, or other items
• Not seeming to listen when directly spoken to  
• Not following instructions and failing to finish activities, schoolwork,
chores or duties in the workplace
• Avoiding or disliking tasks that require ongoing mental effort or
concentration

Of the four ADHD subcategories, Hyperactive-Impulsive Type is the most distinguishable, recognizable, and the easiest to diagnose.  The hyperactive and impulsive symptoms are behaviorally manifested in the various environments in which a child interacts: i.e., at home, with friends, at school, and/or during extracurricular or athletic activities.  Because of the hyperactive and impulsive traits of this subcategory, these children naturally arouse the attention (often negative) of those around them.   Compared to children without ADHD, they are more difficult to instruct, teach, coach, and with whom to communicate.  Additionally, they are prone to be disruptive, seemingly oppositional, reckless, accident prone, and are socially underdeveloped.  

Parents of ADHD youth often report frustration, anger, and emotional depletion because of their child’s inattention, impulsivity, and hyperactivity.  By the time they receive professional services many parents of ADHD children describe complex feelings of anger, fear, desperation, and guilt.  Their multiple “failures” at trying to get their children to focus, pay attention, and to follow through with directions, responsibilities, and assignments have resulted in feelings of hopelessness and desperation. These parents often report feeling guilty over their resentment, loss of patience, and reactive discipline style.  Both psychotherapists and psychiatrists have worked with parents of ADHD youth who "joke" by saying "if someone doesn't help my child, give me some medication!"

The following statistics (Dr. Russel Barkley and Dr. Tim Willens) illustrate the far reaching implications of ADHD in youth.   
• ADHD has a childhood rate of occurrence of 6-8%, with the illness continuing   
into adolescence for 75% of the patients, and with 50% of cases persisting into  
adulthood.
• Boys are diagnosed with ADHD 3 times more often than girls.
• Emotional development in children with ADHD is 30% slower than in their non-ADHD peers.
• 65% of children with ADHD exhibit problems in defiance or problems with authority figures. This can include verbal hostility and temper tantrums.
• Teenagers with ADHD have almost four times as many traffic citations as non ADD/ADHD drivers. They have four times as many car accidents and are seven times more likely to have a second accident.
• 21% of teens with ADHD skip school on a regular basis, and 35% drop out of school before finishing high school.
• 45% of children with ADHD have been suspended from school at least once.
• 30% of children with ADHD have repeated a year of school.
• Youth treated with medication have a six fold less chance of developing a substance abuse disorder through adolescence.
• The juvenile justice system is composed of 75% of kids with undiagnosed learning disabilities, including ADHD.

ADHD is a genetically transmitted disorder.  Research funded by the National Institute of Medical Health (NIMH) and the U.S. Public Health Service (PHS) have shown clear evidence that ADHD runs in families.  According to recent research, over 25% of first-degree relatives of the families of ADHD children also have ADHD.  Other research indicates that 80% of adults with ADHD have at least one child with ADHD and 52% have two or more children with ADHD.  The hereditary link of ADHD has important treatment implications because other children in a family may also have ADHD.  Moreover, there is a distinct possibility that the parents also may have ADHD.  Of course, matters get complicated when parents with undiagnosed ADHD have problems with their ADHD child. Therefore, it is crucial to evaluate a family occurrence of ADHD, when assessing an ADHD in youth.

Diagnosing Attention Deficit Disorder Inattentive Type in youth is no easy task.  More harm than good is done when a person is incorrectly diagnosed.  A wrong diagnosis may lead to unnecessary treatment, i.e., a prescription for ADHD medication and/or unnecessary psychological, behavioral and/or educational services.  Unnecessary treatment like ADHD medication may be emotionally and physically harmful.  Conversely, when an individual is correctly diagnosed and subsequently treated for ADHD, the potential for dramatic life changes are limitless.  

Psychologists, Clinical Social Workers, Licensed Clinical Professional Counselors, Neurologists, Psychiatrists, and Pediatricians/Family Physicians can diagnose ADHD. Only physicians (M.D. or D.O.), nurse practitioners, and physician assistants (P.A.) under the supervision of a physician can prescribe medication.  However, psychiatrists, because of their training and expertise in mental health disorders, are the best qualified to prescribe ADHD medication.

While the ADHD Hyperactive Type youth are easily noticed, those with ADHD Inattentive Type are prone to be misdiagnosed or, worse, do not even get noticed.   Moreover, ADHD Inattentive Type youth are often mislabeled, misunderstood, and even blamed for a disorder over which they have no control.  Because ADHD Inattentive Type manifests more internally and less behaviorally, these youth are not as frequently flagged by potential treatment providers.  Therefore, these youth often do not receive potentially life-enhancing treatment, i.e., psychotherapy, school counseling/coaching, educational services, and/or medical/psychiatric services.  Unfortunately, many “fall between the cracks” of the social service, mental health, juvenile justice, and educational systems.  

Youth with unrecognized and untreated ADHD may develop into adults with poor self concepts low self esteem, associated emotional, educational, and employment problems.  According to reliable statistics, adults with unrecognized and/or untreated ADHD are more prone to develop alcohol and drug problems.   It is common for adolescents and adults with ADHD to attempt to soothe or “self medicate” themselves by using addictive substances such as alcohol, marijuana, narcotics, tranquilizers, nicotine, cocaine and illegally prescribed or street amphetamines (stimulants).    

There is no "cure" for ADHD. Children with the disorder seldom outgrow it.
Approximately 60% of people who had ADHD symptoms as a child continue to have symptoms as adults. And only 1 in 4 of adults with ADHD was diagnosed in childhood—and even fewer are treated.  Thanks to increased public awareness and the pharmaceutical corporations’ marketing of their medications, more adults are now seeking help for ADHD.  However, many of these adults who were not treated as children, carry emotional, educational, personal, and occupational “scars.”   As children, these individuals, did not feel “as smart, successful and/or likable” as their non ADHD counterparts.  With no one to explain why they struggled at home, with friends, and in school, they naturally turned inward to explain their deficiencies.  Eventually they internalize the negative messages about themselves, thereby creating fewer opportunities for success as adults.          

Similarly to youths, adults with ADHD have serious problems with concentration or paying attention, or are overactive (hyperactive) in one or more areas of living. Some of the most common problems include:
• Problems with jobs or careers; losing or quitting jobs frequently
• Problems doing as well as you should at work or in school
• Problems with day-to-day tasks such as doing household chores, paying bills, and organizing things
• Problems with relationships because you forget important things, can't finish tasks, or get upset over little things
• Ongoing stress and worry because you don't meet goals and responsibilities
• Ongoing, strong feelings of frustration, guilt, or blame

According to Adult ADHD research:  
• ADHD may affect 30% of people who had ADHD in childhood.
• ADHD does not develop in adulthood. Only those who have had the disorder since early childhood really suffer from ADHD.
• A key criterion of ADHD in adults is "disinhibition"--the inability to stop acting on impulse. Hyperactivity is much less likely to be a symptom of the disorder in adulthood.
• Adults with ADHD tend to forget appointments and are frequently socially
inappropriate--making rude or insulting remarks--and are disorganized.  
• They find prioritizing difficult.
• Adults with ADHD find it difficult to form lasting relationships.
• Adults with ADHD have problems with short-term memory.
• Almost all people with ADHD suffer other psychological problems-particularly depression and substance abuse.

While there is not a consensus as to the cause of ADHD, there is a general agreement within the medical and mental health communities that it is biological in nature. Some common explanations for ADHD include: chemical imbalance in the brain, nutritional deficiencies, early head trauma/brain injury, or impediments to normal brain development (i.e. the use of cigarettes and alcohol during pregnancy).  ADHD may also be caused by brain dysfunction or neurological impairment.   Dysfunction in the areas in the frontal lobes, basal ganglia, and cerebellum may negatively impact regulation of behavior, inhibition, short-term memory, planning, self-monitoring, verbal regulation, motor control, and emotional regulation.  

Because successful treatment of this disorder can have profound positive emotional, social, and family outcomes, an accurate diagnosis is tremendously important.  Requirements to diagnose ADHD include: professional education (graduate and post graduate), ongoing training, supervision, experience, and licensure.  Even with the essential professional qualifications, collaboration and input from current or former psychotherapists, parents, teachers, school staff, medical practitioners and/or psychiatrists creates more reliable and accurate diagnoses.  The value of collaboration cannot be understated.      

Sound ethical practice compels clinicians to provide the least restrictive and least risky form of therapy/treatment to youth with ADHD. Medication or intensive psycho-therapeutic services should only be provided when the client would not favorably respond to less invasive treatment approaches. Therefore, it is crucial to determine whether “functional impairment” is or is not present. Clients who are functionally impaired will fail to be successful in their environment without specialized assistance, services, and/or psycho-therapeutic or medical treatment.  Once functional impairment is established, then it is the job of the treatment team to collaborate on the most effective method of treatment.    

All too often, a person is mistakenly diagnosed with ADHD, not due to attention deficit issues, but rather because of their unique personality, learning style, emotional make-up, energy and activity levels, and other psycho-social factors that better explain their problematic behaviors.  A misdiagnosis could also be related to other mental or emotional conditions (discussed next), a life circumstance including a parent’s unemployment, divorce, family dysfunction, or medical conditions.  In a small but significant number of cases, this diagnosis of ADHD better represents an adult’s need to manage a challenging, willful and oppositional child, who even with these problems may not have ADHD.    

It is critical that before an ADHD diagnosis is reached (especially before medication is prescribed), that a clinician consider if other coexisting mental or medical disorders may be responsible for the hyperactive, impulsive, and/or inattentive symptoms.  Because other disorders share similar symptoms with ADHD, it is necessary to consider the  probability of one mental/psychological disorder over that of another that could possibly account for a client’s symptoms.  For example, Generalized Anxiety Disorder and Major Depression share the symptoms of disorganization, lack of concentration, and work completion issues. A trained and qualified ADHD specialist will consider differential diagnoses in order to arrive at the most logical and clinically sound diagnosis.  Typical disorders to be ruled out include: Generalized Anxiety, Major Depression, Post Traumatic Stress Disorder, and Substance Abuse Disorders.  Additionally, medical explanations should be similarly sought: sleep disorders, nutritional deficiencies, hearing impairment, and others.  

When a non-medical practitioner formally diagnoses a client with ADHD, i.e. a licensed psychotherapist, it is recommended that a second opinion (or confirmation of the diagnosis) be sought from a psychiatrist.  Psychiatrists are medical practitioners who specialize in the medical side of mental disorders.  Psychiatrists are able to prescribe medicine that may be necessary to treat ADHD.  In collaboration, the parents, school personnel, the referring psychotherapist, and the psychiatrist, will monitor the effectiveness of the medical component of the ADHD treatment.  

In summary, ADHD is a mental health and medical disorder that has become increasingly more accepted and consequently treated more effectively.  To achieve high professional assessment, diagnostic, educational, and treatment standards, it is important that trained and qualified practitioners understands the multidimensional aspects of ADHD: history, diagnosis, statistics, etiology, and treatment. Training, experience, a keen interest for details, a solid foundation of information, and a system of collaboration creates the potential for positive outcomes in the treatment of ADHD.


References
1.  Genetic factors, not necessarily sex of child, influence ADHD by Jim Dryden    
http://record.wustl.edu/archive/1999/04-15-99/articles/ADHD.html
2.  What are the risk factors and causes of Attention Deficit Hyperactivity    
Disorder
http://www.adhdissues.com/ms/guides/adhd_risk_factors/main.html
3.  What Causes ADHD?
http://add.about.com/od/adhdthebasics/a/causes.htm
4.  History of ADHD by Keith Londrie
http://EzineArticles.com/?expert=Keith_Londrie
5.  Taking Charge of ADHD, Dr. Russell Barkley
http://www.healthcentral.com/adhd/c/1443/13716/addadhd-statistics/
6.  ADHD Facts by Dr. B, Murray, Ph.D.
http://www.upliftprogram.com/bob_murray.html
7.  Cause ADHD
http://www.myadhd.com/causesofadhd.html
8.  ADHD.org.nz (New Zealand ADHD Support GroupP
http://www.adhd.org.nz/cause1.html
9.   Understanding the Causes of ADHD  Keath Low, About.com
http://add.about.com/od/adhdthebasics/a/causes.htm
10.  Interventions for ADHD: Treatment in Developmental Context  By Phyllis Anne Teeter 1988
11.  Diagnosis of AD/HD in Adults
National Resource Center on AD/HD Children and Adults with Attention-Deficit/Hyperactivity Disorder
http://www.help4adhd.org/en/treatment/guides/WWK9S
12. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
13.   The Numbers Count: Mental Disorders in America
The National Institute of Mental Health Website  
http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml#KesslerPrevalence
14.  Historical Development of ADHD Margaret Austin, Ph.D., Natalie Staats Reiss, Ph.D., and Laura Burgdorf, Ph.D.
http://resources.atcmhmr.com/poc/view_doc.php?type=doc&id=13848
15.  ADHD, Alcoholism and Other Addictions by Wendy Richardson, M.A., LMFCC
Soquel, CA—1998
http://www.addresources.org/article_adhd_addictions_richardson.php<b></b>
16.   National Institutes of Neurological Disorders and Stroke   
NINDS Attention Deficit-Hyperactivity Disorder Information Page
http://www.ninds.nih.gov/disorders/adhd/adhd.htm