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Attention-Deficit Disorder: A Clinical Information Guide
INTRODUCTION This report has been adapted | INCIDENCE AND PREVALENCE | CAUSES | SYMPTOMS | DIAGNOSIS | ASSESSMENT | TREATMENT FOR ADHD | Barriers, Challenges, and Research Issues | Conclusions & Implications for Child Welfare
ADHD is a psychiatric disorder that interferes with an individual's capacity to regulate activity level (hyperactivity), inhibit behavior (impulsivity), and attend to tasks (inattention) in developmentally appropriate ways. The core symptoms of ADHD include an inability to sustain attention and concentration, developmentally inappropriate levels of activity, distractibility, and impulsivity.
ADHD is a disorder that is thought to be neurologically based, although some clinicians believe that any of the symptoms of ADHD can be caused by environmental and social/emotional factors (psychogenic), such as anxiety, abuse, or neglect. Not all individuals have the symptom of hyperactivity, rather they tend to have problems predominantly in the area of concentration and attention. While ADHD is, in itself, not a developmental disability, it is often associated with delays and disturbances in a broad range of developmental areas.
As its name implies, attention-deficit/hyperactivity disorder (ADHD) is characterized by two distinct sets of symptoms: inattention and hyperactivity-impulsivity. Although these problems usually occur together, one may be present without the other to qualify for a diagnosis (DSM-IV). Difficulties paying attention may not become apparent until a child enters the challenging environment of elementary school. Such children then have difficulty paying attention to details and are easily distracted by other events that are occurring at the same time; they find it difficult and unpleasant to finish their schoolwork; they put off anything that requires a sustained mental effort; they are prone to make careless mistakes, and are disorganized, losing their school books and assignments; they appear not to listen when spoken to and often fail to follow through on tasks (DSM-IV; Waslick & Greenhill, 1997).
Children suffering from ADHD may perform poorly at school; they may be unpopular with their peers, other children may perceive them as unusual or find them to be a nuisance; and their behavior can present significant challenges for parents, leading some to be overly harsh (DSM-IV).
Inattention tends to persist through childhood and adolescence into adulthood, while the symptoms of motor hyperactivity and impulsivity tend to diminish with age. Many children with ADHD develop learning difficulties that may not improve with treatment (Mannuzza et al., 1993). Hyperactive behavior is often associated with the development of other disruptive disorders, particularly conduct and oppositional-defiant disorder. The reason for the relationship is not known. Some believe that the impulsivity and heedlessness associated with ADHD
interfere with social learning or with close social bonds with parents in a way that predisposes to the development of behavior disorders (Barkley, 1998).
Even though a great many children with this disorder ultimately adjust (Mannuzza et al., 1998), some, especially those with an associated conduct or oppositional-defiant disorder are more likely to drop out of school and fare more poorly in their later careers than children without ADHD. As they grow older, some teens that have had severe ADHD since middle childhood experience periods of anxiety or depression. This seems to be especially common in children whose predominant symptom is inattention (Morgan et al., 1996). Excellent reviews of ADHD can be found in DSM-IV and other sources5.
The interplay between ADHD, school, social experiences, and emotional well being are vitally important. The distractibility, inattention, difficulty with concentration, and fidgetiness that is often associated with ADHD are the very behaviors that are the most problematic in a school environment, which requires attention to detail, patience, turn-taking, delayed gratification, and concentration. Students with ADHD are often so overwhelmed by extraneous noises outside the classroom windows, steps in the hallway, or internal thoughts and sensations that they are unable to attend to the class lessons. This results in poor academic achievement, falling grades, and often times, behavioral and emotional difficulties.
Coupled with the difficulties in school, ADHD children often have significant difficulties in social situations. Their difficulty in concentrating and focusing is often evident on the playground where they have great difficulty constraining their motor energy. They often appear to be running and darting from one area of the playground to the other without rhyme or reason. Initiating and maintaining appropriate social interactions are made more difficult by their inability to focus and attend to the informal conversations and interchanges that are such a vital part of friendship formation and social interactions.
ADHD has assumed many aliases over time from hyperkinesis (the Latin derivative for "superactive") to hyperactivity in the early 1970s. In the 1980s, DSM-III dubbed the syndrome Attention Deficit Disorder, or ADD, which could be diagnosed with or without hyperactivity. This definition was created to highlight the importance of the attention deficit that is often but not always accompanied by hyperactivity. The revised edition of DSM-III, the DSM-III-R, published in 1987, returned the emphasis back to the inclusion of hyperactivity within the diagnosis, with the official name of ADHD. With the publication of DSM-IV, the name ADHD still stands, but there are varying types within this classification, to include symptoms of both inattention and hyperactivity-impulsivity, signifying that there are some individuals in whom one or another pattern is predominant (for at least the past 6 months). In the International Classification of Diseases (used predominantly in other Western countries), the term "Hyperkinetic Disorder" is used, but the criteria are the same as for ADHD/combined type
Over the past twenty years the diagnosis of ADHD has become much more frequent, partly owing to a greater awareness of developmental issues facing young children. There has also been greater urbanization and dislocation, deleterious effects of poverty, abuse and neglect, and drug and alcohol abuse, which may have contributed to the increased prevalence rate of ADHD children.
ADHD is the most commonly diagnosed disorder of childhood, estimated to affect 3 to 5 percent of school-age children, and occurring three times more often in boys than in girls. On average, about one child in every classroom in the United States needs help for this disorder (Anderson et al., 1987; Bird et al., 1988; Esser et al., 1990; Pelham et al., 1992; Shaffer et al., 1996c; Wolraich et al., 1996). Pediatricians report that approximately 4 percent of their patients have ADHD (Wolraich et al., 1990), but in practice the diagnosis is often made in children who meet some, but not all, of the criteria recommended in DSM-IV (Wolraich et al., 1990) (see also Treatment later in this section). The disorder is found in all cultures, and although prevalences differ, these differences are thought to stem more from differences in diagnostic criteria than from differences in presentation (DSM-IV).
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.
Comorbidity (occurrence of other problems) occurs in most children clinically treated for ADHD. ADHD can co-occur with learning disabilities (15-25%), language disorders (30-35%), conduct disorder (15-20%), oppositional defiant disorder (up to 40%), mood disorders (15-20%), and anxiety disorders (20-25%). Up to 60 percent of children with tic disorders also have ADHD. Impairments in memory, cognitive processing, sequencing, motor skills, social skills, modulation of emotional response, and response to discipline are common. Sleep disorders are also more prevalent.
The exact etiology of ADHD is unknown, although neurotransmitter deficits, genetics, and perinatal complications have been implicated. In the early post-World War II years, a number of pediatricians, neurologists, and child psychiatrists noted that brain-damaged children were often hyperactive (Strauss & Lehtinen, 1947; Eisenberg, 1957; Laufer & Denhoff, 1957). These observations led to the diagnostic concept of `minimal brain damage' (Wender, 1971), which was thought to be characterized by hyperactivity, inattention, learning difficulties, and a wide variety of behavior problems. However, large epidemiological studies (Rutter & Quinton, 1977) of grossly brain-damaged children with cerebral palsy, epilepsy, and so forth, did not find an excess of hyperactivity, and more recent imaging studies have found no evidence of gross brain damage in children with ADHD (Swanson et al., 1998). The past view that ADHD is a form of minimal brain damage has therefore been abandoned by experts. Many brain-damaged children are, if anything, significantly underactive. In the late 1970s, it was postulated that the core problem in hyperkinetic children was one of inattention (Douglas & Peters, 1979). This view led, in 1980, to the adoption, in the official DSM-III (American Psychiatric Association, 1980) nomenclature, of the new diagnostic label attention-deficit disorder.
Because the symptoms of ADHD respond well to treatment with stimulants, and because stimulants increase the availability of the neurotransmitter dopamine, the `dopamine hypothesis' has gained a wide following. The dopamine hypothesis posits that ADHD is due to inadequate availability of dopamine in the central nervous system. The neurotransmitter dopamine plays a key role in initiating purposive movement, increasing motivation and alertness, reducing appetite, and inducing insomnia, effects that are often seen when a child responds well to methylphenidate. The dopamine hypothesis has thus driven much of the recent research into the causes of ADHD.
The fact that ADHD runs in families suggests that inheritance is an important risk factor. Between 10 and 35 percent of children with ADHD have a first-degree relative with past or present ADHD. Approximately one-half of parents who had ADHD have a child with the disorder (Biederman et al., 1995). Over the past decade, a large number of twin studies have shown that, when ADHD is present in one twin, it is significantly more likely also to be present in an identical twin than in a fraternal twin (Goodman & Stevenson, 1989). These findings have led geneticists to estimate that genes are important in a high proportion of children with ADHD.
Research to pinpoint abnormal genes is honing in on two genes: a dopamine-receptor (DRD) gene on chromosome 11 and the dopamine-transporter gene (DAT1) on chromosome 5 (Cook et al., 1995; Smalley et al., 1998). Several studies have found evidence that children with ADHD have genetic variations in one of the dopamine-receptor genes (DRD4), although the largest of these studies suggests that the presence of such a variation is associated with only a modest increase in the risk of developing ADHD (Smalley et al.,1998). Several other studies have found evidence for abnormalities of the dopamine-transporter gene (DAT1) in children with very severe forms of ADHD (Cook et al., 1995; Gill et al., 1997; Waldman et al., 1998).
Yet for most children with ADHD, the overall effects of these gene abnormalities appear small, suggesting that nongenetic factors also are important. Although none of the many imaging studies have found evidence of gross brain damage, some investigators have suggested that exposure to toxins, such as lead, or episodes of oxygen deprivation for the fetus, as may occur during some complications of pregnancy, may adversely affect dopamine-rich areas of the brain. These theories support observations that hyperactivity and inattention are more common in children whose mothers smoked during pregnancy (Nichols & Chen, 1981), in children who have been exposed to high quantities of lead (Needleman et al., 1990), and in children who had a lack of oxygen in the neonatal period (Whittaker et al., 1997).
Some investigators have noted that the parents of hyperactive children are often over intrusive and over controlling (Carlson et al., 1995). It has therefore been suggested that such parental behavior is another possible risk factor for ADHD. However, others have noted that, when children are treated with methylphenidate, there is a reduction in parental negativity and intrusiveness. This suggests that the observed over-intrusive and over-controlling behavior of the parent is a response to the child's behavior rather than the cause (Barkley et al., 1985).
Neuroimaging research has shown that the brains of children with ADHD differ fairly consistently from those of children without the disorder in that several brain regions and structures (pre-frontal cortex, striatum, basal ganglia, and cerebellum) tend to be smaller. Overall brain size is generally 5% smaller in affected children than children without ADHD. While this average difference is observed consistently, it is too small to be useful in making the diagnosis of ADHD in a particular individual. In addition, there appears to be a link between a person's ability to pay continued attention and measures that reflect brain activity. In people with ADHD, the brain areas that control attention appear to be less active, suggesting that a lower level of activity in some parts of the brain may be related to difficulties sustaining attention.
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 have trouble making friends. They may spend agonizing hours each night struggling to keep their mind on their homework, then forget to bring it to school. In addition, problems with peers and friendships are often present in children with ADHD. In adolescence, these children are at increased risk for motor vehicle accidents, tobacco use, early pregnancy, and lower educational attainment. When a child receives a diagnosis of ADHD, parents need to think carefully about treatment choices. And when they pursue treatment for their children, families face high out-of-pocket expenses because treatment for ADHD and other mental illnesses is often not covered by insurance policies. School programs to help children with problems often connected to ADHD (social skills and behavior training) are not available in many schools. In addition, not all children with ADHD qualify for special education services. All of this leads to children who do not receive proper and adequate treatment. To overcome these barriers, parents may want to look for school-based programs that have a team approach involving parents, teachers, school psychologists, other mental health specialists, and physicians.
The core symptoms of ADHD are:
· Inattention. People who are inattentive have a hard time keeping their mind on one thing and may get bored with a task after only a few minutes. Focusing conscious, deliberate attention to organizing and completing routine tasks may be 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. They may roam around the room, squirm in their seats, wiggle their feet, touch everything, or noisily tap a pencil. They may also feel intensely restless.
· Impulsivity. People who are overly impulsive, seem unable to curb their immediate reactions or think before they act. As a result, they may blurt out answers to questions or inappropriate comments, or 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 are upset.
Although ADHD can be diagnosed a virtually any age, different expressions (some subtle, some pronounced) of the disorder are associated with different age periods.
Although ADHD is not formally diagnosed during infancy, there are a number of behaviors that parents tend to remember being present while the child was very young (birth-two years). Excessive crying, difficulty being soothed, sleep and feeding problems (poor sucking, and problematic interactive behaviors seem to have occurred in these young children who later receive the diagnosis of ADHD.
Children three to four years of age often display behaviors that can be described as restless, inattentive, impulsive, and distractible. Because of this it often very difficult to differentiate between a youngster with ADHD and a normal active child. The degree of disruption caused by the behaviors and the duration of them often help in making a diagnosis. Significant behaviors to watch for are motor restlessness, insatiable curiosity, overly vigorous play, low levels of compliance, difficulty with sleep, delays in language development, and overly demanding of parental attention.
Between the ages of 6-12 years is the most likely time for a diagnosis of ADHD to be made. Children are faced with the increased demands of school, a more active and demanding schedule, and increased demands for `maturity'. What teachers and parents often report is that the ADHD child is easily distracted, restless, impulsive, unable to sustain attention to detail, `clowns around' in class, and has increasing difficulty with peers.
Usually the children demonstrate two kinds of global problems: behavior (as noted above) and cognitive impulsivity by making frequent and unnecessary mistakes.
Many of the more glaring motor behaviors associated with ADHD begin to diminish during adolescence, although the distractibility and impulsivity remain as problems. The continued frustrations and difficulty experienced during the pre-adolescent years often gives rise to depression and anxiety during this period. There are also increases in discipline problems and family conflicts (above those expected for this age), drug and alcohol use, as well as lethargy, and academic difficulties.
For many, the overt symptoms of ADHD lessen by adolescence. Students in high school report greater ability to concentrate and attend. However, the many years of frustration and academic difficulty often lead to continued delays in academic achievement, depression, anxiety, and other mental health problems.
This change from difficult child to more apparently sedate and focused teenager hides some potentially very significant issues. With the diminution of the more overt symptoms of ADHD what is increasingly evident is extreme frustration with school, continued poor academic achievement, and significant lowered self-esteem. The ADHD teenagers are at greater risk for drug and alcohol abuse, school dropout, and other anti-social behaviors.
The diagnosis of ADHD can usually be made using well-tested diagnostic interview methods. Diagnosis is based on both history and observable behaviors in the child's usual settings. Ideally, the clinician making a diagnosis should include input from parents and teachers. It is helpful to determine what precipitated the request for evaluation and what approaches had been used in the past. To obtain a diagnosis of ADHD using the DSM-IV diagnostic criteria, the individual must have six (or more) symptoms from one of the following two categories (inattention or hyperactivity/impulsivity). These symptoms must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.
I. Inattention
· often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
· often has difficulty sustaining attention in tasks or play activities
· often does not seem to listen when spoken to directly
· often does not follow through on instructions and fails to
· finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
· often has difficulty organizing tasks and activities
· often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
· often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
· is often easily distracted by extraneous stimuli
· is often forgetful in daily activities
II. Hyperactivity/Impulsivity
Hyperactivity
· often fidgets with hands or feet or squirms in seat
· often leaves seat in classroom or in other situations in which remaining seated is expected
· often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
· often has difficulty playing or engaging in leisure activities quietly
· is often "on the go" or often acts as if "driven by motor"
· often talks excessively
Impulsivity
· often blurts out answers before questions have been completed
· often has difficulty awaiting turn or interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, to meeting DSM-IV criteria for ADHD, at least some of the hyperactive-impulsive or inattentive symptoms that cause impairment must have been present before age 7 years. The symptoms need to be present in two or more settings (e.g., at school [or work] and at home). There must be clinically significant impairment in social, academic, or occupational functioning. Finally, the symptoms must not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
As of yet, there is no independent test for ADHD. Most diagnoses of ADHD derive from behavioral check-lists completed and submitted by teachers, parents, and others who have on-going contact with the individual, as well as observations made by the examining clinician (e.g. neurologist, psychiatrist, psychologist). It is important to note that for many youngsters with attention difficulties, the one-to-one attention and boundaries provided in an assessment environment may provide sufficient structure to allow the individual to function without overt displays of the symptoms of ADHD. As such, information from a variety of sources and environments is important to have prior to making a diagnosis of ADHD.
The assessment of ADHD needs to be completed through careful observation of the individual and the analysis of information obtained through formal assessment measures, including structured interviews, behavior rating scales, and neuropsychological tests. Because the one-to-one testing environment is often quieter, more free of distractions, and allows for greater structuring of tasks, many of the more overt symptoms associated with ADHD are often not observed. As a result, clinicians need to obtain information from a variety of sources concerning the individual's behavior. It is often said that ADHD is a `diagnosis based on history' because the clinician often relies a great deal on what others have observed and reported. There are a number of assessment strategies available to the clinician.
Structured Interviews
· NIMH Diagnostic Interview Schedule for Children (DISC). This measure can be administered by a trained non-professional.
· Diagnostic Interview for Children and Adolescents (DICA). The DICA covers all DSM-IV diagnoses and is very easy to administer. It has an excellent computerized version.
· Schedule for Affective Disorders and Schizophrenia for School-Age Children (Kiddie-SADS). This instrument is well researched and thorough. It is administered by a trained clinician.
Behavior Rating Scales - Parents
· The Conners Parent Rating Scale-Revised (CPRS-R). The Conners comes in both a long and short form that contains items that are rated on a four-point scale. The main factors assessed cover oppositionality, cognition, hyperactivity, anxiety, perfectionism, and social and psychosomatic problems.
· The Child Behavior Checklist (CBLC). The CBCL contains items that are scored on two scales, Social Competence and Behavior problems. Children with ADHD tend to score higher on the Behavior Problems scale.
Behavior Rating Scales - Teachers
· The Conners Teachers Rating Scale-Revised (CTRS-R). Similar to the CPRS-P, this scale contains both a long and short form, which contains items to assess oppositionality, hyperactivity, and cognition. The CTRS-R also contains a 12-item ADHD Index scale that can be utilized to do a quick screening.
· The Child Behavior Checklist-Teacher Report Form (CBCL-TRF). The CBCL-TRF is a long questionnaire (126 items) that consists of two scales: Adaptive Functioning and Behavior Problems. It is recommended that ratings be obtained from multiple teachers, across many different settings.
Self-Report Scales
· The Child Behavior Checklist-Youth Self Report (CBCL-YSR). The CBCL-YSR is designed for children and adolescents 11-18 years of age. Very similar to the parent and teacher versions.
· The Conner/Wells Adolescent Self-Report of Symptoms (CASS). This scale covers six areas of functioning. It does an excellent job of discriminating between ADHD-adolescents and non-ADHD adolescents. The CASS has items to identify depression and anxiety.
Continuous Performance Tests
· Continuous performance tests (CPTs) are interactive, computer-administered tasks that measure attention and impulsivity by tallying patterns of correct, incorrect, and non-responses to visually-presented stimuli . One widely-used CPT is the Conners' CPT-II Computer Program for Windows.
The major means for treating ADHD involve psychopharmacology, behaviorally based interventions, or a combination of the two (multi-modal approach). There are various forms of behavioral interventions used for children with ADHD, including psychotherapy, cognitive-behavioral therapy, social skills training, support groups, and parent and educator skills training.
Psychosocial Treatment
Psychosocial treatments are useful for the child who does not respond to medication at all or for whom the therapeutic benefits of the medication have worn off and for the child who responds only partially to medication or cannot tolerate medication. In addition, some families express a strong preference not to use medication. Even children who are receiving medication may continue to have residual ADHD symptoms or symptoms from other disorders, such as oppositional defiant disorder or depression, which make specialized child management skills necessary and helpful. Furthermore, children with ADHD can present a challenge that puts significant stress on the family. Skills training for parents can help reduce this stress on parents and siblings.
Behavioral Treatment
Behavioral treatments involve working with the client. If the client is a child, then the parent and teacher are an integral part of treatment. Behavioral techniques, which are described more fully below, typically employ time-out, point systems, and contingent attention (adults reinforcing appropriate behavior by paying attention to it).
Behavioral training for parents and teaches, as well as systematic programs of contingency appear to be the best behavioral approaches. Of these options, systematic programs of intensive contingency management conducted in specialized classrooms or summer camps with the setting controlled by highly trained individuals is the most effective (Abramowitz et al., 1992; Carlson et al., 1992; Pelham & Hoza, 1996). The efficacy of behavioral training of teachers is well established, while the evidence for parent training is less solid, according to the criteria noted earlier, which are promulgated by the American Psychological Association Task Force (Pelham et al., 1998).
The improvements in the symptoms of ADHD achieved with psychosocial treatments are not as large as those found with psychostimulants (Pelham et al., 1998). Behavioral interventions tend to improve targeted behaviors or skills but are not as helpful in reducing the core symptoms of inattention, hyperactivity, or impulsivity. Questions remain about the effectiveness of these treatments in other settings. To be fully effective, treatments for ADHD need to be conducted across settings (school, home, community) and by different people (e.g., parents, teachers, therapists); a consistency and comprehensiveness that can be hard to achieve.
Cognitive-Behavioral Treatment
Cognitive-behavioral therapy (CBT), primarily training in problem solving and social skills, has not been shown to provide clinically important changes in behavior and academic performance of children with ADHD (Pelham et al., 1998). However, CBT might be helpful in treating symptoms of accompanying disorders such as oppositional defiant disorder, depression, or anxiety disorders (Abikoff, 1985; Hinshaw & Ehardt, 1991; Lochman, 1992).
Psychoeducation
Although there are no studies evaluating the efficacy of psychoeducation as a treatment modality for ADHD, providing information to parents, children, and teachers about ADHD and treatment options is considered critical in the development of a comprehensive treatment plan (AACAP, 1991). Educational accommodations for children with ADHD are federally mandated, and mental health providers are required to ensure that patients and families have access to adequate and appropriate educational resources
Multimodal Treatment
Many researchers and families have long suspected that Multimodal Treatment, medication used together with multiple psychosocial interventions in multiple settings, should be more effective than medication alone. To determine whether multimodal treatment is indeed effective, the recent NIMH Multimodal Treatment Study of ADHD (called the MTA Study) examined three experimental conditions: medication management alone, behavioral treatment alone, or a combination of medication and behavioral treatments. The study compared the effectiveness of these three treatment modes with each other and with standard care provided in the community (the control group). The behavioral treatment condition consisted of parent training, a school intervention, and a summer treatment program. The MTA Study was also designed to determine the relative benefits of these treatments over time (Richters et al., 1995). All subjects were treated for 14 months and then followed for an additional 22 months.
Results of the MTA Study comparing the 14-month outcomes of 579 children randomly assigned to one of the four treatment conditions were presented in the fall of 1998 (MTA Cooperative Group, 1998). At 14 months, medication and the combination treatment were generally more effective than the behavioral treatment alone or the control treatment. Notably, the combined treatment resulted in significant improvement over the control condition in six outcome areas: social skills, parent child relations, internalizing (e.g., anxiety) symptoms, reading achievement, oppositional and/or aggressive symptoms, and parent and/or consumer satisfaction; whereas the single forms of treatment (medication or behavior therapy) were each superior to the control condition in only one to two of these domains.
The conclusions from this major study are that carefully managed and monitored stimulant medication, alone or combined with behavioral treatment, is effective for ADHD over a period of 14 months. Addition of behavioral treatment yields no additional benefits for core ADHD symptoms but appears to provide some additional benefits non-ADHD-symptom outcomes.
School-based Interventions
There are numerous strategies that can be utilized in the schools, to reduce the effects of ADHD and to maximize a child's ability to function and learn. In addition to psychostimulants there are numerous environmental and behavioral strategies that the child welfare worker should be aware of. Listed below are a few of the many strategies that have been successfully utilized to address the problems associated with this disorder.
· Study areas/blinder. Placing ADHD students in study carrels to provide reduced auditory and visual stimuli, allowing greater concentration.
· Sitting student in front of room, near teacher. Similar to above, placing ADHD student in closer physical proximity to teacher for more structure to reduce chance of distractions.
· Teacher Aide. One-to-one instruction to provide both physical boundaries and academic assistance is often successful.
· Front-loading academic work. It has been clinically established that ADHD students fatigue more easily in the afternoon than non-ADHD students. Reserving the mornings for concentrated academic instruction, and the afternoon for less required and demanding work is done to maximize learning opportunities. This requires both an understanding by the teacher of the dynamics of ADHD, and a willingness to be flexible with class schedules and work assignments.
· Cardio-vascular exercise. High rates of aerobic activity have been shown to be successful in reducing many of the overt symptoms of ADHD. The "endorphin high" associated with aerobic exercise often produces greater focus and ability to concentrate. Participation in jogging, swimming, biking, and other team sports have been shown to improve attention, concentration and academic performance.
Psychostimulant Medications
One theory suggests that ADHD is related to difficulties in inhibiting responses to internal and external stimuli. Evidence to date suggests that those areas of the brain thought to be involved in planning, foresight, weighing of alternative responses, and inhibiting actions when alternative solutions might be considered, are under-aroused in persons with ADHD. Stimulant medication may work on these areas of the brain, increasing neural activity to more normal levels. More research is needed, however, to firmly establish the mechanisms of action of stimulants.
Careful medication management is important in treating a child with ADHD. Psychostimulant medications, including methylphenidate (Ritalin®) and amphetamines (Dexedrine®, Dextrostat®, and Adderall®), are by far the most widely researched and commonly prescribed treatments for ADHD. Numerous short-term studies have established the safety and efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD. National Institute of Mental Health (NIMH) research has indicated that the two most effective treatment modalities for elementary school children with ADHD are a closely monitored medication treatment and a treatment that combines medication with intensive behavioral interventions. Additionally, antidepressant medications may also be used as a second line of treatments for children who show poor response to stimulants, who have unacceptable side effects, or who have comorbid conditions (such as tics, anxiety, or mood disorders). Tricyclic antidepressants (e.g., imipramine, amitriptyline) have also shown good clinical effects in 60-70% of children with ADHD.
Pharmacological treatment with psychostimulants is the most widely studied treatment for ADHD. Stimulant treatment has been used for childhood behavioral disorders since the 1930s (Bradley, 1937). Psychostimulants are highly effective for 75 to 90 percent of children with ADHD. At least four separate psychostimulant medications consistently reduce the core features of ADHD in literally hundreds of randomized controlled trials: methylphenidate, dextroamphetamine, pemoline, and a mixture of amphetamine salts (Spencer et al., 1995; Greenhill, 1998a, 1998b; Greenhill et al., 1998).
There are significant differences in access to mental health services between children of different racial groups; and, consequently, there are differences in medication use. In particular, African American children are much less likely than Caucasian children to receive psychotropic medications, including stimulants, for treatment of mental disorders
Stimulant medications are metabolized, leave the body fairly quickly, and work for 1 to 4 hours. Administration is timed to meet the child's school schedule, to help the child pay attention and meet his or her academic demands, and to mitigate side effects. These medications have their greatest effects on symptoms of hyperactivity, impulsivity, and inattention and the associated features of defiance, aggression, and oppositionality. They also improve classroom performance and behavior and promote increased interaction with teachers, parents, and peers. Small effects were found on learning and school achievement (see reviews by Barkley, 1990; Pelham, 1993; Swanson et al.,1993, 1995b; Greenhill et al., 1998; Cantwell, 1996a; Spencer et al., 1996.) However, psychostimulants do not appear to achieve long-term changes in outcomes such as peer relationships, social or academic skills, or school achievement (Pelham et al., 1998).
Children who do not respond to one stimulant may respond to another (Elia et al., 1991; Elia & Rapoport, 1991). Children should be reevaluated without the medication to see if stimulant treatment is still indicated. Many families choose to have their child take a "drug holiday" on weekends and vacations to reduce overall exposure, but the utility of this strategy has not been demonstrated (AACAP, 1991).
Dosing
Measuring the effectiveness of stimulant treatment requires awareness of the various types of response curves. Stimulant drugs are typically administered between 1-3 times each day.
· Linear Response. This is the most common response curve, where an increasing dose leads to increasing improvement.
· Threshold Response. In this response, no beneficial effects are seen at lower doses until a threshold level is achieved.
· Quadratic Response. In this response, there is an initial positive response as dose increases, then a worsening of the behaviors after dose exceeds a certain level.
Different individuals will react differently to different dosages. It is imperative that the physician monitoring the medication titrate the doses to achieve the maximum beneficial effect with the lowest possible dose.
Table 2: STIMULANT DRUGS, RECOMMENDED DOSEAGES AND SCHEDULE
STIMULANT DOSAGES DOSE SCHEDULE
Methylphenidate (Ritalin) |
5-80 mg/day in split doses |
Bid or tid |
Dextroamphetamine (Dexedrine) |
5-60 mg/day in split doses |
Bid or tid |
DextroStat |
5-60 mg/day in split doses |
Bid or tid |
Adderall |
5-60 mg/day in split doses |
QAM or bid |
Pemoline (Cylert) |
18.75-112.5 mg/day |
QAAM or bid |
Stimulant Side Effects
Common stimulant side effects include insomnia, decreased appetite, stomach aches, headaches, and jitteriness. Some children may develop tics, but a recent study suggests that tics disappear with continued treatment (Gadow et al., 1995). Rebound activation (i.e., a sudden increase in attention deficit and hyperactivity) has been noted anecdotally after the child's last dose of medication wears off (Johnston et al., 1988). Most of the side effects are mild, recede over time, and respond to dose changes. Children rarely experience cognitive impairment, which, if it does occur, can be resolved with reduction or cessation of the drug (Cantwell, 1996). A few cases of psychosis have been reported. Pemoline has been associated with hepatotoxicity, so monitoring of liver function is necessary. Two studies have shown no long-term effects of stimulants on later height or weight (Klein & Mannuzza, 1988; Vincent et al., 1990). Nonetheless, regular precautionary monitoring of weight and height for children on stimulants is recommended.
Other Medications
For children with ADHD who do not respond to stimulants (10 to 30 percent) or cannot tolerate the side effects, there are other useful medications. The antidepressant bupropion has been found to be superior to placebo, although the response is not as strong as that found with stimulants (Cantwell, 1998). Bupropion can also be used as an adjunct to augment stimulant treatment. Well-controlled trials have shown tricyclic antidepressants to be superior to placebo but less effective than stimulants (Elia et al., 1991; Elia & Rapoport, 1991). Reports of sudden death of a few children in the early 1990s on the tricyclic compound desipramine led to great caution with the use of tricyclics in children (Riddle et al., 1991).
Neuroleptics have been found to be occasionally effective (Green, 1995), yet the risk of movement disorders, such as tardive dyskinesia, makes their use problematic. Lithium, fenfluramine, or benzodiazapines have not been found to be effective treatments for ADHD (Cantwell, 1996a; Green, 1995), nor have SSRIs, such as fluoxetine (Goldman et al., 1998). Furthermore, more than 20 studies have shown that dietary manipulation (e.g., the Feingold diet) is not efficacious (Mattes & Gittelman, 1981), and controlled studies failed to demonstrate that sugar exacerbates the symptoms of children with ADHD (Milich & Pelham, 1986).
Several short-term studies of antidepressants show that desipramine produces improvements over placebo in parent and teacher ratings of symptoms. Results from studies examining the efficacy of imipramine are inconsistent. Although a number of other psychotropic medications have been used to treat ADHD, the extant outcome data from these studies do not allow for conclusions regarding their efficacy.
Treatment Controversies
Over-prescription of Stimulants. Concerns have been raised that children, particularly active boys, are being over-diagnosed with ADHD and thus are receiving psychostimulants unnecessarily. However, recent reports found little evidence of over-diagnosis of ADHD or over-prescription of stimulant medications (Goldman et al., 1998; Jensen et al., 1999). Indeed, fewer children (2 to 3 percent of school-aged children) are being treated for ADHD than suffer from it. Treatment rates are much lower for selected groups such as girls, minorities, and children receiving care though public service systems (Bussing et al., 1998a, 1998b).
However, there have been major increases in the number of stimulant prescriptions since 1989 (Hoagwood et al., 1998), and methylphenidate is being manufactured at 2.5 times the rate of a decade ago (Goldman et al., 1998). Most researchers believe that much of the increased use of stimulants reflects better diagnosis and more effective treatment of a prevalent disorder.
Nonetheless, some of the increase in use may reflect inappropriate diagnosis and treatment. In one study, the rate of stimulant treatment was twice the rate of parent-reported ADHD, based on a standardized psychiatric interview (Angold & Costello, 1998). While many children who do meet the full criteria for ADHD are not being treated, the majority of children and adolescents who are receiving stimulants did not fully meet the criteria. These findings may reflect a failure of proper, comprehensive evaluation and diagnosis rather than a failure of the diagnostic criteria, which are clear and validated by research (Angold & Costello, 1998).
Family practitioners are more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or provide follow-up care (Hoagwood et al., 1998).
Safety of Long-Term Stimulant Use. Even though the MTA Study found no safety issues over a 14-month period (Greenhill et al., 1998), concerns have been raised about the longer-term safety of stimulant treatment. Since ADHD has an early onset and requires an extended course of treatment, research is needed to examine the long-term safety of treatment and to investigate whether other forms of treatment could be combined with psychostimulants to lower their dose as well as to reduce other problem behaviors found with ADHD. Such combined treatments could be targeted for symptoms of disorders that often accompany ADHD, such as conduct disorder, substance abuse, and learning disabilities, and could be targeted to improve overall functioning (Laufer, 1971; Gittelman et al., 1985).
Because stimulants are also drugs of abuse and because children with ADHD are at increased risk for a substance abuse disorder, concerns have also been raised about the potential for abuse of stimulants by children taking the medication or diversion of the drug to others. While stimulants clearly have abuse potential, the rate of lifetime non-medical methylphenidate use has not significantly increased since methylphenidate was introduced as a treatment for ADHD, suggesting that abuse is not a major problem (Goldman et al., 1998). Case reports describing abuse by children prescribed stimulants for ADHD are rare (Hechtman, 1985). 5 Taylor, 1994; Cantwell, 1996; Waslick & Greenhill, 1997; Barkley, 1998; and NIH Consensus Statement 110, 1998).
Certain issues about the diagnosis of ADHD have been raised that indicate the need for further research to validate diagnostic methods. Clinicians who diagnose this disorder have been criticized for merely taking a percentage of the normal population who have the most evidence of inattention and continuous activity and labeling them as having a disease. In fact, it is unclear whether the signs of ADHD represent a bimodal distribution in the population or one end of a continuum of characteristics. Nevertheless, related problems of diagnosis include differentiating this entity from other behavioral problems and determining the appropriate boundary between the normal population and those with ADHD.
ADHD often does not present as an isolated disorder, and comorbidities (coexisting conditions) may complicate research studies, which may account for some of the inconsistencies in research findings. Although the prevalence of ADHD in the United States has been estimated at about 3 to 5 percent, a wider range of prevalence has been reported across studies. The reported rate in some other countries is much lower. This indicates a need for a more thorough study of ADHD in different populations and better definition of the disorder. All formal diagnostic criteria for ADHD were designed for diagnosing young children and have not been adjusted for older children and adults. Therefore, appropriate revision of these criteria to aid in the diagnosis of these individuals is encouraged. In summary, there is validity in the diagnosis of ADHD as a disorder with broadly accepted symptoms and behavioral characteristics that define the disorder.
In addition, the direct costs of medical care for children and youth with ADHD are substantial. These costs represent a serious burden for many families because they frequently are not covered by health insurance. In the larger world, these individuals consume a disproportionate share of resources and attention from the health care system, criminal justice system, schools, and other social service agencies. Methodological problems preclude precise estimates of the cost of ADHD to society. However, these costs are large. For example, additional national public school expenditures on behalf of students with ADHD may have exceeded $3 billion in 1995. Moreover, ADHD, often in conjunction with coexisting conduct disorders, contributes to societal problems such as violent crime and teenage pregnancy.
Short-term trials of stimulants have supported the efficacy of methylphenidate (MPH) dextroamphetamine and pemoline in children with ADHD. Few, if any, differences have been found among these stimulants on average. However, MPH is the most studied and the most often used of the stimulants. These short-term trials have found beneficial effects on the defining symptoms of ADHD and associated aggressiveness as long as medication is taken. However, stimulant treatments may not "normalize" the entire range of behavior problems, and children under treatment may still manifest a higher level of some behavior problems than normal children. Of concern are the consistent findings that despite the improvement in core symptoms, there is little improvement in academic achievement or social skills.
Emerging data suggest that medication using systematic titration and intensive monitoring methods over a period of approximately one year is superior to an intensive set of behavioral treatments on core ADHD symptoms (inattention, hyperactivity/impulsivity, aggression). Combined medication and behavioral treatment added little advantage overall over medication alone, but combined treatment did result in more improved social skills, and parents and teachers judged this treatment more favorably. Both systematically applied medication (monitored regularly) and combined treatment were superior to routine community care, which often involved the use of stimulants. An important potential advantage for behavioral treatment is the possibility of improving functioning with reduced dose of stimulants. This possibility was not tested.
There is a long history of a number of other interventions for ADHD. These include dietary replacement, exclusion, or supplementation; various vitamin, mineral, or herbal regimens; biofeedback; perceptual stimulation; and a host of others. Although these interventions have
generated considerable interest and there are some controlled and uncontrolled studies using various strategies, the state of the empirical evidence regarding these interventions is uneven, ranging from no data to well-controlled trials. Some of the dietary elimination strategies showed intriguing results suggesting the need for future research.
The current state of the empirical literature regarding the treatment of ADHD is such that at least five important questions cannot be answered.
1. It cannot be determined if the combination of stimulants and psychosocial treatments can improve functioning with reduced dosage of stimulants.
2. There are no data on the treatment of ADHD, Inattentive type, which might include a high percentage of girls.
3. There are no conclusive data on treatment in adolescents and adults with ADHD.
4. There is no information on the effects of long treatment (treatment lasting more than 1 year), which is indicated in this persistent disorder.
5. Given the evidence about the cognitive problems associated with ADHD, such as deficiencies in working memory and language processing deficits, and the demonstrated ineffectiveness of current treatments in enhancing academic achievement, there is a need for application and development of methods targeted to these weaknesses.
Primary care and developmental pediatricians, family practitioners, (child) neurologists, psychologists, and psychiatrists are the providers responsible for assessment, diagnosis, and treatment of most children with ADHD. There is wide variation among types of practitioners with respect to frequency of diagnosis of ADHD. Data indicate that family practitioners diagnose more quickly and prescribe medication more frequently than psychiatrists or pediatricians. This may be due in part to the limited time spent making the diagnosis. Some practitioners invalidly use response to medication as a diagnostic criterion, and primary care practitioners are less likely to recognize comorbid (coexisting) disorders. The quickness with which some practitioners prescribe medications may decrease the likelihood that more educationally relevant interventions will be sought. Diagnoses may be made in an inconsistent manner with children sometime being over diagnosed and sometimes under diagnosed. However, this does not affect the validity of the diagnosis when appropriate guidelines are used. Some practitioners do not use structured parent questionnaires, rating scales, or teacher or school input. Pediatricians, family practitioners, and psychiatrists tend to rely on parent rather than teacher input.
There appears to be a "disconnect" between developmental educational (school-based) assessments and health-related (medical practice-based) services. There is often poor communication between diagnosticians and those who implement and monitor treatment in schools. In addition, follow-up may be inadequate and fragmented. This is particularly important to ensure monitoring and early detection of any adverse effect of therapy. School-based clinics with a team approach that includes parents, teachers, school psychologists, and other mental
health specialists may be a means to remove these barriers and improve access to assessment and treatment. Ideally, primary care practitioners with adequate time for consultation with school teams should be able to make an appropriate assessment and diagnosis, but they should also be able to refer to mental health and other specialists when deemed necessary.
Studies identify a number of barriers to appropriate identification, evaluation, and treatment. Barriers to identification and evaluation arise when central screening programs limit access to mental health services. The lack of insurance coverage for psychiatric or psychological evaluations, behavior modification programs, school consultation, parent management training, and other specialized programs presents a major barrier to accurate classification, diagnosis, and management of ADHD. Substantial cost barriers exist in that diagnosis results in out-of-pocket costs to families for services not covered by managed care or other health insurance. Mental health benefits are carved out of many policies offered to families, and thus access to treatment other than medication might be severely limited. Parity for mental health conditions in insurance plans is essential. Another cost implication lies in the fact that there is no funded special education category specifically for ADHD, which leaves these students underserved, and there is currently no tracking or monitoring of children with ADHD who are served outside of special education. This results in educational and mental health service sources disputing responsibility for coverage of special educational services.
Barriers exist in relationship to gender, race, socioeconomic factors, and geographical distribution of physicians who identify and evaluate patients with ADHD. Other important barriers include those perceived by patients, families, and clinicians. These include lack of information, concerns about risks of medications, loss of parental rights, fear of professionals, social stigma, negative pressures from families and friends against seeking treatment, and jeopardizing jobs and military service. For health care providers, the lack of specialists and difficulties obtaining insurance coverage as outlined above present significant obstacles to care.
Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed neuro-behavioral disorder of childhood that represents a major problem for the child welfare system. Children with ADHD usually have pronounced difficulties and impairments resulting from the disorder across multiple settings. The traumas and added risks associated with abuse and neglect make children with ADHD even more vulnerable to social and psychological problems. They can also experience long-term adverse effects on academic performance, vocational success, and social-emotional development. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial in many public and private sectors.
The impact of ADHD on individuals, families, and schools is profound. While access to services have improved for many children, they often are delivered in a nonintegrated manner. Lack of consistent improvement beyond the core symptoms leads to the need for treatment strategies that utilize combined approaches.
Effective treatments for ADHD have been evaluated primarily for the short term (approximately three months). These studies have included randomized clinical trials that have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating the core symptoms.
The risks of treatment, particularly the use of stimulant medication, are of considerable interest. Substantial evidence exists of wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus among practitioners regarding which ADHD patients should be treated with psychostimulants. However, there is also no evidence regarding the appropriate ADHD diagnostic threshold above which the benefits of psychostimulant therapy outweigh the risks. Existing diagnostic and treatment practices, in combination with the potential risks associated with medication, point to the need for improved awareness by clinicians concerning an appropriate assessment, treatment, and follow-up. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance.
The child welfare worker needs to be aware of the symptoms of ADHD and make the appropriate referral for assessment and diagnosis. Proper diagnosis by a trained clinician is the critical first step in identifying successful treatment strategies. Combining appropriate medical treatments with behavioral training and environmental adjustments is seen as the most effective strategies for treating ADHD. Communication between the treating physician, family, school, and child welfare worker is critical to effective treatment of this disorder.
1 This report has been adapted from a number of sources, including: Mental Health: A Report to the Surgeon General (2000), DSM-IV, National Institute of Health (NIH) Consensus Statements 2000; NIH Research & Treatment (1999), ADHD in Adults and Children (Conners, et. al. 2000), the American Association of Pediatrics Guidelines on Diagnosis and Treatment of ADHD (2000), and Attention Deficit Hyperactivity Disorder (National Institute of Mental Health, 1996).
INTRODUCTION This report has been adapted | INCIDENCE AND PREVALENCE | CAUSES | SYMPTOMS | DIAGNOSIS | ASSESSMENT | TREATMENT FOR ADHD | Barriers, Challenges, and Research Issues | Conclusions & Implications for Child Welfare