Attention-deficit hyperactivity disorder

The Story of Fidgety Philip

“Let me see if Philip can
Be a little gentleman;
Let me see if he is able
To sit still for once at table.”
Thus spoke, in earnest tone,
The father to his son;
And the mother looked very grave
To see Philip so misbehave.
But Philip he did not mind
His father who was so kind.
He wriggled
And giggled,
And then, I declare,
Swung backward and forwardAnd tilted his chair,
Just like any rocking horse;-
“Philip! I am getting cross!”

See the naughty, restless child,
Growing still more rude and wild,
Till his chair falls over quite.
Philip screams with all his might,
Catches at the cloth, but then
That makes matters worse again.
Down upon the ground they fall,
Glasses, bread, knives forks and all.
How Mamma did fret and frown,
When she saw them tumbling down!
And Papa made such a face!
Philip is in sad disgrace.

Where is Philip? Where is he?
Fairly cover’d up, you see!
Cloth and ll are lying on him;
He has pull’d down all upon him!
What a terrible to-do!
Dishes, glasses, snapt in two!
Here a knife, and ther fork!
Philip, this is naughty work.
Table all so bare, and ah!
Poor Papa and poor Mamma
Look quite cross, and wonder how
They shall make their dinner now.

Attention-deficit hyperactivity disorder (ADHD) is considered to be a neurological syndrome that exhibits symptoms such as hyperactivity, forgetfulness, mood shifts, poor impulse control, and distractibility, when judged to be chronic, as symptoms of a neurological pathology. It is seen in both children and adults and is believed to affect between 3% to 5% of the human population.

Much controversy exists surrounding the diagnosis, such as over whether or not the diagnosis denotes a disability in its traditional sense, or simply describes a personal or neurological property of a patient. Those who believe that ADHD is a traditional disability or disorder often debate over how it should be treated, if at all. According to a majority of medical research in the United States, as well as other countries, ADHD is now generally regarded as a non-curable neurological disorder for which a wide range of effective treatments are available. Methods of treatment include the use of medication, psychotherapy, a combination of both, as well as other techniques. Many patients are able to control their symptoms over time, even without the use of medication.

ADHD is most commonly diagnosed in children. When diagnosed in adults, it is regarded as adult attention-deficit disorder (AADD). It is believed that anywhere between 30 to 70% of children diagnosed with ADHD retain the disorder as adults.

Terminology

The most appropriate designation of ADHD is currently disputed; the terms below are known to be used to describe the condition. A difficulty in the condition’s nomenclature arises when some scientific research suggests that certain behaviors are directly attributable to ADHD, while other research concludes that the same behaviors constitute disorders that need to be classified independently of ADHD. For the purposes of this article, the “Terminology” section will be used only to name ADHD and its near equivalents, while the names for its manifestations and subtypes will be listed in “Symptoms” section, below.

• Attention-deficit hyperactivity disorder (ADHD): In 1987, ADD was in effect renamed to ADHD in the DSM-III-R. In it, ADHD was broken down into three subtypes (see ‘symptoms’ for more details):
  • predominantly inattentive ADHD
  • predominantly hyperactive-impulsive ADHD
  • combined type ADHD

• Attention deficit disorder (ADD): This term was first introduced in DSM-III, the 1980 edition. Is considered by some to be obsolete, and by others to be a synonym for the predominantly inattentive type of ADHD.

• Undifferentiated attention-deficit disorder (UADD): This term was first introduced in the DSM-III-R, the 1987 edition. This was a miscellaneous category, and no formal diagnostic criteria were provided. UADD is approximately the predominantly inattentive type of ADHD in the DSM-IV-TR. The DSM-III-R diagnosis of attention-deficit hyperactivity disorder required hyperactive-impulsive symptoms in addition to the inattentive symptoms.

• Attention-deficit syndrome (ADS): Equivalent to ADHD, but used to avoid the connotations of “disorder”.

• Hyperkinetic disorders (F90) is the ICD-10 equivalent to ADHD. The ICD-10 does not include a predominantly inattentive type of ADHD because the editors of Chapter V of the ICD-10 believe the inattentivity syndrome may constitute a nosologically distinct disorder.
  • Disturbance of activity and attention (F90.0)
  • Hyperkinetic conduct disorder (F90.1) is a mixed disorder involving hyperkinetic symptoms along with presence of conduct disorder
  • Other hyperkinetic disorders (F90.8)
  • Hyperkinetic disorder, unspecified (F90.9)

• Hyperkinetic syndrome (HKS): Equivalent to ADHD, but largely obsolete in the United States, still used in some places world wide.

• Minimal cerebral dysfunction (MCD): Equivalent to ADHD, but largely obsolete in the United States, though still commonly used internationally.

• Minimal brain dysfunction or Minimal brain damage (MBD): Similar to ADHD, now obsolete.

Formal definitions

Neurologically, the U.S. Surgeon General and ICD-10-CM, describe ADHD as a metabolic form of encephalopathy, which impairs the release and homeostasis of neurological chemicals, thereby possibly reducing the function of the limbic system.

From a developmental/behavioral standpoint, the Diagnostic and Statistical Manual of Mental Disorders-IV-TR states that ADHD is a developmental disorder that presents during childhood, in most cases before the age of seven, and is characterized by developmentally inappropriate levels of inattention and/or hyperactive-impulsive behavior. The DSM-IV also stipulates that in order to be diagnosed, the condition must also result in significant impairment of one or more major life activities, including interpersonal relations, educational or occupational goals, as well as cognitive or adaptive functioning. ADHD may be also diagnosed in adulthood, but symptoms must have been present prior to age seven, in order to yield a positive diagnosis.

Symptoms of ADHD

The symptoms of ADHD fall into the following two broad categories:

Inattention:

1. Failing to pay close attention to details or making careless mistakes when doing schoolwork or other activities

2. Trouble keeping attention focused during play or tasks

3. Appearing not to listen, when spoken to

4. Failing to follow instructions or finishing tasks

5. Avoiding tasks that require a high amount of mental effort and organization, such as school projects

6. Frequently losing items required to facilitate tasks or activities, such as school supplies

7. Excessive distractability

8. Forgetfulness

Hyperactivity-impulsive behavior

1. Fidgeting with hands or feet or squirming in seat

2. Leaving seat often, even when inappropriate

3. Running or climbing at inappropriate times

4. Difficulty in quiet play

5. Frequently feeling restless

6. Excessive speech

7. Answering a question before the speaker has finished

8. Failing to await one’s turn

9. Interrupting the activities of others at inappropriate times

A positive diagnosis is usually only made if the patient presents with at least six of the above symptoms. In addition, a positive diagnosis is made if six or more of these symptoms presented before the age of seven; the symptoms usually begin to appear between the ages of four and six.

Children who grow up with ADHD often continue to have symptoms as they grow into adulthood. Adults face some of their greatest challenges in the areas of self-control, motivation, as well as executive functioning (also known as working memory). If the patient is not treated appropriately, co-morbid conditions, such as depression and anxiety may present as well. If a patient presents with such conditions as well, the co-morbid condition is usually treated first.

Diagnosis

The Centers for Disease Control and Prevention (CDC) emphasize that a diagnosis of ADHD should only be made by trained health care providers, as many of the symptoms may also be part of other conditions, such as bodily illness or other physical disorders, such as hyperthyroidism. Further, it is not uncommon that physically and mentally nonpathological individuals exhibit at least some of the symptoms from time to time. Severity and pervasiveness of the symptoms leading to prominent functional impairment across different settings (school, work, social relationships) are major factors in a positive diagnosis.

Psychoanalytical Testing

Due to the lack of objectivity that surround the critical factors, many question the reliability of ADHD diagnosis. The American Academy of Pediatrics Clinical Practice publishes guidelines to aid providers in making an objective diagnosis, but even if strictly adhered to, doubt still remains among some patients, as well as providers. Other diagnostic methods, such as those involving magnetic resonance imaging (MRI), may detect the presence of ADHD by analyzing images of the patient’s brain, are usually not recommended (see brain scans). In a majority of cases, diagnosis is therefore dependent upon the observations and opinions of those who are close to the patient; in many patients, especially as they approach adulthood, self-diagnosis is not uncommon.

Publications that are designed to analyze a person’s behavior, such as the Brown Scale or the Conners Scale, for example, attempt to assist parents and providers in making a diagnosis by evaluating an individual on typical behaviors such as “Hums or makes other odd noises”, “Daydreams” and “Acts ‘smart’”; the scales rating the pervasiveness of these behaviors range from “never” to “very often”. Connors states that, based on the scale, a valid diagnosis can be achieved; critics, however, counter Connors’ proposition by pointing out the breadth with which these behaviors may be interpreted. This becomes especially relevant when family and cultural norms are taken into consideration; this premise leads to the assumption that a diagnosis based on such a scale may actually be more subjective than objective (see cultural subjectivism). The scales are further criticized, because they were originally developed to measure the effectiveness of stimulant medication, and not to detect ADHD. Therefore, the scales might merely evaluate a patient’s response to stimulant medication, such as Ritalin or Adderall, rather than the presence of ADHD.

Clinical Testing

The American Academy of Pediatrics Clinical Practice Guideline for children with ADHD emphasizes that a reliable diagnosis requires:

1. The use of explicit criteria for the diagnosis using the DSM-IV-TR.

2. The importance of obtaining information about the child’s symptoms in more than one setting (especially from schools).

3. The search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning.

A proper diagnosis is dependent upon a physician fulfilling all three of these criteria. The first criteria can be satisfied by using an ADHD-specific instrument such as the Conners Scale. The second criteria is best fulfilled by examining the individual’s history. This history can be obtained from parents and teachers, or a patient’s memory. The requirement that symptoms be present in more than one setting is very important because the problem may not be with the child, but instead with teachers or parents who are too demanding. The use of intelligence and psychological testing (to satisfy the third criteria) is essential in order to find or rule out other factors that might be causing or complicating the problems experienced by the patient.

Computerized tests

Computerized tests of attention are not especially helpful in providing a further independent assessment because they have a high rate of false negatives (real cases of ADHD can pass the tests in 35% or more of cases), they do not correlate well with actual behavioral problems at home or school, and are not especially helpful in determining treatments. Both the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry have recommended against the use of such computerized tests for now in view of their lack of appropriate scientific validation as diagnostic tools. In the USA, the process of obtaining referrals for such assessments is being promoted vigorously by the President’s New Freedom Commission on Mental Health.

Brain scans

Neurometrics, PET scans, FMRI, or SPECT scans have the potential to provide a more objective diagnosis. However, these are not typically suitable for very young children, and may unnecessarily expose the patient to harmful radiation. Because the etiology of the disorder is unknown, and a complete neurological definition of this disorder is lacking, a majority of clinicians doubt the current predictive power of these objective tests to detect ADHD to be used to direct clinical treatment. Currently, the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry recommend against using these neuro-imaging methods for clinical diagnosis of individuals who may have ADHD. They remain, however, useful research tools when studying groups of patients with ADHD. An October 2005 meta-analysis by Alan Zametkin, M.D., with the NIMH entitled “The ADHD Report”, concluded that these diagnostic methods lack adequate scientific research on accuracy and specificity to be used as a primary diagnostic tool.

Incidence

ADHD has been found to exist in every country and culture studied to date. While it is most commonly diagnosed in the United States, rates of diagnosis are rising in most industrialized countries as they become more aware of the disorder, its diagnosis, and its management.

Nearly four million children younger than 18 in the United States had been diagnosed with attention deficit hyperactivity disorder (ADHD). In general, 5-8% of children are likely to have ADHD while 4-5% of adults do so. More than twice as many boys have been diagnosed than girls (10% vs. 4%).

The ADHD treatment rate among Caucasian children is significantly higher than among African and Hispanic Americans (4.4% Caucasian, 1.7% African, 1.5% Hispanic in 1997)

The same study notes that outpatient treatment for ADHD has grown from 0.9 children per 100 (1987) to 3.4 per 100 (1997).

Possible causes

Research indicates that the frontal lobes, their connections to the basal ganglia, and the central aspects of the cerebellum (vermis) are most likely to be involved in this disorder, as may be a region in the middle or medial aspect of the frontal lobe, known as the anterior cingulate. The cerebellum, which is believed to play important roles in “short-term memory, attention, impulse control, emotion, higher cognition, [and] the ability to schedule and plan tasks,” has been shown to be smaller in the brains of those who have ADHD.

A 1990 study at the U.S. National Institute of Mental Health correlated ADHD with a series of metabolic abnormalities in the brain, providing further evidence that ADHD is a neurological disorder.

The source of these differences is not yet known, but a couple of theories have been presented.

Hereditary dopamine deficiency

Research suggests that ADHD arises from a combination of various genes, many of which have something to do with dopamine transporters. Suspect genes include the 10-repeat allele of the DAT1 gene and the 7-repeat allele of the DRD4 gene. Other studies have documented an association between ADHD and the dopamine beta hydrozylase gene (DBH TaqI).

SPECT scans found people labeled as ADHD have reduced blood circulation, and a significantly higher concentration of dopamine transporters in the striatum which is in charge of planning ahead.

Metabolism

It has long been suggested that ADHD could be the result of a nutritional problem. Recent studies have begun to find metabolic differences in these children, indicating that an inability to handle certain elements of one’s diet might contribute to the development of ADHD, or at least ADHD-like symptoms. For example, in 1990 the English chemist N.I. Ward showed that children with ADHD lose zinc when exposed to a food dye. Waring, McFadden, and others have shown that children with autism or ADHD are low in sulfation metabolism, in particular the enzyme Phenol Sulfotransferase-P. Some studies suggest that a lack of fatty acids, specifically omega-3 fatty acids can trigger the development of ADHD. Support for this theory comes from findings that breast-fed children are less likely to have ADHD than their bottlefed counterparts and until very recently, infant formula did not contain any omega-3 fatty acids at all. Time will tell whether or not this is coincidence or a true correlation.

External Factors

There is no compelling evidence that social factors, alone, can create ADHD. The few environmental factors implicated fall in the realm of biohazards including alcohol, tobacco smoke, and lead poisoning. Allergies (including those to artificial additives) as well as complications during pregnancy and birth– including premature birth–might also play a role.

Smoking during pregnancy

It has been observed that women who smoke while pregnant are more likely to have children with ADHD. Nicotine is known to cause hypoxia (lack of oxygen) in the uterus. Hypoxia causes brain damage. Therefore it is entirely possible that smoking during pregnancy could cause the fetus to suffer brain damage.

Head injuries

It has been known for some time that head injuries can cause a person to display ADHD-like symptoms. This is possibly because of the damage done to the victim’s frontal lobes. This is also why one of the earliest names for ADHD was “Minimal Brain Damage”.

Dopamine deficiency caused by sleep apnea

Another theory is that ADHD is caused by brief pauses in breathing (apnea) during infancy. In October 2004, Dr. Glenda Keating and Dr. Michael Decker of Emory University presented data at the Society for Neuroscience’s annual meeting showing that repetitive drops in blood oxygen levels in newborn rats similar to that caused by apnea in some human infants is followed by a long-lasting reduction in dopamine levels, associated with ADHD. Apnea occurs in up to 85% of prematurely born human infants. It remains to be seen whether or not these findings can be replicated in human babies.

Treatment of ADHD

There are many options available to treat people diagnosed with ADHD. The options with the greatest scientific support include a variety of medications, behavior-changing therapies, and educational interventions.

Findings of a large randomized controlled trial suggest that:

• Medication alone is superior to behavioral therapy alone.

• The combination of behavioral therapy and medication has a small benefit over medication alone.

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Damir Pejin

Damir Pejin finished secondary medical school and then the International College for Classical Homeopathy. He also did additional study in acupuncture. He currently works as a homeopath, educator and mentor at Simillimum College for Classical Homeopathy in Belgrade.