Attention Deficit Hyperactivity Disorder By Mark B. Levin, M.D. and Timothy J. Patrick-Miller, M.D. The Pediatric Group, P.A., Princeton

This timely three-part article, the thirtyfifth in a series for Princeton Online, deals with a complex issue that affects many children and their families. Click here for an archive of other articles.

PART I: Introduction and Physiology

Most young children will have days when their behavior is out of control. At these times, they may be impatient, talk incessantly, speed around non-stop, and crash into everything around them. At other times, they may appear to be daydreaming, not paying attention or not finishing tasks they start. For children with ADHD (Attention Deficit Hyperactivity Disorder), these behaviors are more than occasional and persist through the post-kindergarten age. ADHD children manifest behaviors that interfere with their ability to function normally and interfere with the lives of those around them. These children often miss social cues, resulting in lost relationships with siblings and peers, both at school and at home. They have trouble learning at a level that is consistent with their intellect. Their impulsive nature may put them in actual physical danger as they act before considering risks. They may be labeled as bad kids, underachievers, loners or accident-prone. (Indeed, ADHD children are accident-prone, and need greater supervision in risky situations, such as around traffic, swimming pools, firearms, lawn mowers, poisonous chemicals, medicines, and cleaning supplies.) Left untreated, more severe ADHD can spiral into serious, lifelong problems such as poor school and job performance, failed relationships, criminal activities and psychiatric conditions. Automobile insurers know that drivers with untreated ADHD have markedly higher accident (and death) rates than non-ADHD drivers. Milder forms may allow successful completion of life tasks but often require an inordinate investment in time, effort and worry. Effective treatment is available. If your child has ADHD, your pediatrician can offer a management approach to help your child lead a successful, happy and healthy life. As a parent, you have a critical role in recognizing the signs of ADHD and implementing a plan to enhance your child's personal growth.

ADHD is a familial, biochemical condition of the brain that makes it difficult for people to focus on the task at hand. It is common, affecting up to 12 % of the population. As diagnostic techniques are refined, that number may increase. Males, who are more likely to be singled out because of a tendency toward hyperactivity, are diagnosed approximately three times more frequently than females, but the actual gender distribution is probably about even. Because of its inherent biochemical nature, ADHD is a lifelong condition. People with ADHD who adapt to their functional style can lead productive, happy lives. They do so by seeking environments where they can succeed and taking medication, when necessary, to modify their attending abilities. In many careers, having a high-energy behavior pattern can be an asset. Without adaptation, guidance and, perhaps, medication, they may maladjust, becoming dysfunctional.

The Hyperactive type of ADHD has been identified for generations, but has been given various other labels. Historically, before ADHD was recognized as a biochemical entity involving neurotransmitter function, its associated hyperactive behavior was thought to be due to brain injury. Hence the initial terminology, Minimal Brain Damage, derived from the belief that perhaps some disadvantageous episode in the perinatal period was responsible. Later, when scientific study discounted this theory for the majority of people with ADHD, the terminology was changed to Minimal Brain Dysfunction. As the symptom complex characterizing ADHD became clearer to investigators, the moniker was changed to a term more descriptive of the symptom that helped clinicians the most easily recognize the condition, Attention Deficit Disorder. Most recently, concurrent with further elucidation of the condition's biochemical basis, the name was again changed to more accurately reflect the variety of ways it presents, ADHD.

Harrison demonstrated in 1907 that adjacent nerve cells relate at a gap (called a synapse) that separates them. In 1964, Eccles demonstrated that nerves communicate through the action of natural chemicals released by the transmitting nerve ending into the synapse. These chemicals, called neurotransmitters, find their way across the synapse to the receiving nerve, causing the nerve impulse corresponding to a thought, sensation or action to be propagated along the next nerve. The process is repeated at each nerve junction until the impulse reaches its final destination (for example, a muscle). The metabolic nature of ADHD has been confirmed through the use of newer sophisticated technology. Positron Emission Tomography, familiarly known as a PET scan, is a recent technique that demonstrates metabolic activity in the scanned area of the body. An ADHD brain displays far less diffuse metabolic activity under mental challenge than does a non-ADHD brain. When people with ADHD take stimulant medication, their PET scan pattern resemble those of non-ADHD people. When the effect of the medication wears off, their PET scan images revert to the pre-medicated pattern. This implies that interneuronal transmission (in the region of the synapse) is less active in an ADHD brain than in a non-ADHD brain. Although PET scans are just now being used more for clinical diagnosis, they have heretofore been used mainly for research. As more data accumulates, PET scans may become a useful tool in making the diagnosis of ADHD. There is no credible scientific evidence that ADHD is caused by sugar intake, food additives, allergies or immunizations. However, any physiologic stress (e.g., fatigue, hunger, illness or worry) may temporarily simulate and/or exacerbate ADHD symptoms.

Although we all share 99.9% of our genetic makeup with other humans, there are myriad differences in that remaining 0.1%. With respect to our neurologic function, we can differ in the following ways:

having a different mix of neurotransmitters;
having a different molecular neurotransmitter structure;
having varying amounts of each component of the neurotransmitter mix;
having different rates of flow of the neurotransmitters to and across the synapse;
having a different sensitivity of a nerve to the effects of the neurotransmitters;
having an enhanced ability to metabolize and eliminate the neurotransmitters from the synapse;

We know of numerous body chemicals that serve as neurotransmitters - epinephrine, norepinephrine, dopamine, serotonin, tyrosine, and 5-hydroxy-indole acetic acid are a few of the well known ones. With just these factors, there are 479,001,600 possible different functional type combinations available. There are many more neurotransmitters than are mentioned here and there may be dozens more that are as yet undiscovered. No wonder we all function differently! The challenge these differences pose to clinicians in determining which of us fits a diagnosis and which deserves treatment is obvious.

PART II: Differentiation from Learning Disabilities, Classification and Diagnosis

Many people confuse processing style with ADHD. Although issues of processing style overlap considerably with those of ADHD, their mechanisms are distinct. While some of us can process information regardless of the mode in which it is presented, most of us prefer it either in auditory, visual or tactile form. Concepts of math and science, for example, often require translating abstract thought into concrete principle. Those of us who require visual input to grasp these concepts are visual learners and usually excel in the courses requiring a large amount of reading that the auditory learner dreads. Visualizing a "3" means nothing to a visual learner unless he understands the abstract principle of the plurality of what a "3" represents. Seeing three objects, however, is a more concrete way of allowing visual learners to understand math concepts. The auditory learner, however, intuitively understands math concepts. Other children are more concrete in their learning, requiring tactile input to be able to understand an idea and be able to use it. Showing or describing a hammer to a tactile learner does not cause him to comprehend its function and uses. If that same child is given the opportunity to pound a few nails into a piece of wood, then he will understand a hammer. A child is called "learning disabled" when he or she finds information presented in a particular format difficult to process because of innate learning style.

ADHD is classified as Inattentive type, Hyperactive type or Combined type. Children with pure ADHD- Inattentive type (most commonly diagnosed in females) are generally considered well behaved, but may actually be day dreaming, thereby missing instruction. Disruptive or destructive behaviors are not characteristic of the Inattentive type ADHD child.

The Hyperactive type ADHD child, most commonly a male with boundless energy jumping into action before considering the consequences, is easier to recognize. Though well meaning, he will often be destructive and accident-prone. The non-ADHD active preschooler is not easily distinguishable from a hyperactive one. While a preschooler might have ADHD, the immaturity of his thought process makes the diagnosis unreliable. Where in the spectrum of activity level a post-kindergarten child is labeled as normal and where he is labeled as ADHD is best defined by the child's ability to function. If an active child is not disruptive, has good social relationships and succeeds academically, he is more likely just an active normal child. If an active child, however, struggles frustratingly with poor school performance, fails to socially integrate with peers or is frequently injured, the suspicion of ADHD is heightened.

Children with the Combined type ADHD have characteristics of both inattention and hyperactivity/impulsivity and are diagnosed more often than either of the other two types. As our knowledge of the course and causes of ADHD increases, the diagnosis and classification of ADHD will continually be refined.

Some masqueraders and confounding situations deserve mention. Boredom can mimic inattention, as can the influence of drugs, fatigue, hunger, grief, depression, anxiety, perceived intimidation by a teacher, excessive work load or other stressful social situations. Remember that it is the symptom complex evaluated collectively rather than any individual symptom that may suggest ADHD. As previously mentioned for preschoolers, normal immaturity makes the diagnosis difficult to confirm. Likewise, in adolescence, mood swings, rebelliousness and motivational issues can mimic Inattentive or Hyperactive type ADHD. Lapses in judgment become particularly problematic when adolescents assume responsibility for making decisions about an increasing number of adult (and, therefore, risky) behaviors, such as participation in sex, driving, social relationships, drinking alcohol and using licit and illicit drugs. In the face of self-image issues and peer pressures, these lapses require heightened parental vigilance and involvement with regard to an ADHD teen's activities.

Although often evident early in a child's educational career, the symptoms of ADHD may not present until high school, college or adulthood. The age at which symptoms of ADHD lead parents or teachers to suspect the diagnosis varies with the processing style and intellect of the child and the expectations adults have for the child. An ADHD visual learner may appear to focus well on some activities, especially those that fit her processing style. For example, a visual learner with ADHD may appear to concentrate for long periods on a book (particularly if she likes the story), while missing important details in the story. A smart child can often synthesize appropriate answers to questions, even when she misses the details, thereby obscuring the diagnosis. So, a child, whose response to a question is based on her life experience or memorized data, may give the impression that she understands an abstract problem that otherwise confounds her.

The ADHD child's response to the challenge of academic work may vary with the child's personality and coping skills. One child will quickly complete his work, but refuse help and refuse to re-check his work for errors, claiming that he has learned all he can from it the first time. On the other end of the spectrum is the child who, being loath to commit errors, spends an inordinate amount of time reviewing her work compulsively to the exclusion of other activities. Neither type child is happy with his or her performance. Either type is at risk for the social consequences of this unhappiness - being oppositional, dropping out of school, and assuming alternative cultural styles in order to be accepted into a social group. ADHD children who have an associated LD are doubly challenged. The auditory ADHD child may readily memorize multiplication tables, but be unable to work out multiplication problems on paper. An ADHD tactile learner may sit for hours constructing a building out of Lego® blocks but be unable to sit for five minutes for story time or math problems.

Making the diagnosis is the first step to take to avoid the pitfalls that await the unsuspecting ADHD child and to begin to provide an environment where the child can grow and learn happily and successfully. If you suspect ADHD in your child, your initial gesture should be to contact your pediatrician, who can guide you through the diagnostic process. As he or she will tell you, there is no single or proven diagnostic test for ADHD. The process requires several steps and involves a great deal of information gathering from multiple sources, including your child, you, other care-givers, and teachers. Using survey type questionnaires (such as the well known Connor's Scale) and following the guidelines elaborated by the American Academy of Pediatrics*, your pediatrician can make an initial judgment as to whether your child's behavior and achievement differs sufficiently from that expected to warrant further investigation.

*The guidelines promulgated by the AAP include:

Behaviors that occur in more than one setting;
Behaviors that are more severe than in other children the same age;
Behaviors that start before the child reaches seven years old, even if they are not recognized until an older age;
Behaviors that continue for at least six months;
Behaviors that make it difficult for the child to function at school, at home and/or in social situations.

If ADHD is suspected and a full medical history and complete physical examination have not been recently performed, your pediatrician will arrange for this as a next step. After the examination, you pediatrician may wish to refer your child to a pediatric subspecialist if he or she has concerns in one of the following areas:

Developmental disorders such as speech or motor difficulties;
A Learning Disability (also termed Individual Learning Style Difference);
Chronic illness being treated with medication that may interfere with learning;
Trouble with hearing or vision;
History of physical, sexual or psychological abuse;
Major Anxiety or Depressive Disorder;
Severe aggression;
Possible seizure disorder;
Mental retardation or brain damage.

At this stage, an assessment by a psychoeducational specialist (usually a specially trained psychologist) is often requested. This evaluation is designed to discover valuable data regarding the child's intellectual level (to be able to gauge expectations), learning style (to assess coexisting learning disabilities), emotional status (to determine coexisting psychological disorders) and to gain insights into processing speed and ability to maintain attention. Usually, this specialist will interview the child's parents, review teacher comments from early schooling through the present, ask for input from other adults who have extended contact with your child (clergy or coaches, for example), spend from three to eight hours in one or two sessions evaluating the child and devote another one to two hours presenting the findings to the parents (and child). This summary will include recommendations for classroom environment, teaching suggestions, appropriate learning aids and recommendations regarding medical counsel for prescription medication. Be sure your pediatrician receives a copy of this report, as it is often she or he who will help you interface with the educational system and help you regulate any necessary medication.

If your child is suspected of having a coexisting psychiatric disorder (Obsessive Compulsive Disorder, Oppositional Defiant Disorder, Anxiety Disorder and Depression are among the most common) or neurologic disorder (e.g., Tourette Syndrome) you will likely be referred to a pediatric/adolescent psychiatrist or neurologist for confirmation and management suggestions. Tourette Syndrome, an inherited condition associated with frequent motor tics and unusual vocal sounds, is unrelated to ADHD. Some children may have both conditions. The treatment of one may or may not influence the other. Up to fifty percent of ADHD children have a coexisting condition and about thirty-three percent have two. Suggestions for managing coexisting learning disabilities can be implemented by a Learning Disability Teaching Consultant (LDTC) or a teacher with appropriate training.

PART III: Treatment

ADHD is common and chronic. These traits, along with the fact that appropriate treatment is time and labor intensive, have spawned a plethora of popular, but unproved, treatments. The drawback of unproven treatments is not just the possible toxicity from herbal preparations or megavitamin doses, but wasted time and expense that would have been better spent on effective treatments. Several of the more widely promoted ineffective or unproven treatments are listed below with a brief statement as to why they should be avoided.

If you decide to pursue alternative treatments, you should advise your pediatrician in case there are any interactions with other medications he or she may prescribe. Research into more effective approaches for ADHD is ongoing.

Many parents fear that "labeling" a child with ADHD will cast a pejorative shadow on the child's future. On the contrary, as in any other condition, identifying that condition allows the institution of appropriate therapy, which improves the child's life. Because of governmental and school regulations, children are able to take advantage of services available in the school (through college level) only if documentation of the diagnosis is shared with the school. Schools want children to succeed. Moreover, the law prohibits discrimination against a child because of ADHD. The child who is deprived of these services and whose educational suffers is at a far greater disadvantage in life than the child who has recognized his condition and sought appropriate help.

What then are the treatments available for children with ADHD? The most important part of a treatment plan for ADHD is education of the parents, the child and the teachers about ADHD. Only when the teachers and parents understand the mechanism and impact of ADHD can they afford the child any meaningful assistance. The importance of the child understanding his or her own learning style can not be overstated. With this understanding, the child will be less inhibited and more able to participate in the treatment process and assessment system. The first intervention, therefore is to share the psychoeducational specialist's report with your pediatrician, the school personnel and your child. Together, these parties can elaborate an appropriate setting and teaching program for your child, enlisting whatever school services are available and fitting. If certain services are needed but unavailable in the school, they can be sought elsewhere with the support of the school officials. It is critically important for parents to be aware of The Individuals with Disabilities Education Act, Part B (IDEA) and Section 504 of the Rehabilitation Act of 1973 (commonly referred to as "section 504 accommodations") which require schools to meet the educational needs of students with disabilities. These apply to learning disabilities and emotional disabilities as well as ADHD. Your State Department of Education can supply you with materials regarding this Federal legislation.

Creating the right setting for the child not only improves his or her ability to use his or her intellect, but also demonstrates to the child what type of learning environment he or she should seek out in the future to enhance his or her learning functionality. Examples of some special accommodations are a small class size, a teacher versed in techniques appropriate for an ADHD child, preferential seating, extended time for tests, minimal distractions on the walls and in the halls, note takers, study partners, laptop computers, and FM transmitters. Part of your responsibility as a parent includes assuring adequate rest and diet for your child and control of ancillary physical conditions, such as allergies. If a child is not physiologically well, his school performance will suffer. Inform the teacher of your child illnesses so he or she will know that an unexpected decrease in functionality is temporary.

Environmental modification may include an alteration in parenting techniques. The parenting approach you used before knowing about ADHD may now seem counterproductive. Consult with your pediatrician, a behavior modification specialist or family counselor regarding how you can change to a more effective parenting style in light of what you now know. In establishing a treatment plan, you should target between three and six behaviors for improvement. These targets must be realistic (Can they be achieved?) and measurable and may include improved social relationships, improved schoolwork, more independent self care or homework, improved self-esteem, fewer disruptive behaviors, and/or safer behaviors.

At the onset, you will need to establish an assessment system to objectively determine to what degree your interventions are successful. This can be accomplished by asking teachers to fill out a simple weekly questionnaire, such as:

An abbreviated Connor's Scale (Multi-Health Systems, Inc.),
The Abbreviated ADHD Symptom Checklist (Checkmate Plus),
A Diagnostic Criteria scale (Ross Labs),
The ADHD Symptom Tracking System (Compact Clinicals),
The BASC Teacher Rating Scale (AGS),
The Behavior Dimensions Scale (Hawthorne Educational Services).

Alternatively, you can identify a quantifiable event that occurs because of the ADHD (such as how much time homework consumes, the frequency of a child's crying during homework, how often a child forgets homework assignments, etc.). An assessment system is necessary to optimize your interventions.

Much of the disparaging press about ADHD concerns the use of stimulant medication. Contrary to what has so long been in the public ear, medication, in carefully selected cases, is exceptionally helpful in ameliorating the symptoms of ADHD. In no case should medication be prescribed in the absence of the psychoeducational changes outlined above. When diagnostic evaluation has been inadequate and non-medication approaches have not been tried, children may be given medication unnecessarily. Whether to start medication early in the treatment program or later is an individual decision based on the child's age, school performance and the results of the psychoeducational evaluation. Before accepting medication as a treatment option, it is important to understand its mode of operation. Once understood, much of the apprehension associated with its use dissipates. As you recall from the preceding discussion of the biochemical nature of ADHD, each of us is programmed with our own special blend of neurotransmitters. To the best of our knowledge, the commonly used stimulant medications merely enhance the function of these neurotransmitters temporarily. Methylphenidate derivatives (Ritalin®, Methylin®, Metadate® and Concerta®) simply increase the speed with which these neurotransmitters descend down the nerve toward the synapse. Dextroamphetamine derivatives (Dexedrine®, Dextrostat®, and Adderall®) speed the descent of these neurotransmitters and decrease the rate of their elimination from the synapse. They do not change genetic design. Once these medications have worn off, there is no further detectable effect. They are not sedating or tranquilizing.

It is true that these medications, as any other medications, can be misused. In excessive (actually, huge) doses, they can be used to get a "high", although the margin of safety between a "high" and serious pharmacological effects like hallucinations, seizures and death is slim. For this reason, these medications are carefully regulated by the Federal government. Anything to excess is, in general, to be avoided. One can die from drinking excessive amounts of water to the point where blood salts are dangerously diluted. It is not true that these medications, in the doses prescribed, are addictive or lead to addiction with other substances. In fact, studies have shown that an untreated ADHD person is more likely to have trouble with drug addiction that a treated one. People with ADHD are naturally impulsive and tend to take risks. Those with ADHD who are taking stimulant medication are actually at lower risk of using other drugs. People with coexisting psychological conditions may be at increased risk for illicit drug use regardless of medication used for ADHD. The adverse psychological and societal consequences of unrecognized ADHD are highly correlated with dysfunctional, maladaptive behaviors.

In its simplest analogy, stimulant medication for ADHD is nothing more than a tool that allows an ADHD person to use the intellect and talent he innately has. It differs little in concept from the outfielder in a hardball game who is asked to catch a fly ball without a baseball glove. Without the glove, regardless of his or her coordination and understanding of how the game is played, he or she is likely to drop the ball or get hurt trying to catch it. With the tool (the glove), the player can play the game to the best of his or her innate ability. If medication is appropriate for your child, your pediatrician can help you decide which medication is best for him or her, whether the chosen medication is influenced by food intake and whether alternative methods of administration are available (they all are manufactured in tablet or capsule form). It may take some time before the proper medication and the proper dose is found. Because a person's metabolism may adapt to stimulant medication, changes in dosage should not be made more frequently than weekly.

Careful follow up of whatever treatment plan is instituted is imperative, as the child's response can change with advancing age and educational demands may change with increasing grade level. If medication is chosen, regular pediatrician visits and review are necessary to monitor the need for altering the medication dosage, the possibility of adverse influences on growth and development and the emergence of other untoward effects. The most common effects requiring modification of a medication regimen are sleeplessness and appetite loss.

The following is a list of resources for those who wish to further explore this timely and important topic. Inclusion on this list does not imply endorsement of any organization by The Pediatric Group, P.A. Your pediatrician can guide you to local support and information groups as well as to competent specialists who deal with ADHD. Specifics of diagnosis and a treatment plan are individual and are best recommended by your pediatrician or primary medical care giver.

National Institute of Mental Health
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892-9663
www.nimh.nih.gov

Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD)
8181 Professional Plaza, Suite 201
Landover, MD 20785
www.chadd.org

National Attention Deficit Association
1788 Second Street, Suite 200
Highland Park, IL 60035
www.add.org

National Information Center for Children and Youth with Disabilities
P.O. Box 1492
Washington, DC 20013-1492
www.nichcy.org

Medem
www.medem.com

The Attention Deficit Information Network, Inc.
475 Hillside Avenue
Needham, MA 02194
www.addinfonetwork.com

Dr. Mark B. Levin 

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Timothy Patrick-Miller Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.

©All rights reserved, The Pediatric Group, P.A. 2002