Virginia Commission on Youth

Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) is one of several childhood disorders brought into the public arena in recent years. ADHD is the current term for a specific developmental disorder describing specific behavioral difficulties. Children with ADHD experience an inability to sit still and pay attention in class. ADHD is also characterized by multiple symptoms of persistent and dysfunctional patterns of overactivity, impulsiveness, inattention, and distractibility (Murphy, Cowan & Sederer, 2001).

Table 1
Facts about Attention Deficit Hyperactivity Disorder
National Institute of Mental Health, 2000

° ADHD affects an estimated 4.1% of youths age 9 to 17 in a six-month period.

° About 2 to 3 times more boys that girls have ADHD.

° Children with untreated ADHD have higher than normal rates of injury.

° ADHD often co-occurs with other problems, such as depressive and anxiety disorders, conduct disorder, drug abuse, or antisocial behavior.

° Symptoms of ADHD usually become evident in preschool or early elementary years.

° The disorder frequently persists into adolescence and into adulthood.

° Treatment may be required throughout life.

Children with ADHD experience harmful consequences as a result of their behavior. They frequently experience peer rejection and academic and social difficulties which may have long-term effects. According to the National Institute of Mental Health (NIMH) these children may have conduct disorders, experience drug abuse, exhibit antisocial behavior, and incur injuries of all sorts. For many individuals, the impact of ADHD continues into adulthood (NIMH, 2000).

ADHD has been given numerous names since it was first documented. Some of these names include Minimal Brain Dysfunction, Hyperkinetic Reaction of Childhood, and Attention-Deficit Disorder With or Without Hyperactivity (CHADD, 2001). According to the organization Children and Adults with Attention Deficit Disorders (CHADD), with the Diagnostic and Statistical Manual, 4th Edition (DSM-IV) classification system, the disorder has been renamed Attention Deficit Hyperactivity Disorder. The current name reflects the importance of the inattention characteristics of the disorder, as well as hyperactivity and impulsivity (CHADD).

ADHD is one of the best researched disorders in medicine. Studies over the past 20 years involving twins, adoptions, and molecular investigations have revealed that there is a genetic basis for the disorder (MediFocus, 2002). Recent imaging studies have documented the factual etiology of ADHD within specific areas of the brain.

Since ADHD runs in families, inheritance appears to be an important factor. Families with a child diagnosed with ADHD are more likely than those without ADHD offspring to have family members with the disorder. The heritability of ADHD averages approximately 80 percent, rivaling the heritability factor for the trait of height (Barkley, 2001). Several other developmental characteristics are associated with ADHD. Perinatal injury, malnutrition and substance exposure have also been linked to ADHD (Murphy et al., 2001).

Although a diagnostic test for ADHD is not available, (CHADD, 2001) there is insurmountable evidence supporting the validity of the disorder.

According to the National Institute of Mental Health (NIMH), ADHD is not usually an isolated disorder and comorbidities may complicate research studies. Specifically, ADHD can occur with learning disabilities (15-25 percent), language disorders (30-35 percent), conduct disorder (15-20 percent), oppositional defiant disorder (up to 40 percent), mood disorders (15-20 percent), and anxiety disorders (20-25 percent). Up to 60 percent of children with tic disorders also have ADHD.

Difficulties with memory, cognitive processing, sequencing, motor skills, social skills, modulation of emotional response, and response to discipline are commonly associated with ADHD (NIMH, 2000). Sleep disorders are also more prevalent in children who suffer from ADHD.

There is no treatment available to cure this disorder but many treatments are available that effectively assist with its management. A wide variety of treatments have been used to treat ADHD. Foremost is education of the family and school staff about ADHD and its management.

Among the treatments that result in the greatest degree of improvement in the symptoms, research strongly supports the use of stimulant medications. Methylphenidate is the first-line agent followed by d-amphetamine (Murphy et al., 2001).

Studies on the efficacy of medication and psychosocial treatments for ADHD support the effectiveness of the combination of stimulants and psychosocial treatments for ADHD. Studies also reveal the superiority of stimulants compared to psychosocial treatments (NIMH, 2000).

A Consensus Statement published by the National Institute of Mental Health (1998) maintains that psychosocial treatment for ADHD has included a number of behavioral strategies such as contingency management (e.g., point/token reward systems, and timeout) that typically are conducted in the classroom, parent training (where the parent is taught child management skills), clinical behavior therapy (parent, teacher, or both are taught to use contingency management procedures), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, problem-solving strategies, self-reinforcement). Clinical behavior therapy, parent training, and contingency management have also produced beneficial effects. Intensive direct interventions in children with ADHD have produced improvements in key areas of functioning. However, no studies have been conducted on some of these intensive interventions or on how these interventions work with medications prescribed for ADHD.

Studies did reveal that the combination of medication and behavioral treatments usually were not much more effective then just medication alone. However, combined treatment did result in more improved social skills and accordingly, parents and teachers judged this treatment more favorably. Both medications and combined treatment was superior to routine community care, which often involved the use of stimulants.

Treatment of ADHD requires behavioral, psychological and education components. Education of the child and family regarding the nature of the disorder and the methods proven to manage the disorder is crucial in its management. Treatment must be provided over long periods to assist those with ADHD in the ongoing management of their disorder.

The following is based on information from the National Institute of Health (1998). Stimulants are generally considered to be first line treatment for ADHD and are often prescribed by pediatricians, family physicians, specialized psychiatrists or child psychiatrists.

Short-term trials of stimulants have supported the effectiveness of methylphenidate dextroamphetamine (MPH). Few differences have been found among these stimulants. However, MPH is the most studied and the most often used of the stimulants. For a variety of reasons including side effects, incomplete responses or other circumstances, other medications are often recommended in combination with or following unsuccessful trials of stimulants.

Trials have found beneficial effects on the defining symptoms of ADHD and associated aggressiveness for as long as medication is taken. However, stimulant treatments may not regulate the entire range of behavior problems, and children under treatment may still show a higher level of behavioral problems than children without ADHD. The findings also show that there is little improvement in academic achievement or social skills.

It is critical that all involved with the use of these powerful medications in children be clear as to what the treatment targets are for a particular medication so that it can be maintained if it is successful and stopped if it is not effective.

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. Some of the dietary elimination strategies showed intriguing results, suggesting the need for future research. Although these treatments have generated considerable interest and there are some controlled and uncontrolled studies using various treatment strategies, the research regarding these interventions is disproportionate, ranging from no data to well-controlled trials.

It is important to realize that simple inattention or hyperactivity by itself is not sufficient for diagnosis. ADHD has been misdiagnosed in both children and adults by parents, teachers, and even by patients themselves. Misbehavior by children or teens has been inappropriately diagnosed and treated by persons looking for a simple solution to personality difficulties in hopes of avoiding psychotherapy.

While no treatment can cure ADHD, caregivers and parents must educate themselves about this disorder so they can understand it and design an effective treatment plan. It is up to the caregiver to become an informed consumer and learn to distinguish the accurate information from the inaccurate. Relatives, teachers and caretakers need to understand that ADHD is neurobiological and a child’s brain works a bit differently. ADHD is not the result of too much sugar or too little discipline.

Effective treatment involves the use of a multimodal approach that includes an appropriate educational program; behavior modification; parent, child and teacher education; and sometimes counseling and medication (CHADD, 2001). Caregivers need to advocate for their children in academic settings as well as in their home environment. Children with ADHD are now eligible for special educational services in the public schools under both the Individuals with Disabilities in Education Act (IDEA: Public Law 101-476) and Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112) (Barkley, 2001). Maximizing positive outcomes under these laws is possible with caregiver involvement.

Effective parent training teach strategies to modify behaviors and improve outcomes. Because ADHD is highly hereditary, many parents of children with ADHD discover that they too have ADHD when their child is diagnosed (CHADD, 2001). Parents with ADHD may need the same types of evaluation and treatment that they seek for their children.

Children and Adults with Attention Deficit Disorders (CHADD). (2001). The Disorder Named AD/HD – CHADD Fact Sheet #1. 2001.

National Institute of Mental Health. (2000). Attention Deficit Hyperactivity Disorder. Questions and Answers. [Online]. Available: http://www.nimh.nih.gov/publicat/adhdqa.cfm. [June 2002].

Murphy, M. J., Cowan R. L., and Sederer, L.L. (2001). Disorders of Childhood and Adolescence. Second Edition. Blueprints in Psychiatry. (pp. 40-41). Malden, Mass: Blackwell Science, Inc.

Barkley, R. (1995). Taking Charge of ADHD¾ The Complete Authoritative Guide for Parents. New York: Guilford Press.

Children and Adults with Attention Deficit Disorders (CHADD)
8181 Professional Place, Suite 201, Landover, MD 20785
CHADD National Call Center (800) 233•4050; Business (301) 306•7070 FAX (301) 306•7090
http://www.chadd.org

Clark, L. (1985). SOS! Help for Parents¾ A Practical Guide for Handling Common Everyday Behavior Problems. Bowling Green, KY: Parents Press.

National Institution of Mental Health. (2000). Attention Deficit Hyperactivity Disorder. Questions and Answers.

Barkley, R. (1998). Attention deficit hyperactivity disorders: A handbook for diagnosis and treatment. New York: Guilford Press.

Brown, T.E. (2000). Attention-deficit disorders and comorbidities in children, adolescents, and adults. Washington, D.C.: American Psychiatric Press, Inc.

Goldstein, S. (1999). The facts about AD/HD: An overview of attention-deficit hyperactivity disorder. CHADD 1999 Conference Book, Landover, MD: CHADD.

Parker, H.C. (1988). The attention deficit disorder workbook for parents, teachers and kids. Plantation, FL : Impact Publications.