Every year the National Information Center for Children and Youth with Disabilities (NICHCY) receives thousands of requests for information about the education and special needs of children and youth with Attention-Deficit Disorder (ADHD, ADD/ADHD). Over the past several years, ADD or A.D.D. (ADHD, ADD/ADHD) has received a tremendous amount of attention from parents, professionals, and policymakers across the country - so much so, in fact, that nearly everyone has now heard about ADD or A.D.D.
While helpful to those challenged by this disability, such widespread recognition creates the possibility of improper diagnostic practice and inappropriate treatment. Now, more than ever, parents who suspect their child might have ADHD (A.D.D. ADD/ADHD, ADD-ADHD, A.D.D.) and parents of children diagnosed with the disorder need to evaluate information, products, and practitioners carefully.
This NICHCY Briefing Paper is intended to serve as a guide to help parents and educators know what ADHD (A.D.D. ADD/ADHD, ADD-ADHD, A.D.D.) is, what to look for, and what to do. While acknowledging that adults, too, can have ADHD (ADD/ADHD, ADD-ADHD, A.D.D.), this paper focuses on the disorder as it relates to children and youth.
What is Attention-Deficit Disorder?
ADD is officially called Attention-Deficit/Hyperactivity Disorder, or AD/HD (American Psychiatric Association, 1994), although most lay people, and even some professionals, still call it ADD or A.D.D. (the names given in 1980) or ADHD. The disorder's name has changed as a result of scientific advances and the findings of careful field trials; researchers now have strong evidence to support the position that AD/HD [ A.D.D. or ADHD ] [as we will refer to the disorder throughout the remainder of this Briefing Paper] is not one specific disorder with different variations. In keeping with this evidence, AD/HD [ A.D.D. OR ADHD ] is now divided into three subtypes, according to the main features associated with the disorder: inattentiveness, impulsivity, and hyperactivity. The three subtypes are:
AD/HD [ A.D.D. OR ADHD ] Predominantly Combined Type,
AD/HD [ A.D.D. OR ADHD ] Predominantly Inattentive Type, and
AD/HD [ A.D.D. OR ADHD ] Predominantly Hyperactive-Impulsive Type.
These subtypes take into account that some children with AD/HD [ A.D.D. OR ADHD ] have little or no trouble sitting still or inhibiting behavior, but may be predominantly inattentive and, as a result, have great difficulty getting or staying focused on a task or activity. Others with AD/HD [ A.D.D. OR ADHD ] may be able to pay attention to a task but lose focus because they may be predominantly hyperactive-impulsive and, thus, have trouble controlling impulse and activity. The most prevalent subtype is the Combined Type. These children will have significant symptoms of all three characteristics.
What Causes AD/HD [ A.D.D. OR ADHD ]?
AD/HD [ A.D.D. OR ADHD ] is a neurobiologically-based developmental disability estimated to affect between 3-5% of the school age population (Professional Group for Attention and Related Disorders,1991). No one knows exactly what causes AD/HD [ A.D.D. OR ADHD ]. Scientific evidence suggests that the disorder is genetically transmitted in many cases and results from a chemical imbalance or deficiency in certain neurotransmitters, which are chemicals that help the brain regulate behavior. In addition, a landmark study conducted by the National Institute of Mental Health showed that the rate at which the brain uses glucose, its main energy source, is lower in subjects with AD/HD [ A.D.D. OR ADHD ] than in subjects without AD/HD [ A.D.D. OR ADHD ] (Zametkin et al. 1990).
Even though the exact cause of AD/HD [ A.D.D. OR ADHD ] remains unknown, we do know that AD/HD [ A.D.D. OR ADHD ] is a neurologically-based medical problem. Parents and teachers do not cause AD/HD [ A.D.D. OR ADHD ]. Still, there are many things that both can do to help a child manage his or her AD/HD [ A.D.D. OR ADHD ]-related difficulties. Before we look at what needs to be done, however, let us look at what AD/HD [ A.D.D. OR ADHD ] is and how it is diagnosed.
What Are the Signs of AD/HD [ A.D.D. OR ADHD ]?
Professionals who diagnose AD/HD [ A.D.D. OR ADHD ] use the diagnostic criteria set forth by the American Psychiatric Association (1994) in the Diagnostic and Statistical Manual of Mental Disorders; the fourth edition of this manual, known as the DSM-IV, was released in May 1994. The criteria in the DSM-IV (discussed below) and the other essential diagnostic features listed in the box labeled "Defining Attention-Deficit/Hyperactivity Disorder" are the signs of AD/HD [ A.D.D. OR ADHD ].
As can be seen, the primary features associated with the disability are inattention,hyperactivity, and impulsivity. The discussion below describes each of these features and lists their symptoms, as given in the DSM-IV.
A child with AD/HD [ A.D.D. OR ADHD ] is usually described as having a short attention span and as being distractible. In actuality, distractibility and inattentiveness are not synonymous. Distractibility refers to the short attention span and the ease with which some children can be pulled off-task. Attention, on the other hand, is a process that has different parts. We focus (pick something on which to pay attention), we select (pick something that needs attention at that moment) and we sustain (pay attention for as long as is needed). We also resist (avoid things that remove our attention from where it needs to be), and we shift (move our attention to something else when needed).
When we refer to someone as distractible, we are saying that a part of that person's attention process is disrupted. Children with AD/HD [ A.D.D. OR ADHD ] can have difficulty with one or all parts of the attention process. Some children may have difficulty concentrating on tasks (particularly on tasks that are routine or boring). Others may have trouble knowing where to start a task. Still others may get lost in the directions along the way. A careful observer can watch and see where the attention process breaks down for a particular child.Symptoms of inattention, as listed in the DSM-IV, are: *
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.
* (American Psychiatric Association, 1994, pp.83-84)
Excessive activity is the most visible sign of AD/HD [ A.D.D. OR ADHD ]. The hyperactive toddler/preschooler is generally described as "always on the go" or "motor driven." With age, activity levels may diminish. By adolescence and adulthood, the overactivity may appear as restless, fidgety behavior (American Psychiatric Association, 1994). *Symptoms of hyperactivity, as listed in the DSM-IV, are:
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 act as if "driven by a motor;"
often talks excessively.
* (APA, 1994, p. 84)
When people think of impulsivity, they most often think about cognitive impulsivity, which is acting without thinking. The impulsivity of children with AD/HD [ A.D.D. OR ADHD ] is slightly different. These children act before thinking, because they have difficulty waiting or delaying gratification. The impulsivity leads these children to speak out of turn, interrupt others, and engage in what looks like risk-taking behavior. The child may run across the street without looking or climb to the top of very tall trees. Although such behavior is risky, the child is not really a risk-taker but, rather, a child who has great difficulty controlling impulse. Often,the child is surprised to discover that he or she has gotten into a dangerous situation and has no idea of how to get out of it.Symptoms of impulsivity, as listed in the DSM-IV (p. 84), are:
often blurts out answers before questions have been completed;
often has difficulty awaiting turn;
often interrupts or intrudes on others (e.g. butts into conversations or games).
note that, in the DSM-IV, hyperactivity and impulsivity are no longer considered as separate features. According to Barkley (1990), hyperactivity-impulsivity is a pattern stemming from an overall difficulty in inhibiting behavior.
In addition to problems with inattention or hyperactivity-impulsivity, the disorder is often seen with associated features. Depending on the child's age and developmental stage, parents and teachers may see low frustration tolerance, temper outburts, bossiness, difficulty in following rules, disorganization, social rejection, poor self-esteem, academic underachievement, and inadequate self-application (American Psychiatric Association, 1994).
Defining Attention-Deficit/Hyperactivity Disorder *Instead of a single list of 14 possible symptoms as listed in the prior edition of the DSM (the DSM-III-R), the DSM-IV categorically sorts the symptoms into three subtypes of the disorder:
Combined Type -- multiple symptoms of inattention, impulsivity, and hyperactivity;
Predominantly Inattentive Type -- multiple symptoms of inattention with few, if any,of hyperactivity-impulsivity;
Predominantly Hyperactive-Impulsive Type -- multiple symptoms of hyperactivity-impulsivity with few, if any, of inattention.
Symptoms of inattention, hyperactivity, or impulsivity must persist for at least six months and be maladaptive and inconsistent with developmental levels;
Some of the symptoms causing impairment must be present before age 7 years;
Some impairment from the symptoms is present in two or more settings (e.g. at school/work, and at home);
Evidence of clinically significant impairment is present in social, academic, or occupational functioning;
Symptoms do not occur exclusively during the course of 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 Personality Disorder).
* Drawn from the American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders (4th ed.), pp. 83-85. Reprinted with permission.
Don't All Children Show These Signs Occasionally?
From time to time, all children will be inattentive, impulsive, and overly active. In the case of AD/HD [ A.D.D. OR ADHD ], these behaviors are the rule, not the exception. When a child exhibits the behaviors listed above as symptomatic of AD/HD [ A.D.D. OR ADHD ], even if he or she does so consistently, do not draw the conclusion that the child has the disorder. Until a proper evaluation is completed, you can only assume that the child might have AD/HD [ A.D.D. OR ADHD ]. Conversely, people have been known to read symptom lists and, finding one or two exceptions, rule out the possibility of the disorder's presence. AD/HD [ A.D.D. OR ADHD ] is a disability that,without proper identification and management, can have long-term complications. Parents and teachers are cautioned against making the diagnosis by themselves.
How Do I Know For Sure If My Child Has AD/HD [ A.D.D. OR ADHD ]?
Unfortunately, no simple test such as a blood test or urinanalysis exists to determine if a child has this disorder. Diagnosing AD/HD [ A.D.D. OR ADHD ] is complicated and much like putting together a puzzle. An accurate diagnosis requires an assessment conducted by a well-trained professional (usually a developmental pediatrician, child psychologist, child psychiatrist, or pediatric neurologist) who knows a lot about AD/HD [ A.D.D. OR ADHD ] and all other disorders that can have symptoms similar to those found in AD/HD [ A.D.D. OR ADHD ]. Until the practitioner has collected and evaluated all the necessary information, he or she must follow the same rule of thumb as the parent or teacher who sees the behavior and suspects that the child has the disorder: Assume the child might have AD/HD [ A.D.D. OR ADHD ].The AD/HD [ A.D.D. OR ADHD ] diagnosis is made on the basis of observable behavioral symptoms in multiple settings. This means that the person doing the evaluation must use multiple sources to collect the information needed. A proper AD/HD [ A.D.D. OR ADHD ] diagnostic evaluation includes the following elements:
A thorough medical and family history
A physical examination
Interviews with the parents, the child, and the child's teacher(s)
Behavior rating scales completed by parents and teacher(s)
Observation of the child
A variety of psychological tests to measure I.Q. and social and emotional adjustment, as well as to indicate the presence of specific learning disabilities.
It is important to realize that, almost characteristically, children with AD/HD [ A.D.D. OR ADHD ] often behave well in new situations, particularly in those that are one-on-one. Therefore, a well-trained diagnostician knows not to make a determination based solely on how the child behaves during their time together. Sophisticated medical tests such as EEGs (to measure the brain's electrical activity) or MRIs (an X-ray of the brain's anatomy) are NOT part of the routine assessment. Such tests are usually given only when the diagnostician suspects another problem, and those cases are infrequent. Similarly, positron emission tomography (PET Scan) has recently been used for research purposes but is not part of the diagnostic evaluation.
After completing an evaluation, the diagnostician makes one of three determinations:
the child has AD/HD [ A.D.D. OR ADHD ];
the child does not have AD/HD [ A.D.D. OR ADHD ] but his or her difficulties are the result of another disorder or other factors; or
the child has AD/HD [ A.D.D. OR ADHD ] and another disorder (called a co-existing condition).
To make the first determination -- that the child has AD/HD [ A.D.D. OR ADHD ] -- the professional considers his or her findings in relation to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders (4th edition), the DSM-IV, of the American Psychiatric Association (1994). A very important criterion for diagnosis is that the child's symptoms be present prior to age 7. They must also be inappropriate for the child's age and cause clinically significant impairment in social and academic functioning.
To make the second determination -- that the child's difficulties are the result of another disorder or other factors -- the professional considers the exclusionary criteria found in the DSM-IV and his or her knowledge of disorders with similar symptomatology. According to the DSM-IV, Attention-Deficit/Hyperactivity Disorder is not diagnosed if the symptoms are better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder,Dissociative Disorder, Personality Disorder, Personality Change Due to a General Medical Condition, or a Substance-Related Disorder). In all these disorders, the symptoms of inattention typically have an onset after age 7 years, and the childhood history of school adjustment generally is not characterized by disruptive behavior or teacher complaints concerning inattentive, hyperactive, or impulsive behavior" (American Psychiatric Association,1994, p. 83).
Furthermore, psychosocial stressors, such as parental divorce, child abuse, death of a loved one,environmental disruption (such as change in residence or school), or disasters can result in temporary symptoms of inattention, impulsivity, and overactivity. Under these circumstances,symptoms generally arise suddenly and, therefore, would have no long-term history. Of course, a child can have AD/HD [ A.D.D. OR ADHD ] and also experience psychosocial stress, so such events do not automatically rule out the existence of AD/HD [ A.D.D. OR ADHD ].
To make the third determation -- that the child has AD/HD [ A.D.D. OR ADHD ] and a co-existing condition -- the assessor must first be aware that AD/HD [ A.D.D. OR ADHD ] can and often does co-exist with other difficulties, particularly learning disabilities, oppositional defiant disorder, and conduct disorder. All factors must be considered to ensure the child's difficulties are evaluated and managed comprehensively.
Clearly, diagnosis is not as simple as reading a symptom list and saying, "This child has AD/HD [ A.D.D. OR ADHD ]!" This Briefing Paper explores the issue of diagnosis in some depth, because no one wants children to be misdiagnosed. As parents, the more we know, the more we can help our children to succeed. We probably do not need to know how to use the DSM-IV. We probably do need to know that the person evaluating our child is using the specified criteria for AD/HD [ A.D.D. OR ADHD ] and all the components of a comprehensive assessment.
Author's Final Note
This Briefing Paper is intended to serve as a guide and introduction to AD/HD [ A.D.D. OR ADHD ] only. Due to space restrictions, much valuable and explanatory information has reluctantly been omitted. Yet such information is essential for developing a full understanding of this disorder. I encourage you to read further on the subject.
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