by Julie T. Steck, Ph.D., HSPP
Over the years, there has been a great deal of debate about ADHD. Does ADHD really exist? Is it over-diagnosed? Is it over-treated? Are we seeing more ADHD? Does excessive use of video games cause ADHD? Can we treat ADHD through changing a child’s diet or through re-training the brain? These are some of the questions raised by parents, teachers and others who work with children and adolescents. The good news is that we have a lot of research-based information about ADHD: the causes, the evidence-based treatments, the long-term outcomes if left untreated, and the other conditions that often co-occur with ADHD.
ADHD is the most studied condition of child and adolescent psychiatric conditions. There are hundreds of studies in this area, so what we know about ADHD is based on rigorous scientific research. So, what do we know?
- Approximately 11% of children and adolescents have met criteria for ADHD at some time in their lives.
- Nearly 9% (8.8%) of children and adolescents meet criteria for ADHD at any given time.
- ADHD has been inherited from one or both parents in the vast majority of cases (80%).
- Other causes include prematurity, toxins such as lead in the environment, accidents, and maternal smoking and drinking during pregnancy.
- Crack/cocaine exposure alone is not a risk factor.
- ADHD is not due to “bad parenting”, food allergies, too much TV or video games, or a reaction to life stressors.
- The rate of ADHD is higher in males.
- Girls are less likely to be diagnosed with ADHD even when they have the disorder, in part because they are more likely to have the Inattentive subtype (with fewer hyperactive symptoms that are easy to recognize).
- Impulsivity typically appears two to three years before inattention is noted.
- ADHD causes at least a 30% delay in a young person’s development of effective self-regulation skills.
- The severity of the symptoms of ADHD may depend on the situation or the environment that the person is in.
Dr. Russell Barkley is a psychologist who has spent most of his career researching ADHD. He has published extensively in this area. He has retired and made many of his presentations and lectures available online at www.adhdlectures.com and on www.youtube.com. Dr. Barkley’s research has emphasized the deficits in executive functioning that those with ADHD experience. He defines executive functions as “those capacities for self-control that allows us to sustain action and problem-solving toward a goal.” The executive functions impacted by ADHD include:
- the ability to inhibit behavior
- the ability to use visual imagery to guide behavior (by using hindsight, foresight, and an accurate sense of time)
- the ability to talk to ourselves to guide behavior
- the ability to control emotions and motivation
- the ability to plan and problem solve over time
The Diagnostic and Statistical Manual of Mental Disorders (DSM-V; 2013) defines ADHD as “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.” The three subtypes of ADHD include Combined presentation, Predominantly Inattentive presentation, and Predominantly Hyperactive/Impulsive presentation. Those with the hyperactive/impulsive characteristics of ADHD are most likely to have externalized behavioral difficulties. However, all three forms of the disorder produce deficits in the executive functions described above, even in individuals who are very intelligent. Understanding these executive functioning impairments is critical to knowing how to address and intervene in the behavioral difficulties posed by children and adolescents with ADHD.
ADHD can cause impairment in almost every domain of life: education, employment, social interactions and friendships, legal, dating and marital relationships, driving, leisure activities, daily responsibilities and financial management. It is only with diagnosis and treatment that those with ADHD have a chance of navigating the rocky path life lays out for them. So how is ADHD diagnosed? ADHD can be diagnosed by a qualified medical or mental health professional. Assessment should include these components:
- a thorough developmental and psychosocial history from the patient and/or parent or other reliable informant
- review of past and current medical history
- completion of rating scales from parents, teachers (or others who know the person well) and the individual regarding every day functioning
- direct testing of other possible co-morbid conditions such as learning disorders, intellectual disabilities, and Autism Spectrum Disorder
- possible computerized testing of attention
So where is the hope in ADHD? The hope is in diagnosis, parent and patient education about ADHD, and treatment of the disorder. Treatment includes consideration of medication, ongoing psychoeducation, therapy and coaching and intervention at the points of performance. ADHD is not a benign disorder but it is fairly common, treatable and responsive to environmental supports. Predictors of positive outcome include:
- higher socioeconomic status
- higher cognitive levels
- the positive support of family and friends
- consistent use of appropriate medications to treat the symptoms of ADHD
- consistent follow-up with an ADHD specialist
- academic, family and social supports
- absence of co-morbid conditions (except for mild anxiety)
ADHD has high rates of co-morbidity with anxiety, depression, bipolar disorder, substance abuse, obesity, accidents and other conditions that alter life expectancy and functioning. Identifying, treating and ameliorating the impact of ADHD are critical to the positive outcomes those with ADHD can experience when their needs are understood and addressed.
References
ADHD (American Psychological Association).
http://www.apa.org/topics/adhd/index.aspx
Barkley, R.A. (1998) Attention-Deficit Hyperactivity Disorder (2nd Edition). New York: The Guilford Press.
Barkley, R. A. & Gordon, M. (2002). Comorbidity, cognitive impairments, and adaptive functioning in adults with ADHD: Implications of research for clinical practice. In
Barkley, R., Murphy, K., & Fischer, M. (2008). ADHD in adults: What the science says. New York: The Guilford Press.
Biederman, J., Petty, C.R., Monuteaux, M., Fired, R., Byrne, D., Mirto, T., Spencer, T., Wilens, T., & Farone, S (2010). Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. American Journal of Psychiatry, 167(4), 409-417.
Froehlich, T.E., Lanphear, B.P., Epstein, J.N., Barbaresi, W.J., Katusic, S.K., & Kahn, R.S. (2007). Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Pediatric Adolescent Medicine, September 161(9), 857-864.
Goldstein, S. & Teeter, A. (Eds.), Clinical interventions for adult ADHD: A comprehensive approach (pp.46-69). New York: Academic Press.
Hinshaw, S., Huggins, S., Montenegro-Nevado, A., Owens, E., Schrodek, E., Swanson, E., & Zalecki, C. (2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: Continuing impairment includes elevated risk for suicide and self-injury. Journal of Consulting and Clinical Psychology, 80(6), 1041-1051.
Mannuzza, S., & Klein, R.G. (2000) Long-term prognosis in attention-deficit/hyperactivity disorder. Child and Adolescent Psychiatric Clinics of North America, 9, 711-726.
The New CHADD Information and Resource Guide for AD/HD (2005). Published by CHADD. http://www.chadd.org/NRC.aspx
Wilens, T.E., & Morrison, N.R. (2012). Substance-use disorders in adolescents and adults with ADHD: Focus on treatment. Neuropsychiatry, 2(4), 301-312. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480177/
