From Parenting New Mexico March 1999

ARTICLE ONE OF FOUR ARTICLES ON
ATTENTION DEFICIT/HYPERACTIVITY DISORDER

ADHD:
What It Is and Isn't

Nearly 100 years ago medical research began into a condition which for much of this century was called Hyperkinetic Syndrome. The research focused on children who showed serious problems with sustained attention to tasks and impaired "inhibitory volition" (poor self control). By the 1920's the most common medications used to treat Hyperkinesis even to this day (Ritalin and Dexadrine) were in use. Yet much remained then, and still today, to be known about this disorder. Refinements in knowledge about the syndrome had by the 1970's brought into use the diagnostic label Attention Deficit Disorder which was recognized has having two subtypes, with hyperactivity (ADD-H) and without hyperactivity (simply ADD). Further research, especially with adolescents and adults, again produced an official change in the diagnostic name in the late 1980's to Attention Deficit/Hyperactive Disorder (ADHD). There are three recognized subtypes which are discussed below. The older term, ADD, is still commonly used in conversation even among mental health and medical professionals.

Defining ADD/ADHD

Medically, ADHD is a specific development disorder which begins in early childhood (by first or second grade) and is marked by distinct daily impairments in: resisting distraction (distractibility), inhibiting responses (impulse control), and regulating motoric activity (hyperactivity). In general, ADHD is a disorder of impaired self control, and neurological research has distinctly shown ADHD to be associated with abnormalities in areas of the brain which control and regulate behavior.

Regarding distractibility, ADHD individuals find it very difficult to attend to a single task when faced with competing stimuli in their environment. The competing stimuli may be as simple as an interesting object near them. The ADHD child, adolescent, or adult almost always reports that other people talking around them or walking by makes it very difficult for them to remain attentive to a task. However, many ADHD sufferers find that background noise, especially instrumental music, aids their concentration by masking environmental distracters. For example, to write this article I shut my office door and turned on a music CD with no lyrics. As you may have guessed I have ADHD. My wife calls me the Rooster because I "roost" in solitary places to do things like read the newspaper. A TV or radio in the background is my worst enemy.

Poor impulse control makes it difficult for most individuals with ADHD to be patient and delay gratification. Trouble waiting one's turn while playing a game, interrupting conversations, and not thinking or planning ahead are common observations. ADHD sufferers need, and demand, much external stimulation; that's why they are so easily bored and tend to create their own stimulation, like pestering others, when they have to wait. I know, board games drive me to distraction; they seem so slow.

And then there is just plain hyperactivity. In children this is the classic and incessant can't set still, out of the chair, into everything behavior. In older adolescents and adults, hyperactivity is typically constant restlessness (playing with things around them or fidgeting) and being "on the go." When the stimulation around ADHD individuals drops they often create their own by increased movement which adds to their hyperactivity. Given their desire and need for movement, stimulation, and action, someone with ADHD can be a great fit for a job like being a FedEx/UPS delivery driver or a fast paced sales person, but not a librarian!

While distractibility, poor impulse control, and hyperactivity are the primary markers of ADHD, there are a number of common ancillary symptoms including: poor organization, forgetfulness caused by being distracted during multi-step tasks, winding down to get to sleep, becoming sleepy when bored (at a slow paced movie, for example - ask my family!) and having difficulty developing and executing long term plans especially when short term rewards are not forthcoming. Additionally, many ADHD individuals have social troubles caused by withdrawing to avoid distracters or from being so active and impulsive in groups that they are perceived as overbearing.

The Subtypes

Most ADHD sufferers, especially boys and men, have major difficulties in all three symptom categories (distractibility, poor impulse control, and hyperactivity) making the most commonly diagnosed subtype the Combined Type, meaning that significant impairment exists in all three areas. However, a second subtype is quite often seen, especially in girls and women, the Predominantly Inattentive Type. Individuals in this group have strong difficulties with distractibility, but insignificant problems with hyperactivity and impulse control. A third group is represented in the Predominantly Hyperactive-Impulsive Type. For these individuals sustaining attention is not their major difficulty, but controlling their actions, thoughts, and
movement is.

What Causes ADHD And How Common Is It?

It is widely recognized that ADHD is an organic disorder with psychological overlays from growing up with its impairments. ADHD is not caused by poor parenting, stress, trauma, or school learning problems, even though these conditions may exacerbate ADHD symptoms. Very thorough nutritional research over the last 25 years has also clearly shown that with the exception of possibly very rare cases ADHD is not caused or exacerbated by allergies, food additives, or sugar. However, believing that you will be hyperactive or distractible after eating additives or sugar, or being exposed to certain environmental chemicals, typically results in ADHD-like behavior after ingestion or exposure.

The most common cause of ADHD is inheritance. Over 70% of ADHD individuals have a family member (parent, grandparent, aunt, or uncle) with the disorder. Research with twins, even identical twins who grew up in different homes, has strongly supported the genetic link. For the twenty-some percent who do not have a clear inheritance pattern, the cause is most often related to physical problems occurring during pregnancy or at birth. Among these problems are: anoxia (loss of oxygen) during birth as can occur when the umbilical cord wraps around the neck, toxemia, substance abuse by the mother during pregnancy, smoking during pregnancy, low birth weight, and teenage pregnancies. For unknown reasons, children born in late August, September, and early October are also at a higher risk for ADHD. We also know that low levels of lead or mercury poisoning, while uncommon today, produce ADHD-like symptoms.

Regarding prevalence, we must first recognize that ADHD is a disorder of degree; in other words we all have some distractibility, trouble with impulse control, and hyperactivity. ADHD is not a simple you have it or you don't. Rather the diagnosis relates to the level of the symptoms and impairment relative to the peer group. In groups of young school children where the official diagnostic criteria are strictly adhered to, including observed daily impairment at a moderate to severe level, approximately two percent have ADHD. Among these children, approximately seven boys meet the diagnostic criteria for every girl. And a good portion of the girls have the Predominantly Inattentive Type. In a sample of high school students, most often about two thirds of those diagnosed in childhood continue to have significant daily impairment. Reductions in hyperactivity followed by improved impulse control are the most common changes in teenagers. By young adulthood about half of those diagnosed as children are no longer significantly impaired. In adults the most common continuing symptoms are motoric restlessness,
always being "on the go," and distractibility.

Diagnosing ADHD

The accurate diagnosis of ADHD is difficult because so many of the symptoms cannot be reliably observed during a brief office visit. For this reason, almost all mental health and medical professionals rely heavily on reports and behavioral rating scales supplied by the child, adolescent, or adult being evaluated, their family, school teachers or coworkers, and others who know them well.

A sound evaluation always includes reports of daily behavior from a variety of sources. Many clinicians also include the results of a Continuous Performance Test (CPT) or neuropsychological tests assessing attention and impulse control. On a CPT the person must attend and respond to a simple, but boring, task on a computer screen, and frequently also to auditory stimuli via speakers or headphones. The computer measures the person's attention maintenance, response stamina, and patience compared to a national sample of ADHD and non-ADHD individuals in the same age range.

Also very important during the diagnostic process is screening for the myriad of other mental health problems which often coexist with ADHD or look like it. Among these are behavior problems (defiance, opposition-ality, aggression, and lying), learning disabilities (reading, visual-perceptual, and memory problems), depression, substance abuse, and a variety of neurological disorders. The accurate diagnosis of ADHD is essential to selecting the most appropriate behavioral, medical, or environmental treatments. There is help for ADHD, but only if it is correctly identified.

Diagnostic Criteria for
Attention-Deficit/Hyperactivity Disorder

A. Either (1) or (2)

(1) six (or more) of the following symptoms of
inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.

Inattention
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) 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)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to
engage in tasks that require sustained mental efforts (such as schoolwork or homework)
(g) often loses things necessary for tasks and activities (e.g., toys, school assignments, pencils, books or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities

 

(2) six (or more) of the following symptoms of
hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.

Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations
(c) often runs about or climbs excessively in situations
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively

 

Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment where present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school (or work) and at home)
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

Reprinted from: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994, American Psychological Association, Washington, D.C., pg. 83-84

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Dr. Zieman is an Albuquerque psychologist who specializes in the evaluation of child and adolescent disorders. He also works with adults having ADHD and learning disabilities such as Dyslexia.

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ADHD Articles
Part 2 | Part 3 | Part 4

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Copyright by Parenting New Mexico and Gayle L Zieman PhD. This article may not be published in part or in its entirety in any medium without written permission from Gayle L Zieman PhD or Parenting New Mexico magazine. Links to this page are welcome.