Attention Deficit Disorder or Disorders

There are many articles and texts written on the subject of Attention Deficit Disorder with or without a Hyperactivity component. The American Academy of Pediatrics task force on ADHD estimates that it affects 4-12% of children; it is the most common learning disorder that afflicts children. There have been many theories on its exact nature with attempts to correlate problems within specific neuroanatomic structures and the behaviors that seem to cluster in the classic ADHD child. Unfortunately, there is no clear-cut explanation nor is there a clear-cut consensus on exact nature of ADHD.

Dr. Mel Levine heads the neurodevelopmental department at the University of North Carolina at Chapel Hill. He promotes the theory that there are many different causes for the deficits in attention that children exhibit. His web site all kinds of minds offers a very informative look into the complexities of understanding what ADD is:

http://www.allkindsofminds.org

Dr. Daniel Amen has devoted years to studying the neuroanatomy of children who were diagnosed with ADD, seeking to define areas of the brain that are utilized differently, or at least image differently with PET scans (positive emission technology). He has attempted to define different major types of ADD by the different areas of the brain that images with each one. He also has created an online evaluation tool that patients can use to help define a particular type of ADD that they might have: http://www.amenclinic.com/ac/tests/subtype_test1.php

These two websites are our more favored. We suggest you visit both: Dr Levine's to increase your understanding and to help with strategies (see Learning Base) and Dr. Amen's to take the online evaluation to help confirm the diagnosis.

The American Academy of Pediatrics has convened a task force that has reviewed the volumes of literature and has developed clinical practice guidelines to assist pediatricians in the care of children with ADD:

• In a child 6 to 12 years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD
• The diagnosis of ADHD requires that a child meet DSM-IV criteria
• The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment
• The assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, the duration of symptoms, the degree of functional impairment, and coexisting conditions. A physician should review any reports from a school-based multidisciplinary evaluation where they exist, which will include assessments from the teacher or other school-based professional
• Use of these scales is a clinical option when diagnosing children for ADHD
• Use of teacher global questionnaires and rating scales is not recommended in the diagnosing of children for ADHD, although they may be useful for other purposes
• Evaluation of the child with ADHD should include assessment for coexisting conditions
• Other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD

As a review of these guidelines indicates, the diagnosis of ADHD is made on history, specifically on the history of inattentiveness, hyperactivity, impulsivity, academic underachievement, or behavioral problems. The symptoms should be in more than one setting typically school and home; the history is important but need not be as specific as a particular rating scale. In general the behaviors of a child with ADHD may be quite similar to those of a child without ADHD. This is especially true when you consider the writings of both Dr. Levine and Dr. Amen that suggest there is no one form of ADHD. The critical factor in the history is not whether a particular symptom or sign exists, but rather how much trouble a child is having. The greater the disability, the more imperative it is to establish a diagnosis.

Below are listed the Diagnostic Statistical Manual-IV definition of ADHD:

DSM_IV Criteria for Attention Deficit Disorder:
Persisting for at least 6 months to a degree that is maladaptive and immature, the patient has either inattention or hyperactivity-impulsivity (or both) as shown by:
Inattention. At least 6 of the following often apply:
-Fails to pay close attention to details or makes careless errors in schoolwork, work or other activities
-Has trouble keeping attention on tasks or play
-Doesn't appear to listen when being told something
-Neither follows through on instructions nor completes chores, schoolwork, or jobs (not due to oppositional behavior or failure to understand)
-Has trouble organizing activities and tasks
-Dislikes or avoids tasks that involve sustained mental effort (homework, schoolwork) Loses materials needed for activities (assignments, books, pencils, tools, toys)
-Easily distracted by extraneous stimuli
- Forgetful
Hyperactivity-Impulsivity. At least 6 of the following often apply:
HYPERACTIVITY
-Squirms in seat or fidgets
-Inappropriately leaves seat
-Inappropriately runs or climbs (in adolescents or adults, the may be only a subjective feeling of restlessness)
-Has trouble quietly playing or engaging in leisure activity
-Appears driven or "on the go"
-Talks excessively
IMPULSIVITY
-Answers questions before they have been completely asked
-Has trouble or awaiting turn
-Interrupts or intrudes on others Begins before age 7. Symptoms must be present in at least 2 types of situations, such as school, work, home.
-The disorder impairs school, social or occupational functioning.
-The symptoms do not occur solely during a Pervasive Developmental Disorder or any psychotic disorder including Schizophrenia.
-The symptoms are not explained better by a Mood, Anxiety, Dissociative or Personality Disorder.

Given the lack of methods to confirm the diagnosis of ADHD through other means, it is important to recognize the limitations of the DSM-IV definition. Most of the development and testing of the DSM-IV has occurred through studies of children seen in psychiatric settings. Much less is known about its use in other populations, such as those seen in general pediatric or family practice settings. Despite the agreement of many professionals working in this field, the DSM-IV criteria remain a consensus without clear empirical data supporting the number of items.

The behaviors listed in the criteria are frequently seen in many different children. The overlap makes the testing needed to provide data very difficult. As the following chart demonstrates, there are many similarities between ADHD and other syndromes or conditions:

ATTENTION DEFICIT / HYPERACTIVITY DISORDER Alternative Diagnoses
	ADHS (DSM-IV)	Sensory Integration Dysfunction (Ayres)	Leaning Related Visual Problems (Kavner)	Nutrition Allergies (Rapp, Cook & Smith)	Normal Child Under 7 (Gesell)
Inattention (at least 6 necessary)
Often fails to give close attention to details or makes careless mistakes	x	x	x	x
Often has difficulty sustaining attention in tasks or play activities	x	x	x	x	x
Often does not follow through on instructions or fails to finish work	x	x	x	x	x
Often has difficulty organizing tasks and activities	x	x	x	x	x
Often avoids, dislikes or is reluctant to engage in tasks requiring sustained mental effort	x	x	x	x	x
Often loses things	x	x	x	x	x
Often distracted by extraneous stimuli	x	x	x	x	x
Often forgetful in daily activities	x	x	x	x
Hyperactively and Impulsivity (at least 6 necessary)
Often fidgets with hands or feet or squirms in seat	x	x	x	x	x
Often has difficulty remaining seated when required to do so	x	x	x	x	x
Often runs or climbs excessively	x	x		x	x
Often has difficulty playing quietly	x	x		x
Often "on the go"	x	x		x	x
Often talks excessively	x	x	x	x
Often blurts out answers to questions before they have been completed	x	x	x	x
Often has difficulty awaiting turn	x	x	x	x	x
Often interrupts or intrudes on others	x	x	x	x	x

The result of all the history taking from both parents and teachers may well be inconclusive. The DSM IV criteria plus the behavior inventory scales are so non-specific that at times the decision to treat is an empiric one. In all cases if the decision is to treat, there should be a finite number of days that comprise a trial period before a conclusion is reached as to the effectiveness of the treatment. The American Academy of Pediatrics task force presented recommendations in 2001 regarding treatment:

• Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition.
• The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management.
• The clinician should recommend stimulant medication and/or behavior therapy, as appropriate, to improve target outcomes in children with ADHD.
• For children on stimulants, if one stimulant does not work at the highest feasible dose, the clinician should recommend another.
• When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions (strength of evidence.
• The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child.

The treatments of ADHD are primarily with stimulants: methylphenidate and forms of amphetamine. The table below shows the typical dosing of some of the various treatment regimens.

Finally, with all this information, parents and patients may wish for an opportunity to ask questions and discuss the condition with families experiencing the same kinds of problems. Below are listed web sites for chat rooms, organizations and additional resources:

http://www.chadd.org/faq.htm chat rooms

http://www.familyvillage.wisc.edu/lib_adhd.htm organizations and chat rooms

http://www.addresources.com/bookstore.htm books for parents, teachers, students and adults

November 2001