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Attention Deficit Hyperactivity Disorder (ADHD)

ADHD refers to a family of related chronic neurobiological disorders that interfere with an individual's capacity to regulate activity level (hyperactivity), inhibit behavior (impulsivity), and attend to tasks (inattention) in developmentally appropriate ways. The core symptoms of ADHD include an inability to sustain attention and concentration, developmentally inappropriate levels of activity, distractibility, and impulsivity. As its name implies, attention deficit hyperactivity disorder (ADHD) is characterized by two distinct sets of symptoms: inattention and hyperactivity-impulsivity.Although these problems usually occur together, one may be present without the other to qualify for a diagnosis. Inattention or attention deficit may not become apparent until a child enters the challenging environment of elementary school. Such children then have difficulty paying attention to details and are easily distracted by other events that are occurring at the same time; they find i!

t difficult and unpleasant to finish their schoolwork; they put off anything that requires a sustained mental effort; they are prone to make careless mistakes, and are disorganized, losing their school books and assignments; they appear not to listen when spoken to and often fail to follow through on tasks. Symptoms of hyperactivity may be apparent in very young preschoolers and are nearly always present before the age of 7. Such symptoms include fidgeting, squirming around when seated, and having to get up frequently to walk or run around. Hyperactive children have difficulty playing quietly, and they may talk excessively. They often behave in an inappropriate and uninhibited way, blurting out answers in class before the teacher’s question has been completed, not waiting their turn, and interrupting often or intruding on others’ conversations or games. Many of t!

hese symptoms occur from time to time in normal children. However, in children with ADHD they occur very frequently and in several settings, at home and at school, or when visiting with friends, and they interfere with the child’s functioning. Life can be hard for children with ADHD. They're the ones who are so often in trouble at school, can't finish a game, and have trouble making friends. They may spend agonizing hours each night struggling to keep their mind on their homework, then forget to bring it to school. It is not easy coping with these frustrations day after day for children or their families. In adolescence, these children are at increased risk for motor vehicle accidents, tobacco use, early pregnancy, and lower educational attainment. When a child receives a diagnosis of ADHD, parents need to think carefully about treatment choices b!

ecause when they pursue treatment for their children, families sometimes face high out-of-pocket expenses because treatment for ADHD along with other mental illnesses are often not covered by insurance policies. School programs that help children with problems often connected to ADHD (social skills and behavior training) are not available in many schools. In addition, not all children with ADHD qualify for special education services. All of this leads to children who do not receive proper and adequate treatment. To overcome these barriers, parents may want to look for school-based programs that have a team approach involving parents, teachers, school psychologists, other mental health specialists, and physicians. Physicians and parents should be aware that schools are federally mandated to perform an appropriate evaluation if a child is suspected of having a disability that impairs academic functioning. The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. Diagnosis is based on history and observable behaviors in the child's usual settings. Ideally, a health care practitioner making a diagnosis should include input from parents and teachers. The key elements include a thorough history covering the presenting symptoms, differential diagnosis, possible comorbid conditions, as well as medical, developmental, school, psychosocial, and family histories. It is helpful to determine what precipitated the request for evaluation and what approaches had been used in the past. As of yet, there is no independent test for ADHD. This is not unique to ADHD, but applies as well to most psychiatric disorders, including other disabling disorders such as schizophrenia and autism. !

A federall policy that was recently strengthened by regulations implementing the 1997 reauthorization of the Individuals with Disabilities Act (IDEA), which guarantees appropriate services and a public education to children with disabilities from ages 3 to 21. For the first time, IDEA specifically lists ADHD as a qualifying condition for special education services. If the assessment performed by the school is inadequate or inappropriate, parents may request that an independent evaluation be conducted at the school's expense. Furthermore, some children with ADHD qualify for special education services within the public schools, under the category of "Other Health Impaired." In these cases, the special education teacher, school psychologist, school administrators, classroom teachers, along with parents, must assess the child's strengths and weaknesses and design an Individualized Education Program. These special education services for children with ADHD are available though IDEA. Historically, the changes that take place in a child’s psyche between birth and adulthood were largely ignored. Child development first became a subject of serious inquiry at the beginning of this century but was mostly viewed from the perspective of mental disorders and from the cultural mainstream of Europe and white America. Some of the"grand theories" of child development, such as that propounded by Sigmund Freud, grew out of this focus, and they unquestionably drew attention to the importance of child development in laying the foundation for adult mental health. Even those theories that resulted from the observation of healthy children, such as Piaget’s theory of cognitive development, paid little attention to the relationship between the development of the"inner self" and the environment into which the individual was placed. In contrast, the interaction of an !

individual with the environment was central to the school of thought known as behaviorism. Many children with ADHD develop learning difficulties that may not improve with treatment. Some believe that the impulsivity and heedlessness associated with ADHD interfere with social learning or with close social bonds with parents in a way that predisposes to the development of behavior disorders. Inattentive people have a hard time keeping their mind on one thing and may get bored with a task after only a few minutes. Focusing conscious, deliberate attention to organizing and completing routine tasks may be difficult. Even though a great many children with this disorder ultimately adjust, some-especially those with an associated conduct or oppositional-defiant disorder-are more likely to drop out of school and fare more poorly in their later careers than children without ADHD!

. As they grow older, some teens who have had severe ADHD since middle childhood experience periods of anxiety or depression. This seems to be especially common in children whose predominant symptom is inattention. They have a hard time keeping their mind on one thing and may get bored with a task after only a few minutes. Focusing conscious, deliberate attention to organizing and completing routine tasks may be difficult. Psychosocial treatment of ADHD has included a number of behavioral strategies such as contingency management (e.g., point/token reward systems, timeout, response cost) that typically is 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). Cognitive-behavioral treatment has not been found to yield beneficial effects in children with ADHD. In contrast, clinical behavior therapy, parent training, and contingency management have produced beneficial effects. Intensive direct interventions in children with ADHD have produced improvements in key areas of functioning. However, no randomized control trials have been conducted on some of these intensive interventions alone or in combination with medication. Studies that compared stimulants with psychosocial treatment (behavioral intervention)consistently reported greater efficacy of stimulants. Some various forms of behavioral interventions used for children with ADHD, are psychotherapy, cognitive-behavioral

therapy, social skills training, support groups, and parent and educator skills training. An example of very intensive behavior therapy is in the NIMH Multimodal Treatment Study of Children with ADHD which involved the child's teacher, the family, and participation in an all-day, 8-week summer camp. The consulting therapist worked with teachers to develop behavior management strategies that address behavioral problems interfering with classroom behavior and academic performance. A trained classroom aide worked with the child for 12 weeks in his or her classroom, to provide support and reinforcement for appropriate, on-task behavior. Parents met with the therapist alone and in small groups to learn approaches for handling problems at home and school. The summer day camp was aimed at improving social behavior, academic work, and sports skills. In the NIMH Multimodal Treatment Study for Children with ADHD, which included nearly 600 elementary school children across multiple sites, nine out of ten children improved substantially on one of these treatments. Additionally, antidepressant medications may also be used as a second line of treatments for children who show poor response to stimulants, who have unacceptable side effects, or who have comorbid conditions (such as tics, anxiety, or mood disorders). Tricyclic antidepressants have shown clinical efficacy in 60-70% of children with ADHD. While the medications were extremely beneficial to most children, MTA findings indicated that medications alone may not necessarily be the best strategy for many children. For example, children who had accompanying problems (e.g., anxiety, stressful home circumstances, social skills deficits, etc.), over and above the ADHD symptoms, appeared to obtain maximal benefit from the combined treatment.

Emerging data suggest that medication using systematic titration and intensive monitoring methods over a period of approximately 1 year is superior to an intensive set of behavioral treatments on core ADHD symptoms (inattention, hyperactivity/impulsivity, aggression). Combined medication and behavioral treatment added little advantage overall, over medication alone, but combined treatment did result in more improved social skills, and parents and teachers judged this treatment more favorably. Both systematically applied medication (monitored regularly) and combined treatment were superior to routine community care, which often involved the use of stimulants. An important potential advantage for behavioral treatment is the possibility of improving functioning with reduced dose of stimulants. The current state of the empirical literature regarding the treatment of ADHD is such that at least five important questions cannot be answered. First, it cannot be determined if the combination of stimulants and psychosocial treatments can improve functioning with reduced dose of stimulants. Second, there is no data on the treatment of ADHD, Inattentive type, which might include a high percentage of girls. Third, there is no conclusive data on treatment in adolescents and adults with ADHD. Fourth, there is no information on the effects of long-term treatment (treatment lasting more than 1 year), which is indicated in this persistent disorder. Finally, given the evidence about the cognitive problems associated with ADHD, such as deficiencies in working memory and language processing deficits, and the demonstrated ineffectiveness of current treatments in enhancing academic achievement, there is a need for application and development of methods targeted to these weaknesses. The expected duration of treatment has lengthened during this past decade as evidence has accumulated that benefits extend into adolescence and adulthood. However, many factors work against continued treatment during adolescence including the partial resolution of the most obvious symptoms, the short-lasting effects of medications that require multiple doses per day, and the need for regular physician written prescriptions. Additionally, parents often discontinue medication even when benefit has been demonstrated or because they see the child improve and don't think the medication is necessary any longer. Data from 1995 show that physicians treating children and adolescents wrote six million prescriptions for stimulant medications-methylphenidate (Ritalin) and dextroamphetamine (Dexedrine). Of all the drugs used to treat psychiatric disorders in children, stimulant medications are the most thoroughly studied. Stimulant drugs, when used with medical supervision, are usually considered quite safe, Although they can be addictive when abused by teenagers and adults. When taken as prescribed for ADHD, these medications do not show to be addictive nor lead to substance abuse problem. They seldom make children "high" or jittery, nor do they sedate the child. Although little information exists concerning the long-term effects of psychostimulants, there is no evidence that careful therapeutic use is harmful. When adverse drug reactions do occur, they are usually related to dosage and are always reversible. Effects associated with moderate doses are decreased appetite and insomnia. These effects occur early in treatment and may decrease with time. There may be negative effects on growth rate, but ultimate height appears not to be affected.

Existing studies come to conflicting conclusions as to whether use of psychostimulants increases or decreases the risk of abuse. So will children taking these medications for ADHD become drug addicts? Actually, it appears to be just the opposite. Although an increased risk of drug abuse and cigarette smoking is associated with childhood ADHD, this risk appears mostly due to the ADHD condition itself, rather than its treatment. In a study jointly funded by the NIMH and the National Institute on Drug Abuse, boys with ADHD who were treated with stimulants were significantly less likely to abuse drugs and alcohol when they got older. Caution is warranted, nonetheless, as the overall evidence suggests that persons with ADHD (particularly untreated ADHD) are indeed at greater risk for later alcohol or substance abuse. Because some studies have come to conflicting conclusions, more research is needed to understand these phenomena. Regardless, in view of the substantial, well-established findings of the harmful effects of inadequate or no treatment for a child with ADHD, parents should not be dissuaded from seeking effective treatments because of misconstrued or exaggerated claims about substance abuse risks. A major limitation of inferences from observational databases is the inability to examine independently the use of stimulant medication, the diagnosis and severity of ADHD, and the effect of coexisting conditions. Continued research on ADHD is needed from many perspectives. The societal impact of ADHD needs to be determined. Studies in this regard include (1) strategies for implementing effective medication management or combination therapies in different schools and pediatric healthcare systems; (2) the nature and severity of the impact on adults with ADHD beyond the age of 20, as well as their families; and (3) determination of the use of mental health services related to diagnosis and care of persons with ADHD. Additional studies are needed to improve communication across educational and health care settings to ensure more systematized treatment strategies. Basic research is also needed to better define the behavioral and cognitive components that underpin ADHD, not just in children with ADHD, but also in unaffected individuals. This research should include (1) studies on cognitive development, cognitive and attentional processing, impulse control, and attention/inattention; (2) studies of prevention/early intervention strategies that target known risk factors that may lead to later ADHD; and (3) brain imaging studies before the initiation of medication and following the individual through young adulthood and middle age. Finally, further research should be conducted on the comorbid (coexisting) conditions present in both childhood and adult ADHD, and treatment implications.

Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a major public health problem. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial in many public and private sectors. Although an independent diagnostic test for ADHD does not exist, evidence supporting the validity of the disorder can be found. The impact of ADHD on individuals, families, schools, and society is profound and necessitates immediate attention. Studies have included randomized clinical trials that have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Studies have also included randomized clinical trials that have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness which inturn has indicated that stimulants are more effective than psychosocial therapies in treating these symptoms.The lack of information and education about accessibility and affordability of services must be remedied. Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains speculative. Consequently, we have no strategies for the prevention of ADHD.


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Hoagwood, K., Jensen, P.S., Vitiello, B., Feil, M., Bhatara V. Medication management of stimulants and other psychotropics in pediatric practice settings. J. Developmental and Behavioral Pediatrics, in press.

Hoagwood, K., Kelleher, K., Feil, M., Comer, D. A national perspective on treatment services for children with ADHD. In Diagnosis and Treatment of Attention Deficit Hyperactivity Disorders: An Evidence-based Approach. (Eds. P Jensen & J. Cooper). APA Press, Washington, D.C. In press.

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Jensen, P, Kettle, L, Roper, M, Sloan, M , Dulcan, M, Hoven, C, Bird, H, Bauermeister, J, Payne, J: Are Stimulants Over-prescribed? Treatment of ADHD in Four U.S. Communities. J Am Acad Child Adol Psychiatry, 38:797-804, 1999.

Lahey, B, Applegate, B, McBurnett, K, Biederman, J, Greenhill, L, Hynd, G, Barkley, R, Newcorn, J, Jensen, P, et al : DSM-IV Field Trials for Attention Deficit/Hyperactivity Disorder in Children and Adolescents. Am J Psychiatry 151:1673-1685, 1994.

Glock, Martha H.; Jensen, Peter S.; Cooper, James R., compilers. Diagnosis and treatment of attention deficit hyperactivity disorder [bibliography online]. Bethesda (MD): National Library of Medicine; 1998 Sep [insert cited year month day in brackets]. [insert no. of screens or lines in brackets]. (Current bibliographies in medicine; no. 98-2). 1440 citations from January 1980 through August 1998. Available from: URL

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