Mental Health and Illness - Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a relatively new name for a psychiatric disorder that usually begins or becomes apparent in preschool- and elementary school-aged children. Children with ADHD cannot sit still, have difficulty controlling their impulsive actions, and are unable to focus on projects long enough to complete them. Although teachers originally dubbed ADHD a "learning problem," the disorder affects more than just schoolwork. Children with ADHD have trouble socializing, are often unable to make friends, and suffer from low self-esteem. Left untreated, ADHD can leave children unable to cope academically or socially, possibly leading to depression.

The NIMH estimates that 3-5% of children—about two million—suffer from ADHD. Boys are affected two to three times more frequently than girls. ADHD frequently coexists with other mental health problems such as substance abuse, anxiety disorders, depression, or antisocial behavior. Children diagnosed with ADHD are usually affected into their teen years, but for most, symptoms subside in adulthood and adults become more adept at controlling their behavior. Vigilance is warranted, however, because research reveals an increased incidence in juvenile delinquency and subsequent encounters with the criminal justice system among adults who were diagnosed with ADHD in their youth.

The reported incidence of ADHD has increased over the past twenty years, possibly because of better diagnosis, changing expectations, or insufficient supportive social structures. In the absence of clear criteria for ADHD or guidelines by which to diagnose it, researchers fear that the disorder may be underdiagnosed or over-diagnosed. The cause of ADHD is as yet unknown. Factors thought to contribute to increased risk of developing the disorder include prenatal toxic exposures and premature birth as well as a family history of school problems, behavioral disorders, or other psychosocial problems. A biological explanation of ADHD arose because its symptoms respond to treatment with stimulants such as methylphenidate, which increase the availability of dopamine—the neurotransmitter that is vital for purposeful movement, motivation, and alertness. This led researchers to theorize that ADHD may be caused by unavailability of dopamine in the central nervous system.

The evidence of a genetic component is inconclusive. There is an increased incidence of ADHD in children with a first-degree relative with ADHD, conduct disorders, antisocial personality, substance abuse, and others, but this observation does not resolve the question of whether nature (genetics) or nurture (family and environmental influences) contributes more strongly to the origins of ADHD. Twin studies have found that when ADHD is present in one twin, it is significantly more likely also to be present in an identical twin than in a fraternal twin. These findings support inheritance as an important risk in a proportion of children with ADHD.

Although imaging studies have revealed differences in the brains of children with ADHD, and scientists have found a link between inability to pay attention and diminished utilization of glucose in parts of the brain, some researchers question whether these changes cause the disorder. They argue that the observed changes may result from the disorder, or simply coexist with it. Today, there are mental health professionals and educators who concede that while some children are legitimately diagnosed with ADHD, others are mislabeled. They speculate that maybe the latter group may be simply high-spirited, undisciplined, or misbehaving.

Treatment for ADHD

Much controversy about ADHD has focused on its treatment. Prescription stimulants—such as methylphenidate (Ritalin), dextromethamphetamine (Dexedrine), and amphetamine (Adderall)—have proved to be safe and effective for short-term treatment of ADHD. Despite the results of a study of six hundred children reported by the NIMH in December 1999 confirming the safety of this treatment, some researchers still question the wisdom of treatment with potentially addicting, powerful stimulants. NIMH research has indicated that there are two effective treatment methods for elementary-school children with ADHD—a closely monitored medication regimen and a combination of medication and behavioral interventions. Behavioral interventions include psychotherapy, cognitive behavioral therapy, social skills training, support groups, and parent and educator skills training.

Alternatives to drug treatment include therapy techniques such as behavior modification and parent counseling along with modifying the environment to minimize distractions and offering opportunities for one-to-one instruction with teachers. Parental concern about drug treatment of ADHD and intensifying interest in alternative therapies were reported by Benedict Carey in "Focusing on the Mind: Interest Rises in Non-Drug Therapies for Attention Deficit in Children" (Los Angeles Times, September 15, 2003). The article cited increased interest in using restrictive diets and nutritional supplements, such as vitamins, iron, zinc, and fatty acids, as well as use of biofeedback (a technique that uses monitors to teach voluntary control of certain body functions such as heartbeat, blood pressure, muscle tension, and brainwave activity) to treat children and teens with ADHD.

Use of restrictive or elimination diets is based on the notion that food dyes, preservatives, and other additives found in processed foods may cause allergic reactions in susceptible children. Ohio University Emeritus Professor of Psychiatry L. Eugene Arnold estimated that between 5% and 10% of children with ADHD might benefit from restrictive diets. Other investigators feel there is no harm experimenting with this alternative therapy provided that parents consider other strategies if the diet fails to improve symptoms. They caution, however, that effective treatment should be actively pursued so that children do not suffer life-altering consequences of the disorder, such as dropping out of school or progressing to an even more disabling mental disorder.

Using electroencephalogram (EEG) technology, researchers have found that persons with ADHD have distinctive patterns of lower frequency wave patterns emanating from the frontal cortexes of their brains. Biofeedback uses EEG technology to teach affected individuals to sharpen their focus and enhance their concentration. Several small studies comparing the use of biofeedback to treatment with methylphenidate (Ritalin) revealed that weekly biofeedback improved symptoms of participants receiving drug treatment as well as those who were not taking drugs, but the results are not conclusive. Detractors question the variable and subjective measures used to assess the effectiveness of biofeedback and wonder whether study participants are simply benefiting from the placebo effect—responding favorably to the attention given them during the bio-feedback sessions.

Attention Deficit Hyperactivity Disorder in Adults

For many years it was thought that ADHD generally subsided before or during early adulthood. Beginning in the late 1970s, however, studies began to show that significant numbers of adults suffer from ADHD. L. B. Silver in "Attention-Deficit Hyperactivity Disorder in Adult Life" (Child and Adolescent Psychiatric Clinics of North America, 2000) estimated that anywhere from 30% to 70% of children with ADHD continue to exhibit symptoms as adults. For an adult to be diagnosed with ADHD, he or she must have symptoms of the disorder that first manifested during their childhood and have persisted into adulthood. Treatment for ADHD in adults is similar to treatment for the disorder in children.