ATTENTION-DEFICIT / HYPERACTIVITY DISORDER (AD/HD)
What is AD/HD?
Attention Deficit Disorder (ADD) and Attention-Deficit/Hyperactivity Disorder (AD/HD) are considered to be developmental disorders, rather than delays of development. AD/HD typically emerges in early childhood (by age 7). AD/HD is considered to be largely neurological in origin, yet the diagnosis of AD/HD is made based on observable behaviors, rather than specific medical tests (such as blood testing, a CT scan, etc.). Children with AD/HD present with persistent pattern of impulsivity, inattention and/or hyperactivity. Inattention refers to a having short attention span and being easily distracted. Impulsivity refers to acting without regard for consequences, especially in the area of risk-taking. Hyperactivity refers to an excessive activity level that disrupts functioning in various settings (e.g., social, school, family).
ADHD in Pre-school?
The symptoms of AD/HD become obvious among school-age children, when developmental and academic expectations advance and become more uniform. For example, some diagnostic criteria for AD/HD include: making careless mistakes in schoolwork, failing to finish schoolwork (not due to oppositional behavior), difficulty organizing tasks, losing things (e.g., books, assignments), often leaving one’s seat in the classroom, blurting out answers and interrupting frequently. Clearly, these particular criteria that I have listed here are developmentally inappropriate and premature expectations for preschoolers. Among preschool-age children, symptoms are often difficult to identify with certainty, given that “normal” behavior for preschoolers includes a certain degree of inattention, impulsivity, and/or hyperactivity. Among preschoolers, then, AD/HD is distinguished from normal behavior by the severity and persistence of symptoms. But this is no small task, especially when it is considered that research finds among preschool children who are “hyperactive,” about half are no longer so by kindergarten and do not go on to develop AD/HD.
How many children have an Attention Deficit Disorder?
On average, AD/HD is estimated to affect about 5% of the population, but epidemiologists have historically found widely discrepant incidences of Attention-Deficit/Hyperactivity Disorder among children in different geographic areas (e.g., from 2% to 17%!). What explains these differences is, perhaps, varying interpretations of diagnostic criteria among professionals who diagnose. A comprehensive study of 8,500 children conducted by the Mayo Clinic has found that given natural, expected statistical variability, when properly diagnosed AD/HD affects between 3.5% and 7.5% of school-aged children.
Does AD/HD have a cure?
At this time AD/HD is generally considered to be chronic, and while no “quick fix” or cure is available, ADHD can be effectively managed with a multi-disciplinary approach (see below).
What are the long term outcomes for children with AD/HD?
About 50 to 60% of children diagnosed with ADHD maintain the diagnosis into adulthood.
What causes AD/HD – Is it genetic?
There is wide agreement among scientists and professionals that AD/HD is caused and/or influenced by a number of factors, including genetics, neurotransmitter function, metabolic function, and perhaps other medical factors (e.g., premature birth, hypoxia, elevated lead levels, head trauma, etc.). Studies appear to support a heritability factor with AD/HD. Twin studies show that the genetic contribution to AD/HD may be as high as 75%.
What is the best treatment for AD/HD?
To optimally treat a child with AD/HD, a multidisciplinary approach is recommended, which may include clearly defining goals, setting realistic expectations, establishing (and using!) a comprehensive and dynamic system of behavior management, home and school collaboration (e.g., use of “learning contracts”), making accommodations (to increase chances of academic success), counseling (with older children), and (often) medication.
What about medication for AD/HD, and what about medication for Preschoolers?!
Given the relatively subjective nature of an ADHD diagnosis, medication decisions are difficult. For example, parents and doctors must decide not only whether to use medication, but when to begin. Paradoxically, “stimulant” medications are used for children with ADHD. Generally, the FDA has approved use of stimulant medications for use with children 6 and older, and there has been extensive study of the use of these medications, but there have been very few studies of medication with preschoolers. In 2006, the Journal of the American Academy of Child and Adolescent Psychiatry published the Preschool ADHD Treatment Study, the first long-term study on the effects of Ritalin (methylphenidate) among 3- to 5-year-olds with ADHD (it should be noted that the study was sponsored by the National Institute of Mental Health and some major universities – Not by pharmaceutical companies). Three-hundred three children participated in the study. About 30% of parents reported side effects, the most common of which were sleep disruption and changes in appetite. As would be expected, side effects were more frequent with higher doses. There were significant improvements in symptoms of AD/HD among many of the preschoolers, however these improvements were not as great as those seen among older children with AD/HD who are medicated. Further, the preschoolers who responded positively to medication responded most positively to low doses of Ritalin. The study concluded that preschoolers with AD/HD who are medicated may experience improvement as well as side effects. When looking at expected results among preschoolers versus school-age children, the preschoolers may experience less of an improvement with greater side effects. The authors also recommend the use of behavior management interventions and classes to improve parenting skills prior to the use of medications (and along with medications in the event that medication is prescribed).
Controversy: Is AD/HD a fraud, a myth, and/or benign?
The validity of the AD/HD diagnosis has been questioned by some from both within and outside of the early childhood educational and medical community. Have we over-pathologized normal behavior? Have we been guilty of focusing too heavily on a child’s deficits? Based on our societal and educational norms, have we turned some strengths into deficits simply defining them as such?
In 2002, over 80 of the world’s leading authorities on AD/HD signed the The International Consensus Statement on ADHD (and in 2005 over 100 additional experts on AD/HD signed the document). The purpose of the document was to provide a position statement (supported by peer-reviewed scientific evidence) that counteracts media misrepresentation of AD/HD as a fraud, a myth, or a benign disorder.
Still, there is controversy. There are conspiracy theorists who argue that the increase in AD/HD is due to pharmaceutical companies that have been “pushing” drugs on kids through physicians. There are those who argue for stricter discipline (e.g., “Those ADHD kids just need a swift swat on the bottom, just like my father gave me, and, look, I turned out alright”). A more thoughtful, positive, and refreshing interpretation on the controversey that surrounds AD/HD is offered in the book, The Gift Of ADHD: How To Transform Your Child's Problems Into Strengths. Author Lara Honos-Webb recognizes that AD/HD can indeed result in great dysfunction, but she convincingly argues for a paradigm shift. Specifically, she suggests that many AD/HD symptoms may simply be gifts, such as rich imagination, high energy level, ability to enjoy the moment, and out-of-the-box ways to think, see, and act on the world. What do you think?