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What is ADHD?

Numbers in parenthesis refer to reference materials that are listed on a separate page.

Introduction

Attention Deficit–Hyperactivity Disorder (ADHD) is one of the most common psychiatric disorders of children. Approximately 3–5% of children around the world have this disorder. About 50% have another psychiatric disorder with ADHD. In the past, it was thought that ADHD was only present in boys. However, we now know that many girls have it, too. You are probably reading this article because you, a family member, or friend has been diagnosed with this disorder.

Clinical Description

As a psychiatrist, I have found that some signs of ADHD are present in a number of kids. Others signs are rarely present unless the child has disabling ADHD. The signs that are usually only present in disabling ADHD are in bold below (28)

All four areas—A, B, C and D— must be present to have the diagnosis.

A. Signs and Symptoms

Inattention

Six or more of the following symptoms of inattention must persist for at least six months to a degree that is maladaptive and inconsistent with the developmental level.

1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. often has difficulty sustaining attention in tasks or play activities
3. often does not seem to listen when spoken to directly
4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to failure to understand instructions)
5. often has difficulty organizing tasks and activities
6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
8. often easily distracted by extraneous stimuli
9. often forgetful in daily activities

Hyperactivity–Impulsiveness

Six or more of the following symptoms must persist for at least six months to a degree that is maladaptive and inconsistent with the developmental level

1. often fidgets with hands or feet or squirms in seat
2. often leaves seat in classroom or in other situations in which remaining seated is expected
3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents, this may be limited to subjective feelings of restlessness)
4. often has difficulty playing or engaging in leisure activities quietly
5. often "on the go" or often acts as if "driven by a motor"
6. often talks excessively
7. often blurts out answers before questions have been completed
8. often has difficulty awaiting turn
9. often interrupts or intrudes on others (e.g., butts into conversations or games)

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

C. Some impairment from the symptoms is present in two or more settings (e.g., at school and at home)

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

There are Three Types of ADHD:

• Combined type—symptoms and signs of both attention deficit and hyperactivity–impulsiveness.
• ADHD without hyperactivity—symptoms and signs of attention deficit only
• ADHD, hyperactiveþimpulse type—symptoms and signs of hyperactivity–impulsiveness only.

ADHD at Each Stage of Development

The examples below are for the combined type of ADHD. Persons with either the Inattentive Type or Impulsive Hyperactive Type will only have some of these signs and symptoms.

Infant (0—12 mo.)

It is not uncommon that parents can see signs of ADHD even before children can walk. When compared to other babies, they are often more squirmy and are a less able to cuddle. Infants who will go on to develop ADHD often have a more difficult temperament. They are more impatient, easily frustrated, and require more attention than the average baby. They have more colic. On the other hand, many children that grow up to have ADHD show no abnormalities at this stage..

Toddler (1—3 years)

For many children, the first point at which signs of ADHD become apparent is as a toddler. Here are the findings.

Attention

Toddlers naturally have a short attention span. They usually can entertain themselves for a few minutes and often can work on an activity with their parents for a little bit longer. Toddlers with ADHD cannot even sustain their attention that long. What this means is that conversations are interrupted by any distracting sound or sight. Eye contact during conversations is poor. The toddler with ADHD will often automatically develop responses to requests with, "Huh?" or "What?" Most toddlers with ADHD will be able to sustain their attention for a few favorite activities—certain videos, wrestling, and playing at a playground. If you are the caregiver for a child like this, you are spending more time than usual in direct one–to–one contact to keep the child occupied and out of trouble. At its most severe end, children with ADHD can only concentrate on things like running or wrestling. Toys, books and games are played with for a few minutes only and then either ignored or destroyed. The physician will rarely see a toddler with ADHD in which the parents' chief concern was attention span.

Impulsiveness–Hyperactivity

Toddlers are known for their high activity levels. They spend a lot of time doing things without thinking. Since they are naturally hyperactive and impulsive, one would assume that it would be impossible to be more hyperactive than the norm. However, children with ADHD, at this stage, can be incredibly hyperactive. They are often so squirmy they cannot be cuddled. They want to be running or in motion at all times. Their lives consist of climbing, destroying or messing up wherever they are. Often they are too busy to sit still and eat or to sit still to use the toilet. They are constantly breaking things. When excited, it can take hours before they are relatively calm again. With a lot of stimulation, they can become absolutely wild, hitting everyone, screaming uncontrollably, and looking as if they are only distantly related to human beings.

For most children, impulsiveness goes with hyperactivity. Just as the normal hyperactivity of toddlers is magnified in ADHD, normal impulsiveness is also. Toddlers with ADHD jump off decks or windows, take more than their share of cleaning product overdoses, experience more accidental falls, break toys more often, and run into the road more frequently.

This hyperactivity and impulsiveness can be exhausting for the parents. Every minute of the child's day must be supervised or else the child is injured or objects wrecked. Even more exhausting is that toddlers with ADHD often have sleep problems. They can be difficult to settle down, do not sleep soundly through the night, and can be up around 5 a.m. A toddler with ADHD will wake up in the middle of the night ready to play, go to the playground, or just run around. First there is not enough sleep in the ADHD child or the parent leading to a more inattentive, irritable, and hyperactive child a more frustrated, exhausted, and impatient parent. This leads to worsening sleep cycle for the child.

Preschool (3–5 years)

Attention

In this stage children usually are still relatively inattentive. They should be able to sit and do some activity on their own for a few minutes such as sitting at a table or to listening to a story. Preschoolers with ADHD are usually unable to consistently manage these listening activities. This is the age when the degree of interest impacts the child's attention. An example would be playing with cars and trucks on his own without problems, but unable to concentrate on coloring for the same length of time. This aged child with ADHD is ready to change activities every few minutes, but a child without ADHD will want to keep with something for at least 10–15 minutes

Hyperactivity–Impulsiveness

The hyperactivity–impulsiveness part of ADHD gets them into bigger trouble as they age. Preschoolers with ADHD are often starting to get into fights, running into streets without looking, falling out of windows or trees, starting cars, or being bitten by dogs they have bothered. ADHD kids at this stage are in a big hurry, and unable to sit for a meal, use the toilet, or speak clearly; Some will become very, very talkative at this point. Their best friends, if they have them, are other very active children.

Preschool sometimes is a problem in that many "school oriented" programs have too much sitting time. Some ADHD kids at this age will be expelled from preschool. It is usually unsafe behavior plus expulsion from multiple day care or preschool programs that brings children with ADHD to the physician's attention at this stage.

Toddler and Preschooler ADHD can destroy families and children.

Recent studies show that this age group has serious deficits. The children are aggressive and have poor social skills. They cause severe family stress (three times normal). They disobey twice as often as normal children. They behave inappropriately five times as often. Not surprisingly, parents felt that the stress in their lives was three times that seen in a family without a preschool ADHD child. (31) What does this mean? Preschool ADHD leads to mom's (and occasionally dad's) becoming mentally ill. It can lead to marriage break ups. It can lead to other siblings becoming dysfunctional.

Early Elementary School

Attention

Completion of first and second grades requires a huge increase in a child's ability to sustain attention. More importantly, the child must be able to sustain attention on topics that they are not really interested in. Outside of school too, there is an increase in the attentional demands, but not as much as in school. The major problems are at school. Children with ADHD will be able to enthusiastically start nearly any task, however, their attention drifts away and the work is not completed. Some will hurry every aspect of their work, as a result it will be messy. Others are so distracted by everything that is going on in a classroom that their thoughts they never get to the crayon or pencil to the paper. Consider this, if you respond poorly to extra stimulation and distractions, a busy classroom is the worst place to be. Children with ADHD will occasionally amaze their teachers because the task is something they are very interested in for one reason or another, or it is one of their better days. Uneven performance begins at this stage and drives teachers and parents crazy. They know that the child is smart, but she only shows it rarely. The teachers may respond with "if they only tried harder".

Additionally, a lack of organizational skills becomes noticeable. Materials to go home don't, and papers to go back to school don't. This is a difficult expectation as children with ADHD will lose backpacks, get distracted on the way to school and, again, on the way home.

Some children have these signs but are so intelligent they can still successfully complete the lower grades without ever organizing themselves and really working. Others will have teachers who do not require a lot of organization or who will mark a child based on their best effort rather than an average over time. Many parents will be told their child is lazy, uninterested, and not trying. There is a difference though. Children with ADHD cannot pay attention; lazy children will not.

Impulsiveness–Hyperactivity

A second grade child spends as much time sitting at his desk as the average adult. While the attentional demands increase, the demands to sit still increase even more. This is what usually sinks the ADHD child. Children are expected and able to work carefully in groups and then shift to another activity with only a few breaks in the day. They are expected to listen to the teacher, take turns, and immediately calm down after a break. Children with ADHD often cannot easily transition between activities. They cannot sit still, or even sit upright. They may be walking around the room before they even realize it, climb over furniture, and bug other kids. Others are constantly talking and interrupting. Children with ADHD will impulsively throw the stone even when the supervisor is looking right at them; they are caught 90% of the time, while a less impulsive child will be caught only 25% of the time. The worst punishment that can happen is to have recess restricted as the child has even less of a chance to blow off steam.

At home there is often a safety issue. Children with ADHD have more accidental poisonings, fractures, and cuts needing stitches that those without ADHD. Many can best be described as an accident waiting to happen. By this time, the child will have found a few activities that can sustain attention, such as video games, computers, and Lego's. Many children happily spend their time outdoors if they can.

Homework begins at this age on an occasional basis for most kids but almost daily for ADHD children. Unfinished schoolwork is frequently sent home to be done. The parent must create the calm environment and supply the structure that the child cannot create for himself. The parent must sit down with the child, in a quiet, dull spot and go through the schoolwork. The parent will have to refocus the child's attention back to the work multiple times. What would take another child five minutes to complete, takes an hour for the child with ADHD. This usually drives parents around the bend.

To have ADHD, you must show either attention problems or impulsiveness–hyperactivity by age seven. Some children will show both and come to a physician's attention. Some children with primarily attention problems and little or no hyperactivity problems will get by, even though these problems are present, and not require clinical attention. It is unfortunate that the children with only attentional problems are rarely thought to be anything more than lazy, eccentric, or immature.

Later Elementary School

Attention

There is a large gap in expectations between second and third grade; expectations increase in earnest in third grade. There is more work in class, more homework and the work is often the type that requires multiple steps and planning, such as book reports and other large projects.

It is the organizational demands that sink children with ADHD at this age. They often have great ideas, but either can't get started or quit part way through. Left on their own, everything is late however, they still mystify their teachers and family by occasionally doing brilliant work on something with high interest. The amount of homework is so great that most parents cannot help the child keep up unless they spend over an hour a day in homework. It is at this stage that children with ADHD without hyperactivity will start to come to clinical attention; they are the lucky ones. Since these children are often quiet, and not a behavior problem, some will just drift through these years, using only a fraction of their capabilities. Most are thought to be lazy or uninterested.

Impulsiveness–Hyperactivity

Most children with ADHD will settle down a little by this stage, can sit in a chair, but are quite squirmy, less likely to walk around but more likely to talk out of turn, bug other kids, or become class clowns. Outside of class they still have a hard time being still. They spend a lot of time doing things outside. The common problem is impulsiveness. With ADHD the older you get, the more trouble impulsiveness can get you into, e.g., shoplifting, taking apart appliances, starting fires, getting into fights, nearly drowning, serious bike injuries, climbing on roofs, and saying very stupid things to those in authority. The physician may see many extremely impulsive children at this stage because their parents can see where things are headed and don't want their child to go down that road. Very impulsive and hyperactive kids at this stage are often labeled as "criminals of the future" because they are doing dumb things and getting caught.

Junior and Senior High School

When ADHD persists into this age range, a whole new set of problems emerges. As a result, ADHD in teenagers can be devastating.

Executive Functioning

Recent ADHD research finds that as children get older, they show major deficits in executive functioning. Executive functioning is your ability to plan, prioritize, persist, organize, and do multiple tasks. It is thought that the frontal areas of your brain are involved in this. The following examples show what executive functioning means:

Plan:

At nine you don't need to plan much as your parents and teachers will do this for you but as an teen or adult each day requires planning to meet your needs.

At sixteen Joceyln has six subjects in school and a part time job at Subway 10 hours a week. She has no boyfriend, and after failing last year is not involved in any other outside activities. Her life is one big crisis, partly due to being unable to plan. She has a research paper due in three weeks. Rather than work on it a little each day she leaves it until the last minute. Then she throws all her energy into it, is late for work, overtired, and behind in school. After the paper is handed in (late) she has to work extra hard at her part time job to avoid being fired.

Prioritize:

By twelve, there are many competing needs and desires in a day and not enough time to satisfy them all. If you can't decide what is the most important you will be lost.

At age thirteen Matt is still willing to do his homework, but it never seems to get done. He has difficulty determining where to place his effort. He needs to make a science report that includes a title page. Before starting on the report, he checks virtually every font available on the computer, searches innumerable sites for the perfect clip art, and then finally messes with the sizing of each part until he has it right. He can't understand why his parents aren't satisfied with his "two hours of working on my project".

Persist:

As a child persistence helps but is not absolutely necessary for most children; however, this changes as adulthood nears. Being unable to "stick with" a hard job is disabling.

Terry dropped out of school at fifteen, and is working at a boat shop. He is to spend his time sanding today. He sands for five minutes then checks the cord, checks his watch, gets a drink, wipes his eyes, adjusts his mask, replaces the sand paper, and complains about the work. His boss figures Terry works 50% of the time, so he pays him 50% of his wages the first week and explains why. Terry quits.

Organize:

Elementary teachers spend hours organizing their students but this doesn't happen in high school or at work.

Melinda dropped out of school as she lost everything at school, on the way to school, and at home. Many great projects never got handed in. She is lucky this week. Her sister has found her a temporary job helping at an insurance office when two secretaries are ill. Melinda is eager to start. By the end of the week, six invoices totaling over $10,000 are lost. It takes about a week to undo the "work" that Melinda did.

Multiple tasks:

Teachers, spouses, and employers all expect that a person can follow several directions or tasks at a time. If you only have enough working memory to do one task at a time, life will be difficult.

An 11th grade teacher expects the students to listen to what is taught, read the syllabus, and take notes if something important is not in the syllabus. Sarah can easily do one or two of these tasks but not all. She prefers to listen and follow along but they are graded on their notes. When the teacher sees no notes, she gets a zero. Sarah's reply, "But I can't listen and write at the same time." falls on deaf ears.

Although these examples have concentrated on academics, the problems they reveal are disabling socially, psychologically, and in the family. Executive functioning deficits are what drive this disorder from a mild problem in childhood to a potential nightmare in teenage and adulthood.

Attention in Teenagers

Attentional demands on adolescents are great. They have little choice over the courses they take and yet have very adult expectations. The distractions between classes are immense. The adolescent with ADHD is part of the group who didn't outgrow ADHD at puberty (see Prognosis section). While their attention span may be that of a fourth grader or less the demands for sustained attention on uninteresting topics is age appropriate. If they don't do any work they fail because they are not trying or they become the clown to keep from working. Even the most dedicated parents cannot keep a child going. It is sink or swim and most start to sink. Many will drop out, skip classes, get in trouble, or only do those few things that actually interest them. It is common to see a child who has failed three times in middle school be able to teach other kids how to do something that they have not learned themselves. At this point, the schools may have written off the child as trouble or not able to do academic work. The physician will see kids in this age group in for the first time when the parents have discovered that they cannot do what they did in grade school and are watching their child fail.

Impulsiveness–Hyperactivity in Teenagers

Teens with ADHD are usually fidgeting and restless but, unless you spend a fair amount of time with them they don't seem very hyperactive. There is usually a clear preference for activities that don't involve sitting quietly. Children get suspended for skipping school, making disrespectful remarks and fighting. The most impulsive kids will be involved with drugs, alcohol, smoking, and minor vandalism. Many adolescents with ADHD are only minimally impulsive and hyperactive and are less likely to get into so much trouble. They are more likely to just be frustrated, depressed, and drink. By late adolescence, untreated, severe ADHD is a horrible problem and can be life threatening.

Attention Deficit Disorder in Adults

While some adults with ADHD will outgrow it about 30% will continue to have it. The lucky ones find a combination of the right partner, the right job, and, sometimes the right medication. The unlucky ones go on to have failed relationships, troubles with the law, drug and alcohol abuse, and occupational failure. Adults with ADHD may see a physician for help because their children had been diagnosed and successfully treated for ADHD. Partners and friends may also encourage an adult with ADHD to check out treatment.

Subtypes of ADHD

Some children have problems with hyperactivity and impulsiveness while others have no hyperactivity or impulsiveness at all.

Hyperactive–impulsive Subtype

These are children who are able to perform academically as long as someone is keeping them busy. They are children who can stand at their desk and walk all around it while still doing their work or reading. These children will be in fights, engage in risky behaviors, and yet be able to do their work without too much difficulty. Little is known of this group. About 5% of children with ADHD have this picture.

ADHD Without Hyperactivity Subtype

Children with ADHD without hyperactivity are different in many ways from ADHD kids. They may have lower energy than normal and are less assertive than normal; as a result they have many friends in elementary school compared to hyperactive ADHD kids. They are much more likely to have learning disorders (especially Math) than ADHD kids. They are much less likely to have Oppositional Defiance Disorder (ODD) or conduct disorders. ADHD without hyperactivity kids do not get identified early in school. They are more likely to quietly daydream and accomplish little. These children have a tendency to just drift through school. About 15% of ADHD children have this type.

Causes of ADHD

There are two types of causes: genetic and environmental.

Genetic

90% of ADHD is genetic. Studies of adults with ADHD have found that about 50% of their children will also have ADHD. It is certainly possible that ADHD that disappears at puberty will be less inherited than this, but there are no data on this. Some researchers have found that if a mother has ADHD it is much more likely to be passed on than if the father has it. Another factor is that more often than by chance two people with ADHD will marry each other. From basic genetics one could then estimate that 75% of the children would have ADHD. Another common issue is that people with ADHD marry people who have learning disabilities, also strongly inherited.

What is being inherited that causes ADHD?

The answer isn't totally clear yet, but researchers are a lot closer to knowing than they were five years ago. A chemical called Dopamine is involved in ADHD. Researchers believe that changes in the genes that make the chemicals that transport Dopamine and bind it in the brain may be inherited. (25)

Alcoholism in parents is also associated with an increased risk of ADHD. If a parent has alcoholism, their child is about twice as likely to have ADHD. If both parents have alcoholism, the risk is three times as high. It is unclear whether this is from being related to an alcoholic parent or from living with them. (19)

Environment

The most important part of the environment is that in the womb and the birth. About 15% of ADHD cases are related to birth trauma or problems with the pregnancy. Women who smoke during pregnancy are more likely to have a child with ADHD. ADHD is more common in most genetic syndromes and also common in cases of mental retardation. Severe head trauma can produce ADHD, too. About one out of five children with head trauma will develop ADHD. (6) A common question I am asked is if you can "make" a child have ADHD from things like abuse? No one is sure, but probably not. What is certain is that you can worsen ADHD by family chaos, deaths or separation of parents, poverty, abuse and neglect. Food colorings and additives may also worsen ADHD in some cases (see dietary treatment section).

Brain Studies

Recently researchers have looked at the brain in people with ADHD and have found some clear abnormalities. MRI scanners take a very detailed picture of the brain in cross section. They show, in people with ADHD, that parts of the base of the brain associated with attention are smaller on the right side. The part of the brain that connects the left and right front of the brain has also been found to be smaller in a couple of studies using MRI. When researchers look at work different parts of the brain are doing, they have found decreased activity in the front parts of the brain in ADHD. Studies of Ritalin usage show no change in brain activity whether on or off medication, with these tools even though the children perform better on the drug. All of these studies suggest that the parts of the brain that we know are involved in planning, attention, and controlling motor activity show some minor abnormalities. They cannot be used to test for ADHD, but they certainly confirm its biological basis.

Comorbidity in ADHD

Comorbidity is when diseases or conditions tend to occur together more often than chance would predict. (An example is Diabetes and high blood pressure.) Identifying comorbid conditions when ADHD is present has led to better treatments and great advances in child psychiatry.

When a child is assessed for ADHD, it is essential to see if any of the other common co–morbid disorders are present. The presence of these co–morbid problems predicts which treatments will work and the long–term prognosis. About 50% of children have ADHD plus some other disorder. Here is a brief description of the common disorders comorbid with ADHD. Virtually all the child hood psychiatric disorders are more common in ADHD. Girls tend to have more comorbid disorders than boys.

Conduct Disorder

This is an inherited disorder characterized by cruelty, violence, and disregard for the rights of others. Approximately 25% of ADHD children have this. Children and adolescents with ADHD without hyperactivity do not have an increase in Conduct Disorder. A third of ADHD children with Conduct Disorder will have committed multiple crimes by the time their teenage years are over compared to 3–4% of children who have only ADHD. Children with ADHD and Conduct Disorder have a higher rate of becoming criminals as adults, too. (8)

Oppositional Defiant Disorder

This is a disorder characterized by aggression, bad temper tantrums, and a desire to irritate and oppose others. About 80% of children with this also have ADHD. Children and adolescents with ADHD without hyperactivity do not have an increase in Oppositional Defiant Disorder.

Tic Disorders

Sudden movements of the body or sudden sounds which are not voluntary are characteristic of Tourette's and related problems. ADHD and tics often go together. Tics can change the treatment of ADHD.

Anxiety Disorders

Anxiety disorders are not uncommon in children, but ADHD children are twice as likely to have them. One–third of ADHD children have anxiety disorders. They predict school failure and strongly influence the treatment of ADHD. Children with ADHD and anxiety are less hyperactive and impulsive than children with ADHD only. On the other hand, children with ADHD plus anxiety have more difficulty with difficult work and get "bogged down" more frequently.

Depression

Varying degrees of depression are present in many children with ADHD, especially after about age 10. This changes the treatment and predicts a worse outcome. About 40% of children with ADHD have marked depression. Often a child with ADHD will have relatives with depression. In some families, some relatives will have ADHD and others depression. Children with ADHD and depression are not more likely to commit suicide. (8)

Learning Disabilities

About one third of ADHD children have learning disabilities. Children with ADHD without hyperactivity have more learning disabilities. If a child with just learning disabilities is given stimulant medication for ADHD, it will not improve their learning. However, if a child with ADHD and learning disabilities (especially a reading problem) is given stimulant medication, their reading improves markedly. (8)

Mania

Mania is quite rare in children. It is the opposite of depression. About 90% of manic children have ADHD.

Autism and Related Disorders

ADHD is present in about a quarter of this group; about five times what you would expect.

Enuresis and Encopresis

Enuresis and Encopresis is not being in control of urine or feces and is much more common in ADHD than in children without ADHD. Having ADHD can make it harder to control these problems; On the other hand, many times the treatment of ADHD will improve these problems. About 30% of children with ADHD have enuresis.

Developmental Coordination Disorder

Being exceptionally clumsy and poorly coordinated is much more common in ADHD children. This combination can lead to very poor self–esteem, especially in boys.

Speech—Language Disorder

This is one of the most well documented connections. ADHD is much more common in this group. ADHD can make speech therapy much more difficult.

Epilepsy

About 20–30% of children with epilepsy also have Attention Deficit Hyperactivity Disorder. In a recent study, 70% responded positively to medications for Attention Deficit Hyperactivity Disorder. (11) The medications for Attention Deficit Hyperactivity Disorder are safe with most seizure medications.

Auditory Processing Disorder

These persons hear, but they have a hard time filtering out sounds that are not important. About 50% also have ADHD or one of the sub–types of ADHD.

Substance Abuse

If you go to drug and alcohol programs for teenagers, you will find many more cases of ADHD than you would expect. ADHD alone is not associated with an increased risk of substance abuse, outside of cigarettes. Conduct disorder is associated with a marked increase in substance abuse. So if your child has conduct disorder and ADHD, there is a great risk of substance abuse. But if the child just has ADHD, he or she is not at a higher risk for drug abuse as a teenager. (22) There is some evidence to suggest that if a person still has ADHD as an adult, even without conduct disorder, they will be at a greater risk for alcoholism. (23)

Substance abuse can cause many signs of ADHD. The most likely is Pot or Cannabis. 14% of teenagers who go to their family doctors test positive on a urine drug screen for street drugs.(12) In children with school problems, some types of epilepsy and certain disorders of the brain and metabolism can have similar signs as ADHD; but these are very rare.

Sleep Apnea

There are a few other disorders that sometimes can look like ADHD. One is Sleep Apnea. In this problem children are often snoring and they stop breathing in their sleep for a few seconds. This interrupts their sleep and can cause hyperactivity, inattentiveness, and other behavior problems. It is important not to miss this. It is not that rare. 1–2 % of children has this, but up to18% of children who are having major problems in school have it.(10) Some children can be markedly improved when this is treated. The treatment often involves surgery.

Comorbidity doesn't always mean just two disorders. It is not uncommon to see two or three different disorders besides ADHD in one child.

Diagnosing ADHD

In medicine, there are three methods used to diagnosis diseases. These are the history (about the patient and his family), the examination of the patient, and lab tests. Each has a role in ADHD diagnosis. The job in diagnosis is to find signs of the disorder and make sure it is not something else. One of the common problems with checklists of symptoms is that for ADHD symptoms to count, they must be severe enough to be disabling either at home, at school, or with friends. Even if you have all the signs of ADHD and it is disabling, if it came on for the first time at age 15, it isn't ADHD. When this is the history, it is key to look more carefully at what else might be going on. Drugs? Abuse? Mood disorder? Head injury? Epilepsy? These need to be ruled out.

History

A lot of the diagnosis is based on the history the family, school, and child tell. This can take a good hour.

Examination

Checking for signs of ADHD and the many other comorbid conditions doesn't usually mean a general physical. It means watching how they relate to others, play, read, write, interact with the physician and many other things. The most important part of the examination is a very thorough history from all the individuals who interact with the child. ADHD can be diagnosed without an exam, but will often be wrong, especially about comorbid problems.

All children who are thought to have ADHD should have their hearing tested to ensure that there is not a problem related to the ability to hear.

In the vast majority of children, the diagnosis is clear from the history and examination without special tests.

Diagnosing ADHD Without Hyperactivity

There are few conditions in pediatrics that cause hyperactivity and impulsiveness that begins before age seven and never goes away. That makes diagnosing ADHD relatively easy. The same does not hold true with ADHD without hyperactivity.

Being disorganized, inattentive, distracted, and forgetful can be caused by a number of other brain disorders that are in the family of learning disorders and language disorders. It is easy to understand this if you understand how what we see or hear becomes memory. As an example, when a teacher tells a child something, a number of things must happen for it to "register". To understand information a teacher says the child must be able to hear the sounds the teacher makes. Hearing loss from ear infections and fluid behind the eardrum are two common causes of problems at this level. If this is the problem, children have as much trouble hearing good news as homework assignments. All children who are not listening should be checked to make sure they are hearing.

If the child cannot focus attention on the teacher's voice ADD or ADHD is the cause of problems. A child with ADD can hear what he is interested in and totally ignore a teacher or parent, even if the person is quite loud. If child can't "tune out" other sounds such as other children talking, and trucks going by, then Central Auditory Processing disorder is the usual culprit. Children with this problem can do normal work if there are no distracting sounds.

Even if you can hear, pay attention, and tune out other sounds, it will get you nowhere if you cannot understand the meaning. The subject matter must be at a level the child can understand. For example, if you are reading at a 2nd grade level and the class is reading at a 6th grade level, you will not be able to follow what is going on no matter how attentive you are. Some Learning Disabilities, language disorders, and mental retardation can cause this. The level of difficulty is just too far "over their head" Often the child must remember what was said by the teacher the next day or later. A learning disability in memory can cause this difficulty. The child knows and understands it today, but never heard of it tomorrow unless it is repeated over and over. All children with listening problems need to be checked for learning disorders.

All of the problems above could exist along with ADD. For example, a child might have a learning disorder in reading and ADD. The bottom line is—if a child appears to have ADD—each of these other possibilities needs to be ruled out first. Sometimes, that's easy and sometimes, it is very difficult.

Prognosis ADHD (What Does the Future Hold?)

As children with ADHD grow older, one of three things will happen.

1. The symptoms will go away. About 15–20 % of children with ADHD will grow out of it sometime in childhood or early adolescence. If a child has had this disorder for a long time, then he or she is less likely to grow out of it. For example if a child is diagnosed with this disorder between ages 2–4, they have about a 50% chance of outgrowing it. If not diagnosed until age 5, only about 25% will ever out grow it.(13) Family problems are associated with preschool children not outgrowing this disorder.(14)
2. The symptoms will partially go away. Some children will show mild signs of it throughout their life but get by without too much trouble.
3. The symptoms will stay the same or worsen. About a third will have the full syndrome their entire life. It is more likely that ADHD will continue into adulthood if there is a strong family history of ADHD, a dysfunctional home, or comorbid psychiatric disorders. If two or three of these factors are present, it is almost certain that the child will have ADHD as an adult.

As children with ADHD get older, comorbid disorders become more frequent. If you watch children with ADHD for four years, they have about 20 % more likelihood of having a comorbid disorder. 60% will end up using some psychiatric medication at one time or another. 45% will have been in a resource class. 40% will have repeated a grade.

Cigarette smoking is likely in children with ADHD. About 20% of 10 yr. olds with ADHD will be smoking four years later, twice as much as normal children. Children with ADHD are more likely to have lacerations requiring sutures and are more likely to break bones. They are much more likely to have severe head trauma. That is, if you look at children who have severe head trauma, ADHD is four times as common as one would expect in a group of children (6).

A poor outcome is more likely in children who 1) come to clinical attention before school age, 2) those with two or more comorbid conditions, 3) those who are abused or come from chaotic families, and 4) those who receive no treatment. What do I mean by poor outcome? They may experience poverty, suicide, psychiatric disability, no stable partner, alcoholism, prison, and unemployment. ADHD is six times more common in suicide victims than in the general population.

ADHD is a serious condition. Some children will grow out it and have few problems; many will not. It is in these children that treatment is essential. My psychiatric and experience views are that ADHD should be treated aggressively; children should be treated early. A number of different interventions should be tried. Parents should learn all they can about this condition and demand the best possible treatment for their children.

The prognosis sounds bleak, but that doesn't mean that it is hopeless. I have seen children and adolescents with multiple comorbid conditions and other poor prognostic features do well with treatment that involves a variety of interventions. I have also seen many children who seem immune to any intervention.

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Dr. Jim Chandler is originally from Minneapolis, Minnesota. He graduated from the University of Minnesota Medical School in 1983 then moved to Iowa City, Iowa for a residency in psychiatry. He now lives and works in Yarmouth, Nova Scotia where he practices both pediatric and adult psychiatry. This information on ADHD is from a series of pamphlets Dr. Chandler wrote to provide accurate, unbiased information on common pediatric psychiatric disorders.

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