ADHD Gets Some Attention (AttentionDeficit Hyperactivity Disorder)

Attention Disorder Hyperactivity Disorder(ADHD) affects between 1.5 and 3.5 million school-age children inthe U.S., or an estimated 5% of all boys and 2% of all girls. Why ADHDaffects more boys than girls is a mystery at this point. Up to 60% ofthese children will continue to have symptoms into adulthood. Accordingto the National Institutes of Health, more than a million children takeprescription medicines to control hyperactive behavior. The estimatedcost to schools is about 3 billion dollars. If you had ADHD, youwould have had trouble reading that first paragraph without gettingdistracted. You would have thought of other things to do. You would have looked around the room, focusing on things other than thecomputer screen. You might have even gotten up and wandered off. No wonder children with ADHD have trouble being in school and focusing on schoolwork.

Signs to Look For Almost all people at some point exhibitsome of the symptoms of ADHD. We all get distracted at times; we all havehad trouble finishing work or tasks. However, children with ADHD are, ingeneral, less ableto care for themselves, less able to recognize appropriate socialbehavior, and less able to communicate than non-ADHD children of the sameage. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)published by the American Psychiatric Association has a very specificlisting of behaviors that must be observed before a diagnosis of ADHD ismade. There are many reasons other than ADHD why children may have thesebehaviors. Infections, learning disabilities, or educational issues mayresult in symptoms similar to ADHD. Patterns of behavior that may indicateADHD: Inattention Being easily distracted Failing to pay attention to details and making careless mistakes Forgetting things, such as pencils, that are needed to complete atask Rarely following directions completely or properly Hyperactivity Not being able to sit still Talking non-stop Leaving seat when sitting is expected/instructed Impulsivity Being unable to suppress impulses such as making inappropriatecomments Shouting out answers before a question is finished Hitting other people Behavior which puts one in danger, such as dashing intothe street Somedays, for some reason, these symptoms may be absent, leading othersto think that the person with ADHD can control the behaviors. A definitediagnosis is difficult because there are no tests that consistently detectADHD. A physician can only observe behaviors and guess whether the childhas ADHD. Many children have trouble concentrating, or may not be in amood to cooperate on the day they see the doctor. This could lead to anincorrect diagnosis. ADHD must be diagnosed by a health careprofessional who specializes in these types of disorders incooperation with parents and teachers.

Examining the Cause There is no clear-cut cause of ADHD. Itappears that certain receptors in the brain which normally respond to theneurotransmitter called dopamine are not working properly. Most likely,dopamine is not being produced at normal levels in the brain. Recentwork in adults points to a defect in an enzyme called dopadecarboxylase which helps make dopamine. This defect in dopamineproduction occurs in the anterior frontal cortex, an area associated withcognitive processes such as focusing and attention. There isalso evidence that children who were born weighing less than 1500grams (3.3 pounds) or who had birth complications may be more prone toADHD. Additionally, studieshave linked resistance to thyroid hormones to hyperactivity and lackof impulse control, but it is unclear how this impacts ADHD. Other factors which are being investigated to see what role they may playin ADHD are exposure during preganancy to: Toxins (such as lead) Drugs (such as alcohol or cocaine) According to the NationalInstitutes on Health, ADHD is not usually caused by: Too much TV Food allergies Excess sugar Poor home life Poor schools There is increasingevidence that ADHD is an inherited condition. If oneidentical twin has symptoms of ADHD, the other twin has a 75-91% chance ofsharing the same trait. Children who have ADHDare likely to have one close relative who also has ADHD. One-third of allfathers who had ADHD when they were young have children who have ADHD. Adoption studies provide more evidence of a genetic link to ADHD:biological relatives of children with ADHD have a higher chance of havingADHD than adoptive relatives of children with ADHD.

Structural Signs Studies in the past few years have shown that boys with ADHD tend to have brains that aremore symmetrical in shape. Three structures in the ADHDboys' brains were smaller than in non-ADHD boys of the same age: prefrontal cortex, caudate nucleus, and the globus pallidus. The prefrontal cortex is thought to be the brain's "command center;" the other two parts translate the commands into action. Nowthere is evidence that not only are some of the structures slightlydifferent, but the brain may use these areas differently. By taking abrain scan, researchers have noticed that boys with ADHD have an abnormalincrease of activity in two structures: the frontal lobe and striatalareas below it. These areas work in part to control voluntary action. Sothe ADHD boys were working harder to control their impulses than non-ADHDboys. Once given Ritalin, this abnormal activity quieted down. This effectwas not seen in the non-ADHD boys. So Ritalin may act differently on ADHDbrains compared to "normal" brains. Although the brain scan, called functional magnetic resonance imaging(fMRI), is expensive--about $1500--and may not be covered by insurance, itmay provide a more accurate way to diagnose ADHD. As science explores moreof the mysteries of the brain, ADHD may be thought of more as a disabilityor disorder, rather than a behavioral problem.

Treatment Three medications classified as stimulants are used to control thesymptoms of ADHD. Generic Name Brand Name Length of Action Methylphenidate Ritalin 3-8 hours Dextroamphetamine Dexedrine, Dextrostat 3-8hours Pemoline Cylert 5-10hours These medications can beaddictive in teenagers and adults, but they have not been found to beaddictive in children. Nine out of 10 children improve on one of thesestimulants, so if one does not work, the others are tried. If thesemedications do not work, some children respond well to antihistamines,usually prescribed for allergies. Clonidine, a drug normally used to treathypertension, also alleviates some symptoms of ADHD. With any of thesemedications, adjusting the dosage for each child is vital for treating thesymptoms of ADHD. People who do NOT have ADHDmay also respond to stimulants and may find that their attention andability to focus will improve. This reaction does not mean that they haveADHD. It is not recommended for people without a diagnosis of ADHD to usethese drugs. No one knows if stimulants have the long-term effects. Ritalin is the best knowndrug used to treat ADHD. It was first used in the 1950s to treatnarcolepsy, an illness where people suddenly fall asleep at irregulartimes. It works by making more dopamine available in the brain byreducing dopamine reuptake. Therefore, dopamine can stay in the synapsefor a longer time. Ritalin curbs symptoms such as hyperactivity and otherbehavioral problems, but it does not improve IQ. Ritalin is being prescribed at an astonishing rate. Statistics mentionedin a TIMEmagazine article are telling: Ritalin production in the US hasincreased more than sevenfold in the past eight years. Ninety-percent ofit is consumed by people in the US. Why have the prescriptions skyrocketed? Part of the reason maybe pressure--pressure from teachers for children to behave, pressure fromparents for their children to do well in school and to succeed in otherpursuits, and pressure from society for children to do more and better, ata younger age. Ritalin has side effects that include irritability, decreased appetite,inability to sleep, depression, and personality changes. With the increasein information about where dopamine may be deficient, medication could bedesigned to target those deficient areas instead of increasing dopamineproduction in the entire brain. This may reduce the side effectsassociated with Ritalin and other drug medications.

Controversy Ritalin is one of the most commonlyprescribed drugs for children, but there are worries about its long-termeffects. There are no studies on children who have taken Ritalin for morethan 14 months. Ritalin affects the brain in a way very similar tococaine, one of the most addictive substances known. Are children who takeRitalin more likely to use illegal drugs in the future? Are they morelikely to smoke as adults? There is reason for this concern. Rats who were exposed to stimulants weremore likely to help themselves to cocaine, suggesting that early exposureto some drugs may "prime" a person for future drug use. The data onwhether there is a link between Ritalin and later substance abuse arecontroversial. Some studies show that Ritalin makes people more prone toaddiction to certain substances. Other researchers insist that ADHDchildren are not more likely to use drugs of any type later in life.

Combining Therapies Prescription medications help control the symptoms of ADHD, but othertherapies, such as psychotherapy and behavioral therapy, can also helpADHD children. Many experts now advocate combining drugs with therapy. Other helpful approaches include: creative teaching, visual signs toremind children of the task at hand, constant reinforcement, adding rulesand structure to the daily routine, special education, and othertechniques used for learning disabled students. The immediate problem with this is that insurance companies will be morelikely to cover the cost of a pill, but may hesitate to cover long-termtherapy sessions. Thus, often the treatment for ADHD is focused on theshort-term, not on the long-term.

Coping Strategies The NIH booklet on ADHD lists ways for people with ADHD to cope better atwork or school: When necessary, ask for instructions again--don't guess about what you'resupposed to do. Break large or complex tasks into smaller jobs. Set deadlines for eachtasks and reward yourself when you complete each one. Each day make a "to do" list. Use a calendar to keep you on track. Work in a quiet area. Do one thing at a time. Give yourself shortbreaks. Create a routine. Do the same things in the same order each day. Eat a balanced diet, exercise, and get enough sleep eachnight.

NIHADHD Booklet

Watch your Head! Hospitalrecords indicate that children with ADHD may be more accident prone.And not only that, but the injuries were more severe than in non-ADHDchildren of the same age and gender. This is one more reason to puton a helmet when riding a bike, skating, rollerblading, or skateboarding. The Road Ahead Althoughscientists have gained much information in the past few years, ADHD is keeping some of its secrets. Why does it affect more boys than girls? Is ADHD "real" or is society simply labeling children who arehaving difficulties? And how does dopamine fit into this? Is Ritalin the beginning of a drug dependency or an antidote for needing illegal drugs in order to function? Are the abnormalities in a child with ADHD the same as those seen in adults who have ADHD? Much more work still liesahead.

References and further information can be obtained from: National Institutes of Health, National Institute of Mental HealthADHD brochure.NIH Publications #96-3572, reprinted 1996 Approaching aScientific Understanding of What Happens in the Brain in AD/HD Attention! magazine "Subtle BrainCircuit Abnormalities Confirmed in ADHD," July 1996 Motluk, Alison, "Calm Before theStorm," The New Scientist, April 18, 1998 Gibbs, Nancy, "TheAge of Ritalin," TIME Magazine, Nov. 30, 1998,pages 86-96 "AConcentration Killer: Study Shows Brain Chemistry Defect is Keyto Attention Deficit Hyperactivity Disorder in Adults," Science DailyMagazine, Aug. 14, 1998 "Childrenwith ADHD Have Related Functional Disabilities," Science DailyMagazine, June 6, 1997 Spinney, Laura, "Attention ProblemTracked in Twins," The New Scientist, June 28, 1997 "Differencein Brain Function Found for Attention Deficit Disorder," Science DailyMagazine, Nov. 24, 1998 HyperactivityLinked to Thyroid Hormones," Science Daily, March 12, 1997 ADHD -Scientific American (September, 1998)