Children with ADHD typically have significant difficulties staying on task, completing tasks, sitting still, following rules and directions, waiting patiently, organizing their activities, and avoiding careless errors and distractions.
ADHD is not just about being inattentive or over active. ADHD is a serious disorder characterized by significant impairments in the ability to control one’s self. Russell Barkley, argues quite eloquently that the defining feature of ADHD is a deficit in the ability to inhibit or delay behavior. ADHD is really a disorder of self-control. Thus, children with ADHD have significant difficulties with impulse control, activity level, and the capacity to sustain attention (to stay on task and complete tasks).
What causes ADHD? The consensus among the leading experts in the field is that ADHD is an inherited or genetic disorder. It is not the result of poor parenting, bad diet, or changes in our society. Preliminary evidence as well as theory, suggest that the deficits associated with ADHD may be linked to differences in frontal area of the brain, the orbital-frontal cortex, which has been shown to be associated with the capacity for self-control and goal directed behavior.
Is ADHD really a disorder?
Almost everyone has had an occasional problem with staying on task, completing a task, misplacing something, and/or interrupting a conversation. Such behavior is even more common place with children. Occasional problems with inattention, impulsive behavior and restlessness/fidgetiness are not a disorder. Children do develop greater abilities to control and manage their behavior, complete tasks and attend as they get older.
ADHD is present when problems of self-control/impulsivity are so severe as to cause significant problems in individuals’ daily lives. ADHD is a real disorder which causes real problems.
Children with ADHD have been found to have: consistently lower levels of achievement (compared to peers and relative to their assessed ability), higher rates of disruptive behavior in school (including higher rates of suspension), higher rates of substance abuse in adolescence, poorer language skills (for problem solving and explaining ideas), and higher rates of injuries due to accidents.
ADHD is not, as some claim, a disorder of modern times. While a few have asserted that ADHD is a product of our modern culture (face paced, technology filled, and over stimulating) there is much evidence to suggest that ADHD exists in very different cultures. Moreover, ADHD symptoms have been noted as a childhood problem as far back as the beginning of the 20th century.
Do adolescents and adults have ADHD?
For many years professionals believed that children outgrew ADHD when they entered adolescence. However, this is clearly not the case. Barkley and his colleagues have found that ADHD persists into adolescence and adulthood, and that 50% to 70% of persons diagnosed with ADHD as children show significant symptoms of ADHD in adulthood. Adults with ADHD often struggle with time and money management, organization, and task completion.
What is the difference between ADHD and ADD?
There is much debate whether ADHD and ADD (referring to a disorder characterized by significant difficulties with attention) are subtypes of the same disorder, or really different disorders. Hopefully ongoing research will clarify this issue.
ADHD is a tricky disorder to diagnose. All ADHD symptoms are behaviors that children occasionally exhibit. Children misplace things, interrupt, fidget, and get distracted. Therefore, it is critical to not mistake typical childhood behaviors for ADHD.
What distinguishes normal childhood behavior from ADHD?
The severity and intensity of problems. Children with ADHD have significant difficulties managing many of the tasks that other children their age do without great effort. They frequently forget, misplace, and fail to turn in school work. They often are in trouble for breaking rules, despite apparent good intentions to be well behaved. They are impulsive and do not seem to not learn from mistakes. They have trouble staying focused on school work and mundane tasks.
In sum, these children have significant problems with attention and impulse control. These problems are to such a degree that their performance in school and other areas of life are noticeably compromised.
How can we be sure a child really has ADHD?
There is no way to be 100% certain that a child has ADHD. However, by strictly adhering to diagnostic criteria one can be more confident that an accurate diagnosis has been made. The established diagnostic criteria for ADHD, as specified in the DSM IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) is:
- sufficient number of symptoms are present (6 required)
- symptoms are of sufficient intensity, frequency and duration
- onset of symptoms occurred prior to age 7
- symptoms clearly interfere with functioning
- symptoms occur in more than one setting
- no better explanation for current difficulties exists
To diagnosis ADHD professionals need to obtain a thorough understanding of the child’s current behavior and history of difficulties. Detailed interviewing, accompanied by standardized rating scales, is the best method for evaluating ADHD. It is essential to obtain information from teachers because they typically observe children in the setting where there is the greatest demand for sustained focus and self-regulation.
Isn’t ADHD really immaturity or laziness?
Children vary in how quickly they mature. Their behavior often oscillates, at different times the same child can show immature and mature behavior. While children with ADHD often are inconsistent in their behavior, given their impulsiveness, ADHD is not the equivalent of immaturity. ADHD is a disorder characterized by significant deficits in the capacity to control and direct one’s behavior. Children with ADHD have far more significant problems with attention and impulsivity than do their peers. Children who are immature do not just have weakness in attention and impulse control, but exhibit problems with maturity in multiple areas.
Lack of motivation, a tendency to focus on immediate gratification rather than long term goals, is typical of children with ADHD. However, these problems are due to the child’s ADHD rather than a character flaw. Because children with ADHD are impulsive they are less likely to think ahead, are more likely to focus on the immediate, and are less aware of and influenced by long term consequences.
How do we know it is ADHD, not something else? Differential Diagnosis:
Differential diagnosis (the process of determining an accurate diagnosis and distinguishing between different disorders) is particularly important with ADHD. A number of other disorders have some similar symptoms, including: anxiety, depression, bipolar disorder, learning disabilities, and behavioral disorders such as Oppositional Defiant Disorder. Thus, a thorough assessment is needed to make sure that these disorders are not present and do not offer a better way of explaining the child’s difficulties. For example, children who are depressed may have trouble concentrating, while anxious children may be restless and fidgety.
Major family stresses such as marital conflict, divorce, and substance abuse negatively effect children. Children often act out their distress and behave in disruptive ways, when under stress. Thus, it is important to examine how family stresses are affecting the child, and to consider what role these stresses play in the child’s current difficulties.
The consensus within the field is that optimal treatment involves a combination of medication based treatment and therapy. Research has shown that stimulant drugs are effective in improving the symptoms of ADHD. However, family therapy is also a critical part of the treatment process. Many parents need assistance developing more effective ways to provide their children with more consistent structure. Parents often also need help responding to the problematic behaviors associated with ADHD.
Coordination with school personnel is critical for assisting children with ADHD.
Helping parents and school personnel develop a more effective partnership is particularly important as many children with ADHD struggle to consistently complete and turn in school work, and tend to behave in disruptive ways in school. Thus, it is critical to develop a coordinated effort/plan to insure that children are functioning more effectively in school.
Therapists and prescribing physicians need to coordinate their treatment efforts. This is particularly important with adolescents to help insure compliance with medication based treatment and to gauge the benefits of medication.
Finally, parents may need help understanding treatment options and limitations. This is increasingly true as there is a plethora of treatment options. Parents need guidance and education because many “new” treatment approaches lack sound scientific evidence to support their usefulness, e.g., nutritional supplements and chiropractic treatment. Thus, therapy often includes education about resources and treatments for ADHD.
Please note: The information about ADHD detailed in this handout is drawn from the work of Russell Barkley, Ph.D. (see Russell Barkley, Ph.D.’s, Attention Deficit Hyperactivity Disorder, A Handbook for Diagnosis and Treatment, 2nd Edition, a comprehensive examination of ADHD research and theory).
Bibliography and Resources
American Academy of Pediatrics Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105: 1158-1170.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association, 1994.
Barkley, R.A., Attention-deficit Hyperactivity Disorder: A Handbook for diagnosis and treatment, 2nd, Guilford Press, N.Y., 1998.
Barkley, R.A., ADHD and the Nature of Self Control. Guildford Press, N.Y., 1997.
Barkley, R.A., Taking Charge of ADHD, Revised Edition, Guilford Press, N.Y., 2000.
Conners, C.K., & Jett, J.L., ADHD in Adults and Children: The Latest Assessment and Treatment Strategies. MHS, North Tonawanda, N.Y., 1999.
Goldstein, S. & Goldstein M., Managing Attention Deficit Hyperactivity Disorder in Children, 2nd ed. John Wiley & Sons, N. Y., 1998.
Parker, H. ADAPT: Attention deficit accommodation plan for teacher. Specialty Press, Plantation, Fl, 1992.
Helpful websites include:
www.chadd.org – Children and Adults with Attention Deficit/Hyperactivity Disorder, (CHADD), a national advocacy group’s website offering information, newsletters and support group listings.
www.nichq.org – National Initiative for Children’s Healthcare Quality (NICHQ), a site offering information for parents and professionals on ADHD, and other disorders of childhood.
www.psychcentral.com – Site established to review mental health websites. Provides ratings of and links to other sites. Frequently updates information.