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Attention Deficit Disorder 

by Dr. Maurice Blackman
From the August/September 1995 issues of Medical Scope Monthly

Introduction
Bradley in 1937 first began the treatment of children with behavioral disorders using amphetamines in this case Benzidrine and noted a good response. These children were better able to concentrate and appeared more settled after medication. This was a heterogeneous group of institutionalized children many retarded or with other stigmata. 
Laufer et al in 1957 first introduced the diagnostic category of hyper kinetic behavioral disorder. They noted that many individuals with brain disease or brain injury had persistent disturbances of behavior particularly hyperactivity. They also noted that some children had the same problems without any evidence of underlying brain disorder and extrapolated a similar underlying neuropathology.

There have been many attempts since then to categorize this condition or group of conditions and various nomenclatures have been applied including minimal brain dysfunction, hyperkinesias or hyperactivity, learning disorder, and behavior disorder.

General agreement has been reached that the cardinal features are a level of activity often purposeless, that is substantially greater than normal children of the same age. Also, an inability to sustain attention on any one topic for a minimum period of time, plus impulsivity and distractibility. The DSM III-R (Diagnostic and Statistical Manual of Mental Disorders) which is the nosology recognized in North America defines two variants. attention deficit disorder without hyperactivity and attention deficit disorder with hyperactivity. It is perhaps most useful to consider it as a spectrum of disorders with similar presentations using the rubric attention deficit hyperactive disorder (ADHD). This is the umbrella term that I will use this evening to describe all varieties of this syndrome.

The presentation this evening will not attempt to address all aspects of this interesting and complex condition but will focus in detail on two aspects, diagnosis and treatment.


Epidemiology

ADHD is a chronic disorder more common in boys than girls with a patio of 5 to 3. It is present in one percent to five percent of children thus representing a fairly common condition. Problems may present in two areas of the child's life, at home, and in school. ADHD may affect relationships with family and peers. ADHD may be associated with learning problems either primary or secondary as well as evidence of developmental delays in fine and gross motor coordination. ADHD children may have problems with handedness and laterality, and visual and auditory perceptual problems. In addition many children with ADHD have specific learning problems including dyslexia, dyscalculia or dysgraphia or a combination of all three, dyslexia being the most common.

ADHD was for many years considered environmentally determined, but mope recently studies have shown it to have a familial basis with perhaps some genetic component. ADHD has also been found to be associated with greater family dysfunction and it has been suggested that it may be that a hyperactive parent has difficulty in relationships, leading to family breakdown. It should also be emphasized that ADHD is a chronic syndrome which may persist into adulthood and that it may present for treatment in adults who were not diagnosed as children.

The outcome of ADHD is varied and studies have shown that 1/3 of children seem to remit at puberty. One third continue into adulthood leading to problems in academic and vocational achievement. 1/3 become serious conduct disorders and may enter the criminal justice system.

It is not possible presently to predict which children will enter each of these categories although it has been suggested that low IQ, serious conduct problems and mental disorders in parents all herald a poorer prognosis. Nor is it possible to predict except anecdotally which children will respond well to pychopharmacology treatment. It is known however that at least 75% of children show a positive response to stimulant medications.

While it is agreed that the central features of ADHD include over-activity, impulsivity, short attention span and distractibility diagnostic categorizations differ and many children with these presentations are diagnosed as having conduct disorders in Great Britain while they are diagnosed as ADHD in North America. This has been shown to be related to the diagnostic categorizations used rather than differences in actual rates of disorder. Also it should be noted that attention deficits disorder may occur without hyperactivity and may be overlooked leading to a child who underachieves at school consistently.

In an attempt to create some order out of the general confusion, the DSM III of the American Psychiatric Association has laid down very specific criteria governing the diagnosis of ADHD.

Diagnostic criteria for ADHD

A. A disturbance of at least six months during which at least 8 of the following are present. In every case the symptoms must be measured against what is considered to be developmentally normal for age. 

restless, fidgets with hands and feet 
difficulty in remaining seated for protracted periods of time 
easily distracted by extraneous stimuli 
difficulty in awaiting turns in games or group situations. 
may blurt out answers, before questions have been completed 
difficulty in following through on directions 
difficulty in sustaining attention 
often shifts from activity to activity without completing 
has difficulty in playing quietly 
often talks excessively 
interrupts or intrudes on others 
does not seem to listen to what is being said to him or her 
frequently loses things necessary for activities at school or home. 
may engage in difficult or dangerous activities without considering possible consequences. 
B. Onset must be before age 7

Differential Diagnosis
The differential diagnosis of ADHD is of more that small interest. The activity level of children varies considerably and normal children may vary enormously in activity level depending on temperament, parental expectations and environmental conditions. Such children although overactive may not be hyperactive, and may respond better to environmental manipulation rather than any specific medications. ADHD rarely presents as a recent phenomena and any sudden change in behavior or personality in a child suggests problems other than ADHD even though the immediate presentation may be similar. Children faced with family disruption including conflict in the home including parental separation and divorce, or abuse either physical or sexual may present with symptoms similar to ADHD.

Similarly, children may be hyperactive as an expression of underlying emotional, and or social problems and treatment must then be directed at those problems rather than at the activity level.

Children tend to act out their feelings so that the anxious or depressed young child may present as more than usually active and have symptoms of impaired concentration

Hyperactivity and attention deficit problems may be the Presenting problems of children with: 
Conduct disorder 
Mental retardation 
Unipolar or bipolar affective disorder 
Psychosis 
Pervasive developmental disorders (PDD, autism) 
Tourettes syndrome 
Obsessive compulsive disorders (OCD) 
Each of these syndromes may be excluded following a careful clinical evaluation including history taking and clinical examination prior to instituting treatment.

Aids in diagnosis
ADHD may present differentially depending on the setting in which the child is seen. For example a child maybe quite well behaved in the doctors office for a short visit, but may become quite hyperactive under social conditions where there is a great deal more stimulation such as the waiting room the shopping center, the home or classroom.

The hyperactive child especially the young child often presents for the first time on entering playschool or kindergarten and diagnosis may be made by the playschool supervisor, or kindergarten teacher. Alternatively a child may be found to be disruptive in the classroom in grade school and be unable to benefit from classroom instruction and on psychological assessment is found to have ADHD.

Some children especially those who have ADD without hyperactivity may be referred after continued failure to learn and may present primarily with learning disabilities or failure to progress academically. Teachers may comment that these children are poorly motivated, lazy or not trying.

In making the diagnosis of ADHD it is essential to follow the usual method of historical inquiry focusing on the following areas: pregnancy, birth and development.

ADHD children often present as colicky difficult to manage infants, who are fractious, sleep little and tend to be clumsy and show mild developmental delays. Others however are described by their parents as unusually active from birth and early developers often walking and talking earlier than other children. Some parents find the precocious ness of their children quite pleasing so that a problem does not become apparent until they leave the home environment.

Socialization
ADHD children do not socialize as easy as other children and parallel play persists much longer than normal. They may be more egocentric and aggressive in their use of toys and display poor frustration tolerance in relation to other children of similar age.

At home
ADHD children have difficulty in following directions and parents report them as careless and unable to complete tasks or follow direction. In this case differentiation must be made between unsocialized children who come from chaotic and poorly supervised home environments.

In school
ADHD children usually are reported by teachers as having poor attention,. They are distractible and unfocused. They may had problems in completing assignments in reading and writing and be unable to progress with their same aged peers.

Family history
Special attention here needs to be devoted to questions and inquiry into family stability and any stresses that might be disruptive, or disturbing to the child. Other signs of emotional dysfunction including disturbed sleep, and nightmares, recent change in personality or unusual preoccupations and appetite disturbance may suggest an affective illness.

The child who is under pressure to perform beyond their ability at school may develop an overanxious disorder of childhood which may present as ADHD. Differentiating features include other evidence of anxiety or phobic behavior

Clinical examination

Direct observation
Although indirect reports tend to predominate in the consideration of ADHD, they do not substitute for direct clinical observation. The diagnosis of ADHD and its severity can indeed be made based on the disorder of the physicians office, and his or her stress after the visit.

Any child referred for ADHD should be subjected to a full examination including clinical observation. It is not hard to diagnosis the classical ADHD child since the level of activity observed in the office will be characteristic. It is worth doing a neurological screening test, since some of these children will show "soft neurological signs". Also having the child draw, read and write depending on age level may well be diagnostic. The ADHD child tends to draw in an explosive and expansive manner. He or she is careless in the approach to the task and tries to finish it as quickly as possible. Associated learning difficulties can be diagnosed by having the child write his ABC's, or draw numbers, letter or number reversals may be noted. Similarly such children often have difficulties with handedness, being neither right nor left handed or have difficulty in fine motor coordination.

The presence of fidgeting, unusual facial tics or unusual mannerisms may indicate Tourettes disorder. Stimulant medications have been associated with the onset of tics and children with Tourettes syndrome may be worsened if treated for ADHD. A number of assessment questionnaires are available that can be completed by the physician, teacher or parent. The teacher's rating scales in particular have been found to be reliable indicators of true ADHD. The most common scales used are the conners rating scales. These basically list the various symptoms of ADHD, and may be scored. The conners rating scales are also good indicators of response to treatment.

Treatment
As in most child psychiatric conditions the treatment of ADHD is multi-modal and addresses biological, psychological and psychosocial issues. Acknowledging the primary effects of ADHD on the child and the secondary effects of ADHD on the child, family and community.

Neurobiological
There have been various theories of the neurobiological site of presumed dysfunction in ADHD. It is now considered most likely that ADHD is related to dysfunction of the hypothalamus and the prefrontal cortex. Spect studies measuring cerebral function, have shown frontal lobe hypo function and caudate lobe hypo function in children with ADHD. It has also been observed that following stimulant medication and clinical improvement, blood flow to the hypothalamus is improved.

Neurochemistry and psychpharmacology
ADHD has been linked to catecholamine metabolism, i.e., the increased reuptake and release of dopamine and norepinephrine. Many different medications either singly or combined have been utilized in ADHD. As previously noted, the treatment of ADHD was originally based on an empirical observation that amphetamines helped some children with behavioral problems. However since then a major body of research has accumulated reflecting the positive effects of stimulants especially methylphenidate (Ritalin) both in the short term and long term assistance of children with ADHD. It is important to note that there is nothing paradoxical in the use of stimulants in children. Amphetamines have the same action in children as they do in adults, that is they produce a state of increased concentration and alertness, so that the child is more able to focus. Stimulant medication does not necessarily improve behavior.

Other medications used include dextroamphetamine. Magnesium pemoline and tpicyclic antidepressants particularly desimiprimine. Tricylics are not considered as good as stimulants but do work.

Methylphenidate has been shown to improves vigilance, and both methylphenidate and desimipramine have positive effect on short term memory and visual problem solving. Also a combination of both these medications has been found to affect higher order learning.

Problems in medication use in ADHD
There are many problems associated with the use of stimulants not the least of which is parent and physician resistance to its use. So it is worthwhile to address some of these issues in particular in relation to psycho stimulants such as methylphenidate (Ritalin)



1) My child/patient will become addicted.

Fact: It has been established that children who have been prescribed Ritalin are less likely to become addicts to amphetamines as adults that the average population.

2) Ritalin will stunt growth.

Fact: Some mild self-correcting growth delays have been noted on very high Ritalin usage but none so significant that the Ritalin needs to be stopped.

3) Ritalin reduces appetite.

Fact: Ritalin like other amphetamines is a stimulant and Appetite reducer. Parents often report that children's appetites are reduced with Ritalin. This is also generally self limiting and does not pose a risk in treatment. Children's food consumption does of course vary with growth patterns. In many years of observation of children on Ritalin in hospitals and in my office, I have never observed any substantial appetite reduction.

Hyperactive children tend to have little patience with eating preferring high energy junk foods. It may be that during treatment parents have more time to notice the child's eating habits.

4) Ritalin will make the child into a 'zombie'.

Fact: Improvement in attention and concentration of children on Ritalin and quieting as a result of less hyperactive behavior may be a novel experience for parents.

5) Ritalin made the child worse.

Fact: Not all children with ADHD respond to Ritalin, and not all hyperactive children have ADHD. Correct diagnosis will enable maximum success to be achieved. Also Ritalin may not be efficacious alone and may have to be used in combination with other medications.

6) The child gets worse behaviorally some time after Ritalin is given after an initial positive response.

Fact: Ritalin is a short acting drug which is cleared from the body in about 3 to 5 hours. In the period following the elimination of the drug between dosages, there may indeed be a short term withdrawal phenomenon with increased irritability. This can be dealt with by the combination with Neuleptil a neuroleptic drug.

7) The child was prescribed Ritalin before but it did not work.

Fact: the most common reasons for Ritalin not to work relates to inadequate dosage and non compliance.

Inadequate dosages. It is not uncommon for a schedule of 5 mg daily or twice daily to be prescribed for two weeks. When this is not useful the regime is stopped. Ritalin dosages may be as high as 60 mg to 80 mg daily. Generally dosages should be increased to the point where there is maximal response, often in the region of 20 mg to 40 mg daily.

Non compliance - Parents may have unreal expectations in expecting young children to be responsible for their own medication. Children may be given medication to take to school. Also medication may be given sporadically.

8) Ritalin interferes with sleep.

Fact: Ritalin is a stimulant and may indeed increase wakefulness. Generally Ritalin should not be given after 3 pm. If sleep remains a problem, but the overall effects of the medication are good, then a small dosage of a tranquilizer can be given at night generally at supper time.

Ritalin should be only given on weekdays with weekend holidays

Fact: Most ADHD children have problems at home and at school. It makes no rational sense to stop the drug on weekends or during school holidays.

10) Ritalin should be stopped when the child reaches puberty.

Fact: The usage of Ritalin like any other medication needs to be measured against the patient's need for the medication and not on age. A significant number of children remain hyperactive into the teens and even into adulthood. It is counterproductive to stop Ritalin at this age when the child has not only to cope with the ADHD but also with the turbulence of emerging adolescence.

As noted other drug regimes include desimipramine, pemoline are used in treatment, even the ubiquitous Prozac. All are reported successful in some children and may be considered drugs of second or third choice.

Non-pharmacological treatments

Diet
There was a period of time when allergies from various food additives and vitamin deficiencies were blamed for hyperactivity. Red food coloring, sugar, pop, chocolate and other foods have been implicated and parents often expend very considerable energy in developing suitable diets for children. Research has not confirmed this although parents still will insist that their child does worsen behaviorally on ingestion of these compounds. These are not ideas easy to shake and are essentially harmless and need not be discouraged.

Vitamins
There is no objective evidence that vitamins play any proven role in the prevention or treatment of ADHD although again their use need not be actively discouraged.

Essential concomitant treatments

Educational
Many children with ADHD have leaning problems that interfere with normal school performance. The ADHD child may indeed be doubly handicapped. First learning is difficult because of the ADHD. Second learning is hampered by associated developmental learning problems. ADHD children do poorly in large classrooms which provide an over-stimulating environment. Most ADHD will benefit from a small structured classroom with one to one teacher attention. A special educational environment may be essential if progress is to be achieved.

Psychological and psychosocial
Many ADHD children present at first visit with problems related to behavioral difficulties. While behavioral problems may be cardinal signs of ADHD, they may also be secondary to the rejection and negative feedback that these children inevitably face both at home and school. It is essential in treatment of ADHD that sufficient attention be devoted to the child's mental status particularly encouraging a positive self esteem and recognizing the child's limitations.

Behavioral therapies have been the mainstay of non medical treatment of ADHD for many years. Although useful as part of a multi-modal treatment approach, behavioral treatments in themselves have not proven useful. By definition the ADHD child has problems in attention and may not easily integrate new information or connect actions with consequences. This does not imply that behavioral approaches are not useful. It is indeed doubly important that ADHD children are brought up in consistent and externally structured environments since they are unable to construct such realities for themselves. Also behavioral therapies are a useful adjunct to chemotherapy.

Psychosocial
Living with an ADHD child can be testing both for parents and children. It is important to listen to parental concerns, to explain the condition adequately and to counsel parents in effective management. The hyperactive child is generally not willful but rather impulsive, he or she has poor frustration tolerance and may continue to display age inappropriate developmental behaviors.

Summary
In summary the management of the ADHD child involves careful diagnosis, parental reassurance and the inclusion of a combined treatment approach including medication, modification of school environments, and behavioral management. Family counseling should be supportive and not blaming. ADHD is essentially a chronic disorder and the ADHD child remains high risk throughout their school life. Prognosis need not be bad and successful outcome is determined by the energy and resources that can be brought to play on behalf of the child and their family.

Attention Deficit Disorder
Anxiety and Depression
Eating Disorders
Family Disharmony
Child Behavioral problems
Academic problems
.