Attention Deficit Disorder
by Dr. Maurice Blackman
From the August/September 1995 issues of Medical Scope Monthly
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.
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
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
B. Onset must be before age 7
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
Hyperactivity and attention deficit problems may be the Presenting
problems of children with:
Unipolar or bipolar affective disorder
Pervasive developmental disorders (PDD, autism)
Obsessive compulsive disorders (OCD)
Each of these syndromes may be excluded following a careful clinical
evaluation including history taking and clinical examination prior to
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.
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.
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.
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.
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
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
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
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
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.
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.
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
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
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
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
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
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
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.
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.
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
Essential concomitant treatments
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.
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.
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.