Tourette Syndrome Plus - Conditions -Attention Deficit Hyperactivity Disorder Overview

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Information Section: Conditions
Condition: ADHD
Article: Attention Deficit Hyperactivity Disorder Overview
Source: Leslie E. Packer, PhD
File Last Revised: January 24, 2009

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OVERVIEW

Using the current diagnostic system in the DSM-IV-TR, clinicians talk about three different subtypes of ADHD: (1) children who are primarily inattentive, (2) children whose main problem is impulsivity-hyperactivity, and (3) children who have both inattention and impulsivity-hyperactivity problems to a significant degree (the combined subtype).

The current diagnostic DSM-IV-TR criteria for ADHD have been controversial on a number of levels and are likely to change when the DSM-V is released in a few years. I think it is unlikely that the revised criteria will resolve all controversies, however. Although some people have questioned whether ADHD should really be considered a disorder (cf, the discussion by William Carey, M.D., and papers by Rubia or Shaw et al. (2007) on ADHD as a maturational delay), most healthcare professionals consider ADHD a neurological disorder. Recent research such as that of Qiu et al. finding volumetric differences and abnormal shape of basal ganglia structures in boys diagnosed with ADHD are offered as support for that position.

Although anyone who has parented, taught, or worked with children and teens diagnosed with ADHD is fully aware that many of these children have extraordinary flashes of brilliance, creativity, and an intensity to life that we can only marvel at, there are so many grim statistics on the outcomes for children and teens diagnosed with ADHD that regardless of whether one believes it is a neurological disorder or a condition that reflects variations in normal temperament, I think it is important to be aware of the risks so that they can be addressed.

A PICTURE SPEAKS 1,000 WORDS

Many people erroneously assume that if the child is hyperactive, the brain must also be overactive. This is not the case, however, as this brain scan from the research of Dr. Zametkin (1990) shows:

In the image above, high levels of glucose metabolism are indicated by red, orange, and yellow, while lower levels of are indicated by greens and blues. Glucose metabolism is an indication of energy or mental activity. When given a problem to think about, the "normal" control subject's brain indicates energy being used to think about the problem posed, but the ADHD subject's brain shows little activity. It would be interesting to see what would happen if the question or problem happened to be of especial interest to the individual with ADHD, but that was not explored in this study.

The image suggests a useful way of thinking about ADHD as "Who turned out the lights?" (Packer, 1999, unpublished). If you think of the brain of an individual with ADHD as usually being in a "browned-out" state, it becomes somewhat evident why they might have trouble sustaining their focus. It also helps to explain why responses and behavior may be disinhibited: when there is too little activity, the "brakes" that would inhibit behavior are underperforming, leading to more behavior that would otherwise be inhibited.

Do such data show that ADHD is strictly a biological problem? No. ADHD also appears to be influenced by environmental factors such as home environment, classroom structure, and peers. Kieling, Goncalves,Tannock, and Castellanos (2008) provide a review of the neurobiology of ADHD and the potential role of environmental factors.

Saying that ADHD is influenced by environmental factors such as home environment or classroom environment does not mean that ADHD is caused by faulty parenting or education. Rather, it means that we have an opportunity to make things better or worse. Certainly biological parents are responsible, on some level, for their child - particularly when we consider the genetic research that shows that ADHD is highly heritable. Does this mean that the parents "caused" their child's ADHD? Yes, on some level, but only in the same sense that we say a parent "caused" their child's eye color, height, intelligence, or athletic or artistic ability.

ADHD takes a toll on the parents, and when the child has inherited ADHD from one or both parents, the parents may have less than ideal parenting styles because of their own ADHD symptoms. As consequences, they may not be able to provide the structures and support the child needs, or they may react poorly to the child's symptoms, thereby worsening the child's situation, marital discord, and entire family functioning. A 2008 study by Wymbs et al. found that the divorce rate among parents of children aged 8 or younger with ADHD was significantly higher than the divorce rate in the general population. But it is not just the caregivers who are affected by the child's symptoms. Recent research also suggests that non-ADHD siblings may also suffer academic impact due, perhaps, to the ADHD child demanding so much time and attention from the parents. A number of studies have found that parent training that includes teaching parents how to structure the home, how to arrange consistent and effective contingencies for behavior and how to engage the child in problem-solving is an effective psychosocial intervention as part of a comprehensive treatment program.

Schools also have the potential to ameliorate or exacerbate a child or teen's symptoms. In some cases, children who function well outside of school are inappropriately diagnosed as ADHD simply because they do not well in the type of structure and under the conditions of the classroom or school setting. A diagnosis of ADHD should not be made if functioning is only impaired in one of the three main settings: home, school, and community. If problems occur in only one setting, other factors may be responsible.

DIAGNOSING ADHD

ADHD is characterized by either inattention and/or hyperactivity-impulsivity. There is a veritable "Chinese menu" for determining whether a particular patient meets the diagnostic criteria for ADHD, and if so, for which subtype. As a result, two individuals could both be diagnosed with ADHD and yet have significantly different features or challenges.

In the United States, mental health professionals use the DSM-IV diagnostic criteria * while in Europe, mental health professionals generally use the ICD-10 diagnostic criteria. A variety of ADHD screening tools are listed on Neurotransmitter.net.

Note that in the American criteria, a child need not have both hyperactivity-impulsivity and inattention. It is possible to be diagnosed if inattention is the primary or sole problem. Although many children and teenagers will meet criteria for both inattention and hyperactivity-impulsivity (i.e., they will meet diagnostic criteria for the "combined" subtype), keeping the different subtypes (primarily inattentive, primarily hyperactive-impulsive, or combined) in mind is helpful.

The diagnostic criteria include other conditions that must be ruled out before a diagnosis of ADHD is made. Because there are many other possible explanations for inattentive or hyperactive-impulsive behavior, the professional needs to collect information from multiple sources of information. A few of the many other conditions that produce behavior patterns or symptoms that might at first blush appear to be ADHD include:

A learning disability that leads to poor performance in school, frustration, and a behavior pattern where the child seems to stop paying attention or "gives up" listening to the teacher;

Attention lapses caused by petit mal seizures;

Attention lapses caused by obsessive thoughts or silent compulsive rituals;

A middle ear infection causing an intermittent hearing problem that interferes with the child's ability to respond to orally presented requests or material;

Disruptive or unresponsive behavior due to anxiety, depression, or bipolar disorder;

Environmental factors or stressors that lead to restlessness or inattention (such as divorce, problems on the job, etc.)

A difficult differential diagnosis question is whether a child has ADHD+Oppositional Defiant Disorder or Bipolar Disorder, or both. When a child or teen presents with a more chronic and severe irritability in the presence of signs of ADHD, then even if they have "rages," that does not mean that they have Bipolar Disorder if there are no clear cycles (a "rage" does not constitute a cycle). The family's history may help clarify whether the child is likely to have ADHD+depression, ADHD+Oppositional Defiant Disorder, ADHD-DEP-ODD, or Bipolar Disorder.

In addition to some of the differential diagnoses mentioned above, Many sources on ADHD do not list another differential diagnosis that I would include: giftedness. On this web site, you will find some information on differentiating between ADHD and giftedness. Although it is certainly possible that some children and teenagers have both ADHD and giftedness, in some cases, gifted children are being misunderstood -- and misdiagnosed -- as having ADHD.

Although a variety of professions may be licensed to diagnose ADHD, my firm recommendation is that the diagnosis not be made unless the child has been fully evaluated by a developmental pediatrician, a board-certified neurologist, or a child and adolescent psychiatrist who can rule out other medical problems that may mimic the symptoms of ADHD.

In another section on this site, a condition known as Executive Dysfunction is described. If you are already familiar with EDF, you will have noted that many of its symptoms described sound remarkably like the inattentive criteria in the DSM-IV criteria for ADHD. Specifically, the following signs or symptoms of "inattention" may also indicate executive dysfunction:

Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities;

Often has difficulty sustaining attention in tasks or play activities;

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions);

Often has difficulty organizing tasks and activities;

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework);

Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools);

Is often easily distracted by extraneous stimuli

In order to clarify diagnostic issues, a neuropsychological assessment may be helpful or necessary.

It is important to note that although there is significant overlap between executive dysfunction and "inattention" as described in the DSM-IV, not all individuals with ADHD have EDF, and EDF occurs comorbid with a number of conditions or disorders, not just ADHD.

EDF is discussed in its own section of this web site.

GENDER DIFFERENCES

For a number of years, the prevailing wisdom was that there were significant gender differences in ADHD. Not only were boys more likely to have ADHD than girls, but their patterns of subtypes and comorbidity were supposedly different. In 2005, however, Dr. Joseph Biederman and his colleagues published the results of a community-based study that found no gender differences, suggesting that previous studies had detected differences that were artifacts of referral biases. Thus, it appears that although boys are approximately 2.5 times as likely to be diagnosed with ADHD than girls and are more likely to be suspended or expelled from school than are girls, our understanding of any gender differences or gender x subtype differences may have been colored by referral biases. More work is clearly needed in this area using community samples.

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NOTE

[fn 1] The diagnostic criteria are not on this site because of copyright issues, but clicking on the link will take you to a site where they are published.

Information Section: Conditions
Condition: ADHD
Article: Attention Deficit Hyperactivity Disorder Overview
Source: Leslie E. Packer, PhD
File Last Revised: January 24, 2009

Page 1 2

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