Attention-Deficit Hyperactivity Disorder


Sam Goldstein, Ph.D.
Neurology, Learning and Behavior Center
University of Utah
Salt Lake City, Utah

The Facts About ADHD:

Attention-Deficit Hyperactivity Disorder (ADHD) is characterized by inattentive,
hyperactive, and impulsive behavior. These problems are often inappropriate and
cause difficulty in daily life. ADHD is a “biopsychosocial” disorder. That is, there
appear to be strong genetic, biological, life experience, and social factors that
contribute to the extent of problems. ADHD affects 3% to 5% of individuals throughout
their life. Early identification and proper treatment dramatically reduces the family,
educational, behavioral, and psychological problems experienced by individuals with
ADHD. It is believed that through accurate diagnosis and treatment, these problems-including
school failure and dropout, depression, behavioral disorders, vocational and relationship
problems, and substance abuse-can be properly managed or even avoided.

At one time, it was thought that the symptoms of ADHD lessen by adolescence. Research
has now found that the majority of individuals with ADHD become adults with a very
similar pattern of problems. Adults with ADHD experience problems at work, in the
community, and in their families. They also exhibit a greater degree of emotional
problems, including depression and anxiety.

Researchers first described the inattentive, hyperactive, and impulsive problems
of children with ADHD in 1902. Since that time, the disorder has been referred to
by different names, including Minimal Brain Dysfunction, Hyperkinetic Reaction of
Childhood, Attention Deficit Disorder, and, currently, Attention-Deficit Hyperactivity
Disorder.

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What is ADHD?

ADHD interferes with an individual’s ability to stay attentive, particularly in
the face of repetitive tasks; to manage effectively emotions and activity level;
to respond consistently to consequences; and, perhaps, most importantly, to inhibit,
i.e., to stop from doing something. Individuals with ADHD may know what to do, but
do not do what they know, because they are unable to stop and think prior to responding,
regardless of the setting or the task.

Characteristics of ADHD occur in early childhood for most individuals. Chronic behaviors
last at least six months, with an onset often before seven years of age.

Four subtypes of ADHD have been defined. The first type is ADHD-Inattentive Type,
and is defined by an individual experiencing at least six of the following characteristics:

  • Fails to give close attention to details or makes careless mistakes
  • Difficulty sustaining attention
  • Does not appear to listen
  • Struggles to follow through on instructions
  • Difficulty with organization
  • Avoids or dislikes tasks requiring sustained mental effort
  • Often loses things necessary for tasks
  • Easily distracted
  • Forgetful in daily activities

The second type is ADHD-Hyperactive/Impulsive Type, and is defined by an
individual experiencing six of the following characteristics:

  • Fidgets with hands or feet, or squirms in seat
  • Difficulty remaining seated
  • Runs around or climbs excessively (In adults, it may be limited to subjective feelings of restlessness.)
  • Difficulty engaging in activities quietly
  • Acts as if driven by a motor
  • Talks excessively
  • Blurts out answers before questions have been completed
  • Difficulty waiting in turn-taking situations
  • Interrupts or intrudes upon others

The third type is ADHD-Combined Type, and is defined by an individual meeting
both the inattentive and the hyperactive/impulsive criteria.

The fourth type is ADHD-Not Otherwise Specified, and is defined by an individual
who shows some characteristics, but an insufficient number of symptoms to reach
a full diagnosis. These symptoms, however, disrupt daily life.

School-age individuals with ADHD have a greater likelihood of not advancing to the
next grade level, school dropout, academic underachievement, and social and emotional
problems. It has been suggested that the symptoms of ADHD may cause children to
fail in two of the most important areas for their development-school and peer relationships.

With increasing medical, educational, mental health, and community knowledge about
the symptoms of and the problems caused by ADHD, an increasing number of individuals
are being identified, diagnosed, and treated. Nonetheless, it is still suspected
that a significant group of individuals with ADHD either go undiagnosed or misdiagnosed.
Their problems intensify and create significant hurdles meeting life’s demands.

Often, ADHD has been inaccurately portrayed as a learning disability. ADHD is a
performance disorder. Children with ADHD are able to learn, but they have difficulty
performing in school due to the impact of the ADHD symptoms. However, approximately
20% to 30% of children with ADHD do have a learning disability, which makes the
identification and treatment of ADHD more difficult. In the childhood years, individuals
with ADHD also have an increased risk of developing problems related to oppositional
defiance, delinquency, conduct disorder, depression, and anxiety. However, research
suggests that it is not ADHD alone, but rather ADHD combined with the development
of conduct disorder that may cause the most terrible adolescent outcomes, particularly
those related to criminal behavior and substance abuse.

Adults with ADHD also experience problems related to anti-social behavior, vocational
and educational underachievement, depression, anxiety, and substance abuse. Unfortunately,
many adults, today, with ADHD were not properly diagnosed as children. They grew
up struggling with a disability that often went undiagnosed, misdiagnosed, or untreated.

The majority of adults with ADHD have symptoms very similar to those experienced
by children. They are restless, easily distracted, inattentive, impulsive, and impatient.
Often, they are unable to handle stress. Within the workplace, they may not achieve
positions or status equal to that of their siblings or intellectual ability.

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What causes ADHD?

Commonly suspected causes of ADHD have included toxins, developmental impairments,
diet, injury, ineffective parenting, and heredity. It has been suggested that these
potential causes affect brain functioning; thus, ADHD is considered a disorder of
brain function. A number of studies have shown significant differences in the structure
and brain function of individuals with ADHD, particularly in the right hemisphere
of the brain, pre-frontal cortex, basal ganglia, corpus callosum, and cerebellum.
These structural and metabolic studies, combined with family, genetic, and drug
response studies, have indicated that ADHD is a neurobiological disorder. Though
the severity of problems experienced by individuals with ADHD may vary based upon
life experience, genetics appears to be the primary underlying factor in determining
if an individual will show the symptoms of ADHD.

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How is ADHD diagnosed?

Diagnosing ADHD is a multifaceted process. Many biological and psychological problems
can cause symptoms similar to those shown by individuals with ADHD. For example,
inattention is a symptom of depression. Impulsive behavior is a characteristic sign
of delinquency.

A comprehensive evaluation is necessary to diagnose ADHD, in addition to considering
and evaluating other causes, and determining the presence or absence of other conditions.
Obtaining a careful life history is the most important aspect in diagnosing ADHD.
Often, an evaluation for ADHD will assess intellectual, academic, social, and emotional
functioning. A medical examination is important to rule out other possible causes
of ADHD-like symptoms (e.g., adverse reaction to medications, thyroid problems,
etc.). The diagnostic process must include gathering information from teachers and
other adults who interact routinely with the individual being evaluated. Although
office- or laboratory-based paper and pencil, problem solving, and computerized
tasks are popular in assessing ADHD, researchers are evaluating their validity.

With adults, it is even more important to obtain a careful history of childhood,
academic, behavioral, and vocational problems. Since ADHD has been recognized as
a disorder that occurs throughout life, questionnaires and other related tools for
diagnosing ADHD in adults have been standardized and are available.

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How is ADHD treated?

Treating ADHD in children requires a coordinated effort between medical, mental
health, and educational professionals, with the parents. The combined set of treatments
offered by various individuals is referred to as “multi-modal intervention.” A multi-modal
treatment program for ADHD should include the following:

  • Parental training about ADHD and effective behavior management strategies
  • An appropriate educational program
  • Individual and family counseling, when needed, to minimize family problems
  • Medication, when required

Psychostimulants are the most widely used medications to manage ADHD symptoms. At
least 70% to 80% of children and adults with ADHD respond positively to psychostimulant
medications. These medications are considered performance enhancers. Thus, they
may, to some extent, stimulate the performance of all individuals. However, given
their specific problems, children with ADHD appear to improve, with a reduction
in impulsive and hyperactive behavior and an increase in attention span.

Behavior management is important for children with ADHD. The use of positive reinforcement
with punishment, in a model referred to as “response cost,” is particularly effective
for children with ADHD.

Most children with ADHD can be taught in a regular classroom with minor adjustments
in the classroom setting, the addition of support personnel, and/or special education
programs provided outside of the classroom. The most severely affected children
with ADHD often require specialized classrooms.

Adults with ADHD may benefit from learning to structure their environment; to develop
organizational skills; to receive vocational counseling; and, if needed, to have
short-term psychotherapy to cope with life experiences and personal problems. For
some individuals, with a combination of ADHD and other problems, particularly depression,
long-term psychotherapy can be beneficial to teach behavior change and coping strategies.

ADHD treatments are effective in reducing immediate, symptomatic problems. However,
the long-term outcome research for children with ADHD has led researchers to conclude
that symptom relief alone may not significantly impact the long-term outcome. Thus,
ADHD treatments are provided to relieve symptoms, while efforts also are made to
assist the ADHD individual in building life success.

To help parents in treating their ADHD child, a nine-point set of strategies is
outlined below (Goldstein and Goldstein, 1998).

Step 1: Learn About ADHD. It is important to understand that managing ADHD-driven
behavior at home requires accurate knowledge of the disorder and its complications.
This is not a problem that can be cured. It will affect children throughout their
life. You must be consistent, predictable, and supportive of a child in daily interactions.
You will be repeatedly placed in an advocacy position with schools and community
resources. It is suggested that you consider joining a parent support organization
directed at ADHD.

Step 2: Understanding Incompetence vs. Non-Compliance. You must distinguish
between problems that result from incompetence and those that result from non-compliance.
The former must be dealt with through education and skill building. The latter is
usually quite effectively dealt with through consequences. You must understand that
punishing a child for symptoms of ADHD may lead to remorse and a promise of better
behavior, but stands little chance of changing behavior in the future.

You must develop a set of strategies to deal with ADHD symptoms by making tasks
interesting, payoffs more valuable, and increasing consistency at home, while providing
a consistent set of punishments for non-compliant behavior. The best way of dealing
with non-compliance is to make certain that you have control over consequences,
issue appropriate commands, manage rewards, and use response cost techniques.

Step 3: Give Positive Directions. You must make certain that positive, rather
than negative, directions are given. A positive direction tells the child what to
begin doing, rather than focusing on what to stop doing. Such directions are clear
(e.g., “please begin your math homework”), rather than vague (e.g., “pay attention”).
The need for repeated trials cannot be overemphasized. You serve as a control system
for your child. Your child is going to require more management and supervision in
an appropriate, consistent, affirmative way than other children.

Step 4: Provide Ample Rewards. You must provide ample rewards for appropriate
behavior. Social and tangible rewards must be provided more frequently when an ADHD
child succeeds. Children with ADHD also require more immediate, frequent, predictable,
and consistently applied consequences. It is important for the child to learn to
consistently act when expected behaviors are required. Most children with ADHD know
how to do what is requested, but have difficulty doing so when they are supposed
to. Children with ADHD also have been found to receive less positive reinforcement
than their siblings.

It is important to avoid negative reinforcement. This only results in removing the
negative consequences when the child complies. This often leads to immediate compliance,
but, in the long run, it reinforces, rather than discourages, inappropriate behavior.

Token systems, which are particularly effective for children and early teens with
ADHD, should be used. Often, token systems fail at home, not because they are ineffective,
but because they can be cumbersome and then poorly managed. Tokens should be used
with children who are four to seven years old, and points with those children who
are eight years and older. Required activities should be kept to a reasonable length,
and an extensive list of reinforcers should be available, with at least one third
of points or tokens available each day. Children should be able to spend about two
thirds of points or tokens earned each day. Bonuses should be paid for a good attitude.
You should always allow your children to earn their way off a system through compliant
behavior, but a minimum of six to eight weeks on a token system, once it is initiated,
should be required.

Step 5: Choose Your Battles. You should choose your battles carefully. While
it is essential for you to stay one step ahead, it also is important for you to
recognize and accept the difficulties that your child experiences due to ADHD. You
should reinforce positive behavior, apply immediate consequences for behaviors that
cannot be ignored, and use tokens or points with ADHD children. Consequences, both
rewards and punishments, should be provided quickly and consistently.

Step 6: Use Response Cost Techniques. You must understand the use of response
cost, a punishing technique in which you might lose what you have earned. If a give
and take response cost system is used, you must make certain the child does not
go bankrupt. It may be equally effective, especially with older children and teens,
to start with the entire payoff and then have the individual work to keep it. For
example, instead of providing the child with a allowance at the end of the week
when she behaves appropriately, parents may place in nickels in a jar on the
shelf that is visible to the child. As long as the child behaves appropriately,
the belongs to the child. For every infraction that has been clearly defined
and agreed upon between the parents and the child, a nickel is removed from the
jar. At the end of the week, the remaining amount is given to the child.

Step 7: Plan Appropriately. You must learn to respond to the child’s limits
in a proactive way. Accepting the diagnosis of ADHD means accepting the need to
make changes in the child’s environment. Routines should be consistent and rarely
vary. Rules should be stated clearly and concisely. Activities or situations in
which the child has a history of risk for problems should either be avoided or carefully
planned.

Step 8: Punishing Appropriately. Most likely, punishment alone will not reduce
the symptoms of ADHD. However, punishment does play a role as a consequence for
non-compliant behaviors. Punishment also is partially appropriate if a rule is violated,
even as the result of ADHD. However, in this circumstance, punishment must not be
provided alone, because it will not change the child’s long-term behavior. For a
child with ADHD, you must understand that unless a managing strategy is provided
along with punishment, it is not likely that the punishment will cause a change
in behavior.

Step 9: Building Islands of Competence. Because of your child’s ADHD, there
is a greater likelihood that the relationship between you and your child will be
strained. However, in the end, it is what is right about children, rather than what
is wrong about them, that best predicts their life outcome. Increasingly, the mental
health field is focusing on building strengths, rather than attempting to hammer
away at weaknesses. One of the best predictors of building strengths is the parents’
relationship with their child. If you approach each day with a sense of hope, encouragement,
acceptance, and honesty, you will empower your child. If you approach each day with
a sense of despair, discouragement, anger, and blame, you will not only jeopardize
your child’s future, but also further feed their sense of powerlessness and hopelessness.

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What research is being done?

Most likely, ADHD will continue to be the most widely researched and debated area
in mental health and child development. New ground is broken daily. The five-year,
multi-site, multi-modal ADHD treatment study recently completed by the National
Institute of Mental Health has provided an expanded set of answers concerning the
diagnosis, treatment, and outcome of individuals with ADHD. Ongoing studies of molecular
genetics also may soon reliably identify the genes related to this disorder.

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Other Information

Organizations, such as CH.A.D.D., 8181 Professional Plaza, Suite 201, Landover, MD 20785, (301) 306-7070, offer parents information, monthly magazines, newsletters, and presentations.

A large trade library of books, videos, and cassette tapes is available for parents, providing accurate information concerning ADHD and research proven effective parenting strategies.

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References

Barkley, R.A. (1998). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 2nd edition. New York, NY: Guilford Press.

Barkley, R.A. (1997). ADHD and the Nature of Self-Control. New York, NY: Guilford Press.

DuPaul, G.J. & Stoner, G. (1994). ADHD in the Schools: Assessment and Intervention Strategies. New York, NY: Guilford Press.

Goldstein, S. (1997). Managing Attention and Learning Disorders in Late Adolescence and Adulthood: A Guide for Practitioners. New York, NY: Wiley Interscience Press.

Goldstein, S. & Goldstein, M. (1998). Managing Attention Deficit Hyperactivity Disorder: A Guide for Practitioners, 2nd Edition. New York, NY: Wiley Interscience Press.

Greenhill, L.L. & Osman, B.B. (1991). Ritalin: Theory and Patient Management. New York, NY: Mary Ann Liebert, Inc. Publisher.

Matson, J.L. (1993). Handbook for Hyperactivity in Children. Boston, MA: Allyn & Bacon.

Nadeau, K.G. (1995). A Comprehensive Guide to Attention Deficit Disorder in Adults. New York, NY: Brunner/Mazel Publishers.

About the Author

Sam Goldstein, Ph.D. is a member of the faculty at the University of Utah. He is on staff at Primary Children’s Hospital and the University Neuropsychiatric Institute. Dr. Goldstein has served as Chairman of the National Professional Advisory Board for the organization Children and Adults with Attention Deficit Hyperactivity Disorder and is a member of the Professional Advisory Boards for the Attention Deficit Disorder Association and the National Parenting Instructors Association.

Dr. Goldstein’s publications include articles, guides, book chapters and twelve texts on subjects including genetic and developmental disorders, depression, classroom consultation, learning disability and Attention Deficit Hyperactivity Disorder. His most recent texts include the Handbook of Neurodevelopmental and Genetic Disorders in Children (Guildford, 1998) and Managing Attention Deficit Hyperactivity Disorder in Children – 2nd Edition (Wiley, 1998).

Dr. Goldstein serves as Associate Editor for the Journal of Attention Disorders and is a member of the Editorial Boards of the ADHD Report, Archives of Clinical Neuropsychology and the Journal of Learning Disabilities.

Copyright 2012 Sam Goldstein, Ph.D., All Rights Reserved