Attention-Deficit Hyperactivity Disorder
Sam Goldstein, Ph.D.
Neurology, Learning and Behavior Center
University of Utah
Salt Lake City, Utah
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.
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.
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.
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.
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 $5 allowance at the end of the week when she behaves appropriately, parents may place $5 in nickels in a jar on the shelf that is visible to the child. As long as the child behaves appropriately, the $5 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.
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.
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.
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