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What is ADHD?

 

By James Chandler, MD FRCPC Yarmouth, NS Canada

Table of Contents

Introduction

·     Clinical Description

Criteria for Diagnosis

There are three kinds of ADHD:

ADHD isn’t just about being impulsive, Hyperactive and Inattentive….

Clumsiness

Time perception

Planning things out

·     ADHD at each stage of development

Infant

Toddler (1-3)

Preschool (3-5)

Early Elementary

Later Elementary School

Junior and Senior High School

Attention Deficit Disorder in Adults

·     Subtypes of ADHD

·     Causes of ADHD

Genetic

Environment

Brain findings

·     Co-morbidity in ADHD

·     Making the Diagnosis of ADHD

Common Mistakes in Diagnosis

Sleep Disorders

·     Not enough sleep (62)

Things the child is doing or taking that make him aroused

Environment

Sleep Apnea (61, 63)

Diagnosing Sleep Apnea

And what if the surgery doesn’t work?

Restless Leg Syndrome and ADHD (58)

Other Mistakes in Diagnosis

Diagnosing ADD without hyperactivity

To truly understand something a teacher says-

·     Prognosis of ADHD (What does the future hold?)

 

 

Introduction

Attention Deficit-Hyperactivity Disorder (ADHD) is one of the most common psychiatric disorders of children. Approximately 3-5% of children around the world have this disorder. About 50% have another psychiatric disorder with ADHD. In the past, it has been thought that this was only present in boys. You are probably reading this because a family member, pupil, or friend has the disorder.

·         Clinical Description

Criteria for Diagnosis

All four main areas must be present (A. through D.)

A. Signs and Symptoms

Six or more of the following symptoms of inattention must persist for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level.

 

Some of the signs of ADHD are present in a lot of kids. Others are rarely present unless people have really disabling ADHD. The signs that are usually only present in disabling ADHD are written in Red below (28)

Inattention
  1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  2. often has difficulty sustaining attention in tasks or play activities
  3. often does not seem to listen when spoken to directly
  4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to failure to understand instructions)
  5. often has difficulty organizing tasks and activities
  6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
  8. is often easily distracted by extraneous stimuli
  9. is often forgetful in daily activities
Hyperactivity-impulsiveness

Six or more of the following symptoms must persist for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level

  1. often fidgets with hands or feet or squirms in seat
  2. often leaves seat in classroom or in other situations in which remaining seated is expected
  3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents, this may be limited to subjective feelings of restlessness)
  4. often has difficulty playing or engaging in leisure activities quietly
  5. is often "on the go" or often acts as if "driven by a motor"
  6. often talks excessively
  7. often blurts out answers before questions have been completed
  8. often has difficulty awaiting turn
  9. often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school and at home)

But half the children I know have those signs!

That is why the last criteria is in here-

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

There are three kinds of ADHD:

Combined type- symptoms and signs of both attention deficit and hyperactivity-impulsiveness.

ADHD without hyperactivity - symptoms and signs of attention deficit only.

ADHD, hyperactive-impulse type - symptoms and signs of hyperactivity-impulsiveness only.

ADHD isn’t just about being impulsive, hyperactive and inattentive….

Recent studies have shown that people with ADHD have some other interesting problems. These include:

Clumsiness

Children with ADHD tend to fall down more, tip over more things accidentally, and have worse fine motor skills than other children. While some of this is related to their hyperactivity, a good part of it is not. This is partly the reason that people with ADHD have more accidents, have poorer handwriting, and always seem to be spilling things. This poor coordination predicts a poor outcome as adults. Those children who have marked coordination problems and ADHD are much more likely to have trouble with the law, reading problems, work difficulties and substance abuse problems as adults. (54)

Time perception

To be coordinated and get things done, we need to have a stable internal clock. People with ADHD have much more difficulty figuring out how much time has really passed either in the short term (while trying to coordinate a movement) or in the long term (trying to decide how fast to work to get something done in a certain time frame).  (53) This inability to judge time does improve with medication.(52)

Planning things out

For a discussion of this, click here

Deficient emotional self-regulation

This means that people with ADHD have a hard time regulating their emotions. They get excited easier when things are going good. They frustrated easier when there are problems, and they have more temper problems when they get mad. They are also more likely to argue. Lots of people with ADHD have this problem and it causes a lot of grief for everyone.  (66)

·         ADHD at each stage of development

The examples below are for the combined type of ADHD. Persons with either the inattentive type or impulsive hyperactive type will only have some of these signs and symptoms.

Infant

It is not uncommon that parents can see signs of ADHD even before children can walk. When compared to other babies they are often squirmier and are a less able to cuddle. Infants who will go on to develop ADHD often have a more difficult temperament. They are more impatient, easily frustrated, and require more attention than the average baby. They have more colic. On the other hand, many children that will grow up to have ADHD show no abnormalities at this stage. I have never seen or heard of an infant referred for ADHD.

Toddler (1-3)

For many children, the first point at which signs of ADHD become apparent is as a toddler. Here are the findings.

Attention

Toddlers naturally have a short attention span. They usually can entertain themselves for a few minutes and often can work on an activity with their parents for a little bit longer. Toddlers with ADHD can not even sustain their attention that long. What this means is that conversations are interrupted by any distracting sound or sight. Eye contact during conversations is poor. The toddler with ADHD will often automatically develop responses to requests like, "huh?" or "What?". Most toddlers with ADHD will be able to sustain their attention for a few favorite activities - certain videos, wrestling, and playing at a playground. If you are the caregiver for a child like this, you are spending more time than usual in direct one to one contact with the child to keep her occupied and to keep her out of trouble. I have never seen a toddler with ADHD in which the chief concern was attention span. At its most severe end, Children with ADHD can only concentrate on things like running or wrestling. Toys, books and games are played with for a few minutes only and then either ignored or destroyed.

Impulsiveness-Hyperactivity

Toddlers are known for their high activity levels. They also spend a lot of time doing things without thinking. Since they are naturally very hyperactive and impulsive, one would assume that it would be impossible to be more hyperactive than the norm. Unfortunately, this is not the case. Children with ADHD at this stage can be incredibly hyperactive. They are often so squirmy they can not really cuddle. They want to be running or in motion at all times. Their lives can consist of climbing, destroying or messing up wherever they are. Often they are too busy to sit still and eat. They can be too hyperactive to sit still to use the toilet. They are constantly breaking things up. If someone winds them up, it can take hours before they are relatively calm. When there is a lot of stimulation, they can be absolutely wild, hitting everyone, screaming uncontrollably, and looking as if they are only distantly related to human beings.

For most children, impulsiveness goes with hyperactivity. Just as the normal hyperactivity of toddlers is magnified in ADHD, normal impulsiveness is also. Toddlers with ADHD jump off of decks, jump out windows, take more than their share of cleaning product overdoses, have more accidental falls, and tend to do other normal impulsive things more frequently. They break toys more often, write on walls more frequently and run into the roads more frequently.

This hyperactivity and impulsiveness can be absolutely exhausting. It means that every minute of the child's day must be supervised or else the child gets hurt or things get wrecked. What is even more exhausting is that toddlers with ADHD often have sleep problems. They can be incredibly difficult to settle, do not sleep soundly through the night, and can be up around 5 a.m. Sometimes a toddler with ADHD will wake up in the middle of the night and be ready to play, go to the playground, or just run around. This leads to a horrible cycle. First there is not enough sleep in the ADHD child or the parent. This leads to a more inattentive, irritable, and hyperactive child. It also leads to a more irritable, frustrated, exhausted, and impatient parent. This usually leads to worse sleep for the ADHD child and so on. When I have had to see toddlers with ADHD it is often because they were very hyperactive and did not sleep.

On the other hand, there are many children who will develop ADHD who do not show signs of it in the toddler age. This is because you have to have pretty severe ADHD to stand out from an age group in which inattentiveness, impulsiveness, and hyperactivity are the norm.

Daily routine

Here is an example of a typical toddler's day with ADHD.

Robert wakes up at 6 a.m. most mornings and his parents don't even know he is awake until about 6:01 when he jumps down the steps and turns the TV on loud enough to hear in the back yard. Robert watches TV for about 2 minutes, since it is not one of his favorite shows, and is trying to undo the latch to the backyard when his mom comes down to begin her day. While she fixes a cup of coffee, he empties out the cupboards of pots and pans, something she doesn't mind. But when she goes to get some cream for her coffee, he manages to throw most of them down the basement stairs at the dog which brings Robert his first Time Out of the day. Mercifully, Robert's brothers are fairly well behaved in the morning until Robert throws one of the backpacks, complete with assignments, in the toilet while mom is making breakfast for one of the brothers. Robert has had breakfast, too. He ate ¼ piece of toast (the rest is somewhere to be found later in the day) ½ cup of milk (he spilled the rest when he had to run and see a power company truck go by) and a whole bowl of cereal, which he ate only under the threat of more Time Out.

After the big kids have gone to school, Robert is like a big dog, aching to go outside. Robert's mom, Yvonne, does not like to go out to the playground at