What is ADHD?
ADHD stands for Attention Deficit Hyperactivity Disorder. A person with ADHD, as compared to most persons his or her age, has certain symptoms, and these symptoms are present in more than one setting. Examples of the kind of symptoms I’m talking about are things like making careless mistakes, keeping attention on school work, not finishing work, having trouble organizing projects, procrastinating, putting things off, losing things, and getting distracted. We call these kinds of symptoms inattentive symptoms. Then there is a whole other set of symptoms that we call hyperactive impulsive symptoms. These involve having trouble with being on the go too much, fidgeting too much, getting up out of his or her chair too much, running around when it’s not appropriate, making noise or talking all the time, interrupting, having trouble waiting turns, or blurting out answers. If enough of these symptoms are happening in more than one setting, if some of these symptoms have been going on since before a child was 7 years old, and if these symptoms are getting to the point where they’re causing impairment or trouble for a child, then it could very well be ADHD.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
ADHD vs. ADD
The terms ADHD and ADD actually refer to the same disorder. ADD is an older term used to differentiate children who had just primary attention problems from kids who had attention problems and hyperactivity. The majority of children, about 85 percent, have some combination of inattention, impulsivity, and hyperactivity. A small percentage (about 10%) of kids, have just attentional problems. All of the ADHD/ADD disorders are treated in the same way: a combination of medication and behavioral interventions that help overcome the troubles that these children and their families face with their illnesses.
Stuart Goldman, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
Different names for the same group of kids
There have been a lot of terms used over the past 50 years to describe children in adolescence who have attentional and activity issues. The names have ranged from minimal brain dysfunction to hyperactivity disorder to ADD to ADHD. In general, these names take different looks at what are really very similar groups of kids who have problems sustaining their attention. People have tried to organize groups they think will be helpful for treatment decisions and possibly be helpful for understanding the etiology of the disorders.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
Different kinds of ADHD
There are 3 kinds of ADHD. The most common type is what we call the Combined Type, when both hyperactive and inattentive symptoms are present. There are some kids who do not have any hyperactive symptoms, but just have the problems with attention; we call that having the Predominately Inattentive subtype of ADHD. There is a smaller number of kids who only have the hyperactive and impulsive symptoms and don’t have any trouble with attention, and those kids have what we call the Hyperactive/Impulsive subtype.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
Is it ADHD?
Parents often want to know if their child’s problem is ADHD, or if their child is having attentional problems because of another underlying medical issue, and there are, in fact, medical causes for attentional problems. The most obvious ones are hearing loss or visual loss; if you can’t hear well or see well, you can look very much like you have attentional problems.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
ADHD can be hard to diagnose
ADHD, according to the American Academy of Pediatrics, is a disorder that should be diagnosed and treated by a pediatrician, and only when there is something unusual about it should there be a referral to a specialty practice. However, there are some pediatricians who are uncomfortable with the disorder; they don’t feel there is a clear cut way to diagnose it. Diagnosing ADHD is different than when diagnosing, for instance, diabetes, where you have a Fasting Plasma Glucose Test that tells you if you have diabetes or not. With ADHD, there is not a specific test you take or a black and white differentiation that tells you if you have it or not. Some pediatricians feel uncomfortable with that, especially if there are other co morbid conditions present. If a patient has ADHD and some other disorder, depending on the co morbid condition, a pediatrician might be inclined to consult a different provider. So for instance, if a patient has anxiety or depression or an evident mood disorder, then the patient will be referred to a psychiatrist, perhaps. But if the patient is having problems in school, there is inattentiveness, a lack of concentration or hyperactivity, the family might come see a pediatric neurologist.
Alcy Torres, MD, Pediatric Neurologist
A lifelong issue
The majority of children with ADHD do not outgrow it. For about two thirds of kids it is a lifelong illness that you have to learn how to live with and compensate for. If parents and children get the idea that they are going to have to live with this illness and it is not going away, they develop the needed behavioral and emotional skills and understand how to use medication when appropriate. Thinking about it as something they have to live with instead of as something that’s just going to go away helps parents and children address the problems presented by ADHD more completely and effectively.
Stuart Goldman, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
ADHD has a chronic course
In my conversations with parents, once a diagnosis of ADHD is confirmed, I provide psycho education about the symptoms, development, the family’s and the child’s strengths, and that ADHD is a neurobehavioral disorder that does have a chronic course, and symptoms tend to present along developmental lines. It is one of the most difficult messages that’s I communicate, but I stress that children and parents have many strengths, can learn and add to the skills they may already have to manage the symptoms of ADHD.
Marcus Cherry, PhD, Child and Pediatric Psychologist
What are the statistics?
Probably around 60 to 85 percent of the kids who have ADHD as young kids will still have ADHD symptoms and meet full criteria when they become teenagers. About half the people who have ADHD as children will meet full criteria as adults. But 90 percent of people who had it as kids will actually have at least 4 or 5 symptoms of ADHD, which is not enough to meet full criteria but still enough to cause impairment. These people may still benefit from treatment.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
Where does ADHD come from?
About 90 percent of cases of ADHD seem to be genetic. There are some neurological disorders like epilepsy, or head injury, or strokes that can produce ADHD symptoms. Kids who were born premature, or with low birth weights, or who had stress during the birthing process, or whose mothers smoked cigarettes or drank alcohol while pregnant all are at higher risk for having ADHD. There has been a lot of research examining the brains people with ADHD through using imaging techniques, and the research has found differences in brain regions for people with ADHD and people without ADHD. These differences help support the notion that ADHD is a brain-based disorder.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
Where it doesn’t come from?
I’ve had parents think their child has ADHD because of something they didn’t feed their child, bad parenting, family conflict, or spoiling their child too much. The research that exists on ADHD does not indicate that psychosocial factors cause ADHD. There is evidence that ADHD is associated with impairment of the frontal lobe of the brain, which is responsible for carrying out executive functions like managing attention, focus, and planning. There is also evidence of a genetic component. In the course of an evaluation, I provide a great deal of information about normative child development and how ADHD can impact that development. I also provide psycho education about ADHD that makes sure parents truly understand the causes and that they don’t rely on the myths that bad parenting, parental conflict, trauma, etc. cause ADHD.
Marcus Cherry, PhD, Child and Pediatric Psychologist
Meet parents where they are
When explaining the ADHD diagnosis to the parents, I often review what the criteria are for ADHD from the DSM IV. I might do that very formally by getting my book down and showing them what you have to have symptom wise to meet the criteria for ADHD according to the DSM-IV. Or I might do it more informally depending on who the parent is. A lot of parents who I see speak Spanish and have an interpreter, and because I don’t speak Spanish, I sometimes do it through the interpreter. I adapt to what the need of the parent is and also to what they know about ADHD already. Many parents have information from the Internet, and sometimes they have misinformation or have gotten mixed messages about ADHD. I try to find out from the parent what his or her understanding of ADHD is, and then really go from there.
Frances Johnson, Advanced Practice Nurse
The job of the physician
We all have inattentiveness to a certain degree. Diagnosing ADHD is a like diagnosing other psychiatric disorders– you don’t treat everyone for an anxiety disorder that gets anxious on the first day that they feel anxious. It requires a little bit more of an extreme, and identifying a child who truly has ADHD is the job of the physician, as well as to exclude the other potential diagnoses, and then to treat the child’s symptoms appropriately.
Alcy Torres, MD, Pediatric Neurologist