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Attention Deficit – Hyperactivity Disorder / ADHD

ADHD is a disorder that is characterized by a persistent and age-inappropriate pattern of hyperactivity/impulsivity and/or inattention. How ADHD will affect a particular individual is complicated, depending on many variables including their intellectual and academic abilities, personality traits, and family structure, as well as their level of self-awareness and willingness to participate in treatment.

Hyperactivity includes being fidgety, over-talkative, having trouble staying seated, or existing in “perpetual motion.” Examples of impulsivity are calling out in class, not “thinking before acting,” and being “accident prone.” Inattentiveness may be shown in distractibility, difficulty concentrating on priorities, or being “spacey,” or “daydreaming,” and loosing track of what is happening around them. Sleep problems are common among those with ADHD, and important to evaluate and treat.

ADHD impacts an estimated 8% of children between the ages of 4 and 17, as well as many adults. There has, however, recently been some heightened concern that this condition is being over-diagnosed and over-treated, so it is important to use the proper due diligence in the diagnostic process.

Although specifying the exact cause of ADHD in a particular person is beyond reach at present, research has shown that this condition tends to appear more often in certain families; therefore there are likely genetic components. Additionally, lower than normal overall brain activity and smaller than normal size of certain neurological structures have been potentially linked to ADHD. However, running in families should not be taken to imply that a parent or other relative is “at fault” if a child has ADHD.

Some may ask, is ADHD a real condition or just an excuse? ADHD is a very real condition that is in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Not so far in the past, the “treatment” for ADHD tended to consist of learning from “hard knocks,” being told to “pull yourself up by your own bootstraps,” or being shunted to less desirable classes and vocations. However, it best not to use ADHD to excuse negative behaviors or lack of achievement either. ADHD can be found in individuals with many strengths, including intelligence, talent, and creativity. Many, many famous and highly accomplished people have overcome ADHD, or even found a way to use it to their advantage.

In order to receive a diagnosis of ADHD, symptoms must be have been present before the age of seven. However, many individuals are diagnosed after symptoms have been present for many years, but went unrecognized. Early diagnosis of ADHD is a key to successful interventions. Nevertheless, some parents are reluctant to pursue a diagnosis, fearing their child will be stigmatized or hoping they’ll eventually “grow out of it.

Children with ADHD are often described as having problems in “executive functioning” as well as a “sluggish cognitive tempo.” Thus, abilities to plan, organize, and follow through on tasks to completion are often significantly below expectations. Social immaturity and accident-proneness is also often found among children with ADHD. They often have trouble “learning from experience,” which makes them more vulnerable to having trouble with rules and authority. It is not surprising that having ADHD makes succeeding in school more challenging, exemplified by trouble organizing and completing homework, or remembering to turn it in.

ADHD diagnoses are far more common in boys than in girls until adulthood at which point rates for males and females start to equalize. Girls with ADHD are more likely to be more inattentive than impulsive and hyperactive. Unfortunately, this also means that they are more likely than boys to “fall between the cracks” and not be identified and receive help as early as possible.

There is no one definitive diagnostic test for ADHD. ADHD is most effectively diagnosed after completing a comprehensive series of cognitive and neuropsychological tests, and combining these findings with a thorough clinical evaluation and behavioral observations across settings, including home and school. It is important not to jump to a diagnosis of ADHD too quickly, as there are many other problems, conditions, and medical issues that can appear like ADHD at first glance. For instance, a child that has been traumatized or is undergoing a great deal of stress within their family can seem like they have ADHD when they do not. At very young ages ADHD can be particularly easy to misidentify, e.g. distinguishing it from just normal childhood high energy.

Many conditions are known to co-occur and inter-twine with ADHD including: Oppositional Defiant Disorder (problems with authority), Mood Disorders, Anxiety Disorders, Obsessive-Compulsive Disorder, Learning and Communication Disorders, and Tourette’s Disorder/Tic Disorders. Sometimes, those with ADHD are selectively perfectionistic (“perseverative”), and perform far beyond expectations when they are “interested.” This can create a faulty impression that they can turn their attention on if they “wanted to” when this is not actually true.

ADHD is very frequently treated with medications. Although there are other options, often stimulants are used. Early over-reliance on medications may make some children more prone to misusing or abusing other substances later in their lives. Also, the use of medications, especially in young children, always needs to be expertly weighed against side effects, like negative effects on sleep or appetite, or other potential adverse effects on long-term health. Accordingly, many behavioral health experts recommend that psychological and behavioral interventions be tried, either alone, or in conjunction with medicinal approaches. These include individual counseling, cognitive-behavioral therapy (CBT), Attentional-control training/mindful meditation, family therapy, and educational guidance. If there is a specific problem in working memory, there is some evidence that an intervention called COGMED Working Memory Training might be helpful.

Obtaining an expert psychoeducational evaluation, which integrates well-validated, age-referenced objective tests, school records, parent and educator observations and questionnaires, medical and developmental findings, and direct behavioral observation with clinical impressions is often instrumental in determining an accurate diagnosis.

Should the school be informed that a child has ADHD? While this is always a decision that ultimately must be made by the child’s parents, telling a child’s school about an ADHD diagnosis may help the school to better understand the child’s needs and allow them to provide any necessary special services, like medication monitoring, accommodations for any associated learning issues, or behavioral interventions. Making educators more aware can also reduce the potential for a child’s ADHD being confused with oppositional or defiant behavior or lack of interest or motivation.

With timely, consistent, and effective treatment the outcomes for children with ADHD can be greatly improved. Also, in some cases, ADHD can start to wane in later teenage or young adult years. However, perhaps as many as 60% of children diagnosed with ADHD will continue to have at least some symptoms of this condition present into adulthood. In fact, looking at their present and past difficulties, and seeking an explanation, is a common reason why adults might seek diagnosis and treatment. However, the way ADHD appears in adults can differ greatly from how it presents in children. They are often prone to a variety of problems, including difficulties with substances, managing their finances, maintaining appropriate relationships/sexual behavior, and functioning effectively in the workplace. In recent years, the problem of adult ADHD has received more focus, as it became clear that so many people had not received the proper diagnosis when they were younger.

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