Attention Deficit Disorder

Across the Lifespan: Symptoms and Treatment Options

By Joe Peraino, Ph.D.

What is ADHD/ADD?

  • Attention Deficit Disorder
  • Attention Deficit Hyperactivity Disorder
  • A diagnosable mental disorder whose hallmark symptoms include inattention and impulsivity with or without hyperactivity
  • Significant impairments seen in social, academic and/or occupational functioning

    Symptoms (CHILDREN AND TEENS)

1. Inattention
  • Great difficulty sustaining attention
  • Most notable in dull, boring, repetitive tasks
  • Diminished persistence not necessarily more distracted
  • “Doesn’t seem to listen”
  • “Fails to finish assignments”
  • “Daydreams”
  • “Often loses things necessary for school”
  • “Can’t concentrate”
  • “Easily distracted”
  • “Shifts from one uncompleted activity to another”
  • “Can’t work independently”
2. Impulsivity or Behavioral Disinhibition
  • Considered hallmark symptom of ADD
  • Poorly regulated activity and impulsivity
  • “Trouble waiting turn”
  • “Doesn’t cooperate”
  • “Rude”
  • “Blurts out in class and at home”
  • “Interrupts others”
  • “Takes frequent unnecessary risks”
  • “Immature and childish”
3. Hyperactivity
  • More active than normal
  • Even when asleep!
  • Situational fluctuations exist
  • Failure to regulate self consistent with setting or situation
  • “Always on the go”
  • “Acts as if driven by a motor”
  • “Can’t sit still” (e.g., in class seat or at dinner)
  • “Talks excessively”
  • “Taps, fidgets, drums fingers constantly”
  • “Often hums or makes odd noises”
4. Other behaviors
  • Great variability of task performance
  • Differing behavior towards fathers than mothers-well established
  • Average 7-15 points lower on IQ tests; 10-15 on achievement tests
  • Delay in onset of talking (2-5% of normals; 6-35% of ADDs)
  • Speech problems (2-25% of normals; 10-54% of ADDs)
  • More minor physical abnormalities
  • More health problems (24% of normals; 51% of ADDs)
  • More accident-prone (46% accident-prone with 15% having 4+ serious accidents; three times higher than non-ADD)
  • Sleep problems (falling asleep 23% vs. 56%; tired upon waking 27% vs. 55%)
  • Emotional disturbance (44% have one other diagnosable problem; 32% have two problems; 11% have three or more)
  • 30% anxiety disorder
  • 40% mood disorder
  • 50% Conduct or Oppositional Defiant Disorder
  • 25% Learning Disabilities
  • Conduct problems (50% have significant social relationship problems)
  • Estimated in 3-5% of child population
  • Average age of onset between 3-4 but varies from 0-7
  • 3:1 male to female ratio
  • 63% of females and 78% of males have ADHD
  • 70-80% will continue symptoms into adolescence
    hyperactivity tends to lessen
    58% fail at least one grade

Symptoms (ADULTS)

Sometimes called “ADD Residual Type”
Symptoms vary but can include any of the following:

1. Inattention
  • Fails to finish what started
  • Often does not seem to listen
  • Easily distracted
  • Difficulty concentrating on sustained-attention tasks
  • Difficulty sticking to an activity
2. Impulsivity
  • Often acts before thinking
  • Shifts excessively from one activity to another
  • Difficulty working independently
  • Frequently talks out or interrupts
  • Difficulty waiting turn
3. Hyperactivity
  • Excessive pacing or fidgeting
  • Difficulty staying seated
  • Moves about excessively during sleep
  • Always on the go
4. Emotionality
  • Overly sensitive to rejection and frustration
  • Shifts mood suddenly and unexpectedly
  • Frequent negative thinking after a success
  • Unexplained, chronic, recurrent depression
  • Finds being soothed and held difficult
  • Needs excessive sensory input (TV, music) to blot out extraneous noise
5. Other facts:
  • 50-65% of children will continue symptoms into adulthood but only 20% hyper
  • Only 3% are free from other diagnoses
  • 80% anxiety symptoms
  • 75% interpersonal problems (vs. 50% controls)
  • 20% sexual adjustment problems (vs. 2.4% of controls)
  • 10% attempt suicide
  • 5% die from suicide or accident (10x that of controls)
  • 30% drop out and never finish high school
  • Only 5% continue into college (vs. 41% controls)

    Bottom line: ADHD is a serious developmental impairment

 

CAUSES

  • ADHD a biochemical brain disorder, largely hereditary: 80-90% genetic, 10-20% environmental
  • (twin studies: 90% identical vs. 25% fraternal)
  • If child is diagnosed with ADD, 15-20% of their mothers have ADD; 20-30% of fathers; 25% of siblings vs. 2% in controls
  • Environmental causes: food allergies/diet 5%; head injury; poor maternal health; poor infant health.

Alternate ADD Theories (none proven)

  • Allergic or toxic reactions to food and diet
  • Feingold theory (dietary techniques for better behavior, learning and health)
  • Sugar theory
  • Tempo of life theory
  • Child raising theory
  • Head injury theory
  • Blood lead level theory
  • Too much TV theory
  • Bad home environment theory
  • Poor schooling/teacher theory

ADD Myths

  • Just normal childhood rambunctiousness
  • Over diagnosed and medications over prescribed
  • Basically due to bad parenting and lack of discipline
  • Ritalin, and other psychostimulants, are addictive
  • Stimulant medication stunts growth
  • Stimulant medication turns kids into “zombies”
  • No evidence for stimulant medication
  • Kids with ADD are learning to make excuses
  • Teachers push pills to control children’s behaviors
  • Children outgrow ADD
  • It is not possible to accurately diagnose ADD

Treatment: Medications

  • Stimulants (thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space)
  • Methylphenidate (Concerta, Metadate, Ritalin)
  • Adderall
  • Dexedrine
  • Nonstimulant: Strattera (relatively new; not a controlled substance)

Stimulants Found to Improve

  • Core Symptoms
  • Inattention
  • Impulsivity
  • Hyperactivity
  • Secondary Concerns
  • Noncompliance
  • Impulsive aggression
  • Social interactions
  • Academic efficiency
  • Academic accuracy

Documented Side Effects

  • Loss of appetite/weight loss*
  • Trouble sleeping/insomnia*
  • Stomach pain
  • Rapid heart rate/high blood pressure
  • Possible slow growth pattern
  • Dizziness, drowsiness or changes in vision
  • Diarrhea
  • Dry mouth
  • Tics
  • Impotence (teens and adults)
    *most common side effects

 

Summary of Medications

  • Stimulants and Strattera are FDA approved first line agents for treatment of ADD/ADHD
  • Antidepressants are second line agents (Welbutrin and SSRIs)
  • Antihypertensives (HBP) are alternate agents typically used adjunctively with other medications

Treatment: Behavioral

  • Children: Alter parental response to elicit desired behaviors and diminish undesired behaviors; provide parent training
  • Adolescents: Increase attention to consequences; provide family and individual therapy
  • Adults: Coaching the adult in self-management of ADD; provide individual and couple’s therapy

For More Information

CHADD www.chadd.org 
Attention Deficit Disorder Association
Driven to Distraction (1994). Hallowell, E. & Ratey, J.
A Parents Guide to ADD (1991). Bain, D.
ADHD in Adults (1995). Nadeau, K.
Adolescents and ADD: Gaining the Advantage (1995). Quinn, P.
ADHD/Hyperactivity: A Consumer’s Guide (1991). Gordon, M.