| There have also been “unbelievers” who have fed on these
difficulties to create controversy, misgivings, and fear. Nonetheless, by 1998
the scientific response to all of this controversy had created a body of
research on ADHD that led the American Medical Association to call ADHD “one
of the best-researched disorders in medicine, and the overall data on its
validity is far more compelling than for many medical conditions.”11
Perhaps the most compelling of this data came from the research that
demonstrated the clear genetic basis of ADHD. The strongest data comes from the
ten twin studies that reported heritability between 0.6 and 0.9 (1.0 means a
solely genetic pattern of transmission) across various sets of diagnostic
criteria.12
Adoption and family studies (see review by Faraone and Biederman13)
support the concept that there is little contribution from the environment.
ADHD usually runs in families. Stressors and bad parenting can make the
manifestations and impairments worse but they do not cause ADHD.
The evidence that ADHD is a brain-based developmental disorder has far-flung
implications. Just as no other genetically based developmental disorder
disappears with age, neither does ADHD. However it’s manifestations and the
individual’s compensation to the disorder may change throughout the lifespan.14
The basic features, impairments, and treatments are very similar for both
children and adults. People do not “outgrow” ADHD just as no one outgrows any
other genetic disorder or any other developmental disorder. All people develop
better abilities to pay attention and control impulses as they grow older. Most
patients will benefit from lifelong medication even if they have “learned to
cope with ADHD” because life stresses increase rather than diminish with age.
Our
understanding of attention deficit hyperactivity disorder (ADHD) has progressed
more in the past 10 years than in all the years since it was first described in
1902. We now have studies using magnetic resonance imaging (MRI), positron
emission tomography (PET), and (SPECT) which provide us with some understanding
of the functional anatomy of the human brain. Neuropsychiatric research has
provided new insights into basic mental functions and processes. Until recently
all research into ADHD was done on hyperactive boys leaving us in a complete
void regarding girls, adults and those with problems with inattention. The ADHD
picture has been enlarged by new studies giving us a more comprehensive
understanding of the far ranging effects of this disorder.
ADHD has a strong genetic clustering (80%) but its etiology is still in
question. The current requirement that all of the symptoms must be manifested
by seven years of age will probably be dropped in future diagnostic criteria.15
Once it was thought that ADHD disappeared in adolescence but what we were
really seeing was the transformation of the most visible feature of
hyperactivity, calm into mere restlessness. The degree to which ADHD “persists”
depends upon the criteria that are used to define persistence. About 35% of
children who met full DSM criteria in childhood continue to meet full criteria
as adults. If you lower the cut off to just five out of nine symptoms instead
of six, the persistence rates jump to 65%. If you define persistence as having
met criteria in childhood and still having areas of significant impairment as an
adult, the persistence rate reaches 85%.17
The disorder is manifested as a persistent pattern of inattention/easy
distractibility and/or hyperactivity-impulsivity that is significantly more
severe than that observed in persons of a comparable level of development. This
inattention and/or impulsivity interferes significantly in all areas of function
(school, work, social/family relationships, mood regulation, and self-esteem).
Historic estimates for prevalence are 3 to 5 percent of the population but only
the hyperactive or “disruptive” child was identified and the “silent” or
inattentive child was missed. Two recent nearly identical prospective studies
give clearer estimates:
|
SAMPLE |
INATTENTIVE TYPE |
IMPULSIVE
HYPERACTIVE SUBTYPE |
COMBINED |
TOTAL |
|
TENNESSEE 18 |
4.9% |
3.4% |
4.4% |
12.7% |
|
GERMANY 19 |
9.0% |
3.9% |
4.8% |
17.7% |
If these current prevalence estimates are
accurate, ADHD is more common than major Depression, Bipolar Disorder,
Schizophrenia, Panic Disorder And Obsessive Compulsive Disorder combined. ADHD
is not over-diagnosed nor is it a fad diagnosis. Three out of four people with
the disorder still go undetected. Jensen20
has demonstrated that a majority of children still go untreated even if
accurately diagnosed as having ADHD. The recent council report of the American
Medical Association spells this out in great detail. 21
Despite having been
described since the turn of the century and having a good treatment since 1937,
ADHD is still a controversial concept and diagnosis for several reasons:
The condition may be
“silent” or “noisy.” The majority (70%) of people with ADHD do not have
hyperactivity and are, therefore, less likely to be detected and treated. ADHD
is often silent in girls leading them to be undiagnosed more often than boys.
The diagnostic criteria are subjective and dependent upon some measure of
interpretation by evaluators. The symptoms are relatively non-specific and occur
in other psychiatric illnesses as well as in ADHD. Inattention can occur in any
Organic Brain Syndrome, Depression, OCD, Schizophrenia, Petit Mal Seizures,
Sleep Apnea, or Dissociative states. Impulsivity is a hallmark of head injury,
intoxication states, mental retardation, and psychoses. Hyperactivity is seen
after encephalitis or head injury, and in mania. To complicate matters, 41% of
adults with ADHD have another Axis I major psychiatric disorder and 38% have two
or more additional psychiatric diagnoses. 22,23
Comorbidity is the rule and a thorough diagnostic history must be taken in every
case.
The best treatment is
Schedule II controlled substances.
Middle class American
values dictate that if you “suck it up, buckle down and try hard enough” you can
overcome any obstacle. The reality that some people are born hardwired to be
inattentive, impulsive, and fidgety goes against this tenet of faith.
“Attention Deficit
Hyperactivity Disorder” is not an appropriate name for this problem. People
with ADHD report that their attention is not deficient but instead they are
drawn to all the stimuli around them equally and simultaneously. They are
like jugglers who give fleeting attention to each ball in the air. Nothing gets
undivided, sustained attention unless their attention is captured by something
of great interest or challenge to them. As many as 40% of adolescents and
adults with ADHD can enter what appears to be an altered state of consciousness
while doing activities which they consider particularly intriguing. While in a
hyper focused state of consciousness the individual performs at almost 100%
efficiency, does not notice the passage of time, does not become tired or hungry
(or notice they need to visit the toilet) and has virtually 100% comprehension
and retention of what they read. This inconsistency of performance based on
interest leaves the impression that the ability to function is under the control
of the ADHD person who is just being lazy or uncooperative.
Just as with many
personality traits, there is a positive aspect to ADHD as well as the negative.
People with ADHD often have a higher than average intelligence, they tend to be
very creative and inventive and can often pull together the threads of a complex
problem to develop ingenious solutions that no one else would have seen. They
have a “relentless determination” when they hook into a challenge. People with
ADHD tend to be intense but sensitive and may be described by friends and family
as being “high maintenance but high reward” individuals.
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References:
11
Goldman LS, op cit.
12
Todd RD. Genetics of Attention Deficit Hyperactivity Disorder. Am J Med
Genetics 96:241-243, 2000.
13
Faraone SV, Biederman J. Genetics of Attention Deficit Hyperactivity
Disorder, Child Adolescent Psychiatric Clinics N AM3:285-301.
14
Wender P., The Hyperactive Child, Adolescents and Adult Attention Deficit
Disorder Through the Life Span. Oxford University Press, New York, 1987.
15
Applegate B, et al., Validity of the Age of Onset for ADHD: A Report from
the DSM IV Field Trials. J AM Acad Child and Adolescent Psychiatry 36(9)
1211-1221, 1997.
17
Biederman J, Faraone S, Spencer T, et al. Predictors of persistence and
remission of ADHD into adolescents: Results from a four year prospective
follow-up study. J Am Acad Child and Adolescent Psychiatry 35:343-351, 1996.
18
Wolraich MD, et al, Comparison of diagnostic criteria for Attention Deficit
Hyperactivity Disorder in a country wide sample. J Am Acad Child and
Adolescent Psychiatry 35:319-324, 1996.
19
Baumgartel A, et al, Comparison of diagnostic criteria for Attention Deficit
Hyperactivity Disorder in a Germany elementary sample. J Am Acad Child and
Adolescent Psychiatry, 34:629-638, 1995.
20
Jensen PS, et al, Are stimulants overprescribed? Treatment of ADHD in four
communities. J Am Acad Child and Adolescent Psychiatry 38(7): 797-804, 1999.
21 Goldman LS, Genel M, Bezman RJ, Slanetz
PJ, Diagnosis and
treatment of Attention Deficit Hyperactivity Disorder in children and
adolescents. JAMA 279(14): 1100-1107, 1998.
22
Tzelepis A, et al, Differential Diagnosis and Psychiatric Comorbidity
Patterns in Adult ADD, in A Comprehensive Guide to ADD in Adults, Nadeau KG,
Ed Bruner/Mazel, New York, 1995.
,23
Hornig M. Addressing Comorbidity in Adults with Attention Deficit
Hyperactivity Disorder. J Clin Psychiatry 59 (supplement 7): 69-75, 1998.
|
The
first clinical description of ADHD was reported in the British journal, Lancet,
by Dr. George Still in 1902. Dr. Still was a British physician treating
children who noticed some of his patients were uninhibited and impulsive. In
the 1930’s in the United States, Dr. Charles Bradley made further observations
on the effect of stimulant medication on children. Since that time, the
descriptive terms that have been used to identify ADHD people have reflected the
current scientific understanding of the day as to what this condition
represented biologically. 