Most of us know a boy like 8-year-old Nicolas. He can’t sit still. He talks too much and interrupts others, doesn’t wait his turn when playing games or answering the teacher, and leaves his homework and chores unfinished. He has a lot of trouble getting organized or just paying attention. It’s hard for his parents, teachers and classmates to understand him: how could such a bright boy be such a “bad” kid?
In the not-too-distant past, Nicolas would have been labeled a troublemaker. The behaviors he exhibited were considered just that – behaviors – not symptoms of a serious disorder. Today, children like Nicolas are more often seen for what they are: good, smart kids with attention deficit hyperactivity disorder (ADHD). In the case of Nicolas, his adoptive mother, teachers, therapists and other health care professionals are all playing roles in his treatment. Nicolas hasn’t yet turned into the world’s best student; still, there’s been a lot of progress and he even received an "outstanding" rating from his teacher for an entire week not too long ago.
A Widespread Issue
Of the nearly 4 million school-age children in the U.S. with learning disabilities, according to the National Institutes of Health, at least 20% have a type of disorder that leaves them unable to focus their attention. The attention deficit is accompanied by hyperactivity in a large proportion of affected children, mostly boys, putting children with symptoms like Nick’s in a huge percentage of classrooms.
Mariellen Fischer, PhD, Professor of Neurology at the Medical College of Wisconsin, is board certified in Clinical Neuropsychology. Her clinical practice focuses on patients age 2 to 18, so she sees a lot of children with ADHD whose stories are similar to Nicolas’ and those of the estimated 3-5% of American children with attention deficit disorders.
In a recent interview with HealthLink, Dr. Fischer discussed ADHD and contemporary treatments. She first addressed some lingering perceptions that ADHD is just a behavioral issue and that kids are being medicated merely to make the lives of adults easier.
“With any disorder there can be misdiagnosis,” Dr. Fischer said. “But there’s a lot of evidence that ADHD is a true disorder. There are behaviors that hang together that are problematic, the behavior is seen across cultures, and the disorder also predicts particular outcomes. If it weren’t a real thing we wouldn’t expect it to have any predictive value for the future.”
Dr. Fischer said symptoms now associated with ADHD include “over-activity or difficulty modulating activity level to the demands of the environment around the individual, impulsivity, acting before thinking through consequences, and difficulties with sustained attention.”
Genetics a Likely Factor
As research into ADHD continues, signs point to genetic makeup as the most significant risk factor but not the only cause. “I think we recognize at this point in time that about 60-80% of people who have the disorder have it on the basis of genetic risk, that there is a clear genetic pattern that is observed,” Dr. Fischer said.
“There is a smaller group of people who did not appear to have a gene, or the multi-factorial genes for a disorder, but acquired it on the basis of pregnancy or birth complications. A very small group may acquire it after birth as a result of central nervous system injury or trauma. They’re certainly the minority, for example children who acquire the disorder because of lead poisoning. Most people who have the disorder were not lead poisoned.”
Environment may play a role in how ADHD manifests itself and whether and how it is diagnosed, but there is little evidence that, for example, foster children such as Nicolas are inclined to the condition at a higher rate just because they come from unstable homes. “You really don’t get the disorder because of bad parenting or a bad neighborhood or a bad environment,” Dr. Fischer said.
“Certainly those factors can make the symptom expression worse. There’s variability in how children are managed in various settings. And we think that many of those parents may have had attention deficit disorder themselves, and that various behaviors, including impulsivity, put them in a situation where they no longer have the care of their biological children.”
The objective criteria for ADHD diagnosis are becoming clearer, according to Dr. Fischer. “We look for the core symptoms of the disorder and we want to see them reported across settings that the child is in at home, at school, etc. And we want to also show that they’re at a clinically severe level. If you talk to parents and teachers of 6 to 11 year-old boys, many of them will say ‘yeah, he’s kind of restless, gee, you know he doesn’t pay attention too well.’”
“Yet we don’t want to over-diagnose, so we use standardized behavior rating scales that are filled out by parents and teachers to ensure that someone is really in the most severe 5% to 7% of children of the same age and sex before we make the diagnosis. And then we also want to rule out other conditions that might appear to be the disorder but aren’t the disorder.”
Two Distinct Disorders?
Dr. Fischer noted that the distinction between ADHD and attention deficit disorder (ADD, without the element of hyperactivity) is becoming clearer. “What the disorder is, and the inattention in it, has been the subject of some controversy and changing thinking over time. What we recognize now is that attention deficit disorder (without the hyperactivity) probably is a wholly separate disorder. It has different correlates, it has different outcomes.
“The disorder that combines hyperactive, impulsive and inattentive symptoms probably is the true developmental ADHD. I think we’re going to see what people have called attention deficit disorder without hyperactivity, or attention deficit hyperactivity disorder predominately inattentive type, split off from ADHD. I think we’re really seeing it as two different disorders.”
Medication and Behavior Management
Dr. Fischer agreed that the use of medication to treat children with ADHD, other behavior disorders, and/or mental illness has grown almost exponentially in recent years. Stimulants such as methylphenidate and amphetamine are the most commonly prescribed drugs to treat ADHD.
It may sound like a contradiction, but stimulants can have a very positive effect on children with ADHD by diminishing impulsive behaviors and motor over-activity; they can also result in improved physical coordination and more sustained attention.
There’s no evidence that medication minimizes a child’s ability to learn to focus or develop other coping skills in the long term, Dr. Fischer said. “It’s sort of a myth that you can learn to focus as you get older if you have ADHD. Attention span improves in normal individuals as they mature and attention span improves in ADHD individuals as they mature, but the attention span of an ADHD individual is not going to ever really meet that of someone without the disorder of the same age.”
“You can learn coping techniques, you can learn how to put yourself in situations that better meet your needs, but it’s inaccurate to say that you can learn how to focus. So using the medication doesn’t take away your opportunity to learn to focus because it’s not a volitional thing. We don’t say that giving diabetic children insulin keeps them from learning how to produce insulin themselves. It’s not going to happen.”
“The two primary treatments are medication and behavior management. Those are the two things that really have the most significant impact on the disorder,” Dr. Fischer added. So medication alone won’t do the trick for kids like Nick. A collaborative treatment approach is recommended, involving parents and other caregivers, teachers and school-based health professionals, family physicians and psychologists.
“Definitely, that’s really the most comprehensive way to evaluate a child and make a diagnosis,” Dr. Fischer said. “An important thing about attention deficit disorder is that children don’t show their symptoms at the same level all the time. In a physician’s office where they’re getting one-on-one attention and it’s a new and novel situation, they’re less likely to show those symptoms so it’s very important to gain information from people who are very familiar with the child across all the settings that the child is in.”
“It’s really parents who have the final decision-making power about whether or not a child tries medication,” says Dr. Fischer said. “We know that medication does not help 100% of children with the disorder...at best we can improve the symptoms in about 85% with medication.”
Psychotherapy, family therapy and social skills training are also used depending on the needs of the child and family, Dr. Fischer said, not to treat the symptoms but to aid in coping and quality of life.
With Treatment, a New Direction is Possible
In either case, there is no identified “cure” as such. Children with the disorders seldom outgrow them, according to the National Institutes of Health. The physical hyperactivity exhibited by children like Nicolas usually subsides into fidgeting and restlessness by adolescence. However, adults with ADHD can expect continuing problems with concentration and attention. The impact in the workplace can be great as adults produce careless or messy work, encounter trouble organizing tasks or finishing jobs, and appear as though they aren’t listening or following directions.
Yet there is a great deal of hope for the Nicolases of the world, who used to be “diagnosed” as kids who get into trouble because they’re just out of control. Dr. Fischer noted that parents often react to an ADHD diagnosis not just with the dread that comes with knowing their child has a disorder, but often with the relief that comes with knowing that there’s a reason for the way their child is behaving. And that there are some things that they can do about it to give their child a shot at a productive adulthood that they can control.
Support for Attention Deficit Disorders
For Parents of Children and Adults with Attention Deficit Disorders: Local meetings held on the second Wednesday of the month (except for December), 7:30 to 9:00 p.m., Helfaer Auditorium at Froedtert Hospital West, 92nd St. entrance. Call (414) 299-9422 for information.
For Adults with Attention Deficit Disorder: Local meetings held on the second and fourth Wednesday of the summer months, 6:30 to 8:30 p.m., Froedtert Hospital cafeteria.
Children and Adults with Attention-Deficit/Hyperactivity Disorder web site: www.chadd.org
