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Attention-deficit/hyperactivity disorder (ADHD) is a diagnostic label describing children and adults who demonstrate developmentally inappropriate levels of inattention, hyperactivity, and impulsivity. This disorder has been identified by many different names in the past, including attention-deficit disorder (ADD) with and without hyperactivity. It is one of the most commonly diagnosed disorders of childhood and accounts for a significant percentage of referrals to mental health and primary care clinics. Once considered a childhood disorder that one would “grow out of,” it is now recognized that symptoms and impairment persist across the lifespan for many individuals, with an increasing number of adults seeking treatment. Although prevalence rates vary as a function of diagnostic method, it is estimated that 5 to 8 percent of children and 1 to 3 percent of adults meet criteria for ADHD as outlined by the American Psychiatric Association (1994). ADHD is more often diagnosed in boys, but prevalence rates are fairly consistent across diverse geographic and racial populations.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the primary reference for mental health professionals in the United States (APA 1994), identifies three subtypes of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. At least six of nine inattentive or hyperactive-impulsive symptoms must be present for at least six months for diagnosis, with the subtype determined by which symptoms are predominant. Inattentive symptoms include inattention to details or making careless mistakes, difficulty sustaining attention, not listening, not following through and completing tasks, avoiding or disliking tasks requiring sustained mental effort, disorganization, forgetfulness, losing things, and distractibility. Hyperactive symptoms include fidgeting, difficulty remaining seated, being “on the go,” running or climbing excessively (feelings of restlessness in adults), difficulty playing quietly, and talking excessively. Impulsive symptoms include blurting out, difficulty waiting, and interrupting or intruding on others. These symptoms must be sufficiently maladaptive and developmentally inappropriate to warrant diagnosis.
DSM-IV criteria also require that at least some of the symptoms must have caused impairment for the individual before the age of seven. Although symptoms may be overlooked in some children when they are younger, particularly those who are higher functioning, the developmental nature of the disorder requires a chronic and pervasive pattern of difficulties across time. Thus, one cannot develop “adult onset” ADHD. When symptoms present in adulthood for the first time, there is often an alternative explanation for them, such as anxiety, depression, or another medical condition. Because inattention and hyperactivity-impulsivity can have numerous causes, diagnosis actually requires that symptoms are not better accounted for by another psychiatric disorder and that they do not occur solely in the context of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. Finally, ADHD-related impairments must occur across settings (i.e., in the home, during social activities, and at school or work) and there must be evidence of clinically significant impairment in social, academic, or occupational functioning. That is, the symptom severity is more than mild and interferes in individuals’ daily lives and activities. Although these criteria have limitations, notably their appropriateness for different ages and subtypes, they are the most rigorous and empirically derived in the history of ADHD.
When the DSM-IV criteria are carefully followed using well-defined practice parameters for children (AACAP 1997; AAP 2000), ADHD can be reliably diagnosed. The parent interview lies at the core of the assessment process and covers questions regarding symptoms, impairment, history (medical, developmental, psychiatric, and family), and alternative explanations for the child’s behavior. Developmental history forms, symptom screening checklists, and diagnostic interviews are useful tools in collecting this information. Standardized parent and teacher rating scales that include ADHD-specific items aid in documenting developmental deviance and pervasiveness of symptoms. Additional feedback from the child’s school, including testing reports and observations, may also be obtained. Although medical and cognitive tests are not routinely indicated, they may help identify coexisting conditions. Assessment of ADHD in adults includes the same basic components, with age-appropriate interviewing tools and the use of rating scales completed by the adult and another informant, such as a spouse or coworker (Weiss and Murray 2003). The reliability and validity of these measures are less well established, however.
Despite concerns about large-scale overdiagnosis, epidemiological studies have found little evidence of this. According to the 2003 National Survey of Children’s Health that assessed over 100,000 U.S. children through parent phone interviews, approximately 7.8 percent of 4–17 year olds were reported to have been identified by a professional as having ADHD (Centers for Disease Control 2005). Similarly, William J. Barbaresi, Slavica K. Katusic, Robert C. Colligan, et al. (2002) found that 7.5 percent of children in a birth cohort of over 5,000 in Minnesota had received clinical diagnoses of ADHD according to medical record documentation. These numbers closely resemble prevalence rates found in carefully conducted diagnostic studies (Barkley 2006), suggesting that there is not substantial over-identification in practice. The American Medical Association came to a similar conclusion after reviewing over 20 years of literature using a National Library of Medicine database (Goldman et al. 1998). Rather, more children, particularly girls and adolescents, are being identified than in the past, particularly with recently changed and expanded diagnostic criteria. Nonetheless, some practitioners who do not conduct thorough evaluations using validated diagnostic criteria may be inappropriately diagnosing and treating children. Dramatically increasing prescription rates for medications to treat ADHD are also believed to represent more effective treatment patterns, although concerns of misuse and diversion are recognized.
Course, Impact, and Comorbidity
Children with ADHD experience frequent learning difficulties and are more likely than others to be placed in special education, retained, and suspended; they are also more likely to fail to graduate. Furthermore, they are at higher risk for peer rejection, physical injury, delinquency, and substance use (Barkley 2006). Adults with ADHD are also at higher risk for smoking, drug abuse, driving citations and accidents, and poorer physical and mental health. They often experience higher levels of anxiety and depression, more job-related turmoil, and relationship difficulties (Wender 1995).
Outcomes for children with ADHD vary based on risk factors and the presence of coexisting psychiatric conditions, which commonly include oppositional behavior and conduct problems, anxiety, depression, tic disorders, and learning disorders. Overall, 15 to 20 percent of children with ADHD appear normalized as adults; 20 to 30 percent experience marked impairments in occupational, relational, and mental health functioning, and the remainder exhibit persistent symptoms with mild to moderate difficulties (Biederman et al. 1998). Factors predicting a worse outcome include psychosocial adversity, a family history of ADHD, and the presence of oppositional behavior (Biederman et al. 1996).
History of the Disorder and Its Treatment
First described in the early 1900s, thousands of studies on ADHD were conducted in the latter half of the twentieth century, making this the most well-researched childhood disorder. Significant advances have been made in our understanding of the nature of ADHD, resulting in changes to diagnostic criteria and ongoing exploration of risk factors and prognosis. Once attributed to brain injuries or environmental maladjustment, the neurobiological nature of the disorder is now well established (Barkley 2006). Research suggests that the causes of ADHD are complex, although most cases can be accounted for by heredity. Neuroimaging research has identified frontal lobe functioning deficits and structural brain abnormalities associated with ADHD, and molecular genetics studies are investigating specific genes that may be implicated, with a goal of developing more sophisticated treatment strategies (Biederman 2005).
A wide range of treatments for ADHD has been developed, with many having little or no empirical basis (e.g., dietary interventions, biofeedback, and optometric training). Proven treatments for ADHD include parentmanagement training, direct behavior modification in schools and specialty camps, and stimulant medications, primarily methylphenidate products (AACAP 1997; Pelham et al. 1998). More recently, efficacy has been demonstrated for specific norepinepherine reuptake inhibitors such as atomoxetine. A multimodal treatment approach is generally considered the best practice, although knowledge of long-term benefits and methods for individualizing treatments is limited. There is also a lack of information on the availability and effectiveness of typical community and school services for ADHD. Use of stimulant medications remains controversial, although there is considerable evidence of short-term benefit for core symptoms in children (MTA Cooperative Group 1999) and growing support for the use of these medications in adults. Psychosocial treatments for adults that incorporate behavioral compensation skills and cognitivebehavioral modification are being developed but have not yet been well evaluated.
- American Academy of Child and Adolescent Psychiatry (AACAP). 1997. Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 36 (10) Suppl.: 85S–121S.
- American Academy of Pediatrics (AAP). 2000. Clinical Practice Guideline: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity Disorder. Pediatrics 105 (5): 1158–1170.
- American Psychiatric Association (APA). 1994. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: Author.
- Barbaresi, William J., Slavica K. Katusic, Robert C. Colligan, et al. 2002. How Common Is Attention-Deficit/Hyperactivity Disorder? Incidence in a Population-Based Birth Cohort in Rochester, MN. Archives of Pediatrics and Adolescent Medicine 156: 217–224.
- Barkley, Russell. 2006. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 3rd ed. New York: Guilford.
- Biederman, Joseph. 2005. Attention-Deficit/Hyperactivity Disorder: A Selective Overview. Biological Psychiatry 57 (11): 1215–1220.
- Biederman, Joseph, et al. 1996. Predictors of Persistence and Remission of ADHD into Adolescence: Results from a FourYear Prospective Follow-up Study. Journal of the American Academy of Child and Adolescent Psychiatry 35 (3): 343–351.
- Biederman, Joseph, Eric Mick, and Stephen Faraone. 1998. Normalized Functioning in Youths with Persistent AttentionDeficit/Hyperactivity Disorder. Journal of Pediatrics 133 (4): 544–551.
- Centers for Disease Control and Prevention. 2005. Mental Health in the United States: Prevalence of Diagnosis and
- Medication Treatment for Attention-Deficit/Hyperactivity Disorder–United States, 2003. Morbidity and Mortality Weekly Report 54 (34): 842–847.
- Goldman, Larry S., Myron Genel, Rebecca J. Bezman, and Priscilla J. Slanetz. 1998. Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Journal of the American Medical Association 279 (14): 1100–1107.
- MTA Cooperative Group. 1999. A 14-month Randomized Clinical Trial of Treatment Strategies for AttentionDeficit/Hyperactivity Disorder. Archives of General Psychiatry 56: 1073–1086.
- Pelham, William, Trilby Wheeler, and Andrea Chronis. 1998. Empirically Supported Psychosocial Treatments for Attention Deficit Hyperactivity Disorder. Journal of Clinical Child Psychology 27 (2): 190–205.
- Weiss, Margaret, and Candice Murray. 2003. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults. Canadian Medical Association Journal 168 (6): 715–722.
- Wender, Paul. 1995. Attention-Deficit Hyperactivity Disorder in Adults. New York: Oxford University Press.
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