Understanding ADHD





No matter what age your child is, no doubt you've heard of ADHD - and at some point, you may even have wondered if your own child is exhibiting ADHD-like symptoms. But what is ADHD, and how can you tell if your child has it? Isn't ADHD just an overused, catch-all term for children who need better discipline anyway? Child and adolescent clinical psychologist Dr Melanie Woodfield addresses some common myths and misconceptions about ADHD.

Attention-Deficit/Hyperactivity Disorder (ADHD) is a very hot topic nowadays. You may have gathered this from the number of times it's mentioned in the media, or how often you hear people casually saying things such as, "He's so full-on! I wonder if he's 'ADD'?" A quick search of one well-regarded research database identified over 11,000 articles related to ADHD, with approximately 350 published in 2008 alone. Even more impressive, Google returns 34.5 million hits!
     Despite the huge amount of scientific research into the causes, assessment and treatment of ADHD, there is still a significant amount of misunderstanding in the community. The research doesn't seem to spread beyond the journals, and instead, myths are often perpetuated by word of mouth. The purpose of this article is to outline some of these common myths, and hopefully share some things you didn't know (and always wanted to know!) about this relatively common condition.


How is ADHD diagnosed?
First things first: We ought to understand how ADHD is diagnosed. The diagnostic criteria for mental health issues in New Zealand (along with much of the world) are found in the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short. The DSM is reviewed regularly, with occasional revisions being made to diagnostic criteria based on research that has occurred since the last revision. The current edition is DSM-IV-TR (Fourth edition, Text Revision), and the DSM-V (Fifth edition) is due for release in 2012.
     In a nutshell, according to DSM-IV-TR criteria, children need to display six or more symptoms of inattention (e.g. being easily distracted, forgetful, having trouble sustaining attention) and/or hyperactivity-impulsivity (e.g. fidgeting, running about or climbing excessively, often talking excessively or blurting out answers and interrupting others) for at least six months "to a degree that is maladaptive and inconsistent with developmental level". In other words, while we'd expect several of these behaviours from the average two-year-old, we'd expect fewer from a four or five-year-old. These symptoms need to be present in two or more settings (e.g. home, Nana's house, and kindy), and need to result in "clinically significant impairment" - if these symptoms aren't a problem for you or your child, then your child doesn't meet criteria for the diagnosis. The final point to note is that some of the above symptoms need to have been present before age seven, to a degree that "caused impairment", not just inconveniences.
    These criteria may be a surprise in themselves - many people assume that almost all children can be diagnosed with ADHD, when in fact the criteria are very carefully considered, and relatively tight. For example, while many children under five will show inattentive and/or overactive behaviour, very few children will continue to display these behaviours to the same degree for longer than six months.

Common myths about ADHD
Myth: "All hyperactive kids have ADHD."
Fact: Most children have periods of time where they are hyperactive and/or impulsive. In fact, the activity levels of children (and adults) can be thought of as varying on a continuum, from those children who are hardly ever hyperactive or impulsive, to those children who are often hyperactive and impulsive. Most diagnoses, particularly in the area of mental health, are simply a way of drawing "a line in the sand" on that continuum according to well-researched criteria. On one side of the line, we have children with "normal" activity levels (or activity levels common to most children), and on the other side, those children with "abnormal" levels (or activity levels that are far less common statistically). As mentioned earlier, several other criteria need to be met, over and above being "hyper", for a child to be diagnosed with ADHD.
    So, it is very possible to be boisterous, but not meet the criteria for ADHD. And, just to complicate things, another common myth...

 

Myth:"All kids with ADHD are 'hyper'."
Fact: We've all seen the stereotypes of children with ADHD  - the kids who are always on the go, butting in, constantly running, jumping, and demanding attention. This type of presentation can describe a child with ADHD. But did you know that there are other types of ADHD? According to DSM-IV-TR, there are three subtypes of ADHD:
•  ADHD, Predominantly Hyperactive-Impulsive Type. This is the "stereotypical" ADHD.
•  ADHD, Predominantly Inattentive Type. Hyperactivity symptoms are not present with this subtype. This subtype is often under-diagnosed, as children tend to present as distracted or daydreaming, unfocused, and inattentive. These children are not "climbing the walls", present less of a problem for parents/carers/teachers, and so are often not identified as readily as other children with ADHD. Sometimes parents refer to this as "ADD"; that is, ADHD without the hyperactivity component.
•  ADHD, Combined Type. Both inattention and hyperactivity/impulsivity symptoms are present.
So, it is very possible to not be hyperactive, and still meet criteria for ADHD (predominantly inattentive type).

Myth:"It seems like everyone has ADHD these days. It didn't even exist in my parents' day!"
Fact: While ADHD is one of the more common childhood mental health issues, it is still relatively rare compared to many physical health issues such as asthma, obesity or diabetes. The DSM-IV-TR estimates that ADHD affects between 3-5% of children.
    Chances are, ADHD did exist in your parents' day - it was just known as something different. Various diagnoses or conditions that are basically the same as what we now know as ADHD have been identified for almost a century. The term ADHD was first used in the DSM approximately 25 years ago.
    The other aspect to this myth is the unspoken doubt about the validity of the diagnosis itself. ADHD has received much attention in the media over the last decade in particular, portraying both accurate and inaccurate information. In 2002, a collection of over 75 world-renowned researchers and practitioners felt so strongly about the unhelpful media attention regarding ADHD that they published a "Consensus Statement on ADHD" in the European Child & Adolescent Psychiatry Journal.
    The statement began, "We, the undersigned consortium of international scientists, are deeply concerned about the periodic inaccurate portrayal of attention deficit hyperactivity disorder (ADHD) in media reports... We fear that inaccurate stories rendering ADHD as myth, fraud, or benign condition may cause thousands of sufferers not to seek treatment for their disorder. It also leaves the public with a general sense that this disorder is not valid or real or consists of a rather trivial afliction."
    The authors go on to emphasise that, "The US Surgeon General, the American Medical Association (AMA), the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry (AACAP), the American Psychological Association, and the American Academy of Pediatrics (AAP), among others, all recognise ADHD as a valid disorder."
    A pretty powerful endorsement! The authors go on to summarise that "as a matter of science, the notion that ADHD does not exist is simply wrong. All of the major medical associations and government health agencies recognise ADHD as a genuine disorder because the scientific evidence indicating it is so overwhelming." What more can we say?


Myth:
"Kids with supposed ADHD have just had too much sugar and no boundaries at home."
Fact: Although many parents assume that sugar causes hyperactivity, there is very little research-based evidence to support this (although some food additives have been associated with hyperactivity - see my article "A Spoonful of Sugar" in Issue 1 of OHbaby! Magazine). While there is sometimes a link between lots of sugar and children being hyperactive (picture those birthday parties!), the research shows it's more likely to be a result of other factors (such as the party/celebration context in which the sugar is given) that encourages hyperactivity - not the sugar itself causing the hyperactivity. Of course, that's not to say that children having lots of sugar is a good thing!
    Regarding the "no boundaries" notion: Parents putting in place consistent and sensible boundaries and consequences for children (and, very importantly, consistent and sensible praise or other rewards for appropriate behaviour) is very helpful for all children. This includes children with ADHD, who usually respond very well to a structured approach to behavioural expectations of them. But, while poor boundaries may exacerbate the difficulties that a child with ADHD faces, they don't cause ADHD in and of themselves.


Myth:
"If my child is diagnosed with ADHD, I'll have to give him/her Ritalin, and I've heard bad things about it."
Fact: Ritalin and other medication used to treat ADHD have received a lot of media attention, often not favourable. These medicines have even been referred to as "kiddie cocaine", which is completely misleading, and a good reminder to be very vigilant about the source of any information you read. If you Google "Ritalin", you're likely to bring up a mixed bag of both biased and independent information, and determining the difference can be very difficult!
    Fortunately, there has also been a lot of research in reputable journals - the Journal of the American Academy of Child and Adolescent Psychiatry published a review of the use of stimulant medication (such as Ritalin) for children, in which the authors noted that "studies of the short-term benefits of stimulants on the symptoms of ADHD constitute the largest body of treatment literature of any childhood onset psychiatric disorder."
    In short, Ritalin (and other similar medications) usually work, and work well, without long-term side-effects. Psychologists are often seen to be "anti-medication", but there really is no denying the abundant collection of research into how effective this medication is in improving the core ADHD symptoms in most children with ADHD. However, as a parent, you would never be forced or required to medicate your child for ADHD, and you should always be provided with full and complete information about the benefits and side-effects of any medication, including Ritalin.


Assessing ADHD
Before even considering the issue of medication, you and your child would participate in a thorough assessment for ADHD. If your child met the criteria, you would then usually be provided with several treatment options, one of which might be treatment with stimulant medication.
    These days, there are several medications subsidised by the New Zealand government, which suit different children in different circumstances. The other point to note is that using medication doesn't have to be an "all or nothing" decision - many parents choose to medicate their child for kindy or school, and not in the evenings and weekends, or have regular "medication holidays".
    Also, while medication may treat the core symptoms of ADHD, other issues, such as social skills problems, oppositional behaviour, and aggression are often best treated with a combination of medication and other interventions (such as social skills training, parent education, behavioural training, or family therapy).
    You may be interested to learn that, in New Zealand, dexamphetamine and methylphenidate (Ritalin), both used to treat ADHD, are known as controlled drugs, and can only be prescribed by specialist Paediatricians or Psychiatrists. Your GP can only prescribe these medicines when acting on the recommendation of one of these professionals. This is to further monitor and control the prescription of these medications, and ensure that they are prescribed carefully and responsibly.

 

 


Dr Melanie Woodfield is a child and adolescent clinical psychologist. She lives in Auckland with her husband and two young boys.



References
•  American Academy of Child and Adolescent Psychiatry. "Practice
parameters for the use of stimulant medications in the treatment of children, adolescents and adults." Journal of the American Academy of Child and Adolescent Psychiatry 41.2 (2002).
•  Barkley, RA et al. "Consensus Statement on ADHD." European Child & Adolescent Psychiatry 11 (2002): 96-98.

For further information
•  "New Zealand Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder." Published by the Ministry of Health (2001) and available for download from
www.moh.govt.nz
•  The NZ ADHD online support group
www.adhd.org.nz
•  Children and Adults with Attention Deicit/Hyperactivity Disorder (American website)
www.chadd.org

 

As seen in OHbaby! magazine Issue 3: 2008

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