ATTENTION-DEFICIT/HYPERACTIVITY

DISORDER

I. DEFINITION

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD)

The main feature of Attention-Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.

(DSM-IV, 1994)

II. DIAGNOSTIC CRITERIA

NOTE: The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills.

Following are the diagnostic criteria Attention-Deficit/Hyperactivity Disorder according to the American Psychiatric Association (DSM-IV, 1994):

1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level:

Inattention

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
   
   
2. Often has difficulty sustaining attention in tasks or play activities.
   
   
3. Often does not seem to listen when spoken to directly.
   
   
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
   
   
5. Often has difficulty organizing tasks and activities.
   
   
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
   
   
7. Often loses things necessary for tasks or activities e.g., toys, school assignments, pencils, books, or tools.
   
   
8. Is often easily distracted by extraneous stimuli.
   
   
9. Is often forgetful in daily activities.

2. Six (or more) of the following symptoms of hyperactivity -- impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat.
   
   
2. Often leaves seat in classroom or in other situations in which remaining in seat is expected.
   
   
3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
   
   
4. Often has difficulty playing or engaging in leisure activities quietly.
   
   
5. Is often "on the go" or often acts as if "driven by a motor."
   
   
6. Often talks excessively.
   
   Impulsivity
   
   
7. Often blurts out answers before questions have been completed.
   
   
8. Often has difficulty awaiting turn.
   
   
9. Often interrupts or intrudes on others (e.g., interrupts conversations or games).

3. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
   
   
4. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
   
   
5. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
   
   
6. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

SUBTYPES BASED ON DIAGNOSTIC CRITERIA (DSM-IV, 1994)

Attention-Deficit/Hyperactivity Disorder, Combined Type. This subtype should be used if six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity have persisted for at least 6 months. Most children and adolescents with the disorder have the Combined Type. It is not known whether the same if true of adults with the disorder.

Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type. This subtype should be used if six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) have persisted for at least 6 months.

Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type. This subtype should be used if six (or more) symptoms of hyperactivity-impulsivity (but fewer than six symptoms of inattention) have persisted for at least 6 months. Inattention may often still be a significant clinical feature in such cases.

If ADHD is left unidentified or untreated, a child is at great risk for:

• impaired learning ability
  
  
• decreased self-esteem
  
  
• social problems
  
  
• family difficulties
  
  
• potential long-term effects

("Attention Deficit Disorder: an educator’s guide," 1993)

III. ASSOCIATED FEATURES

OTHER BEHAVIORS IN INDIVIDUALS WITH ADHD

(Validity of ADHD syndrome, AADD23)

• non-compliance
  
  
• attention-getting behavior
  
  
• immaturity
  
  
• school problems
  
  
• emotional difficulties
  
  
• poor peer relationships
  
  
• family interaction problems

(DSM-IV, 1994)

• low frustration tolerance
  
  
• temper outbursts
  
  
• bossiness
  
  
• stubbornness
  
  
• excessive and frequent insistence that requests be met
  
  
• mood lability
  
  
• demoralization
  
  
• dysphoria (a state of dissatisfaction and restlessness)
  
  
• rejection by peers
  
  
• poor self-esteem
  
  
• family relationships characterized by resentment and antagonism

ADHD & LEARNING PROBLEMS

Only 20% to 40% of ADHD diagnosed children also have learning problems. Frequently, they are one or more of the following (validity of ADHD Syndrome, AADD23):

1. Auditory perception and processing problems.
   
   
2. Visual perception and visual processing problems
   
   
3. Auditory and visual memory problems (both short- and long-term)
   
   
4. Sequencing problems
   
   
5. Fine-motor problems
   
   
6. Visual-motor integration delays
   
   
7. Poor eye-hand coordination and dysgraphia
   
   
8. Dyslexia and reading disorders
   
   
9. Written language problems
   
   
10. Spelling disorders
    
    
11. Math disorders
    
    

IV. AGE AT ONSET, COURSE, PREVALENCE

AGE AT ONSET:

• In approx. half of all cases, onset of the disorder is before age 4 (DSM-IV, 1994).
  
  
• Frequently, the disorder is not recognized until the child enters school (DSM-IV 1994).

COURSE:

• In the majority of cases, symptoms of the disorder last throughout childhood and is relatively stable throughout adolescence (DSM-IV, 1994).
• Studies have indicated that the following features predict a poor course: coexisting Conduct Disorder, low IQ, and severe mental disorder in the parents (DSM-III-R, 1987).

PREVALENCE:

• May occur in as many as 3% to 5% of school-age children (DSM-IV, 1994).
  
  
• About 70% of ADHD children continue to have behavioral problems in adolescence ("Attention deficit disorders--not just for children," 1993).
  

GENDER NOTE:

In clinical samples of the American Psychiatric Association, ADHD is from six to nine times more common in males than females. In community samples, multiple signs of the disorder occur only three times more often in males than is females (DSM-III-R, 1987).

V. ADULTS AND ADHD

(Attention deficit disorders--not just for children," 1993)

• ADHD is a "hidden disorder" (the symptoms of ADHD are often obscured by problems with relationships, staying organized, and holding a steady job) in adults. Adults are often first diagnosed with ADHD because of problems with substance abuse or impulse control.
  
  
• Following are some characteristics of adults with ADHD:
  
  
  • distractibility
    
    
  • disorganization
    
    
  • forgetfulness
    
    
  • procrastination
    
    
  • chronic lateness
    
    
  • chronic boredom
    
    
  • anxiety
    
    
  • depression
    
    
  • low self-esteem
    
    
  • mood swings
    
    
  • employment problems
    
    
  • restlessness
    
    
  • substance abuse or addiction
    
    
  • relationship problems
    
    
• about two-thirds of children with ADHD continue to have behavioral problems in adolescence
  
  
• about one-third to one-half of these adolescents continue to have symptoms of ADHD in their adult years

VI. CAUSES OF ATTENTION DISORDERS

5 MAJOR CATEGORIES

(Validity of ADHD Syndrome, AADD23)

1. Constitutional or innate biological factors: these relate particularly to temperament and heredity;
   
   
2. Organic factors: these include all physiological injury to the central nervous system and/or brain;
   
   
3. Diet, nutrition, allergies, and food intolerance;
   
   
4. Environmental toxins: including lead, formaldehyde, and chemical pesticides, among others; and,
   
   
5. Secondary to other medical problems

VII. GENETICS/PREDISPOSING FACTORS/BRAIN PATHOLOGY

GENETICS

• More prevalent among first-degree biologic relatives of people with the disorder than in the general population (DSM-III-R, 1987).

ADHD OFTEN COINCIDES WITH:

(DSM-IV, 1994)

1. Tourette’s Disorder (a disorder involving tics--sudden involuntary muscle spasms)
   
   
2. Child abuse or neglect
   
   
3. Multiple foster home placement
   
   
4. Usually lower IQ
   
   
5. Neurotoxin exposure (lead, etc.)
   
   
6. Infection (e.g., encephalitis)
   
   
7. Drug exposure in utero
   
   
8. Low birth weight
   
   
9. Mental retardation

OTHER PREDISPOSING FACTORS

• Some ADHD symptoms result from infection or trauma after birth (this is more difficult to treat than inherited ADHD because it usually involves some brain damage) (Validity of ADHD Syndrome, AADD23).
  
  
• Drugs and/or alcohol can cause sever ADHD symptoms and learning problems (fetal alcohol syndrome).

BRAIN PATHOLOGY

• Research strongly suggests that the majority of attention disorders result from a deficiency or imbalance of neurotransmitters (specifically norepinephrine and dopamine) or brain chemicals. These chemicals affect the frontal and central brain structures important for alertness and attention, and the premotor cortex responsible for motor inhibition and impulse control. (Validity of ADHD Syndrome, AADD23).
  
  
• In 1990, the New England Journal of Medicine reported that "the rate at which the brain uses glucose, its main energy source, was shown to be lower in persons with ADHD, especially in the portion of the brain that is responsible for attention, handwriting, motor control, and planning."
  
  
• Reticular Activating System--Mel Levine’s theory
  
  
• Brain Wave Abnormalities--EEG info.

VIII. POSSIBLE TREATMENTS

1. Drug Therapy. Ritalin is the most common stimulant used to calm the hyperactive symptoms of ADHD (low doses control the brief attention span symptom). Motor overactivity can only be controlled with higher doses of Ritalin, but with this, the optimum conditions for learning are sacrificed (Rosenhan, et. al., 1989).
   
   
2. Behavior Management. This method uses operant conditioning techniques, which means that it focuses on straightforward use of attention and tangible reinforcers of behavior which are systematically applied. For example, one research group gave an incredibly overactive little boy a penny for every ten seconds that he sat still. While the first session only lasted about five minutes, by the eighth session, his hyperactivity had virtually ceased (Rosenhan, et. al., 1989).

IX. BEST EDUCATIONAL APPROACH & ELS™

CH.A.D.D. LIST OF SUGGESTIONS FOR TEACHING ADHD CHILDREN

("Attention Deficit Disorder: and educator’s guide," 1993)

1. Predictability. With ELS™, especially if using a sequence, the student knows exactly which exercise consecutively follows.
   
   
2. Structure. This is built into ELS™: the lesson word construction and progression, mastery cycles, levels broken into cyclic lessons, and sequences that automatically proceed from one task to the next, are just a few of the structural means by which ELS™ reaches students.
   
   
3. Shorter work periods. ELS™ is different from most learning systems in that there is a time when the student gets out of his or her chair and reads to the teacher, or checks written work, or gets a worksheet graded--all of these are opportunities for the ADHD student to have a quick break and then get back to work.
   
   
4. Small student-teacher ratio. CEI always recommends a small student- teacher ratio for students with learning differences.
   
   
5. Individualized instruction. ELS™ was designed to cater to the needs of one individual. Each exercise provides the teacher an opportunity to change specific features of the task to best suit the student. The prescribed sequences were also designed with the specialized needs of the students in mind.
   
   
6. Motivating and interesting curriculum. The best way to describe ELS™ in its entirety is "motivating" and "interesting" to the students. Just ask them!
   
   
7. Use of positive reinforcement. ELS™ always provides feedback to any answer, right or wrong. Positive reinforcement )like the friendly voice, or points for trying to answer a question) in ELS™ is an essential element of a child gaining self-confidence in scholastic areas.

WORKS CITED

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed. rev.). Washington, DC: Author.

Attention Deficit Disorder: an educator’s guide. (1993) CH.A.D.D. Facts, 5, 1-4.

Attention Deficit Disorders--not just for children. (1993) CH.A.D.D. Facts, 7, 1-3.

Clayborn, M., Long, T., & Whitt, S. (1990). [Overview of ADD--title unknown]. 1-39.

Medical management of attention deficit disorders. (1993). CH.A.D.D. Facts, 3, 1-4.

Parenting a child with Attention Deficit Disorder. (1993). CH.A.D.D. Facts, 2, 1-2.

Parker, Harvey C., Ph.D. (1992). ADD fact sheet. Children with attention deficit disorders, 1-2

Rosenhan, D.L., & Seligman, M.E. P. (1989). Abnormal Psychology. New York: W.W. Norton and Company.

The disability named ADD: an overview of attention deficit disorders. (1993). CH.A.D.D. Facts, 1, 1-2.

Validity of ADHD syndrome. [No further documentation information available--AADD23 in CEI library], 14-36.

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