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Attention Deficit Disorders in Childhood
by Peter Raffalli, M.D., Division of Pediatric Neurology
Attention Deficit Disorder comprises a spectrum of conditions starting in childhood, and often continuing into adulthood. These conditions affect executive functioning, including ability to maintain attention to task and to maintain age appropriate inhibition of impulse and movement. The diagnosis is often abbreviated "ADD" or "ADHD", the latter including "h" for hyperactivity.
Diagnosis
ADD is not a new diagnosis. Descriptions of children who have had problems with attention span and hyperactive behavior date back to the turn of the century. The term ADD itself is relatively new, however, and was established in the late 1970's and early 1980s.
Diagnosis of the condition is purely clinical and based on a thorough history by a medical doctor experienced in the diagnosis of this spectrum of disorders. Medical diagnosis is crucial because there are other neurological, psychiatrist and medical disorders that can mimic ADD. Proper treatment ultimately depends on a very careful and accurate diagnosis. No laboratory test to diagnose the disorder exists at the present time. Clinical doctors who commonly diagnose the condition are pediatric neurologists and pediatric psychiatrists.
Attention Deficit Disorders are estimated to affect 3-5% of the school age population in the U. S. There is often a family history of the condition. Older adult family members may not have been diagnosed with ADD, since this term is relatively recent. They may, however, clearly remember having similar difficulties with attention span, impulse control and school work as children. Some children seem to have no evidence of any family history of the disorder. The disorder affects boys more frequently than girls by a ratio of approximately 4 to 1. The diagnosis should be suggested in the history of the child as early as or before the age of seven years.
The Question of Hyperactivity
Not all children with ADD have hyperactivity. Since hyperactivity is often one of the more urgent reasons for referring a child for evaluation, the children without hyperactivity often do not come to medical attention until they are a bit older. It is important, therefore, to take a thorough history of the child, including elementary school years, to try to establish the entire course of the child&Mac185;s school functioning and social functioning.
Common ADD and ADHD Behavior
Examples of the types of problems that children with attention deficit disorder manifest include careless mistakes, difficulty sustaining attention, seeming not to listen, failing to finish tasks, difficulty organizing, avoiding tasks that require sustained attention, losing things, and being easily distracted and forgetful. These are clinical criteria set forth in the DMS IV, a diagnostic manual used by physicians across the country.
Examples of hyperactivity can include a number of types of overactive behaviors, including fidgeting more than expected for age, inability to stay seated, and excessive movement. Impulse is now recognized as a type of hyperactivity, and behavior that reflects impulsivity would include blurting out answers in a classroom before the teacher&Mac185;s question is completed, difficulty awaiting a turn, interrupting frequently, and intruding on others. Remember that children with primarily inattentive type of ADD may not have any hyperactive features and may manifest problems that are chiefly related to sustaining attention and maintaining vigilance to tasks.
A Biological Disorder
Attention deficit disorders are understood to be biological disorders based in neurochemistry. There have been a number of scientific studies documenting abnormal metabolism in the brains of patients with ADD. The dysfunction is based in neuro-transmitter activity.
Children with ADD have difficulty because they are disinhibited, not hyperexcited. It is the disinhibition or lack of "self control" that makes it difficult or impossible to sustain attention and control of their impulses. Recent scientific investigation has pointed to two particular neuro-transmitters, norepinephrine and dopamine, as key players in attention deficit disorders.
Treatment Pathways
Treatment for attention deficit disorders includes both pharmacological and non-pharmacological options. Not all children with ADD require medication, but for many children medication significantly improves the quality of life and their ability to learn. All children with ADD should have the option of academic adjustments and basic behavior modifications in place. As the children get older, and if they continue to struggle with the disorder, other superimposed emotional difficulties can result.
It is common for children with ADD to have low self-esteem and a very poor ability to tolerate frustration. It is common, therefore, to develop depression and other mood and conduct related disorders. For this reason, it is important that children receive an appropriate evaluation and treatment plan as early as possible.
Conclusion
In summary, the attention deficit disorders comprise a spectrum of conditions that affect a young child's ability to sustain attention and to inhibit himself or herself. ADD is both a medical condition and a learning disability and can significantly impact a child's ability to learn and ability to function socially. Pediatric neurologists and child psychiatrists are among the specialists that diagnose and treat this condition. A comprehensive treatment program, including both pharmacological and non- pharmacological strategies is often employed.
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