|Publisher:||American Academy of Pediatrics|
|Product dimensions:||5.90(w) x 8.90(h) x 0.80(d)|
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What Is ADHD?
Andrew Scott had always been an active child. From the time he learned to walk his parents noticed he was "into everything." Andrew's preschool teachers frequently commented on how active he was, and his kindergarten teacher observed that he was "quite a handful." First grade passed without any major problems, though his level of activity seemed to overwhelm some of the other children during playtime. In third grade, however, Andrew began to fall behind in math and reading. His teacher said he was too restless. During class he bothered the children around him. He seemed unable to focus on a learning activity for longer than a few minutes. On the playground he was "over-physical" with his peers, invading their space and then overreacting when they pushed him away.
Around the middle of the year, Andrew's teacher met with his parents. His teacher told them that Andrew's problems paying attention, his high activity level, and troubles with schoolwork may indicate the presence of attention-deficit/hyperactivity disorder (ADHD). She explained that ADHD often goes undetected until children enter school and academics and social relationships begin to be affected.
Despite the teacher's positive attitude, Andrew's parents were stunned by her recommendation that their son be evaluated for the causes of this behavior. They had always been challenged by their active child, but they had never considered his behavior out of the ordinary for a healthy young boy. As Andrew's father often pointed out, Andrew was "just like me when I was in school" — eager, excited, and always on the go. While both parents agreed that Andrew could use some extra help with his social skills and reading, they did not see how these behaviors could be thought of as a medical condition. "I think his teacher just can't handle him in class," Andrew's mother told her husband later when they were back at home. "She has a discipline problem and she calls it ADHD. I think it's the school that should be evaluated."
The Keller family was experiencing similar confusion. Their 12-year-old daughter, Emma, was also having problems. However, she was on the quiet and somewhat anxious side. Since early childhood, she had been a "dreamer" whose thoughts tended to drift easily. She often forgot things she had recently learned or been told and spent much of her time alone. In recent years, her "randomness" and lack of organization had begun to seriously affect her school performance, social life, and family relationships. She was having trouble completing tasks and was messy and careless about her schoolwork. Her parents noted that she was often forgetful or spacey. At times it seemed as if her mind was elsewhere and that she was not listening. Still, Emma's parents felt that her behavior was typical of many girls her age and was nothing that a little maturation and help with organization could not cure. Was it really necessary, they asked Emma's pediatrician, to consider this a medical issue or to start an evaluation?
As different as Andrew's and Emma's situations seem to be, both are typical for children with ADHD. Attention-deficit/hyperactivity disorder limits children's ability to filter out unimportant input, focus, organize, prioritize, delay gratification, think before they act, or perform other activities called executive functions that most of us perform automatically. In children such as Andrew, with hyperactive-impulsive elements to his ADHD, the disorder presents itself as his not being able to control impulses or regulate activity levels, even when he knows how he is expected to behave. In those with inattentive-type ADHD, including Emma, not being able to filter information means that someone walking by the classroom can claim as much attention as the teacher's lecture, and that a date with a friend can be forgotten in a flood of unsorted information.
These behaviors — short attention span, forgetfulness, not being able to sit still, unusually high activity level, and a tendency to act before thinking — are common in children. Families are often surprised when their child is referred for an evaluation. Adding to their confusion is the fact that these behaviors are present but to a lesser degree in all children and adolescents, although those with ADHD exhibit more extreme and immature forms of these behaviors. Many school systems will not allow teachers to describe their concerns as "perhaps ADHD" because they feel this is a diagnosis to be made by a physician or a psychologist. Instead they will describe the behaviors that a child is showing that are interfering with his learning.
These behaviors interfere in significant ways with children's day-to-day functioning, and they do not outgrow them at the same pace that other children do. Because other disorders, such as learning disabilities, oppositional defiant disorder, autism spectrum disorder, obsessive-compulsive disorder, anxiety, and depression can resemble ADHD (and, in fact, often accompany it), it can be difficult to tell whether a child has another condition, ADHD, or both. Finally, the fact that ADHD is diagnosed through careful observations of inattentive, hyperactive, and impulsive behaviors across the major settings of a child's life — rather than with laboratory tests used to diagnose such disorders as type 1 diabetes — leads some adults and the popular press to question whether ADHD exists at all.
Yet a large body of convincing evidence suggests that ADHD is a biological, brain-based condition. The scientific research on ADHD is more thorough and compelling than for most behavioral and mental health disorders, and even many medical conditions. Even so, among many parents, it remains controversial and misunderstood. As early as 1998 the National Institutes of Health, responding to public concern and debate about ADHD diagnosis and treatment, assembled a group of experts for a consensus conference on ADHD. These experts published their conclusions stating that ADHD is indeed a medical disorder.
Attention-deficit/hyperactivity disorder is among the most prevalent chronic childhood disorders, second only to asthma. National survey data from 2016 show 9.4% of US children have been diagnosed with ADHD. The Centers for Disease Control and Prevention has reported that about 4.5 million children (ages 3–17 years) in the United States have ADHD, and the condition currently accounts for as many as 30% to 50% of child referrals to mental health services. Many people believe that the prevalence of ADHD has increased significantly in recent decades, perhaps due to environmental factors, but there is no convincing evidence that this is the case. The number of children who have ADHD has likely remained roughly stable, but the number of children diagnosed with the condition has increased as more clinicians have become familiar with its symptoms and the problems it can cause. In addition, while it was originally thought to go away by puberty, it is now clear that many continue to have symptoms even into adulthood.
A generally reliable method for diagnosing ADHD based on the child's behavior and functioning has been established. Parents whose children have been adequately evaluated for ADHD, and who have implemented appropriate treatment as a result, frequently report that the difference before and after their child's treatment is "like night and day." While ADHD cannot be cured, children can be helped to compensate for their problems so that school performance and social relationships improve. As a result, their self-esteem increases, as do their chances for future successes.
In this book, you will learn how ADHD is defined and recognized, how it is evaluated, and how, according to the latest reliable scientific research, it can best be treated. Researchers have identified the types of behavioral, academic, and social supports most likely to be useful at school and at home. Courses and specific therapies have been developed to pass this information on to parents and teachers in the community. You will also learn about special concerns in the evaluation and treatment of preschoolers and adolescents with ADHD, and the changing effect of this chronic condition over time. This is not to say that we now know everything there is to know about the nature and proper treatment of ADHD. A number of questions remain to be answered, and there is a great deal of research still to be done. Active, ongoing studies may provide further insight into how these children can improve their experience at each stage of life. The good news is that the evaluation and treatment of ADHD is at a much more advanced stage today than ever before. Armed with the knowledge provided to you in these pages, you and your child will be able to address the challenges of ADHD with confidence and optimism.
Before learning about how ADHD is recognized, diagnosed, and treated, however, it is necessary to understand exactly what ADHD is — and what it is not. In this chapter you will learn
How the view of ADHD has evolved over time
How ADHD is defined today
What scientists believe may cause ADHD
How the condition typically alters a child's experience and what are its long-term effects
Through it all, always keep in mind that you have "a child with ADHD," rather than "an ADHD child." He is a child first and foremost, and the problems associated with ADHD can be worked on. Never lose sight of the whole picture.
How Is ADHD Defined?
On television and online, in magazines and newspapers, in social media, and in thousands of everyday conversations, there is ongoing debate around whether certain "ADHD-type" behaviors are a typical childhood experience or constitute a disorder that requires treatment. The issue of exactly where and how to draw the line between typical behavior and a clinical condition may become even clearer as increasingly sophisticated diagnostic techniques provide researchers with more information about the nature of the precise brain processes involved in children with ADHD, but the use of these tools and techniques for these purposes still lies in the future.
For more than a century physicians have been aware of children displaying the behaviors that we now call ADHD. In 1902 British pediatrician George Still first formally documented a condition in which children seemed inattentive, impulsive, and hyperactive, stating his belief that this was a result of biological makeup rather than poor parenting or other environmental factors. Research in the 1980s supported this hypothesis and led to the use of the term attention-deficit disorder. In 1987, in response to even more precise information provided by new studies, the term attention-deficit/hyperactivity disorder was introduced.
Today ADHD is defined by the American Psychiatric Association as developmentally inappropriate attention and/or hyperactivity and impulsivity so pervasive and persistent as to significantly interfere with a child's daily life. Children with ADHD have difficulty controlling their behavior in most major settings, including home and school. They may speed about in constant motion, make noise nonstop, refuse to wait their turn, and crash into everything around them. At other times they may drift as if in a daydream, failing to pay attention to or finish what they start. They may have trouble learning and remembering; they may appear disorganized. An impulsive nature may put them in actual physical danger. Because they have difficulty controlling this behavior, they may be labeled a "bad kid" or a "space cadet." These problems begin to occur relatively early in life (before age 12 years), though they sometimes are not recognized until a child is older. However, if there are absolutely no indications of ADHD before age 12 years, an alternative explanation for a child's later behaviors should be sought.
Professionals have identified clear differences between the functioning of a child without ADHD and a child with the condition. The presence of ADHD may be suspected if the
1. Inattentive, impulsive, or hyperactive behavior is not age appropriate — that is, if it is not typical of children of the same age who do not have ADHD.
2. Behavior leads to chronic problems in daily functioning. A mild tendency to daydream or an active temperament, which may cause occasional problems for a child but is not seriously disabling, is not considered evidence of ADHD.
3. Behavior is the child's usual way of acting and not a result of poor care, physical injury, abuse or neglect, disease, or other environmental influences. One way to determine whether the problem is environmental is to look at whether the problem occurs in more than one setting, such as at home and at school. If not, then an environmental cause, such as stresses at home or an inappropriate classroom placement, is more likely than ADHD to be the cause of the problem for the child.
For a child's condition to be diagnosed as ADHD, all 3 of these conditions must be met. Attention-deficit/hyperactivity disorder can only be recognized by its symptoms and by the problems that these symptoms create for the child. This is why it is so important for parents, teachers, mental health professionals, and medical experts to work together when evaluating a child for ADHD. Each contributes his or her own observations, experience, and expertise to create a comprehensive picture of the child's social, academic, and emotional progress.
Attention-deficit/hyperactivity disorder is divided into 3 general subtypes: predominantly hyperactive-impulsive presentation, predominantly inattentive presentation, and combined presentation. Children with predominantly hyperactive-impulsive–type ADHD may fidget or squirm in their seat, have difficulty waiting their turn, and show a tendency to be disorganized. They may act immaturely, have a poor sense of physical boundaries, and tend toward destructive behaviors and conduct problems. Children with predominantly inattentive-type ADHD, on the other hand, may seem distracted and "spacey" or "daydreamy" but not show the hyperactive component of the disorder. They may seem to process information slowly and may also have a learning disorder, anxiety, or depression. Children with combined-type ADHD typically exhibit many of the behaviors of the first 2 subtypes.
These subtypes tend to be diagnosed at different ages and stages of development. Because of the hyperactivity and impulsivity, children with predominantly hyperactive-impulsive type or combined type may be diagnosed as early as the preschool years in extreme situations. Children with predominantly inattentive type often go undetected until fourth grade or even later, when increased demands for sustained attention and more homework lead to significant problems in functioning. In the early grades children learn to read, but at around fourth grade they need to begin to read to learn. When this transition takes place, children with inattentive type typically begin to have more problems.
While the problems of hyperactivity/impulsivity and inattentiveness may seem at first to be unrelated, they both influence a child's inability to focus and function well in school, with peers, and in the family. Attention-deficit/hyperactivity disorder can be thought of as a range of "attentional disorders" with a number of possible symptoms shown at different ages and developmental stages.
What Causes ADHD?
No single cause has yet been identified for ADHD. Many risk factors have been noted, however, that affect a child's brain development and behavior, which, acting in combination, may lead to ADHD symptoms. They include genetic factors, variations in temperament (a child's individual differences in emotional reactivity, activity level, attention, and self-regulation), medical causes (especially those that affect brain development), and a host of environmental influences on the developing brain (including toxins such as lead, prenatal alcohol use, and nutritional deficiencies). Some research finds that children with ADHD may experience a delay in the typical maturing of their brain. Despite the many advances in research on the causes of ADHD, none of these findings are yet ready to help physicians make the diagnosis of ADHD.
Researchers are certain that ADHD tends to run in families. Close relatives of people with ADHD have about 5 times greater chance of having ADHD themselves, as well as a higher risk for such common accompanying disorders as anxiety, depression, learning disabilities, and conduct disorders. An identical twin is at high risk of sharing his twin's ADHD, and a sibling of a child with ADHD has about a 30% chance of having similar problems. Although no single gene has been identified for ADHD, research continues in this area. Brain imaging studies have found some differences in brain anatomy between children diagnosed with ADHD and those who have not been diagnosed, but no consistent pattern has yet emerged from these studies that would be helpful in confirming a diagnosis. The fact that children and adolescents respond so consistently to stimulant medications, and that these medications influence biochemical systems in the brain, suggests that biochemical causes may contribute to ADHD symptoms as well. This remains an area of active research. In the coming years newer brain-imaging tools and more sophisticated genetic techniques are likely to continue to shed more light on the processes underlying ADHD. Still, it is unlikely that a single cause will be identified.(Continues…)
Excerpted from "ADHD"
Copyright © 2019 American Academy of Pediatrics.
Excerpted by permission of American Academy of Pediatrics.
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Table of Contents
Please Note viii
A Note on Gender viii
Chapter 1 What Is ADHD? 1
Chapter 2 Does My Child Have ADHD? Evaluation and Diagnosis 17
Chapter 3 What Should We Do? Treatment Options 39
Chapter 4 The Role of Medications 67
Chapter 5 Managing ADHD at Home 95
Chapter 6 Parent Training in Behavior Management: Parenting Techniques That Work 119
Chapter 7 Your Child at School 151
Chapter 8 Advocating for Your Child and Others 189
Chapter 9 When It Is Not Just ADHD: Identifying Coexisting Conditions 211
Chapter 10 Complementary and Alternative Treatments for ADHD 249
Chapter 11 ADHD in Adolescence 273
Chapter 12 A Look at Your Child's Future 309