Riverview Psychiatric Center
Psychology Articles by Dr. Arthur Dingley
Living With Attention-Deficit/Hyperactivity Disorder
Dr. Art Dingley
A lot of ink has been wasted on Attention-Deficit/Hyperactivity Disorder (ADHD). The less one knows about it, the more he has to say. Most of this dithering supports one of two positions:
The first position is that ADHD is greatly over-diagnosed. Proponents of this idea blame psychiatrists for making a disease out of normal behavior. They blame schools for not teaching well enough to hold children’s interest and blame female educators for not understanding that boys are naturally more rambunctious. They blame drug companies for exaggerating the severity of ADHD to maximize sales.
The second position is that ADHD is greatly overlooked. Proponents of this idea blame psychiatrists for not diagnosing and treating ADHD, especially in adults. They blame schools for punishing the symptoms of ADHD as mere bad behavior or for passing children on to the next grade when they haven’t mastered the curriculum because of undiagnosed ADHD. They claim that medicines for ADHD should be more aggressively used.
When you encounter one of these positions, ask yourself whether the writer has some broader agenda. Is this someone who equates psychiatry with “mind control”? Does the writer complain chronically about the failings of public schools? Is the writer promoting some philosophical, political, or religious platform? Has he just written a new book, available soon in a store near you?
Mental health professionals approach the diagnosis of ADHD with great caution. Since the symptoms, by definition, must have been present before age seven, one may confuse ADHD with other childhood problems, and even with normal behavior. Children younger than seven are not very experienced at explaining their feelings, difficulties, and motivations. Diagnosing ADHD depends upon information from other sources, such as patents, relatives, and teachers. In one way, a diagnosis of ADHD requires the elimination of other problems as an explanation for a child's difficulties. A parent or teacher who is feeling overwhelmed by competing demands may long for a child who is better-behaved. A child may fail to complete school assignments, not from inattention, but from lack of adult supervision or expectations at home. He may fail in school, not from inattention, but from a pattern of oppositional behavior. A child who appears distracted or disorganized may have a learning disability or a developmental disability. He may have an undiagnosed visual or auditory deficit.
ADHD is a disorder of childhood. It may persist into adult life, but the symptoms must have started, by definition, before the age of seven. The child shows a persistent pattern of inattention or hyperactivity and impulsivity. Some children have both inattention and hyperactivity. The pattern must be present in more than one setting. If a child is inattentive or hyperactive only at school, ADHD is not the explanation. The difficulties caused by inattention or hyperactivity must go way beyond mere inconvenience. There must be clear evidence that the symptoms interfere with academic and social functioning.
The inattention of ADHD results in a child doing messy work with many careless mistakes, and without much real thought. She has trouble staying on task and completing games. She appears not to be listening and her mind wanders. She often appears not to have heard what was just said. She will develop a strong dislike for activities which require sustained mental effort or concentration. The child appears disorganized. His belongings and materials are carelessly handled, scattered, damaged, or lost. He is derailed from ongoing tasks by distractions other children easily ignore.
The hyperactivity of ADHD is seen as fidgeting, squirming, or refusing to remain seated. A hyperactive child has great difficulty with quiet activity. She climbs on things or runs inappropriately. She may seem to be “driven by a motor”, constantly in motion. She may talk non-stop. The impulsivity of ADHD is seen as impatience, refusal to wait for a turn, interrupting others, grabbing things from others, handling things she’s been asked to leave alone.
Remember that these symptoms are more or less continual, and are seen in every context. They aren’t merely annoying to others. They seriously interfere with the child’s participation in school, church, sports, clubs, friendships, and so forth. The symptoms may be worse in some situations, though, especially those requiring sustained concentration, or those perceived as boring.
ADHD is diagnosed many times more often in boys. The reason for this is unclear. It may be that boys are more prone to the hyperactive and impulsive form of ADHD. This form is hard to miss. Girls may suffer from the inattentive form more frequently. The inattentive form is less colorful and easier to ignore. If that is true, it is likely that girls under-diagnosed. Three to five percent of school-age children have ADHD. Children with ADHD are more likely to have close relatives with ADHD. These children are more likely to have close relatives with mood disorders, anxiety disorders, learning disorders, drug and alcohol abuse, and criminal behavior.
ADHD usually gets better on its own after adolescence. However, some children with ADHD carry all, or some, of their symptoms into adulthood. ADHD in adulthood looks different because the tasks of adult life are different. Adults with ADHD become frustrated with their seeming inability to accomplish anything which requires planning and persistence. They may jump from task to task, completing nothing. ADHD is impossible to diagnose in adults without being able to follow a clear trail of inattention or hyperactivity all the way back to childhood.
What makes ADHD worse? Children with ADHD may come to feel that they are “lazy or crazy”. The poor self-image that results from these ideas is guaranteed to make things worse. Being forced to use sustained attention in the presence of distracting noise or activity will make things much harder for someone with this disorder. Structured group activities are always difficult. Adolescents with ADHD may be seriously harmed by alcohol which increases impulsivity. Impulsive adolescents are risk takers, and the daily news is full of the tragic results. Adolescents with ADHD may discover a fondness for stimulant drugs such as cocaine and methamphetamine, resulting in addiction and criminal prosecution.
How is ADHD treated? Some children with ADHD respond well to frequent rewards for “good” behavior. Imposing strict, predictable, control for periods of time may help. Presenting information one-on-one is much more helpful than presenting it in a group situation where the opportunities for distraction increase geometrically. There are several medicines for ADHD. Although these medicines are very effective, they have side effects in some people. Fortunately, recent concerns that some medicines for ADHD were causing heart problems in children turned out to be incorrect. Some medicines for ADHD are highly abusable and may be sold, stolen, or misused, either by the patient or his family members. Students at competitive universities tell me that medicines prescribed for ADHD are widely available on the campus “black market” as study aids. The pills are being sold by students with legal prescriptions for them. There is a good deal of information on the internet about how to fake symptoms of psychiatric illness to get prescriptions for certain kinds of drugs, or to qualify for disability payments, and so forth. All of this makes doctors perhaps overly conservative in prescribing medicine for ADHD.
My next column will be about how psychiatric problems affect people with mental retardation.
Dr. Dingley is a psychiatrist with Evergreen Behavioral Services in Farmington. He may be contacted at adingley@fchn.org
