Hyperactivity

Definition

This is a syndrome affecting children, adolescents and rarely adults, characterized by learning and behavior disabilities.

The symptoms may be mild or severe and are associated with functional deviations of the central nervous system without signs of major neurologic or psychiatric disturbance. Also called attention deficit disorder, hyperkinesis, and minimal brain dysfunction.

Description

ADHD (Attention Deficit and Hyperactivity Disorder) is a syndrome characterized by inattentiveness, lack of impulse control and excess energy (hyperactivity).

ADHD affects approximately 3 to 5 percent of all American children. The syndrome is 4 to 6 times more likely to occur in males than in females. In about half the cases, the age of onset occurs before age 4.

Hyperactivity is when the child seems to fidget, squirm and move about constantly and can't sit still for any length of time. Inattentiveness is when the child is easily distracted and has difficulty focusing or concentrating on a task. Lack of impulse control is when the child may get into frequent fights or act aggressively toward others with little cause.

Attention Deficit Disorder in Adults

Only recently has attention deficit/hyperactivity disorder (ADHD) been recognized in adults. Previously, it was thought that ADHD symptoms resolved in adolescence after brain development reached a certain point or when hormonal or other developmental changes occurred. Studies have since documented, however, that many children with ADHD continue to have symptoms in adolescence and adulthood.

An estimated 2 to 5 million adults have ADHD. In many cases, adults with ADHD symptoms never received a diagnosis or treatment as children.

The common clinical complaints among adults with ADHD are disorganization, poor concentration, inability to finish tasks before shifting activities, and procrastination, in addition to anticipatory anxiety and impulsive outbursts.

The consequences of untreated or inadequately treated adult ADHD include fewer completed years of education and more complaints of a disabling symptom such as inattentiveness or restlessness.

Other complaints may include sexual dysfunction, interpersonal problems, and antisocial personality disorders. The three psychostimulants most often used to treat adults with ADHD are dextroamphetamine sulfate (Dexedrine), methylphenidate HCI (Ritalin HCI), and pemoline (Cylert). Some adults do not respond to, or cannot tolerate, CNS stimulants. These patients may respond to a tricyclic antidepressant such as imipramine.

Causes and Risk Factors

A unitary biologic model to explain the syndrome has not been established. Some researchers believe that ADHD is due to a genetic defect that results in altered brain biochemistry. Differences in biochemistry are considered to be the cause of poor regulation of attention, impulsivity and motor activity.

In 1990, the New England Journal of Medicine published a landmark study by researchers at the National Institute for Mental Health which documented the neurobiological effects of ADHD through brain imaging. 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 inhibition responses.

Additionally, some researchers suggest that prenatal conditions such as maternal alcohol or drug abuse and birth complications may contribute in some cases.

Symptoms

ADHD characteristics often arise in early childhood. These characteristics may include:

• Fidgeting with hands or feet

• Difficulty in staying seated

• Difficulty in awaiting turns in games

• Difficulty in following through on instructions

• Shifting from one uncompleted task to another

• Difficulty in playing quietly

• Interrupting conversations and intruding into other children's games

• Appearing to be not listening to what is being said

• Doing things that are dangerous without thinking about the consequences

Diagnosis

The fact that the child exhibits ADHD-like behaviors does not prove that they are suffering from this disorder. It is quite possible that some other problem is causing these symptoms. In order to correctly diagnose ADHD the doctor must first rule out these "look-alike" factors by conducting a thorough physical examination and administering laboratory and other diagnostic tests:

Medical conditions. Allergy and effects of allergy medication, hearing loss, thyroid disorders, visual disturbances, genetic disorders (such as Fragile X syndrome), seizure disorders and chronic medical conditions.

Mental disorders. Anxiety disorders, conduct disorder, depressive disorders, oppositional defiant disorder, pervasive development disorder or Tourette's syndrome.

Behavioral and neurologic conditions. Articulation problems, coordination problems, encopresis (a type of soiling problem whereby children defecate in inappropriate places), enuresis (bed-wetting), night terrors and sleep difficulties.

Learning and language disabilities. Difficulties with listening, speaking, thinking, reading, writing, reasoning and performing mathematical calculations.

Additionally the doctor will take a thorough medical history and consult rating scales to confirm ADHD. The history should include a family, birth and general medical history gathered from family as well as school and day-care (if applicable) workers.

Treatment

Most ADHD therapy today involves a "biopsychosocial" approach - "bio" refers to medication, "psycho" refers to counseling and psychotherapy and "social" refers to instruction in self-management and training in social skills.

Medications

For decades, medications have been used to treat the symptoms of ADHD. Three medications in the class of drugs known as stimulants seem to be the most effective in both children and adults. These are methylphenidate (Ritalin), dextroamphetamine (Dexedrine or Dextrostat), and pemoline (Cylert).

For many people, these medicines dramatically reduce their hyperactivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as handwriting, and ability in sports.

Stimulants are not appropriate for every child with attention disorder. For instance, they are not intended for anyone with a primary psychiatric illness (such as schizophrenia, in which the person loses touch with reality) because they can worsen the disturbances. They can aggravate emotional problems, such as anxiety. They can bring out tics (involuntary movements) in a patient with a family history of tics.

Even a correctly administered stimulant can cause adverse effects, for no drug is completely without risk. The side effects most frequently reported are decreased appetite and insomnia. Less common are drowsiness, hypersensitivity, weight loss, headache, nausea, and blood pressure changes.

Whether a child should be given stimulants is a case-by-case decision in which the benefits are weighed against the risks. In the past, most stimulant treatments for ADHD were prescribed only for two to three years and only for children. But today, treatment may extend over longer periods and may be given to adolescents and adults.Stimulants clearly are not intended to be the sole treatment.

Other medications include clonidine (Catapres) and tricyclic antidepressants.

Counseling and Psychotherapy

Close communication between the physician and school personnel is essential.

Behavior Modification. Parents and children can be instructed in positive reinforcement techniques for rewarding desirable behavior and reducing negative behavior. Here are some strategies:

• Discipline can best be maintained by establishing a few consistent rules with immediate consequences when ever each rule is broken. Rules should be phrased positively in terms of what the child should do. Praise the child and reward him or her for good behavior.

• Structure a system of rewards for good behavior. This system encourages the child to work to earn privileges or rewards he or she wants by accumulating points for desired behaviors and removing points for undesirable behaviors.

• Make a written agreement (a contract) with the child in which the child agrees to do his or her homework every night or to demonstrate other desired behavior in return for a privilege.

• Provide a specified time-out location for when the child is out of control. This should not be seen as a place of punishment but a "calm down" spot.

• Set up a study area away from distractions and establish a specific time each day to do homework.

• Have the teacher make a checklist of homework to be done.

• Put up a calendar of long-term assignments and other tasks.

• Avoid emotional reactions such as anger, sarcasm and ridicule.

Psychotherapy. There are three different types of psychotherapy available: individual psychotherapy, cognitive behavioral therapy and family therapy. Individual therapy helps children with anxiety, difficulties with self-esteem, depression and other emotional problems. Cognitive behavioral therapy teaches children to modify their behavior by correcting the way they think about it. Family therapy assists the child and his or her family in understanding the condition.

Self-management/Social Skills

Self-management and training in social skills helps children curb aggressive, impulsive and socially maladaptive behaviors.

Alternative & Complimentary Therapies

There is no evidence to support the use of dietary management. Megavitamins, restriction of sugar, and supplementary trace minerals do not appear effective. Diets low in food additives or coloring are not effective.

Questions to Ask Your Doctor

How do you diagnose a hyperactive child?

How do you know the child's disorder is caused by deviations of the central nervous system versus just environmental discipline problems?

Would you prescribe a medication for part of the treatment?

What are the side effects?

How should I expect the child's behavior to change after starting the medication?

How long will the medication have to be taken?

What can be done to prevent social and emotional problems?

Does eliminating sugar and caffeine products help reduce hyperactivity?

What kind of behavior therapy will be planned?

And will someone be able to work with the family and teachers to follow the behavioral plan?

With medications and behavior-modification techniques, when should we start to see a change in the child's behavior and learning problems?