Attention-Deficit/Hyperactivity Disorder

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What Causes AD/HD?

AD/HD is a neurobiologically-based developmental disability estimated to affect between 3-5% of the school age population (Professional Group for Attention and Related Disorders, 1991). No one knows exactly what causes AD/HD. Scientific evidence suggests that the disorder is genetically transmitted in many cases and results from a chemical imbalance or deficiency in certain neurotransmitters, which are chemicals that help the brain regulate behavior. In addition, a landmark study conducted by the National institute of Mental Health showed that the rate at which the brain uses glucose, its main energy source, is lower in subjects with AD/ HD than in subjects without AD/ HD (Zametkin et al., 1990).

Even though the exact cause of AD/HD remains unknown, we do know that AD/HD is a neurologically-based medical problem. Parents and teachers do not cause AD/ HD. Still, there are many things that both can do to help a child manage his or her AD/HD-related difficulties. Before we look at what needs to be done, however, let us look at what AD/HD is and how it is diagnosed.

What Are the Signs of AD/HD?

Professionals who diagnose AD/ HD use the diagnostic criteria set forth by the American Psychiatric Association (1994) in the Diagnostic and Statistical/ Manual of Mental/ Disorders; the fourth edition of this manual, known as the DSM-IV, was released in May 1994. The criteria in the DSM-IV (discussed below) and the other essential diagnostic features listed in the box on the next page are the signs of AD/HD.

As can be seen, the primary features associated with the disability are inattention, hyperactivity, and impulsivity. The discussion below describes each of these features and lists their symptoms, as given in the DSM-IV.

A child with AD/HD is usually described as having a short attention span and as being distractible. In actuality, distractibility and inattentiveness are not synonymous. Distractibility refers to the short attention span and the ease with which some children can be pulled off-task. Attention, on the other hand, is a process that has different parts. We focus ( pick something on which to pay attention), we select (pick something that needs attention at that moment) and we sustain (pay attention for as long as is needed). We also resist (avoid things that remove our attention from where it needs to be), and we shift (move our attention to something else when needed).

When we refer to someone as distractible, we are saying that a part of that person's attention process is disrupted. Children with AD/HD can have difficulty with one or all parts of the attention process. Some children may have difficulty concentrating on tasks (particularly on tasks that are routine or boring). Others may have trouble knowing where to start a task. Still others may get lost in the directions along the way. A careful observer can watch and see where the attention process breaks down for a particular child.

Symptoms of inattention, as listed in the DSM-IV, are:

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. (American Psychiatric Association, 1994, pp. 83-84)
   
   

Excessive activity is the most visible sign of AD/I ID. The hyperactive toddler/preschooler is generally described as "always on the go" or "motor driven." With age, activity levels may diminish. By adolescence and adulthood, the overactivity may appear as restless, fidgety behavior (American Psychiatric Association, 1994).

Symptoms of hyperactivity, as listed in the DSM-IV, are:

1. often fidgets with hands or feet or squirms in seat;
   
   
2. often leaves seat in classroom or in other situations in which remaining seated 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. (APA, 1994, p. 84)
   
   

When people think of impulsivity, they most often think about cognitive impulsivity, which is acting without thinking. The impulsivity of children with AD/HD is slightly different. These children act before thinking, because they have difficulty waiting or delaying gratification. 'The impulsivity leads these children to speak out of turn, interrupt others, and engage in what looks like risk-taking behavior. The child may run across the street without looking or climb to the top of very tall trees. Although such behavior is risky, the child is not really a risk-taker but, rather, a child who has great difficulty controlling impulse. Often, the child is surprised to discover that he or she has gotten into a dangerous situation and has no idea of how to get out of it.

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., butts into conversations or games).
   
   

It is important to note that, in the DSM-IV, hyperactivity and impulsivity are no longer considered as separate features. According to Barkley (1990), hyperactivity-impulsivity is a pattern stemming from an overall difficulty in inhibiting behavior.

In addition to problems with inattention or hyperactivity-impulsivity, the disorder is often seen with associated features. Depending on the child's age and developmental stage, parents and teachers may see low frustration tolerance, temper outbursts, bossiness, difficulty in following rules, disorganization, social rejection, poor self-esteem, academic underachievement, and inadequate self-application (American Psychiatric Association, 1994).

How Do I Know For Sure If My Child Has AD/HD?

Unfortunately, no simple test such as a blood test or urinanalysis exists to determine if a child has this disorder. Diagnosing AD/HD is complicated and much like putting together a puzzle. An accurate diagnosis requires an assessment conducted by a well-trained professional (usually a developmental pediatrician, child psychologist, child psychiatrist, or pediatric neurologist) who knows a lot about AD/HD and all other disorders that can have symptoms similar to those found in AD/HD. Until the practitioner has collected and evaluated all the necessary information, he or she must follow the same rule of thumb as the parent or teacher who sees the behavior and suspects that the child has the disorder: Assume the child might have AD/HD.

The AD/HD diagnosis is made on the basis of observable behavioral symptoms in multiple settings. This means that the person doing the evaluation must use multiple sources to collect the information needed. A proper AD/HD diagnostic evaluation includes the following elements:

1. A thorough medical and family history
   
   
2. A physical examination
   
   
3. Interviews with the parents, the child, and the child's teacher(s)
   
   
4. Behavior rating scales completed by parents and teacher(s)
   
   
5. Observation of the child
   
   
6. A variety of psychological tests to measure I.Q. and social and emotional adjustment, as well as to indicate the presence of specific learning disabilities.
   
   

It is important to realize that, almost characteristically, children with AD/HD often behave well in new situations, particularly in those that are one-on-one. Therefore, a well-trained diagnostician knows not to make a determination based solely on how the child behaves during their time together.

Sophisticated medical tests such as EEGs (to measure the brain's electrical activity) or MRls (an X-ray of the brain's anatomy) are NOT part of the routine assessment. Such tests are usually given only when the diagnostician suspects another problem, and those cases are infrequent. Similarly, positron emission tomography (PET Scan) has recently been used for research purposes but is not part of the diagnostic evaluation.

After completing an evaluation, the diagnostician makes one of three determinations:

1. the child has AD/HD;
   
   
2. the child does not have AD/ HD but his or her difficulties are the result of another disorder or other factors; or
   
   
3. the child has AD/HD and another disorder (called a co-existing condition).
   
   

To make the first determination, that the child has AD/HD, the professional considers his or her findings in relation to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders (4th edition), the DSM-IV, of the American Psychiatric Association (1994). A very important criterion for diagnosis is that the child's symptoms be present prior to age 7. They must also be inappropriate for the child's age and cause clinically significant impairment in social and academic functioning.

To make the second determination, that the child's difficulties are the result of another disorder or other factors, the professional considers the exclusionary criteria found in the DSM-IV and his or her knowledge of disorders with similar symptomatology. According to the DSM-IV, ''Attention-Deficit/ Hyperactivity Disorder is not diagnosed if the symptoms are better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, Personality Disorder, Personality Change Due to a General Medical Condition, or a Substance-Related Disorder). in all these disorders, the symptoms of inattention typically have an onset after age 7 years, and the childhood history of school adjustment generally is not characterized by disruptive behavior or teacher complaints concerning inattentive, hyperactive, or impulsive behavior" (American Psychiatric Association, 1994, p. 83).

Furthermore, psychosocial stressors, such as parental divorce, child abuse, death of a loved one, environmental disruption (such as change in residence or school), or disasters can result in temporary symptoms of inattention, impulsivity, and overactivity. Under these circumstances, symptoms generally arise suddenly and, therefore, would have no long-term history. Of course, a child can have AD/HD and also experience psychosocial stress, so such events do not automatically rule out the existence of AD/HD.

To make the third determination, that the child has AD/HD and a co-existing condition, the assessor must first be aware that AD/ HD can and often does co-exist with other difficulties, particularly learning disabilities, oppositional defiant disorder, and conduct disorder. All factors must be considered to ensure the child's difficulties are evaluated and managed comprehensively.

Clearly, diagnosis is not as simple as reading a symptom list and saying, "This child has AD/HD!" This Briefing Paper explores the issue of diagnosis in some depth, because no one wants children to be misdiagnosed. As parents, the more we know, the more we can help our children to succeed. We probably do not need to know how to use the DSM-IV. We probably do need to know that the person evaluating our child is using the specified criteria for AD/HD and all the components of a comprehensive assessment.

How Do I Have My Child Evaluated for AD/HD?

When a child is experiencing difficulties which suggest that he or she may have AD/HD, parents can take one of two basic paths to evaluation. They can seek the services of an outside professional or clinic, or they can request that their local school district conduct an evaluation.

In pursuing a private evaluation or in selecting a professional to perform an assessment for AD/HD, parents should consider the clinician's training and experience with the disorder, as well as his or her availability to coordinate the various treatment approaches. Most AD/HD parent support groups have knowledge of clinicians trained to evaluate and treat children with AD/ HD. Parents may also consult their child's pediatrician, community mental health center, university mental health clinics, or hospital child evaluation units.

It is important for parents to realize, however, that the schools have an affirmative obligation to evaluate a child (aged 3-21) if school personnel suspect that he or she might have AD/HD or any other disability that is adversely affecting educational performance. This evaluation is provided free of charge to families and must, by law, involve more than one standardized test or procedure.

Thus, if you suspect that your child has an attentional or hyperactivity problem, or know for certain that your child has AD/HD, and his or her educational performance appears to be adversely affected, you should first request that the school system evaluate your child. When making this request, it is a good idea to be as specific as possible about the kinds of educational difficulties your child is experiencing.

If your child is an infant or toddler, you may want to investigate what early intervention services are available in your state through the Part H program of the individuals with Disabilities Education Act (IDEA). You can find out about the availability of these services in your state by contacting the State Department of Education or local education agency (both of which are listed on NICHCY's State Resource Sheet), by asking your pediatrician, or by contacting the nursery or child care department in your local hospital. While your state may not specifically list AD/HD as a disability to be addressed through the Part H program, most states have a category such as "atypical children" or "other" under which an AD/HD assessment might be made.

Preschoolers (children aged 3-5) may be eligible for services under Part B of the IDEA. If your child is a preschooler, you may wish to contact the State Department of Education or local school district, ask your pediatrician, or talk with local day care providers about how to access special education services in order to have your child assessed.

Also, under the 1993 Head Start regulations, AD/HI) is considered a chronic or acute health impairment entitling the child to special education services when the child's inattention, hyperactivity, and impulsivity are developmentally inappropriate, chronic, and displayed in multiple settings, and when the AD/HD severely affects performance in normal developmental tasks (for example, in planning and completing activities or following simple directions).

If your child is school-aged, and you suspect that AD/HD may be adversely affecting his or her educational performance, you can ask your local school district to conduct an evaluation. With the exception of the physical examination, the assessment can be conducted by the child study team, provided a member of the team is knowledgeable about assessing Attention-Deficit/ Hyperactivity Disorder. If not, the district may need to utilize an outside professional consultant trained in the assessment of AD/ I ID. This person must know what to look for during child observation, be competent to conduct structured interviews with the parent, teacher(s), and child, and know how to administer and interpret behavior rating scales.

Identifying where to go and whom to contact in order to request an evaluation is just the first step in the process. Unfortunately, many parents experience difficulty in the next step: getting the school system to agree to evaluate their child. If the school district does not believe that the child's educational performance is being adversely affected, it may refuse to evaluate the child. In this case, parents may wish to pursue a private evaluation. It is also important to persist with the school, enlisting the assistance of an advocate, if necessary. Parents can generally find this type of assistance by contacting the Parent Training and information (PTI) center for their state, the Protection and Advocacy (P&A) agency, or the local parent group. A school district's refusal to evaluate a child suspected of having AD/HD involves issues that must be addressed on an individual basis; these organizations will typically be able to provide information on parent's legal rights, offer direct assistance, in many cases, and give specific suggestions on how to proceed.

For children who are evaluated by the school system, eligibility for special education and related services will be based upon evaluation results and the specific policies of the state. Many parents have found this to be a problematic area as well, and so eligibility for special education services is discussed in greater detail towards the end of this Briefing Paper. For the moment, however, let us look at what we know about managing AD/HD and the specific difficulties associated with the disorder.