What is New in Our Understanding of ADHD?
What a difference a decade makes.
Today, the disorder those letters represent - attention deficit disorder, more commonly known now as attention deficit/hyperactive disorder, or ADHD - is the subject of what seems like almost daily coverage in newspapers, magazines and even on TV.
"Many more people are aware of attention deficit disorder now," says Edward M. Hallowell, M.D., a psychiatrist and nationally recognized expert on ADHD who is on the faculty of the HarvardMedicalSchool. When Hallowell wrote his best-selling book Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood in 1994, most people hadn't heard of the disorder, he says. "On the other hand," he adds, "most people are still misinformed about what it is. While they have heard of it, they don't know what it is and they have many misconceptions and preconceptions."
What Is ADHD?
While diagnosis of the disorder is complicated by the fact that there is no precise test to identify it, ADHD is defined by the AmericanAcademy of Pediatrics (AAP) as a brain condition that makes it difficult for children to control their behavior. Though the disorder can manifest itself in different ways, children with ADHD tend to be inattentive, hyperactive and impulsive. Many children also experience trouble in school, difficulty in relationships with family members and their peers, academic underachievement and low self-esteem.
Citing the disorder as the most common neurobehavioral disorder of childhood, the AAP describes ADHD as one of the most prevalent chronic health conditions among school-age children, with between 4 percent and 12 percent affected by the disorder.
In Driven to Distraction, Hallowell - who has ADHD himself - wrote that ADHD was both underdiagnosed and overdiagnosed. That statement holds true still today, he says.
"It's two sides of the same coin," says Hallowell. "Some don't know about it so they miss it, and others, once they see it, they see it everywhere."
Greater Understanding and Treatment Options
The good news about ADHD is that recent years have seen an increase in the overall understanding of what the disorder looks like, says Alison Schonwald, M.D., a pediatrician at the DevelopmentalMedicineCenter at Children's Hospital in Boston and a pediatrics instructor at HarvardMedicalSchool.
"We know that not every child with ADHD is hyperactive," Schonwald says. "And not every child who is inattentive has ADHD."
For the past decade or so, there has been much controversy surrounding the use of medication to treat children with ADHD. For those who are properly diagnosed with ADHD, though, Schonwald says, the appropriate medication can provide a tremendous benefit.
This position is supported by the findings of a 14-month nationwide cooperative study called the "Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder." Known as the MTA, the study involved nearly 600 children, ages 7 to 9, and was the first study to look at long-term treatment of ADHD children. Essentially, the MTA's findings - the first of which were released in December 1999 - show that ADHD children do best with treatment plans that include both medication and intensive counseling. It also showed that medication alone is the best treatment if behavioral therapy is unavailable.
The medication most closely associated with the treatment of ADHD is Ritalin®. And though Ritalin used to be virtually the sole option for treating the disorder, Hallowell notes that the list of medications commonly used to treat ADHD has grown in recent years to include about a dozen different options.
The increased number of pharmacological options means that those with ADHD have more opportunity to find a medication that works well for them, Schonwald says.
"People are becoming more aware of the fact that stimulant medications can be so effective that it's important to try different classes of them to find the right match for a child," she says. "Just because one doesn't work, that doesn't mean another won't."
In recent years, new long-acting medications have grown in popularity. Where standard medications might be effective for three or four hours, the new long-acting ones typically remain effective long enough so that a child does not have to be dosed during school hours. The medication might also be effective long enough to carry a child through an after-school activity and even homework time. And there are other benefits as well.
"Often children don't like to be different," Schonwald notes. "And going to the school nurse to get their medication makes them different. Also, for some children, the highs and lows of short-acting medications are harder to tolerate. When a medication is wearing off, not only do many children have a harder time paying attention, but they can also get tearful."
Another study, just released in the January 2003 issue of the AAP journal, Pediatrics, may help allay some parents' fears about the use of stimulants to treat ADHD. This study, undertaken by Dr. Timothy Wilens, a child psychiatrist at Massachusetts GeneralHospital and HarvardMedicalSchool, found that children who take Ritalin or other stimulants to control the symptoms of ADHD actually cut their risk of future substance abuse by 50 percent compared to ADHD children who go untreated.
"Patients with untreated ADHD are at increased risk for developing substance abuse, likely due to self-medicating," Schonwald says. "By treating ADHD with stimulants, the risk of abuse actually diminishes substantially."
Hallowell looks forward to the day when there is a precise diagnostic test - perhaps in the form of a brain scan - that can be used to definitively diagnose ADHD. He believes that day might arrive within the next 10 years.
Focus on Behavioral Treatments
And while medications have been the focus of many current studies, Linda Pfiffner, Ph.D., director of the Hyperactivity, Attention and Learning Problems (HALP) Clinic in the Children's Center at Langley Porter, University of California - San Francisco, hopes that behavioral therapy will find a greater emphasis in the near future.
"All of the new medication interventions have been great in reducing symptoms. But medicine is not the magic bullet answer," says Pfiffner, the author of All About ADHD: The Complete Guide for Classroom Teachers. "Some parents will always choose not to medicate their children. I think we haven't taken behavioral therapy as far as it could go yet. That's the direction I'd like to see us go toward."
To that end, Pfiffner and her colleagues at the HALP Clinic have recently launched a three-year study funded by the National Institute of Mental Health to develop and evaluate a psychosocial intervention program for children with the inattentive type of ADHD without hyperactivity/impulsivity. The program includes parent groups, child groups and a teacher consultation component.
"I think we need more effort put toward nonpharmacological interventions," Pfiffner says. "And we need to do more work in coming up with programs that can be used in schools and also by parents."
Hallowell also calls for more attention to elements - aside from medication - that he considers vital to a person's success in coping with the disorder.
"The basic principles of treatment - for adults and children both - are structure, lifestyle changes and finding and developing your talent," he says. "There is a lot of focus on the medication, but you build a life on identifying your talent and pursuing it."
"Help children find and develop their talents," he advises. "That is very important and is often overlooked. What happens is people look for what's wrong and how to remediate the problems. And so, the child is given the message that he's a walking defect. What builds a sense of confidence and joy in life is helping a child find something that he or she is good at."
As for what the future holds in terms of increased understanding of ADHD, Hallowell says it's obvious that public education efforts need to continue.
"We need a grassroots effort where teachers, parents and grandparents are all part of the education process and ADHD becomes part of the received wisdom of childhood. We're a long way from where we need to get to," he says. "It's a very slow and difficult process. But we're certainly better off now than we were 10 years ago."
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