Attention-Deficit Hyperactivity Disorder

Attention-Deficit Hyperactivity Disorder (ADHD) is most often described as a childhood disorder but is more recently considered a problem that has consequences throughout ones lifetime. This article describes the disorder as it is primarily seen in children. ADHD is often called ADD, but techinically, this actual doagnosis according to the diagnostic manual is ADHD, primarily innattentive type. Other “types” include primarily hyperactive, meaning behavior shows overactivity, and “combined” type which shows both hyperactivity and difficulties with concentration and attention.

ADHD as described by The DSM-IV (Diagnostic and Statistical Manual- IV) includes either symptoms of inattention or hyperactivity-impulsivity with at least six symptoms in either area. Symptoms of inattention include: problems listening, following through on instructions, organizing work or activities, forgetfulness, reluctance or distaste of tasks that require sustained attention, and loosing things that are required for tasks or activities. Symptoms of hyperactivity include: general inability to sit still, fidgeting, problems playing quietly, driven behavior, and excessive talking. Impulsivity includes problems with blurting out answers, problems waiting turn and interrupting or intruding on others. Young children may be naturally more prone to hyperactive and impulsive behavior- so the criteria should have an onset prior to age 7 and should continue beyond that age and should create impairment in two or more areas at a clinically significant level.

ADHD is often difficult to distinguish from anxiety or oppositional behavior for a couple of reasons. First, children with ADHD often have co-morbid symptoms of anxiety and oppositional behavior. Second, anxiety and oppositional behavior often “look like” ADHD and can become confusing when presented by a parent or teacher who has already made up their mind the child has ADHD.

The following are two brief vignettes that one may see in clinical practice. This is an example of what behaviors might be observed in day-to-day life.

Little Johnny’s mother describes him as “very hyper”. She says that Johnny “is always moving, never sits on the couch but climbs all over it, and won’t stop talking”. Furthermore, his teacher says that he can’t stay in his seat for more than a few minutes, always butts in line when going to the lunchroom and he yells at the other children to hurry when playing a game. He often tries to play out of turn. Johnny is currently 12 and he has been having increasing problems for the past several years.

In this example, it is likely that Johnny has ADHD- Primarily Hyperactive-Impulsive Type. Three symptoms of hyperactivity and three of impulsiveness are described. (actual diagnosis requires more comprehensive information)

Billy is 10. His mother also describes him as “very hyper”. He does not like to go to bed at night and often puts up a fight. He does not play well with other children. He is impatient and often yells and fights with them. Billy does not listen when told to do his chores and he can’t seem to follow instructions given by the teacher. He is failing in school. He has been having these problems for some time.

In this example, Billy may have ADHD, inattentive type. However, the diagnostic criteria are not met. He may be oppositional based on his refusal to go to bed and fighting and he may be refusing to follow instructions rather than having trouble attending to them. If he is fearful of going to bed, he may suffer from anxiety, night terrors or he may simply be afraid of the dark. Often, anxious children may have trouble sitting still. School failure may be due to a specific Learning Disorder or reading problem and the course of the disorder is not clear from the description. This description might meet the diagnostic criteria for ADHD, Not Otherwise Specified, but the symptoms of inattention and hyperactivity-Impulsivity must be differentiated from anxiety, oppositional behavior and learning disorders. It is possible that these other symptoms are co-morbid with ADHD. An important question clinically may be: are oppositional and anxiety symptoms primary or secondary to ADHD.