ABC Health & Wellbeing

Fact File

ADHD

by Peter Lavelle

Attention deficit hyperactivity disorder, or ADHD, is one of the most controversial topics in kid's health today. There is disagreement on how the disorder's definition is applied to individuals, and some people are concerned about the treatments prescribed for it.

Published 24/04/2003

[Image source: iStockphoto]

• Background
• Symptoms
• Diagnosis
• Treatment
• More info

Background

Few topics to do with kid's health arouse more controversy than Attention Deficit/Hyperactivity Disorder – or ADHD (also called Attention Deficit Disorder, or ADD).

Doctors vary in the way they apply the definition of the condition to individual children. Some experts argue that it's a set of behavioural characteristics and not a medical condition at all.

Also, it is usually treated with a class of drugs – psychostimulants – that are considered to be addictive and dangerous in adults.

But many people who have lived with ADHD, or have kids with it, say that since they were diagnosed and treated, their lives have been transformed. Where once they were unmanageable, they can now lead normal lives.

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Symptoms

Children with ADHD are unusually inattentive, hyperactive and show impulsive behaviour at home, school and in social settings – to a degree that is inappropriate for their age and development. They may:

• fidget and squirm in their seats
• have trouble concentrating on tasks or games
• not listen when they're spoken to
• talk excessively, run about, and seem to be always on the go
• get easily distracted
• act impulsively
• not wait their turn and blurt out answers.

This behaviour makes life difficult – often extremely difficult – for parents, siblings and teachers, and often for the child as well.

What causes this behaviour isn't known. It's thought that there may be a problem in those parts of the brain which normally inhibit impulsive behaviour – the cortex and the limbic system. This may be due to an imbalance in the brain's message-transmitting chemicals (neurotransmitters) in these areas. ADHD often runs in families – studies with twins have shown that ADHD is inherited – so these changes may be partly genetic.

There may also be social or environmental factors at work. In some cases children who have these symptoms haven't bonded well with their parents. In the case of boys, the father may sometimes be absent or emotionally distant.

There are two types of ADHD. The most common is 'Combined' type, where the child has poor attention and poor impulse control and is hyperactive. Less common is the 'Predominantly Inattentive' type, where the child is inattentive but not impulsive or hyperactive.

Boys are affected five times more often than girls. The symptoms usually start before the age of seven. It's been estimated that between three and five per cent of Australian primary school children are affected.

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Diagnosis

The diagnosis is usually made by a paediatrician or child psychiatrist, who interviews the parents and the child. If the child has enough behavioural characteristics indicative of ADHD, then the diagnosis of ADHD will be made.

In general, the paediatrician or child psychiatrist will take a detailed developmental history. Sometimes they also ask the child's teacher to fill in a questionnaire. For a positive diagnosis the symptoms need to have lasted for at least six months, begun before the child turned seven, and been happening both at home and school.

Because all two- to three-year-olds (and many four- and five-year-olds) are impulsive and inattentive, the symptoms must be slowing the child's ability to learn, socialise or function before an ADHD diagnosis is given.

The problem is that deciding whether a child has those characteristics is very subjective. To make things more complicated, there's no sign of physical abnormality in these children, and therefore there is no definitive physical test to prove that a child has the condition.

Paediatricians and child psychiatrists differ in how often they will diagnose ADHD, and sometimes it will come down to which paediatrician or child psychiatrist the child sees as to whether the diagnosis of ADHD is made.

A recent article in the Medical Journal of Australia highlighted the dangers of children mistakenly being diagnosed as ADHD when there may be other reasons why the child has these symptoms – social and environmental problems in the home, for example – and the child reacting to these.

So doctors should take a careful history of the child's family and social background to see whether things like upbringing and parental factors are the cause of the symptoms before a diagnosis of ADHD is made. It shouldn't be made after a single session with the child.

Parents also need to be well informed about the condition, through reading about and researching ADHD, before accepting the diagnosis.

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Treatment

Children diagnosed with ADHD are given a management plan, with the aim of reducing the effects of ADHD on the child's social, emotional and academic functioning.

The most common treatment for ADHD is psychostimulant medication such as dexamphetamine (trade name Dexadrine) or methylphenidate (Attenta, Ritalin). These are thought to act by normalising the imbalance in the brain's neurotransmitter chemicals. In general, only psychiatrists and paediatricians are allowed to prescribe them. They are given daily (in two to three doses) in tablet form and may need to be continued for months or years.

Ritalin LA (long-acting capsules) have recently been released in Australia. They only need to be taken once a day.

In many cases (about three-quarters of cases where the child has been correctly diagnosed) they work wonders – the child becomes much calmer and more controlled. Teachers especially notice the difference as the child is much more focussed on their work (although there's no evidence that school performance is actually improved).

Like all medications the stimulants can have side effects. The most common include loss of appetite and difficulty falling asleep. Some children initially become irritable, teary and withdrawn – this usually settles. In general, side effects are less common with methylphenidate (Ritalin) than with dexamphetamine. Children taking stimulant medication should be monitored.

The long-term effect on the development of the child's brain and nervous systems isn't known. And this is cause for concern amongst parents and some paediatricians, who worry that too many children are being treated with stimulants. Australia has about 50,000 children taking stimulants for ADHD, which makes it (per capita) the third highest consumer in the world after the United States and Canada. Consumption is especially high in Western Australia, where there are five times as many as children on stimulants than in Victoria.

Some paediatricians believe this is too high and that there should be more effort made to look at other possible social causes of the child's symptoms. If there are problems in the family or at school, then these need to be addressed, rather than having the child put on stimulants.

Some people turn to alternative therapies, and a diverse range of complementary and alternative therapies are used. None have been subjected to scientific research trials. Some of these therapies can be expensive, and some practitioners offer parents unrealistic hopes of a cure.

Not all children with ADHD require medication and those that do shouldn't be treated with medication alone. Parenting behaviours may need to change. Some suggestions for parents of a child diagnosed with ADHD include:

• Accept the situation; be patient.
• Set non-negotiable rules for behaviour and clearly state the consequences of not following the rules. If the rule is broken, warn, then act calmly and without argument.
• Set a routine and stick to it.
• Give praise and rewards for good behaviour.
• Be tolerant; ignore all but the important misbehaviours.

Reviewed by Dr Daryl Efron, Centre for Community Child Health, Royal Children's Hospital Melbourne.