Hear the terms “attention deficit,” “ADHD” or “hyperactivity” and you probably conjure up images of a fidgety eight-year-old boy giving his teacher a hard time.
It’s normal for children to be fidgety and to become bored in certain social situations. For the child with attention deficit hyperactivity disorder (ADHD) these symptoms are more severe and occur more frequently. Diagnostic criteria require that the child have significant trouble staying focused, paying attention and controlling hyperactive behavior for six months or longer and to a degree greater than other children of the same age.
About nine percent of American school children are diagnosed with ADHD and taking medications to treat it. What happens to these children when they grow up? Does the attention deficit disorder simply go away?
Actually, in 70 to 80 percent of cases, it apparently does. Hyperactivity tends to diminish with age, and environments change. An active adult can choose an active vocation and not be cooped up in a classroom for six to eight hours a day.
One study found that persons who carry a certain gene have thinner brain tissue in areas of the brain associated with attention. As the person matures, these areas develop a normal thickness.
The other 20 to 30 percent, however, continue to show signs of attention deficit disorder, although it may have different manifestations. An adult with ADHD may try to do too many things at once and have a hard time focusing on one task long enough to complete it or do a thorough job. He or she may go after quick fixes rather than focusing on long-term goals.
The Troubled ADHD Adult
Many of these individuals lead troubled lives, according to a recent study published in the Archives of General Psychiatry [October 15, 2012]. Researchers at the New York University Child Study Center have been following 135 males diagnosed with ADHD at a mean age of eight and 136 similar males with no such diagnosis. After 33 years, researchers found that those with an ADHD diagnosis were not faring so well.
Only 3.7 percent of these subjects had more than a high school diploma (compared to 29.4 percent of control subjects), and this group had lower occupational and socioeconomic status. Nearly one third had been divorced at least once, and 57 percent had developed a psychiatric disorder.
The most common problems faced by the subjects with ADHD were substance abuse and antisocial personality disorder. And these subjects had an increased risk of committing suicide or spending time in prison.
According to the researchers, none of these troubled adults had developed any new problems. The substance abuse, underachievement, antisocial behavior and relationship issues had all been present during adolescence. In this group of patients diagnosed in the 1970s, however, the usual course was to discontinue treatment during the teen years because of a perceived risk of addiction to stimulants–the primary treatment at that time.
Many ADHD diagnoses are made among middle class children with good access to health care. These outcomes could be even worse among persons from lower socioeconomic status, the researchers pointed out.
This study makes a strong case for aggressive efforts to identify and treat ADHD at a young age and to continue this treatment in adults who continue to have symptoms. That might mean an even larger percentage of school children being treated.
Not all experts agree on this point, but those who argue that the disorder is already diagnosed too frequently are usually most concerned about the use of medication to treat children.
There is no cure for ADHD, but low doses of stimulant medications such as amephetamines and methylfenidate have been found effective in helping the patient manage symptoms and stay more focused. Recently, a few non-stimulant medications such as atomoxetine, guanfacine and clonidine have been added to the treatment arsenal.
Under medical supervision, these medications are considered safe. Recent studies have found no evidence that stimulants used to treat ADHD produce any risk of later cardiovascular effects in children without existing heart conditions. Anyone taking these medications over the long term, though, should be monitored for possible cardiovascular effects.
Side effects, which are usually minor and disappear over time, include decreased appetite and sleep problems. Very young children should be monitored closely for possible slower than average growth rates.
These medications are solely for managing symptoms, however. Although they may help a child pay attention in class and complete assignments, there is no clear evidence that they have any effect on learning.
Other components of treatment may be even more important:
• Behavioral therapy may include practical assistance in controlling anger, organizing tasks and completing homework.
• Social skills training may focus on sharing toys, asking for help, handling teasing.
• Family therapy is usually necessary to handle the mutual frustration, blame and anger that have built up. A therapist can teach the child and his/her family new skills, attitudes and ways of relating to one another.
• In many cases, parenting skills training is necessary–how to structure situations in a more positive way so that the child has a chance to get rewards and praise rather than constant criticism. Parents also benefit from learning stress management techniques.
ADHD often is just one part of the problem. Co-existing problems may include a learning disability, oppositional defiant disorder, conduct disorder, anxiety or depression, bipolar disorder, Tourette syndrome or substance abuse. These also require treatment. And, of course, it’s important not to confuse one of these problems with ADHD.
Children vary greatly, of course, in their activity level and behavior. Teacher and parents vary at least as much in their tolerance for certain behaviors.
Diagnosis of ADHD must never be taken lightly. A child should not be given drugs just for the sake of order and discipline in the home or classroom. On the other hand, failure to treat ADHD can sentence a child to a lifetime of trouble.
REFERENCES:
William T. Basco, Jr., M.D., M.S., “Trends in the diagnosis and management of ADHD,” Medscape Pediatrics, 2012.
Deborah Brauser, “Dopamine pathway alterations may be associated with symptoms of adult ADHD,” Medscape Medical News, September 11, 2009 (JAMA, 2990;302:1084-1091).
Megan Brooks, “ADHD persists in adulthood, ups mental illness, suicide risk,” Medscape Medical News, March 4, 2013 (Pediatrics online March 4, 2013).
Nassir Ghaemi, M.D., “ADHD at age 41: absent or antisocial or moody/anxious,” Free Associations blog, November 1, 2012.
Pam Harrison, “Childhood ADHD linked to poor outcomes in adulthood,” Medscape Medical News, October 18, 2012 (Archives of General Psychiatry, online October 15, 2012).
Nancy A. Melville, “Childhood ADHD linked to obesity in adults for first time,” Medscape Medical News, May 20, 2013 (Pediatrics online Mary 20, 2013).
National Institute of Mental Health, “Attention deficit hyperactivity disorder (ADHD),” NIH Publication No. 12-3572, revised 2012.
National Institute of Mental Health, “Attention deficit hyperactivity disorder: FAQ.”
Dr. Stephanie Sarkis, “French kids do have ADHD: an inteview,” Psychology Today, September 22, 2012.
Marilyn Wedge, Ph.D., “Why French kids don’t have ADHD,” Psychology Today, March 8, 2012.
Monica Williams, Ph.D., “When ADHD has nowhere to hide,” Psychology Today, May 17, 2013.
11/20/2013
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