Attention Deficit Hyperactivity Disorder
by Kenneth Lyen
Hyperactivity refers to a pattern of behavior, affecting both children and adults, which is manifested by an excess of physical activity, poor attention span, easy distractibility, weak impulse control, and disruption to classroom and other activities. Attention deficit disorder (ADD) may be considered a milder form of this disorder, and includes a short concentration span, without the more severe manifestations of hyperactive behavior.
Problems with the Diagnosis
The definition of hyperactivity varies according to the culture the child finds himself in, and this makes diagnosis difficult. Asians, for example, tend to be less tolerant of hyperactive behavior, and expect children to be well-disciplined. Unfortunately, there are no definitive tests to diagnosis hyperactivity, and the boundary between normal and abnormal is very blurred. In this article, the term hyperactivity will be used interchangeably with attention deficit hyperactivity disorder (ADHD).
Hyperactive behavior is a condition which can be traced back to ancient times. Research into this condition was first documented in the early 1900s by the English physician, George Still. He thought that hyperactive behavior was due to brain problems rather than moral failing, which was the prevailing attitude of that era. During the 20th century, many labels and definitions of the disorder have come and gone. These include "minimal brain damage, minimal brain dysfunction, hyperkinetic reaction of childhood, defect in moral control, post-encephalitic disorder, and hyperkinesis." Current diagnostic changes have revolved around delineating the disorder according to whether the symptom of inattention exists with or without the symptom of hyperactivity.
In the West, hyperactivity and attention deficit affects 3 to 5 percent of the childhood population. This rate is about three times higher if teacher or parental interviews are used to obtain the information.
If one member of the family has an attention deficit, there is a 70 percent genetic risk of another member getting it. Hyperactivity is three times more common in boys than in girls. It is probable that hyperactivity is under-diagnosed in girls. About 80 percent of children with hyperactivity perform below their academic potential, with about 20 to 30 percent of these children evidencing true learning disorders. Approximately 25 percent of children and adolescents with hyperactivity demonstrate antisocial behaviors and conduct disorder.
A low frustration threshold predisposes such children to uncontrollable tantrums. A short attention span and inability to concentrate may result in failure at school even if the child displays a high IQ. Poor judgement and lack of "common sense" are often observed. They become especially troublesome as the child grows older.
The diagnosis of attention deficit hyperactivity disorder can be quite difficult, because each child has a unique set of manifestations. In addition, the pattern may fluctuate from time to time. Symptoms may range from mildly abnormal behavior (eg. difficulty focusing) comparable to that of a normal lively child, to severely aggressive and disruptive conduct. Sometimes, a single symptom or only a few symptoms may be present, and thus the child would be missed.
- Easily distracted and forgetful
- Difficulty focusing, cannot pay attention
- Going from one activity to another quickly, failing to complete homework or chores
- Difficulty sitting still, squirming in the seat
- Being fidgety, playing with fingers, or tapping with the feet
- Talking incessantly
- Interrupting frequently
- Not listening when directly spoken to
- Difficulty waiting for ones turn
- Blurting our answers to questions
- Difficulty obeying instruction
- Difficulty playing quietly
- Losing things frequently
- Often doing potentially dangerous activities, prone to accidents
Hallowell and Ratey used the analogy of shortsightedness. Like myopic people who have difficulty focusing with their eyes, people with attention deficit hyperactivity disorder have difficulty focusing with their minds. Both conditions are invisible to others but very much apparent to the person who suffers from it. Both are amenable to treatment if the condition is severe enough to warrant it.
The diagnosis of hyperactivity is subjective and difficult. To qualify for a diagnosis of hyperactivity, a child must exhibit several of the above symptoms for a period longer than six months, and the symptoms must have appeared before the age of seven years. It is of interest to note that one does not need to be hyperactive to have attention deficit disorder (ADD). Indeed up to a third of children with ADD do not display overt hyperactive behavior. But they do have problems focusing their mind. Three types of ADD are now recognized.
- ADD predominantly characterised by hyperactivity symptoms.
- ADD predominantly characterized by symptoms of inattention
-ADD with a significant number of both kinds of symptoms.
There are many causes of hyperactivity, but for a given child with the condition, the cause usually cannot be determined. Known factors predisposing to hyperactive behavior include genetic influences, or children whos mothers who during their pregnancy have been heavy drinkers of alcohol, have been on illicit or addictive drugs, or have been heavy smokers. There is increasing evidence that food additives, such as artificial coloring, preservatives and flavors, may contribute toward hyperactive behavior. Intolerance or allergy to certain foods or drinks, such as milk, shellfish, sugar and wheat, may produce hyperactivity in some children. Toxic pollutants such as lead, mercury, cadmium, insecticides, and herbicides, have also been implicated as potential causes.
It has been noted that children with brain injury or autism spectrum disorder often have hyperactivity. However, the converse is not the case. It is rare for children with attention deficit hyperactivity disorder to have any brain damage or autism spectrum disorder.
The treatment of hyperactivity is controversial. There are those who advocate behavior modification and psychotherapy, some who recommend medication, and others who believe in the elimination of food additives (Feingold diet). The results of treatment are often variable. In Singapore, the medicine available is Ritalin (methylphenidate). This is available in the standard preparation, and as sustained release. Contrary to popular belief, Ritalin is not a sedative. In fact it is a brain stimulant. The medicine works by enhancing higher brain activity which improves concentration, and reduces restlessness. The controversy with drug therapy is as follows:
- Some parents do not like to see a quieter child, preferring the personality and behavior of the original hyperactive child. One possible solution is to give the medication during schooldays, and to stop it at weekends and holidays.
- There are side effects of Ritalin, such as loss of appetite and weight loss. This can be obviated by taking the medicine after food. It can cause insomnia, and therefore Ritalin should be given after breakfast and not in the afternoon. It can also cause irritability and tics.
- The standard preparation tends to wear off after a few hours, and there may be rebound restlessness. This can be ameliorated by using the sustained-release formulation.
- When the hyperactive behavior is improved, underlying disorders, such as autism, may become more apparent.
A small number of children with hyperactivity improve when placed on a special diet in which food additives are eliminated. Often referred to as the Feingold Diet, this includes the avoidance of "fast foods", carbonated drinks, cordials, tinned food, restaurant food, and the elimination of food and drinks to which the child has an allergic type of sensitivity. Another controversial therapy is based on the premise that if you give an affected child lots of physical exercise, this will exhaust him, and he will behave better.
Strategies for the Home
Children with hyperactivity can learn to keep in check certain facets of their behavior. Parents need to draw up and implement a system of rules and rewards. They should also try to recognise their childs strengths and weaknesses in order to help them build up their own self-regard and assurance. Try the following strategies:
- Establish a few consistent rules of conduct. Phrase these rules positively in terms of what your child is expected to do. If these rules are broken, deal with them immediately with a set of actions that you have previously worked out. You should have a set of "deterrents" that you and your spouse have agreed upon, and you must not display disagreements on their imposition in front of your child.
- Praise your child and reward him for good behavior. Hyperactive children tend to respond well to a structured system of rewards for good behavior. By awarding points for preferred behavior and subtracting points for undesirable conduct, this system encourages the child to earn privileges or rewards through better behavior. You can make charts or use stickers to demonstrate the results of good behavior. Try to concentrate on a few behaviors at a time. Additional behaviors can be tackled as others are controlled.
- For the older child, draw up a written contract with your child whereby he promises to do his homework every day or exhibits certain desired behaviors. On completion of the task or adherence to the behavior, the child can choose certain privileges, such as the right to watch a particular television program. If your child fails to discharge his side of the contract, the promised privilege can be withdrawn.
- Provide a time-out place for your child to go to when he or she is unmanageable. This should not be seen as a location for punishment, but rather as a place the child uses to cool off. The best place is probably the childs bedroom. Just ensure that the place is safe for the child. Younger children may have to be instructed to go to the time-out location, but older children should realize themselves when they need to cool off and go on their own.
- Create an area free from distractions and specify a time every day for your child to do homework. He should not be permitted to watch TV or listen to loud rock music while doing homework.
- Keep a calendar of long-term plans and stick it on the refrigerator door or noticeboard.
- Make your child write in a notebook what homework the teacher has set him, and check it every night to ensure that it has been done.
In general, adopt positive strategies such as using praise and rewards. Do not expose or dwell upon your childs weaknesses. Instead, you should help your child build his personal strengths. Avoid using sarcasm, mockery, or hostility. It only makes him feel dejected when told: "its so easy, anyone can do it." Short, mild rebukes can help him focus his mind.
It used to be thought that children will totally grow out of their hyperactive behavior. Some symptoms, such as attention deficit, will improve with age. However, there is evidence that just over half the children with hyperactivity will continue to experience related problems as adults.
Many adolescents with hyperactivity lag behind their peers academically and are more prone to substance abuse and antisocial ats. Hence, psychological services and support should be provided throughout the entire period of the hyperactive childs schooling. Smaller class sizes enabling teachers to give more individualized attention, discovering and encouraging special skills in art, music and sports, can also help the hyperactive child.
Any Advantages to Having Attention Deficit Hyperactivity?
According to Hallowell and Ratey, individuals with ADHD tend to be warm, creative, flexible, loyal, innovative and hard-working. Unfortunately, if their hyperactivity is too severe, they may not have the opportunity to express these positive qualities.
The diagnosis and assessment of hyperactivity is subjective and difficult. Unless there are more objective measures of the degree of hyperactivity, the efficacy of treatment will always be open to doubt. The author proposes that one could borrow techniques used in computerized gait analysis and combine it with continuous video recording, to derive an index of motor hyperactivity. These data can then be added to results of psychological testing. A composite picture can then be derived which will not only assist in the diagnosis, but will also help in measuring the degree of hyperactivity. There is obviously a lot more work to do before we can understand more fully the cause and management of this challenging condition.
[This article first appeared in Rainbow Dreams.]