ADHD - Attention Deficit Hyperactivity Disorder
ADD - Attention Deficit Disorder

Distraction, disruption, dyslexia and drugs
This feature article on attention deficit hyperactivity disorder was written by Dr Tony Hanne, an Auckland GP who specialises in ADHD. Your own family doctor will be able to provide help with ADHD.

What do the following people have in common?
A 10-year-old boy with a high IQ who still cannot read or write;
A 12-year-old girl with the nickname ‘motor mouth’ who cannot stop talking;
A 4-year-old from a stable home who has been expelled from kindergarten for leading a mass escape;
A mother of two whose home is in chaos because no job ever gets finished;
A teenager who is a chronic TV channel surfer and a constant fidget;
A father of many kids by numerous partners who keeps moving on because he is bored;
A soldier who volunteered for bomb disposal and found a minefield in Cambodia to be the most fulfilling place of his life.
The answer may well be attention deficit hyperactivity disorder (ADHD).

The problem is not new - it was first accurately described in children by Dr Still in 1902. The effectiveness of stimulants in its treatment was first observed in 1937. Its modern title, ADHD, goes back to 1983. But the realisation that ADHD is not just a childhood disorder came not much more than 10 years ago.
ADHD is a problem that affects about 5% of the population. Even so, it has taken a long time for ADHD to be accepted as an important problem, and it remains a very controversial topic.

How is ADHD defined?
ADHD is defined as being excessively distracted, and this is usually accompanied by impulsiveness. It is present by the age of seven years and it should be apparent in more than one setting, for example at home and in the classroom. People can be distracted from an idea, an emotion, an action or a relationship. The distraction may come from outside or be within our own thoughts. With the tendency to be distracted usually goes poor short-term memory.

What are the consequences of ADHD?
In children, this combination (distraction and poor short-term memory) can cause learning difficulties and underachievement compared with the child’s actual ability. Sometimes, this includes dyslexia, even to the point of illiteracy. In adults, distraction will cause forgetfulness for names, phone numbers, appointments, car keys, cell phones and wallets. One man with ADHD claimed he had broken into his own house 30 times during the last year. Poor organisation is stressful for everyone involved, and stress often leads to conflict and depression. More than 50% of the adults I have seen with ADHD have been diagnosed with, and often treated for, depression. Impulsiveness is the tendency to speak or act without thinking of the consequence. Most people have a thought, and then hold a ‘mental committee meeting’ to consider the effect of the plan. Very often, the committee will abandon the idea for the sake of the individual or others. In ADHD, the committee is always ‘out to lunch’. The result is actions that cause damage to many relationships – family, friends, teachers, employers, marriages. This can take many forms, for example, opening the mouth and ‘putting the foot in it’, substance abuse, criminal behaviour, violence, suicide, gambling, dangerous driving. Some recent statistics on ADHD are deeply disturbing. Untreated ADHD sufferers are twice as likely to be substance abusers, five times as likely to be in jail and four times more often involved in traffic accidents than the rest of the population.

Frequent myths about ADHD :
Young people with ADHD may be hyperactive, particularly up to intermediate school age, but it is a common misconception that no hyperactivity means no ADHD. The condition presents as a spectrum, from the extremely hyperactive and impulsive through to the inattentive dreamer. Many of those at the dreaming end of the scale are missed throughout the school system and just written off as lazy or dumb. Another frequent misconception is that this is a disease of boys. While it is true that boys are diagnosed with ADHD about four times more frequently than girls, there is probably no difference between the sexes in true incidence. Certainly, among adults, the numbers of men and women with ADHD are about equal. Since, by definition, the problem had to be there by the age of seven years, it is obvious that the girls were missed because their behaviour did not create enough trouble to bring them to attention.

What is the cause of ADHD?
Many explanations of the causes of ADHD have been fashionable. Head or birth injuries, chemical poisoning from sprays, additives, or heavy metals, allergies and poor parenting have all been blamed. Any of these factors may have aggravated the problem, but there is no evidence they are causes of true ADHD. Head injuries are more common in ADHD patients than the rest of the population simply because poor concentration and impulsiveness frequently make them accident-prone. ADD is jokingly defined by some as ‘Absent Dad Disorder’, but this is an effect not the cause. Certainly, a far higher proportion of ADHD kids than one would expect are living in solo-parent families but often the family story reveals the solo status being the result of having a parent with ADHD. Coping with an ADHD child can be immensely demanding, and just one burden too many in an already struggling marriage. A loving, stable, two-parent home moderates the effects of ADHD but it does not prevent the condition. Dr Christopher Green, a world expert on ADHD, says that often the parents of ADHD kids are the best in the world – they have to be! The evidence is now clear from much research that the disease process behind ADHD is a relative lack of the brain chemical dopamine (important in concentration) in certain areas of the brain. This relative deficiency has a strong genetic basis. Specific gene sites have been demonstrated in some affected families. It is often helpful to draw up a family tree and identify the family members probably affected by ADHD. Difficult family relationships are then easier to understand. In general, if one parent is affected, there’s about a 50% chance the child will have the same problem. I have some families in which both parents have ADHD, in which case the risk of ADHD children rises to about 75%. In other families I am aware of ADHD through four generations. It is important to remember this sort of exercise is not there to allow people to blame others. Identifying family members with the same problem is a way to allow better understanding, not attribute guilt.

How is ADHD diagnosed?
The diagnosis of ADHD is based on details obtained from careful listening by the doctor to the patient’s history. Often, it can take up to a whole hour for a family to tell their story in their own words, with minimum prompting by the doctor. Questionnaires are sometimes used to help make sure all of the key areas are covered but some doctors do not use them because they can in fact give bias towards details that are not necessarily part of the patient history. Some questionnaires are available on the internet or in books such as ‘Driven to Distraction’ by Hallowell and Ratey. The most popular are from overseas experts such as CK Connors and TM Achenbach. Corroboration of the story from parents, siblings, spouses and teachers is often sought. School reports over a number of years are a great help because, even in today’s environment of politically correct reports (where no child is acknowledged as having a problem), comments about concentration, distraction and having trouble completing work crop up year by year. It is important to allow for a full assessment by a doctor before arriving at a firm ‘yes’ or ‘no’ conclusion to the question of ADHD. And it is important to keep an open mind until this assessment is complete, as it can be much harder to assess the person accurately if someone, or their family, has already made their mind up. Simple tests of concentration and of intelligence are used during the doctor’s assessment, and sometimes a visit to an educational psychologist will help to obtain a more accurate measure of ability and specific learning difficulties. Another test, sometimes used, is the computer-based Test Of Variable Attention (TOVA), which can measure concentration and impulsivity either visually or auditorally. The test is both specific and sensitive for ADHD; however, no test is more important than the careful detailing of the person’s history. While ADHD can often be a relatively straightforward diagnosis for a doctor to make, there are other possibilities to consider, some of which may co-exist with ADHD or else be separate issues. At least half the children with ADHD also have oppositional defiant disorder (always taking the opposite point of view), conduct disorder (antisocial behaviour with no apparent conscience) or a specific learning disorder. Other conditions can be confused with or be present in addition to ADHD. Asperger’s syndrome describes children who seem emotionally cut off from others while sharing many of the other features of ADHD. Depression is common because of the frustration caused by ADHD. Anxiety may accompany ADHD because past experience has shown that impulsive decisions frequently go wrong. Obsessive-compulsive disorder occurs particularly in those with ADHD who are perfectionists, frustrated by their unreachable standards in the face of poor concentration. Tourette’s syndrome is a rare and progressive neurological condition that starts off like ADHD. Petit mal epilepsy can mimic the inattention of ADHD. Intellectual handicap from birth or brain damage can appear as poor attention, but these people are achieving according to their limited ability. In adults, schizophrenia and bipolar disorder can occur on top of pre-existing ADHD. Hypothyroidism will cause slow responses in those affected, but this condition should be abundantly evident for other reasons.
There are several options for managing ADHD Medications may come immediately to mind. They can be life changing, if used appropriately, but they are only a part of good management in ADHD. There are four other key ways to making progress. Lifestyle change is vital in children and adults. It begins with understanding the problem better through reading, listening to educational tapes or attending educational groups, and then establishing new habits including routines, taking on one task at a time, and learning to hold the ‘mental committee meeting’. Dietary modification in children. This means reducing amines, salicylates and glutamates, and differing reports claim it helps between about 5% and 20% of ADHD sufferers, mainly those under six years. While diet modification is a complex area, a good discussion of this and alternative treatments is available at New Zealand ADHD online. Importantly, beware of extreme and faddish diets. Life is hard enough for such children, without making them miserable on weird diets. (The most significant ‘dietary’ problem in young adults is marijuana, with alcohol a close second. These, and caffeine, are widely used for self-medication.) Educational help. This is most effective on a one-to-one basis. Specific Learning Disabilities Federation (SPELD) tutors are great for dyslexic problems. Understanding and working with the best learning styles, whether visual, auditory or hands-on, is a huge help. Support. Family and friends who encourage but do not take over are a big asset. Voluntary organisations like the ADHD Association, ADDvocate and Teenadders all do a brilliant job. Psychotherapy of all kinds has not been shown in studies to make a significant difference, and can even get in the way of good family support.
Medications for ADHD have been around for a long time Methylphenidate (Ritalin, Rubifen) and dexamphetamine have been around since 1954 and 1937, respectively. They are equally effective and each suits a different 80% of ADHD patients. Methylphenidate has been the first choice drug in New Zealand . It has an excellent record of safety and, properly used, it is not addictive. It raises the dopamine level and so improves concentration. Side effects are usually minor and brief. Despite popular rumour, physical growth is not affected long term. The dose required varies according to the child’s response; however, it should be remembered that the goal is optimal concentration and learning, and this may be achieved at a lower dose than that needed to result in compliant behaviour. The slow-release form of methylphenidate, which lasts six to eight hours, helps avoid the need for a lunch time (at school) dose. However, it does not suit everyone. Antidepressants of various kinds are also used in ADHD but they have much less effect on concentration. Clonidine (a drug usually used to treat high blood pressure) does nothing for attention but may help to contain really difficult behaviour. Risperidone (an antipsychotic drug) is becoming more widely used for the same purpose. All these can be taken with methylphenidate – your doctor can explain how best to take them and what to watch out for in terms of side effects. None of the numerous so-called natural products for treating ADHD have been shown in randomised controlled trials to provide a better result than placebo (dummy medication).

Stimulant abuse :
Abuse of stimulant drugs is a difficult issue. The medical and pharmacy professions prevent it as far as possible by regulating the supply and through close co-operation, while maintaining drug availability for the patients who need it. This is for the benefit of everyone - the vast majority of ADHD patients do not abuse the medications but the safety measures need to be in place for the few who might. Having ADHD does predispose that person to substance abuse, so there will be a number of people with both ADHD and a substance abuse problem. There is a risk such ADHD patients will be denied stimulant treatment, but this may be avoidable if the patient is motivated to deal with the abuse and there is good medical, family and community support. There are wider treatment options overseas including Adderall, a long-acting dexamphetamine, and Ritalin LA, which last for 12 hours. These medications are not currently subsidised by the New Zealand government, and their importation is not permitted. New potential drugs are being tested but it will be some time before they have the proven record of effectiveness and safety of the currently available medications. The most effective way to manage this common and potentially damaging problem is good teamwork, which includes a motivated patient. This article was orginally published in Pharmacy Today newspaper. Ó 2003 MediMedia (NZ) Ltd.

For further reading, I recommend:
Understanding ADHD by Dr Christopher Green
The Hidden Handicap by Dr Gordon Serfontein
You and Your ADD Child by Ian Wallace
ADD in Adults by Dr Gordon Serfontein
Driven to Distraction by Drs Hallowell and Ratey
Answers to Distraction by the same authors

All of these are available from good bookshops or the library.