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Davis Square Family Practice
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Deborah Bershel, MD
Michelle Clark, NP
Carmen Phillips, NP
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Christopher Mulvey, NP
Attention -Deficit / Hyperactivity Disorder:
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Attention Deficit Disorder In Children and Adults
Diagnosis and Treatment Approaches


Attention deficit hyperactivity disorder (ADHD) is a developmental and behavioral disorder that affects 3% to 5% of all school-age children.

Although the condition usually manifests in childhood, it can persist into adulthood, causing difficulties at home, at school and at work if not recognized and treated.

In fact, experts now estimate that ADHD affects about 60% of adults who had ADHD in childhood.

Childhood ADHD is diagnosed after a child has shown six or more specific symptoms of inactivity and/or hyperactivity on a regular basis for more than six months in more than two settings. There is no single test for ADHD.

A physician can diagnose ADHD with the help of standard guidelines. The diagnosis of ADHD involves the gathering of information from several sources, including school, caregivers, and parents. The doctor will consider how a child's behavior compares with that of other children the same age.

Adult Attention Deficit disorder is really just coming to be recognized as a fairly common entity. Please refer to the section on inattention to see what the major criteria are for this diagnosis. As you might note, depression carries with it most of the same symptoms so please keep that in mind before jumping to any conclusions.

Treatment Note:(Detailed and important comments on treatment are listed at the end of this information sheet).

ADD vs. ADHD
Some children have problems that are related to attention (ADD). Others have ADHD, which refers to attention deficit hyperactivity disorder. If one has ADHD by the time adulthood is reached the hyperactivity component is often markedly diminished. There are 3 main aspects of attention deficit - input, output and energy level (for more info on this concept read “One Mind at a Time” by Mel Levine, MD)
Input - The information coming in gets ‘scrambled’
Output- The information going out from the child or adult gets scrambled
Energy - The person’s energy level is variable. For some children (and adults) there just isn’t the energy to perform certain tasks after a period of time. For example, after 15 minutes of solving math problems the child’s mind just cannot process another calculation.

SYMPTOMS of ADD and ADHD
Children with ADHD show signs of inattention, hyperactivity, and/or impulsivity in specific ways.

Inattention
Inattention may not become apparent until a child enters the challenging environment of elementary school. In adults, symptoms may manifest in work or in social situations.

A person with ADHD may have some or all of the following symptoms:

• Difficulty paying attention to details or prone to making careless  
  mistakes in school or other activities. Work is often messy and
  careless. 
• Easily distracted by irrelevant stimuli and frequently interrupt ongoing
  tasks to attend to trivial noises or events that are usually ignored by
  others. 
• Inability to sustain attention on tasks or activities. 
• Difficulty finishing schoolwork or paperwork or performing tasks that
  requires concentration. 
• Frequent shifts from one uncompleted activity to another. 
• Procrastination 
• Forgetful in daily activities (for example. forgetting to bring lunch) 
• Failure to complete tasks like homework or chores 
• Frequent shifts in conversation, not listening to others, not keeping   
  ones mind on conversations and not following details or rules of
  activities in social situations

Hyperactivity
The symptoms of hyperactivity may be apparent in very young preschoolers and are nearly always present before the age of seven

Symptoms include:

• Fidgeting, squirming when seated 
• Having to get up frequently to walk or run around 
• Running or climbing excessively when its inappropriate (in teens this
  may appear as restlessness) 
• Difficulty playing quietly or engaging in quiet leisure activities 
• Always on the go 
• Often talks excessively

Hyperactivity may vary with age and developmental stage Toddlers and preschoolers with ADHD tend to be constantly in motion, jumping on furniture and having difficulty participating in sedentary group activities (such as listening to a story) School-age children display similar behavior, but with less frequency They are unable to remain seated, squirm a lot, fidget or talk excessively In adolescents, hyperactivity may manifest itself as feelings of restlessness and difficulty engaging in quiet sedentary activities.

Impulsivity
Symptoms of impulsivity include:

• Impatience 
• Difficulty delaying responses
• Blurting out answers before questions have been completed 
• Difficulty awaiting one's turn 
• Frequently interrupting or intruding on others to the point of causing
  problems in social settings 
• Initiating conversations at inappropriate times

Impulsivity may lead to accidents (knocking over objects, banging into people, etc) Children with ADHD may also engage in potentially dangerous activities without consideration for the consequences (climbing to precarious positions).

Many of these symptoms occur from time to time in normal youngsters However, in children with ADHD they occur frequently, at home and at school, or when visiting with friends, and they interfere with the child's ability to function normally.

ADHD is diagnosed after children consistently display some or all of these behaviors in at least two settings, such as at home and in school, for at least six months.

Treatment

Most children and adults with ADD do not require treatment. This condition presents as a spectrum and often does not significantly hamper a child’s or adult’s ability to live a fully functional and happy life. But when a child is thrust into a classroom setting or an adult is working in certain job setting or personal relationship, conflicts may arise.

For the child with ADD, it is important to understand that she is not (necessarily) being defiant or lacks intelligence but that she has struggles with certain tasks that many children find easy. Over time, many of the features of ADD will lessen but the child’s learning style may always be a bit nontraditional. As parents we have to find a balance between the importance of fostering our child’s self-esteem and our fears (which are often unfounded) that if we don’t ‘find a solution’ right away then our child will not function well as an adult.

As an adult, the distractibility, absentmindedness, chronic lateness and general inability to focus on important (but perhaps boring) tasks can persist.  This can hamper an adult with his ability to perform on the job and make long-term relationships challenging to maintain (or leave).

Medication:

Medication works- We used to use tricyclic antidepressants more often but there was a rare incidence of heart rhythm irregularities in children. We now use low dose  amphetamines or Strattera for medical treatment. Both of these medications can cause ticks. With amphetamines there can be a loss of appetite and weight and some minor temporary slowing down of growth. There is no evidence that using low dose amphetamines to treat ADD increases the risk of substance abuse as a teen or adult (of course, some do end up abusing drugs). In fact, there is a marked reduction in substance abuse among children with ADD who are placed on medication. The big question in my mind is what happens to people who are on these medications for 30-40 years. Is there a permanent change in the brain that is not ideal. So far there is NO EVIDENCE for any damage and amphetamines have been used for childhood ADD for many years.

At the Hallowell Center (a clinic that focuses on ADD)  in Sudbury they have begun to use neurofeedback to treat ADD in patient who don’t respond to behavior modification training, don’t want to take medication or did not respond to medication. Neurofeedback is about as effective as medication to treat ADD. At the end of 2009 I went out to California to be trained in neurofeedback. At the time of this writing (Jan. 2010) I have had limited personal experience with the use of neurofeedback to treat ADD but I am quite convinced of it’ safety. I am interested in providing this treatment to patients who might be interested.

Resources:

www.chadd.org  Website for the organization (Children and Adults with Attention Deficit Hyperactivity Disorder)

Helpful Books For Childhood ADD

One Mind at a Time - Mel Levine, MD (delves into ADD and many other aspects of learning -very readable and inexpensive book)

Driven to Distraction - Ned Hallowell, MD

Jones, C. (1991). Sourcebook for Children with Attention-deficit Disorder. Tucson, AZ:
Communication Skill Builders, 3830 Bellevue, PO Box 42050, Tucson, AZ 85733

Jones, C. (1994). Attention-deficit Disorder Strategies for School Age Children. Tucson,
AZ: Communication Skill Builders, 3830 Bellevue, PO Box 42050, Tucson, AZ 85733

Jones, C. et al (1999). Parent Articles About AD/HD. Tucson, AZ: Communication Skill
Builders, 3830 Bellevue, PO Box 42050, Tucson, AZ 85733

Books for Adult ADD

Steven Safren, Susan Sprich, Carol Perlman and Michael Otto, "Mastering Your Adult ADHD: A cognitive-behavioral treatment guide for organizing, ignoring distractions, and controlling impulses” (Oxford University Press 2005)
Symptoms of Childhood ADHD

One Mind at a Time - Mel Levine, MD (as noted in children’s section)
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