Attention deficit disorder: characteristics, diagnosis, and management

Attention Deficit Disorder

According to the American Psychiatric Association (APA) (1994), Attention Deficit Hyperactivity Disorder (ADD or ADHD) is a diagnosis given to children and adults who display certain characteristic behaviors on a consistent basis over an extended period of time. The most common behaviors that characterize ADD include inattention, hyperactivity, and impulsivity.

According to statistics, people living with ADHD experience a continuous movement of sounds, images, and thoughts, similar to a fast-paced kaleidoscope (Johnson, 2002). ADD victims are easily bored yet are unable to concentrate. They are easily distracted and tend to daydream. The following statement describes the behavior of a typical child who suffers from ADD or ADHD: "Tommy can't sit still. He is disruptive at school with his constant talking and clowning around. He leaves the classroom without the teacher's permission. Although he has above-average intelligence, Tommy has trouble reading and writing. When he talks, the words come out so fast no one understands him" (Rees, 1994, p. 311).

As our knowledge of Attention Deficit Disorder increases, we are learning that ADD is more than just a disorder of childhood (Richardson, 1999). ADD is a life-long condition, as children with ADD grow up to be adults with ADD. ADD victims have relationships, children, and create families with many people. Thus, it is essential to treat children and adults with ADD, and their entire families.

The Importance of Treatment

It is widely believed that ADD runs in families (Richardson, 1999). Estimations show that there is a 30% chance that a child with ADD has at least one parent with ADD. There is also a 30% chance that the same child will have a sibling with ADD. According to Richardson, "Living in a family with ADD can be like living in a five ring circus. There is always someone or something that demands attention."

Parents naturally want to support their children and are often willing to sacrifice their needs for the needs of their children. The problem with this is that it is hard for people with ADD to provide consistent parenting for any child, let alone a child with ADD.

Families with ADD are prone to physical and verbal abuse. Substances like alcohol, food and drugs are often used to self-medicate the pain and frustration of untreated ADD (Richardson, 1999). Many parents of children with ADD suffer from Post-traumatic Stress Disorder (PTSD), which is a condition that occurs when people are subjected to extreme, ongoing stress that exceeds normalcy. PTSD symptoms include depression, anxiety, sleep disturbances, hyper-vigilance, and more.

For these reasons, it is imperative that ADD is treated in the context of the family, or individual's environment (Richardson, 1999). Behavioral therapy that is specific to addressing the symptoms of ADD is important. Family therapy that includes parents and siblings with and without ADD is also important.

Treating ADD

According to the Canadian Psychological Association (CPA), the best way to treat attention deficit disorders is by combining behavior therapy and medication. Behavior therapy can be very helpful in addressing and modifying the social and behavior problems in children with ADD (Johnson, 2002). Behavior therapy utilizes a series of techniques, concentrating on establishing distinct rules for a patient's behavior and giving him or her feedback through rewards and mild punishments. Some forms of behavior therapy include modeling, problem-solving, and social skills training. For children, behavior therapy often occurs in the classroom and at home, with the help of parents and teachers.

In some cases, it may be necessary and beneficial for a child with ADD to be medicated, in addition to participating in behavior therapy (Johnson, 2002, Rabiner, 2001). However, when determining whether or not medication is necessary, it is crucial to distinguish between the major symptoms of inattention, hyperactivity, and impulsivity, and the associated problems such as academic struggles, disruptive behavior, social difficulties, and emotional problems, including depressed mood and low self-esteem.

The American Psychological Association (1994) cites the importance of psychological assessment in diagnosing and treating childhood behavioral disorders, such as ADD. According to the APA, only psychological assessment has the ability to correctly distinguish between possible alternate diagnoses and improve intervention outcomes by: "describing current functioning across a range of environments; confirming or refuting clinical impressions; identifying treatment needs; identifying appropriate interventions; and providing a means of monitoring treatment progress. (APA, 1994)"

According to the American Academy of Pediatrics (AAP), following an accurate diagnosis, specific goals for treatment should be established (Seay, 2002). These goals, or target outcomes, may include improvements in relationships with parents, siblings, teachers, and peers; decreased disruptive behaviors and improved academic performance. The AAP recommends setting three to six goals and stresses that they should be "realistic, attainable, and measurable."

Goals should be reviewed and progress continually during treatment (Seay, 2002). Lack of improvement should result in a change in treatment plan, a reconsideration of goals, or in some instances, the possibility of a change in diagnosis.

The AAP stresses that "primary care clinicians cannot work alone in the treatment of school-aged children with ADHD (Seay, 2002)." Rather than relying solely on the doctor, the AAP recommends a team approach with continued communication between parents, teachers, and other professionals as they monitor the effectiveness of treatment.

Adults with ADD

Although the hyperactivity of childhood ADD may be somewhat "outgrown," recent research suggests that clinically significant inattentiveness and impulsivity often persist through adulthood (Watts, 2002). "This disorder causes significant problems for millions of adults," according to Dr. Leonard Adler, Associate Professor of Clinical Psychiatry and Neurology at NYU School of Medicine. "Yet their doctors, including internists and general practioners, often miss it."

Approximately eight million American adults are believed to be affected by ADD, but a majority remains undiagnosed, with only one quarter seeking medical treatment for symptoms associated with ADD. Adler and other ADD clinicians, in conjunction with the World Health Organization, have developed a new symptom assessment tool, the Adult ADHD Self-Report Scale (ASRS), to enable physicians to effectively evaluate the symptoms of ADD in adults.

Dr. Edward Hallowell, author of Driven to Distraction, expressed concern that general practitioners will misdiagnose patients with ADD if using these screening tools indiscriminately (Watts, 2002). "It is impossible to diagnose ADD properly," he says. "I would speculate that 55% of the population has what I call 'pseudo-ADD, sort of a severe case of modern life. They're going so fast, they're doing so much, they're so saturated with information overload that they look distracted, impulsive and restless."