Attention-Deficit Hyperactive Disorder

By Travis Meyer



I. Introduction


Attention-deficit Hyperactivity disorder is defined by the DSM IV as such: “The essential feature of Attention Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.”

ADHD is perhaps the disorder with which regular education teachers are most familiar. This could be due to the fact that it is not categorized as a learning disability, but as an “other health impairment.” It is a disorder characterized by its effects on the student’s ability to focus, sit still during instruction, and/or control impulsivity of action. Because such characteristics as these are inherent to children in general many teachers seem to believe the prevalence of ADHD in school-age children is higher than the actual statistics show. In reality, only 3%-7% of school-age children (American Psychiatric Association, 2000) are affected by the disorder. But because environmental factors, namely a child’s upbringing, can directly contribute to behavioral patterns in school, such undesired behaviors can be too easily attributed to undiagnosed ADHD.

II. History of ADHD

Though attention deficits have surely afflicted people throughout human history, it was not until George Still, in 1902, first wrote about attention problems of his subjects. Though there was no such diagnosis of ADHD at the time, his observations included many characteristics that would later be associated with the disorder. Over time, as these observable attention deficits were being studied more prevalently, the symptoms were crystallized into many names, such as “hyperkinetic impulse disorder”, and “hyperactive child syndrome” (Barkley, 1997). This term, in the DSM II, then became “hyperkinetic reaction of childhood” (Barkley, 1997). It is important to understand though, that the disorder, throughout evolution of its definition and diagnosis, was mainly understood as a syndrome characterized by hyperactivity. The latter term did, however, contain in its definition, a mention of attention problems and distractibility. By 1980, the disorder was renamed Attention-Deficit Disorder (ADD).

And finally, by 1990, because of the work of researchers like Russell Barkley, the hyper-activity component of the disorder was included, thus it was renamed Attention-Deficit/Hyperactivity Disorder (ADHD) (Barkley, 1997). The structure of this wording is very important. It is the same structure that currently leads to misunderstanding of the disorder’s manifestations. The backslash (/) punctuation serves to show that the disorder can be characterized by either attention-deficit or hyperactivity, and that it could be a combination of both. Unfortunately, the misunderstanding of ADHD has come full-circle, where now it is seen more as a hyperactivity disorder, and that a diagnosis of ADD, or attention deficit disorder, would characterize those with more of the attention deficit component. But all attention deficits diagnoses are given the label ADHD, regardless of which end of the spectrum the individual falls.


III. Causes of ADHD


The executive functioning of the frontal lobe is a critical focus area of research on ADHD, as many researchers have been working to build evidence to support the connection of its functioning with the manifestations of the disorder. While there are many factors that researchers believe contribute to ADHD, such as genetics, exposure to maternal smoke and alcohol during pregnancy, and other environmental factors, the executive functioning of the frontal lobe is where the difference lies between individuals with the disorder and those without. If one is searching for information on ADHD, then overloading the content of a wikispace such as this with all of the possible causes does no real good.

If you are interested in more information about possible causes, here is a helpful and informative link: http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/what-causes-adhd.shtml.

So in terms of causes of ADHD, the information contained herein is confined to the connection of executive function to the symptoms of the disorder. This is because the primary goal of this research is to help the parent, sibling, friend, educator, or the ADHD sufferer himself understand the disorder and how it affects the individual with the disorder. In turn, it is my hope that this will help those supporting the individual with ADHD be able to understand what he deals with on a daily basis. For the sufferer, hopefully this research will provide some insight into why he feels the way he does, and how he can help himself.

The etiology of the disorder shows that the direct cause of problems with executive functioning is an imbalance of norepinephrine and dopamine in the pre frontal cortex. This imbalance decreases the ability to communicate with other regions of the brain. But what does this really mean for the individual with the disorder? What are the actual effects that can be attributed to this chemical imbalance and lack of communication between the regions of the human brain? For the teacher, the parent, or the sufferer, this answer is critical to understanding the negative effects ADHD can have on daily tasks.


III. Symptoms:


These are the six clusters of cognitive functions that tend to be impaired in individuals with ADHD: (For a complete description of each executive function, click the link below and read the article by Thomas E. Brown, PhD)

1. Activation
2. Focus
3. Effort
4. Emotion
5. Memory
6. Action
Link: http://www.drthomasebrown.com/pdfs/cmgarticle.pdf

These six clusters, listed as one-word descriptions of functioning, only help to further generalize what most people already know or assume about sufferers with ADHD. If you were to click the link and read the article by Brown, a much clearer picture of what the ADHD sufferer goes through would be painted. I will help to explain each through a summary of the important points described by Brown and a commentary on the misconceptions by those who do not suffer from the disorder:


  1. Activation: Individuals with ADHD have difficulties starting tasks, which can be characterized by excessive procrastination. As Brown states, “It is as if they cannot get themselves started until the point at which they perceive the task to be an acute emergency” (Brown, 2009). Think of the frustration for the sufferer—they are perceived as careless and lazy, because they do not start the task until the very last minute. This is caused, not by some motivational flaw in them as a person, but by the low levels of activity in the brain that would otherwise allow the individual to perceive the appropriateness of starting a task promptly.
  2. Focus: Brown uses the descriptions of individuals with ADHD to brilliantly illustrate what it feels like to focus on a task. In fact, the descriptions can really only be so clearly understood and thus illustrated by someone who has first-hand knowledge of the disorder’s effects. They describe trying to complete a task while distractions around them as well as their own thoughts continually get in the way. And the example of a radio station fading in and out while trying to listen to the music is a perfect analogy. It should then be easy for a teacher to understand how a student could quickly fall behind in a class despite giving the students ample time to read, work, and prepare to execute new skills.
  3. Effort: Brown describes effort in terms of alertness. He does this to show that it is not that an ADHD sufferer is not putting-forth effort when attempting to complete a task and consequently failing to do so, but is actually struggling, feeling not fully awake. It is here that Brown offers the correlation between sleep and ADHD. Sufferers are said to have difficulty sleeping because their brains continue to remain active. This could cause them to get insufficient sleep. Then, during the waking hours of the day, when tasks must be completed, they struggle to do so because of the lack of mental alertness. Thus, we can see that ADHD affects sleep, and sleep exacerbates problems with effort, focus, and activation.
  4. Emotion: This aspect of executive function helps to see the interconnection between all of the executive functions. Many with the disorder find it difficult to dismiss emotions such as frustration, anger, worry, disappointment, desire (Brown, 2009), but instead focus too heavily on them, allowing them to pervade their every thought. It becomes apparent, when considering this difficulty, how the simplest tasks may not even be attempted by an individual with ADHD if they are experiencing one of these emotions.
  5. Memory: The description of memory functioning helps to understand why a task may not be completed by an individual with ADHD. Brown shows how they have described having exceptional long-term memory, but struggle to remember things that have just occurred. This difficulty only adds to their inability to complete tasks by providing another, perhaps more significant, hurdle to overcome.
  6. Action: This executive function deals with the individual’s ability to control impulses, which is one of the main criteria for diagnosis. Most know ADHD’s affect on controlling actions, what one says, and the ability to monitor appropriateness. But this description goes beyond this common understanding to explain how patients have trouble regulating the timing of their actions. Again, we can see how all of the functions are interconnected. If a task is to be completed, the individual must know how fast he must work to finish in an appropriate amount of time. This can directly affect the quality and the completion of many different tasks.

A common misconception is to think that all people can be said to have ADHD, because all people struggle with these functions at one time or another. But Brown clearly states that those legitimately diagnosed with ADHD differ from others in that they are significantly impaired by chronic difficulty with these cognitive functions (Brown, 2009).

A thought for teachers: Based on this important research and first-hand accounts from individuals with the disorder, it should be easier to see how difficult a day in school must be for a student with ADHD. If we can look at the problems they have with executive function, we should be able to see that these students are not inherently lazy, careless, or defiant. Instead, educators should see the lack of task completion, distractedness, hyper-activity, and impulsivity as effects of something beyond their ability to cope. This does however, open the door for the thinking that teachers should help these students find ways to be successful in order to overcome these problems.



IV. Education and the ADHD student:


Students with ADHD experience a variety of problems in school. These problems, like their symptoms, are interconnected, meaning that each problem can serve to affect all aspects of the student’s school-life. This of course, does not mean the effects are exclusive to school-life. The effects on relationships with others as well as on the individual himself reach beyond the classroom.

Academic performance is certainly affected. The child’s inability to begin a task, to focus during task completion, and follow through with completion can negatively affect their learning. Students with ADHD show poor performance on tests, poor writing, and careless work (Wolraich et al., 2005). Their poor performance on standardized tests are most likely directly affected by their higher rates of absenteeism (Barbaresi, et al., 2007).

Social consequences of ADHD are caused by the students’ hyperactivity, impulsivity, and inattention during class. It can be difficult for these students to make friends because their classmates can have difficulty tolerating their disruptive behavior (DeNisco et a., 2005).

Interventions for students with ADHD

The most effective interventions to help students with ADHD become more successful in school are those that use the Function-Based Assessment approach, or FBA. The function of the behavior, be it to obtain something preferred or avoid something nonpreferred, once identified, is used to inform intervention efforts (Stahr et al., 2006). Basically, a student’s reason for a behavior must be identified before interventionists can help the student monitor, change, or eliminate the undesired behavior. FBA addresses this by allowing for a systematic approach to uncovering the student’s function of their behavior, thus informing the approach that must be taken to change the behaviors.

One such study illustrated the effectiveness of such interventions. The study by Brenna Stahr et al. (2006), focused on a fourth-grade boy with ADHD whose off-task behaviors where exhibited at high rates throughout the school day. Through interviews, observations, rating scales, and experimental analysis, the interventionists were able to determine that the student’s behavior was maintained by the teacher’s attention to these negative behaviors.

As a result of the systematic FBA procedures being carried out, the interventionists were able to implement self-monitoring strategies and a checklist. They were able to determine that planned ignoring would allow for extinction of attention seeking behaviors. And the interventionists were able to develop a system for the student to request help and gain praise. None of the successful interventions implemented would have been possible without FBA.



V. Future Research: Adult ADHD



Most of the research that exists on ADHD focuses on children with the disorder. But there is more and more research being done on adults with the disorder. A recent study of self-reported symptoms of ADHD by college students showed that 10.3% of students who were never diagnosed with ADHD experienced high levels of ADHD symptoms (Garnier-Dykstra et. al, 2010). The study acknowledges the fact that one-third to one-half of children diagnosed with ADHD experience symptoms that persist into adulthood Garnier-Dykstra et. al, 2010). But the researchers’ wanted to determine the prevalence of significant symptoms of ADHD in those who were never diagnosed with the disorder.

Their findings, that 10.3% of those surveyed had high levels of symptoms, suggests that more study is needed in the area of adult ADHD. It also highlights the importance of discussing and studying the DSM-IV’s diagnostic criteria that at least some symptoms of ADHD must have been present before the age of 7 years. This is something that Brown highlights in his article, stating that no empiric justification for this stipulation has ever been established (Brown, 2009). Perhaps there is some value in studying whether or not symptoms of ADHD can actually become more acute as an individual gets older. Perhaps the symptoms exist before age 7, but are not as pronounced. Brown makes the critical point that the cognitive functions impaired in ADHD are among the slowest brain functions to fully mature. He goes on to state that brain functions that provide infrastructure for executive functions do not fully come on line until the late teens or early 20s. For some affected individuals, impairments of ADHD may not be noticeable until they are challenged with increased demands for self-management typically not presented until late adolescence or early adulthood (Brown, 2009). This point, while expressing a well-understood concept of development, goes against common diagnostic practice.

It is easy to see that an individual could struggle all through grade-school and still get by. But when the demands for performance increase, these individuals may reach out for help or search for answers. At this point, they may not remember their symptoms being so severe when they were children. But regardless, they should still be considered for diagnosis of ADHD if they are found to fit the other criteria.


References:


Barbaresi, W;, Katusic, S;, Colligan, R;, Weaver, A., & Jacobsen, S. (2007). Long-term school outcomes for children with attention-deficit/hyperactivity disorder: A population-based perspective, Journal of Developmental and Behavioral Pediatrics, 265-273.

Barkley, Russell A., (1997). ADHD and the Nature of Self Control, 4-6. New York, New York.

Brown, Thomas E. (2009). ADD/ADHD and Impaired Executive Function in Clinical Practice. Current Attention Disorder Reports, 37-41.

Brown TE: Attention Deficit Disorder: The Unfocused Mind in Children and Adults. New Haven, CT: Yale University Press; 2005.

Barbaresi, W;, Katusic, S;, Colligan, R;, Weaver, A., & Jacobsen, S. (2007). Long-term school outcomes for children with attention-deficit/hyperactivity disorder: A population-based perspective, Journal of Developmental and Behavioral Pediatrics, 265-273.

DeNisco, S., Tiago, C., & Kravitz, C. (2005). Evaluation and treatment of pediatric ADHD. The Nurse Practitioner, 14-30.

Garnier-Dykstra, Laura M., Pinchevsky, G., Caldeira, K., Vincent, K., & Arria, A. (2010). Self-reported Adult Attention-Deficit/Hyperactivity Disorder Symptoms Among College Students. Journal of American College Health 133-136.

Salmeron, Patricia A. (2009). Childhood and adolescent attention-deficit hyperactivity disorder: Diagnosis, clinical practice guidelines, and social implications. Journal of the American Academy of Nurse Practitioners, 488-495.

Stahr, Brenna, Cushing, D., Lane, K., & Fox, J., (2006). Efficacy of a Function-Based Intervention in Decreasing Off-Task Behavior Exhibited by a Student With ADHD. Journal of Positive Behavior Interventions, 201-211.

Wolraich, M., Wibbelsman, C., Brown, T., Evans, S., Gotlieb, E., Knight, J., et al. (2005). Attention-deficit/hyperactivity disorder among adolescents: A review of the diagnosis, treatment, and clinical implications. Pediatrics, 1734-1746.