Why write about ADHD?
I was recently asked to write a paper to contribute to a volume addressing changing trends in child psychiatry. I chose to write about ADHD. I made this choice for many reasons. One reason is that more parents bring their children to me with ADHD as one of their stated concerns than any other problem. Another reason is the evolution of thinking about ADHD has grown to appreciate the complexity of the problem (though back in 1992, Leon Eisenberg warned about the rush to medicate) (Eisenberg, 1992). That makes it interesting. And yet, despite the greater complexity of what is currently known about ADHD, many clinicians still behave as if it were a simple disease entity with a single etiology, and consider medication the first and often the only treatment option. Finally, I think the young child psychiatrists I teach and the parents and teachers I consult to should have access to contemporary knowledge on the subject.
I know I promised to blog more about executive function. I intend to do that. However, my reading about ADHD interrupted my agenda for a good reason. There is a large overlap between ADHD and EFD. That is due in part because there is no clear definition of executive function in the literature. Basically, executive functions refer to the internal processes an individual uses to organize the knowledge he has in the service of accomplishing goals. Problems with executive functioning include difficulty organizing oneself in time and space; initiating and formulating a plan of action to accomplish a goal; maintaining motivation during a goal oriented activity; avoiding distractions while working; and following through to a satisfactory result. You can see the similarities between dysfunction of these processes and ADHD.
I am going to write several installments on the subject of ADHD. They will be somewhat academic and may try the patience of readers who want a quick explanation and a “how to” section, but unfortunately (or fortunately) life isn’t that way. Our children are complicated, and in order to understand them we have to be patient and learn all we can learn about what makes them tick. Here is the beginning.
What is ADHD?
Among many stated claims that are unclear about ADHD, there are three facts are clear.
- The first is that the number of children diagnosed with ADHD is growing. Between 2003 and 2011, 2 million more children in the U.S. aged 4 to 17 were diagnosed with ADHD (Visser et al, 2014, p. 34).
- The second is that there is a central nervous system basis for ADHD symptoms. This fact is supported by many candidate gene studies that show associations between ADHD and dopamine transporter and dopamine receptor genes (Lou et al, 2004; Bralten et al, 2013), and also by neuroimaging studies that identify functional connectivity abnormalities in particular neural networks in the brain (Konrad et al, 2010; Liston et al, 2011; Levitt et al, 2013).
- The third is that a multi-dimensional assessment and treatment approach is far preferable to a rush to medication.
ADHD is characterized by inattentiveness, distractibility, impulsivity, and overactivity. It is certainly not a disease. Many attest to the heterogeneity of ADHD (Jensen, 2000; Musser, 2013; Arnold, 2014). Some even question whether it is a disorder rather than an extreme of temperamental variation (Jensen, 2000, p. 195). This consideration is based on the observation that a significant group of children with ADHD seem to “grow out of” ADHD (Hechtman, 1992), as well as studies that demonstrate the influence of social and school environment on the diagnosis of ADHD (Schneider & Eisenberg, 2006). It does seem likely that the demands our current culture places on children to sit still and pay attention, to manage frequent transitions, and to multi-task, may not be as easy for some “normal” children to accommodate as for others. This kind of consideration has led some to argue for a “dimensional” rather than a “categorical” diagnosis of ADHD (Vande Voort, 2014).
In the next installment I will write about some of the neurodevelopmental findings on ADHD.
Arnold L, Ganocy S, Mount K, Youngstrom E, Frazier T, Fristad M, Horwitz S, Birmaher B, Findling R, Kowatch R, Demeter C, Axelson D, Gill M, Marsh L (2014). Three year latent class trajectories of attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical sample not selected for ADHD, JAACAP 53(7):745-760.
Bralten J, Franke B, Waldman I, Rommelse N, Hartman C, Asherson P, Banaschewski T, Ebstein R, Gill M, Miranda A, Oades R, Roeyers H, Rothenberger A, Sergeant J, OOsterlann , Sonuga-Barke E, Steinhausen H , Faraone S, Buitelaar J, Arias-Vasquez A (2013), Candidate genetic pathways for Attention-Deficit/Hyperactivity Disorder (ADHD) show association to hyperactive symptoms in children with ADHD, JAACAP, 52(11):1204–1212.
Eisenberg L (1972). The clinical use of stimulant drugs in children, Pediatrics 49:709-715.
Hechtman L (1992). Long-term outcome in attention deficit hyperactivity disorder. Child Adolesc Psychiatr Clin North Am 1:553-565.
Jensen PS. Commentary: The NIH ADHD consensus statement: win, lose, ordraw? J Am Acad Child Adolesc Psychiatry 2000; 39: 194-197.
Konrad K, Eickhoff SB. Is the ADHD brain wired differently? A review on structural and functional connectivity in attention deficit hyperactivity disorder. Hum Brain Mapp. 2010;31:904-916.
Lawrence K, Levitt J, Loo S, Ly R, Yee V, O’Neill, Alger J, Narr K (2013). White matter microstructure in subjects with Attention Deficit Hyperactivity disorder and their siblings, JAACAP, 52(4):431-440.
Lou, H. C., Rosa, P., Pryds, O., Karrebaek, H., Lunding, J., Cumming, P., & Gjedde, A. (2004). ADHD: increased dopamine receptor availability linked to attention deficit and low neonatal cerebral blood flow. Developmental Medicine & Child Neurology, 46, 179–83.
Liston C, Malter Cohen M, Teslovich T, Levenson D, Casey BJ. Atypical prefrontal connectivity in attention-deficit/hyperactivity disorder: pathway to disease or pathological end point? Biol Psychiatry. 2011;69:1168-1177.
Musser E, Galloway-Long H, Frick P, Nigg J (2013). Emotion regulation and heterogeneity in Attention-Deficit Hyperactivity Disorder, JAACAP, 52(2):163-171.
Vande Voort J, He J-P, Jameson N, Merikangas K (2014) Impact of the DSM-5 Attention-Deficit Hyperactivity Disorder age-of-onset criterion in the US adolescent population, JAACAP, 53(7):736-744.
Visser S, Danielson M, Bitsko R, Holbrook J, Kogan M, Ghandour R, Perou R, Blumberg S (2014). Trends in the parent-report of health of health care provider-diagnosed and medicated Attention Deficit/Hyperactivity Disorder: United States, 2003-2011, JAACAP, 53(1):34–46.