WHAT IS ADHD?

 

(PLEASE NOTE THIS ARTICLE IS AN EXCERPT OF A BOOK WE WILL BE PUBLISHING BY 2013)


ADHD is not a “new fad” as some critics would suggest.  Restless and inattentive students have tormented teachers since the days of Socrates, whose description of typical ADHD symptoms takes us back to classical Greece.  German educators in the 19th century invented various contraptions, especially chairs with straps for legs and arms, to contain their “hyperactive” students in the early days of universal public education.  Children with ADHD symptoms have been found in every culture worldwide including “primitive” societies studied by anthropologists in this century.

 

In the days when ADHD was understood only in terms of “hyperactivity,” it did seem like the kids “outgrew it.”  By sixteen or seventeen they were less overactive. But, eventually some psychologists and psychiatrists began to recognize that the mental or “cognitive” impairments were usually still present long after the overactivity appeared much improved.  Further, clinicians began to recognize the same exact mental/cognitive symptoms in children and adolescents who were NOT hyperactive – in fact some of these kids seemed “hypoactive,” i.e., underactive, quiet, retiring, and shy.  So it became common during the 1970’s to call these children ADD without Hyperactivity (ADD or ADDWO) in contrast to ADD with Hyperactivity (ADHD).  Now, since DSM-IV, we use the diagnostic term ADHD-Inattentive Type.

 

As more and more studious clinicians and researchers looked far more carefully at the families of these children toward the end of the 1970’s and into the early 1980’s another surprise emerged; in case after case, the child with ADHD was a virtual carbon copy of one of the parents at the same age, and when that parent was evaluated more closely, ADHD symptoms were still clearly present.  We now realize that ADHD is clearly a genetic disorder; the apples do not fall far from the tree!  Efforts to identify and locate the responsible genes are well under way and likely to be successful before the turn of the century.  ADHD is inherited like eye color, skin color, diabetes, a tendency toward developing certain cancers, etc.  We no longer have any real scientific “controversy” regarding the origin of ADHD – it has been with us since the earliest days of our species, tormenting parents and teachers since families and schools first began, and will require our best diagnostic and treatment efforts until genes can be modified – a time that may be closer to dawning than we can imagine today.

 

In order to try to understand ADHD in adults, it is VITAL to first try to fully understand it in children.  Children with ADHD-Hyperactive/Impulsive type (ADHD-HI) are often described by their mothers as overactive as early as the seventh month of pregnancy; they are typically rambunctious toddlers, “into everything,” and grandparents make comments like, “You’ve got a real tiger by the tail with this one!”  Baby sitters complain and sometimes cannot handle the child at all; preschool staff struggle to cope with their overactivity, disruptive behavior, disinclination to follow rules, peer problems, etc.  I recall one unusually difficult case in which a frantic, working, single mother went through seventeen babysitters and day care providers in two years!  The usual call to her at work was: “Come and get your obnoxious little brat, and DO NOT bring him back ever again!”  In Kindergarten the usual label is “immature.”  Teachers often recommend waiting another year and trying again, or repeating Kindergarten.  Symptoms become steadily worse in first, second, and third grades.

 

ADHD-HI


May be a “tough call” in many children, but the DSM-IV diagnostic manual lists these symptoms as typical; answer the questionnaire from what you remember as a child, and now as an adult:

 

 

HYPERACTIVITY

 

 

FREQUENT

OCCASSIONAL

RARE

1)  Often fidgets with hands or feet or squirms in seat.

2)  Often leaves seat in classroom or in other situations where remaining seated is expected.

3) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults may be limited to subjective feelings of restlessness).

4) Often has difficulty playing or engaging in leisure activities quietly.

5)  Is often “on the go” or often acts as if “driven by motor.”

6)  Often talks excessively.

 

IMPULSIVITY

 

 

FREQUENT

OCCASSIONAL

RARE

7)  Often blurts out answers before questions have been completed.

8)  Often has difficulty awaiting turn.

9)  Often interrupts or intrudes on others (e.g., butts into conversations or games).

 

In the event a child is considered positive for at least six or more of the symptoms above, ADHD-HI would be a significant concern.  Many ADHD-HI children will receive “frequent” on all nine items.  Most of these concerns will be evident in the classroom only, and will not be necessarily be so evident at home where there is less social stimulation, and they will be especially minimal when 1:1 with a parent (especially and ADHD-HI boy and his father).

 

There are several associated symptoms pertaining to ADHD-HI which consistently are of concern even though they are not on a formal diagnostic symptom list.  These are:

 

1)    Inconsistent:  Cooperative one day, oppositional the next.  Cheerful one day, pouty the next.

2)    Irritable, moody, angry, sometimes defiant, negative.

3)    Temper outbursts.

4)    Angry, aggressive behavior: pushing, hitting, shoving in line; lots of conflict with peers.

 

Children who showed many or most of the above four mood-related symptoms were very often labeled “behavior problems.”  In fact, as we now understand ADHD-HI better in adolescents and adults, these are consistent features in the history of older patients with ADHD-HI and there is no question this aspect of the syndrome starts early – as early as preschool, and almost always is evident by the end of elementary school.

 

In addition, one usually sees a lot of over-reactivity, and especially in boys, preoccupation with violent themes.  They can “hyperfocus” on exciting things: video games, cartoons, Legos, etc. Exceptional variability is NORMAL for ADHD children.

 

 

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ADHD-I

(ADHD Inattentive form) is different.  DSM-IV symptom checklists are more focused on attention issues; answer this questionnaire from what you remember of your behavior as a child, and now as an adult.

 

 

FREQUENT

OCCASSIONAL

RARE

1)  Often fails to give close attention to details or makes careless errors in school work, work or other activities.

2)  Often has difficulty sustaining attention in tasks or play activities.

3)  Often does not seem to listen when spoken to directly.

4)  Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace.

5)  Often has difficulty organizing tasks and activities.*

6)  Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).

7)  Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools).

8)  Is often distracted by extraneous stimuli.**

9)  Is often forgetful in daily activities.

 

*  This simply refers to organizational ability and consistency.  It would be positive when an adult repeatedly forgets things necessary for the job (e.g. tools, paperwork, etc.) or when there is often a mess of papers in front of him/her.

 

**  Extraneous stimuli refers to noise, activity, people talking, TV, etc.  ADHD-I adults, like children, are more distracted than others by these things.  This proves to be a tough time to rate consistently because, of course, all adults are distracted sometimes by such things!  Rate this positive if you seem to be more distracted than others.

 

Further highly suggestive symptoms pertaining to ADHD-I are these:

 

1)    Often stares into space, “tunes out,” appears to be daydreaming.

2)    Often appears to be low in energy, sluggish, drowsy.

3)    Often appears to be apathetic or unmotivated to engage in assigned activities or work, but   well-motivated to participate in favored or passive activities.

4)   Very inconsistent in motivation and work production; energetic and productive some days; little or nothing accomplished on others, for no apparent reason.

5)     Appears very “moody:” engaging, interactive and perky some days; grumpy, withdrawn and irritable on other days, also for no apparent reason.

 

An adult who can confidently respond with six or more “frequent” answers to the first nine questions should be considered strongly suspect for ADHD-I – especially if many or most of the other associated five items are also rated positive.

 

In addition, ADHD-I adults are often described as “dreamy,” “spacey,” too quiet, under-reactive, incredibly forgetful – bright in many areas they have an interest in (these can be very unusual subjects), but “absent minded professors” in the sense that they seem to learn and know little about common subjects.

 

Further, in a substantial majority of adults, patients will be “positive” for at least six of the nine symptoms listed for both ADHD-I and ADHD-HI.  In those cases we now use the designation ADHD-C: Combined.  Most ADHD-C patients are men; at least 80% of patients with ADHD-HI are men, but at least 50% of patients with ADHD-I only are women.

 

Over the years, a large number of professionals in this field have worked on symptom check lists for the various forms of ADHD, trying to research the most specific traits and refine the symptom lists to improve diagnostic specificity.  Further, they have tried to define the condition in a fashion, which covers the full spectrum of ages, from very young through elderly.

 

While this effort is laudable, to many of us the traits listed now seem too “distilled,” or too age-neutral – so much so that valuable traits and behaviors listed pertaining just to children in the past were dropped to try to broaden the criteria to include adults, while simultaneously not yet being specific enough to adequately describe the adult situation!

 

As you will see in the following discussions of ADHD-R and ADHD-NOS, this can get very complex!

 

ADHD SUBTYPES

 

ADHD-R is the condition we frequently encounter in older adolescents and in adults who once had one of the ADHD disorders as a youngster, but now have fewer significant symptoms.  In most cases, the Hyperactivity feature of the condition is substantially reduced by late adolescence, although many adults with ADHD-R are still quite “restless,” impatient, temperamental, and are now far more prone to what we call mood problems irritability, quick to anger, periods of feeling hopeless and “down,” and often a sense of feeling “depressed.”  Most adults with this condition still have difficulty paying closer attention to details, reading with full comprehension, reading anything which seems too long or tedious, listening carefully and remembering details of conversations, daydreaming when they should be working, and getting and keeping “things organized.”  Most still have problems with impulsive decisions and judgment, and many struggle to maintain acceptable conventional social behavior.

 

Routinely encountered during examination of a child for ADHD there is almost always a parent with   ADHD-R present, usually never previously diagnosed.  Given the typical genetics of the syndrome, a careful family history will reveal typical ADHD-R features in numerous extended family adults, and usually also other ADHD conditions among the child’s cousins, older and younger siblings, etc.

 

While the overt Hyperactivity has “been outgrown,” the Residual symptoms are almost always disturbing to the adult/parent, to his/her spouse, to all their children and relatives, and to co-workers.  Many of these symptoms especially relate to mood and irritability. Many very intense, bright, hard-working, and independent men and women have significant symptoms of ADHD-R.  Usually these symptoms are far, far more obvious to everyone around them than they are to the affected ADHD-R individual.

 

This is especially true when this adult is a man, when he is bright and intense and creative and independent, and symptoms flare during moments of frustration and conflict.  Although adults of both sexes with ADHD-R may have significantly impaired self-observation skills, men comparatively possess very poor insight into the symptomatic aspect of their behavior.  One of the many commandments of ADHD is: “Thou shall go from happy to Raging Lunatic in seconds, often over something very trivial.”  An associated commandment is: “Thou shall have forgotten what thee was angry about within hours, and by the next day forgotten it ever happened at all.”

 

Although some professionals would suggest these people are “in denial” about their symptoms, this is an incomplete explanation.  In ADHD-R self observation and personal insight is simply too impaired for the affected individual to recognize he/she has any significant symptoms, and many such people are so headstrong and stubborn they simply do not and will not listen to the feedback from spouses, their own children, co-workers, or their own friends and parents.

 

Older adolescents and young adults with untreated ADH-R whose personal history includes a background of ADHD-HI or ADHD-C are especially at risk for substance abuse, conflicts with the juvenile legal system, and later with the adult criminal legal system.  Their vocational performance is usually very poor until they get into an “ADHD friendly” job: one where most of their work is interesting to them, where they control the pace and activity themselves, where their ingenuity and creativity can be used productively, and their outbursts of energy and zeal are valuable assets.

 

Those individuals with ADHD-R who do not develop significant conduct disorder symptoms during adolescence often can flounder around for a while, maintain a close and supportive connection with their family, find their niche and go on to do well.  Many famous business entrepreneurs, entertainers, artists, and professionals in law and medicine have succeeded because of some of the positive features of   ADHD-R, and despite the negative features of the condition.

 

When the adolescent or young adult has a history of strictly ADHD-I symptoms as a child, without any significant HI features, then one can usually find them encountering some point in school where their best efforts fail and they begin to slowly and quietly flounder.  For many this point is reached in Junior High School, for others High School; some “make it” through High School but hit The Wall in College and drop out there; a few others manage to find a way to cope with symptoms in College and obtain advanced degrees.  Quite a few experiment with self-medication, especially “speed” or “crank,” to try to improve their concentration.  Untreated, they consistently feel like failures, and their families may use terms “unfulfilled potential.”  Many young people with this form of ADHD-R become more moody and “depressed” as they age, and when they seek help are commonly misdiagnosed as Depressive Disorder only.  Almost all ADHD-R adults, as they age, develop significant mood and/or anxiety disorders unless they obtain expert help.

 

There was a time, 25-30 years ago or so, when I felt most ADHD patients would “outgrow” this condition and go on to success in all respects.  During the past decade widespread conviction has developed among ADHD professionals that most children with any form of ADHD will experience some changes in their symptoms over time, but very, very few will ever be completely free of some impairing features of the disorder.

 

There is no way to “test” for this outcome during childhood or early adolescence.  Realistically, during those years patients and families need intensive education about the likely future course of the condition, how to recognize which symptoms are residual of ADHD as they age, and what they can do to obtain help for them.  I tell patients and parents it is unrealistic to imagine the prospect of ever fully becoming completely free of all features of this condition, no matter what treatment is provided during childhood and earlier adolescence; meanwhile, it is important to plan ahead and work towards developing a coping strategy to maximize the positive, creative, inventive, engaging, and intuitive features of ADHD!

 

ADHD-NOS

(ADHD-Not Otherwise Specified) may make almost no sense whatsoever to laypeople!  However, it certainly does to professionals with ample experience in this field.

 

To explain why, look back at the criteria listed for ADHD-I and ADHD-HI: there are nine symptomatic features listed, and to reach “diagnostic significance” one is supposed to find the child or adolescent “frequent” on at least six in one cluster or another.  Each one of the nine symptoms were researched intensively, but some were much more “powerful” or consistently valid than others, some other traits were very nearly as powerful as the ones used, and yet others suffered from confusion and controversy in the wording of the behavioral description.

 

Some symptoms very well understood by parents were left off the list of nine because teachers could not respond consistently or reliably, but parents could, and vise versa.  For instance, relating to ADHD-I:

 

  • x)  In absence of close supervision, often has difficulty following through on instructions form others.
  • y)   Often shifts from one activity to another.

 

Notice these are traits that anyone familiar with ADHD-I would strongly endorse as typical of people with this condition are NOT on the list of nine symptoms of ADHD-I.  Why?  Because these traits proved difficult to “score” properly due to difficulties with the consistency of observation, not because traits of this kind are not characteristics of ADHD-I individuals.   

 

Now look at the ADHD-HI symptom list, and notice this trait is not on the list:

 

·        z)  Cannot talk or play quietly; disrupts others with talk or actions.

 

Instead, we just have “Often talks excessively,” but the “disrupts others” and reference to play and actions is gone.  How strange: if you are a teacher observing your class, this symptom is readily observed and a powerful, highly correlated trait associated with ADHD-HI.  However, you can see how this symptom (z) would be hard to judge consistently at home compared to school, and since DSM-IV represented some effort to make the HI symptom lists more adult-oriented than in the past, symptom (z) did not have adequately broad enough implication to both child and adult HI symptom lists, and in adequate application at home vs school.

 

WHAT THIS ALL MEANS IS:  There are many symptoms of ADHD other than those on the lists, and there are other ways of wording similar traits pertaining more or less to different age groups.  Further, of course, the perspective “power” of certain symptom clusters varies greatly from home to school, there are many ways of misunderstanding the wording, and then there is always observer judgment to consider: teachers and parents are very, very different in their perspective on these matters!

 

To explain that point further, obviously when a teacher happens to be, for instance, a young, energetic, and active man who is a bit zany, creative, and constantly engaging his Fifth Grade class in hands-on projects, a boy with quite significant HI symptoms may be captivated, interested, eager to please, and happy to go to school every day.  The teacher noting the same energy and inventiveness and zest for the unconventional he had as a kid, and still substantially has now, may really like the boy and their interaction is very positive.  Since he so readily identifies with these HI features in the child, when given a complete symptom check list most of his responses are “rare” or “occasional.”  The parents are confused but very pleased, since for the past two years they were getting lots of calls from prior teachers who were very frustrated with the boy.  Now the parents are wondering: maybe he doesn’t have ADHD!

 

However, later in the school year this teacher leaves and is replaced by an elderly, kindly, but very firm lady.  When I was a kid we always labeled teachers with various fruit and vegetable names, and she is what we used to call an “Old Prune.”  She wants children to work quietly, stay in their seat, raise their hands, and wait lengthy periods to be called on. And do all their work very neatly.  For her, comportment and neat, careful organization of their work is important, more so in many respects than content.  There is one call home the first week, several the second, and a parent teacher conference the third.  Her symptom ratings for HI are 9/9 “frequent,” and 7/9 Inattentive.

 

At home, many fathers with residual ADHD features engage and interact with their sons in precisely resonating ADHD-HI patterns, e.g., they connect using a style of communication and play which masks the negative ADHD-HI features and they get a mutual kick out of the positive features: doing things together, energetic games, play fighting, playing catch, climbing, jumping, racing, shooting, and all manner of other “boy stuff.”  Like the male teacher, they do not see many negative ADHD-HI features in their son because their engagement with him masks and overcomes – in their interaction time together only – the problems the child has with sitting still, concentrating, work organization, restlessness, etc.  When dad gets home the boy seems to sprout little wings and a halo after a full afternoon of driving his mother Over the Edge, thus he rarely sees or understands that anything is wrong, the kid is just “being all boy,” and though maybe “a bit hyper” isn’t really that bad!

 

The same kind of pattern, of course, may apply to Father-Daughter, Mother-Son, or Mother-Daughter interactions.  The point is: both the child’s behavior and the observers behavior and assessment are shaped and skewed by many factors which can never been fully controlled on any symptom check list, so there definitely is no magic in any formula, and certainly not in any highly debatable series of nine traits, nor in any number of these nine – whether four or five or six or seven – which are necessarily 100% valid in making any diagnosis of any form of ADHD.

 

This is why the concept of ADHD-NOS is valuable.  When we can see there are many features of the condition, and these symptoms have continued for six months or a year or more in different settings, but we see there are many areas of variability depending on the circumstances, we a re not locked into overly rigid diagnostic criteria for either ADHD-I or ADHD-HI.  Many adults as well as children have unusual patterns of ADHD symptoms, and both respond to treatment efforts to help with specific symptoms rather than imagining we always must treat the individual as if he/she has a “clearly defined syndrome” meeting all research criteria!