DEFICIT HYPERACTIVITY DISORDER
Part II of
VII Understanding the Problem
Mark, age 14, has more energy than most boys his age.
But then, he's always been overly active. Starting at age 3, he was a human tornado,
dashing around and disrupting everything in his path. At home, he darted from one activity
to the next, leaving a trail of toys behind him. At meals, he upset dishes and chattered
nonstop. He was reckless and impulsive, running into the street with oncoming cars, no
matter how many times his mother explained the danger or scolded him. On the playground,
he seemed no wilder than the other kids. But his tendency to overreactlike socking
playmates simply for bumping into himhad already gotten him into trouble several
times. His parents didn't know what to do. Mark's doting grandparents reassured them,
"Boys will be boys. Don't worry, he'll grow out of it." But he didn't.
At age 17, Lisa still struggles to pay attention and act
appropriately. But this has always been hard for her. She still gets embarrassed thinking
about that night her parents took her to a restaurant to celebrate her 10th birthday. She
had gotten so distracted by the waitress' bright red hair that her father called her name
three times before she remembered to order. Then before she could stop herself, she
blurted, "Your hair dye looks awful!"
In elementary and junior high school, Lisa was quiet and
cooperative but often seemed to be daydreaming. She was smart, yet couldn't improve her
grades no matter how hard she tried. Several times, she failed exams. Even though she knew
most of the answers, she couldn't keep her mind on the test. Her parents responded to her
low grades by taking away privileges and scolding, "You're just lazy. You could get
better grades if you only tried." One day, after Lisa had failed yet another exam,
the teacher found her sobbing, "What's wrong with me?"
Although he loves puttering around in his shop, for
years Henry has had dozens of unfinished carpentry projects and ideas for new ones he knew
he would never complete. His garage was piled so high with wood, he and his wife joked
about holding a fire sale.
Every day Henry faced the real frustration of not being
able to concentrate long enough to complete a task. He was fired from his job as stock
clerk because he lost inventory and carelessly filled out forms. Over the years, afraid
that he might be losing his mind, he had seen psychotherapists and tried several
medications, but none ever helped him concentrate. He saw the same lack of focus in his
young son and worried.
What Are the Symptoms of ADHD?
The three people you've just met, Mark, Lisa, and Henry,
all have a form of ADHDAttention Deficit Hyperactivity Disorder.
ADHD is not like a broken arm, or strep throat. Unlike
these two disorders, ADHD does not have clear physical signs that can be seen in an x-ray
or a lab test. ADHD can only be identified by looking for certain characteristic
behaviors, and as with Mark, Lisa, and Henry, these behaviors vary from person to person.
Scientists have not yet identified a single cause behind all the different patterns of
behaviorand they may never find just one. Rather, someday scientists may find that
ADHD is actually an umbrella term for several slightly different disorders.
At present, ADHD is a diagnosis applied to children and
adults who consistently display certain characteristic behaviors over a period of time.
The most common behaviors fall into three categories: inattention, hyperactivity, and
- Inattention. People who are inattentive have a hard time
keeping their mind on any one thing and may get bored with a task after only a few
minutes. They may give effortless, automatic attention to activities and things they
enjoy. But focusing deliberate, conscious attention to organizing and completing a task or
learning something new is difficult.
Lisa found it agonizing to do homework. Often, she forgot to plan ahead by writing down
the assignment or bringing home the right books. And when trying to work, every few
minutes she found her mind drifting to something else. As a result, she rarely finished
and her work was full of errors.
- Hyperactivity. People who are hyperactive always seem to
be in motion. They can't sit still. Like Mark, they may dash around or talk incessantly.
Sitting still through a lesson can be an impossible task. Hyperactive children squirm in
their seat or roam around the room. Or they might wiggle their feet, touch everything, or
noisily tap their pencil. Hyperactive teens and adults may feel intensely restless. They
may be fidgety or, like Henry, they may try to do several things at once, bouncing around
from one activity to the next.
- Impulsivity. People who are overly impulsive seem unable
to curb their immediate reactions or think before they act. As a result, like Lisa, they
may blurt out inappropriate comments. Or like Mark, they may run into the street without
looking. Their impulsivity may make it hard for them to wait for things they want or to
take their turn in games. They may grab a toy from another child or hit when they're
Not everyone who is overly hyperactive, inattentive, or
impulsive has an attention disorder. Since most people sometimes blurt out things they
didn't mean to say, bounce from one task to another, or become disorganized and forgetful,
how can specialists tell if the problem is ADHD?
To assess whether a person has ADHD, specialists
consider several critical questions: Are these behaviors excessive, long-term, and
pervasive? That is, do they occur more often than in other people the same age? Are they a
continuous problem, not just a response to a temporary situation? Do the behaviors occur
in several settings or only in one specific place like the playground or the office? The
person's pattern of behavior is compared against a set of criteria and characteristics of
the disorder. These criteria appear in a diagnostic reference book called the DSM (short
for the Diagnostic and Statistical Manual of Mental Disorders).
According to the diagnostic manual, there are three
patterns of behavior that indicate ADHD. People with ADHD may show several signs of being
consistently inattentive. They may have a pattern of being hyperactive and impulsive. Or
they may show all three types of behavior.
According to the DSM, signs of inattention include:
- becoming easily distracted by irrelevant sights and
- failing to pay attention to details and making careless
- rarely following instructions carefully and completely
- losing or forgetting things like toys, or pencils, books,
and tools needed for a task
Some signs of hyperactivity and impulsivity are:
- feeling restless, often fidgeting with hands or feet, or
- running, climbing, or leaving a seat, in situations where
sitting or quiet behavior is expected
- blurting out answers before hearing the whole question
- having difficulty waiting in line or for a turn
Because everyone shows some of these behaviors at times,
the DSM contains very specific guidelines for determining when they indicate ADHD. The
behaviors must appear early in life, before age 7, and continue for at least 6 months. In
children, they must be more frequent or severe than in others the same age. Above all, the
behaviors must create a real handicap in at least two areas of a person's life, such as
school, home, work, or social settings. So someone whose work or friendships are not
impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems
overly active at school but functions well elsewhere.
Can Any Other Conditions Produce These Symptoms?
The fact is, many things can produce these behaviors.
Anything from chronic fear to mild seizures can make a child seem overactive, quarrelsome,
impulsive, or inattentive. For example, a formerly cooperative child who becomes
overactive and easily distracted after a parent's death is dealing with an emotional
problem, not ADHD. A chronic middle ear infection can also make a child seem distracted
and uncooperative. So can living with family members who are physically abusive or
addicted to drugs or alcohol. Can you imagine a child trying to focus on a math lesson
when his or her safety and well-being are in danger each day? Such children are showing
the effects of other problems, not ADHD.
In other children, ADHD-like behaviors may be their
response to a defeating classroom situation. Perhaps the child has a learning disability
and is not developmentally ready to learn to read and write at the time these are taught.
Or maybe the work is too hard or too easy, leaving the child frustrated or bored.
Tyrone and Mimi are two examples of how classroom
conditions can elicit behaviors that look like ADHD. For months, Tyrone shouted answers
out in class, then became disruptive when the teacher ignored him. He certainly seemed
hyperactive and impulsive. Finally, after observing Tyrone in other situations, his
teacher realized he just wanted approval for knowing the right answer. She began to seek
opportunities to call on him and praise him. Gradually, Tyrone became calmer and more
Mimi, a fourth grader, made loud noises during reading
group that constantly disrupted the class. One day the teacher realized that the book was
too hard for Mimi. Mimi's disruptions stopped when she was placed in a reading group where
the books were easier and she could successfully participate in the lesson.
Like Tyrone and Mimi, some children's attention and
class participation improve when the class structure and lessons are adjusted a bit to
meet their emotional needs, instructional level, or learning style. Although such children
need a little help to get on track at school, they probably dont have ADHD.
It's also important to realize that during certain
stages of development, the majority of children that age tend to be inattentive,
hyperactive, or impulsivebut do not have ADHD. Preschoolers have lots of energy and
run everywhere they go, but this doesn't mean they are hyperactive. And many teenagers go
through a phase when they are messy, disorganized, and reject authority. It doesn't mean
they will have a lifelong problem controlling their impulses.
ADHD is a serious diagnosis that may require long-term
treatment with counseling and medication. So it's important that a doctor first look for
and treat any other causes for these behaviors.
What Can Look Like ADHD?
- Underachievement at school due to a learning disability
- Attention lapses caused by petit mal seizures
- A middle ear infection that causes an intermittent
- Disruptive or unresponsive behavior due to anxiety or
Can Other Disorders Accompany ADHD?
One of the difficulties in diagnosing ADHD is that it is
often accompanied by other problems. For example, many children with ADHD also have a
specific learning disability (LD), which means they have trouble mastering language or
certain academic skills, typically reading and math. ADHD is not in itself a specific
learning disability. But because it can interfere with concentration and attention, ADHD
can make it doubly hard for a child with LD to do well in school.
A very small proportion of people with ADHD have a rare
disorder called Tourette's syndrome. People with Tourette's have tics and other movements
like eye blinks or facial twitches that they cannot control. Others may grimace, shrug,
sniff, or bark out words. Fortunately, these behaviors can be controlled with medication.
Researchers at NIMH and elsewhere are involved in evaluating the safety and effectiveness
of treatment for people who have both Tourette's syndrome and ADHD.
More serious, nearly half of all children with
ADHDmostly boystend to have another condition, called oppositional defiant
disorder. Like Mark, who punched playmates for jostling him, these children may overreact
or lash out when they feel bad about themselves. They may be stubborn, have outbursts of
temper, or act belligerent or defiant. Sometimes this progresses to more serious conduct
disorders. Children with this combination of problems are at risk of getting in trouble at
school, and even with the police. They may take unsafe risks and break lawsthey may
steal, set fires, destroy property, and drive recklessly. It's important that children
with these conditions receive help before the behaviors lead to more serious problems.
At some point, many children with ADHDmostly
younger children and boysexperience other emotional disorders. About one-fourth feel
anxious. They feel tremendous worry, tension, or uneasiness, even when there's nothing to
fear. Because the feelings are scarier, stronger, and more frequent than normal fears,
they can affect the child's thinking and behavior. Others experience depression.
Depression goes beyond ordinary sadnesspeople may feel so "down" that they
feel hopeless and unable to deal with everyday tasks. Depression can disrupt sleep,
appetite, and the ability to think.
Because emotional disorders and attention disorders so
often go hand in hand, every child who has ADHD should be checked for accompanying anxiety
and depression. Anxiety and depression can be treated, and helping children handle such
strong, painful feelings will help them cope with and overcome the effects of ADHD.
Of course, not all children with ADHD have an additional
disorder. Nor do all people with learning disabilities, Tourette's syndrome, oppositional
defiant disorder, conduct disorder, anxiety, or depression have ADHD. But when they do
occur together, the combination of problems can seriously complicate a person's life. For
this reason, it's important to watch for other disorders in children who have ADHD.
NIH Publication No. 94-3572