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What Is ADHD Causes and TreatmentResearch Paper

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Attention-Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD):

Conditions

Symptoms and Diagnosis

Attention-deficit disorder (ADD) and attention-deficit disorder with hyperactivity (ADHD) are both classified as neurodevelopmental disorders of childhood although the definitions of both have been broadened to encompass adults, given the acknowledgement that appropriate diagnosis may not have been given in childhood ("Facts," 2015). According to the most recent revised criteria for the DSM-5, "individuals younger than 17 must display at least 6 of 9 inattentive and/or hyperactive impulsive symptoms" to warrant diagnosis of ADD or ADHD (Rabiner 203).

Symptoms of inattentiveness according to the DSM-5 include careless mistakes; difficulty in sustaining attention to either work or play; an apparent refusal to listen; a failure to follow through on tasks; difficulties in organizing activities; difficulties in sustaining effort; losing things; distractedness; and forgetfulness (Rabiner 2013). Impulsivity may be evident in fidgeting; leaving one's seat when expected to remain still; inappropriate activity (or desire to be engaging in it) like running or climbing; difficulty to engage in sustained leisure activities; constantly needing to be on the go; excessive talking and blurting out answers before questions have been asked; interrupting or the inability to wait on one's turn (Rabiner 2013). In recognition of the fact that even many neurologically normal children may have moments of excessive activity but older children are expected to exercise more self-control "for individuals 17 and above ... only 5 or more symptoms are needed. This change from DSM-IV was made because of the reduction in symptoms that tends to occur with increasing age" (Rabiner 2013).

Given the neurological basis for ADHD, these symptoms must have been evident before the age of seven. They must also not have been caused by drugs (such as caffeine) or other psychiatric or physical illnesses. Symptoms must be evident in at least two contexts such as work and school (i.e., there must not be a very specific environmental trigger to the behavior). There must be "clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning" (Rabiner 2013). Inattentive behaviors must be evident for a diagnosis but once a diagnosis is made then the child can be screened for the hyperactivity criteria. Severity is gauged as mild, moderate, or severe. ADHD Not Otherwise Specified (NOS) diagnosis can be given to those individuals with symptoms that do not meet the specified criteria (Rabiner 2013).

The DSM-5 criteria has a notably more flexible threshold for diagnosing the disorder reflecting the fact that adults may not have been appropriately diagnosed as children even though the disease is considered biological and hard-wired into the individual's neurological circuitry at birth (Rabiner 2013). The threshold of impairment has also been considerably lowered as the need for "clinically significant impairment' has been changed to evidence that symptoms interfere with or reduce the quality of performance in important life domains" which has given rise to criticisms that this has increased the rate of over-diagnosis (Rabiner 2013). As noted by Rabiner (2013), "individuals who will be diagnosed with the 'mild' specifier, and even some with the 'moderate' specifier" would not have been diagnosed under previous criteria in the DSM-IV and "an increase in diagnoses may also result in more individuals being treated with medication when this is not really necessary" or given more accommodations in a school or work setting than is really needed.

Neurobiology of ADHD

Despite the controversies about over-diagnosis, there is clear evidence that ADHD is a neurobiological disorder. MRIs of afflicted children compared with those of control groups have shown a persistent pattern of "diffuse and more specific alterations in brain structures and neural networks" in children with ADHD (Purper-Ouakil, Ramoz, Lepagnol-Bestel, Gorwood, & Simonneau 2011). A "study of functional MRI in children and adolescents with ADHD showed decreased connectivity in a fronto-striato-parieto-cerebellar network" (Purper-Ouakil, et al. 2011). These patterns could account for poor executive functioning and the inability to control impulses, including physical impulses to move. Delays in thickening of cortical membranes and failures of the middle prefrontal cortex to mature have also been noted and in diagnosed children. "Normalization of volumes in different brain regions such as the parietal cortex and the hippocampus parallel clinical improvement of symptoms" while losses in the "cerebellar regions and hippocampus were associated with persistent symptoms" well into adulthood (Purper-Ouakil, et al. 2011).

There is also evidence for specific genetic patterns for children with ADHD. Although genetic mapping has not found a single, definite gene associated with manifesting ADHD, the chances of being diagnosed with the disorder notably increase when a close family relative has ADHD. "The results of a recent meta-analysis of twin and adoption studies indicated that genetic factors accounted for 71 and 73% of the variance of inattentive and hyperactive symptoms, respectively" (Purper-Ouakil, et al. 2011). Even "unaffected co-twins of ADHD performed worse than controls in a majority of neuropsychological tasks," including "response variability, inhibitory control, and processing speed" (Purper-Ouakil, et al. 2011).

The fact that identical twins do not inevitably both have ADHD indicates there may be other environmental factors known to trigger ADHD. Absent parenting, high levels of childhood stress, and other outside stressors all are more prevalent in children with the diagnosis. Other factors associated with higher levels of ADHD include "maternal stress during pregnancy," including exposure to environmental toxins and drugs, as well as birth trauma and prematurity (Purper-Ouakil, et al. 2011). "The dual pathway model of ADHD links inattention and deficits in executive functions ... whereas hyperactivity may be consecutive to dysfunctions of reward response and motivation" and these epigenetic factors may result in impairment (Purper-Ouakil, et al. 2011).

Defenders of the 'over-diagnosis' hypothesis of ADHD note that these conditions are often more likely to be flagged children of lower socio-economic status which may indicate that evaluator bias is at the heart of the current epidemic of ADHD in children and adolescents. Even if certain neurobiological markers are associated with children with ADD and ADHD this does not necessarily mean that the children with such markers are all disordered, rather it may reflect social intolerance to certain types of personalities.

Over-diagnosis: Is There an Epidemic

There is incontrovertible evidence that the diagnosis of ADHD has been increasing. "Data from the Centers for Disease Control and Prevention show that the diagnosis had been made in 15% of high school-age children, and that the number of children on medication for the disorder had soared to 3.5 million from 600,000 in 1990"(Schwarz 2013). Critics contend that there is no way that the genetic makeup of the U.S. population could have been so substantially altered in recent years; defenders of current diagnostic patterns allege that under-diagnosis was rampant. Although even the staunchest critics of the rise in diagnoses and revised, more liberal criteria for diagnosing the disorder acknowledge ADHD to be a legitimate disability for some children, the issue is the extent to which these numbers have been inflated, driven by a corresponding rise in new medications to treat the illness. They note "the rise of ADHD diagnoses and prescriptions for stimulants over the years coincided with a remarkably successful two-decade campaign by pharmaceutical companies to publicize the syndrome" (Schwarz 2013). There has literally been a boom in such drugs and prescriptions for adults have also been on the rise. "Advertising on television and in popular magazines like People and Good Housekeeping has cast common childhood forgetfulness and poor grades as grounds for medication" (Schwarz 2013). Stimulant medication such as Adderall, Concerta, Focalin and Vyvanse, and non-stimulant medications like Intuniv and Strattera are increasingly the first line of treatment for ADHD (Schwarz 2013). The introduction of these new drugs was coupled by aggressive marketing to physicians as well, emphasizing the dangers of ADHD in both children and adults and downplaying symptoms including reports of people that "cannot sleep for days, lose their appetite or hallucinate" and even have suicidal thoughts (Schwarz 2013).

There are alternative, nondrug treatments for ADHD, including cognitive behavioral therapy (CBT), which emphasizes "teaching individualized coping strategies and identifying and modifying maladaptive patterns of thinking that could interfere with effective coping mechanisms" (Knouse & Safren 2010). Although behavioral treatment programs may vary, most include an emphasis on the following: "1) organizing and planning, 2) reducing distractibility, and 3) cognitive restructuring (adaptive thinking)." (Knouse & Safren 2010). Strategies may include tactics such as writing things down, making use of calendars, and offering advice on effective ways of breaking tasks down into manageable chunks (Knouse & Safren 2010). Even for children and adults with severe ADHD, a literature review of recent studies indicates that a combination of medication and therapeutic techniques such as CBT is often more effective than medication in isolation (Knouse & Safren 2010).

ADHD Abroad

Further questioning of the ADHD diagnosis lies in the fact that there is a notable absence of diagnosed cases abroad, including rates in the developed world. For a comparison, while the rate of diagnosis of the condition is 9% amongst school-aged children in the United States, the rate in… [END OF PREVIEW]

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