15.10.1 Attention Deficit/Hyperactivity Disorder

Diego is always active, from the time he wakes up in the morning until the time he goes to bed at night. His mother reports that he came out the womb kicking and screaming, and he has not stopped moving since. He has a sweet disposition, but always seems to be in trouble with his teachers, parents, and after-school program counselors. He seems to accidentally break things; he lost his jacket three times last winter, and he never seems to sit still. His teachers believe he is a smart child, but he never finishes anything he starts and is so impulsive that he does not seem to learn much in school.

Diego likely has attention deficit/hyperactivity disorder (ADHD). The symptoms of this disorder were first described by Hans Hoffman in the 1920s. While taking care of his son while his wife was in the hospital giving birth to a second child, Hoffman noticed that the boy had trouble concentrating on his homework, had a short attention span, and had to repeatedly go over easy homework to learn the material (Jellinek & Herzog, 1999). Later, it was discovered that many hyperactive children—those who are fidgety, restless, socially disruptive, and have trouble with impulse control—also display short attention spans, problems with concentration, and distractibility. By the 1970s, it had become clear that many children who display attention problems often also exhibit signs of hyperactivity. In recognition of such findings, the DSM-III (published in 1980) included a new disorder: attention deficit disorder with and without hyperactivity, now known as attention deficit/hyperactivity disorder (ADHD).

A child with ADHD shows a constant pattern of inattention and/or hyperactive and impulsive behavior that interferes with normal functioning (APA, 2013). Some of the signs of inattention include great difficulty with and avoidance of tasks that require sustained attention (such as conversations or reading), failure to follow instructions (often resulting in failure to complete school work and other duties), disorganization (difficulty keeping things in order, poor time management, sloppy and messy work), lack of attention to detail, becoming easily distracted, and forgetfulness. Hyperactivity is characterized by excessive movement, and includes fidgeting or squirming, leaving one’s seat in situations when remaining seated is expected, having trouble sitting still (e.g., in a restaurant), running about and climbing on things, blurting out responses before another person’s question or statement has been completed, difficulty waiting one’s turn for something, and interrupting and intruding on others. Frequently, the hyperactive child comes across as noisy and boisterous. The child’s behavior is hasty, impulsive, and seems to occur without much forethought; these characteristics may explain why adolescents and young adults diagnosed with ADHD receive more traffic tickets and have more automobile accidents than do others (Thompson, Molina, Pelham, & Gnagy, 2007).

ADHD occurs in about 8% of children (Danielson et al, 2016), and studies estimate that for about 60% of these people, ADHD continues into adulthood (Sibley et al 2016). On the average, boys are 3 times more likely to have ADHD than are girls; however, such findings might reflect the greater propensity of boys to engage in aggressive and antisocial behavior and thus incur a greater likelihood of being referred to psychological clinics (Barkley, 2006). Children with ADHD face severe academic and social challenges. Compared to their non-ADHD counterparts, children with ADHD have lower grades and standardized test scores and higher rates of expulsion, grade retention, and dropping out (Loe & Feldman, 2007). they also are less well-liked and more often rejected by their peers (Hoza et al., 2005).

A recent study found that nearly 81% of those whose ADHD persisted into adulthood had experienced at least one other comorbid disorder, compared to 47% of those whose ADHD did not persist (Barbaresi et al., 2013).

Life Problems from ADHD

Children with ADHD face considerably worse long-term outcomes than do those children who do not have ADHD. Adults diagnosed with ADHD in childhood, but not treated for ADHD, have been reported to have poor outcomes in a wide range of areas of life, including social function, education, criminality, alcohol use, substance use, and occupational outcomes (Arnold et al, 2015). In one investigation, 135 adults who had been identified as having ADHD symptoms in the 1970s were contacted decades later and interviewed (Klein et al., 2012). Compared to a control sample of 136 participants who had never been diagnosed with ADHD, those who were diagnosed as children:

• had worse educational attainment (more likely to have dropped out of high school and less likely to have earned a bachelor’s degree);
• had lower socioeconomic status;
• held less prestigious occupational positions;
• were more likely to be unemployed;
• made considerably less in salary;
• scored worse on a measure of occupational functioning (indicating, for example, lower job satisfaction, poorer work relationships, and more firings);
• scored worse on a measure of social functioning (indicating, for example, fewer friendships and less involvement in social activities);
• were more likely to be divorced; and
• were more likely to have non-alcohol-related substance abuse problems. (Klein et al., 2012)

Longitudinal studies also show that children diagnosed with ADHD are at higher risk for substance abuse problems. One study reported that childhood ADHD predicted later drinking problems, daily smoking, and use of marijuana and other illicit drugs (Molina & Pelham, 2003). The risk of substance abuse problems appears to be even greater for those with ADHD who also exhibit antisocial tendencies (Marshal & Molina, 2006).

Diagnosis, treatment, and general awareness of ADHD has certainly improved in the decades since the people in the above studies were diagnosed. Studies that include more recent outcomes show positive effects of treatment as opposed to non-treatment (Harpin, 2013; Arnold 2015). In most cases, the same studies indicate that more research and work needs to be undertaken to understand the most effect treatments and their impacts.

Causes of ADHD

Family and twin studies indicate that genetics play a significant role in the development of ADHD. Burt (2009), in a review of 26 studies, reported that the median rate of concordance for identical twins was .66 (one study reported a rate of .90), whereas the median concordance rate for fraternal twins was .20. This study also found that the median concordance rate for unrelated (adoptive) siblings was .09; although this number is small, it is greater than 0, thus suggesting that the environment may have at least some influence. Another review of studies concluded that the heritability of inattention and hyperactivity were 71% and 73%, respectively (Nikolas & Burt, 2010).

The specific genes involved in ADHD are thought to include at least two that are important in the regulation of the neurotransmitter dopamine (Gizer, Ficks, & Waldman, 2009), suggesting that dopamine may be important in ADHD. Indeed, medications used in the treatment of ADHD, such as methylphenidate (Ritalin) and amphetamine with dextroamphetamine (Adderall), have stimulant qualities and elevate dopamine activity. People with ADHD show less dopamine activity in key regions of the brain, especially those associated with motivation and reward (Volkow et al., 2009), which provides support to the theory that dopamine deficits may be a vital factor in the development this disorder (Swanson et al., 2007).

Brain imaging studies have shown that children with ADHD exhibit abnormalities in their frontal lobes, an area in which dopamine is in abundance. Compared to children without ADHD, those with ADHD appear to have smaller frontal lobe volume, and they show less frontal lobe activation when performing mental tasks. Recall that one of the functions of the frontal lobes is to inhibit our behavior. Thus, abnormalities in this region may go a long way toward explaining the hyperactive, uncontrolled behavior of ADHD.

By the 1970s, many had become aware of the connection between nutritional factors and childhood behavior. At the time, much of the public believed that hyperactivity was caused by sugar and food additives, such as artificial coloring and flavoring. Undoubtedly, part of the appeal of this hypothesis was that it provided a simple explanation of (and treatment for) behavioral problems in children. A statistical review of 16 studies, however, concluded that sugar consumption has no effect at all on the behavioral and cognitive performance of children (Wolraich, Wilson, & White, 1995). Additionally, although food additives have been shown to increase hyperactivity in non-ADHD children, the effect is rather small (McCann et al., 2007). Numerous studies, however, have shown a significant relationship between exposure to nicotine in cigarette smoke during the prenatal period and ADHD (Linnet et al., 2003). Maternal smoking during pregnancy is associated with the development of more severe symptoms of the disorder (Thakur et al., 2013).

Is ADHD caused by poor parenting? No. Remember, the genetics studies discussed above suggested that the family environment does not seem to play much of a role in the development of this disorder; if it did, we would expect the concordance rates to be higher for fraternal twins and adoptive siblings than has been demonstrated. All things considered, the evidence seems to point to the conclusion that ADHD is triggered more by genetic and neurological factors and less by social or environmental ones.