The ADHD Pandemic: Prevalence, Causes, Diagnosis and Treatment

Attention Deficit Hyperactivity Disorder (ADHD), is a common mental disorder beginning during childhood and may continue into adolescence and adulthood. The progression of ADHD hinders the performance of children in school as they have trouble focusing or paying attention. There are three major types of ADHD: predominantly inattentive type, predominantly hyperactive-impulsive type, and combination type, each with different symptoms.

ADHD includes distractibility, inattentiveness, impulsivity, and hyperactivity. Distractibility is having difficulty staying focused on just one thing, inattentiveness is having trouble paying attention, impulsivity is acting without thinking and hyperactivity is having trouble sitting still [1]. According to the Diagnostic and Statistical Manual for Mental Disorders or DSM-V, inattention symptoms include failure to pay close attention to details, difficulty listening and sustaining attention, difficulty following through and completing tasks, and forgetfulness in daily activities. Hyperactive impulsive symptoms include fidgeting with hands or feet, leaving seat in classroom inappropriately, running or climbing excessively, talking excessively, difficulty waiting turn and interrupting or intruding on others. As John, an ADHD Clinician from the Children’s Center stated in our interview, “ADHD is real and it is not likely to go away. As a child grows older, the symptoms may become less noticeable with increased coping mechanisms, but a large percentage still continues on into adulthood.”

This case study will go into depth regarding the causes, diagnosis, treatment, and potential misdiagnosis due to comorbidity of ADHD and even present a couple solutions to further misdiagnoses. Sources will include a combination of interviews and research particles, primarily from the Centers for Disease Control (CDC).

Causes

Fifty percent of ADHD is genetic and is passed down from parent to child. However, to get a sense of the non-genetic causes of ADHD, I interviewed and shadowed Dr. Shahida Khan who works as a Neonatologist in Huron Valley Sinai Hospital’s Neonatal Intensive Care Unit. She told me that recently many of the complications arising after delivery are a result of unhealthy conduct on the mother’s part during pregnancy. The babies of mothers addicted to drugs suffer severe withdrawal after birth showing symptoms of respiratory distress, poor feeding, slow weight gain, seizures, etc. She informed me that non-genetic causes of ADHD are smoking or drinking during pregnancy, a child’s exposure to lead or other toxic substances, and any birth complications which may result in the infant’s hospitalization in the NICU [2]. And according to the National Institutes of Mental Health’s ADHD Parents Flier, some studies have found that artificial food additives and dyes increase levels of hyper activeness and dyes [3]. Thus the causes of ADHD are multifaceted combining both genetic and environmental factors.

Figure 1: Example of a Vanderbilt scale which is administered to teachers. Asks teachers to rate students for symptoms on a scale of never to very often and academic performance and classroom behavioral options on a scale of excellent to problematic. Vanderbilt scales for parents are very similar.

Figure 1: Example of a Vanderbilt scale which is administered to teachers. Asks teachers to rate students for symptoms on a scale of never to very often and academic performance and classroom behavioral options on a scale of excellent to problematic. Vanderbilt scales for parents are very similar.

Diagnosis

Five to eight percent of the general population is diagnosed with ADHD with nearly 1-2 victims of ADHD in every classroom, making ADHD a formidable problem in modern society [1]. ADHD can be diagnosed by a child’s physician or mental health specialist who use several rating scales such as the Vanderbilt Assessment Scale. This scale tracks ADHD symptoms such as inattention, daydreaming, trouble with directions, and hyperactivity. Often times Vanderbilt scales are administered at the
beginning and end of a clinical session for families and clinicians to monitor how effective they are [1].

When an individual experiences distress due to the aforementioned symptoms in at least two settings such as the home, school, social settings or work, a diagnosis will be considered. If there is a potential concern, mental health professionals follow a step by step process towards the diagnosis of ADHD. Firstly, they gather information from various settings through observation and interviews with teachers and parents on the child’s behavior and rule out causes other than ADHD. They then gather information about the child’s history including medical, development, family and social environment. Next, rating scales such as the Vanderbilt Assessment Scale are completed by teachers and parents and the results are compared to societal norms, to decide on a final diagnosis [1].

Around what age is ADHD diagnosed?

Children are not usually diagnosed or medicated for ADHD symptoms before the age of 6 as hyperactivity manifestations are part of a child’s normal development. I can speak about this from my weekly volunteering at the Children’s Hospital of Michigan. As a volunteer in the same day surgery playroom, I interact which children anywhere from 1 year of age up to middle schoolers. Most of the younger kids want to run around and play with every single toy in the playroom, rarely sitting still for even a minute and getting easily distracted by a more attractive toy. On the other hand, older kids more readily agree to draw or complete other crafts, quietly sitting in one place while doing so. If we were quick to jump to the diagnosis of ADHD, then all young children would be diagnosed with this disorder.

However, when children start school, ADHD symptoms begin presenting causing impairments in a child’s learning with ADHD usually diagnosed before the age of 12 [4]. If after the age of five or six children are still presenting symptoms, then it may be time for fuller more in depth diagnostic procedures.

Figure 2: This chart shows the different forms of therapy usage during 2009-2010 to treat ADHD by age group (8).

Figure 2: This chart shows the different forms of therapy usage during 2009-2010 to treat ADHD by age group (8).

Treatment

During my interview with John from the Children’s Center, he broke down the different forms of treatment for me. “ADHD is a chemical imbalance in the brain, so medications act as MDOT which comes in and does construction on disrupted neural pathways. Medication is important because it paves the highways and makes them work. Behavioral therapy is necessary such as emotional regulation, helping them identify feelings, being able to identify coping skills, belly breathing, giving them the language to express how they are feeling when they are feeling stressed out.” John’s analogy likening medications and behavioral therapy to the MDOT, made it much easier for me to understand the extent of the problem and the means with which to solve it.

There are many different forms of treatment used to combat ADHD. A few of the most common forms include watchful waiting where the parents or teachers watch the kid and don’t do anything in anticipation that the symptoms will go away. Some clinicians prefer a medication only approach, while others prefer behavioral treatment only, as they do not have to worry about side effects and focus on pure emotional regulation and the building of social skills. The Children’s Center recommends combined treatment as it is the most effective. Behavioral therapy only takes a long time as children’s executive functioning is delayed and thus clinicians must constantly go over rules and taught concepts with them [4]. For parents, Russell Barkley has published many resources on great parenting techniques!

One of my fellow mentors from the Psychology Academic Success Services, Adam Regalski, opened up to me that he was a victim of ADHD as a child. He suffered more of the inattentive symptoms as a child, and was never very hyperactive. Through his experiences with various treatments, he believes that exercise and nutrition are better than ADHD medication. He was turned to behavioral treatment as he found that psychostimulants really disrupt sleep patterns and the side effects aren’t worth it [5].

Last semester, I volunteered as an aide during the weekly ADHD Clinics at the Children’s Center. During these sessions, I helped the children participate in many mindfulness activities to help them notice what was going on inside their bodies and to help them calm down. These activities included deep breathing exercises and yoga. I can say from my personal volunteering experiences, that behavioral and mindfulness activities are a key component to the ADHD treatment regimen.

Figure 3: This study found that more than 60% of children with ADHD had another mental disorder (blue column), frequently conduct disorder (CD) or oppositional defiant disorder (ODD). It also shows that more than 25% of children with ADHD have 2 or more mental disorders (red column).

Figure 3: This study found that more than 60% of children with ADHD had another mental disorder (blue column), frequently conduct disorder (CD) or oppositional defiant disorder (ODD). It also shows that more than 25% of children with ADHD have 2 or more mental disorders (red column).

Reasons behind misdiagnosis/comorbidity with other disorders/other disorders are often mistaken as ADHD

However, since there is no one test used to diagnose ADHD, it is often difficult to diagnose and often times is misdiagnosed. ADHD has a high comorbidity with other mental disorders such as conduct disorder, anxiety disorder, and depression. According to a recent study through the CDC [6], more than half of children with ADHD also had another mental disorder. These children were more likely to have other problems, such as struggling with friendships and getting into trouble in school or with the police.

Figure 4: This study also showed that children with ADHD often had trouble with the police or were suspended or expelled from school. Children with both ADHD and CD/ODD (green column) were most likely to have problems in school, with the police and with friends. This characterizes the early stages of ASPD.

Figure 4: This study also showed that children with ADHD often had trouble with the police or were suspended or expelled from school. Children with both ADHD and CD/ODD (green column) were most likely to have problems in school, with the police and with friends. This characterizes the early stages of ASPD.

John informed me that 40% of children with ADHD have conduct disorder (CD) which includes lying, stealing, and destroying property and serves as the early stages of Antisocial Personality Disorder (ASPD). ADHD symptoms worsen CD and if ADHD isn’t treated within two years, ASPD manifests. According to the Mayo Clinic, symptoms of ASPD include poor or abusive relationships, serious violations of rules and manipulation and lack of empathy for others. ASPD is a serious issue as those effected may participate in homicidal or suicidal behaviors, face jail time, abuse family members, or have low economic status (Mayo Clinic, 7).

In summary, due to ADHD’s comorbidity with other psychological disorders, children faced with multiple comorbid disorders may benefit from varied treatment and interventions that will prevent them from dropping out from school and criminal activity. Overall, this CDC study showed that individualized treatments for specific cases would be much more useful than a broad single one [8].

Brief Interview with a Pediatrician who works with children affected by ADHD

In addition, many psychological disorders are mistakenly diagnosed as ADHD. I came across a striking example of this situation when I interview Dr. Irani, a pediatrician who runs his own private practice Highland Pediatrics:

“I have been in solo pediatric practice for 15 years. I make a diagnosis of ADHD only in children older than 5 years. Below the age of 5 it is very difficult to make the diagnosis as children may show a lot of inattentive & hyperactive behavior that is normal for their age.

I recently diagnosed ADHD in a ten-year-old boy. On Vanderbilt questionnaires completed by parents & teachers he was diagnosed as ADD Inattentive Type. He had no symptoms of hyperactivity. However, he did not do well on medications. Initially he was tried on Ritalin, then changed to Strattera (Atomoxetine) which is specific for ADD Inattentive Type. During the course of various office visits he was noted to show signs of generalized anxiety, fearfulness, sadness, insecurity. On further research I realized that anxiety can present with all the signs and symptoms of and is often misdiagnosed as ADD: the child cannot pay attention and stay focused as his or her mind is full of thoughts that cause fear & anxiety. I will consider having him see a psychiatrist who can evaluate him further and put him on a trial of anxiolytics. He will also benefit from behavioral therapy” [9].

This scenario showed that while ADHD is often comorbid with other psychological disorders, it is also frequently misdiagnosed as the symptoms of ADHD are similar to those of anxiety and depression. The current Vanderbilt questionnaires along with other diagnostic procedures are not foolproof and physicians must do ample research before making an ADHD diagnosis.

Brief interview with a student affected by ADHD

During my interview with Adam Regalski, he opened up to me that he felt that ADHD shouldn’t be labeled as a learning disorder as it is more of a social phenomenon. “The way the education system is currently set up” he states, “ADHD poses a challenge for children, as it is a disability but over time it may grow to be an asset.” He was diagnosed with dyslexia and ADHD as a child. When he was first diagnosed, he was unable to read. However, once he was released from special education in 5th grade he was reading at the 12th grade level. He feels that children with ADHD thrive in certain environments and that while it seemed as a disability at first, it eventually proved to actually be an asset for him.

Prevention of future misdiagnosis and Overall Conclusion

After all my research through the CDC and NIH and primarily through my interview with John, I have reached the conclusion that overall the current diagnostic procedures for ADHD are quite sound. However, the main cause of misdiagnosis is poor education about the symptoms of ADHD. John brought to my attention that many parents do not understand that their child has a problem. They feel that their child is just being plain lazy or stupid. For example, John said “It’s like going to a seminar and you’re excited that the seminar is going to be on hamburgers, but really the seminar is in Mandarin. For ADHD kids, if it is not interesting, they don’t want to do it. This is the reason they can play video games for hours but have trouble sitting still in class.”

Therefore, the first step is to educate parents on how to determine whether their child has ADHD and if the child is diagnosed, to provide the parent with effective coping and parenting techniques. Children should also be referred to an ADHD clinician and a psychiatrist after the initial appointment with a primary care physician. This will confirm the diagnosis and prevent any possible chances of misdiagnosis. And finally, if a child is treated with an effective combination of both behavioral therapy and medications, ADHD can be combatted before it spirals into Conduct Disorder or Oppositional Defiant Disorder.

References:

  1. Angela Tzelepis, Ph.D. (2015). The Children’s Center PowerPoint-ADHD 101. 05 Apr. 2016.
  2. Interview with Dr. Shahida Khan. Personal interview. 17 Mar 2016.
  3. “Attention Deficit Hyperactivity Disorder (Easy-to-Read).” NIMH RSS. N.p., n.d. Web. 17 Apr.
    2016.
  4. Interview with John, An ADHD Clinician from the Children’s Center. Personal interview. 5 Apr. 2016.
  5. Interview with Adam Regalski. Personal interview. 12 Apr 2016.
  6. “Key Findings: Attention-Deficit/Hyperactivity Disorder and Psychiatric Comorbidity:
    Functional Outcomes in a School-Based Sample of Children.” Centers for Disease
    Control and Prevention. Centers for Disease Control and Prevention, 13 Jan. 2016. Web. 17 Apr. 2016.
  7. “Antisocial Personality Disorder.” Symptoms and Causes. N.p., 02 Apr. 2016. Web. 17 Apr.
    2016.
  8. “Key Findings: Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) among Children
    with Special Health Care Needs.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 11 Feb. 2016. Web. 17 Apr. 2016.
  9. Interview with Dr Ardeshir Irani. Personal interview. 06 Apr. 2016.

Sanaya Irani is currently a sophomore in the MedStart Program at Wayne State University pursuing a major in Psychology and a minor in Nutrition and Food Science. She spends a lot of time volunteering with disadvantaged children in the metro Detroit area and would like to pursue a career in Pediatric Neurology.

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