Attention Deficit/Hyperactivity Disorder – ADD/ADHD
Originally this disorder was considered two separate problems: ADD, or attention deficit disorder, and ADHD, attention deficit and hyperactivity disorder. Nowadays, the National Institute for Mental Health just refers to it as ADHD for simplicity.
ADHD is the most commonly diagnosed behavioral disorder of childhood, affecting as many as five percent of school-aged children. It is diagnosed much more often in boys than in girls.
ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for the child’s age and development.
This is one reason why ADHD can go undiagnosed for a fairly long period of time – parents, educators and doctors may be unsure what “the normal range” for their child is.
Also, some children with ADHD may not display the hyperactivity and impulsivity aspects of the syndrome, also referred to as childhood hyperkinesis. Parents may observe their child sitting calmly for hours on end when presented with “pleasurable” activity such as watching television or playing video games. They conclude that their child couldn’t possibly be hyperactive – look, he’s just a couch potato!
It helps to understand the idea of hyperactivity a little better. Our brains are constantly in need of stimulation – it’s what keeps us breathing and digesting and basically staying alive. Did you that many scientists now believe that dreaming is one way of keeping our brains stimulated while we are sleeping?
So the interesting thing is that people who seem to be hyperactive, are actually people who are craving more stimulation. There is some chemical process created by the brain wanting more. That is why one of the treatments for children who are hyperactive is Ritalin, which is basically an amphetamine, or “speed.” It does seem counterintuitive that you would give a kid who is bouncing off the walls a drug that most adults use to make them more stimulated. But in reality, by giving these children a chemical stimulant, we are removing the need for them to get that stimulant through activity, which allows them to be more calm.
So television or video games, which require intense focus but have lots of images moving about constantly, are actually a form of stimulus.
In fact, children who are very quiet and withdrawn may actually be overstimulated – they may be more sensitive to sound or motion or emotion – and so they “shut down.”
Scientists have been learning more and more about how our brains work and one thing studies have shown is that the brains of children with ADHD seem to be different from those of other children. Those with ADHD do not process certain brain chemicals, called neurotransmitters, in the same way as their peers.
Another problem in diagnosing ADHD is that there are number of other disorders that have similar symptoms, like depression or learning disabilities. Some of these disorders may also have their root the processing of neurotransmitters.
Finally, scientists have also learned that the part of the brain that deals with controlling impulsivity and understanding the idea of long-term consequences, the pre-frontal cortex, is not fully developed until well after puberty.
Any child suspected of having ADHD deserves a thorough evaluation to identify exactly what is going on because often you may find there are multiple challenges requiring different types of treatment.
ADHD and Substance Abuse
Research has shown that children with attention deficit hyperactivity disorder (ADHD) are at high risk for later substance abuse. But only recently have psychologists begun to understand that children with certain types of ADHD are most likely to have problems with substance abuse.
ADHD is not yet well understood. It is not a disease or even a disorder with a single cause. Most scientists today believe that ADHD is a label for types of behaviors that are outside of the normal range for age, persistent (lasting longer than 6 months), and not explained by other medical or psychological factors.
There are three subtypes of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Those children who are predominantly inattentive have trouble sustaining attention or fail to pay attention to details. They may appear not to listen when spoken to and have trouble finishing schoolwork or chores. Organization is a problem and they may forget things such as assignments, clothing or other objects.
Those who are predominantly hyperactive-impulsive have great difficulty sitting still. They are constantly on the go, may talk excessively or out of turn. Behavior can be out of control and disruptive at times.
Children with combined ADHD subtype have characteristics of both inattentive and hyperactive-impulsive ADHD.
As many as 50 percent of those with ADHD also have Conduct Disorder (CD), which consists of a pattern of “externalizing” behaviors. This may be aggressive behavior that causes physical harm to people or animals or non-aggressive behavior such as theft, deceitfulness, property damage or repeated violation of rules.
When looking at all of these variables of ADHD, it is those children with hyperactive-impulsive behaviors and those with co-occurring Conduct Disorder who are more likely to have problems with substance abuse than those with only inattentive behaviors. This may be because those children having behaviors that are disruptive at school and at home may be scolded and punished more often, and begin to develop low self-esteem early in life. Difficulties in learning and problems with social relationships can also contribute to low self-esteem – which can set the stage for early experimentation with tobacco, alcohol, and drugs.
It is important for parents to understand how ADHD can predispose a child to substance abuse problems and to work closely with a therapist for early and continued treatment throughout childhood.
Impact of ADHD Treatment on Substance Use Disorders
It’s no secret that individuals with ADHD have the potential to develop other behavioral disorders such as oppositional defiant disorder (ODD) and conduct disorder (CD). Unfortunately, the risk of developing substance use disorder (SUD) increases by as much as four times for individuals with any of these behavioral disorders – a fact that complicates treatment of ADHD.
The most pressing concern about ADHD treatment among both parents and physicians is whether treatment with stimulant medications that have potential for abuse, such as Ritalin, increases the potential for SUD during adolescence or adulthood. And for children who have both ADHD and SUD, how do you treat both conditions without worsening either?
Recent research has suggested that for several reasons, it is important to treat ADHD, even if it means using stimulant medications, regardless of the existence or potential for SUD. For one, those with ADHD, particularly in the presence of CD, are more likely to use substances earlier in adolescence, use them more heavily, and have more trouble recovering. If ADHD is treated, there is less risk for the development of SUD. And if the child already has SUD as well as ADHD, medication used to treat ADHD may assure a better outcome from substance abuse treatment.