Kindergartners, college students and retirees have attention-deficit hyperactivity disorder

I sometimes joke that I got ADHD in college, like a flu going around the dorm (CDC Diagnostic Criteria, Rosenberg, 1998, Angier, 1991, Kluger, 2005, Gilman, 2005). I became easily distracted, fidgety, sometimes forgetful or inattentive of simple, daily activities and occasionally very restless. Most likely, since the symptoms are few in number and not significantly impairing I was simply noticing the effects of a high-stress, academically-challenging environment navigated on little sleep. Although typically a childhood disease, the symptoms may last until adulthood; for some people with attention-deficit/hyperactive disorder symptoms remain unnoticed until placed in a challenging environment with sudden independence, like college. Furthermore, some people afflicted with ADHD are not diagnosed until even later in life—retirement. The structured, scheduled work life they led for decades was taken away exposing for the first time symptoms they later realized were themes throughout their lives. For many people the impetus to see a doctor about these symptoms was a diagnosis of ADHD in their grandchild followed by their child, as ADHD seems to have a genetic component.

According to the Diagnostic and Statistical Manual for Mental Disorders IV there are three types of ADHD (CDC Diagnostic Criteria, CDC What is ADHD, Angier, 1991, Angier, 1994, Moffitt, 2007). One, the predominantly inattentive type, comprised of symptoms such as carelessness, distraction, forgetfulness, trouble organizing, following instructions or completing tasks that require attention or mental effort for long periods of time and inability to keep track of objects. Two, the predominantly hyperactive type, comprised of symptoms such as trouble waiting one’s turn or keeping still, frequent interrupting and excessive talking, restlessness and difficulty remaining quiet. And three, the combined type if criteria are met for both inattentive and hyperactive types. Interestingly, the discrepancy between American and European diagnostic statistics is likely due to a difference in diagnosis. European children typically need to be type three ADHD, the combined type, before being diagnosed. When the same standards are applied to subjects the rates of diagnosis between the continents equalizes, although there are still pockets of higher or lower diagnosis due to awareness and diligence of parents and treating physicians. Although some tests, such as for eye movement and coordination can be more sensitive, the predominant observational method of diagnosis illustrates the inherent subjectiveness and need for a biological method of diagnosis. Strep throat can be diagnosed definitively by a bacterial culture from a throat swab but ADHD has no such concrete method. The personal and cultural standards of proper behavior and impairing behavior color diagnosis and even acceptance of the condition as a disability. For example, many Asian cultures turn a blind eye to mental disorders such as ADHD and instead provide harsher discipline to the afflicted child. On the other hand, the US has seen a trend of overdiagnosis, particularly in boys, because of the characteristic “boys will be boys” behavior that is so similar to ADHD symptoms.

ADHD affects approximately 3-7% of children in the United States (three-quarters of whom are boys) (CDC Research Agenda, CDC What is ADHD, CDC A Public Health Perspective, CDC Injuries and ADHD, CDC Peer Relationships and ADHD, CDC Other Conditions Associated with ADHD, Hersey, 1996, Angier, 1991, Angier, 1994, Wallis, 2006, Kluger, 2005, Kluger, 2003, Harding, 2003, das Neves, 2006, Eisenberg, 2007). About half of these children have another behavioral or learning disorder that can complicate diagnosis and treatment. The ADHD child may have trouble making friends, be accident prone, and have trouble in school despite adequate intelligence. The ADHD child may also have more difficulty identifying dangerous situations, like crossing the street and may need to have distractions such as music or TV removed in order to do homework. Adults with ADHD may have trouble concentrating while driving, keeping a job or be more susceptible to drug addiction. On top of this, families must decide with their physician whether or not to put the child on medication (2.5 million children and 1.5 million adults are medicated for ADHD), rely on behavioral therapy and counseling alone, or substitute alternative treatments like the Feingold diet (artificial additives are removed and certain minerals, amino acids and other supplements are added) for medication. Oddly, a good night’s sleep may be enough to alleviate ADHD symptoms and help the child stay on medication. Approximately twice as many children with ADHD also have sleeping disorders, compared to children without ADHD. Poor sleep not only exacerbates ADHD symptoms but also presents some of the same symptoms, much as I saw in college, that could be misdiagnosed as ADHD.

It is unlikely that the apparent rise in ADHD diagnosis is due to a new cause of ADHD (or lax parenting) but to better diagnosis and establishment of the condition itself (Eisenberg, 2007, Hersey, 1996, Angier, 1994, Harding, 2003). The major debates surrounding ADHD, is it overdiagnosed and is it overmedicated, are based on one fact: the cause of ADHD is unknown. With no physical explanation for ADHD no absolute diagnostic criteria can be established and no mechanism for treatment can be explained. The current treatment of amphetamines, such as Ritalin, is based on 7 decades of observation of changed behavior but little else. Similarly, the Feingold diet is based on observed behavioral changes and has been shown by some studies to be as effective as Ritalin in some children, although no cellular explanation can be given for either treatment. Both are based on the theory that the brain cells are not signaling properly and the addition of an amphetamine (Ritalin) or removal of preservatives and artificial additives together with specific supplements (Feingold diet) restore the correct brain function or bypass the missing signaling component. Until a definitive cause of ADHD and resulting treatment are found there will continue to be underdiagnosed and overdiagnosed (and overmedicated) children simply because of different standards of behavior and unruliness and limited spread of more sensitive tests.

CDC ADHD Diagnostic Criteria: http://www.cdc.gov/ncbddd/adhd/symptom.htm
CDC ADHD Research Agenda: http://www.cdc.gov/ncbddd/adhd/dadagenda.htm
CDC What is ADHD?: http://www.cdc.gov/ncbddd/adhd/what.htm
CDC ADHD A Public Health Perspective: http://www.cdc.gov/ncbddd/adhd/publichealth.htm
CDC Injuries and ADHD: http://0-www.cdc.gov.mill1.sjlibrary.org/ncbddd/adhd/injury.htm
CDC ADHD Peer Relationships and ADHD: http://www.cdc.gov/ncbddd/adhd/peer.htm
CDC ADHD Other Conditions Associated with ADHD: http://www.cdc.gov/ncbddd/adhd/otherconditions.htm
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Rosenberg, Merri. Strategies to Manage a Disorder. The New York Times. 1998.
Angier, Natalie. Kids Who Can’t Sit Still. The New York Times. 1991.
Angier, Natalie. The Nation; The Debilitating Malady Called Boyhood. The New York Times. 1994.
Wallis, Claudia. Getting Hyper about Ritalin. Time Magazine. 2006.
Kluger, Jeffrey. Medicating Young Minds. Time Magazine. 2003.
Kluger, Jeffrey. Sleep Deprivation and ADHD. Time Magazine. 2005.
Gilman, Lois. All Jumbled Up. Time Magazine. 2005.
Moffitt, Terrie E. and Maria Melchior. Why does the worldwide prevalence of childhood attention deficit hyperactivity disorder matter? American Journal of                   Psychiatry, Vol. 164, No. 6. 2007.
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das Neves, Sergio and Rubens Reimao. Sleep disturbances in 50 children with attention-deficit hyperactivity disorder. Arquivos de Neuro-Psiquiatria. Vol. 65,               No. 2-A. 228-233. 2007.
Eisenberg, Leon. Commentary with a historical perspective by a child psychiatrist: When “ADHD” was the “brain-damaged child.” Journal of Child and                          Adolescent Psychopharmacology. Vol. 17, No. 3. 2007.