Attention Deficit/Hyperactivity Disorder (ADHD)

Attention Deficit/Hyperactivity Disorder (ADHD) is the diagnostic term used to describe patterns of behavior, beginning in childhood, related to deficient self-regulation. In the course of the twentieth century, ADHD has been called minimal brain dysfunction, hyperkinesis, or attention deficit disorder. The core symptoms include (a) difficulties in paying attention, particularly in situations that demand concentration, like school classes and homework sessions; (b) impulsivity or poor impulse control— in other words, "acting before thinking"—and behavior that ranges from the annoying to the physically dangerous; and (c) hyperactivity, including fidgetiness, motor restlessness, and actions such as running through a classroom. Given that close attention is demanded from students, ADHD became an important issue with the advent of compulsory education. Considerable notoriety currently surrounds ADHD; there is an ongoing debate over its status as a legitimate diagnosis as opposed to an excuse for the overzealous use of pharmacological treatments or a "medicalized" label for problems that actually result from discordant family interactions, poor schooling, or increasing societal demands for educational attainment (DeGrandpre and Hinshaw 2000).

Part of the reason for the intensity of this debate is that the constituent behaviors are part of normal development. Indeed, inattention, impulsivity, and overactivity are ubiquitous in children— particularly boys—during the preschool or early elementary years, when the frontal lobes of the brain have not fully matured yet demands for compliance and socialization increase markedly. To make an accurate diagnosis, clinicians must document that the behavior patterns are (a) developmentally extreme (i.e., statistically rare for children of the same age); (b) of early onset (aged 6 years or younger); (c) present in both home and school situations (or, for adults, in home and work settings); and (d) impairing with respect to family interactions, educational achievement, friendships, and the attainment of independence (American Psychiatric Association 1994).

In fact, despite the contention that ADHD is a mythical condition, children who meet stringent diagnostic criteria are often severely impaired. School failure is common, despite average or above-average intelligence; discordant parent-child relationships are commonplace; rejection from the peer group is common, as youth with ADHD are almost universally disliked by their peers; selfconcept and self-esteem suffer, particularly as development progresses; and the risk of serious accidental injury—ranging from burns and falls in childhood to serious automobile accidents in adolescence and adulthood—is striking (Hinshaw 1999). Thus, despite allegations that ADHD is a convenient diagnostic term for children who are simply exuberant or bothersome to adults, careful assessment can warn of significant developmental failures and impairments.

A brief office visit is insufficient for a proper diagnostic work-up. A complete evaluation must include parent and teacher ratings of the constituent behaviors (with scales that are carefully normed), a careful history gathered from caregivers, conversations with teachers (and classroom observations), a physical examination (to rule out various medical and neurological conditions that can mimic ADHD), and appraisal of the presence of co-occurring learning and behavioral difficulties. In fact, there are many reasons why a child or adolescent could display symptoms related to ADHD, including life stress, child abuse, depression or various neurological conditions, unstructured family configurations, or grossly disorganized classroom settings (Barkley 1998). Thus, assessment must use multiple sources of information and transcend brief observations of the child in the office, where the novelty of the situation may temporarily suppress the ongoing behavior patterns.