ADHD: What is it? What it is not is simple. There are a
minority of people with problems of attention who have ADHD-Simplex.
That is to say they have a condition that can be treated relatively
easily with medication. ADHD is a condition in which there is a
deficit in the ability to be attentive, a deficit in the ability
to NOT be distracted and a tendency to be impulsive. There are
also problems in something called executive function, which is
the ability to organize oneself. Finally, there are problems in
either being hyperactive or being under-active. The hyperactive,
aggressive types are predominately male (but not always) and the
under-active types are predominately female (but not always).
What about most of the people who have problems in attention?
They can have ADHD or they can have any of several other conditions.
OR, they may have a combination of the other conditions along with
ADHD. What are the other conditions?
Educational issues often cloud the diagnosis of ADHD. If a child
has a problem understanding the concepts of reading, writing and
math, the child will be inattentive and will often be a behavioral
problem. The child feels incapable of getting positive attention,
so therefore becomes the class clown. It is often said that it
is "...better to be wanted by the police than not be wanted
at all...."
There are also medical issues that influence attention. ADHD
is a metabolic problem in the glucose metabolism in the pre-frontal
part of the brain. In addition, iron deficiency, with or without
anemia, can cause inattention and either hyperactivity or under-activity.
It also may cause Periodic Leg Movement of Sleep. Obviously, without
a good quality sleep, performance suffers the next day. Finally,
adolescent girls who were formerly good math students will
decline if their menstrual periods produce a deficiency of iron.
Thyroid dysfunction will cause under-activity if the thyroid is
low whereas hyperactivity can be produced if the thyroid level
is high.
Many sensory issues will cause problems in school. Obviously,
if a child does not see the board or does not hear the teacher, that
child will not do well in school. More subtly, the problems of
Central Auditory Processing Deficiencies will both accompany
ADHD and will masquerade as ADHD. These deficiencies will cause
a student to mishear the words of the teacher or they will not
be able to filter out unimportant sounds while trying to listen
to the teacher. These deficiencies stem either from an inherited
tendency or from an early history of fluid in the ears or
chronic ear infections. This will affect the ability to read when
the student is young and, later on, will affect the ability to
take notes in class.
There are several syndromes that have problems in attention.
The three most prominent are the Autistic Spectrum Disorders, including
Asperger's Syndrome, Sensory Integration Dysfunction and Tourette's
Syndrome. Autistic Spectrum Disorders hinder children in
their ability to use language appropriately, to socialize and to
inhibit repetitive movements. Sensory Integration Dysfunction is
a condition wherein sensory stimuli affect people well beyond the
affect on normal people. They are over-stimulated by visual, auditory
or tactile input and hence react negatively. Tourette's Syndrome
is a condition where the patient cannot inhibit the impulse to
both use their voices and to make movements. It is obvious that
these syndromes often overlap one another in many patients.
Mood disorders also accompany or mimic ADHD. The most important
one is a bi-polar disorder. It is thought that 90% of bi-polar
patients also have ADHD and that 20% of ADHD have a bi-polar
disorder. In adults, there are classically mood swings in which
the patient has very high moods alternating with very low moods.
In children, however, this presentation is rarely seen. They are
generally hypo-manic (just under the mania of the adult form)
and this presents as hyperactivity.
The depressed patient could be mistaken for an under-active ADHD
patient and will generally not be able to pay attention. The patient
with anxiety could be mistaken for a hyperactive ADHD patient and
will also not be able to pay attention.
Sleep disorders often mimic inattention. If you are very tired,
you will either present as an inattentive person, or, in children,
they could be hyperactive. The hyperactivity is a defense
against feeling very tired. They keep moving so they won't
fall asleep. The most common type of sleep disorders are disorders
of sleep schedules. People go to bed too late and wake up too late;
thus, they are too tired when they up to be as functional as they
need to be. When they do get up, they are often late for school
or work and thus skip breakfast ( or eat a quick sugar laden
breakfast. 35% of people who have sugar on an empty stomach suffer
from an overload of adrenalin.
The two other most common sleep problems are Obstructive Sleep
Apnea and Narcolepsy. In children, sleep apnea is caused predominately
by enlarged tonsils and adenoids. In adults, Sleep Apnea is caused
by the central nervous system and most commonly, by obesity, large
necks and by palatal collapse when breathing. There are also people
with deviated septa who have obstructive sleep apnea. Lastly,
allergic rhinitis can also contribute to the problem.
Because they are increasingly sleep, both children and adults
resort to increased caffeine intake. Excessive caffeine then causes
increased insomnia. It is a vicious cycle.
Life style issues have become a very important factor in people
being inattentive. Electronic entertainment has dominated
people's lives for a long time; however, since the explosion of
the internet and video games, both children and adults have become
addicted to these modern inventions. There are children who purposely
wake themselves in the middle of the night so they can play video
games, Thus, they are falling asleep in school. Video games have
been shown to cause boys (much more than girls, who prefer text
messaging) to be hyper-aggressive and hostile. Their pulses, blood
pressures and pupillary responses are increased. In adult men,
the internet poses a problem in the workplace and it often involves
pornography addiction. ADHD people are more prone to addictions
of all types, when untreated. Video games lead to school failure
in children and internet addiction leads to problems at work and
in marriages in adults. Both children and adults who are addicted
to electronic stimulation do not exercise, for the most part. Lack
of exercise increases inattention, depression, and anxiety.
Dietary issues have been a very controversial topic in the field
of school dysfunction over the past 40 years. Special diets have
come and gone. Most have not proven to be beneficial for the majority
of patients. There are a few issues that are uncontroversial. No
breakfasts are a poor way to start the day as far as thinking goes.
As it is said, "You can't run on an empty tank." The
breakfast should include protein.
Life style issues dominate the field of ADHD. Families in the
past few decades eat dinner less and less as a unit. Studies have
shown that children who eat with their families do better in school.
Children with ADHD need structure. Our American society is a "hit
and run" society.
Children do not have a consistent bed time. One reason that there
seem to be more people with ADHD symptoms these days is that our
life style has changed for the worse compared to what it
was 50 years ago. Getting back to the basics of living is essential
if we are to be the best that we can be.
Children, in days gone by, played out doors. There is a body
of literature that suggests that "Green" time is essential
for clear and creative thinking. A good book about this issue is
The Last Child In the Woods...Nature Deficit Disorder by
John Louv. He makes a compelling case for getting youngsters outdoors
to explore their world, Presently, their world is inside, in front
of a T.V., a computer or a video game. For those who claim that
video games are good for eye-hand coordination, I say, get them
a ping-pong table. A few video games would cost the same thing
as a ping-pong table.
Social issues complicate our lives today. Divorce, once uncommon,
is now almost the rule. Children born to unmarried parents are
now an acceptable way to bring them into the world to a lot of
our society. Single mothers don't have the means or the energy
to be involved in their children's lives. They do not give input
to or get input from the schools. Children born to alcoholic and
drug addicted mothers are predictably going to have a higher incidence
of school and behavioral difficulties. This problem is more
and more prevalent in our world.
Children either have no activities, except for indoor activities,
or they are over programmed to take part in so many activities
that they have no time to just be children and explore their world.
Free play produces creative minds. When they are over programmed,
they are left too exhausted and confused to do their homework,
not to speak about their regular work in school.
Thus, it is obvious that ADHD is a very complex field. Those
that think that one pill will solve all of the problems of childhood
are deluding themselves and are short changing their children.
The result of this type of simplistic thinking is one of the causes
of the dysfunction that we find in both children and adults. The solution
is to take an in-depth look at all of the symptoms and come up
with a comprehensive plan.
Joel P. Sussman, MD, FAAP
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