I am writing this because I want to help you understand your child. My first child was born in the age when they did not even have a title for hyperactivity. I spent more days in the school office than I care to count. I hope this blog will give you basic understanding and peace. He is now 42 and still struggles with inattention and memory, self-gratification and impulsivity.
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD has three observable behavior patterns; hyperactivity, impulsivity and inattention. Hyperactivity is labeled as the inability to stay still, talking non-stop, or noticeable fidgeting. Impulsivity is known as being unable to suppress emotions, interrupting, hitting, impatience and harmful behavior. Inattention is classified as being easily distracted, not listening enough to follow through, forgetting things, and rarely following directions completely. A child that has ADHD can have a mixture, of greater or lesser degrees of any of the three symptoms mentioned above, dividing into subtypes. “ADHD individuals have difficulty matching their behavior and brain functioning to current task demands,” according to Schweitzer, J. M.I.N.D. Institute, online.
At the present time, there is no known cause for this disorder. The National Institute of Mental Health (NIMH) believes that gene research can lead us to better treatment for this disorder. Research studies are using imaging (fMRI) on brain structure, brain chemistry and brain function.
The most difficult decision remains the diagnosis. Testing for this disorder is a several-step process because other co-existing conditions must be ruled out. The American Psychiatric Association’s Diagnostic and Statistical Manual-IV, text revision, (DSM-IV-TR), has developed standards in order to correctly diagnose this disorder. One or more behaviors must be present for 6 months or more, affecting home and/or school environments. One of major concerns with correct diagnosis of ADHD has been divided into subtypes for research because of the cross-cutting issues in the biopsychology but not identified as separate neuropathology in the diagnostic criteria. Another problem is the poor individual specificity and sensitivity when using imaging equipment and while conducting experimental groups.
ADHD – Chronic Condition
Treatments include medications and behavior modifications. This may help with symptoms, but this disorder will extend a lifetime and other means past active treatment needs to be considered. Environment factors and family lifestyle must be considered as well. This would include diet and exercise to help the developing brain. It is no longer considered just a childhood disorder. Roughly 60% of children will carry their difficulties into adulthood and adolescents rarely finish school or enter college. The Center for Disease Control and Prevention, (CDC) provided data and statistics online in 2006 stating that the United States has 4.5 million children aging from 5-17 years old having been diagnosed with ADHD, and that number increases 3% annually. Boys are more likely to be diagnosed than girls. Fifty-three percent of the children diagnosed are taking medication for this disorder. The ADHD adult tends to receive more speeding tickets, have more auto accidents, and have higher divorce rates. They may have substance abuse problems and start smoking at an early age as well.
Genetic factors and the neurotransmitter dopamine have been the main investigating targets. The genes being researched are in the dopamine construct. Biological research with imaging instruments has paved the way to help bring the main dysfunctions of the brain to the forefront. It was interesting to see serotonin added to the list of possible reasons for this condition. Genetic research is finding more variants that create neuropsychiatric disorders. ADHD is a neurodevelopmental disorder and is highly inherited. Dr. Langley stated that “ADHD is not caused by a single genetic change but is likely caused by a number of genetic changes interacting with a child’s environment.”
Tests and Research
Nervous system function can now be assessed with a urinary neurotransmitter assessment. Filtration and excretion by the kidneys can help us to identify clinical symptoms and regulate treatment medications. Murdoch Children’s Research Institute is conducting a study to see if omega-3 fatty acids will help children. There is evidence that a lack of fatty acids may be associated with developmental problems. Researchers are investigating this to help replace the current treatment with stimulant medications. Both low zinc and iron were associated with hyperactivity symptoms. Zinc levels were connected to anxiety and conduct problems. Zinc and iron are involved with dopamine metabolism. Low levels of zinc and iron can impair the dopaminergic transmission in these individuals.
Until the cause of ADHD is found and better testing procedures for proper diagnosis is available, medication plus therapy is strongly advised. Dr. Joseph Biederman and colleagues of Harvard Medical School found that treating individuals with stimulants had half the risk of patients abusing other substances. ADHD adults that are medicated with Adderall XR seem to do well and find behavioral therapy helpful. A handbook has been written by Thomas Brown titled, “ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults.”
ADHD – Biopsychology of the Brain
Areas of the brain that are involved with this disorder are the prefrontal lobe, executive function center, amygdala, working memory and the default network. Other studies mention the frontal lobes, inhibitory mechanism of the cortex, limbic system and the reticular activating system. Neuroscientists and neurologists are using imaging techniques to study the neural functioning of the brain. Most evidence so far is pointing to the frontal cortex that manages executive functions. Executive functions include problem solving, attention, reasoning, and planning. Functional magnetic resonance imaging, (fMRI), displays the brain while it is working. The right frontal lobe is shown to be smaller with decrease in the metabolism of the basil ganglia that regulates movement.
There are three interconnected areas of the brain that process emotional information and they are: the medial prefrontal cortex, basolateral nucleus of the amygdala and the ventral segmental area. The neurotransmitter dopamine (DA) has transporters and receptors in those areas and others. Disturbances in this circuitry may manifest the neuropsychiatric disorders of schizophrenia, ADHD, and addiction.
The amygdala was being studied with ADHD, bipolar and severe mood dysregulation in a neutral face emotion test. Amygdala is part of the circuitry in the limbic system responsible for fears and anxieties, emotional processing and facial affects.
ADHD – Neurotransmitter Dopamine
Dopamine is involved with behavior and cognition, voluntary movement, motivation, punishment and reward, sleep, mood, attention, working memory, learning, sexual gratification, and the experiences of pain and pleasure. It is hypothesized that dopamine is a teaching signal for learning new behaviors that bring rewards. Dopamine is our enjoyment and anticipatory signal. This would explain why stimulants work as treatment and how drug addiction happens. Some studies suggest that aggression may release dopamine.
Dopamine is the chief catecholamine neurotransmitter for neurons in the midbrain, substantia nigra pars compacta and a part of the hypothalamus called arcuate nucleus. There are five dopamine receptors; D1 D2, D3, D4, D5. As a neurohormone, dopamine is released by the hypothalamus and inhibits the release of prolactin from the anterior pituitary. Dopamine is degraded in the striatum and the basil ganglia by reuptake dopamine transporter (DAT1). In the prefrontal cortex, dopamine is inactive by reuptake of norepinephrine transporter (NET). Any dopamine that is not broken down after reuptake is stored in vesicles for reuse. If dopamine is not able to control the flow of information in the frontal lobes, this will create a decline in neurocognition, such as, memory, attention and problem solving. The reduction of dopamine in the prefrontal cortex is what the researchers believe causes ADHD. Receptors D1 and D4 are responsible for dopamine’s cognitive abilities. The DA4 receptor seems to play a critical role in the modulation of emotional memory encoding and expression.
Genetics factors can claim 80 % of the phenotype. One third of fathers who had ADHD when they were young have children with ADHD. Gene studies on twins revealed that this could be an inherited factor. If a twin has it, the other twin has a 75-91% chance of having it also. Other twin studies suggest that this disorder is 70 % inherited, as much as bipolar and schizophrenia.
Co-exisiting Conditions and Other Disorders
Children and adults with ADHD may have one or a combination of disorders, such as conduct disorder (CD), personality disorder (PD), obsessive compulsive disorder (OCD), gratification delay disorder, depression, anxiety, bipolar disorder (BD), and learning disabilities, cdc.gov, (2010). The data collected from the National Health Interview Survey, 2004-2006, showed that 4% of children with ADHD had learning disabilities. Longitudinal studies concur that children with ADHD and CD are more likely to use drugs and alcohol.
Children diagnosed with ADHD between the ages 4 to 6 are more likely to suffer from depression and have suicidal thinks as adolescents, reported in The Archives of General Psychiatry. Researchers at the University of Chicago and University of Pittsburgh followed 123 children from ages 4 to 6 for fourteen years. The researchers found out that 18 % of the children diagnosed early were depressed as adolescents. They were five times more likely to have suicide ideation and twice as likely to attempt suicide. Even though more boys suffered from this disorder, being a girl increases your chance of depression.
Children with this disorder have been reported having sleep problems. The sleep problems consist of: difficulty falling asleep, resisting going to bed, restless legs syndrome, breathing difficulties, tired on waking, and nightmares. Valarie Sung, MBBS of the Centre for Community Child Health studied 239 families of school children with this disorder and found 73%, to be affected by sleep problems.
A clinical study of 109 children with this disorder have high IQs, are more likely to smoke or use alcohol at an early age. Parents with ADHD children have reported their children had three times the amount of peer problems and ten times more problems with friendships than normal children, CDC, online.
Although I feel like I barely touched the surface with a multitude of research and testing being conducted around the country, I hope I have given you enough information for a better understanding, and to understand that the acting out is not a part of needing attention, nor is it being a bad child, it is what’s happening with the brain functioning that creates the behavior.
You may wish to check out more information at ADHD.org.nz and Neuroscience for Kids at https://faculty.washington.edu/chudler/adhd.html.
To Your Health and Your Child,