Attention Deficit Disorder is a serious condition that if left untreated can have severe complications. The disorder is prevalent in children and diagnosed cases have been known to progress to adulthood. In the recent past, ADD has generated significant interest from different stakeholders due to tis growing prevalence and significance as a health burden. Parents, practitioners, and policymakers increasingly search for information to aid the diagnosis and management of the disorder. This research paper examines critical aspects of ADD including causes, diagnostic criteria based on DSM-5 manual, and available treatment options, their effectiveness and related issues. The paper seeks to contribute towards understanding of the disorder for individuals of all levels by presenting pertinent issues related to it.
Introduction
Individuals occasionally struggle to sit still, focus, or restrain their impulses. However, people with Attention Deficit Disorder (ADD) with or without Hyperactivity (ADHD) face these challenges on daily basis. As a result, people with ADD can have their self-esteem and ability to function normally in work, social, and school settings critically impaired. Classification of the subtypes of ADHD as per the DSM-5 Manual indicates that ADD specifically refers to the inattentive presentation subtype of the disorder, though ADD and ADHD are often used interchangeably to refer to the disorder. Attention Deficit Disorder is characterized as a neurobiological disorder that causes difficulty in controlling of behavior and paying attention. It impairs the executive functioning skills including important functions such as attention, concentration, memory, motivation and effort, impulsivity, learning from mistake, hyperactivity, organization, and social skills. The condition is usually diagnosed in childhood and often lasts into adulthood. This paper examines important aspects of ADD with the objective to contribute to the growing need for information on the disorder, especially on its diagnosis and management.
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Overview of ADHD Prevalence
There is a consensus among stakeholders that everyone in the U.S. has heard about ADD. This is a direct outcome of increased attention towards the disorder from parents, professionals, and policy makers across the country, a situation evidenced through thousands of requests annually to the National Information Center for Children and Youths with disabilities. In a meta-analytical study of 175 countries worldwide by Thomas, Sanders, Doust et al. (2015), it was estimated that the prevalence of ADHD among children aged 18 and below was 7.2%, which translates to 129 million children with ADHD worldwide based on data from the U.S. Census Bureau that estimates the population of children aged 5-19 worldwide at 1,795,734,009. A similar cross-national study by Fayyad, De Graaf, Kessler et al. (2007) in 10 countries across Americas, Europe, and the Middle Easter estimated worldwide prevalence of ADDHD among adults at 3.4%. In the U.S., a recent analysis of parent reported data from the National Health Interview Survey 2011-2013 by Pastor, Duran, and Reuben (2015) established the prevalence of ADHD among children aged 4-17 at 9.5%. The prevalence varied based on age, gender, and ethnicity with high rates recorded among those aged 12-17 years, majority of the affected being boys, and non-Hispanic white children being the most vulnerable. The statistics highlight the significance of ADD, especially among school going children, and working adults who may be severely incapacitated to perform necessary tasks.
Etiology of Attention Deficit Disorder
Since the 19 th century, literature has addressed the three subtypes of ADHD in children including inattentive presentation. Earlier depictions and etiological theories of the disorder have resemblance to the current descriptions. Nevertheless, the recent past has seen a paradigm shift in the concepts of the fundamental behavioral and neuropathological deficits underlying the disorder. The changes are attributed to the growing body of new knowledge on behavior and brain function of patients suffering from the disorder. In attention refers to a situation where an individual wanders off task, lacks persistence, and is disorganized, problems not associated to defiance or lack of comprehension.
Like many psychiatric disorders, ADD has no specific known cause. However, a number of factors acting individually or in conjunction are thought to be responsible, and the factors may vary from person to another. In examination in the history of ADD, Barkley (2015) highlighted George Stills theory of ‘moral control of behavior.’ The theory postulated that symptoms such as aggressiveness, defiance, resistance to discipline, and excessive emotions or passion, were an outcome of little inhibitory volition over their behavior. Such children also manifested lawlessness, cruelty, spitefulness, and dishonesty. Moreover, Still asserted that gratification of the self was the major highlight for these children who also displayed a major defect in moral control. The theory was largely founded on the belief that moral control of behavior implied the control of action in conformity with the idea of the good of all. However, research evidence has played a critical role in discrediting such misconceptions that led to victimization of individuals affected by ADD. Evidence shows that manifestations from such individuals have no relationship whatsoever to defiance or lack of comprehension, but an outcome of underlying factors that cause alterations in neurobiological functions.
Genetics
Attention Deficit Disorder is characterized as a highly genetic brain-based syndrome associated with a set of neurological functions and behaviors. However, etiology of the disorder is not limited to genetics. The study of familial-genetic factors in ADD had led to narrowing down of the causes hence avoiding myths related to its manifestation. Millichap (1991) established that absence of correlation between ADD and various pre and peri-natal factors, intelligence quotient, parental age, profession, language spoken at home, or education level. It is estimated that between a third and a half of parents with ADD are likely to have a child with the disorder. The genetic characteristics passed down on the offspring are thus perceived to be a significant contributor in the child having ADD. Empirical evidence has shown that a child of a parent with ADD has a 50% chance of developing the disorder; while a child has a 30% chance of developing the condition if their older sibling has it. On the other hand, parents and siblings of a child with ADD are four to five times more likely to have the disorder themselves. It is important to note that the complexity of inherited ADD is not attributed to a single genetic fault.
Genetics is known to be responsible for chemical, structural, and connectivity differences in the brain resulting to impaired functioning. Genes that have been linked to development of the disorder include dopamine receptor genes DRD4 and D2, dopamine transport gene DAT1, as well as genes affecting the activity of serotonin (Gizer, Waldman, Abramowitz et al., 2008; Henrigquez, Henriquez, Carrasco et al. , 2008). Research evidence linking genetics to ADD has contributed to thrashing of long held misconceptions that ADHD was caused by head injuries, poor parenting, digital interactions, traumatic life events, lack of physical activity, foods, or video games, movies, and television. However, these factors can exacerbate the progression or condition of the disorder and act as risk factors in some instances.
Environmental Factors
Evidence on the correlation of ADD to environmental factors is inconclusive. However, it has been shown that children of women who smoke while pregnant are more likely to develop the disorder. The inconclusiveness of such evidence stems from the fact that mothers with ADD have a tendency to smoke, hence genetics cannot be ruled out. On the other hand, nicotine is known to cause hypoxia in utero. Another environmental contribution to ADD has been associated with lead exposure; implying children living in lead exposed environments are at higher risk of developing the disorder. Environments that expose children to toxins or brain injury have also been identified as possible contributors to progression of ADD in minority of the children. The exposure or injury can take place before or after birth. Investigations of ADD like symptoms in previously healthy individuals following injury to the frontal lobes are currently undergoing. Pregnancy problems have also been linked to the development and progression of ADD. Premature birth and low birthweight have also been identified as major factors because they impair with the developmental process resulting to anomalies in the brain structure.
Social, Cultural, and Spiritual Factors
Social, cultural, and spiritual factors have also been linked to ADD. Yeh, Hough, McCabe et al. (2004) established that parents of African America, Asian, and Latino youths were less likely to endorse etiologies of ADHD consistent with biopsychosocial beliefs regarding mental illness. However, racial/ethnic differences existed in relation to sociological factors, though none were found for spiritual or nature disharmony etiologies. Another study on the role of acculturalization on beliefs about ADHD etiologies by Lawton, Gerdes, Haack et al. (2014) established the existence of a positive correlation between the cultural values of familism and traditional gender roles with sociological or spiritual beliefs. It is important to understand that social, cultural, and spiritual etiological factors of ADHD are significant in influencing perceptions about diagnosis and management of the disorder. Their role as causative agents of the disorder remains inconclusive due to lack of scientific evidence.
The DSM-5 Diagnostic Criteria
Diagnosis of ADD presents a challenge to practitioners due to the complexity of signs and symptoms that may be indicative of another underlying condition other than the disorder. The situation is compounded by the fact that there is no medical laboratory or blood tests for this disorder. Practitioners heavily rely on scientific behavioral assessment measures that have been empirically proven. For this reason, it is advised to consult a professional familiar with the disorder. Diagnosis employs extensive interview procedures, behavior, and symptom rating skills, third party observations, and comprehensive history of the case. Comprehensive neuropsychological and psychoeducational testing including brain scans can be helpful in diagnosis and management of the disorder. According to American Psychological Association, the DSM-5 Manual is the most comprehensive and reliable resource as a diagnosis criteria for ADD.
The DSM-5 Manual offers diagnosis guidelines for all the three subtypes of ADHD. Diagnosis criteria for the ADD subtype of ADHD are based on the persistent pattern of inattention that interferes with functioning or development. Positive diagnosis of inattention is based on the persistence of inattention for at least 6 months to a degree inconsistent with the developmental level and negatively impacts social, academic, or occupational activities directly. However, the manual advises that ADD symptoms are not necessarily a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions as illustrated in Barkley (2014). According to the DSM-5, positive diagnosis is done when at least six and at least five of the following symptoms are present in children and older adolescents and adults respectively:
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
During diagnosis, it is imperative for professionals to clarify whether the inattentive symptoms were present before the age of 12 years. It is also important to recognize that some inattentive symptoms may be present in at least two settings. Positive diagnosis is also based on clarity of evidence that symptoms interfere with or reduce the quality of social, academic, or occupational functioning. It is also important to avoid misdiagnosis by ensuring that ADD symptoms do not occur in the course of other related disorders with similar manifestations such schizophrenia, or other mental disorder and have no strong bias towards another mental disorder such as mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal.
Overall diagnosis of ADHD requires examination if symptoms present as a combination with inattention, hyperactivity, and impulsivity being net for the past 6 months. The disorder is predominantly inattention presentation if inattention is met. Specificity is also needed in cases of partial remission where full criteria was previously met, but fewer than full criteria has been met over the last 6 months though the symptoms persistently result in impairment of social, academic, and occupational functioning. The professional must also specify the severity of the disorder where categorization as mild refers to presence of few, if any, symptoms in excess of what is required to make a diagnosis and they result in only a minor distortion of functioning. Moderate severity refers to symptoms between mild and severe. Diagnosis of the disorder as severe implies the presence of many symptoms in excess of those required to make a diagnosis, or several severe symptoms that significantly impair with social and occupational functioning. The absence of a biological etiological factor for ADD implies that care must be exercised to avoid misdiagnosis to ensure proper therapy and management frameworks are employed.
Treatment Approaches to the Disorder
Hippocrates, heralded as the father of modern medicine famously posited that ‘what cannot be cured by medicaments, can be cured by a knife; what a knife cannot cure, can be cured by searing, and what cannot be cure by searing is incurable.’ Such is the dilemma facing professional psychologists and psychiatrists in dealing with Attention Deficit Disorder. Treating a condition whose cause is unknown assumes a speculative process that may not yield thee desired outcome. Unlike diseases with known biological etiologies, which can be targeted for reduction or elimination, treatment of ADD and associated mental disorders mostly seeks to alleviate severity of the symptoms rather than curing the condition. The implication for patients and practitioners is that treatment and management of the disorder is a delicate process that can go wrong at any point and caution must be exercised, especially in ensuring correct diagnosis.
It is important to recognize that ADD does not have one particular standard treatment, which owes to complexity of the disorder from one individual to another. As a result, Barkley (2014) observed that treatment must be designed to meet specific needs of the case in question following a biopsychosocial assessment. Empirical evidence has shown that medications, psychoeducation, social skills training, special supervision at school, and individual psychotherapy can yield positive outcomes when used appropriately. However, evidence also shows that use of a combination of treatment options can result to better outcomes compared to when a single approach is used. These recommendations come in the wake of evidence showing inability of conventional approaches to yield desired therapeutic outcomes. Bowman (2003) posited that traditional approaches such as pharmacotherapy, behavioural treatments, and structural psychotherapy, have continued to show limitations when used in the treatment of ADHD.
Medication
Medication are often used to manage brain based functions and symptoms, hence therapy targets daily thoughts, behaviors, and coping strategies. Medication plays a critical role in normalizing brain activity in respect to chemical balances from genetics related etiological factors including dopamine receptors. Medication assists in normalization of brain activity and care must be exercised during prescription and monitoring should be done by a physician, preferably a psychiatrist rather than a primary care physician. The use of stimulant medicines such as Ritalin, Dexedrine, Adderall, Adderall XR, Concerta, Vyvanse, and Focalin XR is recommended as they have empirically been shown to be the most effective in many people with the disorder. However, Pliszka (2003) explored aspects of one of the many alternative approaches to treatment of ADHD – Non-stimulant treatment that has been proven to be superior to placebos. Other medications may be used with the discretion of the physician.
Psychosocial Therapy and other Alternatives
Psychosocial treatment approaches highlight the critical role played by different stakeholders in the management of ADD. While examining the effectiveness and relevance of drug therapy against ADHD in school settings, Dogget (2004) suggested the need for alternative treatment options including cognitive behavioral therapies, educational interventions, electroencephalograph neuro feedback, and diet. Emphasis should be placed on parents of children with the disorder to ensure they receive necessary assistance to improve their parenting skills where these approaches are concerned. This implies that psychosocial therapy can be targeted at both children and their parents, and adults suffering from the disorder. Frank (2017) posited that the most effective psychosocial treatment options as demonstrated through research are Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and mindfulness therapy. The effectiveness of these therapy options is based on the fact that they seek to identify barriers and work towards influencing change in the present moment.
However, it is important to understand that such effectiveness is highly dependent on the practitioner in question. Patients and their caretakers are advised to look for practitioners with extensive familiarity with the disorder because they do not perceive minor obstacles that may be manifestations of the condition such as lateness to sessions or constant interruptions as manifestations of deep psychological neurosis, but rather understand them as functions of brain-based condition. An experienced therapist who is ADD friendly would views such events as opportunities to build new skills and gain self-awareness, thus improving outcomes of therapy sessions. This is a critical aspect of the treatment process as therapists have a tendency to conduct group sessions where new skills and coping strategies are helpful in handling emotional and interpersonal effects of the disorder following positive diagnosis among them, feelings of shame, failure, guilt, and chronic stress. Individual, couples, or group therapy can be instrumental in achieving desired outcomes. The use of ADHD coaching under these settings has been demonstrated to have improved outcomes towards identification and meeting of goals, keeping a positive approach to change, and improving productivity in a manner that is accountable.
Conclusion
Attention Deficit Disorder is major public health concern across all demographic groups, but severity of the disorder is profound among children of school going age. The need for information about the disorder is on the rise, but parents, practitioners, and policy makers are at loggerheads because of the complexity of ADD. The disorder has no known cause, though empirical evidence links genetics and environmental factors to development and progression of ADD. As a result, diagnosis also poses a challenge despite the availability of a comprehensive resource in DSM-5 manual. Similarly, treatment of the disorder is based on reduction of symptoms rather than its elimination. The implication for stakeholders is that more research on ADHD is mandatory with bias to aiding diagnosis and effectiveness of therapy. Professionals should also be trained specifically in relation to ADHD to avoid case of misdiagnosis and mistreatment that are cited as reasons for increasing prevalence of the disorder.
References
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