Just What is Attention Deficit and Hyperactive Disorder (ADHD)?
The common symptoms of ADHD, which has replaced ADD (Attention Deficit Disorder) as the medical term of choice, are what Hinshaw called “The symptoms of childhood.” After all, most children are at times impulsive, unable to concentrate, and excessively boisterous. So how can clinicians make a confident diagnosis of ADHD?
Hinshaw began his presentation by emphasizing that the symptoms of ADHD, which is much more prevalent in boys, must be “developmentally extreme and present for a long time in at least two settings-not just the home, not just the classroom. The criteria of two settings tries to put the focus [of ADHD] at least somewhat on the child as opposed to just a reaction to a difficult classroom environment or a parent-child conflict.”
Hinshaw said there are a subset of children who have ADHD without hyperactivity, commonly referred to as ADD. “These inattentive children with ADD are not only not hyperactive but are often less active than the perfectly normal peers sitting next to them. They are often described as ‘sluggish,’ ‘in a fog,’ and ‘confused.’ These children demonstrate a lot of anxiety and depression rather than exuberance and climbing on tables and doing obstreperous things.”
Children with correctly diagnosed ADHD, Hinshaw said, constitute about three to four percent of the population-far less than the 15 to 20 percent the media so often report. He also spoke about the two to four year old children who are too young to be diagnosed with ADHD but who have difficult temperaments, sleep poorly, and are wildly hyperactive. As for how many of them will be diagnosed with ADHD by the end of elementary school, Hinshaw said “the answer is about 50 percent from the best data we have—so the doctor who says ‘he’ll grow out of it’ is right 50 percent of the time. The alarmist who says ‘this is severe ADHD, let’s treat with stimulants right now,’ may also be correct about half of the time.”
Peer Rejection of ADHD Children
Hinshaw said that children with ADHD are more disliked than any other group of children, including autistic children, delinquent children, and children with depression. This is critically important, because research demonstrates that the extent to which a child is disliked in first, second, and third grade is the strongest predictor of school dropout, delinquency, and later mental health problems. “If peer rejection is the best predictor of later problems, and if ADHD children are the least liked and most rejected, then it’s no wonder that ADHD doesn’t go away with puberty.”
For several years, Hinshaw and his colleagues have conducted research of both children with ADHD and children without attention disorders at summer camp. They had wondered how long it would take for the children with ADHD to be rejected by their peers, surmising that it would take several weeks for true rejection to set in. Instead they found, to their astonishment, that the children with ADHD were likely to be rejected the very first day. “It took about three hours for kids with ADHD to get singled out by their peers,” Hinshaw commented.
The amount of rejection the children endured closely correlated with how aggressively they interacted with others. “if you want to get disliked by your peers at summer camp and you have ADHD, throw spitballs at the teacher and curse at your friends when they tease you that first day. . . it’s a surefire way to get rejection.”
The point that Hinshaw wanted to underline is that early peer rejection is hard to overcome. Consequently, it is important to start a good treatment regiment early on. “Don’t start off the school year the way some physicians do and say, ‘Well, let’s see if she can go a few weeks without medication.’ By early October, it’s late in the game. Early peer rejection, the trajectory of failure, gets an early toehold.”
The Sometimes Surprising Effects Of Ritalin
Hinshaw left no doubts as to the effectiveness of Ritalin in reducing aggressiveness in children with ADHD. In a study he conducted a number of years ago at a summer camp at UCLA, Hinshaw found that, with the highly aggressive group, a low dosage of Ritalin resulted, on average, in a dramatic reduction of aggression, and with slightly higher dosages, aggression almost fell into the normal ranges. One boy was so aggressive on a placebo trial that he became a danger to other children. He was placed on 10 milligrams of Ritalin and rarely aggressed; on 20 milligrams of Ritalin twice a day he never aggressed.
But Hinshaw did not mean to suggest that Ritalin is a miracle drug, though it is clearly useful and even necessary at times. For one thing, kids who normalize their behavior did not necessarily normalize their peer relationships-many still have difficulties. For another, there are some highly problematic responses. On Ritalin, the children in the summer camp study engaged in property destruction and stealing at a greatly reduced rate. Yet, Hinshaw said that the rates of academic cheating dramatically increased. “It’s good evidence that the stimulants probably increase achievement motivation, and if you really want to do well and you have some anti-social tendencies in the first place, the person is going to say, ‘I’m going to get this right, god damn it, even if I have use the answer key.'”
In a recent study of 579 children with ADHD at six different centers, Hinshaw and his colleagues used “multi-modal” treatments for the disorder. Some children received Ritalin; some a very intensive psychosocial treatment, which included parent training and a behavioral program; some a combination of the two; and some regular community care, which included the administering of medication. What were the results? “We found that combination treatment was statistically superior to medication only,” Hinshaw said. Yet there was a big catch. “The combined treatment led either to pretty dramatic improvement, or in a few cases, families got worse. The bombed out, burned out on that intensive treatment.”
These ambiguous results led Hinshaw to suggest that there is no one best way to treat ADHD; each individual case is different. “I have trouble saying there is one key finding from our study. For simply treating the symptoms of ADHD, well-delivered medication leads to the biggest effects. But when you get into social skills and parent-child relationships, combined treatment starts to pull away as being the most effective. Combined treatment, we think works through its effects on negative and ineffective discipline concerning the child.”