Over the past 50 years, attention deficit/hyperactive disorder — more commonly known as ADHD — has evolved from a little-known condition into arguably the most studied disorder in the field of child psychiatry.
Most commonly diagnosed when children reach school age, ADHD affects millions of children across the country and around the world, according to the Centers for Disease Control and Prevention.
“Historically, there was some recognition of ‘minimal brain dysfunction,’ but we didn’t know much about it,” said Ronald Brown, dean of UNLV’s School of Integrated Health Sciences, who has been studying ADHD for nearly five decades. “Over the years, diagnosis and management have become much more specific, and now we have a checkbox of symptoms that assists us in identifying the disorder.”
Brown, a board-certified clinical health psychologist, said behavioral issues are typically first identified when children begin the first grade, and symptoms are usually more frequently noticed and diagnosed in boys.
“We’ve all heard the saying, ‘boys will be boys’ and ‘they’ll grow out of it,’ but we know that there are children who have significant problems even before they start school,” he said. “When you are 6 or 7, you really have to listen and pay attention in school because it is a much more structured environment than what you might find at home. For kids with ADHD, that can be hard, and that’s when parents start to see that there may be something going on.”
Brown is the co-author of the books, ADHD in Children and Adolescents and ADHD in Adults, both of which have been published in multiple languages and versions around the world. We caught up with him to learn more about ADHD, how it has evolved throughout the years, and signs that parents should look out for if their child is not performing well in school.
What exactly is ADHD? How do you know if you or your child has it?
ADHD is suspected in patients who have several symptoms that are associated with the inability to sustain attention and effort. In the psychiatric field, we rely much more today on functional outcomes than symptoms alone. Thus, in order to have an official ADHD diagnosis, there needs to be a functional impairment, or more specifically, problems in academic performance at school or difficulties holding employment.
What we’ve concluded is that if you have symptoms and they impair you, chances are you need some type of intervention. If you simply have symptoms of ADHD but it does not functionally impair you, it is fairly unlikely that you have ADHD. If you have a kindergartner with a lot of energy, that’s fine. But if they are unable to complete their activities or are unable to pay attention for five minutes, and maybe they are aggressive with their peers, chances are you are on to something.
How has our understanding of ADHD evolved throughout the past 50 years?
Reforms in special education and children with learning problems were very pervasive in the late 1970s and early 1980s. When I was growing up, Dr. Spock was the leading expert on children. It was a time shortly after psychoanalytic psychiatry, and the very beginnings of behaviorism.
When I started graduate school, clinicians started to quantify behavior and particularly symptoms of psychopathology in measurable terms. That’s when they began to designate children as having a problem, which jumpstarted the next stage of discussion. Now we know how ADHD impacts kids and how it impacts their teachers. All of these studies have been done very meticulously. Long-term follow up studies have shown the effects of medication and behavioral therapy over time.
Follow up studies of these children with ADHD show that as adults, they suffer from poorer job performance, have greater difficulties in their marriages, and are at greater risk for substance abuse. These problems are particularly heightened if there is no treatment program.
What is the best way to manage ADHD?
The first thing you need to do is find out if your child actually has ADHD. We assess behavioral symptoms and complete a history on when their behavior started changing. We find out how their behavior is at school and at home, and we us a behavioral checklist and ask the parent and teacher to fill out a grading scale on the child’s behavior.
Once the child has been diagnosed, it’s important to emphasize structure, both at school and in the home. Sometimes symptoms may be elevated depending on how much structure is imposed throughout the day. Behavioral therapy and medication are the only evidence-based therapies for ADHD, according to the American Academy of Pediatrics.
We don’t have an ADHD biomarker, or a specific biological variable that is implicated in the disorder and typically would show on a laboratory test.
Can you explain the difference in how ADHD affects boys and girls?
Girls may suffer the disorder more silently because in school, girls tend to be quieter than boys. Therefore, when girls have ADHD, it can really impact them more severely because it isn’t recognized until later. On the other hand, what we’ve seen is that boys are the ones who typically act out in class, which draws more attention to their behavioral issues.
ADHD is diagnosed three times more frequently in boys, although research suggests that girls may be under-diagnosed. The reason for the difference in diagnosis among genders is that ADHD can manifest differently in boys than in girls. Boys tend to have impulsive, hyperactive and other acting-out behaviors. Girls tend to have more inattentive traits and other psychiatric symptoms that may include symptoms of anxiety and depression. Girls frequently misinterpret, misperceive or miss social cues, misperceive other people’s behaviors, and struggle to fit in a peer group.
Unless you have behavioral disturbances that are bothering others, you’re not going to be identified as quickly. Sometimes, girls aren’t diagnosed until much later in life, which makes it harder as they get older. Industry experts have found that children who receive intervention do better in the long term, and we know the disorder occurs across all cultures, thereby lending validity to the diagnosis.
Are there any long-term effects of medication?
We know that when we follow up with kids who are on medication for ADHD, they haven’t sustained any sort of physiological effects. The medication doesn’t predispose them to drug abuse or hypertension. If anything, it makes them less prone to substance abuse and addiction because it manages their behavior. When you can enhance attention and curb impulse control with the proper amount of medication, kids tend to do better.
The bottom line is that medication and behavior management work. When you can show success with medication, that can be a godsend for some people. We know that 80-90% of children with ADHD respond to their medication. All of the data we have shows that it is safe when prescribed appropriately. Behavior management also has been demonstrated to be an evidence-based treatment for ADHD.