What Is Currently Known About ADHD

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There are degrees of ADHD ranging from mild to severe; types of ADHD with a variety of characteristics; and no one has all of the symptoms or displays the disorder in the exact same way. Symptoms vary in every child, and even within each child with ADHD the symptoms may look different from day to day.

ADHD is not new. It has been around, recognized by clinical science, and documented in the literature since 1902 (having been renamed several times). Some of the previous names for the disorder were "minimal brain damage," "minimal brain dysfunction," "hyperactive child syndrome," and ADD with or without "hyperactivity."

We know that ADHD is not a myth. It is not a result of poor parenting or lack of caring, effort, and discipline. ADHD is not laziness, willful behavior, or a character flaw. There is no "quick fix" or "cure" for ADHD.

Many children/teens with ADHD "slip through the cracks" without being identified and without receiving the intervention and treatment they need. This is particularly true of ethnic minorities and girls.

ADHD exists across all populations, regardless of race or ethnicity. There are racial and ethnic disparities in access to healthcare services. As such, ethnic minorities with ADHD are often underserved and do not receive adequate help and treatment (Satcher, 2001).

Children and teens with ADHD do much better when they are provided with activities that are interesting, novel, and motivating. Generally, the majority of students with ADHD can learn well in general education classrooms when teachers employ proper management, effective instructional strategies, and assistive supports/ interventions.

Fortunately, we know a great deal about:

• Which behavior management techniques and strategies are effective in the home and school for children with ADHD

• The classroom interventions, accommodations, and teaching strategies that are most helpful for students with ADHD

• Specific "parenting strategies" that are most effective with children who have ADHD

• Treatments that have been proven effective in reducing the symptoms and improving functioning of children/teens with ADHD

• Many additional strategies that are helpful for individuals with ADHD, such as organization and time management, stress reduction/relaxation

We also know:

• ADHD can be managed best by a multimodal treatment and a team approach.

• It takes a team effort of parents, school personnel, and health/mental healthcare professionals to be most effective in helping children with ADHD.

• No single intervention will be effective for treating/managing ADHD. It takes vigilance and ongoing treatment/intervention plans, as well as revision of plans and going "back to the drawing board" frequently.

• The teaching techniques and strategies that are necessary for the success of children with ADHD are good teaching practices and helpful to all students in the classroom.

• There is a lot of help out there, and resources are available for children, teens, and adults with ADHD, as well as those living with and working with individuals with ADHD.

• We are learning more and more each day due to the efforts of the many researchers and practitioners (educators, mental health professionals, physicians) committed to improving the lives of individuals with ADHD.

The extensive research into ADHD during the past several years has revealed a lot about the disorder. The following is a summary of the current evidence about ADHD, based on the research from metabolic, brain-imaging, and molecular genetic studies.

Differences in the Brain

Differences between those with ADHD and control groups have been identified using brain activity and imaging tests/scans (MRIs, SPECT, EEG, BEAMS, PET, and functional MRIs). Those brain differences include decreased activity level and lower metabolism levels in certain regions of the brain (mainly the frontal region and the basal ganglia); lower metabolism of glucose (the brain's energy source) in the frontal region; decreased blood flow to certain brain regions; and specific brain structures are smaller than in those unaffected by ADHD.

Note: Imaging and other brain tests are NOT used in the diagnosis of ADHD. To date, a comprehensive history of the problem remains the best way to identify the disorder.

There is very strong scientific evidence which supports that ADHD may be due to imbalances in various neurotransmitters or brain chemicals and/or reduced metabolic rates in certain regions of the brain. These chemicals are believed to travel across the synapses of the brain, affecting the braking mechanism or inhibitory cir cuits of the brain. Dopamine pathways in the brain, which link the basal ganglia and frontal cortex, for example, appear to play a major role in ADHD (Castellanos, 1997).

Genetic Research

Much of the recent research involves molecular genetic studies. One type is whole-genome scanning studies that genotype DNA in entire families to look for patterns and differences. Other genetic research involves "candidate-gene" studies seeking specific forms of genes, which show up more often in children with ADHD compared to those unaffected by ADHD.

Researchers have found at least two candidate genes associated with ADHD. One of those genes, the dopamine transporter gene (DAT1), is involved in regulating the amount of dopamine available in the brain. Researchers have found differences between the structure of the DAT1 gene in families with ADHD and "normal" control families. There is belief that the DAT1 gene in some individuals with ADHD may be causing an "overactive dopamine pump"—sucking up dopamine too fast and not leaving it in the synapse long enough (Barkley, 1998).

A second gene was found (DRD4) that may be involved with ADHD. It apparently makes specific nerve cells less sensitive to dopamine. It is suspected that, because ADHD is a complex disorder with multiple traits, that multiple genes are involved and will be discovered in the future. Researchers believe that variations in dopam-ine receptors or transporters, or both, may result in underactivity of brain regions that are involved in attention and behavior, according to James Swanson and others (Fine, 2001).

Landmark MTA Study

There has also been significant research with regard to treatments for ADHD and their relative effectiveness. The longest and most thorough study of the effects of ADHD interventions was the Multimodal Treatment Study of Children with ADHD (MTA) by the National Institute of Mental Health. This study involved 579 children with ADHD ages seven to nine who were randomly assigned to one of four treatment groups, implemented over fourteen months. The groups were

• Medication alone (carefully managed and adjusted medication that was titrated for maximum benefit, with monthly office visits and phone contact with teachers)

• Behavioral therapy alone (very intensive training of parents and teachers on this approach, with an integrated program of specific psychosocial interventions and trained classroom paraprofessional)

• Combination of the above two treatments

• Routine care (treatment by physician in the community, which generally involved one or two office visits/ year, no direct interaction with teachers, lower doses of medication prescribed) (MTA Steering Committee, 2003)

Researchers found that medication treatment alone and medication combined with behavior treatment worked significantly better than behavior treatment alone or community care alone at reducing the symptoms of ADHD. There was overwhelming evidence as to the effectiveness of well-managed use of stimulant medication in the treatment of ADHD. Stimulant medications have been proven to be very effective in improving the core symptoms of at least 70 to 80 percent of children and adults with ADHD (MTA Cooperative Group, 1999). Some estimates are even higher (up to 90 percent).

Combined treatments offered slightly greater benefits than medication management alone for symptom reduction as well as for other domains, such as peer relations, child-parent relations, and academic outcomes (MTA Steering Committee, 2003).

The MTA group continued to monitor (although not treat) all of the children and families and reevaluated the outcomes after twenty-four months. They generally found that the outcomes for the combined and medication only groups were still superior to the other groups, but the relative superiority was reduced by 50 percent. Those children who had received the MTA medication alone approach were still better off than children who received the intensive behavior therapy alone. This was particularly true for ADHD symptoms and oppositional/aggress-ive symptoms based on ratings by teachers (who were not part of the initial treatment component of the study) as well as by parents. Based on this, they concluded that the benefits of intensive medication management for ADHD extended ten months beyond the intensive treatment phase, although the effects appeared to diminish over time (MTA Steering Committee, 2003).

The investigators also observed "mild growth suppression" in the medication and combined medication/behavioral treatment group. The MTA researchers noted that medication appears to incur some risks in terms of slowing growth and weight. Children treated with medication did grow more slowly (by one-third inch) in the second study year (MTA Steering Committee, 2003).

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