What exactly is Attention Deficit Hyperactivity Disorder?

The key features are distractibility causing poor short term memory and therefore learning impairment, and impulsivity in word and action resulting in social problems. Hyperactivity is present in some. There is a spectrum from the hyperactive-impulsive extreme to the inattentive dreamer. It affects about 5% of the population and may be a lifelong problem. It is definitely treatable, often with exciting results.

Isn’t it due to bad parenting?

Dr Christopher Green, a Sydney Paediatrician with a great interest in ADHD and author of ‘You and Your ADHD Child’, says that far from deserving blame, the parents of ADHD kids are the best in the world – they have to be! For the most part I agree. We could all do better as parents if we had the luxury of repeating history, but we don’t. It is so sad to hear parents who have tried desperately hard to tame their hyperactive kids being criticized by teachers, family, neighbours, social workers, the justice system and the news media. I have often had parents in tears in my surgery, feeling isolated and unsupported, but refusing to give up. I encourage them to support each other at all times, decide on the boundaries together and make them stick – calmly. I encourage them that the sacrifice they make will be very likely to have a good outcome, and that their relationship will be strengthened, like soldiers sharing the same front-line trench.

Isn’t ADD – Absent Dad Disorder?

No, it isn’t! If Dad is absent it may well be a result not a cause of ADHD. An ADHD kid puts major strain on a relationship which may well help to break it up. Remember too that because ADHD is genetic, one or other parent may have the same problem. The rate of breakdown in relationships where one has ADHD is much higher than in the rest of the population. The biggest factor in bringing this about is impulsivity which can lie behind violence, unfaithfulness, particularly the spur of the moment affair, plain boredom, substance abuse and a whole host of destructive factors. The sexual relationship which led to conception, but not commitment, may well have been impulsive without thought for consequence.

A generation or two ago, when being a solo mother was socially unacceptable and financially unsupported, the outcome was often adoption. The rate of ADHD among those who have been adopted is much higher than the 5% in the general population. Adoption has not caused ADHD but ADHD may well have caused adoption. Parents of ADHD kids who have separated and try to share care have it tough. If they have new partners all too often the step-dad or mum find it hard to accept the ADHD kids they did not produce. Everyone blames every one and the result is a mess. What is needed is for all the adults involved to show compassion for the child and patience with each other, and get on the same team for the kid’s sake.

Isn’t it due to environmental poisons, or head or birth injury?
Despite much research there is, as yet, no evidence for this. ADHD is fairly evenly spread through our community regardless of local industrial factors. The evidence now for a genetically determined, chemical basis in key areas of the brain is strong. A careful birth history shows no greater incidence of ADHD in those with difficult births. On the other hand, taken as a whole, ADHD kids have had more head injuries than average. The question is which came first? The impulsivity and risk taking of ADHD lead to more injuries all through life. An example, once they have started to drive, is the fourfold increase in the rate of road accidents in those with ADHD, which is halved by the use of Ritalin.

Don’t they just need old-fashioned discipline?

A curious idea has grown up that discipline equals punishment. Discipline is about producing disciples and a disciple is literally one who follows so as to learn. So yes, of course children need discipline! Another strange modern idea is that children go to school to start to learn. Parenting is about teaching and loving our kids. When my older son started school I told him that I was his teacher and the teachers at school would be my helpers. This point of view got me into trouble with some teachers but the good ones agreed. Parents can be the best teachers a child ever has, not just of literacy and numeracy, but of all sorts of practical and social skills. Above all they need us to teach them a belief system on which they can confidently hang their moral and ethical view of the world. If we don’t, almost certainly no-one else will. At the heart of loving our children is being a great example to them of what we teach. I remember one 8 year old boy with ADHD seeing me with his father. I asked him, ‘Who is your best friend?’ Without hesitation he said, ‘My dad!’ The delighted look on his father’s face was beautiful. To teach our children, we need plenty of time with them. It is often tempting as parents to find every excuse in work or outside interests to avoid much time with our demanding ADHD kids, in which case they become even more demanding to get attention.

Teaching must include correcting. How do we correct an ADHD kid with a very short memory? Many parents report that nothing works whether it is explanation, time out, withdrawal of privilege, an extra duty or even the much debated smack. The key problem is that by the time a consequence comes they have forgotten the impulsive action that constituted the crime. I encourage parents and teachers to be selective and try not to react to every trivial, though irritating, event and to concentrate on the real moral issues. These need absolute consistency, repetition, firmness and love. In time the message gets through. I often hear adults with ADHD telling me how they felt they drove their parents crazy but how the parents’ stubborn persistence and love worked to protect them from major disasters.

Wouldn’t military service be the answer?

Building structure and routine into life is an important part of the practical management of ADHD in children and adults. A structured upbringing reduces the damage from ADHD. Interestingly I have observed that young people with ADHD more often have an ambition to go into the armed services or the police force than their peers. They are attracted by the combination of structure within strict rules, which they know they need, mixed with an element of risk, because adrenalin helps them focus.

They grow out of it, don’t they?

Well, not exactly. ADHD was first described in 1902 by Dr Joseph Still but it did not receive its modern title until 1983. For 90 years it was a disorder of children. It was not until about 20 years ago that the idea of adult ADHD finally found its way into the textbooks. How did we miss something so obvious? It is generally agreed now that about two-thirds of ADHD kids have compensated well enough to cope by their twenties but the remaining third have not and still urgently need understanding and help. When I first meet a new family with an ADHD child I ask the parents, if they are both present, ‘Which one did he/she get it from?’ Most of the time they have no trouble working it out because aspects of the problem still remain. A whole variety of issues like being late for appointments or forgetting them altogether, blurting out insensitive comments, difficulty managing money, TV channel surfing, and even adult illiteracy affect even the high achievers. At the other end of the social scale is substance abuse, criminal behaviour, unemployment, unstable relationships, dangerous driving and a variety of other psychiatric problems, particularly depression. It can be very interesting to draw up a family tree and make some well-informed guesses into which members have ADHD.

So can it be treated in adults? Most definitely, and often with spectacular success when there is strong motivation and good support. Voluntary organizations such as the ADHD Association, www.ADHD.co.nz and ADDvocate, www.ADHD.org.nz have done a superb job for many years of giving support. addventurers@runway.net.nz is a new group based in Pukekohe who have recently started and will have much to offer.

Why did it not exist in the past?

It helps acceptance of the disorder to remind people of probable figures in history like Leonardo Da Vinci, Winston Churchill, Albert Einstein and Ludwig Beethoven who had great difficulty finishing projects but were definitely not underachievers. In New Zealand history there are all kinds of exciting characters whose impulsivity made them heroes. Charles Upham, who won the VC twice, did so not by carefully thought out plans designed to minimize OSH hazards but by wild acts of bravery. It can be entertaining over dinner sometime to review some of our more eccentric politicians and media figures, wondering whether their ADHD just might have something to do with their charisma. For younger patients it helps to know how some of their idols in sports and entertainment acknowledge their diagnosis of ADHD.

Aren’t they just lazy?

It is very interesting to review the school reports from 20 or 30 years ago of adults now being assessed for ADHD. Often these reports have been treasured by loving parents who perhaps hoped for a miracle one day. In the days before teachers had to write in politically correct terms of even their greatest nightmare, they were full of phrases like ‘lazy’, ‘wasting my time and his’, and ‘will get a shock at exam time’. Moving towards the present, the wording changes to ‘Needs to learn to…’ and ‘Must try harder next year’ which means, ‘Does not do it now.’ The key problem in ADHD is distractibility which will lead to a lack of application in study unless the teacher and the material are of compelling interest. It is very noticeable how unevenly ADHD kids perform with different teachers compared to their peers. Many of these young people do better with a computer programme which demands an instant response, one to one, compared with a live classroom with all its distractions.

ADHD is the commonest underlying factor in a specific learning disorder,(SLD) such as dyslexia in which letters are reversed or jumbled. Some kids tell me ‘The words won’t stay still on the page.’ Closely related are a whole family of ‘dys’s’ – dyscalculia where the problem is with numbers, dysgraphia with writing, dyspraxia with coordination, and dysphasia with speech. SLDs come in varying degrees and different combinations but together they hamper literacy, numeracy and communication. When they are unrecognized a kid may be labeled lazy or dumb but at times be very bright to the edge of genius. I have had several patients who reached adulthood illiterate, but with help and understanding have now achieved PhDs. The Ministry of Education have until recently refused to recognize the existent of SLDs. The organization SPELD, who are listed in the phone books in main centres, have done a brilliant job of providing testing and tutoring.

Aren’t they just naughty?

The 7 year old girl who looked up from the mat at her primary teacher and said, ‘You are a dork!’ has the same problem as the 20 year old youth who set light to an unmarked police car which might just have caught him on speed camera. Impulsivity is the behavioural side of ADHD. Most of us have an idea and pass it rapidly before our mental committee, before acting or speaking. For fear that a great idea may be lost because of lapse in concentration, the ADHD person will often bypass the committee with consequences which range from embarrassing to homicidal. One of my patients described impulsivity as ‘ ready, fire, aim.’ The impulsive primary child will be constantly in trouble for talking, poking others, and leaving his seat. The impulsive teenager will be hovering on the edge of suspension for swearing at the teacher, smoking, wagging, or in one young man I remember well, firing an airgun at the principal. By his 20s he may well have been before the court on numerous occasions or already in jail.

It is just an excuse for criminal behaviour, isn’t it?

Surveys in the United States show 25% of their large prison population has ADHD. No-one in NZ has yet been allowed to ask the same question. Studies overseas have found that someone with ADHD is 22 times more likely to spend at least one night in jail at some point in life than those who do not. I write many letters to the courts on behalf of my ADHD patients who have got into trouble. I always emphasise that impulsivity is definitely no excuse for criminal behaviour but it does help to explain why offences have occurred. Courts are becoming much more sympathetic to a diagnosis of ADHD if it leads to a treatment plan which can keep the offender out of future trouble.

Doesn’t it just affect boys?

The kids passing through the health system for assessment of ADHD have been in a proportion of about 5 boys to 1 girl. It has traditionally been assumed to be a condition mainly of males. In my experience in the last 20 years of treating adults also, I have found among 800 adults an almost equal number of males and females. Because by definition the problem must have been present by the age of 7, one has to review evidence from early childhood to make the diagnosis. A large number of ADHD girls were missed as they grew up. In retrospect they were either the dreamers who bothered no-one, or the talkers, who at the risk of sounding sexist, were assumed to be consistent with their gender. The consequence of missing the problem in young girls is serious because it leads to educational underachievement and unfulfilling jobs. They are much more likely to fall into drug and alcohol abuse which has been shown to be twice as common in ADHD. Suicide risk is higher because life has not gone well, and because most suicidal behaviour is impulsive rather than planned. A number of my ADHD patients have worked as prostitutes. They tell me that all the other girls are like them. Sadly this would have to be the ultimate impulsive occupation.

Ritalin is like Speed, isn’t it?

If medication is appropriate in ADHD, whether for children or adults, the preferred choice has been Methylphenidate, better known for many years by its brand name Ritalin, first marketed in 1954. It is not Speed or P, Methamphetamine, but it is chemically similar. Is that bad? Used by the right people in the right dose and by the right route it is effective and safe. It raises the level of dopamine, the brain chemical responsible for preventing distraction. The benefits are almost immediate in improved concentration, learning and often behaviour. Combined with practical life style measures it can turn a person’s life around. Rubifen is another brand but in the SR form is not always as effective possibly because of the way it is absorbed into the body. The other option is Concerta which is also Methylphenidate in a very neatly engineered form providing quick onset, and an even 12 hour effect, with a gentle decline. It is available in 18,36 and 54 mg. Ritalin LA is also longer acting with doses of 10,20,30 or 40mg. Most patients find them superior.. Dexamphetamine, first developed in 1937, is a good alternative in the 20% of patients who have unacceptable side-effects from Methylphenidate. It also suits about 80% overall, but a different 80%. In New Zealand it is only licensed as the 5mg tablet with an effective life of 4-6 hours. Overseas it is marketed in a long acting form which is not even allowed to be imported into this country, let alone funded.

Doesn’t it make them become drug addicts?

Evidence worldwide is that appropriate treatment with Ritalin roughly halves the likelihood of children becoming drug abusers. The high from ‘Meth.’ depends on large amounts being taken in quickly by inhalation, through the nose, or by injection. Ritalin can be abused either by the ADHD patient or when supplied to others. It is obviously important to try very hard to prevent this, while at the same time making sure that those who will benefit are not denied the best treatment. My experience after managing ADHD for 25 years is that those I know or suspect have abused are well under 5% of my patients. If I become aware of a problem, supply has to stop until a secure system is worked out.

Aren’t stimulants going to cause brain/liver/heart damage?

Both these stimulant medications have minor side effects, usually in the first week only. Serious problems are rare if properly used, even after many years. Significant adverse reactions are commoner in aspirin use than with either of these two chemicals. Probably the most important bad reaction would be the occasional occurrence of psychosis. This usually happens with too high a dose, but especially when combined with marijuana which is a very common cause of psychosis. Warning ADHD patients off pot is a high priority. Quite apart from the risk of a psychotic reaction, marijuana damages concentration and memory which the person with ADHD definitely does not need. To try to get around the potential for abuse, a relatively new treatment, Strattera, from a totally different chemical group, has been introduced. As yet research suggests that the benefit is about the same. There are two drawbacks. It takes several weeks to achieve benefit. There has not been the experience of the older products to be sure of long term safety.

Wasn’t ADHD invented by the drug companies to make money?

No it wasn’t, because ADHD was there long before the medications.

Isn’t it better to treat it by natural means?

There are a host of alternative treatments being promoted based on vitamins, minerals, glyco-nutrients, herbs or fish oils. None of them have good evidence for effectiveness when a proper comparison is made by a randomized controlled trial. This involves two treatments being compared in a sufficient number of similar patients without the patient, the family or the doctor knowing which is which. So often if there is a claimed benefit for ‘natural’ products, it is a placebo effect. We believe we will be better and so we are, for a short while. The safety of many so called natural substances is unknown. Arsenic is natural! Families can waste a lot of money they cannot afford on treatments which do not work. Much more benefit is gained, in a small proportion of children, by reducing high amine, salicylate and glutamate containing foods which definitely increase hyperactivity in about 20% of small kids.

Isn’t ADHD over-diagnosed?

The process of diagnosis of ADHD in New Zealand is thorough by taking time to hear the life story at length from, not only the patient, but close friends and family wherever possible. Questionnaires completed by parents and teachers when assessing children, and by adults about themselves, can be helpful to make sure nothing important is missed. Various other tests are useful including IQ, educational levels, personality tests, and computer tests of concentration and impulsivity. Examination both physically and psychologically is important. ADHD is frequently accompanied by other problems such as Specific Learning Disorders, Oppositional Defiant Disorder, whose title speaks for itself, and Conduct Disorder, where there is antisocial behaviour with a seeming lack of conscience. Sufferers may be intellectually handicapped, gifted or anywhere in between. Anxiety, depression, and Obsessive Compulsive Disorder all commonly co-exist with ADHD. Asperger’s syndrome characterized by rigid, repetitive behaviour and a lack of emotional engagement needs to be considered. Petit mal epilepsy can be mistaken for the dreaming of ADHD.

Assuming the generally agreed figure of about 5% of the population in most ethnic groups the number diagnosed with ADHD in New Zealand is far smaller than this, and the proportion receiving treatment is even less. The problem therefore is almost certainly under, not over, diagnosis. Even in the United States where the process of assessment would vary much more widely in standard, only 6% of school aged children are on medication.

Isn’t it because parents push their kids too hard to achieve?

In my experience few children come for assessment because they are not meeting parents’ academic expectations. Most come because of complaints from school or home about impulsive behaviour. The realisation that concentration is a major issue only emerges when questions are asked of teachers and children themselves. Parents concerned about academic progress usually opt for tutoring first before someone suggests ADHD. Asian parents aside, the problem in NZ is so often a lack of parental interest in why children are not learning. Adults on the other hand frequently present because they recognize they have failed academically despite knowing they have ability.

Doesn’t treating ADHD destroy creativity?

I have a number of ADHD patients who are artists, musicians, writers, designers and in the performing arts. Losing their creativity is their fear. Most say the opposite happens. Being able to focus when on medication allows them to do something with their great ideas. A number of my patients on medication have come up with inventions with the potential to have a world market. Beethoven only finished about 60 pieces of wonderful music, leaving about 100 incomplete. Wouldn’t it have been exciting if Ritalin had been around in his time?

Dr. Tony Hanne