Attention Deficit Hyperactivity Disorder, Research Paper Example

Abstract

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder characterized by poor impulse control, seemingly poor concentration skills, and an apparent lack of attentional and organization ability. Because its effect is so prevalent in day-to-day tasks, people with ADHD can be ostracized and criticized for seeming to not pay attention, not caring about putting effort into tasks, and not showing a proficiency for regular tasks performed by people everyday. The causes of ADHD, although fairly widely agreed upon, are not as definitely organized as those for something more known, like influenza. This paper will explore the areas of the brain responsible for ADHD and how millions of people who have ADHD live with it.

Calling Attention to an Attention Disorder

The Diagnostic and Statistical Manual for Mental Disorders (DSM) is a book used by psychologists and psychiatrists to aid in characterizing and grouping mental disorders. In the section for ADHD, the DSM-V describes ADHD as being “characterized by a pattern of behavior, present in multiple settings (e.g. school and home), that can result in performance issues in social, educational, or work settings” (DSM-V, 2013). The DSM-V also sorts ADHD into three categories: inattention, hyperactivity-impulsivity, or both; a diagnosis requires six symptoms from either or both categories if the person is under the age of 17, and five symptoms from either or both categories if the person is over the age of 17. Further, a diagnosis rests on the evidence that the person has exhibited several symptoms in either or both categories before the age of 12, as symptoms are measured as they occur in various stages in the person’s life. Lastly, symptoms must have been present for at least six months before the diagnosis. The following table lists the criteria used in the DSM-V:

Either 1 or 2

1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months, to a degree that is maladaptive and inconsistent with developmental level:

• Often fails to give close attention to details, or makes careless mistakes in schoolwork, work or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions, and fails to finish schoolwork, chores or workplace duties (not due to oppositional behavior
• or failure to understand instructions)
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• Often loses things necessary for tasks or activities (for example, toys, school assignments, pencils, books or tools)
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities

2. Six (or more) of the following symptoms of hyperactivity/impulsivity have persisted for at least 6 months, to a degree that is maladaptive and inconsistent with developmental level:

• Often fidgets with hands or feet or squirms in seat
• Often leaves seat in classroom or in other situations in which remaining seated is expected
• Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings
• of restlessness)
• Often has difficulty playing or engaging in leisure activities quietly
• Is often ‘on the go’ or often acts as if ‘driven by a motor’
• Often talks excessively
• Often blurts out answers before questions have been completed
• Often has difficulty awaiting turn
• Often interrupts or intrudes on others (for example, butts into conversations or games)

1. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age
2. Some impairment from the symptoms is present in two or more settings (for example, at school/work or at home)
3. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning
4. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder, and are not better accounted for by another mental disorder (or example,, mood disorder, anxiety disorder, dissociative disorder or personality disorder)

(Table taken from Antshel et al., 2011)

It almost goes without saying that when diagnosing ADHD in a child or adult, medication and/or drug use must be first ruled out as a possible indicator of behavioral symptoms. For instance, if Patient X has been on Mediation Y for six years and Medication Y has been known to cause symptoms like jumpiness, increased psychomotor activity, and restlessness, withdrawal of Medication Y should also cause withdrawal of these symptoms. As the symptoms listed as being caused by Medication Y mimic symptoms attributed to ADHD, a person cannot be definitely diagnosed as having ADHD until any and all medications are ruled out as being the cause of the symptoms.

Likewise, a diagnosis of ADHD must also include ruling out any other underlying diseases or disorders. Schizophrenia, for example, can cause symptoms such as blurting out inappropriate phrases, fidgety movements, and squirming, and ADHD can be mistakenly attributed to something else.

One of the most widely agreed upon causes of ADHD is genes. Illott et al. (2010) write that “exploration of genetic variants correlated with measures of ADHD and [Activity Level] in infancy provided modest evidence of association with the behavioral measure” (Illott et al., 2010:300). Although it is impossible to say with complete assurance that there is a genetic link between parents and children when it comes to attributing ADHD to heritability, researchers’ studies using twins has shown that there there is an increased chance that children born one or both parents with ADHD will also exhibit symptoms of ADHD, too. The use of twins in research studies, such as those conducted for ADHD, is useful because twins are genetically identical to each other and can be used to differentiate if a disorder is “nature or nurture.”

Along with genetics, a deficit in executive function is thought to be responsible for ADHD, where executive function is the type of thinking and acting responsible for everyday tasks such as being able to use planning ability and working memory to solve the Tower of Hanoi problem (Ozonoff and Jensen, 1999). A person displaying a deficit of executive function may be diagnosed as having ADHD since many of the deficits in executive function are also deficits that are covered by ADHD. It should be pointed out, though, that ADHD cannot be described as a partial or total lack of executive function, as many other disorders such as Autism and Traumatic Brain Injury (TBI) can also lead to a deficit in executive function. Nor it can also be said that a deficit in executive function represents the presence of ADHD. Rather, it is best summed up by saying that a deficit in executive function may be causal or symptomatic of ADHD.

Because ADHD is so strongly linked to the brain, it is important to understand which parts of it and why are responsible for the manifestation of the disorder. One of the main symptoms, poor impulse control, is relatively centralized to the ventromedial prefrontal cortex (vmPFC.) Again, this is not to say that damage to the vmPFC will necessarily cause ADHD, or that poor impulse control is solely linked to the vmPFC, but rather that the two are tied together far more often than not. As well as the vmPFC, poor impulse control can also be attributed to activity in anterior cingulate cortex (ACC) and the amygdala, areas of the brain which are also linked to other activities other than imulse control. (Boes et al., 2008).

Along with poor impulse control, scattered concentration and impaired organizational are also big hallmarks of ADHD, the latter of which is mainly linked to the posterior parietal lobe. Concentration can be generally defined as the ability to attend to an object or task and combine that attention with memory; for the purpose and length of this paper, it is not necessary to go into great detail about the different kinds of memory nor the types of attention displayed during tasks. The ability to concentrate is found mostly in the prefrontal and parietal cortices and like impulse control, these areas are not solely linked to concentration, nor is concentration only found in these areas. Organizational skills can also be linked to the frontal lobe, as well as the parietal lobe.

Although research generally agrees that deficits in certain parts of the brain are linked to ADHD, and that genetics and executive function are strongly indicative of the disorder, some believe that there are other causes, too. For instance, Fritz (2011) lists sugar and food additives as being possible causes of ADHD. However, he is careful to note that “more research discounts [the sugar] theory than supports it”, although he does briefly mention two studies in which children were either given sugar or a sugar substitute and had their activity levels measured. Fritz discusses food additives as being another possible cause of ADHD, but with even more brevity, writing that “recent British research indicates a possible link between consumption of certain food additives like artificial colors or preservatives, and an increase in activity”, with more research being conducted to confirm this initial hypothesis (Fritz, 2011:1.)

Huizink and Mulder (2006) theorize that prenatal smoking, drinking, or cannabis use during pregnancy can have an adverse effect on the fetus, such as possibly increasing the chances that the infant will develop ADHD as it ages, or possibly show symptoms that are congruous with ADHD. By summarizing other previously written reviews that have studied the effects of alcohol, nicotine, and cannabis on the developing fetus, they draw conclusions that these effects are extendable to ADHD with the child manifesting symptoms of inattention, impulsivity, increased externalizing behavior, decreased general cognitive functioning, and deficits in learning and memory tasks.

At the opposite end of the spectrum from innately acquired tendencies to show ADHD is the person’s social surroundings, and how they might “influence” the person into showing symptoms of ADHD. The World Health Organization (WHO) makes the seemingly bold claim that “the diagnosis [of ADHD] can be symptomatic of family dysfunction, rather than individual psychopathology, and may reflect inadequacies in the educational system” (WHO, 2005:2.) Before dismissing this claim entirely, it is worth noting that the WHO (along with being one of Britain’s greatest rock bands) is a body comprised of many of the world’s leading scholars in health and medicine. It is also worth investigating whether or not it is possible to attribute ADHD to familial dysfunction and/or scholastic inadequacies. If Child X’s parents are, say, going through a divorce and fighting viciously with each other, it’s not so hard to imagine that Child X may feel isolated and the need to show impulsivity and inattention in a bid to receive attention. Likewise, if Child X is enrolled at a school in which class sizes are much bigger than normal, or if funding is low and necessary materials and resources can’t be provided, then Child X may also act out in ways that resemble ADHD. However, it seems a bit dubious to say that the cause of ADHD are the ones mentioned by the WHO (for a contrasting opinion, listening to the song “Christmas” from The Who’s Tommy album can provide evidence otherwise.)

Although the reader may have a fairly good sense of what it means for someone to have ADHD and from where it originates, a large portion of the population doesn’t. And with diagnoses cropping up everyday like batches of popcorn, it is hard to not come across a person who has ADHD, whether or not they’ve been diagnosed. If exposed to such a person without prior knowledge or education, reactions to their behaviors can range from being baffled at wondering why a person shows the need to fidget and squirm all the time to anger at their constantly interrupting the conversation. This is not to say that reactions are limited to only these two emotions, but rather that a wide range of emotions can be shown in response to ADHD behavior. If a family member were to start bungee jumping or making what you thought were poor decisions, you’d probably feel worried and confused as to the cause of it, and likely a determination to find a way to fix it.

The pharmaceutical industry thrives on manufacturing medication to treat every disorder under the sun, and ADHD is no exception. Treating ADHD medicinally usually follows one of two paths: with stimulants, or with non-stimulants. In the former category, methylphenidate (Ritalin) is the most common prescribed medication, and atomoxetine a common non-stimulant medication. The reasoning behind giving an already “agitated” person a drug that will seem to further excite them is that the medication will cancel this energy out, and indeed studies have been conducted that show this works (Tillery and Katz, 2000.) But there are also a number of scientists who feel that ADHD should be treated with non-stimulant medication, and research shows that this works, too, with morning doses being more effective, but evening doses being more tolerable (Antshel et al., 2011.)

But in recent years, a growing portion of the population is eschewing drugs in favor of psychosocial therapies such as talk therapy, cognitive behavioral therapy (CBT), or cognitive training paradigms, although Antshel et al. (2011) write that “these date require further research before any meaningful conclusions can be reached” and “these therapies are best used as a complement to ongoing pharmacotherapy rather than as an alternative” (p.6.)

At the very least, though, one way to “treat” ADHD is by learning and educating oneself as much as possible.. This isn’t to say that undertaking these activities will halt or calm ADHD, but it creates a sympathetic bridge between sufferer and observer, allowing the parties to better understand each other and the disorder.

For those who haven’t been exposed to ADHD, or have but haven’t recognized it, real-life case studies are extremely useful in understanding the full scope of the disorder. Orford (1998) writes briefly about three boys in the beginning of the paper: 6-year-old Jack, Peter (age not disclosed), and 12-year-old John.

Jack’s parents with frustrated with their child’s behaviors from when he was very small, labeling him as a “mad child” and being bewildered about his being terrified of chickens. After an incident with chicken pox, his parents took promptly took him away to go on holiday with family in Africa. It wasn’t until Orford told the parents, “No wonder he doesn’t like chickens” (Orford, 1998:256) that the parents realized their failing to communicate with their son in a way he could understand. Orford writes that this is a very general way of understanding Jack’s story, but that his parents found their son’s inattention decreased once their attention to him increased.

Peter, on the other hand, needed Ritalin to alter his behavior. After not being able to contain himself in school and causing his mother much frustration and abuse, Peter was given Ritalin which, while not immediately effective, did give the staff at the unit at a chance to reach out to Peter. After a little while, Peter started to learn and treat his peers with sympathy, and the change in his behavior even caused a change in his sister’s behavior as she grew less anxious over her brother’s behavior.

Last is John, the preteen who frequently reenacted car crashes and accidents for long periods of times. Unsettled by John’s behavior, staff put him on Ritalin and noticed an immediate and remarkable change: instead of violently crashing cars together to resemble gory accidents, John now added a traffic warden who arranged and guided the cars off the double yellow lines on a car mat. Orford describes Ritalin in John’s case as “a sort of traffic policeman in the turbulent mind of a hyperactive child” (Orford, 1998:257.)

To the untrained eye, ADHD, can seem like a jungly mess of behaviors, actions and utterances that are completely out of line with societal norms and expectations, or even a willful disregard for these norms and expectations. This can especially be the case if a person is quite used to seeing those around them act and behave in one way, only to then come across a person who does quite the opposite. Such an upheaval in emotion and behavior can be quite unsettling, especially for family members who are exposed to it on a constant basis. As difficult as it may be to be on the receiving end of this behavior, it is doubly or triply hard to have ADHD. Imagine relatively understanding the business of your own mind and the constant need to fidget and squirm. Initially, it may be a bit of a shock but over time, adjustments are made to a livable stasis. But it is not just living with the near-constant feverish excitement in your own mind, but also the reactions to those around you who aren’t used to it. This can be wearing on children and adults who consistently get feedback that they simply aren’t concentrating or focusing enough, that they need to practice being more polite in conversations, or that they just need to eat a little less sugar. These complaints, if administered often enough over time, can cause deep damage to the psyche of children and adults and can take more time to repair than the time it took to cause them.

It is not easy to figure out that the afflicting disorder is ADHD, as it is a spectrum disorder where symptoms can exist with varying degrees of intensity. Another problem is that many ADHD symptoms can be properly or improperly attributed to other diseases, disorders or causes, such as TBI, Autism, Schizophrenia, familial dysfunction, inadequacies in the education system, or even a fear of chickens linked to a parental lack of attention. It is because of this possibly huge vague area that the DSM-V stipulates that a person with ADHD, whether rooted in inattention, hyperactivity-impulsivity, or some combination of the two, must show at least five (if over the age of 17) or six (if under the age of 17) symptoms in the list of symptoms they have provided, and must have done so for at least six months before the diagnosis can be made. It can be frustrating for loved ones to wait such a long period of time for a definitive answer to what’s been plaguing their friend or family member, but this is done to rule out any outside factors. When the time comes to make a diagnosis of ADHD, the trained professional will also seek to eliminate medications or other diseases or disorders. This is so that an ADHD diagnosis can be done as surely as possible, for medications or other disorders can have symptoms that very closely mirror those of ADHD’s. This is not to say that ADHD cannot exist in conjunction with other disorders, for they can- and do, but to say that what is thought to be ADHD is not simply something else.

While it may not be useful to anyone except those studying and researching ADHD, knowing the areas of the brain correlatively or causatively linked to ADHD can also be of importance. For example, knowing that impulse control is usually found in the vmPFC can give people an indication that a streak of impulsivity can mean a deficit in that area. However, as previously discussed, it is important to note that the vmPFC is not the only part of the brain linked to ADHD, and that ADHD does not necessarily mean a deficit in the vmPFC. The amygdala, while mostly linked to memory and emotion, is also correlative with impulse control. The brain is such a fantastically complex organ that it would be erroneous to say that Area X is solely and completely responsible for Symptom Y of ADHD.

And while it may seem like a Sisyphean task to learn about and deal with ADHD, it is a challenge worth accepting because as more light is shed on it, the more equipped each person will be to handle it with aplomb.

References

American Psychiatric Association. (2013). Attention Deficit/Hyperactivity Disorder. Diagnostic and Statistical Manual of Mental Disorders.

Antshel, K.M., Hargrave, T.M., Simonescu, M., Kaul, P., Hendricks, K., & Faraone, S.V. Advances in Understand and Treating ADHD. BMC Medicine, 9(72), 1-13

Bielefeld, S.D. (2006). An Analysis of Right and Left Brain Thinkers and Certain Styles of Learning. Retrieved from http://www2.uwstout.edu/content/lib/thesis/2006/2006bielefeldts.pdf.

Boes, A.D., Bechara, A., Tranel, D., Anderson, S.W., Richman, L., & Nopoulos, P. (2008). Right Ventromedial Prefrontal Cortex: A Neuroanatomical Correlate of Impulse Control in Boys. Social Cognitive and Affective Neuroscience, 4(1), pp.1-9.

Fritz, G.K. (Ed.) (2011). What Causes ADHD? The Brown University Child and Adolescent Behavior Letter.

Huiznik, A.C., & Mulder, E.J.H. (2006). Maternal Smoking, Drinking or Cannabis Use During Pregnancy and Neurobehavioral and Cognitive Functioning in Human Offspring. Neuroscience and Biobehavioral Reviews, 30(1), pp.24-41.

Illott, N., Saudino, K.J., Wood, A., & Asherson, P. (2010). A Genetic Study of ADHD and Activity Level in Infancy. Genes, Brains and Behavior, 9, pp. 296-304.

Jensen, E. (2000). Revisiting the left/right brain dialogue. Retrieved from http://elc.uark.edu/wp-content/uploads/2012/01/The-Left-Right-Brain-Dialogue.pdf

Martinussen, R.L., Tannock, R., Chaban, P., McInnes, A., & Ferguson, B., (2006). Increasing Awareness and Understanding of Attention Deficit Hyperactivity Disorder (ADHD) in Education to Promote Better Academic Outcomes for Students with ADHD. Exceptionality Education Canada, 16(3), pp.107-128.

Orford, E., (1998). Wrestling with the Whirlwind: An Approach to the Understanding of AD/HD. Journal of Child Psychotherapy, 24(2), pp.253-266.

Ozonoff, S., & Jensen, J. (1999). Brief Report: Specific Executive Function Profiles in Three Neurodevelopmental Disorders. Journal of Autism and Developmental Disorders, 29(2), pp.171-177.

The World Health Organization. (2005). Mental Health of Children and Adolescents. WHO European Ministerial Conference on Mental Health.

Tillery, K.L., & Katz, J. (2000). Effects of Methylphenidate (Ritalin) on Auditory Performance in Children with Attention and Auditory Processing Disorders. Journal of Speech, Hearing, and Language Research, 48, pp.893-901.

West, M. (2010). Right brain learners–A reason your child may have trouble learning. Retrieved from http://therightsideoflearning.com/articles/Why%20Right%20Brain%20Learners%20may%20Struggle%20with%20Learning.pdf